Antibody Response After Influenza Immunization in Renal Transplant Patients Receiving Cyclosporin A or Azathioprine

Nineteen renal transplant recipients receiving cyclosporin A and prednisone, eight kidney recipients receiving azathioprine and prednisone, and 12 healthy volunteers were immunized with 0.5 ml of trivalent influenza vaccine containing A/Bangkok/1/79 (H₃N₂), A/Brazil/11/78 (H₁N₁), and B/Singapore/222/79. Nine patients (47%) in the cyclosporin A group and five (63%) in the azathioprine group showed fourfold rises in titer to at least one virus strain compared with 12 (100%) in the control group.     

Induction Therapy in Renal Transplant Recipients: A Review

Transplant science has improved significantly over the last decade. Influenced by novel advancements, rejection rates and short-term graft losses diminished substantially. Induction therapy was shown to reduce rejection rates and improve short-term graft survival. In this article, we discuss the most commonly used induction agents and the choice of induction therapy in different renal transplant recipient subgroups. The medical literature as well as our own experience was used to prepare this review. At this time, induction therapy is commonly used in upwards of 80%, of renal transplant recipients. Depleting agents are the most frequently used agents and they account for more than 75% of all induction therapies in the United States. Currently, there is no consensus regarding the choice of induction therapy. The type of induction therapy is generally selected based on a comprehensive evaluation of the recipient and the donor’s immunological risks, the risk of developing opportunistic infection and malignancy, recipient comorbidities, financial burden and the choice of maintenance immunosuppressive regimen.     

Infections in Renal Transplant Recipients Receiving Mycophenolate Versus Azathioprine-Based Immunosuppression

Differences in the incidence, etiology, type, and outcome of infections occurring during the first 6 months after transplantation were evaluated in two consecutive cohorts of kidney recipients who received immunosuppressive regimens based on either azathioprine (plus antilymphocyte globulin, cyclosporine A, and prednisone) (ATG-AZA cohort) or mycophenolate-mofetil (plus cyclosporine A and prednisone) (MMF cohort). The overall incidence of infections in the two cohorts was similar (0.99±1.06 infections/patient in the MMF cohort and 1.04±0.99 in the ATG-AZA cohort, P=0.3), as was the incidence of bacterial and fungal infections. In patients who received mycophenolate, cytomegalovirus disease occurred at a higher incidence (0.3±0.54 vs. 0.1±0.34 episodes/patient, P=0.005) and affected the upper gastrointestinal tract more frequently (0.21±0.48 vs. 0.025±0.16 episodes of cytomegalovirus ulcerative esophagitis, gastritis, or duodenitis per patient; P=0.001). A nonsignificant trend toward a higher recipient survival for patients receiving mycophenolate was noted (100% vs. 95%, P=0.07). In multivariate analysis, the following factors were independently associated with a higher risk of cytomegalovirus disease: the serostatus R–/D+ (seronegative recipients who received a kidney from a seropositive donor) (RR=35.7 [95%CI, 7.4–166.7]), treatment with mycophenolate (RR=10.4 [95%CI, 2.7–38.4]), and the development of any episodes of acute rejection (RR=10.1 [95%CI, 2.5–41.6]). These data show that kidney recipients receiving mycophenolate have a higher incidence of cytomegalovirus disease, mainly affecting the upper gastrointestinal tract, compared to those receiving azathioprine-based immunosuppression. Electronic Publication     

Skin Cancer Risk Associated with Immunosuppressive Therapy in Organ Transplant Recipients

The aim of this review is to summarise the available literature regarding the epidemiology and proposed mechanisms of skin cancer development in organ transplant recipients who are receiving lifelong treatment with immunosuppressive therapy and to review the different strategies for managing complications in this group of patients. Organ transplantation is complicated by an increased incidence of certain cancers, of which non-Hodgkin's lymphoma, Kaposi's sarcoma and squamous cell carcinoma are the most common. The most important risk factor for these cancers is immunosuppressive therapy. The relative importance of different immunosuppressive therapy regimens in relation to the development of skin cancer is still unclear. Immunosuppression per se may play the most important role, but other mechanisms, which are independent of host immunity and which may be different for the various agents used, may also be of importance for the increased risk of cancer. Apart from immunosuppressive therapy, exposure to sunlight and infection with human papillomaviruses are believed to be the most important risk factors for the development of cutaneous squamous cell carcinoma in organ transplant recipients. Human papillomaviruses, no doubt, benefit considerably from immunosuppression, as is indicated by the large number of warts found in these patients, but many questions remain unanswered about their significance in cutaneous oncogenesis. The E6 protein from a range of cutaneous human papillomavirus types effectively inhibits apoptosis in response to ultraviolet light damage. It is, therefore, conceivable that the development of skin cancer in organ transplant recipients is the result of a complex interplay between exposure to ultraviolet radiation, human papillomavirus infection and genetic predisposition. Measures for protection from the sun are important for reducing the risk of skin cancer in organ transplant recipients. Regular surveillance of patients with skin problems and easy access to a dermatologist for these patients is advised. Changing the immunosuppressive regimen from azathioprine to cyclosporin or vice versa does not seem to relieve the skin problems. Tapering the immunosuppressive therapy to the lowest possible dose may be of some advantage. Oral retinoids, e.g. acitretin, have some effect in reducing the number of keratotic skin lesions and in the prevention of skin cancer in organ transplant recipients. Resurfacing the back of the hand can be a successful treatment for patients with multiple skin cancers on the back of the hand and can be used prophylactically in patients with severely actinically damaged skin.     

介入治疗患者术前焦虑水平及其影响因素

目的:评估介入治疗患者的焦虑水平,探讨产生焦虑情绪的影响因素。方法:对98例准备接受介入治疗的心血管、脑血管和肿瘤病人施测焦虑自评量表(SAS)、社会支持问卷(SSRS)和中国人人格量表(QZPS)。结果:1.病人的SAS 总均分(33.84±15.0)显著高于常模组(29.78±0.5)(t=2.48.P<0.05);心血管、脑血管和肿瘤病人的SAS 总分分别为39.6±13.4,28.6±16.3,32.4±14.9,差异有统计学意义(F=3.90,P<0.05);2.受教育程度高与病人的焦虑分数存在显著的负相关(r=-0.55,P<0.01),主观社会支持与焦虑水平有显著负相关(r=-0.55,P<0.01);3.人格特质是影响焦虑水平的重要因素,相关和回归分析的结果表明,耐性、乐观、宽和、合群等人格因素对焦虑水平具有预测力(R~2=0.40)。结论:介入治疗患者在接受治疗前会产生焦虑情绪,受教育程度和人格特征与焦虑水平密切相关。     

Puppet Therapy with Pediatric Bone Marrow Transplant Patients

The authors' experience in developing and implementing a formof short-term puppet therapy for children undergoing bone marrowtransplantation is reviewed.     

60例肾活检病人心理状况调查

对象和方法本文采用自拟调查表对60名肾活检病人于活检前后进行了调查。男33人,女27人,年龄13-43岁,平均年龄43岁,受教育程度小学5人,初中18人,高中22人,大专以上15人。结果肾活检前有20%的病人知道肾活检,但全部病人都希望多了解相关知识。95%病人选择由医务人员讲解,讲解方式包括口头(100%)、文字(75%)及影像(85%)。病人所担心问题的前三项是担心肾活检过程(83.3%)、并发症(76.7%)和检查费用(58.3%)。病人对肾活检的恐惧程度一般恐惧占66.7%,非常恐惧占30%,不害怕只有2人。在选择手术施行者方面,以主任医师(70%)为主,其次是主治医师(23.3%…     

AST-120 Improves Microvascular Endothelial Dysfunction in End-Stage Renal Disease Patients Receiving Hemodialysis

PurposeEndothelial dysfunction (ED) is a pivotal phenomenon in the development of cardiovascular disease (CVD) in patients receiving hemodialysis (HD). Indoxyl sulfate (IS) is a known uremic toxin that induces ED in patients with chronic kidney disease. The aim of this study was to investigate whether AST-120, an absorbent of IS, improves microvascular or macrovascular ED in HD patients.ResultsAch-induced iontophoresis (endothelium-dependent response) was dramatically ameliorated at 3 months and 6 months in the AST-120 group. SNP-induced response showed delayed improvement only at 6 months in the AST-120 group. The IS level was decreased at 3 months in the AST-120 group, but remained stable thereafter. cIMT was significantly reduced after AST-120 treatment. No significant complications in patients taking AST-120 were reported.ConclusionAST-120 ameliorated microvascular ED and cIMT in HD patients. A randomized study including a larger population will be required to establish a definitive role of AST-120 as a preventive medication for CVD in HD patients.     

Long-Surviving Patients with Recurrent GIST after Receiving Cytoreductive Surgery with Imatinib Therapy

In the treatment of recurrent or metastatic gastrointestinal stromal tumors (GIST), good prognoses may not be expected by surgery alone. Recently, imatinib has been applied for the treatment of GISTs, resulting in improved patient survival. However, long-term success is limited due to the development of resistance. Herein, we report two cases of long-surviving patients with recurrent GIST after receiving cytoreductive surgery with imatinib therapy. A 49 year-old man was diagnosed to a duodenal GIST with single hepatic metastasis, and an antrectomy including the duodenal lesion with intraoperative radiofrequency ablation were performed in April, 2002. After four months, a new metastatic hepatic lesion was identified. Percutaneous radiofrequency ablation was done, and imatinib therapy was started. A 56 year-old man underwent laparoscopic segmental resection of the distal ileum and partial excision of parietal peritoneum in March, 2001 to treat a malignant GIST of the distal ileum that was attached to parietal peritoneum. After six months, recurrence of GIST with peritoneal seeding and hepatic metastasis was found, and he underwent cytoreductive surgery including right hemicolectomy and wedge resection of liver. After surgery, there was no residual tumor grossly and imatinib therapy was started. In both cases, they were doing well with no evidence of recurrence for 5 years with imatinib therapy. Therefore, in patients with a recurrent GIST, improved survival can be expected with imatinib therapy after cytoreductive surgery.     

Risk of Seizures in Children Receiving Busulphan-Containing Regimens for Stem Cell Transplantation

Busulphan (BU) is associated with neurotoxicity and risk of seizures. Hence, seizure prophylaxis is routinely utilized during BU administration for stem cell transplantation (SCT). We collected data on the incidence of seizures among children undergoing SCT in Italy. Fourteen pediatric transplantation centers agreed to report unselected data on children receiving BU as part of the conditioning regimen for SCT between 2005 and 2012. Data on 954 pediatric transplantation procedures were collected; of them, 66% of the patients received BU orally, and the remaining 34%, i.v. All the patients received prophylaxis of seizures, according to local protocols, consisting of different schedules and drugs. A total of 13 patients (1.3%) developed seizures; of them, 3 had a history of epilepsy (or other seizure-related pre-existing condition); 3 had documented brain lesions potentially causing seizures per se; 1 had febrile seizures, 1 severe hypo-osmolality. In the remaining 5 patients, seizures were considered not explained and, thus, potentially related to BU administration. The incidence of seizures in children receiving BU-containing regimen was very low (1.3%); furthermore, most of them had at least 1—either pre-existing or concurrent—associated risk factor for seizures.     

Use of Mechanical Ventilation and Renal Replacement Therapy in Critically Ill Hematopoietic Stem Cell Transplant Recipients

Hematopoietic stem cell transplantation (HSCT) is a treatment option for both malignant and nonmalignant disorders. HSCT patients remain at high risk for multiorgan failure, with previous studies noting mortality rates exceeding 90% when mechanical ventilation (MV) is required. We propose that advancements in critical care management and HSCT practices have improved these dismal outcomes. We performed a retrospective review of admissions to our bone marrow transplant unit between 2006 and 2010. All HSCT recipients requiring admission to the bone marrow transplant unit who received MV or renal replacement therapy (RRT) were evaluated. A total of 68 patients required MV. Twenty patients required RRT, all of whom required MV. Fifty-nine of the 68 ventilated patients died, for an overall mortality rate of 86.8%. The presence of renal failure and concomitant respiratory or liver dysfunction at the time of intubation was associated with a mortality rate of 100%. High mortality persists in our HSCT population requiring artificial support despite overall advances in critical care and HSCT practices. Critical care triage and management decisions in this high-risk population remain challenging.     

Breast Carcinoma in Patients Receiving Neuroleptic Therapy Morphologic and Clinicopathologic Features of Thirteen Cases

We report 13 cases of breast carcinoma in patients treated with neuroleptics (prolactin releasing drugs). Twelve of the patients were female and one was male. Nine patients had unicentric carcinoma, one had multicentric tumors arising synchronously, and three had bilateral tumors (synchronous in one case and metachronous in two cases). Thirteen tumors in ten patients were invasive ductal carcinomas, two tumors in one patient were mucinous carcinomas, and the two other patients had lipid secreting carcinomas. Immunohistochemical staining showed alpha lactalbumin (α LA) in the lipid-secreting carcinomas at sites exhibiting active lipid secretion. A precise cause effect relationship is difficult to elucidate, since the patients ranged in age from 40 to 64 years (mean: 51 years) when cancer was first diagnosed. However, the relatively high incidence of multiple tumors and the production of lipid and α LA by the cancer cells were unusual features suggesting an association with neuroleptic therapy.