小剂量环孢素A联合小剂量激素治疗原发性肾病综合征疗效观察

目的 观察小剂量环孢素A（CsA）联合小剂量强的松在原发性肾病综合征治疗中的疗效、不良反应及其与足量强的松的比较.方法 67例原发性肾病综合征均经肾活检病理检查证实,前瞻性非随机观察18个月以上.治疗组（n=41）：小剂量CsA联合小剂量强的松,其中难治性肾病综合征8例,强的松0.5 mg· kg-1·d-1 ＋CsA 2.5 mg·kg-1·d-1,强的松最大剂量30 mg/d,连服2～3个月后每隔2～4周强的松、CsA在原剂量基础上交替递减10％或持续应用原剂量.对照组（n=26）：足量强的松组,强的松1.0 mg·kg-1·d-1,强的松最大剂量60 mg/d,连服2～3个月后每隔2～4周在原剂量基础上递减10％.其中10例联合环磷酰胺（CTX）治疗,CTX0.8 g·次-1·月-1,加入生理盐水500 ml静脉滴注,或口服0.1 g/d,CTX总量6.0～8.0g.观察两组治疗前、治疗3、6、9、12、18个月24h尿蛋白定量（MTP）、肝功能（TP、ALB、ALT）、肾功能（Cr、UA）、血糖、血脂（TC、LDL）及不良反应.结果 两组患者治疗后MTP及ALB水平较治疗前均明显好转（P＜0.01）,治疗18个月后治疗组和对照组总有效率（显效＋有效）分别为80.5％和84.6％,两组间无统计学差异（P＞0.05）.治疗组12个月时完全缓解率有升高趋势（P＜0.01）,但18个月后又降至正常,28例显效患者18个月后停CsA随访3年中有5例（17.9％）复发,复发后再次治疗仍然有效.治疗组不良反应：齿龈增生1例,血压升高4例,血尿酸升高6例,停药后或用药均可控制.结论 与足量强的松治疗原发性肾病综合征比较,小剂量CsA联合小剂量强的松具有等同疗效,又可减少CsA及激素毒副作用,为治疗原发性肾病综合征提供了一个比较经济有效安全的方法.     

Monitoring of cyclosporine concentrations by using dry blood-spot samples

We modified the Incstar Cyclo Trac SP kit to enable its use with dry blood-spots on filter paper. The recovery ranged from 92 to 106%. Dilution studies have shown excellent linearity and parallelism throughout the range of the assay. Precision is demonstrated by within-assay CV's of 6.6 and 4.3% at 96 and 342 micrograms/L respectively and between-assay CV's of 9.1 and 7.0% at 138 and 506 micrograms/L respectively. A comparison study (n = 209) with whole blood assay gave a correlation coefficient of 0.97, a slope of 1.04, and an intercept of 13.2. Whole blood and dry blood-spot cyclosporine assays on heart, kidney, liver, and lung transplants were also compared.     

不同检测系统和样品稀释液对环孢素检测结果的影响

目的 比较TDX系统与AXSYM系统检测环孢素的结果，评估不同样品稀释液对超过线性范围的标本进行稀释后对检测结果的影响。方法 在TDX和AXSYM系统上检测100例不同浓度的临床标本，对比检测结果。用全血、蛋白磷酸缓冲液、自制样品稀释液和0点定标液对50例超过AXSYM线性范围的临床标本进行稀释，对比检测结果。结果 TDX系统与AXSYM系统检测环孢素的结果相差显著，按不同浓度范围对两系统检测结果求出了换算公式。以全血、蛋白磷酸缓冲液作为样品稀释液和以0点定标液作为稀释液的标本检测结果有统计学意义，自制样品稀释液和0点定标液检测结果之间无统计学意义。结论 TDX与AXSYM系统检测环孢素结果间的换算公式有助于临床了解方法改变后检测结果的差异，自制样品稀释液可取代0点定标液用于样品稀释。     

环孢素免疫抑制作用的药效动力学监测

目的：以不同的T淋巴细胞功能标志物作为药效动力学指标．探讨环孢素（CsA）免疫抑制作用监测的可能性。方法：采用淋巴细胞体外培养与刺激的方法．分别在正常人外周全血中加入不同浓度（0、10、50、100和200nmol／L）的CsA．然后加入一定浓度的刀豆蛋白A刺激培养：一段时间后分离出淋巴细胞．以流式细胞术检测代表不同T淋巴细胞功能的细胞表面标记（CD25、CD28、CD54）的表达水平和T淋巴细胞内IL-2水平。分析5例健康人．各个药效动力学指标均取均值．以SPSS 13．0作相关性分析。结果：CD25与CsA剂量之间的相关系数r=-0．949．r^2=0．901．P=0．014〈0、05;CD28与CsA剂量之间的相关系数r=0．402,r^2=0．162,P=0．502〉0．05;CD54与CsA剂量之间的相关系数r=-0．974,r2=0．949,P=0．005〈0．01;IL-2与CsA剂量之间的相关系数r=-0．652．r2=0．425．P=0．233〉0．05。CD25和CD54与CsA剂量之间存在较好的负相关,具有显著性意义;而CD28、IL-2与CsA剂量之间相关性较差．不具有显著性意义。所有标志物均显示．在不同的药物浓度作用点上个体间均存在广泛的差异。结论：选择合适的T淋巴细胞功能标志物作为药效动力学指标,有可能对CsA免疫抑制作用进行监测．从而提升CsA治疗的功效和安全性。     

Evaluation of a new pretreatment reagent for use with the EMIT 2000 cyclosporine assay

OBJECTIVES: Evaluate the performance of the new pretreatment (NPT) reagent for use with the EMIT cyclosporine A (CsA) assay. DESIGN AND METHODS: Samples from transplant patients receiving CsA were tested using a COBAS MIRA S. RESULTS: A downward shift in target values for commercial controls was observed using the NPT reagent. There was excellent correlation for patient results when comparing the NPT reagent with methanol pretreatment. CONCLUSION: The NPT reagent is an acceptable substitute for methanol in the EMIT(R) extraction procedure for CsA.     

罗格列酮对急性环孢素A肾毒性的保护作用

目的 探讨急性环孢素A（CsA）肾毒性肾组织中调节激活正常T细胞表达和分泌的细胞因子（RANTES）及基质金属蛋白酶-9（MMP-9）的表达,以及罗格列酮（RGZ）对急性环孢素肾病（ACN）的保护作用.方法 低盐基础上建立ACN大鼠动物模型,随机分成：①对照组（6只）：低盐饮食;②RGZ组（6只）：低盐饮食＋RGZ 5 mg/（kg·d）;③CsA组（8只）：低盐饮食＋CsA 15 mg/（kg·d）;④CsA＋RGZ组（8只）：低盐饮食＋CsA 15 mg/（kg·d）＋RGZ 5 mg/（ks·d）.在实验第14天处死大鼠,用实时荧光定量PCR观察RANTES及MMP-9的表达量,以及HE观察肾脏病理变化.结果 实验第14天时大鼠肾组织RAN-TESmRNA相对表达量：对照组8.38±1.23,RGZ组8.66±1.51,CsA组26.42±8.25,CsA＋RGZ组16.37±1.16;MMP-gmRNA相对表达量：对照组6.81±1.52,RGZ组6.48±1.35,CsA组26.34±7.26,CsA＋RGZ组14,19±1.64.与对照组相比,CsA组及CsA＋RGZ组RANTES、MMP-9的表达均增高（P均〈0.05）,肾小管间质单个核细胞浸润数显著增加（P〈0.05）,且CsA组显著高于CsA＋RGZ组（P〈0.05）,单用RGZ组无明显变化（P〉0.05）.结论 RGZ通过下调趋化因子RANTES和MMP-9的表达,减轻急性环孢素肾病肾间质急性炎症细胞浸润.     

Binding of cyclosporine by erythrocytes: influence on cell shape and deformability

Abstract. Cyclosporine is a widely used immunosup-pressive drug with a high affinity for erythrocytes. It was hypothesized that the hydrophobic agent would interact with the erythrocyte membrane, which could cause a shape change and alter cell deformability. Administration of 300 mg cyclosporine in vivo and incubation of erythrocytes with concentrations up to 100 mg 1^--¹ in vitro at room temperature showed that cyclosporine is found in the cytoplasm, but not in the membrane of erythrocytes and that cell shape or deformability were not affected. Incubation of erythrocytes with the highest cyclosporine concentration (100 mg 1^--¹) at 37°C lead to a time-dependent, slight stomatocytic shape transformation, indicating that the drug is intercalated preferentially into the inner hemileaflet of the membrane under these conditions. Cyclosporine metabolites had no effect on the cell shape. The shape of erythrocyte ghosts was neither affected by cyclosporine nor by its metabolites. It is concluded that cyclosporine is bound in the erythrocyte cytoplasm and does not affect the cell membrane and cell deformability at therapeutic concentrations. These results may contribute to a better understanding of the interactions of cyclosporine with cells.     

促红细胞生成素对环孢素致人肾小管上皮损伤保护作用

目的体外探索促红细胞生成素（EPO）拮抗环孢素A（CsA）所致肾小管上皮损伤的作用机制。方法采用人近曲肾小管上皮细胞作为体外实验模型,实验分对照组、CsA对照组、EPO 15U/mL与CsA合用组、EPO 30U/mL与CsA合用组,MTT法检测细胞增殖抑制率,采用金氏公式评价EPO与CsA合用拮抗作用效果,采用ELISA方法检测细胞培养上清液中肾损伤分子-1（KIM-1）的表达量,采用流式细胞仪检测细胞生存情况。结果采用金氏公式评价结果显示,EPO在15U/mL与30U/mL浓度时可以拮抗CsA对肾小管上皮的损伤作用;对比CsA对照组,EPO在15U/mL与30U/mL浓度可降低细胞培养上清液中KIM-1的表达量（P〈0.05）,降低凋亡细胞比率（P〈0.05）,降低坏死细胞比率（P〈0.05）,增加活细胞比率（P〈0.05）。结论 EPO拮抗CsA所致肾小管上皮损伤,可能通过减少细胞凋亡而实现。     

Assessment and management of cytokine release syndrome and neurotoxicity following CD19 CAR-T cell therapy

ABSTRACT

Introduction: The success of CD19 chimeric antigen receptor (CAR)-T cell therapy for treatment of CD19 positive malignancies has led to the FDA approval of two CD19 CAR-T cell products, tisagenlecleucel and axicabtagene ciloleucel, and ongoing clinical trials of new products. Cytokine release syndrome (CRS) and neurotoxicity are common toxicities associated with CD19 CAR-T cell therapies.

Areas covered: This review will discuss CRS and neurotoxicity associated with CD19 CAR-T cell therapies, including clinical presentation, risk factors, pathophysiology, and therapeutic or prophylactic interventions.

Expert opinion: In conjunction with improved understanding of the pathophysiology of CRS and neurotoxicity, we expect that the recent development of consensus guidelines for the evaluation of these toxicities will enhance management of patients undergoing CD19 CAR-T cell therapies.     

Heparinized blood provides equivalent results to EDTA in the CEDIA and FPIA cyclosporine immunoassays, thus facilitating routine cyclosporine determination

BACKGROUND: CsA measurements are routinely used to allow adequate CsA dosage adjustments. CsA assays routinely require EDTA anticoagulated whole blood; EDTA has been preferred due to differences seen when using heparinized blood in the past. We hypothesized that with new, robust assays, heparinized blood might be appropriate for measuring CsA levels. METHODS: CsA levels from EDTA samples and heparinized samples were compared using the CEDIA assay on a BeckmanCoulter DXC. Also, CsA levels from heparinized blood were compared using the CEDIA assay (BeckmanCoulter) and the FPIA assay (Abbott Axsym). RESULTS: CsA levels from EDTA blood (x) and heparinized blood (y, n=81) showed very good correlation without deviation from linearity by Passing-Bablok analysis (y=-2.4524+1.0210x). In 187 samples obtained from heparinized blood, CsA levels determined by using the CEDIA assay (x) or the FPIA assay (y) also correlated equally well by Passing-Bablok analysis (y=6.1922+1.0221x), also without deviation from linearity. CONCLUSION: CsA determination from heparinized blood is easy to perform and accurate with the two assays described and evaluated. Using heparinized blood reduces handling time as well as hands on time. We suggest that this methodology be formally evaluated by the manufacturers for inclusion into CE labelling of their products to allow improved laboratory work flow.     

抗淋巴细胞球蛋白联合环孢霉素A治疗重型再生障碍性贫血的临床研究

目的探讨进一步提高重型再生障碍性贫血（ＳＡＡ）疗效的方法。方法采用前瞻性同期对照研究方法,比较抗淋巴细胞球蛋白（ＡＬＧ）单用（ＮＩＳＴ方案）或联合环孢霉素Ａ（ＣｓＡ）（ＩＳＴ方案）治疗ＳＡＡ的疗效。结果ＩＳＴ方案组不仅疗效（８３７％）显著高于ＮＩＳＴ方案组（５７６％）,且可降低早期死亡率、缩短脱离红细胞输注时间,治疗有效者骨髓ＢＦＵＥ和ＣＦＵＧＭ数量恢复更为良好。结论ＡＬＧ联合ＣｓＡ治疗ＳＡＡ疗效明显优于单用ＡＬＧ,且治疗有效者骨髓造血功能恢复更为完全。     

环孢素A诱发的大鼠糖尿病模型的建立及其机制的探讨

目的：建立环孢素A诱发的大鼠糖尿病模型,通过血清胰岛素水平、胰岛素敏感指数、胰岛病理改变探讨环孢素A升高血糖作用的机制。方法雄性SD大鼠20只[（89±10）g]随机等分为两组,每组10只。环孢素A组：环孢素25 mg·kg-1·d-1;对照组：每日给予等量生理盐水,大鼠均在空腹（禁食水8 h）时灌胃给药,用药1 h后喂食。每周测量大鼠体重,每月监测大鼠空腹血糖和环孢素A的血药浓度。用药5个月后于空腹状态下将每组大鼠处死,心脏穿刺取血,4%多聚甲醛体内灌流取胰腺组织,放射免疫方法检测大鼠血清胰岛素水平,胰腺组织行病理组织学观察,应用SPSS 13.0统计软件分析对资料进行统计分析。结果给药4个月后,与环孢素A组平均血糖大于7 mmol/L,说明环孢素A诱发大鼠糖尿病模型成功。与对照组相比,环孢素组大鼠的胰岛素抵抗指数均明显升高（P＜0.05）,胰岛素分泌指数明显降低（P＜0.05）,环孢素组大鼠胰腺组织的胰导管均遭到破坏,胰岛细胞数量减少,且明显坏死、空泡化。结论环孢素A导致胰岛细胞坏死,减少胰岛素的分泌、增加胰岛素抵抗从而导致大鼠血糖升高。     

Pure red cell aplasia accompanied by COVID-19 successfully treated using cyclosporine

A 67-year-old Japanese man was admitted to our hospital with severe coronavirus disease 2019 (COVID-19) in March 2020. Mechanical ventilation was initiated 8 days after admission, due to severe respiratory failure. Multiple severe complications such as liver dysfunction, arrhythmia, brain infarction, and venous thromboembolism were also observed. We initially diagnosed Coombs test-positive warm autoimmune hemolytic anemia. Corticosteroids proved ineffective and anemia worsened with severe erythroid hypoplasia (0.5% erythroblasts in bone marrow), so we diagnosed pure red cell aplasia (PRCA). We also identified massive infiltration of cytotoxic T-lymphocytes expressing CD8, granzyme B, and perforin in bone marrow. Systemic cyclosporine was started, with full resolution of anemia and no need for blood transfusions after 4 weeks. We believe that this represents the first report of COVID-19-associated PRCA successfully treated using cyclosporine.     

环孢素联合达那唑治疗难治性特发性血小板减少性紫癜的疗效观察

目的探讨环孢素A(CSA)联合达那唑治疗难治性特发性血小板减少性紫癜(ITP)的临床效果。方法 45例难治性ITP患者随机分为两组,对照组(n=21例)给予长春新碱或环磷酰胺治疗,观察组(n=24例)给予CSA联合达那唑治疗,两组疗程均为3个月。治疗后比较两组疗效及不良反应发生率。结果观察组治疗总有效率(79.2%)明显高于对照组(66.7%),差异有统计学意义(P0.05);两组治疗期间不良反应发生率比较(45.8%vs.47.6%)无显著差异性(P0.05)。结论 CSA联合达那唑治疗难治性ITP疗效显著,安全可靠,值得临床推广应用。     

超声观察环孢素A对兔心脏的影响

目的探讨环孢素Ａ（ＣｓＡ）对心脏形态学及血流动力学的影响。方法应用彩色多普勒超声观察了不同剂量的ＣｓＡ对兔心脏的影响。整个实验过程共２１天,选用体重（１．７５～１．８０ｋｇ）相当的雄性新西兰大白兔１８只,将其随机分为三组,各组用药情况如下：１．Ａ组,静脉注射ＣｓＡ５ｍｇｋｇ－１ｄ－１;２．Ｂ组,静脉注射ＣｓＡ１５ｍｇｋｇ－１ｄ－１;３．Ｃ组,每次注射同等剂量的生理盐水。结果心脏各腔室内径无明显变化;室间隔及左室后壁明显增厚;心肌重量明显增加;Ａ组各瓣口流速未见改变,Ｂ组各瓣口流速减低;两个用药组从第１２天起心包腔内开始出现积液回声,并一直持续到实验末;动脉收缩压和舒张压均减低;左室收缩压减低而舒张压升高。结论ＣｓＡ和心功能衰竭可能是心脏移植术后心包积液的主要原因。     

Extended cyclosporine delivery by silicone-hydrogel contact lenses

Cyclosporine A (CyA) is effective in treating chronic dry eyes and contact lens mediated dry eyes. CyA is delivered through eye drops of an oil-in-water emulsion, which has a small residence time in the eyes, leading to low bioavailability. Here we explore delivery of CyA from contact lenses to provide controlled and extended drug delivery with an increased bioavailability due to enhanced ocular residence time. Loading and release profiles of CyA from commercial contact lenses are presented to show that 1-DAY ACUVUE® releases CyA for about a day and extended wear silicone hydrogel (SiH) lenses release CyA for about 2-weeks. The longer duration from SiH lenses compared to the 1-DAY ACUVUE®lens is due to larger partition coefficients in the gel. A novel approach is presented for increasing release duration from the SiH lenses to the desired 1-month through incorporation of Vitamin E. The results show that Vitamin E loaded lenses can provide CyA release within the therapeutic window for a period of about a month. This pilot study demonstrates the promising potential of delivering CyA from contact lens for treatment of chromic dry eyes and contact lens mediated dry eyes.     

Long-term improvement of hematopoiesis following cyclosporine treatment in a patient with myelodysplastic syndrome

Current treatment of patients with myelodysplastic syndrome (MDS) is unsatisfactory. Very recently, immunosuppressive treatment strategies have been gaining interest. We report a patient with transfusion-dependent MDS who achieved significant hematopoietic improvement following cyclosporine (CsA) therapy and who is now transfusion independent for more than 5 years. This single observation supports the view that CsA, among other immunosuppressive agents, could play an important role in future treatment concepts in MDS and may lead to clinically relevant and sustained improvement of hematopoiesis in a subset of patients.     

Effect of cyclosporine on oxidative phosphorylation and adenylate energy charge of regenerating rat liver

The effect of cyclosporin A (CyA) on regenerating liver was investigated in subtotal hepatectomized rats treated with CyA in terms of mitochondrial phosphorylative activity, hepatic energy charge, and serum bilirubin levels. In the CyA-treated hepatectomized group, the energy charge decreased from normal control value of 0.857 to 0.782 at 6 h after hepatectomy. The decreased energy charge, however, gradually increased and returned to 0.842 at 48 h after hepatectomy with no significant changes being observed between CyA-treated and untreated hepatectomized groups. Phosphorylation rate in the CyA-untreated group increased to 142% of the normal control at 24 h and then decreased to 114% at 48 h after hepatectomy. By contrast, phosphorylation rate in the CyA-treated group increased to 144% of the normal control at 24 h, but remained at the high value of 132% (P less than 0.01; compared to the CyA-untreated group) even at 48 h after hepatectomy. Serum total bilirubin levels in the CyA-treated group were significantly higher than those in the CyA-untreated group during all experimental periods. We conclude that CyA does not exert a direct detrimental effect on mitochondrial function and that, despite the marked hyperbilirubinemia induced by CyA, the mitochondrial phosphorylative activity increases adaptively to provide sufficient energy for enhanced ATP-utilizing reactions in an early process of liver regeneration.     

Effects of metabolic syndrome on onset age and long-term outcomes in patients with acute coronary syndrome

BACKGROUND: We aim to investigate effects of metabolic syndrome on onset age and long-term outcomes in patients with acute coronary syndrome (ACS).     

脑卒中患者肩手综合征红外热像观察

目的通过对临床诊断脑卒中合并肩手综合征患者手部的皮肤温度变化特点的观察,探讨利用红外热像协助早期诊断肩手综合征的方法.方法应用红外热像对16例脑卒中后合并肩手综合征的患者,进行双手和腕部皮肤温度的测量和比较.结果患侧手背和腕部背侧皮肤平均温度分别高于健侧相应部位0.77℃和0.69℃,温度差异有非常显著性(P＜0.001).结论红外热像检查是肩手综合征早期诊断的重要方法之一,对临床中高度可疑的患者应采用该方法诊断,以便及时采取有效措施,控制病情发展.