The higher incidence of squamous cell carcinoma in renal transplant recipients is associated with increased telomere lengths

The incidence and aggressiveness of nonmelanoma skin cancers, including basal cell carcinoma and squamous cell carcinoma (SCC), in immunocompromised renal transplant recipients (RTRs) is dramatically higher (up to 100-fold) compared with the normal population. SCC lesions are also predominant in RTRs, in contrast to the normal population where basal cell carcinoma is more common. The mechanisms underlying this phenomenon are unknown, but effective treatments for these skin tumors would have a significant impact upon morbidity in this group of patients. The fundamental role of telomeres and telomerase in the development of most human cancers, including melanoma, is well established, but very few reports have assessed their function during the onset of nonmelanoma skin cancer. To assess whether telomere maintenance plays any role in the increased incidence of SCC in renal transplant patients, we analyzed both the telomere lengths and telomerase expression levels in 44 SCCs and 22 Bowen's disease (BD) samples (carcinoma in situ) from RTRs and nontransplant patients. Our findings provide statistically significant evidence that the telomeres are consistently longer in both BD RTR and SCC RTR lesions compared with their nontransplant counterparts. We also show by immunohistochemistry that there is a trend toward higher telomerase levels in both the BD RTR and SCC RTR lesions, although this was not statistically significant. Our data thus suggest that telomere lengthening may possibly be an early event in the development of SCC in renal transplant patients and demonstrate that telomere maintenance mechanisms should be further evaluated with respect to developing a future therapeutic strategy for these cancers.     

Diagnostic pitfalls in cytological diagnosis of subcutaneous fungal infection in renal transplant recipients

Renal transplant recipients (RTRs) are at increased risk of the development of a variety of skin infections that can result from graft-preserving immuno-suppressive therapy. In this study, we aimed to determine cytomorphological findings of fungal subcutaneous swelling in seven RTRs and to analyze diagnostic pitfalls in fungal cytology. A retrospective review of fine needle aspiration cytology (FNAC) smears of subcutaneous swelling with positive fungal elements in RTRs from 2008 to 2010 was performed. We had seven cases (all males; age range, 34-58 years, mean, 46.3 years). The time interval between the renal transplantation and appearance of swelling ranged from 8 to 19 months (mean, 13.4 months). The swelling was located on lower limb (six cases) and arm (one case). The lesion was solitary (six cases) and multiple (one case). The cytology of aspirated material showed branched septate fungal hyphae in six cases. These were well delineated on Periodic acid schiffs (PAS) and chromic silver methenamine (CSM) stains. One case showed presence of faint, thin walled, broad ribbon like hyphae. Culture of aspirated material was performed in four cases which grew phaeohyphomycosis in all. Histology of excised tissue showed numerous septate, branched, pigmented fungal elements suggestive of pheohyphomycosis in four cases and broad ribbon hyphae suggestive of zygomycosis in one case. All of our cases responded well with anti-fungal treatment. Fungal infection can manifest as subcutaneous swelling in RTRs. It is often severe, rapidly progressive and difficult to diagnose. FNAC is an important diagnostic tool which is simple, cost effective and rapid method.     

First report and molecular characterization of hepatitis E virus infection in renal transplant recipients in Brazil

Hepatitis E virus (HEV) causes acute and chronic hepatitis in organ transplant recipients. Serological evidence for HEV infection has been discovered in various population groups in Brazil, and a single acute case has been confirmed. To date, however, no cases of HEV infection in immunocompromised patients have been reported in Brazil. This study aimed to identify and characterize hepatitis E cases in renal transplant recipients in Brazil. A retrospective study was performed on 96 serum samples from renal transplant recipients with unexplained liver enzymes elevation. Three confirmed cases of HEV infection were identified that lacked seroconversion to HEV IgG antibodies. The prevalence of HEV in these patients was 3.1%. Using a sequence analysis of a 304‐nucleotide fragment within ORF2, the strains were classified as genotype 3 with a low percent identity to previously characterized strains. This is the first report of hepatitis E infection in renal transplant recipients in Brazil, and the data indicate that a novel genotype 3 subvariant may be present and that further investigation is necessary to characterize the circulating HEV strains. In this setting, HEV infection should be considered as a potential cause of abnormal liver tests of unknown origin. J. Med. Virol. 85:615–619, 2013. © 2013 Wiley Periodicals, Inc.     

Distribution of BK polyomavirus genotypes in Tunisian renal transplant recipients

BK polyomavirus (BKV) is a ubiquitous virus in humans that remains latent in the urogenital tract after a primary infection during childhood. The virus, which is reactivated frequently and excreted in urine, can cause nephropathy in renal transplant recipients. BKV sequences are classified into four subtypes (I-IV). Subtype I and IV are divided further into four and six subgroups, respectively. To characterize the subtypes of BKV prevalent in Tunisia, the presence of the virus was investigated by real-time PCR in urine samples from 77 renal transplant recipients. For subtype identification, a DNA fragment in the VP1 coding region, amplified by nested PCR from positive samples, was sequenced and a phylogenetic analysis was performed. In the studied population, subtype I (75.5%), II (14.5%), and IV (2.5%) were identified with a clear predominance of subtype Ib-2 (73%) as observed in European population. This study suggests that in North Africa, the BKV genotype distribution is similar to that of Europe and different from that of sub-Saharan Africa.     

Chemokines and soluble adhesion molecules in renal transplant recipients with cytomegalovirus infection

Cytomegalovirus (CMV) infection is associated with leucocyte infiltration in various organs, which supports a role for chemokines and adhesion molecules in the pathogenesis of CMV infection. In a prospectively conducted study of renal transplant recipients, 10 patients with CMV disease, five patients with asymptomatic CMV infection and 10 patients who did not have any CMV infection were included. During CMV infection, and in particular during CMV disease, plasma levels of the chemokines IL-8, macrophage inflammatory protein-1alpha (MIP-1alpha) and monocyte chemotactic protein-1 (MCP-1) and the soluble adhesion molecules vascular cell adhesion molecule-1 (VCAM-1), intercellular adhesion molecule-1 (ICAM-1) and L-selectin increased and were positively correlated with the degree of CMV pp65 antigenaemia. Furthermore, a decrease in plasma levels of these chemokines and adhesion molecules was observed following ganciclovir therapy in the patients with CMV disease. This could suggest a role for these molecules in the pathogenesis of CMV infection.     

Outbreak of Pneumocystis jirovecii pneumonia in renal transplant recipients on prophylaxis: Our observation and experience

Pneumocystis jirovecii is a life-threatening opportunistic pathogen affecting immunocompromised hosts, especially renal transplant recipients. This study reports an outbreak of seven such cases, both inpatients and outpatients, occurring in our hospital over a period of 4 months (January–April 2013). All patients were male with a median age of 38 years (range, 28–58 years); the median period between transplantation and diagnosis was 39.5 months (range, 11–123 months). One patient succumbed to the infection. Two were breakthrough cases, developing the infection while on prophylaxis, highlighting the need to view prophylaxis in light of the immunosuppression and clinical picture of such patients.     

Distribution of JC polyomavirus genotypes in Tunisian renal transplant recipients between January 2008 and January 2011

The polyomavirus JC (JCPyV) is a ubiquitous virus in humans, causing progressive multifocal leukoencephalopathy, a fatal demyelinating disease. JCPyV propagates in the adult kidney and excretes its progeny in urine, from which its DNA can be recovered readily. JCPyV isolates worldwide can be classified into 14 subtypes or genotypes, each associated with a specific geographical region. The European genotypes EU‐a‐b‐c are spread throughout Europe and Mediterranean areas. The major African genotype Af2 is spread not only throughout Africa but also in West and South Asia. A minor African genotype (Af1) occurs in Central and West Africa. Partially overlapping domains in Asia were occupied by various genotypes (e.g., B1‐a, ‐b, ‐d, B2, CY, MY, and SC). To characterize the subtypes of JCPyV prevalent in Tunisia, the presence of the virus was investigated by real‐time PCR in urine samples from 98 renal transplant recipients. For subtype identification, a 610 bp typing region of the JCPyV genome was amplified from each urine sample, and its DNA sequence was determined. In the patients studied, the major African subtype Af2 was the predominant (62.5%), followed by the European subtype EU (33.5%). Only one case clustering with the Asian genotype SC (4%) was identified. The presence of the European subtype with high prevalence in this population suggests that the epidemiological distribution of JCPyV virus sequences in North Africa is related partially to the epidemiological data in Europe. J. Med. Virol. 84:1818–1824, 2012. © 2012 Wiley Periodicals, Inc.     

Association of human cytomegalovirus DNAaemia and specific granzyme B responses in lung transplant recipients

In lung transplant recipients (LTRs), human cytomegalovirus (HCMV) DNAaemia could be associated with HCMV disease and reduced allograft survival. In the present study we analysed whether or not HCMV‐specific granzyme B (Grz‐B) responses indicating CD8⁺ T cell cytotoxicity exert an impact on HCMV DNAaemia and relate to specific interferon (IFN)‐γ secretion. HCMV‐specific Grz‐B responses were quantitated by enzyme‐linked immunosorbent assay (ELISA) in 70 samples from 39 HCMV seropositive LTRs who were prospectively investigated for HCMV DNA plasma levels and IFN‐γ kinetics using a standardized CD8⁺ T cell assay (QuantiFERON®‐CMV assay). In all LTRs who were protected from HCMV DNAaemia by early and persistent IFN‐γ responses, Grz‐B responses were also detected. In LTRs who developed episodes of HCMV DNAaemia, the Grz‐B responses which were detected prior to viral DNA detection differed significantly in patients who experienced episodes with high (exceeding 1000 copies/ml) and low plasma DNA levels (P = 0·0290, Fisher's exact test). Furthermore, the extent of Grz‐B release prior to viral DNAaemia correlated statistically with the detected levels of IFN‐γ (P < 0·0001, Spearman's rank test). Of note, simultaneous detection of Grz‐B and IFN‐γ secretion was associated significantly with protection from high HCMV DNA plasma levels during the subsequent follow‐up (P = 0·0057, Fisher's exact test), and this association was stronger than for IFN‐γ detection alone. We conclude that, in addition to IFN‐γ responses, Grz‐B secretion by CD8⁺ T cells is essential to control HCMV replication and a simultaneous measurement of IFN‐γ and Grz‐B could contribute to the immune monitoring of LTRs.     

Azathioprine suppression of natural killer activity and antibody-dependent cellular cytotoxicity in renal transplant recipients

The relative effects of azathioprine (AZA) and prednisone (PRED) on natural killer (NK) activity and the antibody-dependent cellular cytotoxicity (ADCC) of K (killer) cells and the number of FcR and other lymphoid cells were examined in renal transplant recipients. In addition to both long-term (>6 months) and short-term (<6 months) transplant recipients receiving conventional AZA-PRED therapy, an important group of long-term recipients receiving PRED but not AZA was studied for the first time. Both NK activity and ADCC are profoundly reduced in the long-term AZA-PRED group but are normal in the long-term PRED-alone (no-AZA) group. The short-term AZA-PRED group exhibits NK and ADCC levels significantly lower than normal but not as low as those of the long-term AZA-PRED group. Patient groups with low NK and ADCC also have low circulating Fc receptor-bearing (FcR) cells. A single patient in the long-term AZA-PRED group was removed from AZA therapy, and approximately 3 months was required for the patient's suppressed NK and ADCC to return to normal. These findings indicate that AZA rather than PRED is the major drug important in suppressing ADCC and NK activity in renal transplant recipients. Several months are required for combination AZA-PRED therapy to reduce these cytotoxic activities. Similarly, several months are required for suppressed ADCC and NK activity to return to normal upon discontinuation of AZA.     

Frequent detection of hepatitis B virus DNA in hepatocellular carcinoma of patients with sustained virologic response for hepatitis C virus

Hepatocellular carcinoma (HCC) develops several years after the eradication of hepatitis C virus (HCV) by interferon therapy. Risk factors for the development of HCC are only partly understood. To elucidate the role of occult hepatitis B virus (HBV) infection in hepatocarcinogenesis in patients with sustained virologic response, the prevalences of HBV‐related makers were examined. Study group comprised 16 patients with sustained virologic response (group A) and 50 with HCV (group B). Anti‐HBc and anti‐HBs in serum were examined by enzyme‐linked immunoassay. HBV DNA in liver was examined by nested polymerase chain reaction, using primers specific for genes encoding for HBx, HBsAg, HBcAg, and HBV cccDNA. Sequence of the amplified HBV DNA for ‘a’ determinant of HBsAg was determined in HCC. Anti‐HBc was positive in 10 of 16 in group A and 25 of 50 in group B. HBV DNA in liver was detected in 12 of 16 in group A and 21 of 50 in group B (P = 0.044). In group A, HBV DNA in liver was detected frequently in patients without cirrhosis and in those with a longer period from the time of HCV eradication to the development of HCC. Mutation in ‘a’ determinant of HBsAg was found in three HCC of group A. Occult HBV infection may be one of the most important risk factors in hepatocarcinogenesis of Japanese patients with sustained virologic response. J. Med. Virol. 81:1009–1014, 2009. © 2009 Wiley‐Liss, Inc.     

Shell-vial culture and pp65 antigenemia assay in the detection of cytomegalovirus in the first blood sample of renal transplant recipients

The aim of the study was to compare the efficacy of pp65 antigenemia assay and the shell-vial culture (SVC; viremia) for the diagnosis of cytomegalovirus (CMV) infection in renal transplant recipients, comparing the results obtained in the first blood sample and the total number of blood samples analyzed in this group of patients. During the study period, 70 renal transplant recipients were studied: 44 (62.8%) with CMV infection. The method of sedimentation in a dextran solution for leukocyte extraction was used in the pp65 antigenemia assay. The MRC-5 shell-vial assay was used for CMV isolation from leukocytes (viremia). Eighty blood samples were examined from 70 renal transplant recipients: Of the 44 positive samples studied, in 77.5% of cases, both the antigenemia assay and the SVC were positive. In 16.2%, only the antigenemia assay was positive, and, in 6.2%, only the SVC was positive. In all blood samples studied, the antigenemia was present in 93.7% of cases, and the SVC was present in 83.7% (P = 0.04). If the results obtained in only the first blood sample taken for the diagnosis are studied, then we observe that the antigenemia assay was positive in 39 patients (88.6%), whereas the SVC was positive in 41 patients (93.1%), although the difference was not statistically significant (P = 0.39). It is concluded that the inoculation of all of the leukocytes extracted from blood samples in the SVC seems to produce a slight increase in the sensitivity of the cell culture and that the SVC becomes positive before the antigenemia for the detection of CMV in peripheral blood, especially in the first blood sample. J. Med. Virol. 55:240–242, 1998. © 1998 Wiley-Liss, Inc.     

The different telomere lengths in basal and squamous cell carcinomas also differ between the nontransplant and renal transplant population

Renal transplant recipients incur markedly higher rates of nonmelanoma skin cancer, including both basal and squamous cell carcinoma, by unknown mechanisms that are thought to be activated by long-term immunosuppression. These tumors typically arise in sun-exposed areas of the skin and are biologically more aggressive in renal transplant recipients compared with nontransplant patients. Interestingly also, the incidence of squamous cell carcinoma is generally 2- to 3-fold higher than that of basal cell carcinoma in renal transplant recipients, which is a reversal of the trend in the nontransplant population. We have shown in a previous report that the increased incidence of squamous cell carcinoma in renal transplant patients is characterized by increased telomere lengths when compared with the same tumors in the nontransplant population. This suggests a possible role of telomere lengthening via telomerase in the etiology of these lesions. In our current study, we performed a similar analysis of a cohort of 35 basal cell carcinoma samples from both the renal transplant and nontransplant patient groups. We find that, in contrast to the situation in squamous cell carcinoma, the telomeres of the basal cell carcinomas in renal transplant recipients are in fact shorter than their counterparts in the nontransplant population, but also that these lengths are considerably longer in both cases than their squamous cell counterparts. This is the first report to comprehensively show that the telomere lengths significantly differ between basal and squamous cell carcinomas. This may underlie not only the incidence of these tumors in solid organ transplant recipients, but may also reflect their differing biology that remains poorly understood. These data also suggest that future treatment strategies for nonmelanoma skin cancers that are based upon telomerase inhibition, including those arising in transplant patients, may require different approaches for these two different skin lesions.     

Hepatic morphologic findings and viral antigens in acute hepatitis B

Summary In the course of a prospective clinical study, 26 liver biopsies were taken in 24 previously healthy patients with an uncomplicated acute hepatitis B (AHB) and a subsequent complete recovery (UR group). Serum transaminase levels were used to distinguish four AHB stages, as the variability in duration made time dependent staging less appropriate. As a reference, a second group of 22 liver biopsies from 7 patients from the same prospective clinical study who eventually developed chronic hepatitis (CH group) was included. Due to fluctuations of transaminase levels in this group the stages two and three could not be separated, stage four was not reached within the follow-up period of median 5 years. Histopathological criteria and the distribution patterns of hepatitis B surface (HBsAg) and core (HBcAg) antigens were studied.Piecemeal necrosis and bridging hepatic necrosis were a frequently occurring feature in the liver biopsies of the UR group taken during the stage of peak transaminase levels. In this respect, no differences could be demonstrated between the UR group and the CH group. The occurrence of these features in AHB thus appears to have no prognostic value as risk factor for chronic liver disease. In contrast, diffuse cytoplasmic (ground glass) HBsAg localization was only found in stage 2/3 of the CH group.It is concluded that apart from ground glass cells, care must be taken to interpret any histopathological feature in AHB as risk factor of progression to chronicity without reference to the duration of illness. The possible significance regarding the host's immune mechanisms of some features that may persist during chronic liver disease is discussed.     

IgM antibody detection of ppUL80a and ppUL32 by immunoblotting: An early parameter for recurrent cytomegalovirus infection in renal transplant recipients

The value of IgM detection for the early diagnosis of an active cytomegalovirus (CMV) infection in renal transplant recipients was evaluated prospectively. Sequential serum samples obtained from 22 allograft recipients with active CMV infection were tested for the presence of CMV-specific immunoglobulin M antibodies (IgM) by an enzyme-linked immunosorbent assay (ELISA) and a microparticle enzyme immunoassay (MEIA) and were compared with the Western-immunoblotting technique (IB). The time course of CMV IgM antibody detection was evaluated in relation to the shell vial assay (SVA), CMV disease, and immunosuppressive regimen. By IB, IgM antibodies against the capsid protein ppUL80a and the basic matrix phosphoprotein ppUL32 were detected in all 22 recipients with active CMV infection. Using the MEIA and the ELISA, the presence of CMV IgM antibodies was detected in 17 (77%) and ten (46%) of these 22 recipients, respectively. The SVA was the earliest parameter for detection of primary CMV infection in seven of nine (78%) recipients, in contrast to two of 13 (15%) patients with recurrent CMV infection (P < .05). The detection of IgM antibodies by IB was the earliest parameter for detection of recurrent CMV infection in seven out of 13 (54%) recipients in contrast to one out of nine (11%) patients with primary CMV infection (P < .05). During a primary CMV infection, the development of an abundant IgM antibody response was associated with recovery from CMV disease and the end of the viremic phase. © 1996 Wiley-Liss, Inc.     

Treatment of chronic hepatitis B with lamivudine in renal transplant recipients

Treatment of chronic hepatitis B in renal transplant recipients remains one of the major problems in clinical nephrology. Lamivudine is considered to be a drug of choice for these patients, however, its efficacy in patients with hepatitis B after renal transplantation (RT) has not been completely proven. Twenty-two RT recipients treated with lamivudine were evaluated. The duration of treatment was 15.6+/-1.9 months. Fourteen patients (64%) had normalization of aminotransferase (ALT); in 9 of them (41% of the whole group), serum HBV DNA was eliminated. Serum HBeAg was undetectable in 4 out of 15 (27%) previously positive patients. It has been statistically proven that the efficacy of lamivudine therapy correlates with degree of fibrosis and higher histological activity index values. We could not establish any correlation between the outcome of antiviral therapy and patients' age, sex, conditions of contagion (while on dialysis or after RT), time lapsed after the infection had been detected, duration of post-transplant period, type of immunosuppression, HBeAg positivity or negativity, ALT levels, concomitant HCV infection. The efficacy of antiviral HBV therapy is limited by the duration of lamivudine treatment: in 4 out of 5 patients with virologic response, the viremia condition relapsed several weeks after the medication had been stopped. Two patients continued to sustain their biochemical response and 1 patient had ALT levels elevated to above normal, but the value was almost twice as low as initially reported. Liver biopsy was repeated in 4 RT recipients after the end of antiviral therapy; in 3 of them positive morphologic changes were observed.     

Prognostic value of HBsAg/IgM complexes in hepatitis B patients: nature of the proteins involved

Hepatitis B surface antigen (HBsAg)/IgM complexes were measured using a solid phase radioimmunoassay in sera of patients with acute or chronic hepatitis B. These complexes were found in 6 out of 18 patients four weeks after the onset of the disease and only one of them developed chronic hepatitis. HBsAg/IgM complexes correlated with HBsAg, hepatitis B e antigen (HBeAg), and pre-S2 concentration. The precipitation of HBsAg/IgM reactivity by polyethylene-glycol (PEG) and the binding of this activity to the surface of certain uncoated enzyme linked immunosorbent assay (ELISA) plates indicates that HBsAg/IgM positivity may reflect the presence of circulating complexes in serum. HBsAg and pre-S2 were found as components of the complexes but anti-HBs, anti-pre-S2, and polymerized human serum albumin (pHSA) were not. An immune binding between HBsAg and IgM is still questionable. Whatever the nature of the HBsAg/IgM complexes, their detection does not seem to be an earlier indicator of prognosis than HBeAg and/or pre-S2.     

Limited evidence for the effectiveness of educational interventions for renal transplant recipients. Results from a systematic review of controlled clinical trials

Objective

To describe the content and evaluate the effectiveness of patient education programs for renal recipients.

Methods

Randomized controlled trials (RCTs) and controlled clinical trials (CCTs) were identified through systematic literature searches in the Cochrane Central Register of Controlled Trials, Medline, Embase, CINAH, and ERIC. Reference lists and reviews were also examined. Methodological quality was evaluated according to criteria developed by the Cochrane Musculoskeletal Group. Interventional effects were summarized qualitatively.

Results

Nine trials were included, and three were RCT's. The educational interventions varied regarding focus, timing and intensity. No studies were assessed to have low risk of bias. Only two studies, which had a moderate risk of bias, reported beneficial effects in favor of the educational interventions. The strongest evidence was found for the use of preparatory video-assisted teaching prior to discharge and monthly pharmaceutical counseling.

Conclusion

Few included studies with moderate to high risk of bias suggest limited evidence for the effects of educational interventions for renal recipients.

Practice implications

Studies with stronger designs and improved reporting standards are needed. Future educational interventions should include a holistic educational approach and be provided in both early and later stages post transplantation. Furthermore, additional long-term outcome measures are needed.