Tacrolimus Exposure and Evolution of Renal Allograft Histology in the First Year After Transplantation

Tacrolimus has a narrow therapeutic window and is characterized by a large inter-individual variability in bioavailability. The impact of tacrolimus exposure on subclinical evolution of graft histology has not been studied in renal recipients. This analysis included 239 protocol biopsies (obtained at implantation, 3 and 12 months) of 120 consecutive kidney recipients treated with tacrolimus, mycophenolate mofetil (MMF) and corticosteroids. Biopsies were scored according to the Banff 2001 criteria and a chronicity score was calculated. Prospective pharmacokinetic data were included in the analysis (5544 tacrolimus predose blood concentrations and tacrolimus AUC(0-12) at 3 and 12 months). Higher donor age and higher number of human leukocyte antigen-DR (HLA-DR) mismatches were independent predictors of subclinical acute rejection at 3 months, present in 8.7% of patients. The number of HLA-DR mismatches was independently associated with biopsy-proven clinical acute rejection. Biopsy-proven acute rejection episodes and low mean tacrolimus exposure were independently associated with higher increase in chronicity scores between 3 and 12 months after transplantation. This observational study suggests that rejection phenomena and immune-mediated mechanisms remain important in the early progression of chronic allograft pathology. Tacrolimus doses or systemic exposure were not associated with lesions of calcineurin inhibitor nephrotoxicity, suggesting that other factors determine susceptibility to tacrolimus nephrotoxicity.     

Natural history of parathyroid function and calcium metabolism after kidney transplantation: a single-centre study.

BACKGROUND: The natural history of parathyroid function after successful renal transplantation (RT) and the factors predisposing to persistent hyperparathyroidism (HPT) are not well established. A better knowledge of these data may be helpful in the development of algorithms for optimal surveillance and treatment of HPT after successful RT. Our aim was to evaluate the post-transplant natural history of parathyroid function and calcium metabolism in patients with a functional renal graft and to identify risk factors for persistent HPT. METHODS: Charts of 1165 allograft kidney recipients transplanted between 1989 and 2000 were reviewed. Patients with an intact parathyroid hormone (iPTH) level available at the time of transplantation were identified. The charts of the latter patients were checked for a variety of demographic and clinical data, and all determinations of the iPTH concentration available since transplantation were recorded. Serum levels of calcium, phosphorus, alkaline phosphatases and creatinine, concurrently determined, were also registered. RESULTS: After an initial fall, iPTH levels showed a slow but steady decline towards the upper normal limit. The prevalence of persistent HPT, defined as an iPTH level > or =2.5 times the upper normal limit or the need for parathyroidectomy following transplantation, remained stable at approximately 17% up to 4 years after transplantation. Patients with persistent HPT had significantly elevated serum levels of iPTH, calcium and phosphorus at the time of RT, and had spent a longer time on dialysis. Post-transplant iPTH levels correlated significantly with transplant kidney function. CONCLUSION: Kidney transplant recipients with a high iPTH and calcium x phosphate product at the time of transplantation are at risk for persistent HPT especially when renal function is suboptimal. Therapy for persistent HPT, if considered, should be initiated 3 months post-transplantation since further spontaneous improvement of parathyroid function thereafter is limited.     

Plasma Concentrations of Mycophenolic Acid Acyl Glucuronide Are Not Associated with Diarrhea in Renal Transplant Recipients

The aim of this study was to determine whether plasma concentrations of the acyl (AcMPAG) and phenolic (MPAG) glucuronide metabolites of mycophenolic acid (MPA) were related to diarrhoea in renal transplant patients on mycophenolate mofetil (MMF) with cyclosporine (CsA) or tacrolimus (TCL). Blood samples (0, 30, 120 min) were taken at days 3, 10, week 4, months 3, 6 and 12 for determination of MPA, MPAG and AcMPAG. MPA-AUC was estimated using validated algorithms. Two hour AUCs were calculated for MPAG and AcMPAG. Immunosuppressive therapy consisted of CsA/MMF (n= 110) and of TCL/MMF (n= 180). In 70/290 (24%) patients 86 episodes of diarrhoea were recorded during 12 months. Significantly more patients on TCL (31.1%) suffered from diarrhea compared to CsA (12.7%). MMF dose, MPA-AUC and the 2 h AUCs of MPAG and AcMPAG did not differ between patients with and without diarrhoea. Plasma AcMPAG and MPAG concentrations were substantially higher in patients on CsA compared with TCL, while MPA-AUC was lower in the former group. These data support the concept that CsA inhibits the biliary excretion of MPAG and AcMPAG, thereby potentially reducing the risk of intestinal injury through enterohepatic recycling of MPA and its metabolites.     

Differential Effect of Diarrhea on FK506 Versus Cyclosporine A Trough Levels and Resultant Prevention of Allograft Rejection in Renal Transplant Recipients

Diarrhea is the most frequently reported adverse event in patients treated with mycophenolate mofetil. Twenty-six renal transplant patients on a mycophenolate mofetil-based immunosuppressive regime with persistent afebrile diarrhea were examined. Diarrhea caused a significant rise in FK-506 trough levels despite intake of stable doses, necessitating FK-506 dose reductions of 30% to obtain pre-diarrhea trough levels. In contrast, trough levels of cyclosporine A remained stable without dose adjustments. This suggests that absorption and/or metabolism is differentially altered for FK506 compared with cyclosporine A in patients with diarrhea. In nine patients mycophenolate mofetil was reduced or stopped because of persistent diarrhea without identifiable cause. This resulted in end-stage renal disease because of chronic rejection in two patients, and in acute rejection in two patients, all taking FK506 and steroids. Therefore, dose adjustments of FK506 in patients with diarrhea must be carefully monitored, especially when doses of mycophenolate mofetil are also reduced.     

Cells of origin of crossed and uncrossed corticospinal fibers in the cat

Summary The cortical distribution of the cells of origin of the dorsolateral and the ventral corticospinal tracts was studied in cat. This was done by making subtotal spinal transections, which in different experiments spared different portions of one ventral or one lateral funiculus at C5–C7. One week later horseradish peroxidase (HRP) injections were made one segment caudal to the lesion and the cortical distribution of the HRP labeled neurons was studied.Thus, it was found that the dorsolateral corticospinal tract at C5–C7 is composed of crossed and uncrossed fibers in a ratio of about 10 1, while the ventral corticospinal tract, which contains much fewer cortical fibers, is composed of crossed and uncrossed fibers in a ratio of approximately 1 1. Further, the primary motor cortex (area 4) was found to contribute fibers to both the crossed and the uncrossed dorsolateral corticospinal tract as well as to both the crossed and the uncrossed ventral corticospinal tract. The primary somatosensory cortex (area 3a, 3b, 1–2, 5a, 5b) as well as the secondary somatosensory cortex (area 2 pre-insularis), on the other hand, were found to contribute fibers mainly to the crossed dorsolateral tract. Area 4 was found to display a further organization, such that it contains a medial and a lateral part, both of which contribute mainly fibers to the crossed dorsolateral tract, while the remainder of area 4 contributes fibers to the crossed and uncrossed dorsolateral as well as to the crossed and uncrossed ventral tracts.This study was in part supported by grant 13.46.15 of the FUNGO/ZWO (Dutch Organization for Fundamental Research in Medicine) and grant C.R.L. 79.4.337.6.INT. of the INSERM (Institut National de la Santé et de la Recherche Médicale)     

Linkage disequilibrium patterns of the human genome across populations

We studied the patterns of linkage disequilibrium (LD) in the human genome among three populations: African Americans, Caucasians and Ashkenazi Jews. These three populations represent admixed, outbred and isolated populations, respectively. The study examined defined chromosomal regions across the whole genome. We found that SNP allele frequencies are highly correlated between Ashkenazi Jews and Caucasians and somewhat distinct in African Americans. In addition, Ashkenazi Jews have a modest increase in LD compared with Caucasians, and both have greater LD than African Americans. The three populations differed more significantly with regard to haplotype heterogeneity. We found, as expected, that Ashkenazi Jews display the greatest extent of homogeneity and African Americans the greatest extent of heterogeneity. We found that most of the variance in LD can be attributed to the difference between regions and markers rather than to that between different population types. The average recombination rates estimated by low-resolution genetic maps can only explain a small fraction of the variance between regions. We found that LD (in terms of r(2)) decreases as a function of distance even within the so-called 'haplotype blocks'. This has significant consequences when using LD mapping for the genetic dissection of complex traits, as higher density SNP maps will be required to scan the genome.     

Identification of cells of origin of long fiber connections in the cat's spinal cord by means of the retrograde axonal horseradish peroxidase technique

The location of the cells of origin of the propriospinal and long ascending spinal fibers has been determined by injecting horseradish peroxidase (HRP) unilaterally into the white and gray matter of the cat's spinal cord at cervical, thoracic and lumbar levels. In all cases retrogradely labeled neurons were present in the intermediate zone throughout the spinal cord. Caudal to the injections labeled neurons were also present in the dorsal horn, the column of Clarke and the area of the spinal border cells.     

Branching neurons in the cervical spinal cord: a retrograde fluorescent double-labeling study in the rat

Summary Branching neurons giving rise to ascending and descending collaterals were studied in the cervical spinal cord of the rat. After unilateral injection of two retrograde fluorescent tracers, i.e. DY.2HCl at T2 or more caudal levels and TB at C1 or more rostral levels, many DY-TB double-labeled neurons were found in C3 to C8. These neurons were located bilaterally throughout the spinal grey matter, as well as in the lateral spinal nucleus (LSN). However, no double-labeled neurons could be detected in the laminae I and II on either side. The double-labeled neurons must represent branching neurons giving rise to a collateral ascending to the rostral injection-site or above, and another collateral descending to the caudal injection-site or below. The descending collaterals were found to extend to various spinal levels, including the lumbosacral cord. However, most of them terminated at shorter distances from their parent cell bodies; thus 20% of the C3–C8 neurons projecting to C1 or above had a descending collateral reaching T2, 8% had a collateral reaching T9, and 3% a collateral reaching L2/L3. The ascending collaterals of the majority of the branching neurons passed into the most caudal part of the medulla oblongata, and about half of these collaterals reached the level of the rostral part of the inferior olive. In regard to the neurons located in the segments C5–C8, about 13% of those projecting to T2 or below distribute an ascending collateral restricted to C2–C4, while 29% of those had an ascending collateral to C1 or above.     

Distribution of corticospinal neurons with collaterals to the lower brain stem reticular formation in monkey (Macaca fascicularis)

Summary An earlier retrograde double-labeling study in cat showed that up to 30% of the corticospinal neurons in the medial and anterior parts of the precruciate motor area represent branching neurons which project to both the spinal cord and the reticular formation of the lower brain stem. These neurons were found to be concentrated in the rostral portion of the motor cortex, from where axial and proximal limb movements can be elicited. In the present study the findings in the macaque monkey are reported. The fluorescent retrograde tracer DY was injected unilaterally in the spinal cord at C2 and the fluorescent tracer FB was injected ipsilaterally in the medial tegmentum of the medulla oblongata. In the contralateral hemisphere large numbers of single DY-labeled corticospinal neurons and single FBlabeled corticobulbar neurons were present. A substantial number of DY-FB double-labeled corticospinal neurons were also found, which must represent branching neurons projecting to both the spinal cord and the bulbar reticular formation. These neurons were present in: 1. The anterior portion of the cingulate corticospinal area in the lower bank of the cingulate sulcus; 2. The supplementary motor area (SMA); 3. The rostral part of precentral corticospinal area; 4. The upper portion of the precentral face representation area; 5. The caudal bank of the inferior limb of the arcuate sulcus; 6. The posterior part of the insula. In these areas 10% to 30% of the labeled neurons were double-labeled. The functional implications of the presence of branching corticospinal neurons in these areas is discussed.Abbreviations A nucleus ambiguus - AS arcuate sulcus - C cuneate nucleus - Cing. S. cingulate sulcus - corp. call. corpus callosum - CS central sulcus - Cx external cuneate nucleus - DCN dorsal column nuclei - dl dorsolateral intermediate zone - IO inferior olive - IP intraparietal sulcus - Lat. Fis. lateral fissure - LR lateral reticular nucleus - LS lunate sulcus - ML medial lemniscus - MLF medial longitudinal fascicle - mn motoneuronal pool - MRF medial reticular formation - Occ. occipital pole - P pyramid - PG pontine grey - PS principle sulcus - RB restiforme body - RF reticular formation - S solitary nucleus - SPV spinal trigeminal complex - STS superior temporal sulcus - Sup. Col. superior colliculus - TB trapezoid body - VC vestibular complex - vm ventromedial intermediate zone - III nucleus oculomotorius - VI nucleus abducens - VII nucleus, n. facialis - X motor nucleus n. vagus - XII nucleus hypoglossus Supported in part by grant 13-46-96 of FUNGO/ZWO (Dutch organisation for fundamental research in medicine)