J.N.M. IJzermans

Neutrophil Gelatinase-Associated Lipocalin, but Not Kidney Injury Marker 1, Correlates with Duration of Delayed Graft Function.

Background: No specific early biomarker is available to measure kidney injury after kidney transplantation (KT). Both neutrophil gelatinase-associated lipocalin (NGAL) and kidney injury marker 1 (KIM-1) increase after oxidative injury. Their potential as early biomarkers was evaluated in this one-arm pilot study. Materials and Methods: Twenty consecutive KT patients receiving a kidney from a donation after circulatory death donor were included. Graft perfusate was collected, as well as serum samples before transplantation, at the end of surgery, and 1, 4, and 7 days after transplantation. NGAL and KIM-1 were measured using ELISA. Kidney function and delayed graft function (DGF) were monitored. Results: In this cohort, 85% of the KT patients developed DGF. Perfusate NGAL correlated with donor age (r2 = 0.094, p = 0.01) and serum creatinine (r2 = 0.243, p = 0.05). A cardiac cause of death was associated with higher NGAL in the perfusate (p = 0.03). Serum NGAL at day 1 was significantly higher in patients with DGF (730 ng/ml, range 490-1,655, vs. 417 ng/ml, range 232-481; p = 0.01). Serum NGAL levels at day 1, 4, and 7 correlated with the duration of DGF. KIM-1 was not detectable in the perfusate or in the serum until postoperative day 4 in 80% of patients. Conclusions: NGAL in the perfusate correlates with known donor risk factors for DGF. For the first time, we describe that serum NGAL at day 1 can discriminate between DGF and immediate graft function. Also, serum NGAL levels at day 1, 4, and 7 correlate with the duration of DGF. No association with KIM-1 was found. These data suggest that NGAL may be used as an early biomarker to detect DGF and warrants further study.

Portal Flow Diversion Is Essential for Graft Survival in Canine Auxiliary Partial Orthotopic Liver Transplantation

After auxiliary partial orthotopic liver transplantation for inborn errors of metabolism, finding a balance in portal blood flow distribution between native liver and graft is complicated. We investigated the correction of hypoallantoinuria in the Dalmatian dog with a reduced-size Beagle orthotopic auxiliary liver graft, depending on intra-operative intervention in the portal flow. There were three groups: a ligation group, where the host portal vein was tied off, a free-flow group with random flow to both livers and a banding group, where the host portal vein was banded with an adjustable strapband. Metabolic correction was initially seen in all groups, but ligation led to portal hypertension and early mortality. In the free-flow group, correction was lost after 7 days, while banding preserved correction until 6 weeks. We conclude that acute ligation can lead to portal hypertension and free-flow leads to hypoperfusion and early loss of metabolic correction. Banding divided the portal blood flow between host liver and graft and prolonged metabolic correction.

Organ donation after circulatory death

Approximately 17 million inhabitants live in the Netherlands. The number of potential organ donors in 1999 was the lowest in Europe with only 10 donors per million inhabitants. Medical associations, public health services, health insurance companies and the government had to find common solutions in order to improve organ allocation, logistics of donations and to increase the number of transplantations. After a prolonged debate on medical ethical issues of organ transplantation, all participants were able to agree on socio-medico-legal regulations for organ donation and transplantation. In addition to improving the procedure for organ donation after brain death (DBD) the most important step was the introduction of organ donation after circulatory death (DCD). Measures such as the introduction of a national organ donor database, improved information to the public, further education on intensive care units (ICU), guidelines for end of life care on the ICU, establishment of transplantation coordinators on site, introduction of autonomous explantation teams and strict procedures on the course of organ donations, answered many practical issues about logistics and responsibilities for DBD and DCD. In 2014 the number of postmortem organ donations rose to 16.4 per million inhabitants. Meanwhile, up to 60u2009% of organ donations in the Netherlands originate from a DCD procedure compared to approximately 10u2009% in the USA. This overview article discusses the developments and processes of deceased donation in the Netherlands after 15 years of experience with DCD.ZusammenfassungIn den Niederlanden leben ca. 17xa0Mio. Einwohner. Die Anzahl an potenziellen postmortalen Organspender war 1999 mit 10xa0Spenden pro 1xa0Mio. Einwohner die niedrigste in ganz Europa. Medizinische Fachgesellschaften, öffentliches Gesundheitswesen, Krankenkassen und Gesetzgeber mussten gemeinsam Wege zu einer verbesserten Organallokation, Logistik und Anzahl von Transplantationen finden.Nach andauernder Debatte zu medizinisch-ethischen Themen der Organtransplantation, konnten sich alle Beteiligten schrittweise auf ein gesellschaftlich-medizinisch-juristisches Regelwerk zur Organspende und Transplantation einigen. Neben Verbesserung der Abläufe einer Organspende nach Hirntod („donation after brain death“, DBD) war der wichtigste Schritt die Einführung der Organspende nach Herz-Kreislauf-Tod („donation after circulatory death“, DCD). Durch Maßnahmen wie z.u2009B. die Einführung einer nationalen Organspenderdatenbank, verbesserte Aufklärung der Öffentlichkeit, Weiterbildung auf den Intensivstationen, Leitlinien zur intensivmedizinischen Behandlung am Lebensende, Einsatz eines Transplantationskoordinators vor Ort, Einführung autonomer Explantationsteams und strikte Verfahrensanweisungen zum Ablauf der Organspende konnten viele praktische Fragen zu Logistik und Aufgabenteilung der DBD und DCD beantwortet werden.Die Anzahl an postmortalen Organspenden stieg 2014 auf 16,4 pro 1xa0Mio. Einwohner. Mittlerweile stammen bis zu 60u2009% der Organspenden in den Niederlanden aus einem DCD-Verfahren, verglichen mit ungefähr 10u2009% in den USA.Dieser Übersichtsartikel beschreibt die Entwicklungen und Abläufe einer postmortalen Organspende in den Niederlanden nach 15xa0Jahren Erfahrung mit DCD.AbstractApproximately 17 million inhabitants live in the Netherlands. The number of potential organ donors in 1999 was the lowest in Europe with only 10 donors per million inhabitants. Medical associations, public health services, health insurance companies and the government had to find common solutions in order to improve organ allocation, logistics of donations and to increase the number of transplantations. After a prolonged debate on medical ethical issues of organ transplantation, all participants were able to agree on socio-medico-legal regulations for organ donation and transplantation. In addition to improving the procedure for organ donation after brain death (DBD) the most important step was the introduction of organ donation after circulatory death (DCD). Measures such as the introduction of a national organ donor database, improved information to the public, further education on intensive care units (ICU), guidelines for end of life care on the ICU, establishment of transplantation coordinators on site, introduction of autonomous explantation teams and strict procedures on the course of organ donations, answered many practical issues about logistics and responsibilities for DBD and DCD. In 2014 the number of postmortem organ donations rose to 16.4 per million inhabitants. Meanwhile, up to 60u2009% of organ donations in the Netherlands originate from a DCD procedure compared to approximately 10u2009% in the USA. This overview article discusses the developments and processes of deceased donation in the Netherlands after 15 years of experience with DCD.

Successful Use of Ectopic Pelvic Kidney for Living Related Donation Technical Aspects and Literature Review

Ectopic pelvic kidneys can provide an additional source of organs for transplantation. They are often excluded from donation in living donation programs mainly due to aberrant vascular and urinary anatomies. We present a donor with an ectopic left kidney, who successfully donated his kidney. The use of ectopic pelvic kidney for living kidney transplantation is a highly demanding surgical procedure but after extensive preoperative investigation in high volume centers with surgical expertise in vascular reconstruction and access surgery, ectopic pelvic kidneys should not be a contraindication for donation and should be considered as a viable option.

Abstract 4627: Fasting reduces the systemic exposure to irinotecan and its active metabolite SN-38

Proceedings: AACR Annual Meeting 2014; April 5-9, 2014; San Diego, CAnnLimitations to the use of chemotherapeutic agents are the often severe adverse side-effects which may lead to early discontinuation of treatment. Most anticancer agents have a narrow therapeutic index. In previous work we have shown that 72 hours of fasting prior to treatment with a high dose of irinotecan prevents the occurrence of adverse side effects in C26 colon carcinoma bearing mice, while the antitumor activity is not abrogated. To elucidate the mechanism of fasting induced resistance against adverse side effects, we have examined the pharmacokinetics of irinotecan in 72 hours fasted mice in plasma and liver.nnMale BALB/c mice were divided into four groups (n=18/group). Two groups were fasted for 72 hours and two groups were fed ad libitum. After the fasting period, mice were fed ad libitum again. One group of ad libitum and fasted animals was treated with 50 mg/kg and the other with 100 mg/kg irinotecan intraperitoneally. Plasma and liver were collected at 1,4,8,12,24 and 48 hours after irinotecan injection. Tissues were homogenized in lithium heparinized plasma and concentrations of irinotecan (CPT-11) and the active metabolite SN-38 were determined using a validated reversed-phase high-performance liquid chromatography (HPLC) system with fluorescence detection. Pharmacokinetic parameters, including peak concentration, area under the plasma concentration-time curve (AUC), clearance (CL), and the half-life of the terminal disposition phase were calculated.nnIn the fasted group, plasma levels of SN-38 in the 50 mg/kg and 100 mg/kg group showed a 57% and 53% reduction, respectively, compared with ad libitum fed controls (AUC0-inf 5,149 vs. 2,242 ng*h/mL and 7,507 vs. 3,562 ng*h/mL). For CPT-11 the effects of fasting were smaller. An increase of 26% in the 50 mg/kg group and a reduction of 15% in the 100 mg/kg group were observed (AUC0-inf 9,715 vs. 12,235 and 37,360 vs. 31,924 ng*h/mL). In the liver, SN-38 levels in the 50 mg/kg and 100 mg/kg group showed a reduction of 51% and 30%, respectively, in the fasted animals (AUC0-inf 85.4 vs. 41.5 µg*h/g and 126 vs. 87.6 µg*h/g), while CPT-11 levels were reduced with 19% in the 50 mg/kg group and 28% in the 100 mg/kg group (AUC0-inf 218 vs. 177 µg*h/g and 712 vs. 512 µg*h/mg).nnOur data demonstrate that 72 hours of fasting prior to irinotecan administration induces an important change in its metabolism. Plasma and liver levels of the pro-drug CPT-11 were only slightly reduced in fasted animals. Levels of the active metabolite SN-38 were considerably lower in fasted animals compared to ad libitum fed animals. These data suggest that the reduction of side effects by fasting is due to the lower systemic exposure to SN-38, and may have important clinical implications if also found in humans.nnCitation Format: Sander A. Huisman, P de Bruijn, I.M. Ghobadi Moghaddam-Helmantel, J.N.M. IJzermans, E Wiemer, A.H.J. Mathijssen, R.W.F. de Bruin. Fasting reduces the systemic exposure to irinotecan and its active metabolite SN-38. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 4627. doi:10.1158/1538-7445.AM2014-4627

Predictors of Change in Donorsʼ Mental Health Three Months After Living Kidney Donation.: Abstract# A325

Background In order to optimize screening and support of living kidney donors, we examined which factors predict changes in donors’ mental health after living kidney donation. Methods Living kidney donors (N=137) completed validated questionnaires and participated in interviews a median of 2 months before and 3 months after donation. Using multilevel linear models we examined whether psychological complaints and wellbeing were predicted by sociodemographic characteristics, medical outcomes for donor and recipient, and psychological factors based on stress models of Lazarus (1999) and Ursin & Eriksen (2004). Findings There was no main effect of time on psychological complaints while wellbeing increased over time (p<.01). Donors’ home situation, greater stress, appraising donation as an uncontrollable or negative event, expectations of negative personal consequences, coping, social support, and more negative life events predicted negative changes in donors’ mental health. Medical outcomes were not related to changes in donors’ mental health. Discussion We recommend negative appraisals of donation and individual resources as targets for improved donor screening and support.

The Influence of Comorbidity On Graft and Patient Survival After Kidney Transplantation.: Abstract# 2207

2184 Kidneys From DCD Donors Are Underutilized in Pediatric Patients. E. King, N. Desai, D. Segev. Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD. Background. In pediatric patients, donation after cardiac death (DCD) organs account for just over 2% of all kidney transplants. It is diffi cult to defi nitively ascertain survival of DCD grafts through single center studies when the frequency of DCD transplantation is so low. A comprehensive study of national data is necessary to better defi ne outcomes and utilization of DCD compared to donation after brain death (DBD) kidneys. Methods. SRTR data (April 1994 to September 2013) of 7,318 pediatric kidneyonly deceased donor transplant recipients (age<18) were analyzed. Death censored graft survival was defi ned as the time from transplantation to graft loss or last date of follow-up with a functional graft. Kaplan Meier survival analysis was used to compare graft loss between DCD and DBD kidneys. Lorenz curves and Gini coeffi cient were used to compare center-level clustering in use of DCD versus DBD kidneys in pediatric recipients across US centers. Results. Graft survival was not statistically signifi cantly different between DCD and DBD organs in pediatric kidney recipients (p=0.88). There was a slight but not statistically signifi cant difference in the occurrence of delayed graft function (2.9% and 0.7%, p=0.06), however the mean creatinine at discharge following transplantation was higher among those receiving DCD kidneys compared to DBD (2.1 mg/dL and 1.5 mg/dL, p < 0.05). Lorenz curves demonstrate that around 25% of centers in the US performed 100% of DCD kidney transplants in pediatric recipients, in a pattern far more center-clustered than DBD transplants. Conclusions. DCD kidneys offer comparable outcomes in pediatric kidney transplantation, but only a small number of pediatric transplant centers currently utilize these organs. Abstract# 2185 Long-Term Data On the Use of Everolimus and Low-Dose Ciclosporin A in Children After Kidney Transplantation (Tx). L. Brunkhorst,1 T. Ahlenstiel,1 F. Lehner,2 L. Pape.1 1Pediatric Nephrology, Hannover Medical School, Hannover, Germany; 2Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany. Background: Actually, only short-term trials using Everolimus in children after Tx have been published. This is the fi rst prospective study to present four-year data using low-dose Ciclosporin A (CsA), Everolimus and steroid elimination. Methods: 35 children (median age: 10.7 ± 5.6 years) received Basiliximab, CsA and Prednisolone after Tx. Everolimus (1.6mg/m2/day) treatment was added two weeks post Tx. In 83% of the patients Prednisolone was withdrawn 8-10 months post Tx. Long-term target trough levels for CsA and Everolimus were 30-50 ng/ ml and 2-4 ng/ml. Clinical outcome and side effects were evaluated prospectively. Results: Patient and graft survival were 100% and median eGFR was 62, 61, 58 and 65 ml/min/1.73m2 1-4 years after Tx. Acute rejection (BANFF ≥ Ia) was diagnosed in indication biopsies in in 2/35 (6%) children in the fi rst year after Tx. In the remaining observation time, acute rejection was only diagnosed in one child in year 2 and 4. De novo Donor specifi c antibodies were found in 4/35 patients in yearly checkups with the histopathological diagnosis of chronic humoral rejection in one patient. In the four years observation time, one child developed EBV associated PTLD that was successfully treated with Rituximab. Two patients developed transient wound healing problems, 17% aphthous stomatitis. No signifi cant albuminuria > 100 mg/ mmol creatinine was recognized. Height SDS was -0.73 / -0.74 two and four years after Tx. Despite an elevation of estradiol in 33% of the girls, all sex hormone levels were within the normal range. Conclusions: After ped. kidney Tx, de novo immunosuppression with low-dose CsA, Everolimus, and a withdrawal of Prednisolone is followed by excellent graft survival and function, good growth and only a small number side effects. DISCLOSURE: Pape, L.: Grant/Research Support, Novartis. 2185 Long-Term Data On the Use of Everolimus and Low-Dose Ciclosporin A in Children After Kidney Transplantation (Tx). L. Brunkhorst,1 T. Ahlenstiel,1 F. Lehner,2 L. Pape.1 1Pediatric Nephrology, Hannover Medical School, Hannover, Germany; 2Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany. Background: Actually, only short-term trials using Everolimus in children after Tx have been published. This is the fi rst prospective study to present four-year data using low-dose Ciclosporin A (CsA), Everolimus and steroid elimination. Methods: 35 children (median age: 10.7 ± 5.6 years) received Basiliximab, CsA and Prednisolone after Tx. Everolimus (1.6mg/m2/day) treatment was added two weeks post Tx. In 83% of the patients Prednisolone was withdrawn 8-10 months post Tx. Long-term target trough levels for CsA and Everolimus were 30-50 ng/ ml and 2-4 ng/ml. Clinical outcome and side effects were evaluated prospectively. Results: Patient and graft survival were 100% and median eGFR was 62, 61, 58 and 65 ml/min/1.73m2 1-4 years after Tx. Acute rejection (BANFF ≥ Ia) was diagnosed in indication biopsies in in 2/35 (6%) children in the fi rst year after Tx. In the remaining observation time, acute rejection was only diagnosed in one child in year 2 and 4. De novo Donor specifi c antibodies were found in 4/35 patients in yearly checkups with the histopathological diagnosis of chronic humoral rejection in one patient. In the four years observation time, one child developed EBV associated PTLD that was successfully treated with Rituximab. Two patients developed transient wound healing problems, 17% aphthous stomatitis. No signifi cant albuminuria > 100 mg/ mmol creatinine was recognized. Height SDS was -0.73 / -0.74 two and four years after Tx. Despite an elevation of estradiol in 33% of the girls, all sex hormone levels were within the normal range. Conclusions: After ped. kidney Tx, de novo immunosuppression with low-dose CsA, Everolimus, and a withdrawal of Prednisolone is followed by excellent graft survival and function, good growth and only a small number side effects. DISCLOSURE: Pape, L.: Grant/Research Support, Novartis. Cardiovascular Complications in Kidney Transplantation II Wednesday, July 30, 2014 4:00 PM 5:30 PM Room 3016/3018 Abstract# 2207 The Infl uence of Comorbidity On Graft and Patient Survival After Kidney Transplantation. M. Laging,1 J. Kal-van Gestel,1 J. van de Wetering,1 J. Ijzermans,2 M. Betjes,1 W. Weimar,1 J. Roodnat.1 1Internal Medicine, Erasmus MC, Rotterdam, Netherlands; 2General Surgery, Erasmus MC, Rotterdam, Netherlands. Background 2207 The Infl uence of Comorbidity On Graft and Patient Survival After Kidney Transplantation. M. Laging,1 J. Kal-van Gestel,1 J. van de Wetering,1 J. Ijzermans,2 M. Betjes,1 W. Weimar,1 J. Roodnat.1 1Internal Medicine, Erasmus MC, Rotterdam, Netherlands; 2General Surgery, Erasmus MC, Rotterdam, Netherlands. Background Nowadays patients with a large variety of comorbidities are referred for transplantation. Acceptance criteria for kidney transplantation are continuously being eased. We questioned to what extent increasing severity and number of comorbidities interfere with graft and patient survival. Methods In our center, 1728 patients were transplanted between January 1, 2000 and December 31, 2012. Four pre-transplant comorbidity categories were defi ned: cardiovascular

Abstract 1110: Colorectal liver metastases induce a systemic phase shift of the biological clock

Proceedings: AACR Annual Meeting 2014; April 5-9, 2014; San Diego, CAnnCircadian clock genes drive cyclic expression of 10-15% of the transcriptome. Disruption of the circadian clock may deregulate the cells normal functions and can lead to carcinogenesis, indicating that clock genes also act as tumor suppressor genes. In previous work, we have shown that circadian rhythmicity is disrupted in C26 colon carcinoma cell-derived hepatic metastases, as compared to the non-cancerous tissue of the liver. It has been suggested that neoplastic tissue can influence the circadian clock of adjacent tissues, causing a tissue specific phase shift. A better understanding of how tumors affect the circadian system may help elucidate the role of the clock in cancer patients suffering from fatigue and sleep disorders. Therefore, we have examined the circadian clock in liver and kidney tissue of mice carrying hepatic C26 colon carcinoma cell metastases.nnMale BALB/c mice were divided into two groups. In group 1, hepatic metastases were induced by injecting C26 colorectal carcinoma cells into the spleen. Group 2 was sham operated. Three weeks after (sham) surgery, animals were sacrificed over a 24-hour period (6 time points, n=4 per time point) and liver and kidneys were collected to compare circadian rhythmicity in control and tumor bearing animals. RNA was isolated and qRT-PCR was performed to determine the expression levels of 5 clock genes (Rev-Erbα, Per1, Per2, Bmal1, Cry1) and 3 clock controlled genes (Dbp, p21 and Wee1).nnLiver and kidney tissue of healthy control mice showed normal 24-hour oscillations of all clock genes, consistent with normal circadian rhythmicity. Liver and kidney tissue of tumor-bearing mice, as compared to control mice, showed a marked phase difference in clock rhythms. In the liver we observed a 4-hour phase advance for Bmal1, Rev-Erbα and Dbp. In contrast in the kidney, there was a 4-hour phase delay for Bmal1, Rev-Erbα, Cry1 and DBP, and a 8 hour delay for Per2.nnThese data show that colorectal liver metastases induce a phase advance in the liver, and a phase delay in the kidney . This suggests a systemic effect of the tumor on peripheral clocks. This difference in clock phase between tumor-bearing mice and healthy controls may provide new clues to further understand the role of the clock for fatigue and sleep problems in cancer patients, but may also give opportunities to administer chemotherapeutic treatment in a chronotherapeutical setting .nnCitation Format: Sander A. Huisman, F. Tamanini, A. Ahmadi, J.N.M. IJzermans, G.T.J. van der Horst, R.W.F. de Bruin. Colorectal liver metastases induce a systemic phase shift of the biological clock. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 1110. doi:10.1158/1538-7445.AM2014-1110

1595PTHE PROTECTIVE EFFECTS OF FASTING ON IRINOTECAN INDUCED SIDE EFFECTS; A PHARMACOKINETIC STUDY

Aim: Limitations to the use of chemotherapeutic agents are the often severe side-effects which may lead to early discontinuation of treatment. In previous work we have shown that 3 days of fasting prior to treatment with a high dose of irinotecan prevents the occurrence of side-effects in C26 colon carcinoma bearing mice, while the antitumor activity is not abrogated. To elucidate the mechanism of fasting induced resistance against adverse side effects, we have examined the pharmacokinetics of irinotecan in both fasted and ad libitum fed mice in plasma, liver and tumor. Methods: Tumor bearing BALB/c mice were divided into three groups (n=18/group). Two groups were fasted for 3 days and one group was fed ad libitum. The ad libitum fed group and one group of fasted animals were treated with 100 mg/kg irinotecan. The other fasted group received a flat dose (i.e., the same dose as ad libitum fed mice). Plasma, liver-, and tumor tissue were collected at 1,4,8,12 and 24 hours after injection. Tissues were homogenized and concentrations of irinotecan and its active metabolite SN-38 were determined using a validated reversed-phase high-performance liquid chromatography (HPLC) system.

AGE DOES NOT AFFECT SURVIVAL OF KIDNEYS FROM ELDERLY LIVING DONORS: 1359

Introduction: To expand the kidney donor pool, more and more older deceased and living donors (DD and LD) were accepted over the years. We wondered whether donor age had influenced graft survival. Methods: In our centre 2469 kidneys were transplanted into 2001 patients from 1971 to 2010. There were 1550 kidneys derived from DD and 919 from LD. We performed life table survival analyses using SPSS to obtain uncensored, graft and patient survival over a period of 15 years. We analyzed donor age and donor type. Donor age was stratified in 20-years blocks. Older age was defined as >60 years. Results: Kidneys from older (>60y) DD had a graft survival of 64% at 5 years, 49% at 10 years, and 42% at 15 years. Median graft survival of older DD kidneys was significantly (p<0.001) shorter compared to kidneys from the younger age groups. Kidneys from older (>60y) LD had a graft survival of 86% at 5 years, 72% at 10 years, and 67% at 15 years. There was no difference in graft survival of the LD kidneys between the various age groups. We found a 7.5-year better median uncensored survival for older LD kidneys compared to older DD kidneys, while there was no difference in recipient age (p=0.219). Conclusion: Graft survival of older LD kidneys is superior to that of older DD kidneys. Older age significantly affected graft survival of DD, but not that of LD kidneys.