Jong-Da Lian

Long-Term Impact of Hepatitis B, C Virus Infection on Renal Transplantation

Chronic liver disease and its complications are major problems in renal transplant recipients. Our aim was to elucidate the influence of hepatitis B, C virus infection on the long-term outcome of renal transplantation. Four hundred and seventy-seven patients who received renal transplantation between January 1984 and December 1999, and who were followed up at our hospital were enrolled. HBsAg was detected by the RIA method and anti-HCV Ab was assayed by the second-generation RIA kit. SGOT/ SGPT were checked every 3 months. Hepatoma was diagnosed by dynamic CT scan, elevated α-fetoprotein, hypervascularity by angiography and confirmed by pathological examination. The prevalence of HBV, HCV, coinfected HBV/HCV was 9.9% (n = 47), 28.5% ( n = 136), 3.1% (n = 15), respectively. The incidences of hepatoma in the HBV–/HCV–, HBV–/HCV+, HBV+/HCV–, HBV+/HCV+ groups were 1.4% (n = 4), 4.4% (n = 6), 6.4% (n = 3), 6.7% (n = 1), respectively (p = 0.114). The incidences of liver cirrhosis/hepatic failure were 3.2% (n = 9) , 6.6% (n = 9) , 21.3% (n = 10) , 20% (n = 3), respectively (p < 0.001). The frequencies of chronic liver disease were 10.4% (n = 29) , 45.6% (n = 62) , 66% (n = 31) , 80% (n = 12), respectively (p < 0.001). Patient and graft survival rates were lower in the HBV-infected group than in the other groups. Cox regression analysis revealed that HBV infection is likely an independent risk factor for patient mortality although the statistical significance was only borderline. Patients with HBV as well as HCV infection were not at risk of graft loss according to this model of analysis. Patients with HBV infection showed higher incidences of hepatoma, hepatic failure, graft failure and death. Therefore, HBV-infected patients who are candidates for renal transplantation should be carefully evaluated. It seems that HCV infection has little influence on the outcome of renal transplant recipients. A longer period of follow-up is needed to clarify the impact of HCV on renal transplant recipients.

Mycobacterium tuberculosis infection following renal transplantation in Taiwan

Abstract: Background. Tuberculosis (TB) is one of the major causes of morbidity and mortality worldwide. Post‐transplant (post‐Tx) TB is a problem in successful long‐term outcome of renal transplantation recipients. It is a life‐threatening opportunistic infection that is frequently encountered, but the diagnosis is often delayed. With the emergence of newer potent immunosuppressive regimens and an increased incidence of TB in the general population, post‐Tx TB among transplant recipients can be anticipated. Our objective was to describe the pattern and risk factors of TB infection, and the prognosis in an endemic area.

Silibinin inhibits the invasion and migration of renal carcinoma 786-O cells in vitro, inhibits the growth of xenografts in vivo and enhances chemosensitivity to 5-fluorouracil and paclitaxel.

Silibinin is a flavonoid antioxidant that is widely used for its anti‐hepatotoxic properties. It exerts a dose‐dependent inhibition on the invasion and migration of 786‐O renal cell carcinoma (RCC) cells in the absence of cytotoxicity. 786‐O cells were treated with silibinin at various concentrations, up to 50 µM, for a defined period and then subjected to gelatin zymography, casein zymography, and Western blot to investigate the impacts of silibinin on metalloproteinase (MMP) ‐2, ‐9, urokinase plasminogen activator (u‐PA), and MAPK pathway signaling proteins, respectively. The results showed that silibinin decreased MMP‐2, MMP‐9, u‐PA, p‐p38, and p‐Erk1/2 expressions in a concentration‐dependent manner. The reduced expressions of MMP‐2 and u‐PA, as well as inhibition of cell invasion were obtained in the cultures pre‐treated with PD98059 (Erk1/2 inhibitor) and SB203580 (p38 inhibitor). An in vivo anti‐tumor study with a nude mice xenograft model by a subcutaneous inoculation of 786‐O cells demonstrated small solid tumors after eight days following cell inoculation. There was a 70.1% reduction in tumor volume and 69.7% reduction in tumor weight by silibinin feeding on day 44, compared to those of controls. Moreover, combination treatment with silibinin and 5‐fluorouracil, paclitaxel, vinblastine, or RAD‐001 enhanced the chemosensitivity of 5‐fluorouracil and paclitaxel. In conclusion, silibinin inhibits the invasion and migration of 786‐O cells in vitro, inhibits the growth of xenografts in vivo, and enhances chemosensitivity to 5‐fluorouracil and paclitaxel.

Lethal cytomegalovirus ischemic colitis presenting with fever of unknown origin

Abstract: We report a fatal case of cytomegalovirus (CMV) ischemic colitis in a renal transplant recipient. The disease was manifested with fever of unknown origin for 27 days followed by progressive right lower abdominal pain. The clinical condition deteriorated rapidly with development of disseminated intravascular coagulopathy and internal bleeding despite right hemicolectomy and antiviral therapy. The patient died 11 days after the onset of abdominal pain. We conclude that the possibility of CMV ischemic colitis should be suspected if a patient presents with fever and abdominal pain in the early months after transplantation, and that early viral detection by CMV polymerase chain reaction can be lifesaving.

Cytomegalovirus ischemic colitis of a diabetic renal transplant recipient

Abstract:  We report a diabetic renal transplant recipient with cytomegalovirus (CMV) disease who presented with tarry stool diarrhea because of multiple colonic ulcerations. Histopathology revealed diffuse colonic ulcers following a process of ischemic vasculitis. The colonic ulcers disappeared dramatically after 2 wk of intravenous ganciclovir therapy. Hyper‐immunosuppression was initially suspected but acute rejection (AR) developed after immunosuppressive reduction during the ganciclovir therapy. The AR was successfully reversed and the dosage of cyclosporine was returned to the same level prior to the onset of CMV disease. Our experience suggests that ganciclovir is quite effective for healing colonic ulcers caused by CMV and acute allograft rejection may occur during therapy.

High Incidence of Malignancy in Polyomavirus-Associated Nephropathy in Renal Transplant Recipients

Human polyomaviruses (PV), including JC and BK virus, have been reported to cause polyomavirus-associated nephropathy (PVAN), in renal transplant patients. PV infection has been demonstrated to be associated with malignancies in animals; however, the association between malignancy and viral infections in humans is not clear. We retrospectively reviewed our 864 (M:F=502:362) kidney transplant patients over the past 25 years. We identified PVAN in 6 patients (0.69%), including BK nephropathy (n=5) and JC nephropathy (n=1). Three patients (50%) improved after reducing the immunosuppression, but 3 (50%) progressed to graft loss despite this reduction. Malignancy occurred in 5 out of the 6 patients (83%; P<.0001 compared with patients without PVAN), including transitional cell carcinoma (n=2), renal cell carcinoma (n=1), squamous cell carcinoma of skin (n=1) and Kaposi sarcoma (n=1). We concluded that kidney transplant patients with PVAN are at a significantly greater risk to develop malignancy. Whether this is due to a direct effect of PV infection or the result of overimmunosuppression remains to be determined in a future study.

The effect of low-dose cidofovir on the long-term outcome of polyomavirus-associated nephropathy in renal transplant recipients

BACKGROUND Polyomavirus-associated nephropathy (PVAN) has an unfavourable impact on graft survival. The cornerstone of therapy is early reduction of immunosuppressive medications; however, the rate of graft failure is still high. Antiviral drugs, such as cidofovir, are thought to have therapeutic effects, but the benefits of cidofovir in retarding the deterioration of PVAN are still a controversial issue. METHODS Fourteen renal kidney recipients were diagnosed to have biopsy-proven PVAN between 2001 and 2006 in Chung-Shan Medical University Center with nearly 600 renal transplant recipients. After the diagnosis of PVAN, all patients were treated with a reduction of their original immunosuppressive medications with/without converting tacrolimus to cyclosporine. Eight of the 14 patients agreed to receive low-dose cidofovir (0.5 mg/kg) every 2 weeks for a total of six doses. RESULTS During 30 +/- 18 months of follow-up, three (37%) patients in the cidofovir-treated and three (50%) patients in the non-cidofovir-treated group experienced graft loss (P = 0.64). The rejection rate before PVAN diagnosis or other baseline characteristics of the patients between two groups were not significantly different. The long-term survival rate to graft loss and major graft functional decline with Kaplan-Meier analysis between the two groups were not significantly different (P = 0.898 and P = 0.243). In all demographic and clinical characteristics, we found that there was a tendency towards long-term major graft functional decline in the patients with acute rejection prior to PVAN diagnosis (P = 0.04). CONCLUSIONS We concluded that (1) there was no obvious effect of low-dose cidofovir on long-term graft survival in patients with PVAN, and (2) acute rejection prior to PVAN diagnosis was a potential risk factor for poorer long-term graft outcome.

The suppressive effect of Rho kinase inhibitor, Y-27632, on oncogenic Ras/RhoA induced invasion/migration of human bladder cancer TSGH cells.

Urothelial cell carcinoma is the most common type of malignancy found in long-term dialysis patients and kidney transplant recipients in Taiwan. Surgical specimens of tumorous and non-tumorous bladder tissues were collected from 12 patients with bladder cancer. Increased expressions of Ras, RhoA, Akt, PI-3K were demonstrated in the tumors as compared to adjacent control tissues. To understand the impact of Ras over-expression on bladder cancer progression, human bladder cancer TSGH 8301 cells were transfected with Ras DNA. The Ras-transfected cells were then treated with either a PI-3K inhibitor (wortmannin) or Rho kinase inhibitor (Y-27632) and the expressions of Ras, PI-3K, Akt, NF-kappaB, and RhoA were analyzed. Fluorescent phalloidin staining demonstrated more intense F-actin staining in the Ras over-expressed cells than in the control cells, and the intensity of F-actin was inhibited by Y-27632. A gelatin zymography study demonstrated that the MMP-2 and MMP-9 expressions of the Ras-transfected cells were enhanced, and Y-27632 treatment reduced the levels of MMP-2 and MMP-9. Similarly, a wound healing assay revealed that the ability of cell migration was markedly increased by Ras transfection and the healing rate after treatment of Y-27632 was delayed. Our results provide evidence that Ras-induced RhoA and NF-kappaB activation was involved in the invasion/migration of bladder cancer. Through Ras and/or RhoA inhibition, there might be an opportunity for new therapeutic interventions in bladder cancer.

Increased Expression of Intranuclear Matrix Metalloproteinase 9 in Atrophic Renal Tubules Is Associated with Renal Fibrosis

Background Reduced turnover of extracellular matrix has a role in renal fibrosis. Matrix metalloproteinases (MMPs) is associated with many glomerular diseases, but the histological association of MMPs and human renal fibrosis is unclear. Methods This is a retrospective study. Institutional Review Board approval was obtained for the review of patients’ medical records, data analysis and pathological specimens staining with waiver of informed consents. Specimens of forty-six patients were examined by immunohistochemical stain of MMP-9 in nephrectomized kidneys, and the association of renal expression of MMP-9 and renal fibrosis was determined. MMP-9 expression in individual renal components and fibrosis was graded as high or low based on MMP-9 staining and fibrotic scores. Results Patients with high interstitial fibrosis scores (IFS) and glomerular fibrosis scores (GFS) had significantly higher serum creatinine, lower estimated glomerular filtration rate (eGFR), and were more likely to have chronic kidney disease (CKD) and urothelial cell carcinoma. Univariate analysis showed that IFS and GFS were negatively associated with normal and atrophic tubular cytoplasmic MMP-9 expression and IFS was positively correlated with atrophic tubular nuclear MMP-9 expression. Multivariate stepwise regression indicated that MMP-9 expression in atrophic tubular nuclei (r = 0.4, p = 0.002) was an independent predictor of IFS, and that MMP-9 expression in normal tubular cytoplasm (r = −0.465, p<0.001) was an independent predictor of GFS. Conclusions Interstitial fibrosis correlated with MMP-9 expression in the atrophic tubular nuclei. Our results indicate that renal fibrosis is associated with a decline of MMP-9 expression in the cytoplasm of normal tubular cells and increased expression of MMP-9 in the nuclei of tubular atrophic renal tubules.

Plasminogen activator inhibitor-1 5G/5G genotype is a protecting factor preventing posttransplant diabetes mellitus.

OBJECTIVE Plasminogen activator inhibitor 1 (PAI-1) is thought to play a role in the pathogenesis of obesity and insulin resistance. A connection between gestational diabetes mellitus and the functional -675 PAI-1 genotype has been reported. Therefore, we examined the role of the PAI-1 gene polymorphism in kidney transplant recipients. METHODS A total of 376 kidney transplant recipients were prospectively screened for posttransplant diabetes mellitus (PTDM). Eighty-one (21.5%) patients were diagnosed with PTDM and the other 295 patients were non-diabetic following kidney transplantation. DNA samples were isolated from the sera and analyzed for the functional -675 4G/5G promoter polymorphisms of the PAI-1 gene. RESULTS Kidney transplant recipients with PTDM were significantly associated with tacrolimus use (p=0.03), older age (p=0.036), and higher body mass index (p=0.001). The genotype distribution was significantly different between the patients with PTDM (genotype 4G/4G:4G/5G:5G/5G=33.3%:60.5%:6.2%) and those without PTDM (genotype 4G/4G:4G/5G:5G/5G=36.9%:44.1%:19.0%) (p=0.018). Patients with homozygosity for 5G had a significantly lower rate of PTDM (aOR, 0.286, p=0.022) and higher cumulative event-free probability of time to PTDM (log rank test, p=0.0058). CONCLUSION Homozygosity for the 5G allele of the PAI-1 gene constitutes a protecting factor for the development of PTDM. Our findings are similar to a previous study on gestational diabetes mellitus, and strongly support a possible genetic role of PAI-1 in the development of PTDM.