PhD / Introduction Kidney transplantation confers both survival and quality of life advantages over dialysis for most people with end-stage kidney disease (ESKD). The mortality rate on dialysis is 10-15% per year, compared with 2-4% per year post-transplantation. Short-term graft survival is related to control of the acute rejection process, requiring on-going immunosuppression. Most current immunosuppressive algorithms include one of the calcineurin inhibitors (CNI: cyclosporin or tacrolimus), an anti-metabolite (azathioprine or mycophenolate) and corticosteroids, with or without antibody induction agents (Ab) given briefly peri-transplantation. Despite this approach, between 15-35% of recipients undergo treatment for an episode of acute rejection (AR) within one year of transplantation. Transplantation is not without risk, and relative mortality rates for kidney recipients after the first post-transplant year remain 4-6 times that of the general population. Longer-term transplant and recipient survival are related to control of chronic allograft nephropathy (rooted in the interplay of AR, non-immunological factors, and the chronic nephrotoxicity of CNI) and limitation of the complications of chronic ESKD and long-term immunosuppression: cardiovascular disease, cancer and infection, which are responsible for 22%, 39% and 21% of deaths respectively. This thesis is presented as published works on the theme of immunosuppression and cancer after kidney transplantation. The work presented in the first chapters of this thesis has striven to identify, evaluate, synthesise and distil the entirety of evidence available of new and established immunosuppressive drug agents through systematic review of randomised trial data, with particular emphasis on quantifying harms of treatment. The final chapters use inception cohort data from the Australian and New Zealand Dialysis and Transplant Registry (ANZDATA), which is first validated then used to explore the risk of cancer in more detail than was possible from trial data alone. Interleukin 2 receptor antagonists Interleukin-2 receptor antagonists (IL2Ra, commercially available as basiliximab and daclizumab) are humanised or chimeric IgG monoclonal antibodies to the alpha subunit of the IL2 receptor present only on activated T lymphocytes, and the rationale for their use has been as induction agents peri-transplantation. Introduced in the mid-1990s, IL2Ra use has increased globally, and by 2003 38% of new kidney transplant recipients in the United States and 25% in Australasia received an IL2Ra. This study aimed to systematically identify and synthesise the evidence of effects of IL2Ra as an addition to standard therapy, or as an alternative to other induction agents. We identified 117 reports from 38 randomised trials involving 4893 participants. Where IL2Ra were compared with placebo (17 trials; 2786 patients), graft loss was not different at one (Relative Risk -RR 0.84; 0.64 to 1.10) or 3 years (RR 1.08; 0.71 to1.64). AR was reduced at 6 months (RR 0.66; 0.59 to 0.74) and at 1 year (RR 0.66; 0.59 to 0.74) but cytomegalovirus (CMV) disease (RR 0.82; CI 0.65 to 1.03) and malignancy (RR 0.67; 0.33 to1.36) were not different. Where IL2Ra were compared with other antibody therapy no significant differences in treatment effects were demonstrated, but IL2Ra had significantly fewer side effects. Given a 40% risk of rejection, 7 patients would need treatment with IL2Ra in addition to standard therapy, to prevent 1 patient having rejection, with no definite improvement in graft or patient survival. There was no apparent difference between basiliximab and daclizumab. Tacrolimus versus cyclosporin for primary immunosuppression There are pronounced global differences in CNI use; 63% of new kidney transplant recipients in the USA but only 22% in Australia receive tacrolimus as part of the initial immunosuppressive regimen. The side effects of CNI differ: tacrolimus is associated more with diabetes and neurotoxicity, but less with hypertension and dyslipidaemia than cyclosporin, with uncertainty about equivalence of nephrotoxicity or how these relate to patient and graft survival, or impact on patient compliance and quality of life. This study aimed to systematically review and synthesise the positive and negative effects of tacrolimus and cyclosporin as initial therapy for renal transplant recipients. We identified 123 reports from 30 randomised trials involving 4102 participants. At 6 months graft loss was reduced in tacrolimus-treated recipients (RR 0•56; 0•36 to 0•86), and this effect persisted for 3 years. The relative reduction in graft loss with tacrolimus diminished with higher levels of tacrolimus (P=0.04), but did not vary with cyclosporin formulation (P=0.97) or cyclosporin level (P=0.38). At 1 year, tacrolimus patients suffered less AR (RR 0•69; 0•60 to 0•79), and less steroid-resistant AR (RR 0•49; 0•37 to 0•64), but more insulin-requiring diabetes (RR 1•86; 1•11 to 3•09), tremor, headache, diarrhoea, dyspepsia and vomiting. The relative excess in diabetes increased with higher levels of tacrolimus (P=0.003). Cyclosporin-treated recipients experienced significantly more constipation and cosmetic side-effects. We demonstrated no differences in infection or malignancy. Treating 100 recipients with tacrolimus instead of cyclosporin for the 1st year post-transplantation avoids 12 suffering acute rejection and 2 losing their graft but causes an extra 5 to become insulin dependent diabetics, thus optimal drug choice may vary among patients. Target of rapamycin inhibitors for primary immunosuppression Target of rapamycin inhibitors (TOR-I) are among the newest immunosuppressive agents and have a novel mode of action but uncertain clinical role. Sirolimus is a macrocyclic lactone antibiotic and everolimus is a derivative of sirolimus. Both prevent DNA synthesis resulting in arrest of the cell cycle. Animal models suggested TOR-I would provide synergistic immunosuppression when combined with CNI, but early clinical studies demonstrated synergistic nephrotoxicity. Since then diverse trials have explored strategies that avoid this interaction and investigated other potential benefits. The aim of this study was to systematically identify and synthesise available evidence of sirolimus and everolimus when used in initial immunosuppressive regimens for kidney recipients. We identified 142 reports from 33 randomised trials involving 7114 participants, with TOR-I evaluated in four different primary immunosuppressive algorithms: as replacement for CNI, as replacement for antimetabolites, in combination with CNI at low and high dose, and with variable dose of CNI. When TOR-I replaced CNI (8 trials, 750 participants), there was no difference in AR (RR 1.03; 0.74 to 1.44), but creatinine was lower (WMD -18.31 umol/l; -30.96 to -5.67), and bone marrow more suppressed (leucopoenia RR 2.02; 1.12 to 3.66, thrombocytopenia RR 6.97; 2.97 to 16.36, anaemia RR 1.67; 1.27 to 2.20). When TOR-I replaced antimetabolites (11 trials, 3966 participants), AR and CMV were reduced (RR 0.84; 0.71 to 0.99 and RR 0.49; 0.37 to 0.65) but hypercholesterolaemia was increased (RR 1.65; 1.32 to 2.06). When low was compared to high-dose TOR-I, with equal CNI dose (10 trials, 3175 participants), AR was increased (RR 1.23; 1.06 to 1.43) but GFR higher (WMD 4.27 ml/min; 1.12 to 7.41). When low-dose TOR-I and standard-dose CNI were compared to higher-dose TOR-I and reduced CNI AR was reduced (RR 0.67; 0.52 to 0.88), but GFR also reduced (WMD -9.46 ml/min; -12.16 to -6.76). There was no significant difference in mortality, graft loss or malignancy risk demonstrated for TOR-I in any comparison. Generally surrogate endpoints for graft survival favoured TOR-I (lower risk of acute rejection and higher GFR) and surrogate endpoints for patient outcomes were worsened by TOR-I (bone marrow suppression, lipid disturbance). Long-term hard-endpoint data from methodologically robust randomised trials are still needed. Monoclonal and polyclonal antibody therapy for treating acute rejection Strategies for treating AR include pulsed steroids, an antibody (Ab) preparation, the alteration of background immunosuppression, or combinations of these options. In 2002, in the USA 61.4% of patients with AR received steroids, 20.4% received Ab and 18.2% received both. The Ab available for AR are not new: horse and rabbit derived polyclonal antibodies (ATG and ALG) have been used for 35 years, and a mouse monoclonal antibody (muromonab-CD3) became available in the late 1980s. These preparations remove the functional T-cell population from circulation, producing powerful saturation immunosuppression which is useful for AR but which may be complicated by immediate toxicity and higher rates of infection and malignancy. The aim of this study was to systematically evaluate and synthesise all evidence available to clinicians for treating AR in kidney recipients. We identified 49 reports from 21 randomised trials involving 1394 participants. Outcome measures were inconsistent and incompletely defined across trials. Fourteen trials (965 patients) compared therapies for 1st AR episodes (8 Ab versus steroid, 2 Ab versus another Ab, 4 other comparisons). In treating first rejection, Ab was better than steroid in reversing AR (RR 0.57; CI 0.38 to 0.87) and preventing graft loss (RR 0.74; CI 0.58 to 0.95) but there was no difference in preventing subsequent rejection (RR 0.67; CI 0.43 to 1.04) or death (RR 1.16; CI 0.57 to 2.33) at 1 year. Seven trials (422 patients) investigated Ab treatment of steroid-resistant rejection (4 Ab vs another Ab, 1 different doses Ab, 1 different formulation Ab, 2 other comparisons). There was no benefit of muromonab-CD3 over ATG or ALG in reversing rejection (RR 1.32; CI 0.33 to 5.28), preventing subsequent rejection (RR 0.99; CI 0.61 to 1.59), graft loss (RR 1.80; CI 0.29 to 11.23) or death (RR 0.39; CI 0.09 to 1.65). Given the clinical problem caused by AR, comparable data are sparse, and clinically important differences in outcomes between widely used interventions have not been excluded. Standardised reproducible outcome criteria are needed. Validity of cancer data in an end stage kidney disease registry Registries vary in whether the data they collect are given voluntarily or as a requirement of law, the completeness of population coverage, the breadth of data collected and whether data are assembled directly or indirectly through linkage to other databases. Data quality is crucial but difficult to measure objectively. Formal audit of ANZDATA cancer records has not previously taken place. The aim of this study was to assess agreement of records of incident cancer diagnoses held in ANZDATA (voluntary reporting system) with those reported under statute to the New South Wales (NSW) state Central Cancer Registry (CCR), to explore the strengths and weaknesses of both reporting systems, and to measure the impact of any disagreement on results of cancer analyses. From 1980-2001, 9453 residents received dialysis or transplantation in NSW. Records from ANZDATA registrants were linked to CCR using probabilistic matching and agreement between registries for patients with 1 or more cancers, all cancers and site-specific cancer was estimated using the kappa-statistic (κ). ANZDATA recorded 867 cancers in 779 (8.2%) registrants; CCR 867 cancers in 788 (8.3%), with κ =0.76. ANZDATA had sensitivity 77.3% (CI 74.2 to 80.2), specificity 98.1% (CI 97.7 to 98.3) if CCR records were regarded as the reference standard. Agreement was similar for diagnoses whilst receiving dialysis (κ =0.78) or after transplantation (κ =0.79), but varied by cancer type. Melanoma (κ =0.61) and myeloma (κ =0.47) were less good; lymphoma (κ =0.80), leukaemia (κ =0.86) and breast cancer (κ =0.85) were very good. Artefact accounted for 20.8% non-concordance but error and misclassification did occur in both registries. Cancer risk did not differ in any important way whether estimated using ANZDATA or CCR records. Quality of cancer records in ANZDATA are high, differences largely explicable, and seem unlikely to alter results of analyses. Risk of cancer after kidney transplantation Existing data on the magnitude of excess risk of cancer across different kidney recipient groups are sparse. Quantifying an individual transplant candidate’s cancer risk informs both pre-transplant counselling, treatment decisions and has implications for monitoring, screening and follow-up after transplantation. The aims of this study were firstly to establish the risk of cancer in the post-transplant population compared to that experienced by the general population, and secondly to quantify how excess risk varied within the transplanted population, seeking to establish meaningful absolute risk estimates for post-transplant cancer based on unalterable recipient characteristics known a priori at the time of transplantation. 15,183 residents of Australia and New Zealand had a transplant between 1963 and 2004, and were followed for a median of 7.2 years (130,186 person-years), with 1642 (10.8%) developing cancer. Overall, kidney recipients had 3 times the cancer risk, with risk inversely related to age (Standardised Incidence Ratio of 15 to 30 in children reducing to 2 in people > 65 years). Female recipients aged 25 -29 had rates of cancer (779.2/100,000) equivalent to women aged 55 - 59 from the general population. The risk pattern of lymphoma, colorectal and breast cancer was similar to the overall age trend, melanoma showed less variability across ages and prostate cancer showed no risk increase. Within the transplanted population cancer risk was affected by age differently for each sex (P=0.007), and was elevated for recipients with prior non-skin malignancy (Hazard Ratio: HR 1.40; 1.03 to 1.89), of white race (HR 1.36; 1.12 to 1.89), but reduced for those with diabetic ESKD (HR 0.67; 0.50 to 0.89) Rates of cancer in kidney recipients were similar to non-transplanted people 20 -30 years older, but risk differed across patient groups. Men aged 45 - 54 at transplantation with graft function at 10 years had a risk of cancer that varied from 1 in 13 (non-white, diabetic ESKD, no prior cancer) to 1 in 5 (white, prior cancer, ESKD from other causes).

Diss. (sammanfattning) Stockholm : Karol. inst., 2005. / Härtill 5 uppsatser.

Thesis (Ph. D.)--University of Hong Kong, 2009. / Includes bibliographical references (leave 173-189) Also available in print.

Thesis (Ph. D.)--University of Texas at Austin, 1998. / Vita. Includes bibliographical references (leaves 96-105). Available also in a digital version from Dissertation Abstracts.

Thesis (Ph. D.)--Ohio State University, 2005. / Title from first page of PDF file. Document formatted into pages; contains xix, 189 p. ; also includes graphics. Includes bibliographical references (p. 175-189). Available online via OhioLINK's ETD Center.

Les cellules souches mésenchymateuses (CSM) sont des cellules stromales présentes dans différents types de tissus. En plus de leur capacité à se différencier en plusieurs lignées (chondrocytes, adipocytes et ostéoblastes), les CSM présentent également des propriétés immunosuppressives. Bien que ces mécanismes soient loin d'être entièrement compris, leur capacité immunosuppressive a récemment été démontrée comme étant modulée par des miARN. L'arthrose est la forme la plus courante de maladies articulaires sans traitement curatif et se caractérise principalement par la dégradation du cartilage articulaire, avec des altérations osseuses sous-chondrales et une inflammation synoviale. Les CSM pourraient offrir un potentiel thérapeutique intéressant pour le traitement de l'arthrose.Nos travaux ont montré qu'une injection autologue de CSM d'origine adipeuse (ASC) dans une articulation arthrosique améliore la douleur et les niveaux fonctionnels chez les patients. Nous avons souligné la tolérance immunitaire systémique induite à la suite d'injections intra-articulaires d'ASC. Enfin, nous avons étudié le profil d'expression des miARN des CSM humaines lors de leur stimulation par des cellules mononuclées du sang préalablement activés. Nous avons identifié le miR-29a et le PSAT1 comme de nouveaux candidats pour réguler l'activité immunosuppressive médiée par les CSM. / Mesenchymal Stem Cells (MSCs) are stromal cells present in a number of different tissue types. In addition to their ability to differentiate into multiple lineages (chondrocytes, adipocytes and osteoblasts), MSCs also display immunosuppressive properties. Whilst these mechanisms are far from fully understood, their immunosuppressive capacity has recently been shown to be modulated by miRNAs. OA is the most common form of joint diseases without curative treatment and mainly characterized by the degradation of articular cartilage, with subchondral bone alterations and synovial inflammation. MSC might provide therapeutic potential for treatment of OA.Here, we showed that an autologous injection of adipose-derived MSC (ASC) into an osteoarthritic joint improved pain and function levels in patients. We underscored the systemic immune tolerance induced following intra-articular injections of ASCs. Finally, we investigated the miRNA expression profile of human MSCs upon their stimulation by peripheral blood mononuclear cells. We identified miR-29a and PSAT1 as new candidates to regulate immunosuppressive activity mediated by MSCs.

The afflictions suffered by immunocompromised individuals have historically been attributed to overt infections caused by bacterial and fungal pathogens. For this reason, treatment methods have focused on resolving these infections, with great success in terms of reducing short-term morbidity and mortality rates. This initial success only served to reinforce the dogmatic opinion that to ‘cure’ immunodeficiency, one needs only to resolve and prevent recurrence of bacterial and fungal infections. However, reports of long-term health problems in immunocompromised cohorts suggest that treatment of bacterial and fungal infections alone does not resolve all aspects of the disease, and that viruses may play a greater role than previously expected. This thesis investigates whether viral infections do indeed have a significant impact in the immunocompromised patient. The overall prevalence of blood-borne viral infections in immunocompromised cohorts was determined through the combined use of unbiased, metagenomic sequencing and qPCR. The viral species detected were compared with patient records in order to determine whether there were any correlations between viral presence and patient outcome following treatment. Furthermore, by investigating a cross-section of cohorts with both inherited and acquired immunodeficiences, commonalities and differences could be found in terms of the types of viruses that infect these cohorts and their abundance in patients with different types of immunodeficiency. The findings of this work suggest that a large number of clinically undiagnosed viruses infect immunocompromised patients, however the prevalence of these viruses varies according to the form of immunodeficiency and, to a lesser extent, according to differences between individuals in the same cohort. Importantly, some of the more common viruses detected appear to be correlated with poor patient outcomes such as graft rejection and future infectious complications. Overall, these results suggest that viral infections do indeed play a larger role in the health of immunocompromised patients than has previously been thought although whether this is due to a direct cause or as a consequence is yet to be determined.

Made available in DSpace on 2014-06-11T19:24:16Z (GMT). No. of bitstreams: 0 Previous issue date: 2008-09-12Bitstream added on 2014-06-13T19:30:55Z : No. of bitstreams: 1 hoffmann_jl_me_botfm.pdf: 1011094 bytes, checksum: 5a00c88dc2c531f42992842568ecd338 (MD5) / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) / Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) / Universidade Estadual Paulista (UNESP) / A resposta imune na leishmaniose pode resultar em uma polarização da subpopulação dos linfócitos T, levando a um fenótipo celular distinto, que resultam em proteção imune ou exacerbação da doença. As leishmânias persistem no organismo tanto em infecções assintomáticas como após o tratamento, representando risco em condições de imunossupressão. O objetivo deste trabalho foi avaliar o efeito da infecção e da imunossupressão com dexametasona associada à pentoxifilina, sobre o peso dos animais, peso do baço, carga parasitária do baço e do fígado, e da imunopatologia quanto à produção de IFN-γ, IL-10, IL-4 e IL-2 em cultura de células esplênicas de camundongos Balb/c infectados com Leishmania chagasi. A infecção não alterou o ganho de peso dos animais, mas sim o peso e o tamanho do baço. A imunossupressão utilizando a dexametasona associada à pentoxifilina afetou tanto ganho de peso, quanto o peso e o tamanho do baço, de animais infectados e não infectados. A imunossupressão não alterou significativamente o curso da carga parasitária, tanto do baço, como do fígado. A dexametasona e a pentoxifilina afetaram a produção das citocinas estudadas, mas não direcionaram o perfil de resposta Th1/Th2 nos animais infectados. / The immune response in leishmaniasis can result in a polarization of a subpopulation of T lymphocytes, leading to a different cell phenotype, resulting in immune protection or exacerbation of the disease. Leishmanias persist in the body both in asymptomatic infections and after the treatment, representing risk in terms of immunosuppression. The objective of this study was to evaluate the effect of infection and immunosuppression with dexamethasone associated with pentoxifylline on the weight of the animals, weight of the spleen, the parasitic load in the spleen and liver, and immunopathology on the production of IFN-γ, IL - 10, IL-4, and IL-2 in spleen cell culture of Balb/c mice infected with Leishmania chagasi. The infection did not alter the animals’ weight gain, but the weight and size of the spleen increased. The immunosuppression using dexamethasone associated with pentoxifylline affected both weight gains, as the weight and size of the spleen of infected and not infected animals. The immunosuppression did not alter significantly the course of the parasite burden of the spleen and the liver. Dexamethasone and pentoxifylline affected the studied cytokines production, but not influenced the profile of Th1/Th2 response in infected animals.

Made available in DSpace on 2014-10-09T12:54:30Z (GMT). No. of bitstreams: 0 / Made available in DSpace on 2014-10-09T14:07:46Z (GMT). No. of bitstreams: 0 / Dissertacao (Mestrado) / IPEN/D / Instituto de Pesquisas Energéticas e Nucleares - IPEN/CNEN-SP

Orientador: Luiz Carlos Dias / Dissertação (mestrado) - Universidade Estadual de Campinas, Instituto de Quimica / Made available in DSpace on 2018-08-06T22:02:57Z (GMT). No. of bitstreams: 1 SallesJunior_AirtonGoncalves_M.pdf: 2256633 bytes, checksum: 3fa984f2e156e431c4bffe35b6799992 (MD5) Previous issue date: 2006 / Resumo: Este trabalho relata a síntese assimétrica do fragmento C29-C39 do potente imunossupressor sangliferina A. O plano sintético utiliza como etapa-chave a reação aldólica com indução 1,5-anti entre a metil cetona 7.3 e o aldeído 31.3(S). A metil cetona 7.3 foi obtida a partir da amida de Weinreb 10.3 utilizando como etapas principais, reação de Horner-Wadsworth-Emmons, epoxidação régio- e diastereosseletiva e abertura de epóxido com cuprato de alta ordem. A amida 10.3 foi obtida a partir da reação aldólica entre N-propioniloxazolidinona 12.3 e a metacroleína mediada por titânio e hidroboração diastereosseletiva. O rendimento total para obtenção do fragmento C29-C39 foi de 18% para 16 etapas. / Abstract: This work describes the stereoselective synthesis of the C29-C39 fragment of the immunosuppressant sanglifehrin A. Our strategy involved a diastereoselective boron-mediated 1,5-anti aldol reaction of methyl ketone 7.3 with chiral aldehyde 31.3(S) as the key step.j Methyl ketone 7.3 is viewed as arising from Weinreb amide 10.3. Key steps in this approach are Horner-Waddsworth-Emmons homologation, selective epoxidation and epoxide ring opening with a higher order cuprate. The Weireb amide 10.3 is available from a titanium mediated aldol reaction of N-propionyloxazolidinone 12.3 with metacrolein followed by a diastereoselective hydroboration. This approach to the C29-C39 fragment of sanglifehrin A requires 16 steps and produced the desired molecule in 18% overall yield. / Mestrado / Quimica Organica / Mestre em Química