Law Wai Keung. / Thesis (M.Sc.)--Chinese University of Hong Kong, 2002. / Includes bibliographical references (leaves 98-108). / Abstracts in English and Chinese. / Abstract --- p.v / 摘要 --- p.viii / Acknowledgement --- p.x / List of Abbreviations --- p.i / Index of tables --- p.xiv / Index of figures --- p.xv / Chapter 1. --- Introduction --- p.1 / Chapter 2. --- Literature review --- p.3 / Chapter 2.1 --- Immunosuppression in Organ Transplantation --- p.3 / Chapter 2.2 --- Mechanism of Graft Rejection --- p.4 / Chapter 2.3 --- Conventional immunosuppressive drugs --- p.4 / Chapter 2.3.1 --- Corticosteriod --- p.6 / Chapter 2.3.2 --- Azathioprine --- p.6 / Chapter 2.3.3 --- Polyclonal antilymphocyte globulin and OKT3 --- p.7 / Chapter 2.4 --- Cyclosporine A (CsA) --- p.8 / Chapter 2.4.1 --- Mechanisms of CsA --- p.8 / Chapter 2.4.2 --- Pharmacokinetics of CsA --- p.10 / Chapter 2.4.2.1 --- Absorption --- p.10 / Chapter 2.4.2.2 --- Distribution --- p.11 / Chapter 2.4.2.3 --- Metabolism and elimination --- p.11 / Chapter 2.4.2.4 --- Toxicity --- p.12 / Chapter 2.4.3 --- Therapeutic drug monitoring of CsA --- p.13 / Chapter 2.4.3.1 --- CsA trough monitoring --- p.13 / Chapter 2.4.3.2 --- Full AUC monitoring --- p.15 / Chapter 2.4.3.3 --- Limited sampling strategy --- p.16 / Chapter 2.4.3.4 --- Two-hour post dose CsA level monitoring --- p.20 / Chapter 2.4.4 --- Conventional techniques of measuring cyclosporine concentration --- p.23 / Chapter 2.4.4.1 --- High performance liquid chromatography --- p.23 / Chapter 2.4.4.2 --- Non-specific immunoassays --- p.25 / Chapter 2.4.4.3 --- Specific radioimmunoassays --- p.26 / Chapter 2.4.4.4 --- Specific fluorescent polarization immunoassay --- p.26 / Chapter 2.4.4.5 --- Enzyme multiplied immunoassay technique --- p.28 / Chapter 2.4.4.6 --- Cloned enzyme donor immunoassay --- p.29 / Chapter 2.4.4.7 --- Summary for conventional techniques --- p.29 / Chapter 2.5 --- Liquid chromatography mass spectrometry for CsA measurement --- p.30 / Chapter 2.5.1 --- Main components of MS --- p.31 / Chapter 2.5.1.1 --- Specific interfaces to LC --- p.31 / Chapter 2.5.1.2 --- Mass analyzer --- p.33 / Chapter 2.5.1.3 --- Electron multiplier --- p.36 / Chapter 2.5.2 --- Sample preparation for LC-MS/MS for CsA measurement --- p.36 / Chapter 2.5.2.1 --- Liquid-liquid extraction --- p.37 / Chapter 2.5.2.2 --- Solid phase extraction --- p.38 / Chapter 2.5.2.3 --- Column switching --- p.39 / Chapter 2.5.2.4 --- Dilute and shoot --- p.40 / Chapter 2.5.3 --- LC-MS/MS for CsA measurement --- p.40 / Chapter 2.6 --- Summary --- p.42 / Chapter 3. --- Aim of study --- p.43 / Chapter 4. --- Materials and methods --- p.44 / Chapter 4.1 --- Materials --- p.44 / Chapter 4.1.1 --- Chemicals --- p.44 / Chapter 4.1.2 --- Equipment --- p.44 / Chapter 4.1.3 --- Reagent preparation for CsA analysis --- p.45 / Chapter 4.2 --- Methods --- p.48 / Chapter 4.2.1 --- Immunoassay --- p.48 / Chapter 4.2.2 --- Operation of tandem mass spectrometer --- p.48 / Chapter 4.2.2.1 --- Optimization of cone voltage --- p.50 / Chapter 4.2.2.2 --- Optimization of collision energy --- p.50 / Chapter 4.2.3 --- Optimization of LC-MS/MS --- p.51 / Chapter 4.2.3.1 --- Deproteinization procedures of whole blood --- p.52 / Chapter 4.2.3.2 --- Optimization of mobile phase flow rate --- p.52 / Chapter 4.2.3.3 --- Optimization of source temperature --- p.53 / Chapter 4.2.3.4 --- Optimization of the drying gas flow rate --- p.53 / Chapter 4.2.4 --- Matrix interference on MS/MS response --- p.53 / Chapter 4.2.5 --- Analytical performance of CsA on LC-MS/MS --- p.54 / Chapter 4.2.5.1 --- Linearity study --- p.54 / Chapter 4.2.5.2 --- Precision performance --- p.54 / Chapter 4.2.5.3 --- Accuracy performance --- p.54 / Chapter 4.2.5.4 --- The lowest detection limit of the CsA analysis --- p.55 / Chapter 4.2.5.5 --- Correlation study of the CsA analysis --- p.55 / Chapter 4.3 --- CsA pharmacokinetic studies in Chinese patients --- p.56 / Chapter 4.3.1 --- Determining the time point of CsA correlating better with AUC --- p.56 / Chapter 4.3.1.1 --- Patient and method --- p.56 / Chapter 4.3.1.2 --- Statistical analysis --- p.57 / Chapter 4.3.2 --- "Intra-individual variability of CO, C1 and C2" --- p.57 / Chapter 4.3.2.1 --- Patient and method --- p.57 / Chapter 4.3.2.2 --- Statistical analysis --- p.57 / Chapter 5. --- Results and discussion --- p.59 / Chapter 5.1 --- Optimization of MS parameters --- p.5 9 / Chapter 5.1.1 --- Optimization of cone voltage --- p.61 / Chapter 5.1.2 --- Optimization of collision energy --- p.63 / Chapter 5.2 --- Optimization of LC-MS/MS --- p.63 / Chapter 5.2.1 --- Optimization of mobile phase flow rate --- p.63 / Chapter 5.2.2 --- Optimization of ion source temperature and drying gas flow rate --- p.67 / Chapter 5.3 --- Matrix interference on MS/MS response --- p.69 / Chapter 5.4 --- Analytical performances of CsA on LC-MS/MS method --- p.71 / Chapter 5.4.1 --- Linearity --- p.71 / Chapter 5.4.2 --- Precision performance --- p.71 / Chapter 5.4.3 --- Accuracy performance --- p.72 / Chapter 5.4.4 --- The lowest limit of detection --- p.73 / Chapter 5.4.5 --- Correlation study of the CsA analysis --- p.80 / Chapter 5.5 --- The correlation between CsA at different point and AUCo-6 --- p.84 / Chapter 5.6 --- "Intra-individual variability of CO, C1 and C2" --- p.88 / Chapter 5.7 --- Therapeutic ranges of C2 --- p.90 / Chapter 5.8 --- Practical consideration for C2 measurement by LC-MS/MS method --- p.94 / Chapter 6. --- Conclusions --- p.97 / References --- p.98

A inflamação é um evento intrínseco ao transplante que é desencadeado após o dano causado pela cirurgia. No presente trabalho realizou-se a caracterização fenotípica e funcional das células inflamatórias presentes no enxerto, após o transplante alogênico ou singênico de pele em camundongos. Os resultados obtidos mostraram diferenças significativas na produção de citocinas pró e anti-inflamatórias entre o transplante alogênico e singênico, diferenças já detectáveis nas primeiras 24 horas pós-transplante. Mostrou-se que existe produção aumentada de IL-10 no transplante singênico em relação ao transplante alogênico indicando que a produção de IL-10 no enxerto possui um importante papel para o aceite de transplantes de pele. Além disso, na ausência de IL-10, a rejeição de enxertos alogênicos apresentou-se acelerada e surpreendentemente uma grande parcela dos enxertos singênicos não foi aceita e apresentava aspecto de fibrose com grande deposição de colágeno. O conjunto dos dados indica que a IL-10 possui um importante papel regulatório na inflamação local do enxerto. / Inflammation is an intrinsic event of transplantation that occurs due to to damage caused by surgery. In this study, phenotypic and functional characterization of inflammatory cells present in the graft was performed, after allogeneic or syngeneic skin transplantation in mice. Our results show significant differences in the production of pro and anti-inflammatory cytokines between the syngeneic and allogeneic grafts, detectable as early as 24 hours after transplantation. Higher production of IL-10 was shown in the syngeneic grafts in comparison to allogeneic grafts, indicating that production of IL-10 in the graft is important for acceptance. This is reinforced by data that shows that in the absence of IL-10, rejection of allografts is accelerated and that, surprisingly, a high percentage of the syngeneic grafts is not accepted as well, or shows fibrosis with high deposition of collagen. Taken together, this data indicates that IL-10 has an important regulatory function in the local inflammation of the graft.

Lung transplantation is the only therapeutic approach for patients presenting end-stage pulmonary failure. Despite progress made in organ preservation and immunosuppression, primary graft dysfunction and obliterative bronchiolitis still hamper short-term and long-term outcomes, respectively. Interleukin-17 recently emerged as a major actor in several immuno-inflammatory disorders. Clinical and experimental evidence also suggest the implication of interleukin-17 or type 17 CD4+ T cells in lung rejection. We therefore investigated the contribution of this cytokine to graft pathology in a murine model of tracheal transplantation that recapitulates pathological features of lung rejection including the development of obliterative airway disease.<p>We first demonstrated that interleukin-17 contributes to inflammatory lesions in the early phase post-transplantation. Interleukin-17 was found to be produced by &61543;&61540;+ T cells and CD4+ T cells infiltrating the graft and interleukin-17 neutralization significantly reduced the development of epithelial lesions together with inhibition of interleukin-6 and heat-shock-protein 70 gene transcription.<p>We then investigated the contribution of interleukin-17 to obliterative airway disease. Although interleukin-17 did not play a dominant role in absence of immunosuppression, it was found to contribute to airway pathology in animals receiving cyclosporin A. Under this treatment, we first observed dramatic changes in the composition of the lymphocyte populations infiltrating the graft: the numbers of CD8+ T cells producing interferon-&61543; and type 1 CD4+ T cells were dramatically decreased while the numbers of type 17, and also type 2 CD4+ T cells were unaffected. The pathological relevance of these findings was first demonstrated by the prolongation of graft survival afforded by the depletion of CD4+ T cells in cyclosporin A-treated animals. Furthermore, graft rejection was also delayed in mice genetically deficient in either interleukin-17 or interleukin-4, providing evidence that type 17 and type 2 CD4+ T cells actively contribute to graft rejection in cyclosporin A-treated recipients. On the other hand, parallel experiments in interferon-&61543;-deficient mice revealed that interferon-& / Doctorat en Sciences médicales / info:eu-repo/semantics/nonPublished

Summary<p>Immune homeostasis relies on a subtle balance between fight towards pathogens and inhibitory mechanisms that prevent inappropriate responses against self and environmental antigens (allergy). Regulatory T (Treg) cells play a central role in this balance. Optimizing Treg effects represents a promising approach for new stratetiges aiming to induce or restore tolerance against allo or self antigens. The first part of this work demonstrates that CD4+ lymphocytes that secrete IL-17A (Th17) promote allograft rejection in a murin model of skin transplantation with minor antigen disparities. Interestingly, Treg cells strengthen rather than inhibit Th17 effector mechanisms in this model. Indeed, we found that in vivo Treg depletion prevented IL-17 production by recipient T cells. An adoptive cotransfer of Treg with naive monospecific antidonor T cells in lymphopenic hosts biased the immune response towards a dominant Th17 phenotype. Finally, we observed that IL-6 was central for balancing Treg and Th17 cells as demonstrated by the prevention of Th17 differentiation, the enhanced Treg/Th17 ratio, and rejection blockade in the absence of IL-6. In conclusion, the ability of Treg to promote a Th17 pathway of rejection we described should be considered as a potential drawback of Treg-based cell therapy.<p>Based on the hypothesis that Treg promote Th17 immune response, we tested the effect of IL-17A neutralization in a model in which long-term skin allograft survival depends on a transient in vivo Treg expansion induced by exogenous IL-2. As expected, IL-2 administration prevented rejection of MHC class II disparate skin allografts. Surprisingly this treatment was inefficient in IL17A-/- recipients. We attested that IL-17A was not required for IL-2-mediated Treg expansion, recruitment or suppressive capacities. Instead, IL-17A prevented allograft rejection by inhibiting Th1 alloreactivity independently of Treg. Indeed, T-bet expression of naïve alloreactive CD4+ T cells and the subsequent Th1 immune response was significantly enhanced in IL-17A deficient mice. Our results illustrate, to our knowledge, for the first time a protective role of IL-17A in CD4+-mediated allograft rejection process.<p>In the last part of this work, we used the same mouse model of MHC class II-mismatched skin grafts in which long-term acceptance is achieved by a short-term administration of exogenous IL-2. We first confirmed that Tregs play a central role in preventing skin graft rejection as attested by the prompt donor skin destruction occuring after Treg cell depletion.<p>In the context of IL-2-mediated anti-rejection therapy, concomitant costimulatory blockade with CTLA4-Ig paradoxically restored skin allograft rejection and Th1 alloreactivity indicating that Treg-mediated suppresion absolutely required CD28-B7 or CTLA4/B7 interactions. Further experiments showed that CTLA4-Ig inhibited IL-2-driven Treg expansion, and prevented in particular the occurrence of ICOS+ Treg endowed with potent suppressive capacities. Restoring CD28 signaling was sufficient to counteract the deleterious effect of CTLA4-Ig on Treg expansion and functionality, in keeping with the hypothesis that costimulatory blockade inhibits Treg expansion and function by limiting the delivery of essential CD28-dependent signals. Inhibition of regulatory T cell function should therefore be taken into account when designing tolerance protocols based on costimulatory blockade.<p> <p>RÉSUMÉ<p>Le bon fonctionnement du système immunitaire résulte d’un équilibre entre les réponses immunes « effectrices » qui luttent contre les pathogènes et des mécanismes « régulateurs » permettant de les contrôler. Parmi ces mécanismes inhibiteurs, les lymphocytes T régulateurs (Treg) jouent un rôle crucial. En empêchant le débordement des réponses effectrices, ils préviennent l’apparition des allergies et des maladies auto-immunes ou inflammatoires. Dès lors, il est aisé d’imaginer le potentiel thérapeutique de ces cellules pour contrecarrer les phénomènes autoimmuns ou les réponses allogéniques responsables du rejet en transplantation. C’est donc l’étude des Treg chez la souris qui se trouve au centre des nos préoccupations dans ce travail.<p>Dans la première partie, nous avons démontré le rôle des lymphocytes CD4+ sécréteurs d’IL-17A (Th17) dans le rejet de greffe de peau présentant une disparité d’antigène mineur de transplantation. Dans ce modèle de rejet « Th17 », les données indiquent que, contrairement aux lignées Th1 et Th2, la réponse Th17 est favorisée par les Treg renversant ainsi le paradigme absolu du « Treg inhibiteur ». En effet, la déplétion des Treg dans notre modèle abolit l’expression des gènes caractéristiques de la voie Th17. De plus, dans un système de transfert adoptif chez la souris lymphopénique, l’ajout de Treg à une population T CD4+ effectrice naïve favorise leur différenciation en Th17. Enfin, en invalidant le gène de l’IL-6 dans notre combinaison allogénique mineure, nous avons mis en évidence la place importante de cette cytokine dans le rejet Th17 ainsi que dans la balance Th17/Treg en alloimmunité. <p>En partant du postulat que les Treg favorisent les réponses Th17, nous avons étudié l’impact de la déficience en IL-17A dans un modèle de greffe de peau réalisée en présence de quatités acrues de Treg. Pour cela, nous avons utilisé un modèle de rejet induit par une disparité isolée du CMH II au cours duquel les Treg sont amplifiés par l’injection d’IL-2 exogène durant les trois premiers jours de greffe. Dans ce système, l’expansion transitoire des Treg chez le receveur « sauvage » bloque le rejet dans 75% des cas jusqu’au jour 60 après la greffe sans le moindre traitement immunosuppresseur. Contre toute attente, l’absence d’IL-17A dans ce système restaure le rejet (receveurs IL-17A-/-). Nous avons démontré que l’IL-17A n’est pas requise pour l’expansion, la migration ou la fonction des Treg amplifiés par l’IL-2. En fait, les résultats suggèrent que l’IL-17A bloque le rejet en inhibant la réponse Th1 indépendamment des Treg. Ce point est appuyé par l’exacerbation de la voie Th1 chez le receveur IL-17A-/- et l’inhibition de l’expression de T-bet sous l’influence de l’IL-17A en culture mixte lymphocytaire. Paradoxalement, cette partie du travail rapporte donc un effet protecteur de l’IL-17A illustrant toute la complexité des rôles joués par cette cytokine. <p>La dernière partie du travail utilise le même modèle de greffe de peau allogénique (disparité du CMH II) dans lequel le rejet aigu est bloqué par l’expansion in vivo des Treg induite par l’IL-2 exogène. Nous avons confirmé que l’acceptation à long terme des greffons repose sur les propriétés inhibitrices des Treg amplifiés. Cette inhibition du rejet nécessite impérativement l’intégrité des interactions survenant entre les Treg et les cellules présentatrices d’antigènes du receveur via les molécules B7/CD28. L’ajout de CTLA4-Ig, un immunosuppresseur bloquant les interactions de ces molécules, conduit invariablement à l’accélération paradoxale du rejet. Cet effet pro-inflammatoire du CTLA4-Ig, s’explique par une action délétère sur la survie et la qualité des Treg. En conclusion, les données expérimentales obtenues dans ce dernier volet démontrent l’effet délétère potentiel de ce type de traitement dans les protocoles d’induction de tolérance basé sur l’emploi des Treg.<p> / Doctorat en sciences médicales / info:eu-repo/semantics/nonPublished

Aujourd’hui, il est clairement établi que les lymphocytes T (LT) du donneur stimulés chroniquement par les antigènes mineurs (mHAgs) du receveur sont responsables du développement de la maladie du greffon contre l’hôte (GVHD). Il devient dès lors primordial de mettre au point des mécanismes permettant de contrôler l’activité et la fonctionnalité des LT du donneur soumis à une stimulation antigénique persistante.<p>\ / Doctorat en Sciences biomédicales et pharmaceutiques / info:eu-repo/semantics/nonPublished

Costimulation blockade based on a donor-specific transfusion and anti-CD154 mAb is effective for establishing mixed allogeneic hematopoietic chimerism and inducing transplantation tolerance. Despite its potential, recent evidence suggests that the efficacy of costimulation blockade can be reduced by environmental perturbations such as infection or inflammation that activate toll-like receptors (TLR). TLR agonists prevent costimulation blockade-induced prolongation of solid organ allografts, but their effect on the establishment of hematopoietic chimerism has not been reported. In this dissertation, we hypothesized that TLR activation during costimulation blockade would prevent the establishment of mixed hematopoietic chimerism and shorten skin allograft survival. To test this hypothesis, costimulation blockade-treated mice were co-injected with TLR2 (Pam3Cys), TLR3 (poly I:C), or TLR4 (LPS) agonists and transplanted with allogeneic bone marrow and skin grafts. Supporting our hypothesis, we observed that TLR agonists administered at the time of costimulation blockade prevented the establishment of mixed hematopoietic chimerism and shortened skin allograft survival. To investigate underlying cellular and molecular mechanisms, we first determined that LPS administration during costimulation blockade did not increase production of alloantibodies or activate natural killer cells. Similarly, costimulation blockade-treated mice depleted of CD4+ or CD8+ cells did not become chimeric when co-injected with LPS. In contrast, mice depleted of both CD4+ and CD8+cell subsets were resistant to the effects of LPS. We next observed that alloreactive T cells were activated by TLR agonists in mice treated with costimulation blockade, and this activation correlated with LPS-induced maturation of donor and host alloantigen-presenting cells. In contrast, TLR4-deficient mice treated with costimulation blockade and LPS did not upregulate costimulatory molecules on their APCs, and mixed chimerism and permanent skin allograft survival were readily achieved. We further observed that injection of recombinant IFN-β recapitulated the detrimental effects of LPS, and that LPS-injected mice deficient in the type I IFN receptor were partially protected. Importantly, alloantigen-presenting cells did not upregulate costimulatory molecules in response to LPS, and mixed chimerism and permanent skin allograft survival were readily established in type I IFN receptor and MyD88 double deficient mice treated with costimulation blockade. We conclude that the TLR4 agonist LPS prevents the establishment of mixed hematopoietic chimerism and shortens skin allograft survival in mice treated with costimulation blockade by inducing the production of type 1 IFN and MyD88-dependent factors that upregulate costimulatory molecules on APCs, leading to the generation of activated alloreactive T cells.

Indiana University-Purdue University Indianapolis (IUPUI) / Sepsis is a clinical syndrome due to a systemic inflammatory response to severe microbial infection. Little is known about the changes in the bone marrow (BM) and how they affect the hematopoietic response to bacterial infection. Using an animal model of severe sepsis induced by Pseudomonas aeruginosa, we have previously reported that hematopoietic stem cells (HSC) undergo a significant expansion in the BM accompanied with myeloid suppression. This bone marrow response was Toll-like Receptor 4 (TLR4)-dependent. TLR4 is activated by bacterial lipopolysaccharide (LPS) and signals through two major independent downstream molecules: TRIF and MyD88. In the present study, I found that the TLR4/TRIF and the TLR4/MyD88 pathways contribute in a distinct manner to the BM response to P. aeruginosa's LPS. TRIF plays a major role in the expansion of the HSC pool, whereas MyD88 is required for myeloid suppression. Following LPS stimulation, HSCs enter in the cell cycle, expand and exhaust when transplanted in healthy mice. Loss of TRIF rescued completely the long-term engraftment and multilineage reconstitution potential of septic HSCs, but did not affect myeloid differentiation. Conversely, MyD88 deficiency prevented completely the myeloid suppression in the myeloid progenitors, but conferred limited protective effects on the HSC function. It is of great therapeutic value to identify the downstream molecules involved in TLR4/MyD88 dependent myeloid suppression. I found miR-21, a microRNA that is involved in inflammation, was up-regulated upon LPS challenge in a MyD88-dependent manner. However, deletion of miR-21 in the BM did not rescue LPS-induced bone marrow dysfunction, demonstrating that miR-21 is not a critical regulator in these processes. Further studies are warranted to determine the precise molecular mechanisms involved in the complex pathogenesis of BM response to sepsis. Taken together, my results show for the first time that the TLR4/TRIF signaling as a key mediator of HSC damage during acute LPS exposure and that activation of the TLR4/MyD88 signaling pathway play a dominant role in myeloid suppression. These results provide novel insights into our understanding of the molecular mechanisms underlying bone marrow injury during severe sepsis and may lead to the development of new therapeutic approaches in this disease.

O diabetes mellitus (DM) é a principal causa de doença renal crônica (DRC) em vários países do mundo. Para pacientes diabéticos com DRC estágio 5 e indicação da terapia renal substitutiva, o transplante (Tx) renal representa uma modalidade terapêutica com técnica bem estabelecida e com excelentes resultados. O transplante simultâneo de rim-pâncreas (TSRP), uma alternativa mais recente praticada em um número mais restrito de centros, apresenta resultados positivos adicionais no controle metabólico, na qualidade de vida e nas complicações crônicas do diabetes. Entretanto, está associado a um risco maior de complicações pós-operatórias e maior número de internações. Tanto o transplante renal quanto o TSRP estão associados a melhor sobrevida do paciente em relação à diálise. A escolha da melhor modalidade de transplante para o paciente diabético com DRC ainda não está clara. O objetivo deste estudo foi analisar os resultados de diferentes modalidades de transplante em pacientes diabéticos com DRC estágio 5, realizados em 3 Centros Brasileiros de Transplante. Assim, analisar a sobrevida do paciente e do enxerto renal após 1, 5 e 8 anos em pacientes DM tipo 1 submetidos a TSRP comparados com transplante renal isolado com doador vivo (DM1-DV) ou transplante de renal isolado com doador falecido (DM1-DF) (Estudo de 3 modalidades de Tx em DM tipo1). Além disso, avaliar em pacientes DM tipo 2, os resultados do transplante renal realizado com doador vivo (DM2-DV) ou doador falecido (DM2-DF) comparados com pacientes DM tipo 1 submetidos ao transplante renal com doador vivo (DM1-DV) ou doador falecido (DM1-DF) (Estudo do Tx em DM tipo 2 vs DM tipo1). Os transplantes foram realizados em 3 Centros de Transplante (Hospital Beneficência Portuguesa, Hospital do Rim e Santa Casa de Porto Alegre). No \"Estudo de 3 modalidades de Tx em DM tipo 1\", foram incluídos 372 transplantes, sendo 262 TSRP, 78 DM1-DV e 32 DM1-DF. No \"Estudo do Tx em DM tipo 2 vs DM tipo 1\", foram incluídos 254 transplantes, sendo 78 DM1-DV, 32 DM1-DF, 61 DM2-DV, 83 DM2-DF. As curvas de sobrevida do paciente e do enxerto renal (Kaplan-Meyer) foram calculadas 1, 5 e 8 anos após o transplante. No \"Estudo de 3 modalidades de Tx em DM tipo 1\", a sobrevida do paciente de receptores de DM1-DV foi significativamente superior comparada com a sobrevida dos receptores de DM1-DF e TSRP no 1º ano (98,7%, 87,5% e 83,2%, respectivamente; p < 0,05) e no 5º ano pós-Tx (90,5%, 70% e 77%, respectivamente; p < 0,05). Não foi observada diferença entre a sobrevida dos pacientes do grupo DM1-DV e TSRP em 8 anos. A sobrevida do enxerto renal foi superior nos receptores DM1-DV no 1º ano pós-Tx, quando comparada com a sobrevida dos receptores DM1-DF e TSRP (96,1%, 84,4% e 80,2%, respectivamente; p < 0,05). Após 5 e 8 anos, a sobrevida do enxerto renal foi semelhante entre os grupos. Ocorreram 90 óbitos durante o período de estudo sendo as principais causas, a infecção (50%) e doença cardiovascular (22%). Óbito com enxerto funcionante e nefropatia crônica do enxerto foram as principais causas de perda do enxerto renal. No \"Estudo do Tx em DM tipo 2 vs DM tipo 1\", como esperado, os pacientes DM tipo 1 eram mais jovens em relação aos pacientes DM tipo 2 (mediana 37,5 e 55 anos, respectivamente; p < 0,0001). Os pacientes transplantados com doador falecido permaneceram maior tempo em tratamento dialítico pré-transplante (mediana 36 meses em DM1-DF e 36 meses em DM2-DF) comparados com pacientes transplantados com doador vivo (mediana 14 meses em DM1-DV e 18 meses em DM2-DV; p < 0,0001). Em pacientes com DM tipo 2, a sobrevida do paciente em 1, 5 e 8 anos nos pacientes DM2-DV foi 95,1%, 87,9% e 81,8%, respectivamente, significativamente maior do que nos pacientes DM2-DF (74,7%, 59,4% e 48,5%, respectivamente; p < 0,01). Em pacientes com DM tipo 1, a sobrevida do paciente em 1, 5 e 8 anos foi 98,7%, 90,5% e 82,1%, respectivamente, significativamente maior do que nos pacientes DM1-DV que nos pacientes DM1-DF (87,5%, 70% e 66,3%, respectivamente; p < 0,01). Comparando-se a sobrevida dos pacientes DM tipo 2 em relação aos DM tipo 1 submetidos a transplante com um mesmo tipo de doador, não foi observado diferença estatisticamente significante. Pacientes do grupo DM2-DV e pacientes DM1-DV apresentaram sobrevidas semelhantes. A sobrevida dos pacientes DM2-DF encontrada foi inferior em relação aos pacientes DM1-DF, porém sem diferença estatística. Em pacientes com DM tipo 2, a sobrevida do enxerto renal em 1, 5 e 8 anos nos pacientes DM2-DV foi 91,8%, 81,2% e 75,3%, respectivamente, significativamente maior do que nos pacientes DM2-DF (73,5%, 54,9% e 44.3%, respectivamente; p < 0,01). Em pacientes com DM tipo 1, a sobrevida do enxerto renal em 1, 5 e 8 anos nos pacientes DM1-DV foi 96,1%, 80,8% e 72,3%, respectivamente, significativamente maior do que nos pacientes DM1-DF (84,4%, 66,8% e 59,3%, respectivamente; p < 0,01) apenas no primeiro ano. Ocorreram 52 óbitos em pacientes DM tipo 2 sendo a infecção principal causa de óbito nos pacientes DM2-DF e a doença cardiovascular a principal causa de óbito nos DM2-DV. Ocorreram 23 óbitos no grupo de pacientes DM tipo 1 e a principal causa foi infecção nos pacientes DM1-DF e a doença cardiovascular nos DM1-DV. A principal causa de perda do enxerto renal foi óbito com enxerto funcionante (74%), seguido pela nefropatia crônica do enxerto (15%). Conclusão: Os resultados do \"Estudo de 3 modalidades de Tx em DM tipo1\" mostraram que em pacientes portadores de DM tipo 1 o transplante renal isolado realizado com doador vivo apresentou resultados superiores em relação às outras modalidades de transplante. Entretanto, em longo prazo, a sobrevida dos pacientes submetidos ao transplante renal com doador vivo não foi estatisticamente diferente do TSRP. Os resultados do \"Estudo do Tx em DM tipo 2 vs DM tipo1\" mostraram que o transplante renal com doador vivo é uma boa opção de terapia renal substitutiva para pacientes com DM tipo 2. Entretanto, os resultados observados nesta análise desencorajam a indicação de transplante renal com doador falecido para pacientes portadores de DM tipo 2, devendo ser indicado apenas em casos selecionados / Diabetes mellitus is the leading cause of chronic kidney disease (CKD) in several countries around the world. For diabetic patients with stage 5 CKD with an indication of renal replacement therapy, renal transplantation is a therapeutic modality with well-established technique and with excellent results. The simultaneous kidney-pancreas transplantation (SPK), a more recent modality of treatment, performed in a limited number of centers, presents additional positive results in metabolic control, quality of life, and chronic complications of diabetes mellitus (DM). However, it is associated with an increased risk of postoperative complications and a higher number of hospitalizations. Both renal and SPK transplantation are associated with better patient survival outcomes compared to dialysis. The choice of the best modality of transplantation for diabetic patients with CKD is not yet clear. The aim of this study was to analyze the results of different modalities of transplant for diabetic patients with CKD stage 5, performed in 3 Brazilian Transplant Centers. More specifically, the aim of this study was to analyze the patient and graft survival after 1, 5, and 8 years post-transplantation in type 1 DM patients submitted to SPK compared with diabetic patients submitted to isolated kidney transplant with living donor (DM1-LD) or deceased donor (DM1-DD) (Study of 3 Tx (transplant) modalities in type 1 DM). In addition, the aim of this study was also to evaluate the results of renal transplantation in type 2 DM performed with living donor (DM2-LD) or deceased donor (DM2-DD) compared with kidney transplantation in type 1 DM performed with living donor (DM2-LD) or deceased donor (DM2-DD) (Study of Tx in type 2 DM vs. type 1 DM). The transplants were performed in 3 Transplant Centers (Hospital Beneficência Portuguesa, Hospital do Rim, and Santa Casa de Porto Alegre). In the \"Study of 3 transplant modalities in type 1 DM\", 372 recipients were included, (262 SPK, 78 DM1-LD, and 32 DM1-DD). In the \"Study of Tx in type 2 DM vs. type 1 DM\", 254 transplants were included, 78 DM1-LD, 32 DM1-DD, 61 DM2-LD, 83 DM2-DD. Patient and graft survival distribution estimates were calculated using the Kaplan-Meier method in the 1, 5 and 8 years post-transplantation. In the \"Study of 3 transplant Tx modalities in type 1 DM\", the patient survival of DM1-LD recipients was significantly higher compared with the survival of DM1-DD and SPK at 1 year (98.7%, 87.5% and 83.2%, respectively; p < 0.05), and at 5 years post-transplantation (90.5%, 70% and 77%, respectively; p < 0.05). After 8 years, there was no significant difference between the survival of patients in group DM1-LD and SPK. The kidney graft survival was higher in DM1-LD, at 1 year, compared with survival of DM1-DD and SPK (96.2%, 84.4% and 80.8%, respectively; p < 0.05). After 5 and 8 years, the kidney graft survival was similar between the groups. There were 90 deaths during the study period and infection (50%) and cardiovascular disease (22%) were the major causes. Death with a functioning graft and chronic allograft nephropathy were the main causes of kidney graft loss. In the \"Study of Tx in type 2 DM vs. type 1 DM\", type 1 DM patients were younger compared to type 2 DM patients (median 37.5 and 55 years, respectively; p < 0.0001). Recipients of deceased donor remained longer time on dialysis before transplantation (median 36 months in DM1-DD, and 36 in DM2-DD) compared with patients transplanted with living donor (median 14 months in DM1-LD and 18 months in DM2-LD, p < 0.0001). In type 2 DM, patient survival at 1, 5 and 8 years in the group DM2-LD was 95.1%, 87.9%, and 81.8, respectively, significantly higher than patient survival in DM2-DD recipients (74.7, 59,4, and 48.5; respectively, p < 0.01). In type 1 DM, patient survival at 1, 5 and 8 years in the group DM1-LD was 98.7%, 90.5% and 82.1%, respectively, significantly higher than patient survival in DM1-DD recipients ( 87.5%, 70%, and 48.5%; respectively, p < 0.01). The comparison between patient survival with type 2 DM and type 1 DM undergoing kidney transplantation with the same type of donor, was not statistically different between the groups. Patient survival in group DM2-LD and DM1-LD was not different. Patient survival in the group DM2-DD was inferior to the group DM1-DD but without significant differences. In type 2 DM, kidney survival at 1, 5 and 8 years in the group DM2-LD was 91.8%, 81 2%, and 75.3%, respectively, significantly higher than patient survival in DM2-DD recipients (73.5%, 54.9%, and 44.3%, respectively, p < 0.01). In type 1 DM, kidney survival at 1, 5 and 8 years in the group DM1-LD was 96.1%, 80.8%, and 72.3%,, respectively, significantly higher than patient survival in DM1-DD recipients (84.4%, 66.8%, and 59.3%, respectively, p < 0.01) only in the first year. In these patients the kidney graft survival was superior in the group DM2-LD compared with DM2-DD. In type 1 DM patients kidney graft survival was 96.1%, 80.8% and 72.3% in patients DM1-LD; 84.4%, 66.8% and 59.3% in patients DM1-DD (p < 0.01); respectively. There were 52 deaths in the group of type 2 DM patients. Infection was the main cause of death in the group DM2-DD, and cardiovascular disease was the main cause in DM2-LD. There were 23 deaths in the group of type 1 DM patients and the main cause was infection in the group DM1-DD and cardiovascular disease in the group DM1-LD. The main cause of kidney graft loss was death with a functioning graft (74%), followed by chronic allograft nephropathy (15%). Patients in group DM2-LD showed good survival rates, particularly in the first year. Conclusion: The \"Study of 3 transplant modalities in type 1 DM\" showed better patient and graft survival with isolated kidney transplantation with living donor compared with others transplant modalities. However, at longer follow up (8 years), survival of patients undergoing living donor kidney transplantation was not statistically different to SPK. In the \"Study of Tx in type 2 DM vs. type 1 DM\", renal transplantation performed with living donor is a good option of renal replacement therapy for type 2 DM. The results observed in this analysis discourage the indication of kidney transplantation with deceased donor for patients with type 2 DM, which should be indicated in selected cases

O citomegalovírus (CMV) é uma séria ameaça aos receptores de transplante de medula óssea. A reativação está associada com uma imunidade mediada por células TCD8+ defeituosa. Nosso objetivo foi correlacionar as diferentes subpopulações de células TCD8+ com a reconstituição imunológica dos pacientes, especificamente a imunidade anti-CMV, analisando as subpopulações de células T infundidas nas diferentes modalidades de transplante de medula óssea. Receptores de transplante alogênico de células tronco mobilizadas para o sangue periférico (n=16) ou coletadas diretamente da medula óssea (n=28) e receptores de transplante autólogo de células tronco mobilizadas para o sangue periférico (n=22) foram avaliados. Verificamos que as transferências de células mobilizadas para o sangue periférico dos doadores, tanto nos transplantes alogênicos como autólogos, são proporcionalmente enriquecidas por subpopulações de células memória efetora e efetora, comparadas às transferências de células procedentes diretamente da medula óssea. Este enriquecimento por subpopulações de células TCD8+ mais diferenciadas foi também correlacionado com maior número de células contendo altos níveis de granzima B, considerado um marcador para linfócitos citotóxicos, sendo também encontrado em maior número nas transferências de células do sangue periférico. Entretanto, no pós-transplante, observou-se que somente os receptores de transplante autólogo de células tronco mobilizadas para o sangue periférico, e não os das outras modalidades de transplante, exibiam números elevados de células T CD8+ de memória-efetora e efetora. Ao mesmo tempo, estes receptores apresentaram menos freqüentemente episódios de reativação pelo CMV, e mais freqüentemente produziram IFN-gama em resposta ao CMV. Portanto, a transferência de células do sangue periférico, desde que em ambiente autólogo, está associada não só com a transferência de células TCD8+ com um fenótipo mais maduro, mas também com uma persistência mais prolongada das mesmas, podendo proporcionar uma resposta imunológica antiviral mais rápida e eficiente, como esperado para as células de memória versus naïve. / Cytomegalovirus (CMV) is a serious threat to the recipients of bone marrow transplantation. Reactivation is associated with defective CD8+ T cell-mediated immunity. We aimed to correlate the different subsets of CD8+ T cells with the patients\' immune reconstitution, specifically anti CMV immunity, by analyzing the CD8+ T cell subsets infused in the different types of bone marrow transplantation. Recipients of allogeneic transplant of peripheral blood stem cells (n=16) or bone marrow (n=28) and recipients of autologous transplant of peripheral blood stem cells (n=22) were evaluated. We show that infusions of stem cells derived from donor\'s peripheral blood, either allogeneic or autologous, are proportionally enriched for the memory-effector and effector phenotypes, compared to the infusions of stem cells of bone marrow origin. This increased number of more differentiated subsets of CD8+ T cells was also correlated with an increased number of cells containing high levels of granzyme B, which is another reliable marker of cytotoxic lymphocyte, and which was also more evident in autologous recipients. However, post-transplant, we observed that only the recipients of autologous peripheral blood cells, and not the recipients of the other transplant modalities, exhibited very high numbers of memory-effector and effector TCD8+ cells. At the same time, they less frequently presented CMV reactivation, and more frequently produced IFN-gama in response to CMV antigens. Thus, transfer of stem cells from peripheral blood, provided in an autologous setting, is associated with transfer and prolonged survival of CD8+ T cells with a more mature phenotype, which may provide a more rapid and efficient anti-viral immune response, as expected for memory versus naïve cells.

O diabetes mellitus (DM) é a principal causa de doença renal crônica (DRC) em vários países do mundo. Para pacientes diabéticos com DRC estágio 5 e indicação da terapia renal substitutiva, o transplante (Tx) renal representa uma modalidade terapêutica com técnica bem estabelecida e com excelentes resultados. O transplante simultâneo de rim-pâncreas (TSRP), uma alternativa mais recente praticada em um número mais restrito de centros, apresenta resultados positivos adicionais no controle metabólico, na qualidade de vida e nas complicações crônicas do diabetes. Entretanto, está associado a um risco maior de complicações pós-operatórias e maior número de internações. Tanto o transplante renal quanto o TSRP estão associados a melhor sobrevida do paciente em relação à diálise. A escolha da melhor modalidade de transplante para o paciente diabético com DRC ainda não está clara. O objetivo deste estudo foi analisar os resultados de diferentes modalidades de transplante em pacientes diabéticos com DRC estágio 5, realizados em 3 Centros Brasileiros de Transplante. Assim, analisar a sobrevida do paciente e do enxerto renal após 1, 5 e 8 anos em pacientes DM tipo 1 submetidos a TSRP comparados com transplante renal isolado com doador vivo (DM1-DV) ou transplante de renal isolado com doador falecido (DM1-DF) (Estudo de 3 modalidades de Tx em DM tipo1). Além disso, avaliar em pacientes DM tipo 2, os resultados do transplante renal realizado com doador vivo (DM2-DV) ou doador falecido (DM2-DF) comparados com pacientes DM tipo 1 submetidos ao transplante renal com doador vivo (DM1-DV) ou doador falecido (DM1-DF) (Estudo do Tx em DM tipo 2 vs DM tipo1). Os transplantes foram realizados em 3 Centros de Transplante (Hospital Beneficência Portuguesa, Hospital do Rim e Santa Casa de Porto Alegre). No \"Estudo de 3 modalidades de Tx em DM tipo 1\", foram incluídos 372 transplantes, sendo 262 TSRP, 78 DM1-DV e 32 DM1-DF. No \"Estudo do Tx em DM tipo 2 vs DM tipo 1\", foram incluídos 254 transplantes, sendo 78 DM1-DV, 32 DM1-DF, 61 DM2-DV, 83 DM2-DF. As curvas de sobrevida do paciente e do enxerto renal (Kaplan-Meyer) foram calculadas 1, 5 e 8 anos após o transplante. No \"Estudo de 3 modalidades de Tx em DM tipo 1\", a sobrevida do paciente de receptores de DM1-DV foi significativamente superior comparada com a sobrevida dos receptores de DM1-DF e TSRP no 1º ano (98,7%, 87,5% e 83,2%, respectivamente; p < 0,05) e no 5º ano pós-Tx (90,5%, 70% e 77%, respectivamente; p < 0,05). Não foi observada diferença entre a sobrevida dos pacientes do grupo DM1-DV e TSRP em 8 anos. A sobrevida do enxerto renal foi superior nos receptores DM1-DV no 1º ano pós-Tx, quando comparada com a sobrevida dos receptores DM1-DF e TSRP (96,1%, 84,4% e 80,2%, respectivamente; p < 0,05). Após 5 e 8 anos, a sobrevida do enxerto renal foi semelhante entre os grupos. Ocorreram 90 óbitos durante o período de estudo sendo as principais causas, a infecção (50%) e doença cardiovascular (22%). Óbito com enxerto funcionante e nefropatia crônica do enxerto foram as principais causas de perda do enxerto renal. No \"Estudo do Tx em DM tipo 2 vs DM tipo 1\", como esperado, os pacientes DM tipo 1 eram mais jovens em relação aos pacientes DM tipo 2 (mediana 37,5 e 55 anos, respectivamente; p < 0,0001). Os pacientes transplantados com doador falecido permaneceram maior tempo em tratamento dialítico pré-transplante (mediana 36 meses em DM1-DF e 36 meses em DM2-DF) comparados com pacientes transplantados com doador vivo (mediana 14 meses em DM1-DV e 18 meses em DM2-DV; p < 0,0001). Em pacientes com DM tipo 2, a sobrevida do paciente em 1, 5 e 8 anos nos pacientes DM2-DV foi 95,1%, 87,9% e 81,8%, respectivamente, significativamente maior do que nos pacientes DM2-DF (74,7%, 59,4% e 48,5%, respectivamente; p < 0,01). Em pacientes com DM tipo 1, a sobrevida do paciente em 1, 5 e 8 anos foi 98,7%, 90,5% e 82,1%, respectivamente, significativamente maior do que nos pacientes DM1-DV que nos pacientes DM1-DF (87,5%, 70% e 66,3%, respectivamente; p < 0,01). Comparando-se a sobrevida dos pacientes DM tipo 2 em relação aos DM tipo 1 submetidos a transplante com um mesmo tipo de doador, não foi observado diferença estatisticamente significante. Pacientes do grupo DM2-DV e pacientes DM1-DV apresentaram sobrevidas semelhantes. A sobrevida dos pacientes DM2-DF encontrada foi inferior em relação aos pacientes DM1-DF, porém sem diferença estatística. Em pacientes com DM tipo 2, a sobrevida do enxerto renal em 1, 5 e 8 anos nos pacientes DM2-DV foi 91,8%, 81,2% e 75,3%, respectivamente, significativamente maior do que nos pacientes DM2-DF (73,5%, 54,9% e 44.3%, respectivamente; p < 0,01). Em pacientes com DM tipo 1, a sobrevida do enxerto renal em 1, 5 e 8 anos nos pacientes DM1-DV foi 96,1%, 80,8% e 72,3%, respectivamente, significativamente maior do que nos pacientes DM1-DF (84,4%, 66,8% e 59,3%, respectivamente; p < 0,01) apenas no primeiro ano. Ocorreram 52 óbitos em pacientes DM tipo 2 sendo a infecção principal causa de óbito nos pacientes DM2-DF e a doença cardiovascular a principal causa de óbito nos DM2-DV. Ocorreram 23 óbitos no grupo de pacientes DM tipo 1 e a principal causa foi infecção nos pacientes DM1-DF e a doença cardiovascular nos DM1-DV. A principal causa de perda do enxerto renal foi óbito com enxerto funcionante (74%), seguido pela nefropatia crônica do enxerto (15%). Conclusão: Os resultados do \"Estudo de 3 modalidades de Tx em DM tipo1\" mostraram que em pacientes portadores de DM tipo 1 o transplante renal isolado realizado com doador vivo apresentou resultados superiores em relação às outras modalidades de transplante. Entretanto, em longo prazo, a sobrevida dos pacientes submetidos ao transplante renal com doador vivo não foi estatisticamente diferente do TSRP. Os resultados do \"Estudo do Tx em DM tipo 2 vs DM tipo1\" mostraram que o transplante renal com doador vivo é uma boa opção de terapia renal substitutiva para pacientes com DM tipo 2. Entretanto, os resultados observados nesta análise desencorajam a indicação de transplante renal com doador falecido para pacientes portadores de DM tipo 2, devendo ser indicado apenas em casos selecionados / Diabetes mellitus is the leading cause of chronic kidney disease (CKD) in several countries around the world. For diabetic patients with stage 5 CKD with an indication of renal replacement therapy, renal transplantation is a therapeutic modality with well-established technique and with excellent results. The simultaneous kidney-pancreas transplantation (SPK), a more recent modality of treatment, performed in a limited number of centers, presents additional positive results in metabolic control, quality of life, and chronic complications of diabetes mellitus (DM). However, it is associated with an increased risk of postoperative complications and a higher number of hospitalizations. Both renal and SPK transplantation are associated with better patient survival outcomes compared to dialysis. The choice of the best modality of transplantation for diabetic patients with CKD is not yet clear. The aim of this study was to analyze the results of different modalities of transplant for diabetic patients with CKD stage 5, performed in 3 Brazilian Transplant Centers. More specifically, the aim of this study was to analyze the patient and graft survival after 1, 5, and 8 years post-transplantation in type 1 DM patients submitted to SPK compared with diabetic patients submitted to isolated kidney transplant with living donor (DM1-LD) or deceased donor (DM1-DD) (Study of 3 Tx (transplant) modalities in type 1 DM). In addition, the aim of this study was also to evaluate the results of renal transplantation in type 2 DM performed with living donor (DM2-LD) or deceased donor (DM2-DD) compared with kidney transplantation in type 1 DM performed with living donor (DM2-LD) or deceased donor (DM2-DD) (Study of Tx in type 2 DM vs. type 1 DM). The transplants were performed in 3 Transplant Centers (Hospital Beneficência Portuguesa, Hospital do Rim, and Santa Casa de Porto Alegre). In the \"Study of 3 transplant modalities in type 1 DM\", 372 recipients were included, (262 SPK, 78 DM1-LD, and 32 DM1-DD). In the \"Study of Tx in type 2 DM vs. type 1 DM\", 254 transplants were included, 78 DM1-LD, 32 DM1-DD, 61 DM2-LD, 83 DM2-DD. Patient and graft survival distribution estimates were calculated using the Kaplan-Meier method in the 1, 5 and 8 years post-transplantation. In the \"Study of 3 transplant Tx modalities in type 1 DM\", the patient survival of DM1-LD recipients was significantly higher compared with the survival of DM1-DD and SPK at 1 year (98.7%, 87.5% and 83.2%, respectively; p < 0.05), and at 5 years post-transplantation (90.5%, 70% and 77%, respectively; p < 0.05). After 8 years, there was no significant difference between the survival of patients in group DM1-LD and SPK. The kidney graft survival was higher in DM1-LD, at 1 year, compared with survival of DM1-DD and SPK (96.2%, 84.4% and 80.8%, respectively; p < 0.05). After 5 and 8 years, the kidney graft survival was similar between the groups. There were 90 deaths during the study period and infection (50%) and cardiovascular disease (22%) were the major causes. Death with a functioning graft and chronic allograft nephropathy were the main causes of kidney graft loss. In the \"Study of Tx in type 2 DM vs. type 1 DM\", type 1 DM patients were younger compared to type 2 DM patients (median 37.5 and 55 years, respectively; p < 0.0001). Recipients of deceased donor remained longer time on dialysis before transplantation (median 36 months in DM1-DD, and 36 in DM2-DD) compared with patients transplanted with living donor (median 14 months in DM1-LD and 18 months in DM2-LD, p < 0.0001). In type 2 DM, patient survival at 1, 5 and 8 years in the group DM2-LD was 95.1%, 87.9%, and 81.8, respectively, significantly higher than patient survival in DM2-DD recipients (74.7, 59,4, and 48.5; respectively, p < 0.01). In type 1 DM, patient survival at 1, 5 and 8 years in the group DM1-LD was 98.7%, 90.5% and 82.1%, respectively, significantly higher than patient survival in DM1-DD recipients ( 87.5%, 70%, and 48.5%; respectively, p < 0.01). The comparison between patient survival with type 2 DM and type 1 DM undergoing kidney transplantation with the same type of donor, was not statistically different between the groups. Patient survival in group DM2-LD and DM1-LD was not different. Patient survival in the group DM2-DD was inferior to the group DM1-DD but without significant differences. In type 2 DM, kidney survival at 1, 5 and 8 years in the group DM2-LD was 91.8%, 81 2%, and 75.3%, respectively, significantly higher than patient survival in DM2-DD recipients (73.5%, 54.9%, and 44.3%, respectively, p < 0.01). In type 1 DM, kidney survival at 1, 5 and 8 years in the group DM1-LD was 96.1%, 80.8%, and 72.3%,, respectively, significantly higher than patient survival in DM1-DD recipients (84.4%, 66.8%, and 59.3%, respectively, p < 0.01) only in the first year. In these patients the kidney graft survival was superior in the group DM2-LD compared with DM2-DD. In type 1 DM patients kidney graft survival was 96.1%, 80.8% and 72.3% in patients DM1-LD; 84.4%, 66.8% and 59.3% in patients DM1-DD (p < 0.01); respectively. There were 52 deaths in the group of type 2 DM patients. Infection was the main cause of death in the group DM2-DD, and cardiovascular disease was the main cause in DM2-LD. There were 23 deaths in the group of type 1 DM patients and the main cause was infection in the group DM1-DD and cardiovascular disease in the group DM1-LD. The main cause of kidney graft loss was death with a functioning graft (74%), followed by chronic allograft nephropathy (15%). Patients in group DM2-LD showed good survival rates, particularly in the first year. Conclusion: The \"Study of 3 transplant modalities in type 1 DM\" showed better patient and graft survival with isolated kidney transplantation with living donor compared with others transplant modalities. However, at longer follow up (8 years), survival of patients undergoing living donor kidney transplantation was not statistically different to SPK. In the \"Study of Tx in type 2 DM vs. type 1 DM\", renal transplantation performed with living donor is a good option of renal replacement therapy for type 2 DM. The results observed in this analysis discourage the indication of kidney transplantation with deceased donor for patients with type 2 DM, which should be indicated in selected cases