O monitoramento de imunossupressores, como os inibidores de calcineurina ou de mTOR, é essencial para evitar desfechos clínicos desfavoráveis, em receptores de transplante renal. Polimorfismos em genes envolvidos na farmacocinética têm sido associados com variabilidade na resposta a imunossupressores, porém o papel de polimorfismos em genes envolvidos na farmacodinâmica é pouco conhecido. O objetivo deste estudo foi investigar a influência de polimorfismos de MTOR, PPP3CA, FKBP1A, FKBP2 e FOXP3, genes envolvidos na farmacodinâmica de imunossupressores, sobre a resposta clínica a tacrolimo e everolimo, em receptores de transplante renal. Foram incluídos 269 pacientes do ensaio clínico original (NCT01354301), realizado no Hospital do Rim e Hipertensão da UNIFESP, e randomizados em três esquemas imunossupressores: tacrolimo 0,05 mg/kg/dia com everolimo 1,5 mg/dia (TAC5/EVR); tacrolimo 0,1 mg/kg/dia com everolimo 1,5 mg/dia (TAC10/EVR); e tacrolimo 0,1 mg/kg/dia com micofenolato de sódio (TAC10/MFS). Foram coletados dados clínicos e laboratoriais, tais como o monitoramento de imunossupressores e desfechos de eficácia de segurança. Os polimorfismos nos genes MTOR (c.4731G>A, c.1437T>C, c.2997C>T); PPP3CA (c.249G>A); FKBP1A (n.259+243936T>C); FBKP2 (c.-2110G>T) e FOXP3 (c.-23+2882A>C, c.-22-902A>G) foram analisados por PCR em tempo real. As frequências alélicas dos polimorfismos estudados foram similares às da população global do projeto 1000genomes. O tratamento com everolimo e tacrolimo em maior dose (TAC10/EVR) foi associado com menor taxa de filtração glomerular estimada (TFGe) e maior creatinina sérica. Enquanto que o tratamento com tacrolimo e micofenolato de sódio (TAC10/MFS) foi associado com maior número de episódios de infecção por citomegalovirus, no 1° ano pós-transplante. Com relação aos desfechos de eficácia, os portadores do genótipo CC de MTOR c.1437T>C e FOXP3 c-23+2882A>C apresentaram maiores concentrações de creatinina sérica, no 12° mês (p<0,05). O polimorfismo FOXP3 c.-23+2882A>C foi associado com maior probabilidade de creatinina sérica aumentada (OR=1,75; IC95%=1,07-2,86; p=0,025). Os resultados da análise de regressão logística mostraram que o alelo MTOR c.4731G (genótipos AG+GG) foi associado com maior risco de rejeição aguda (OR=3,37; IC95%=1,10-10,30; p=0,033). Os portadores do alelo c.4731G apresentaram maior incidência cumulativa de episódios de rejeição, no 1° ano pós-transplante. Com relação aos desfechos de segurança, a variante FKBP2 c.-2110G>T (genótipo GG) foi associada com maior risco de leucopenia (OR=7,10; IC95%=1,81-27,87; p=0,025). O polimorfismo FKBP1A n.259+24936T>C (alelo C) foi associado com maior risco de constipação (OR=2,52; IC95%=1,13 - 5,61; p=0,024), enquanto que os polimorfismos FOXP3 c.-22-902A>G (alelo A) e c.-23+2882A>C (alelo A) foram associados, respectivamente, com maior risco de epigastralgia (OR=2,15; IC95%=1,01-4,56; p=0,047) e náuseas e/ou vômitos (OR=2,38; IC95%=1,05-5,38; p=0,038). O risco de apresentar dislipidemia foi maior nos portadores dos genótipos FKBP2 c.-21110GG (OR=1,92; IC95%=1,01-3,69; p=0,049) e FOXP3 c.-22-902GG (OR=2,06; IC95%=1,08-3,92; p=0,028). Em conclusão, os polimorfismos de genes MTOR, FKBP1A, FKBP2 e FOXP3 influenciam na função renal do enxerto e estão associados com risco de rejeição aguda e de eventos adversos, em receptores de transplante renal. / The monitoring of immunosuppressive drugs, such as calcineurin and mTOR inhibitors, is essential to avoid undesirable kidney transplant outcomes. Polymorphisms in pharmacokinetics-related genes have been associated with variability in the response to immunosuppressive drugs, but the role of polymorphisms in pharmacodynamics-related genes is little known. The aim of this work was to investigate the influence of polymorphisms in MTOR, PPP3CA, FKBP1A, FKBP2 and FOXP3, genes involved in the pharmacodynamics of immunosuppressive drugs, on the clinical response to tacrolimus and everolimus in kidney transplant recipients. Two-hundred seventy-five kidney transplant recipients were included in this study, among the enrolled in the original clinical trial (NCT01354301) carried out at the Hospital do Rim e Hipertensão/UNIFESP, and randomized in three immunosuppressive treatments: tacrolimus 0.05 mg/kg/day with everolimus 1.5 mg/day (TAC5/EVR); tacrolimus 0.1 mg/kg/day with everolimus 1.5 mg/day (TAC10/EVR); and tacrolimus 0.1 mg/kg/day with sodium mycophenolate (TAC10/MFS). Clinical and laboratory data, including immunosuppressive drug monitoring, efficacy and safety outcomes, were recorded. Polymorphisms on the MTOR (c.4731G>A, c.1437T>C, c.2997C>T); PPP3CA (c.249G>A); FKBP1A (n.259+243936T>C); FBKP2 (c.-2110G>T) and FOXP3 (c.-23+2882A>C, c.-22-902A>G) genes were analyzed by real-time PCR. Allelic frequencies of the studied polymorphisms were similar to those of the global population reported by the 1000genomes project. Treatment with everolimus and high-dose tacrolimus (TAC10/EVR) was associated with lower estimated glomerular filtration rate (eGFR) and higher serum creatinine. Meanwhile treatment with tacrolimus and sodium mycophenolate (TAC10/MFS) was associated with higher number of cytomegalovirus infections, at 1-year post-transplantation. With regard to the kidney efficacy outcomes, the carriers of the CC genotype of MTOR c.1437T>C and FOXP3 c.-23+2882A>C had higher serum creatinine, at month 12 (p<0.05). The FOXP3 c.-23+2882A>C polymorphism was associated with high likelihood of increased serum creatinine (OR=1.75, 95%IC=1.07-2.86, p=0.025). The results of the logistic regression analysis showed that the allele MTOR c.4731G (AG+GG genotypes) was associated with higher risk of acute rejection (OR=3.37, 95%IC=1.10-10.30, p=0.033). The carriers of the c.4731G allele showed higher cumulative incidence of acute rejection episodes at 1-year post-transplantation. With regard to kidney safety outcomes, the FKBP2 c.-2110G>T variant (GG genotype) was associated with higher risk of leucopenia (OR=7.10, 95%IC=1.81-27.87, p=0.025). The FKBP1A n.259+24936T>C (C allele) polymorphism was associated with higher risk of constipation (OR=2.52, 95%IC=1.13-5.61, p=0.024), whilst FOXP3 c.-22 902A>G (A allele) and c.-23+2882A>C (A allele) were associated, respectively, with higher risk of epigastric pain (OR=2.15, 95%IC=1.01-4.56, p=0.047) and nausea and/or vomiting (OR=2.38, 95%IC=1.05-5.38, p=0.038). The risk of developing dyslipidemia was higher in carriers of the genotypes FKBP2 c.-21110GG (OR=1.92, 95%CI=1.01-3.69, p=0.049) and FOXP3 c.-22-902GG (OR=2.06, 95%CI=1.08-3.92, p=0.028). In conclusion, the polymorphisms in the MTOR, FKBP1A, FKBP2 and FOXP3 genes influence renal graft function and are associated with risk of acute rejection and adverse events in renal transplant recipients.

Class of 2012 Abstract / Specific Aims: The purpose of this study was to evaluate the effectiveness of various post-operative prophylaxis methods in lung transplant patients by comparing the incidence of venous thromboembolism (VTE) before and after the implementation of a standardized hospital order set at the University of Arizona Medical Center (UAMC) in April 2007. Methods: Paper and electronic medical charts were retrospectively reviewed if patients had a lung transplant date between October 31, 2003 – October 31, 2010. A computerized database was used to collect demographic data, length of stay (LOS), comorbid conditions, prophylaxis type (including dose/frequency), and date/type of thromboembolic events in the post-operative period prior to discharge and up to 1-year post-discharge. Main Results: Ninety-two patient charts were included in the study with 35 charts in the pre-order set (“Before”) group and 57 charts in the post-order set (“After”) group. All baseline characteristics were similar between groups except age (mean age difference 8.1 yrs, p=0.003), use of mycophenolate (Before n=24, After n=54; p=0.002), and use of medications that increase risk of VTE (Before n=6, After n=2; p=0.05). The April 2007 protocol significantly increased the number of patients receiving any method of prophylaxis (p<0.0001). However, receiving prophlyaxis did not significantly reduce event rates or readmissions due to VTE. Conclusions: Although implementation of the April 2007 protocol did not significantly reduce VTE event rates and readmissions, VTE prophylaxis should continue to remain a priority. Adherence to the implemented protocol may reduce the number of patients left without effective methods of prophylaxis.

Coryphantha scheeri var. robustispina (Schott) L. Benson, the Pima pineapple cactus, herein referred to as C. scheeri, was declared an endangered species in 1993 and only occurs in a limited range in Arizona, USA and northern Sonora, Mexico between 2,300'-4,500' asl. Development within the range of C. scheeri threatens individuals, but transplanting to conserve them while allowing for development has been considered to be ineffective for conservation due to low post-transplant survival rates in past studies. The construction of a natural gas pipeline provided the opportunity to conduct a transplant experiment on 82 individual C. scheeri transplanted in July and August 2014. The plants were randomized into one of four transplant methods: bare-root with supplemental water, bare-root without supplemental water, soil-and-plant moved with supplemental water, and soil-and-plant moved without supplemental water. Higher than average precipitation occurred during the 2014 monsoon season including after transplanting. A subset of the transplanted C. scheeri (n=17) were transplanted back onto the pipeline after pipeline construction was completed. Survival rates were monitored through December 2016 and compared to undisturbed C. scheeri near the pipeline ROW and those on other sites. For the plants transplanted once, no significant effect of moving the plants with soil compared to no soil (X2 = 2.9, p = 0.09), no significant effect of adding water at the time of transplant compared to not adding water (X2 = 1.2, p = 0.26), and no significant interaction among treatments (X2 = 0.06, p = 0.81) was observed. For plants transplanted twice, a significant effect of moving the plants with the soil compared to no soil (X2 = 5.0, p = 0.02) was found, while due to the random selection of plants to be transplanted twice there was too little data to adequately test other comparisons. There was no significant difference in mortality between the transplanted once (27% mortality) and the transplanted twice (31% mortality) treatments (p = 0.78), but there was a significant difference between transplanted and non-transplanted plants (2% mortality in non-transplanted plants; p < 0.05). Soil series did not appear correlated with mortality. Plants in good condition (scored 4 or 5 on scale of 0-5) at the time of transplanting had low mortality rates (16%) while plants scored 3 or lower had high mortality rates (60%) but deaths did not occur immediately after transplanting: 5 died after 8 or 9 months, 4 after 13-16 months, and 9 after 23 or 24 months. The majority of the deaths occurred after numerous months of declining in condition but six plants died suddenly. Good condition plants were more likely to flower than those in poor condition. Transplanting appears to conserve some of the C. scheeri population which would have otherwise been lost to development.

Class of 2015 Abstract / Objectives: To assess the efficacy of fluconazole prophylaxis in the prevention of coccidioidomycosis in the post-heart transplant patient and to identify risk factors for coccidioidomycosis infection. Methods: Heart transplant patients with ICD-9 code V42.1 from October 2001 to October 2013, were selected and electronic medical records were retrospectively reviewed for coccidioidomycosis history, Coccidiodes serologies, reason for transplantation, immunosuppressive drug therapy regimens, rejection treatment course, fluconazole dose, and demographics. Negative Coccidiodes serology results post transplantation relative to negative Coccidiodes serology results prior to transplantation will be determined using a Chi Square test. Risk factors for disease contraction will be analyzed using multivariate logistic regression. Results: Between October 2001 and October 2013, 244 patients received a heart transplant at this institution. Fourteen (5.7%) heart transplant recipients with a negative Coccidiodes serology pre-transplantation had a positive Coccidiodes serology post-transplantation. Nine (64.2%) of those recipients received antifungal prophylaxis (p=0.16). Risk factors for developing a positive Coccidiodes serology included using tacrolimus (p=0.05) and non-ischemic cardiomyopathy (p=0.04). Conclusions: Antifungal prophylaxis does not reduce the risk of developing a positive Coccidiodes serology after heart transplantation. Risk factors for developing a positive Coccidiodes serology include the use of tacrolimus and having non-ischemic cardiomyopathy prior to transplant.

Class of 2016 Abstract / Objectives: The purpose of this study was to evaluate if fluconazole 200 mg is an acceptable alternative to the fluconazole 400 mg for fungal prophylaxis in allogenic hematopoietic stem cell patients. Lower fluconazole doses will decrease cost of therapy and may reduce adverse events associated with higher doses. Methods: This study was a retrospective chart review conducted at the Arizona Cancer Center. A total of 58 patients qualified for the study. Primary endpoints were number of days on fluconazole 200 mg and type and number of fungal infections that occurred within 1 year post transplant. Results: Out of the fifty-eight patients who qualified for the study, only eight patients had a breakthrough fungal infection while on 200 mg (13.7%) after one year. Three of those eight were identified as having systemic fungal infections (5.2%). Conclusions: Fluconazole 200 mg is a reasonable low-cost and low side effect alternative to fluconazole 400 mg for antifungal prophylaxis in allogenic hematopoietic stem cell patients.

Background: With an increased understanding of dialysis-treated patients' experiences of waiting for a kidney transplant, the nurses can adjust their care based on patient's individual needs. A changed life situation that requires regular treatment and limiting the patient in their daily life makes it important that the nurse understands the patient's mood and is there to support. Aim: The aim of this study was to highlight the experiences of dialysis-treated patients waiting for a kidney transplant. Method: A literature study based on qualitative research. Friberg ́s five-step model was used for analyze of the articles and results in three main themes and six sub- themes. Results: This result showed that dialysis-treated patients awaiting a kidney transplant experienced both physical and mental barriers and stress. They experienced limitations in daily life as loss of freedom and financial difficulties. The patients' feelings oscillate between hope and uncertainty like an emotional roller coaster and they find support in their relatives, healthcare professionals or in their religion. Conclusion: The experiences of waiting for a kidney transplant are relatively similar, but strategies to get trough this process varies. Common for all patients were that it was a demanding and stressful time. Therefore it is important that nurses pay attention and adapt the care for each individual.

To determine the optimum nitrogen application level required for the production of good quality ‘Drumhead’ cabbage (Brassica oleracea var. capitata) transplants, a glasshouse experiment was conducted. Depending on water requirements, transplants were fertigated every two days (for the first four weeks) and every day (for the last two weeks) by floating trays in plastic tubs containing nutrient solution at 0, 30, 60, 90 and 120 mg•L-1 N until field capacity was reached. Increasing nitrogen from 0 to 120 mg•L-1 increased shoot and root mass of cabbage transplants with more dry mass being partitioned to the shoot than to the roots. Nitrogen at 120 mg•L-1 N produced greatest fresh and dry shoot mass, plant height, leaf area, leaf tissue nitrogen, net assimilation rate, relative growth rate and leaf mass ratio. Nitrogen at 90 mg•L-1 improved dry root mass, pulling success, specific leaf area and leaf area ratio. Greatest values of root: shoot ratio and root mass ratio were obtained at 0 mg•L-1 N. Nitrogen at 90 mg•L-1 was best as it produced transplants with more vigorous root growth which pulled out easily from the seedling trays. To determine the best combination of spacing and nitrogen top-dressing for improved cabbage production under local conditions, a field experiment was conducted. Cabbage ‘Copenhagen Market’ transplants were spaced at 30 x 50 cm, 40 x 50 cm or 50 x 50 cm and fertilized with nitrogen as top-dressing at 50, 100 or 150 kg•ha-1 N applied in two splits (fourth and eighth week after transplanting). There were no interactions between spacing and nitrogen top-dressing for all measured variables. Nitrogen and spacing did not influence dry matter production and leaf tissue nitrogen. Furthermore, spacing did not affect core height and yield (per unit area) of trimmed cabbage heads. Nitrogen at 100 kg•ha-1 produced the greatest head mass and yield for untrimmed cabbage heads. The 30 x 50 cm spacing produced the highest yield of untrimmed heads while 50 x 50 cm spacing produced heavier heads. For trimmed heads, 100 kg•ha-1 N again produced the greatest head mass, head diameter, head height, core diameter and yield. Spacing did not affect the yield for trimmed heads. However, 40 x 50 cm spacing improved head diameter, head height and head mass while core diameter was larger with 50 x 50 cm spacing. The split application of 100 kg•ha-1 N as top-dressing was best for head mass and yield (per unit area) for trimmed and untrimmed heads. Choice of spacing would depend on whether trimmed or untrimmed heads are targeted. / Dissertation (M Inst Agrar (Horticulture))--University of Pretoria, 2005. / Plant Production and Soil Science / unrestricted

Background: Sleep disruption is one of the most commonly reported quality of life concerns among cancer patients who have undergone hematopoietic stem cell transplantation (HSCT). Despite the high percentage of patients reporting sleep concerns, relatively little research has characterized sleep problems or explored relationships with psychological factors. In addition, no studies have used actigraph technology to characterize sleep issues among transplant recipients. Method: Autologous HSCT recipients who were 6 to 18 months post-transplant were invited to participate. Patients completed self-report measures of cancer-related distress, fear of cancer recurrence, dysfunctional cognitions about sleep, and maladaptive sleep behaviors upon enrollment, wore an actigraph and completed a sleep log at home for 7 days, and completed a self-report measure of sleep disruption on day 7 of the study. Results: 84 autologous HSCT recipients (age M = 60, 45% female) were enrolled and provided complete data. Forty-one percent of patients met criteria for sub-clinical or clinical insomnia based on patient self-report. Examination of actigraph data indicated that certain aspects of sleep were poorer than others (wake after sleep onset M = 66 minutes; total sleep time M = 6.5 hours; sleep efficiency M = 78%; sleep onset latency M = 21 minutes). Measures of cancer-related distress, fear of cancer recurrence, cognitive distortions, and maladaptive behavioral patterns were related to subjectively reported sleep disruption, p’s < .05, but were not related to objectively measured sleep disruption. Further examination revealed that the cognitive and behavioral factors accounted for the largest unique variance in subjectively reported sleep disruption. Conclusion: Results from the present study suggest that many HSCT recipients continue to experience sleep disruption during the survivorship period following transplant. Cancer-specific factors, dysfunctional cognitions about sleep, and maladaptive sleep behaviors were related to self-reported sleep disruption and are ripe targets for a cognitive behavioral intervention.

The evaluation of the feasibility and clinical utility of liquid based cytology, human papillomavirus testing and high-resolution anoscopy to screen for anal intraepithelial neoplasia in high-risk groups. Dr Alice Martha Schofield: The University of Manchester for the degree of Doctor of Medicine, January 2016. Background: The increased incidence and natural history of anal cancer in high-risk groups, provides a screening opportunity to detect precancerous lesions, anal intraepithelial neoplasia (AIN), as well as early invasive lesions. The ANALOGY study was performed to strengthen the evidence base required to determine the case for anal screening in terms of the feasibility and clinical utility of liquid based cytology (LBC), high-risk human papillomavirus (HR-HPV) testing and high-resolution anoscopy (HRA) in high-risk groups. Methods: This prospective study offered screening to four cohorts aged over 25 at varying but elevated risk; human immunodeficiency virus (HIV) positive and negative men who have sex with men (MSM), HIV positive women with prior history of abnormal cervical cytology or anogenital warts, HIV negative women who practice anoreceptive sex and transplant recipients (TR). Recruitment commenced in March 2013 and concluded in December 2014, with follow-up until March 2015. All participants underwent testing for HR-HPV, LBC and had HRA performed, sites of abnormality were biopsied. Participants were seen at initial consultation and at a second visit six months later. Immunostaining with Ki67 and p16 antibody was performed on 100 anal tissue biopsies. The cellular positivity of each biomarker were scored by automated and manual methods. H-SCORES of p16 biomarker and block positive staining of AIN2 were quantified and analysed. Results: 409 participants were recruited; 284 MSM (203 HIV positive, 81 HIV negative), nine HIV positive women, four HIV negative women and 112 TR. HR-HPV was highly prevalent in anal samples from MSM (HIV positive 88.0% and HIV negative, 77.8%) and much less so in HIV positive and negative women and TR (19.3%). Despite the high prevalence of cytological abnormality in MSM, almost half of AIN of all grades was associated with negative cytology. AIN3+ on biopsy was found in 4.4% (18/409) of participants; three HIV positive MSM had cancer. One new case of AIN3 was identified at the second visit. Low-grade disease (AIN1/2) was highly prevalent in all groups. Ki67 and p16 biomarker expression increase as the grade of anal disease increased when scored manually. AIN2 histology samples, which demonstrate block positive p16 staining, have an association with an increased H-SCORE.Conclusions: Anal screening in some high-risk groups is clinically feasible in terms of diagnostics with evidence of significant disease prevalence particularly amongst MSM. The high prevalence of HR-HPV infection and frequency of false negative cytology indicates that in terms of sensitivity and specificity, HRA would be the best primary screening tool. The use of Ki67 and p16 in the identification of anal disease appears to have clinical utility, especially in the detection of AIN2; with the majority of samples displaying block p16 staining that corresponded with an increased H-SCORE. The prevalence of AIN3+ in HIV positive MSM lends support for a policy of screening in this group, however limitations of treatment, as well as highly prevalent low-grade lesions of dubious significance, require careful consideration.

Acute kidney injury (AKI), characterized by an abrupt loss of kidney function with retention of nitrogenous waste products, is common in the months to years following kidney transplantation and is associated with an increased risk of transplant failure (graft loss). Kidney transplant patients who experience graft loss and return to dialysis have an increased mortality risk and a lower quality of life. Research involving kidney transplant patients can prove challenging, as they are relatively small in number. To increase statistical power, researchers may utilize administrative databases. However, these databases are not designed primarily for research, and knowledge of their limitations is needed, as significant bias can occur. When using administrative databases to study AKI in kidney transplantation, the method used to define AKI should be carefully considered. The power of a study may be greatly increased if AKI can be accurately defined using administrative diagnostic codes because data on AKI will be universally available for all patients in the database. However, the methods by which diagnostic codes are assigned to a patient allow for error to be introduced. We confirmed that, when compared to the gold standard definition for AKI of a rise in serum creatinine, the diagnostic code for AKI has low sensitivity but high specificity in the kidney transplant population (the best performing coding algorithm had a sensitivity of 42.9% (95% CI 29.7, 56.8) and specificity of 89.3% (95% CI 86.2, 91.8) (Chapter 3). We therefore determined that for the study outlined in Chapter 4, defining AKI using diagnostic codes would significantly under-­capture AKI and misclassify patients. We decided to define AKI using only serum creatinine criteria even though this would limit our sample size (creatinine data was only available for a subset of patients in the administrative databases). In Chapter 4, we derived an index score to predict the risk of graft loss in kidney transplant patients following an admission to hospital with AKI. The index includes six readily available, objective clinical variables that increased the risk of graft loss: increasing age, increased severity of AKI (as defined by the AKIN staging system), failure to recover from AKI, lower baseline estimated glomerular filtration rate, increased time from kidney transplant to AKI admission, and deceased donor. The derived index requires validation in order to assess its utility in the clinical realm.