Prostate cancer is the UK number one male cancer. Evidence from epidemiological studies suggests only age, race and family history as established risk factors. Other factors such as low dose diagnostic radiations and surrogate hormone markers such as baldness, finger length pattern and acne are hypothesized to have a potential role in the aetiology of prostate cancer. It is evident that genetics plays an important role in prostate cancer aetiology. This thesis focuses both environmental and genetic factors. The environmental factors include selected surrogate hormone markers, medical diagnostic radiation procedures and family history of prostate cancer. The genetic part explores genetic polymorphisms that could have implications for interactions with exposures studied. Single nucleotide polymorphisms (SNPs) involved in mechanistic pathways related to DNA repair genes and potential hormone marker genes were the main targets.

Despite the recent introduction of a number of new and more potent anti-rejection drugs, the incidence of rejection and long-term graft survival remain unchanged. There remains a significant difference in long-term graft survival depending on the source of the donor. The purpose of this study was to examine gene expression in the transplanted kidney using microarray technology to identify potential biomarkers that could be used to predict and monitor graft function so that appropriate interventions could be made in the event of graft dysfunction. Over a 5 year period RNA was extracted from 144 donor kidneys that were transplanted. The initial attempts at probe preparation and hybridization were unsuccessful. This led to the development of a new strategy which involved the use of state-of-the-art microarray technology which embraced the advances realised with the completion of the human genome project. Microarray data was analysed using J-Express and Pathway studio. Significance analysis of microarray, hierachical clustering, gene ontology mapping and pathway analysis was performed. The identification of potential biomarkers that had previously been described by other authors validated this approach. In addition novel genes were identified that may have a role as biomarkers of graft function. Other potential biomarkers were identified that represented cellular processes that could be modified by therapeutic intervention thus possibly changing the clinical outcome or allowing monitoring of the success of therapy. Confirmation of previously described biomarkers and the identification of novel potential biomarkers has confirmed that gene expression profiling has a valuable role in identifying processes that are indicative of disease processes including those involved in kidney transplantation. Furthermore with the development of minimally invasive tests to measure these biomarkers, we can potentially change the natural history of the disease process, and hence, preserve graft function and possibly prolong life.

The primary objective of this thesis was to determine any associations between herbal and dietary supplement (HDS) use and the fast progression of chronic kidney disease (CKD) in Thai outpatients with CKD. The secondary objectives were to determine any associations between HDS use and CKD complications, and the prevalence and reasons for HDS use. A survey recruited 421 outpatients with stages 3 to 5 CKD from two kidney clinics in Thailand, from January to June 2012. A prospective cohort study followed up these respondents, in particular noting their serum creatinine, as well as serum levels of potassium and phosphate, for 12 months. Such data were extracted from patients’ medical notes. Three hundred and fifty-seven respondents were followed up. The exposed group was defined as the current and regular users of HDS, and the primary outcome of the cohort study was defined as either a decline in the estimated glomerular filtration rate of at least 5 ml/min/1.73m2/year or the initiation of renal replacement therapy. Sixteen HDS users were recruited from the survey to be interviewed about their reasons for using HDS, using open-ended questions to elicit information in the qualitative study. Exclusion criteria were those with had received renal replacement therapy before recruitment. Univariate and multivariate analyses were performed to determine the associations using Chi-squared tests and multiple logistic regressions. Tests were 2-tailed and a p-value < 0.05 was considered statistically significant. The prevalence of HDS use during the previous year in Thai patients with CKD was 45% (95%CI 40%-50%). The most frequently reported influences on HDS use in the survey and the qualitative study were family members, friends and perception of benefits gained from using HDS. An association between HDS use and CKD progression was not found (adjusted OR 1.16, 95%CI 0.66 – 2.03). Two respondents (0.6%) had acute kidney injury, which may be related to the use of unknown Chinese herbal medicines or river spiderwort combined with diclofenac; issues which were reported by their doctor in their medical note. HDS use was associated with uncontrolled hyperphosphatemia (adjusted OR 3.53, 95%CI 1.20 – 10.43), possibly due to the HDS used in the cohort study which contained phosphate or vitamin D. Health care providers should closely monitor CKD patients using Chinese herbal medicine, river spiderwort or HDS containing phosphorus or vitamin D. Further studies need to examine renal adverse effects of specific herbal medicines, particularly in relation to acute kidney injury.

Haemodialysis patients experience elevated levels of cardiovascular morbidity and mortality that has a profound effect on not only their survival and quality of life but also increases the already high social and economic cost of dialysis. It is increasingly appreciated that the circulatory stress caused by dialysis is a significant contributing factor and helps to accelerate the end organ damage this group of patients is known to experience. In particular the cumulative ischaemic insult suffered by the heart during haemodialysis sessions has been suggested as one of the principal drivers of heart failure and sudden cardiac death – the two principal causes of death in this population. The importance of dialysis induced haemodynamic instability was reinforced as we explored the relationship between cardiac function and the measure of intra-dialytic hypotension most clearly associated with mortality (a blood pressure below 90mmHg) and found that the severity of dialysis induced cardiac injury was experienced across the whole range of dialysis induced hypotension. A nadir blood pressure below 90mmHg was strongly associated with established reduction in systolic contractile function. We then tested two separate interventions designed to mitigate dialysis-induced injury. The first was Remote Ischaemic Preconditioning, a technique that in pre-clinical models and numerous small clinical studies protects against the effect of the ischaemia-reperfusion injury. We found that a single application of RIPC significantly reduces dialysis induced cardiac injury for up to 28 days. The second intervention was the stepwise reduction of dialysate sodium to reduce intra-dialytic fluid accumulation and the need for aggressive ultrafiltration. We found this to be well tolerated and an effective way to reduce inter-dialytic weight gain. This intervention did not have any adverse cardiac consequences and may have resulted in a modest improvement in cardiac tolerability while still being delivered within the context of a conventional 4-hour haemodialysis treatment. Finally, to investigate if transplantation is capable of reversing any of the factors predisposing dialysis patients to increased cardiovascular events, we chose to investigate one of the risk factors that contributes to the abnormalities of the vasculature and leave patients vulnerable to dialysis induced cardiac injury. We measured the deposition of advanced glycation end-products (via the method of skin autofluorescence) in patients who had undergone renal transplantation and compared this to existing cohorts of dialysis and chronic kidney disease patients. We found that following transplantation these markers of metabolic stress regressed to levels comparable to those seen in chronic kidney disease and much lower than seen in dialysis. This finding may suggest that the dialysis procedure itself is responsible for a great deal of metabolic stress and helps to accelerate the process by which the vasculature becomes stiff and non-compliant. In conclusion, we tested two interventions that showed potential to reduce the cardiac stress dialysis patients are subject to. Remote ischaemic preconditioning directly reduces the severity of cardiac injury and the stepwise reduction of dialysate sodium decreases inter-dialytic fluid gains and produces a modest improvement in cardiac tolerability. We also confirmed that transplantation reverses advanced glycation end-product deposition, one of the key non-traditional risk factors for cardiovascular disease in dialysis patients, giving us further insight into the ways in which transplantation improves cardiovascular outcome.

Introduction This study was carried out in Ghana, where the incidence of end stage kidney disease (ESKD) is increasing in a context of limited treatment options. Understanding the issues patients with ESKD grapple with when diagnosed with this life-threatening condition is essential to improve healthcare policy and practice in such low- and middle-income settings. In the absence of evidence related to the African ESKD patient journey, this study aimed at exploring how decisions about ESKD management are being made, especially in under-resourced settings where specific treatment modalities are not always available. The study addresses an important gap in the literature concerning choice and decision making in an international context. The key research question for this study is, in terms of the context, does the problem of limited resources in low- and middle-income countries present different choices to the patient with ESKD facing decisions about their treatment? Methodology and Methods The study employed a qualitative research design, using grounded theory methodology. Twenty-seven participants in three renal centres, comprising twenty-two patients with ESKD and five clinicians, were selected using the theoretical sampling approach and interviewed for this study. Constant comparative analysis was employed in data analysis. Results A conceptual map depicting the ESKD patient journey and key phases of decision making was developed from this study. Ghanaian patients with ESKD are mostly unaware of the implications of their initial symptoms, and end up delaying seeking healthcare from a hospital. Some of those who seek care from hospitals are initially diagnosed with and treated for other conditions other than ESKD. Thus, many patients with ESKD in Ghana present late to a renal centre. Treatment for ESKD is initiated for various reasons, including, initially, the urgent need to avoid premature death. Many approach their condition in terms of hoping for a cure and do not always understand the chronic nature of their condition. Decisions on initiating haemodialysis (HD) are mostly shared between clinicians and patients and/or their families but the process is mainly driven by the need to ascertain patient and family’s ability to finance HD, rather than considering other aspects of treatment burden. The subject of death or conservative management is not openly discussed and, once this is brought up, patients usually do everything possible to opt for another form of treatment, including the simultaneous use of other non-RRT and traditional or faith-based healing approaches. Clinicians play vital roles in the decision making of patients with ESKD although they have general feelings of helplessness while supporting these patients. Convergence between individuals’ experiences of realities of living with and managing ESKD, and support from clinicians in the renal setting ultimately leads to a reconstruction of health expectations that commensurate management goals of ESKD. This sums up the substantive theory of ‘reconstructing health expectations’ that was generated from this study. Conclusions Financial and geographical inaccessibility of renal replacement therapy (RRT) as well as the relative lack of biomedical treatment choices make decision making daunting for the individual with ESKD in Ghana. Reluctance to discuss death as a potential outcome is a hindrance to the consideration of conservative management as a treatment option. Effective realignment of healthcare policies to address changing patterns of diseases is necessary to contribute to prevention, early detection and effective management of ESKD in the country. An improved approach to conservative management is urgently required, including training support for clinicians on shared decision making as well as sensitisation of patients on this modality.

Background and Aims: Catheter-associated urinary tract infections (CAUTI) are a common and costly complication of indwelling urinary catheterisation. No commercial technology exists that protects against the major uropathogens for the lifetime of a long-term catheter. Silicone indwelling urinary catheters were impregnated with the antimicrobials (AUC) rifampicin, sparfloxacin, and triclosan to confer antimicrobial activity. With the overall aim of delivering this technology to urinary catheters users, this thesis aims to firstly, understand the profile of micoorganisms attached to indwelling urinary catheters. Secondly, using a combination of studies investigating the impregnated catheter surface and in vitro models, determine the ability of the AUC to resist mineral encrustation. Thirdly, this thesis will assess the protective activity of the AUC against multi-drug resistant organisms and Enterococcus spp. Finally, the safety and patient acceptability of this AUC will be assessed by a single-centre clinical trial. Methods: Urinary catheters were collected from patients at Nottingham University Hospitals NHS Trust (NUHT), and also over one year from one volunteer. General microbiological methods, including a new method of processing urinary catheters and MALDI-ToF were employed to identify and quantify attached microorganisms. Pulsed-field gel electrophoresis (PFGE) and similarity analysis determined the relationship between isolates of the same species isolated from catheters collected consecutively from the volunteer. The catheter surfaces were investigated after antimicrobial impregnation and soaking using atomic force microscopy and bacterial attachment assays. Reduction of mineral encrustation on the AUC was investigated in the presence and absence of bacteria. Spectrophotocolourimetry quantified phosphate deposition in a static and in vitro flow model. The protective duration of the AUC against Enterococcus spp. and multi-drug resistant bacteria was investigated in a clinically predictive in vitro model. A single-centre, non-randomised safety and patient acceptability study was conducted. The primary outcome measure was rate of adverse events attributable to antimicrobial impregnation. Secondary outcome measures included patient acceptability, withdrawal before the end of the trial, and microorganism colonisation of trial catheters. Results:Sixty-one urinary catheters were collected from patients at NUHT. E. coli and Enterococcus faecalis were the most commonly isolated organisms. A novel method was developed to isolate micoorganisms from the catheter lumens and balloons separately. Nine consecutive urinary catheters were collected from one volunteer over one year. Methicillin-susceptible Staphylococcus aureus, E. faecalis, Citrobacter koseri, and Pseudomonas aeruginosa were isolated from many of the nine catheters over the course of the year. PFGE revealed the isolates were indistinguishable, except for three P. aeruginosa isolates, which were closely related but differed by a 2-3 band difference by PFGE. Surface characteristics of silicone urinary catheters were not adversely affected by antimicrobial impregnation. The AUC prevented blockage and reduced phosphate deposition when challenged with Proteus mirabilis in static and flow models. The AUC was not able to consistently eradicate E. faecalis and E. faecium isolates. The AUC resisted colonisation by methicillin-resistant S. aureus, methicillin-resistant Staphylococcus epidermidis, MSSA, Staphylococcus saprophyticus, extended-spectrum beta-lactamase producing E. coli, New Delhi metallo-beta-lactamase producing E. coli for approximately 12 weeks. Thirty patients were recruited to the safety clinical trial, which demonstrated the AUC was safe and was acceptable to the majority of participants. Only one adverse event was reported that was ‘probably’ associated with antimicrobial impregnation of the catheters and it was mild and resolved within 48 hours. There were significantly less bacterial isolates attached to the balloons of trial catheters compared to the matched original catheters. Conclusions: The AUC is safe and effective technology for long-term catheter users. Next steps include a clinical trial of efficacy and commercialisation.

No description available.

No description available.

Myxovirus (influenza virus) resistance A (MxA) is an interferon regulated protein responsible for a specific antiviral state against viral infection. Our lab has previously shown that MxA is up-regulated by androgens in the normal prostate epithelial cells; however, there is no known role for MxA in cancer. Meta-analysis of different expression databases (e.g. NCBI GEO and Oncomine) suggested a strong inverse association between MxA expression and prostate cancer. To confirm these studies, we performed immunohistochemistry on normal prostate and prostate cancer tissues. Our results revealed that MxA expression was indeed decreased in cancerous as compared to normal prostate, indicating that MxA could be transcriptionally down-regulated in cancer. Previous studies indicated that MxA down-regulation could be due to a specific polymorphism in the proximal MxA promoter at position -88. This single nucleotide polymorphism G>T (rs2071430) is involved in modifying the gene expression and interestingly, it harbors an interferon-stimulated response element (ISRE) that is required for expression in response to interferons. The "T" allele restores whereas the "G" allele attenuates ISRE binding, resulting in increased or decreased MxA expression, respectively. Based on these observations we hypothesized that decreased expression of MxA in prostate cancer could be due to the rs2071430 polymorphism. We investigated this polymorphism in genomic DNA from equal number of disease free and prostate cancer samples. The results provide evidence that the GG genotype (low promoter activity) is higher in PCa (72%) as compared to normal (58.6%). The TT genotype (high activity) was higher in normal (5.7%) compared to PCa (2.4%) p

Id proteins are members of basic helix-loop-helix family. However, Id proteins lack the basic binding domain, which prevents DNA binding, and thereby regulates transcription. There are four members in the Id protein family termed Idl-4. In prostate cancer the expression of Idl and Id3 is high, whereas member Id4 expression is low. Decreased expression of Id4 is due to promoter hypermethylation in prostate cancer as well as many other cancers. This observation led us to hypothesize that Id4 acts as a tumor suppressor in prostate cancer. Furthermore, evidence suggests ectopic Id4 expression in metastatic prostate cancer cell line DU145 induced cell cycle arrest, apoptosis, and senescence. In this study, we expanded on these earlier studies to demonstrate that gain of Id4 attenuates cancer phenotype whereas loss of Id4 promotes cancer phenotype in prostate cancer cell lines DU145 and LNCaP, respectively. Upon over-expression of Id4 in DU145 cells (DU145+W4), there was an increase in apoptosis, due to decreased mitochondrial membrane potential (MMP) and increased expression of pro-apoptotic markers (PUMA, BAX, and p21). Inversely, silencing of Id4 in LNCaP cells (LNCaP-Id4) led to decreased apoptosis due to an intact mitochondrial membrane and decrease in the expression of pro-apoptotic markers (PUMA, BAX, and p21). Since BAX, PUMA, and p21 are direct transcriptional targets of p53, these results therefore prompted us to investigate the effect of Id4 on expression and activity of p53. LNCaP cells express wild-type p53. DU145 cells harbor mutant p53 (P223L and V274F), which lies within the DNA binding domain and abrogates p53 transcriptional activity. DU145 cells also express high levels of p53, due extended half-life. Surprisingly, there was decreased expression of p53 in DU145+Id4 cells associated with nuclear localization indicating enhanced transcriptional activity. We investigated p53 DNA binding and transcriptional activity. We determined that mutant p53 in DU145+Id4 cells was transcriptionally active evident by increased luciferase activity and binding of p53 to the promoters of its targets. In LNCaP-Id4, p53 expression was decreased which resulted in decreased p53 transcriptional activity and decreased DNA binding ability. The data suggested that Id4 can restore mutant p53 activity, which is a significant observation. Our results also suggest that Id4 promotes the assembly of a macromolecular complex involving CBP/p300 that results in acetylation of p53 at K373, a critical post-translational modification required for its biological activity. Loss of Id4 in LNCaP cells also abrogated wild type p53 DNA binding and transcriptional activity with concomitant loss of CBP/p300 requirement and decreased acetylation. In conclusion, we demonstrated that loss of Id4 promotes cancer phenotype in LNCaP cells. We also demonstrated that the tumor suppressor activity of Id4 is in part through regulation of CBP/p300 dependent acetylation and function of p53.