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Introduction After a failed transplant, management of a non-functional graft with pain or recurrent infections can be challenging. Transplant nephrectomy (TN) can be a morbid procedure with the potential for significant blood loss. Embolization of the renal artery alone has been proposed as a method of reducing complications from an in vivo failed kidney transplant. While this does yield less morbidity, it may not address an infected graft or refractory hematuria or rejection. We elected to begin preoperative embolization to assess if this would help decrease the blood loss and transfusion rate associated with TN. Materials and Methods We performed a retrospective analysis of all patients who underwent non-emergent TN at our institution. Patients who had functioning grafts that later failed were included in analysis. TN was performed for recurrent infections, pain or hematuria. We evaluated for blood loss (EBL) during TN, transfusion rate and length of hospital stay. Results A total of 16 patients were identified. Nine had preoperative embolization or no blood flow to the graft prior to TN. The remaining 7 did not have preoperative embolization. The shortest time from transplant to TN was 8 months and the longest 18 years with an average of 6.3 years. Average EBL for the embolized patients (ETN) was 143.9cc compared to 621.4cc in the non-embolized (NETN) group (p=0.041). Average number of units of blood transfused was 0.44 in the ETN with only 3/9 patients requiring transfusion. The NETN patients had average of 1.29 units transfused with 5/7 requiring transfusion. The length of stay was longer for the ETN (5.4 days) compared to 3.9 in the NETN. No intraoperative complications were seen in either group and only one patient had a postoperative ileus in the NETN. Conclusion Embolization prior to TN significantly decreases the EBL but does not significantly decrease transfusion rate. However, patients do require a significantly longer hospitalization with embolization due to the time needed for embolization. Larger studies are needed to determine if embolization before transplant nephrectomy reduces the transfusion rates and overall complications.

Loss of LKB1 activity is prevalent in KRAS mutant lung adenocarcinoma and promotes aggressive and treatment-resistant tumors. Previous studies have shown that LKB1 is a negative regulator of the focal adhesion kinase (FAK), but in vivo studies testing the efficacy of FAK inhibition in LKB1 mutant cancers are lacking. Here, we took a pharmacologic approach to show that FAK inhibition is an effective early-treatment strategy for this high-risk molecular subtype. We established a lenti-Cre-induced Kras and Lkb1 mutant genetically engineered mouse model (KLLenti) that develops 100% lung adenocarcinoma and showed that high spatiotemporal FAK activation occurs in collective invasive cells that are surrounded by high levels of collagen. Modeling invasion in 3D, loss of Lkb1, but not p53, was sufficient to drive collective invasion and collagen alignment that was highly sensitive to FAK inhibition. Treatment of early, stage-matched KLLenti tumors with FAK inhibitor monotherapy resulted in a striking effect on tumor progression, invasion, and tumor-associated collagen. Chronic treatment extended survival and impeded local lymph node spread. Lastly, we identified focally upregulated FAK and collagen-associated collective invasion in KRAS and LKB1 comutated human lung adenocarcinoma patients. Our results suggest that patients with LKB1 mutant tumors should be stratified for early treatment with FAK inhibitors.

Riley J, Troxel S, Wakefield M, Ross G, Weinstein S. Laparoscopic donor nephrectomy – safety in a small-volume transplant center. Clin Transplant 2010: 24: 429–432. © 2009 John Wiley & Sons A/S. Abstract: Introduction: Laparoscopy is a standard surgical option for live donor nephrectomy (LDN) at the majority of transplant centers. Equivalent graft survival with shorter convalescence has been reported by several large volume centers. With the arrival of an experienced laparoscopic surgeon in 2002, we began to offer laparoscopic LDN at our institution. We report our experience as a large volume laparoscopic surgery program but a low volume transplant center. Methods: A retrospective review of the previous 34 LDN (17 open, 17 laparoscopic) performed at the University of Missouri were included. A single laparoscopic surgeon performed all laparoscopic procedures. Hand assisted laparoscopy was performed in 15 and standard laparoscopy with a pfannenstiel incision in two. Open procedures were performed through anterior subcostal or flank incision. A single surgeon performed all open procedures. Results: There was no statistical difference in age, body mass index or American Society of Anesthesiologies Score between the two groups. Mean operative time, estimated blood loss and hospital stay were 229 minutes, 324 cc and 2.2 days respectively in the laparoscopic group compared to 202 minutes, 440 cc and five days for the open group. Average warm ischemia time was 179 seconds. Recipient creatinine for the two groups at one week, one month and one year was not statistically significantly different. Each group had one graft loss due to medication noncompliance. Conclusion: For small transplant centers with an advanced laparoscopic program, laparoscopic LDN is a safe procedure with comparable outcomes to major transplant centers.

Patient adherence to immunosuppressive medications adherence is crucial to survival of the patient and a transplanted kidney, yet adherence is variable. Using a prospective, descriptive design, immunosuppressive medication adherence of 44 renal transplant recipients was followed for 6 months at a Midwestern transplant center using electronic monitoring. Four medication adherence patterns emerged from a hierarchical cluster analysis: those who took medications on time, those who took medications on time with late/missed doses, those who rarely took medications on time and who were late with morning and/or evening doses, and those who missed doses. This study is a step toward developing and implementing interventions targeted to specific patterns of poor adherence.

Background. The transplantation of blood group A 2 /A 2 B deceased donor kidneys into B recipients could improve access to transplantation for blood group B recipients. However, this practice is controversial, and long-term data are lacking. This study analyzed the long-term outcomes of A 2 /A 2 B deceased donor kidneys transplanted into selected B recipients. Methods. We retrospectively assessed the outcomes (graft survival, transplant rates, and acute rejection) of deceased-donor kidneys using an allocation system that transplanted A 2 /A 2 B donors into B recipients with low anti-A blood group antibody titers between 1994 and 2003. Patients received conventional immunosuppression without any specific antibody reduction procedures. We further assessed the impact this system had on access to transplantation by blood group. Results. Of 1,400 kidney transplants, 56 (4.0%) were A 2 /A 2 B to B recipients. The system reduced waiting time for all B recipients, even shorter than for blood group A recipients (median waiting times of A 2 /A 2 B to B transplants=182 days vs. B to B transplants=297 days; and A to A=307 days). Although there was a trend toward increased acute rejection in A 2 /A 2 B to B transplants, the actuarial 7-year death censored graft survival was 72% for B recipients regardless of donor type. Conclusions. Transplanting A 2 /A 2 B deceased donor kidneys into B recipients leads to an equalization of waiting time between blood groups with similar patient and graft survival using conventional immunosuppression. This protocol could lead to more equal access to kidney transplantation in blood group B recipients.

Lung cancer continues to be fatal, in part due to the inability to prevent and treat metastases. Highly metastatic cancers exhibit enhanced glucose uptake to sustain proliferation and importantly, tumor invasion. Among the SLC2A family of facilitative glucose transporters, GLUT1 is largely attributed to be responsible for increased glucose uptake of cancer cells. GLUT1 is however responsible for glucose transport across the blood-brain barrier, expressed in many normal cell types and therefore a less desirable therapeutic target. We previously reported that multiple myeloma cells rely on overexpression and constitutive plasma membrane localization of insulin-responsive glucose transporter, GLUT4. In this study we investigated a role for GLUT4 in lung cancer. To interrogate contributions of GLUT1 and GLUT4 in proliferation, invasion and migration we generated H1299 and A549 GLUT 1 or GLUT4 knockdowns. Knockdown (KD) of GLUT4 did not inhibit proliferation but suppressed migration and invasion assessed through scratch and Boyden chamber assays, respectively. On the contrary, knockdown of GLUT1 reduced proliferation of these lines. Treatment of H1299 and A549 with our newly developed GLUT4-selective inhibitors also reduced invasion, phenocopying the effects detected with GLUT4 KD. GLUT4 inhibition also reduced H1299 invasion in a spheroid invasion model. We utilized H1299 cells to isolate highly invasive less proliferative “leader cells” and less invasive but highly proliferative “follower cells”. Interestingly, examination of these two cell types exhibited a differential expression pattern of GLUT1/GLUT4. Leader cells have elevated expression of GLUT4 and decreased GLUT1. On the contrary, follower cells have high GLUT1 and low GLUT4 expression. Leader cells are more sensitive to GLUT4 inhibitors indicating they are more dependent on GLUT4 than follower cells. In addition, leader cells are more sensitive to mitochondrial complex I inhibitors compared to follower cells, suggesting they rely more on oxidative phosphorylation. A differential reliance on glycolysis/OXPHOS was further supported by evaluation of glucose uptake/oxygen consumption. Isotope tracer and bioenergetics analyses further support altered nutrient dependencies of leader and follower cells. Lastly, we found that GLUT4 is expressed in patient lung adenocarcinoma specimens including more aggressive micropapillary lung adenocarcinoma. Examination of collective invasion packs in human adenocarcinoma demonstrated patchy GLUT1 expression suggestive of a subset of more proliferative “follower” cells. These results suggest that in a lung cancer population a subset of more invasive cells are reliant on GLUT4 with reduced GLUT1 expression while more proliferative cells rely on high GLUT1 expression, making GLUT4 a promising candidate for targeting metastasis in lung cancer. Citation Format: Changyong Wei, Abhinav Achreja, Jessica Konen, Gabriel Sica, Melissa Gilbert-Ross, Deepak Nagrath, Adam Marcus, Mala Shanmugam. GLUT4 exhibits a non-canonical role of regulating lung cancer metastasis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 4904. doi:10.1158/1538-7445.AM2017-4904

A positive crossmatch that is rendered negative by treating the serum with the IgM-reducing agent dithiothreitol (DTT) is generally reported not to influence short-term renal graft outcome. Its effect on long-term (> or = 3 years) cadaveric and live-donor transplant function, however, is less clear. We evaluated the effect of IgM antibodies in a DTT-ameliorated positive crossmatch (DTT-APXM) on long-term renal graft outcome in 1,290 consecutive cadaveric renal transplants (8-year survival) and 384 live-donor renal transplants (7-year survival) from patients transplanted between 1990 and 1999. The data show that 1- and 8-year graft survival for cadaveric renal transplants in patients with IgM antibodies (n=72) (DWFG censored = 91% and 65%; DWFG not censored = 90% and 60%) was not significantly different from the group without IgM antibodies (n = 1,218) (DWFG censored = 92% and 71%; DWFG not censored = 87% and 55%) (log-rank = 0.25 for DWFG censored, log-rank = 0.92 for DWFG not censored). The one- and seven-year graft survival for live-donor renal transplants in patients with IgM antibodies seen in a DTT-APXM (n = 22) (DWFG censored = 95% and 83%; DWFG not censored = 95% and 66%) was not significantly different from the group without IgM antibodies (n = 362) (DWFG censored = 94% and 81%; DWFG not censored = 92% and 73%) (log-rank = 0.61 for DWFG censored, log-rank = 0.89 for DWFG not censored). DR phenotype was found to be associated with the strong (>40% cell death) IgM reactivity in both black and white patients. In white patients, DR2 was more frequently seen with a strong IgM crossmatch (48.2%) than in molecularly typed controls (28.5%) (P < 0.03) and concomitant with that DR increase, DR4 was decreased in white patients (6.8%) compared with controls (25.5%) (P < 0.02). In black patients with strong IgM reactivity, DR6 was increased in patients (46.1%) compared with controls (20.5%) (P = 0.07) and concomitant with that DR6 increase, DR5 was decreased in frequency in black patients (7.6%) compared with controls (41%) (P < 0.03). These data show that long-term graft survival in renal transplantation is not negatively influenced by the presence of donor-reactive lymphocytotoxic antibodies in the crossmatch ameliorated by serum DTT treatment. They also suggest that the strength of the IgM antibody response is regulated in part by certain gene (s) of the DR region.

Background. Cadaveric kidneys experiencing longer cold ischemia time (CIT) are associated with higher levels of delayed graft function, acute rejection, and early graft loss. One mechanism to explain these results is that ischemia/reperfusion (I/R) injury makes the allograft more immunogenic by upregulating molecules involved in the immune response (e.g., HLA Class I/II). Methods. We evaluated the influence of CIT on the production of HLA Class I antibody level, measured by an antihuman globulin panel reactive antibody (AHG PRA) level, in 90 unsensitized recipients of primary cadaveric renal transplants (from a total of 1442 between 1985 and 1997) who rejected their kidneys. Results. By multivariate analysis, a CIT of 15 hr or more (vs.

The purpose of our investigation was to evaluate long-term graft survival and the role of histocompatibility in patients who were highly sensitized to human leukocyte antigen (HLA) Class I antigens and received a cadaveric renal transplant. Our multi-institutional study evaluated 7-yr graft outcomes and the histocompatibility requirements of 61 (6.1%) highly sensitized (anti-human globulin panel reactive antibody [AHG PRA], > or = 80%) cadaveric renal transplantation patients, transplanted between 1988 and 1997, among 999 consecutive cadaveric renal transplants. One- and 7-yr graft survival in the high PRA group (n = 61) was 76 and 59%, and was not significantly different from that in the low PRA group (n = 938), 86 and 59% (Wilcoxon = 0.11; log-rank = 0.45) (died with a functioning graft [DWFG] not censored). When those data were divided into primary and regrafts, 1- and 7-yr graft outcomes for high and low PRA groups were not significantly different [(primary, 1- and 7-yr survival: high PRA = 83 and 74%, n = 30, and low PRA = 87 and 61%, n = 825; log-rank = 0.37 for DWFG not censored) (regrafts, 1- and 7-yr survival: high PRA = 70 and 42%, n = 31, and low PRA = 80 and 43%, n = 113; log-rank = 0.36 for DWFG not censored)]. We did observe a subgroup of the high PRA patient group that had inferior graft outcomes. Graft outcome at 1 and 6 yr in the high PRA group for patients who had one to two DR mismatches (65 and 50%, n = 41) was significantly worse than for high PRA patients who had zero DR mismatches with their donors (100 and 78%, n = 20) (log-rank = 0.01 for DWFG not censored). Furthermore, the mean number of HLA-A and -B mismatches was significantly greater in the high PRA/DR-mismatched group (1.7 +/- 1.2, n = 41) compared with the high PRA/zero DR-mismatched group (0.5 +/- 1.1, n = 19) (p < 0.001). Overall, these data suggest that the patient who is highly sensitized to HLA Class I antigens has a long-term graft outcome that is equivalent to less sensitized patients, but that HLA-DR mismatching and a higher degree of Class I mismatching may be poor prognostic indicators in such patients.

The following report is a critical review of the recently published book by NBC's chief medical correspondent, Dr. Bob Arnot, entitled, The Breast Cancer Prevention Diet: The Powerful Foods, Supplements, and Drugs That Can Save Your Life. The review represents the official opinion of the American Council on Science and Health (ACSH), a nonprofit public health education and advocacy group supported by a board of over 250 scientific and policy advisors. The scientists at the ACSH express their profound concern about the misleading, unscientific, and speculative advice that Dr. Arnot offers to women who wish to reduce their risk of breast cancer, i.e., to all women. The ACSH believes, first, that in the absence of sound, peer-reviewed evidence supporting such advice, there is harm in recommending lifestyle modifications for the purpose of preventing breast cancer. The ACSH also believes that a physician (and particularly one in a position of public trust, such as a professional media health expert) should refrain from selling advice based on the twin philosophies that "you can't afford to wait" for the evidence, and that "you can only improve your health" with this diet. Indeed, unproven interventions such as those put forth in this book can have negative effects on both physical and psychological health. The ACSH contacted many of the scientists quoted or cited in Dr. Arnot's book. Some expressed concerns regarding the book's message or the misrepresentation of their work or both. Those physicians affiliated with the Memorial-Sloan Kettering Cancer Center (MSKCC) in New York, while expressing their concerns about the claims made in the book, informed the ACSH that they had been "advised" not to comment on The Breast Cancer Prevention Diet. The MSKCC public relations office acknowledged that the center had serious concerns about the Arnot book and that these concerns had been conveyed to the publisher, Little, Brown and Co., and to Dr. Arnot. The MSKCC representative noted that Dr. Arnot had "graciously" agreed to delete all references to MSKCC from future editions.

Background Cadaveric renal retransplantation is associated with a higher risk of early graft failure than primary grafts. A large proportion of those graft losses is likely attributable to donor-directed HLA class I antibodies, detectable by flow cytometry cross-matching but not by conventional crossmatching techniques. Methods. Long-term graft survival in a group of 106 recipients of consecutive cadaveric renal regrafts between 1990 and 1997, in whom a negative flow T-cell IgG crossmatch was required for transplantation, was compared with two other groups of cadaveric transplant recipients. The first group consisted of 174 cadaveric regrafts transplanted between 1985 and 1995 using only a negative anti-human globulin (AHG) T-cell IgG crossmatch. The second group was primary cadaveric transplants done concurrently with the flow group (1990 to 1997) using only the AHG T-cell IgG crossmatch. Results. The long-term (7 year) graft survival rate of flow crossmatch-selected regraft recipients (68%; n = 106) was significantly improved over that of regraft recipients who were selected for transplantation by only the AHG crossmatch technique (45%; n=174; log-rank=0.001 ; censored for patients dying with a functioning graft). Graft outcome for the flow cross-matched regraft recipients was not significantly different from that of primary cadaveric patients (72%; n=889; log-rank=0.2; censored for patients dying with a functioning graft). Finally, a positive B-cell IgG flow cytometric crossmatch had no influence on long-term regraft outcome. Conclusions. The use of the flow T-cell IgG cross-match as the exclusion criterion for cadaveric renal retransplantation yields an improved long-term graft outcome over that obtained when only the AHG cross-match is used and has improved survival of regraft recipients to the level of our primary cadaveric renal transplant population.

Background. We have increased the transplantation rate for blood group B cadaveric waiting list candidates by transplanting them with A 2 and A 2 B kidneys. Methods. Since 1991, five of the seven renal transplant programs in our organ procurement organization service area have preferentially transplanted blood group A 2 and A 2 B cadaveric kidneys to B blood group waiting list candidates with histories of low anti-A isoagglutinin titers. Results. Between 1991 and 1997, these five centers performed transplantations on 71 patients from the B cadaveric waiting list. Of those 71 patients, 29% (21 of 71) underwent transplantation with either A 2 (n=18) or A 2 B (n=3) cadaveric kidneys. In 1997 alone, 48% (11 of 23) of the B patient transplant recipients received A 2 or A 2 B kidneys. Conclusions. Transplantation of A 2 and A 2 B kidneys into B waiting list patients has successfully increased access of B patients to kidneys. Such an allocation algorithm implemented nationally may similarly increase the transplantation rate of B waiting list candidates.

Background This article summarizes our 10-year multicenter experience with transplantation of 50 blood group A 2 and A 2 B kidneys into B and O patients. Methods. Since 1986, we have transplanted kidneys from 46 cadaver donors and 4 living donors who were blood group A 2 (47 donors) or A 2 B (3 donors) into 19 B and 31 O patients. In 1991, we began allocating these kidneys preferentially to B and O recipients who were selected based on a history of low (

We describe a case of de novo membranous glomerulopathy in the renal allograft of a diabetic patient, treated with the newer immunosuppressive agent FK 506. Twenty-two months later this patient developed nephrotic range proteinuria.

Vimentin is an intermediate filament protein that has been used in the clinic as a biomarker for metastatic potential and poor patient prognosis across numerous solid tumor types; however, little is known about how vimentin might contribute to cancer progression and metastasis. Here we created a novel genetically engineered mouse model (GEMM) to study the role of vimentin in lung cancer progression and metastasis. We first re-developed an LSL-KrasG12D,LKB1fl/fl mouse model whereby intranasal administration of lentiviral Cre recombinase causes a KrasG12D mutation and LKB1 knockout in the lungs. In this model Kras/Lkb1 GEMM (termed KLV+/+), approximately half the mice that develop primary lung tumors in 8-10 weeks also develop metastasis to the mediastinal lymph nodes in weeks 12-16. We used this model to test the hypothesis that vimentin loss prevents lung cancer metastasis by crossing this GEMM with a Vim-/- mouse to create a novel LSL-KrasG12D, LKB1fl/fl, Vim-/- (termed here KLV-/-) mouse. Our findings show that in the KLV-/- mouse, primary tumor burden and cell proliferation were not significantly different than wild-type KLV+/+ mice; however, KLV-/- mice exhibit significantly less metastasis to the mediastinal lymph nodes compared to their wild type counterpart indicating that vimentin contributes to the metastatic cascade. Consistent with this finding, histological analysis of the primary tumors show that KLV-/- mice exhibit less focal invasion than KLV+/+ and +/- mice, further confirming that KLV-/- mice have reduced invasiveness. Interestingly, vimentin staining in invasive regions of KLV+/+ mice was not found in the cancer cells but rather in fibroblast-like cells surrounding invasive cell buds that we term collective invasion packs (CIPs). These fibroblast-like, vimentin-positive cells also stain positive for alpha smooth muscle actin, which is consistent with cancer-associated fibroblasts (CAFs). Taken together, these results suggest that in this highly metastatic genetic background, vimentin may play a central role in recruiting CAFs to invading cancer cells but not necessarily in cancer cell epithelial to mesenchymal transition (EMT). Citation Format: Alessandra M. Salgueiro, Melissa Gilbert-Ross, Lauren S. Havel, John Shupe, Allyson E. Koyen, Hans E. Grossniklaus, Gabriel Sica, Adam I. Marcus. Beyond EMT: Vimentin function in lung cancer metastasis. [abstract]. In: Proceedings of the AACR Special Conference: Function of Tumor Microenvironment in Cancer Progression; 2016 Jan 7–10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2016;76(15 Suppl):Abstract nr C24.

LKB1 is the 2rd most commonly mutated tumor suppressor gene in human lung adenocarcinoma, is commonly co-mutated with KRAS, and leads to more aggressive, treatment-resistant tumors in mouse models. The identification of druggable signaling molecules that result from specific alterations in LKB1 could result in a personalized clinical strategy to target this high-risk patient population. We have previously published that LKB1 acts to limit focal adhesion kinase (FAK) activity in human lung cancer cells to restrict cell adhesion and migration. Based on our prior published data we hypothesize that FAK pathway inhibition will suppress invasion and metastasis in LKB1-mutant tumors in vivo. To investigate our hypothesis, we have designed the first rolling-enrollment pre-clinical mouse trial to target invasion and metastasis using a small-molecule FAK inhibitor. To enroll mice with early-stage lung adenocarcinoma, we developed a novel lentiviral-Cre induced KrasG12D; Lkb1fl/fl genetically engineered mouse model (GEMM) (KLLLenti) that develops 100% adenocarcinomas, expresses a luciferase reporter gene, and has elevated levels of active FAK in late stage invasive tumors. Importantly, short-term treatment of KLLLenti mice with a pharmacologic FAK inhibitor potently suppresses the invasive progression of primary tumors. Moreover, long-term treatment results in improved progression-free survival, and delays metastatic spread to the lymph nodes. We further pursue mechanistic studies to investigate how LKB1-mutant tumor tissue gains a metastatic advantage in vivo, and using a combination of 3D tumor spheroid assays, and multiphoton microscopy, present results that LKB1-mutant tumors use a unique form of hybrid invasion that relies both on cell:cell and cell-matrix adhesion, and in doing so, are equipped to more efficiently invade into the collagen-dense microenvironment of the lung. We will also present data that similar molecular and cell biologic phenotypes can be found in a subset of KRAS, LKB1-mutant human clinical samples. Our studies suggest that when used early, FAK inhibitors may be a viable clinical strategy to prevent or delay metastasis in the KRAS, LKB1-mutant patient population, and begin to define alternate escape pathways by which this highly invasive cell population may escape first-line therapy. Citation Format: Melissa Gilbert-Ross, Jessica Konen, Junghui Koo, John Shupe, Gabriel L. Sica, Zhengjia Chen, Brian S. Robinson, Madhusmita Behera, Michael R. Rossi, Geoffrey H. Smith, Charles E. Hill, Suresh M. Ramalingam, Haian Fu, Fadlo R. Khuri, Wei Zhou, Adam Marcus. Developing a personalized anti-metastatic therapy to treat KRAS, LKB1-mutant lung adenocarcinoma. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr LB-348.

Lipid abnormalities are seen frequently in renal transplant patients. Cardiovascular disease is an important cause of morbidity and mortality in these patients. We assessed the efficacy and safety of the lipid-lowering drugs, nicotinic acid (short acting) and lovastatin, the 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor. Twelve renal transplant patients who had persistent hyperlipidemia despite 6 weeks of dietary treatment participated in this prospective, randomized, open-labeled crossover trial. At 16 weeks, when compared with control values, nicotinic acid (≥ 1.5 g twice a day) significantly reduced the total cholesterol (from 312 ± 18 [±SEM] mg/dL to 229 ± 19 mg/dL; P = 0.03) and the low-density lipoprotein cholesterol (from 218 ± 15 mg/dL to 142 ± 13 mg/dL; P = 0.03) and significantly increased the high-density lipoprotein cholesterol (from 44 ± 3 mg/dL to 58 ± 5 mg/dL; P = 0.03). The triglyceride level was reduced from 255 ± 40 mg/dL to 150 ± 23 mg/dL ( P = 0.09). At 16 weeks, lovastatin therapy (40 mg/d) significantly reduced the total cholesterol (from 285 ± 13 mg/dL to 233 ± 10 mg/dL; P = 0.005) and the low-density lipoprotein cholesterol (from 201 ± 11 mg/dL to 147 ± 7 mg/dL; P = 0.001). There were no significant changes in the triglyceride and high-density lipoprotein cholesterol levels. Although flushing developed in 67% of patients treated with nicotinic acid, this was not a reason for any of the study dropouts. During this short-term study period no adverse biochemical effects were noted with either of the drugs. These findings indicate that both nicotinic acid and lovastatin reduce the total and low-density lipoprotein cholesterol levels. In addition, nicotinic acid significantly alters the triglyceride and high-density lipoprotein cholesterol levels. Nicotinic acid is an effective and inexpensive lipid-lowering agent in patients who tolerate the drug. Therapy with nicotinic acid could potentially reduce the risk of cardiovascular events in this group of high-risk patients.

LKB1 is the 2rd most commonly mutated tumor suppressor gene in human lung adenocarcinoma, and a biomarker of aggressive disease in stage IV KRAS mutant lung cancer patients. We have previously published that LKB1 acts to limit focal adhesion kinase (FAK) activity in human lung cancer cells to restrict cell adhesion and migration. Based on our prior published data we hypothesize that FAK inhibition will suppress invasion and metastasis in LKB1-mutant tumors in vivo , and represent a viable clinical strategy to target this high-risk patient population. To investigate our hypothesis, we have developed a novel lentiviral-Cre KrasG12D; Lkb1fl/fl Rosa-luciferase genetically engineered mouse model (GEMM) (KLLLenti) that develops 100% adenocarcinomas, and produces a bioluminescent output that correlates with tumor burden, tumor grade, and degree of metastatic colonization of the lymph node. We show that stage IV KLLLenti primary tumors have elevated levels of active FAK in a subset of invasive cells that maintain collective contact via E-Cadherin. Importantly, treatment of KLLLenti mice with a pharmacologic FAK inhibitor potently suppresses invasive progression of primary tumors. Moreover, KLLLenti tumors treated at later stages progress to the same degree as vehicle-treated mice. This result suggests a ‘therapeutic window’ of opportunity, and argues that FAK inhibitors should be part of first-line therapy to treat LKB1-mutant lung cancer patients. We further pursue mechanistic studies to investigate how Lkb1-mutant tumor tissue gains a metastastic advantage in vivo, and using a combination of 3D tumor spheroid assays and multiphoton microscopy present results that Lkb1-mutant tumors use a unique form of hybrid or transitional invasion that on depends on both FAK-based adhesion and collective migration and in doing so, are equipped to more efficiently invade into the collagen-dense microenvironment of the lung. Our studies suggest that when used early, FAK inhibitors may be a viable clinical strategy to prevent metastasis in the LKB1-mutant patient population, and begin to define alternate escape pathways by which this highly invasive cell population may escape first-line therapy. Citation Format: Melissa Gilbert-Ross, Jessica Konen, John Shupe, Junghui Koo, Gabriel L. Sica, Suresh S. Ramalingam, Haian Fu, Fadlo R. Khuri, Wei Zhou, Adam I. Marcus. An early treatment window to target FAK-dependent collective invasion in Lkb1-mutant lung adenocarcinoma. [abstract]. In: Proceedings of the AACR Special Conference on Tumor Metastasis; 2015 Nov 30-Dec 3; Austin, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(7 Suppl):Abstract nr B45.

Erythrocytosis is infrequently seen in renal transplant recipients. Both theophylline and angiotensin converting enzyme (ACE) inhibitors have been reported to decrease the elevated hematocrit (Hct) and hemoglobin (Hgb) levels. We studied the efficacy of the ACE inhibitors ramipril (n=6) and enalapril (n=1) in seven stable renal transplant recipients. Although the ACE inhibitors significantly reduced the elevated Hct and Hgb levels during the short and long term (Hct 53 ± 1 vs 48.8 ± 0.7%; Hgb 17.8 ± 0.4 vs 16.7 ± 0.3 vs 16.7 ± 0.3 gm/dl, at 1 year), the clinical significance of these reductions remains unknown. During therapy there were no significant changes in the blood pressure, serum creatinine and potassium levels and the medications were well tolerated.

495 Background: This was a retrospective review analyzing the epidemiological and pathological association of penile cancer as well as the clinical results in patients managed at the University of Missouri Hospital and Clinics (UMHC) and Harry S Truman VA. Methods: Records were obtained of patients with a pathological diagnosis of penile cancer from 2001−2014 at UMHC and at the Harry S Truman VA. These charts were retrospectively reviewed. Information regarding patient demographics, pathology, treatment, and outcomes were recorded. Results: Forty-four patients with a pathologic diagnosis of penile cancer were identified. Mean age at diagnosis was 64 with 41 being White, 2 unknown, 1 Black, and 1 Hispanic. Seventy-two percent had tobacco exposure, with 66% of all patients having smoked greater than 10 years. HPV was present in 20%. Circumcision status was reviewed showing overall 61% were circumcised, with 4.5% being circumcised before the age of 18. Premalignant lesions were identified in 36% of the patients, with condyloma acuminate being the most common followed by Lichen Sclerosus and severe dysplasia. The vast majority (98%) of penile cancers were squamous cell carcinoma (SCCa), with only one patient having a Buschke−Lowenstein tumor. Invasive SCCa without nodal involvement was the most common pathologic stage (41%) followed by nodal positive disease (36%) and CIS (23%). Of those with node positive disease, 56% were dead less than 5 years after nodal involvement. Ninety-nine procedures with curative intent were performed, with a mean of 2.25 procedure per patient. However, only 79 of the procedures led to a sustainable cure. Of those patients with metastatic disease 13.6% underwent chemotherapy and 9.1% received radiation. Conclusions: Our study reflects the trends in stage, recurrence, treatment, and outcomes at two large centers for penile cancer. In this patient group the majority had exposure to tobacco and almost exclusively had SCCa. A durable cure may require multiple operative interventions. Nodal involvement carries a poor prognosis and high risk of death in less than 5 years once diagnosed.

Hyperlipidemia often occurs after renal transplantation and may contribute to increased cardiovascular morbidity. The National cholesterol education program guidelines (NCEP) recommend dietary modification as the initial therapeutic intervention. We evaluated the effects of the AHA Step I and Step II diets on the serum total cholesterol (TC) and the triglyceride (TG) levels in nondiabetic renal transplant patients. Both the AHA Step I (TC 296 ± 7 vs 294 ± 9 mg/dL, p = ns) and Step II diets (TC 282 ± 8 vs 292 ± 16 mg/dL, p = ns) failed to significantly lower the serum total cholesterol and the triglycerides levels. During this dietary intervention, the patients' body weight and serum creatinine level remained stable. Our data suggest that neither the AHA Step 1 nor the Step II diet are effective in significantly lowering elevated serum lipids in nondiabetic renal transplant recipients.

A total of 96 patients were treated for localized carcinoma of the prostate using combined Iodine-125 (125I) implantation and external beam radiotherapy. The implant was tailored to deliver 10,000 rad to the periphery of the prostate. A significant incidence of serious late rectal complications was observed. Positive pelvic nodes were found in 28 percent of the patients. Disease-free survival at seven years was 76 percent for those with negative nodes and 46 percent for patients with positive nodes.

We describe a renal transplant patient who developed hypercalcemia during treatment with ganciclovir for cytomegaloviral (CMV) infection. To our knowledge such an association has not previously been reported. Hypercalcemia was associated with low levels of serum parathormone (PTH) and an increase in 1,25 dihydroxy vitamin D concentrations. The mechanism(s) of ganciclovir-associated hypercalcemia remains unclear.

The purpose of this prospective descriptive study was to explore the patterns of intrasubject (between medication) adherence of two similarly timed, twice-daily medications using the Medication Event Management System® electronic monitoring cap. Medication adherence was measured for 6 months using electronic monitoring in 25 adult renal-transplant recipients. Data were available from 7,119 electronic medication events. Results indicated that two twice-daily medications scheduled to be taken simultaneously were taken within 5 min of each other 77% of the time and within 10 min, 92% of the time. When only the first scheduled dose of the day was examined, the results are 79% and 95%, respectively. These findings are important to researchers and clinicians who must evaluate medication adherence in transplant recipients while balancing cost and subject burden. This study provides empirical support for monitoring a single immunosuppressive medication electronically to estimate medication adherence with double or triple immunosuppressive drug therapy.

A major mechanism of metastasis is the epithelial to mesenchymal transition (EMT) where epithelial cells from the primary site undergo genetic and epigenetic alterations to become motile and mesenchymal. A canonical marker of EMT and a clinical marker of metastasis is the intermediate filament protein, vimentin. Vimentin expression correlates with increased metastatic potential and poor patient prognosis across most solid tumor types including lung, prostate, and breast cancers; however little is known about how vimentin functions to promote the metastatic cascade. Here we use a lung cancer mouse model to study the role of vimentin in lung cancer metastasis in vivo. We have re-developed an LSL-KrasG12D,LKB1fl/fl mouse model whereby intranasal administration of lentiviral Cre recombinase causes a KrasG12D mutation and LKB1 knockout in the lungs. Consequently, about half of the mice that develop primary lung tumors after 10 weeks also develop metastasis to the mediastinal lymph nodes by week 16. We crossed this mouse with a Vim-/- mouse to create a LSL-KrasG12D,LKB1fl/fl, Vim-/- (termed here KLV) mouse to determine if loss of vimentin prevents lung cancer metastasis in this model. Our findings show that the KLV mouse exhibits significantly less metastasis to the mediastinal lymph nodes (12%) as compared with its vimentin wild type counterpart but does not show a decrease in primary tumor formation. These knockout mice also exhibit less focal invasion at the primary tumor site while maintaining a well-differentiated adenocarcinoma histology independent of vimentin genotype. Taken together, our work indicates that vimentin is critical for lung cancer metastasis but not primary tumor formation. Citation Format: Alessandra M. Salgueiro, Melissa Gilbert-Ross, Lauren S. Havel, John Shupe, Adam I. Marcus. More than a biomarker: Studying the role of vimentin in lung cancer metastasis. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 2290. doi:10.1158/1538-7445.AM2015-2290

To describe a laparoscopic hand-assisted approach to renal autotransplantation that allows both harvest and transplant through the same incision.Three patients underwent renal autotransplantation from May 2003 to April 2004, two for loin pain-hematuria syndrome and one for severe ureteral-stricture disease. Two patients underwent autotransplantation on the left and one on the right. Hand-assisted laparoscopy was planned such that inferomedial extension of the hand-port incision would provide adequate exposure of the iliac vessels for autotransplantation.The average operative time was 240 minutes, the warm ischemia time was 2 minutes 43 seconds, and the hospital stay was 3 days. All three patients had successful graft function by postoperative renal scan with a mean follow-up of 7.1 months.Hand-assisted laparoscopic renal harvest for autotransplantation can be completed with placement of the hand port such that transplantation can be accomplished through the same incision. As many of these patients have had multiple prior retroperitoneal operations, the intracorporeal hand can greatly facilitate these potentially difficult dissections with no added morbidity.

Polyclonal antibodies, used for both induction and rejection therapy in renal transplant recipients, are associated with such side effects as chills and fever. We describe two patients who developed a coagulopathy during antithymocyte globulin (ATGAM) therapy, a previously unknown complication. The laboratory tests revealed prolonged prothrombin and partial thromboplastin times and thrombocytopenia. Discontinuation of ATGAM therapy resulted in correction of these abnormalities.

The authors report the case of an 8-year-old boy with coexisting malignant extraadrenal pheochromocytoma and ipsilateral renal artery stenosis, severe hypertension, normal urinary vanillylmandelic acid levels, and elevated catecholamines and renin levels. Reported mechanisms of the stenosis are reviewed. The interrelationships of catecholamines, renin, and angiotensin and their effects on renal vasculature are discussed.

Increased cardiovascular deaths have been reported in long-term survivors after renal transplantation. In the primary and secondary coronary prevention trials, reduction of elevated cholesterol has been demonstrated to decrease the incidence of cardiovascular events. The authors previously reported that only 33% of renal transplant patients achieved the National Cholesterol Education Program Expert Panel target values of total and low density lipoprotein cholesterol with niacin > or = 2 g/day or lovastatin 40 mg/day. Indeed, combination therapy with the bile acid sequestrant, cholestyramine appears to be a logical choice. Hence, the pharmacokinetics of cyclosporine were studies before (baseline, on day 1) and after starting cholestyramine 4 g/day, given as a single dose at noon (study repeated on day 4) in six nondiabetic renal transplant patients. Included were 1 woman and 5 men; their mean age (+/- SEM) was 45 +/- 6 years, and they were all > 1 year post transplantation. These patients were receiving cyclosporine, azathioprine, and prednisone based maintenance immunosuppression. Compared to day 1 (baseline period), the peak (644 +/- 142 ng/ml versus 625 +/- 168 ng/ml; ns) and trough (196 +/- 17 ng/ml versus 214 +/- 32 ng/ml; ns) cyclosporine levels and the time to peak (2 hr versus 2 hr) were not significantly different on day 4 (post cholestyramine period) of the study. Furthermore, the area under the curve (3721 +/- 586 ng/hour/ml versus 4143 +/- 778 ng/hour/ml; ns) was not significantly different. Our data suggest that cholestyramine 4 g, given once a day at noon, did not interfere with the absorption of oral cyclosporine. Hence, combination therapy with cholestyramine appears to be a reasonable choice in renal transplant patients with resistant hypercholesterolemia.

We describe two cases of de novo membranous glomerulopathy in the renal allograft, with unusual histologic findings. In one patient the allograft nephrectomy specimen showed numerous foam cells in the intima of hyperplastic arteries along with prominent features of chronic rejection. In the other patient, prominent IgM deposits were seen in the glomerular mesangium without chronic rejection.

Background The Rh (D) blood group system has not traditionally been considered to be a clinically relevant histocompatibility barrier in transplantation since conflicting results of its clinical importance have been reported. Methods We analyzed 786 consecutive primary cadaveric renal transplants performed by transplant centers in our Organ Procurement Organization (OPO) between 1990 and 1997. We also analyzed United Network for Organ Sharing (UNOS) data on 26,469 kidney transplants done from April 1994 to June 1996. Results Multivariate analysis revealed that Rh identity between the recipient and donor was significantly related to better graft outcome (risk ratio, 0.43; 95% confidence interval, 0.30 to 0.61; P=0.0001). Multivariate analysis of the UNOS data revealed that the Rh -/- group may have a positive influence on graft survival with a risk ratio of 0.43 (P=0.14). Conclusion Multivariate analysis of primary cadaveric renal allografts performed within the Midwest Organ Bank OPO indicates that Rh (D) is a clinically relevant histocompatibility barrier that influences 7-year graft survival.

A Atherosclerosis-related cardiovascular disease remains an important cause of morbidity and mortality in renal transplant patients. We assessed the efficacy and safety of the newer synthetic HMG-CoA reductase inhibitor, fluvastatin, in 12 renal transplant patients who remained hypercholesterolemic, despite having been on the American Heart Association (AHA) Step I diet for 6 weeks. At 8 weeks, compared to the control phase, fluvastatin therapy, 20 mg/day, reduced the total cholesterol (TC) from 321 +/- 57 [+/-SD] to 301 +/- 123 mg/dl (p = 0.3); low-density lipoprotein cholesterol (LDL-C), from 209 +/- 56 to 176 +/- 81 mg/dl (p = 0.2); and the triglyceride (TG) levels from 343 +/- 119 to 277 +/- 117 mg/dl (p = 0.06); all these changes were statistically insignificant. However, the therapy significantly increased the high-density lipoprotein cholesterol (HDL-C) from 37 +/- 11 to 46 +/- 13 mg/dl (p = 0.006). During this short-term treatment period no adverse biochemical effects were noted with the therapy.

Sixty-three patients with cancer of the prostate T2 or T3 were evaluated. The protocol of treatment called for pelvic lymphadenectomy, 10,000 rad from I125 implant and 4000 rad in 20 fractions using a Cobalt60 machine. They were followed for 1 to 5 years with a plan to rebiopsy the prostate 1 to 2 years after therapy. Six of 59 evaluable patients (10%) showed progressive disease. Distinctive prognostic features in the failure group were younger age, larger prostate, more advanced stage, poorer differentiation, more possibility of positive pelvic lymph nodes, and if the nodes were positive, the involvement of more than two pelvic lymph nodes. On the other hand, the patients with controlled disease with or without positive prostatic biopsy on follow-up showed identical features regarding age, size of prostate, stage, differentiation, involvement of pelvic lymph nodes, and if the nodes were positive, only one or two nodes involved. Positive biopsy 1 to 2 years after radical irradiation in otherwise controlled disease is considered of no prognostic value.

Eighty-five tumors from 49 patients with transitional cell carcinoma were examined in a model for in vitro sensitivity using tumor explant reduction assay. Individual sensitivity patterns were obtained for each tumor tested. Explants were most frequently found to be sensitive to cis-platinum (49 per cent) and least frequently sensitive to thiotepa (20 per cent). Thirteen patients were studied on multiple sequential intervals, with resistance to specific agents noted to develop in 53 per cent of the patients. To date, a prospective cross-over study has been conducted on seven patients with 15 correlates. Overall, clinical correlation of this assay for both resistance and sensitivity is 93 per cent. We report a new assay for transitional cell carcinoma of the bladder that is adaptable to small specimen samples and provides adequate material for testing 73 per cent of the time.

To determine cost-effective, guidelines for the follow-up of patients with superficial transitional cell carcinoma of the bladder (STCCAB), we reviewed clinical histories, pathology reports. and intravenous pyelography results in 84 patients with Stage Ta or TI disease. In 4 patients (4.8%) subsequent upper tract tumors developed with an average interval from initial presentation to the development of upper tract disease of 5.4 years. Three of these patients were treated successfully. We recommend upper tract surveillance in this group of patients with intravenous pyelography at diagnosis and every twenty-four months thereafter, or selection of those patients who are at high risk for development of upper tract disease (i.e., ureteral-vesical reflux) with voiding cystourethrography one month following each resection of tumors near a ureteral orifice. Refluxing patients should then either undergo surgical repair of their reflux or yearly pyelography.

Pararenal pseudocysts developed after an operation, after blunt and penetrating trauma or after contiguous disease processes in 16 patients. Nephrectomy was necessary in 8 cases. Although the duration of the pseudocyst and the extent of conduit injury did to an extent determine the fate of the kidney, the location of the encapsulated extravasate and its propensity for curtailment of urine formation appeared to be more significant factors. The cases were reviewed in light of the individualization in management required for the complex problems they present.

Life table analyses were applied to experiences at the University of Missouri over a 5-year period with center hemodialysis, home hemodialysis, continuous ambulatory peritoneal dialysis (CAPD), living related donor transplantation, and cadaveric transplantation. Patient survival, graft survival, and persistence on therapy were analyzed. Mean ages and the percentage of insulin-treated diabetics were not similar in all groups; many factors influenced the choice of therapy by patient and physician. Nevertheless, the results show the net outcomes of these different therapies at an institution that has offered them all over the 5-year period analyzed. Patient survival and persistence on therapy for CAPD fell within the range of the other forms of therapy. Based on predictions of patient survival from published experiences with end-stage renal disease (ESRD) populations, observed survivals in CAPD were close to those predicted for the age of the population. At 2 years, persistence on therapy (technique survival) was similar for center hemodialysis and CAPD. However, 88% of the nondeath dropouts from center hemodialysis were for kidney transplantation, while 12% were related to technique problems. In contrast, in CAPD only 14% of the nondeath dropouts were for a kidney transplantation, 10% were based on recovery of renal function, and 76% were related to dialysis therapy problems. Nondeath dropouts from home hemodialysis were more similar to those in CAPD, with only 33% for kidney transplantation and 67% for therapy problems. These results cannot be assumed to indicate that the choice of therapy influences outcome. They show net outcomes in a single program are most likely based on multiple factors (age, diabetes mellitus, cardiac status, patient selection bias, physician selection bias, and perhaps the therapy per se) that influence these indices of success. To our knowledge these are the first comparisons of the net outcomes of all these forms of therapy at a single institution over the same period of time.

Our results with radioimmunoassay studies for parathyroid hormone performed during the last 6 years are compared retrospectively to results of the laboratory tests customarily secured when hyperparathyroidism is suspected. The results obtained in patients with known primary hyperparathyroidism and in patients with unconfirmed but presumptive hyperparathyroidism are compared to the results obtained from a group of normal controls. Despite the fact that certain discrepant results were noted in the earlier assay techniques the over-all results and, in particular, those of more recent years have been highly sensitive and reproducible corroboratives of the existence of primary hyperparathyroidism. About two-thirds of the patients with primary hyperparathyroidism will present to the urologist. All patients with calcium-containing stones should have at least 3 determinations of the serum calcium in screening for primary hyperparathyroidism. The radioimmunoassay for parathyroid hormone provides the most reliable confirmation. The patient with calculous disease, elevation of the immunoreactive parathyroid hormone level and hypercalcemia is virtually certain to have primary hyperparathyroidism.