Alemtuzumab preconditioning with tacrolimus monotherapy - The impact of serial monitoring for donor-specific antibody

BACKGROUND. Antibody preconditioning with tacrolimus monotherapy has allowed many renal allograft recipients to be maintained on spaced weaning. METHODS. Of 279 renal allograft recipients transplanted between March 2003 and December 2004, 222 (80%) had spaced weaning (i.e., reduction of tacrolimus monotherapy dosing to every other day, three times a week, twice a week, or once a week) attempted. Routine monitoring for donor-specific antibody (DSA) was begun in September 2004. Mean follow-up is 34±6.5 months after transplantation and 26±8.1 months after the initiation of spaced weaning. RESULTS. One hundred and twenty-two (44%) patients remained on spaced weaning. One- and 2-year actual patient/graft survival was 99%/99%, and 97%/96%. Fifty-six (20%) patients experienced acute rejection after initiation of spaced weaning. One- and 2-year actual patient/graft survival was 100%/98%, and 94%/78%. Forty-two (15%) patients with stable renal function had spaced weaning stopped because of the development of DSA, which disappeared in 17 (40%). One- and 2-year actual patient and graft survival was 100% and 100%. CONCLUSION. Adult renal transplant recipients who are able to be maintained on spaced weaning have excellent outcomes. Patients with stable renal function who have reversal of weaning because of the development of DSA also have excellent outcomes. Routine monitoring for DSA may allow patients to avoid late rejection after spaced weaning. © 2008 Lippincott Williams & Wilkins, Inc

Living donor renal transplantation using alemtuzumab induction and tacrolimus monotherapy

Alemtuzumab was used as an induction agent in 205 renal transplant recipients undergoing 207 living donor renal transplants. All donor kidneys were recovered laparoscopically. Postoperatively, patients were treated with tacrolimus monotherapy, and immunosuppression was weaned when possible. Forty-seven recipients of living donor renal transplants prior to the induction era who received conventional triple drug immunosuppression without antibody induction served as historic controls. The mean follow-up was 493 days in the alemtuzumab group and 2101 days in the historic control group. Actuarial 1-year patient and graft survival were 98.6% and 98.1% in the alemtuzumab group, compared to 93.6% and 91.5% in the control group, respectively. The incidence of acute cellular rejection (ACR) at 1 year was 6.8% in the alemtuzumab group and 17.0% (p < 0.05) in the historic control group. Most (81.3%) episodes of ACR in the alemtuzumab group were Banff 1 (a or b) and were sensitive to steroid pulses for the treatment of rejection. There was no cytomegalovirus disease or infection. The incidence of delayed graft function was 0%, and the incidence of posttransplant insulin-dependent diabetes mellitus was 0.5%. This study represents the largest series to date of live donor renal transplant recipients undergoing alemtuzumab induction, and confirms the short-term safety and efficacy of this approach. © 2006 The Authors

Progress and challenges in using stable isotopes to trace plant carbon and water relations across scales

table isotope analysis is a powerful tool for assessing plant carbon and water relations and their impact on biogeochemical processes at different scales. Our process-based understanding of stable isotope signals, as well as technological developments, has progressed significantly, opening new frontiers in ecological and interdisciplinary research. This has promoted the broad utilisation of carbon, oxygen and hydrogen isotope applications to gain insight into plant carbon and water cycling and their interaction with the atmosphere and pedosphere. Here, we highlight specific areas of recent progress and new research challenges in plant carbon and water relations, using selected examples covering scales from the leaf to the regional scale. Further, we discuss strengths and limitations of recent technological developments and approaches and highlight new opportunities arising from unprecedented temporal and spatial resolution of stable isotope measurements

The predictability of ecological stability in a noisy world

Random environmental variation, or stochasticity, is a key determinant of ecological dynamics. While we have some appreciation of how environmental stochasticity can moderate the variability and persistence of communities, we know little about its implications for the nature and predictability of ecological responses to large perturbations. Here, we show that shifts in the temporal autocorrelation (colour) of environmental noise provoke trade-offs in ecological stability across a wide range of different food-web structures by stabilizing dynamics in some dimensions, while simultaneously destabilizing them in others. Specifically, increasingly positive autocorrelation (reddening) of environmental noise increases resilience by hastening the recovery of food webs following a large perturbation, but reduces their resistance to perturbation and increases their temporal variability (reduces biomass stability). In contrast, all stability dimensions become less predictable, showing increased variability around the mean response, as environmental noise reddens. Moreover, we found environmental reddening to be a considerably more important determinant of stability than intrinsic food-web characteristics. These findings reveal the fundamental and dominant role played by environmental stochasticity in determining the dynamics and stability of ecosystems, and extend our understanding of how the multiple dimensions of stability relate to each other beyond simple white noise environments

Outsiders in Nursing Education: Cultural Sensitivity in Clinical Education

Abstract: Cultural competence is a stated value of nursing and nursing education. However, some institutional and traditional practices in nursing education can unintentionally impede nurses from achieving cultural competence. Both the literature and interviews with nurse educators show that despite educators&apos; intentions to treat all students the same, nontraditional students may feel singled out and may in fact be singled out for closer scrutiny because of their difference from the demographic norms of nursing students. To ensure that the nursing profession reflects the composition of the patient population it serves, nurse educators must first acknowledge the Eurocentric culture of nursing education and, then, work to change the environment in which students are recruited, learn, and take on the role of beginning practicing nurses. Nursing education | Clinical education | Cultural sensitivity | Pre-licensure nursin

Predonation direct and indirect costs incurred by adults who donated a kidney: findings from the KDOC study.

Limited information exists on the predonation costs incurred by eventual living kidney donors (LKDs). Expenses related to completion of the donation evaluation were collected from 194 LKDs participating in the multi-center, prospective Kidney Donor Outcomes Cohort (KDOC) Study. Most LKDs (n = 187, 96%) reported one or more direct costs, including ground transportation (80%), healthcare (24%), lodging (17%) and air transportation (14%), totaling $101 484 (USD; mean =$523 ± 942). Excluding paid vacation or sick leave, donor and companion lost wages totaled $35 918 (mean =$187 ± 556) and $14 378 (mean =$76 ± 311), respectively. One-third of LKDs used paid vacation or sick leave to avoid incurring lost wages. Few LKDs reported receiving financial support from the transplant candidate (6%), transplant candidate\u27s family (3%), a nonprofit organization (3%), the National Living Donor Assistance Center (7%), or transplant center (3%). Higher total costs were significantly associated with longer distance traveled to the transplant center (p \u3c 0.001); however, total costs were not associated with age, sex, race/ethnicity, household income, marital status, insurance status, or transplant center. Moderate predonation direct and indirect costs are common for adults who complete the donation evaluation. Potential LKDs should be advised of these possible costs, and the transplant community should examine additional strategies to reimburse donors for them