Recurrent Crohn's disease in transplanted bowel

Intestinal transplantation is used in patients with short-bowel syndrome after repeated resections for Crohn's disease. We report the apparent clinical recurrence of Crohn's disease in a transplanted intestine. The patient, a 33-year-old Hispanic woman, underwent small-bowel transplantation in December, 1994. Immunosuppression with tacrolimus, methylprednisolone, bone-marrow infusions, and OKT3 was given. In July, 1995, the patient had recurrent abdominal symptoms. The histological diagnosis of Crohn's disease was established by the independent interpretations of four experienced gastrointestinal histopathologists. The prompt appearance of this autoimmune disorder (within 6 months of transplantation), despite massive immunosuppression may provide important insights into the nature of Crohn's disease and of the recurrence of autoimmune disease during immuno-suppression

Avoidance of chronic steroid therapy in african american kidney transplant recipients monitored by surveillance biopsy: 1-year results.

African American (AA) kidney recipients receive chronic steroid therapy to improve outcomes, despite their high susceptibility to side effects, particularly diabetes and hypertension. This study evaluated the safety and efficacy of avoidance of chronic steroid therapy in AA compared to non-AA kidney recipients. Two hundred and six kidney recipients were studied; 103 AA recipients versus 103 non-AA recipients. Induction was basiliximab and maintenance was a calcineurin inhibitor plus mycophenolate mofetil or sirolimus. Surveillance biopsies were preformed at 1, 6 and 12 months to assess subclinical acute rejection (SCAR) and chronic allograft nephropathy (CAN). Biopsy-proven acute rejection (AR) and SCAR were treated by methylprednisolone. The primary end point was AR. Secondary end points were graft function, 1-year patient and graft survival. AR was observed in 16% of AA and 13% of non-AA recipients. SCAR at 1 month was significantly higher in the AA group (p=0.04). One-year actual patient and graft survival in the AA group was 96% and 88% and in the non-AA group 97% and 89%, respectively. Avoidance of chronic steroid therapy directed by surveillance biopsies provides equivalent AR, CAN and 1-year patient and graft survival in AA versus non-AA recipients and a 5% incidence of new onset diabetes mellitus. All recipients remain free of chronic steroid therapy. Longer-term follow-up is ongoing

Safety and efficacy of steroid withdrawal two days after kidney transplantation: analysis of results at three years.

BACKGROUND: Chronic steroid therapy in spite of myriad side effects is widely used in kidney transplantation. This prospective controlled study evaluated safety and efficacy of steroid withdrawal at 2 days in kidney recipients monitored by surveillance biopsy. METHODS: In all, 300 kidney recipients were studied; 150 in second-day steroid withdrawal group and 150 in steroid treated group (control group). Immunosuppression was basiliximab induction and maintenance was a calcineurin inhibitor and mycophenolate mofetil or sirolimus. Biopsy-proven acute rejection (BPAR) was treated by methylpredisolone. Surveillance biopsies were completed to evaluate subclinical acute rejection (SCAR) and chronic allograft nephropathy (CAN). Primary end point was acute rejection. Three-year patient and graft survival, new onset diabetes mellitus (NODM), serum creatinine and creatinine clearance were evaluated. RESULTS: Acute rejection was diagnosed in 14% in control group and 16% in steroid withdrawal group. Three-year patient and graft survival was 89% and 79% in control and 91% and 78% in steroid withdrawal group. Serum creatinine and creatinine clearance was 1.9+/-0.8 and 59+/-11 in control group and 1.8+/-0.9 mg/dl and 61+/-10 mls/minute in steroid withdrawal group. Incidence of SCAR and progression of CAN were comparable in the 2 groups. At 3-years NODM was diagnosed in 21% in control group and 4% in steroid withdrawal group (P\u3c0.01). CONCLUSIONS: Two-day steroid withdrawal in kidney transplant recipients did not affect BPAR, SCAR, CAN, graft function and patient and graft survival compared to control group up to 3 years. NODM was significantly less in steroid withdrawal group. Two-day steroid withdrawal is safe and beneficial in kidney transplant recipients

Successful transplantation of kidneys from deceased donors with acute renal failure: Three-year results.

BACKGROUND: Kidneys from deceased donors with acute renal failure (ARF) are generally not accepted for transplantation because of the expected poor outcome. This prospective study examined the utilization of kidneys from donors with ARF for transplantation and the outcomes. METHODS: Fifty-five kidneys from donors with ARF were transplanted. The outcome was compared with concurrent and matched 55 recipients of standard criteria donor (SCD) kidneys and 55 expanded criteria donor (ECD) kidneys. ARF kidneys were accepted from donors aged \u3c50 \u3eyears, a negative history for kidney disease, and a negative pretransplant biopsy for chronic structural changes. The immunosuppression was similar in all three groups. The outcome measurements included three-year patient and graft survival, biopsy-proven acute rejection (BPAR), subclinical acute rejection (SCAR), and chronic allograft nephropathy (CAN), serum creatinine, and creatinine clearance. RESULTS: Three-year patient and graft survival was 90% and 90% in ARF group, 100% and 89% in SCD group and 83% and 66% in ECD group. BPAR and SCAR were comparable in the groups but CAN was significantly higher in ECD group. Mean serum creatinine levels were 1.9+/-1.1, 1.9+/-0.9, and 2.2+/-1.3 mg/dl and mean creatinine clearances were 66+/-15, 68+/-14, and 58+/-10 mls/minute in ARF, SCD, and ECD groups, respectively (SCD and ARF vs. ECD P = 0.04). CONCLUSIONS: Transplantation of kidneys from selected deceased donors with ARF provides comparable survival and function compared to kidneys from non-ARF donors and may be considered for transplantation to expand the donor pool to overcome the current acute shortage of kidneys

Cellular and molecular immune profiles in renal transplant recipients after conversion from Tacrolimus to Sirolimus

Tacrolimus and Sirolimus are commonly used maintenance immunesuppressants in kidney transplantation. Since their effects on immune cells and allograft molecular profiles have not been elucidated, we characterized the effects of Tacrolimus to Sirolimus conversion on frequency and function of T cells, and on graft molecular profiles. Samples from renal transplant patients in a randomized trial of 18 patients with late Sirolimus conversion and 12 on Tacrolimus maintenance were utilized. Peripheral blood was collected at 0, 6, 12 and 24-months post-randomization with T cell subpopulations analyzed by flow cytometry and T cell alloreactivity tested by IFN-γ ELISPOT. Graft biopsy samples obtained 24-months post-randomization were used for gene expression analysis. Sirolimus conversion led to an increase in CD4+25+++Foxp3+ regulatory T cells. While Tacrolimus-maintained patients showed a decrease in indirect alloreactivity over time post-transplant, Sirolimus conversion increased indirect alloreactive T cell frequencies compared to Tacrolimus-maintained patients. No histological differences were found in graft biopsies, but molecular profiles showed activation of the antigen presentation, IL-12 signaling, oxidative stress, macrophage-derived production pathways, and increased inflammatory and immune response in Sirolimus-converted patients. Thus, chronic immune alterations are induced after Sirolimus conversion. Despite the molecular profile being favorable to calcineurin inhibitor-based regimen, there was no impact in renal function over 30 months of follow-up

Los Mayas de Quintana Roo y la economía de la identidad

The economic importance of tourism, its expansion to areas previously far from the accumulation processes and the use of ethnic and cultural diversity for tourist attraction purposes, is an unavoidable fact in the contemporary globalized world. This article analyzes the use of Mayan identity by a business group of great economic power. Its purpose is to discuss the identity economy among the Mayan peoples in Quintana Roo, Mexico, as one of the most refined examples of the use of indigenous cultures by the tourist capital and to draw attention to the instrumental use of ethnic identity by tourism companies that are part of the large global entertainment chains.La importancia económica del turismo en numerosos países, su expansión hacia áreas antes alejadas de los procesos de acumulación y el uso que se hace de la diversidad étnica y cultural con fines de atracción turística, es un hecho insoslayable en el mundo globalizado contemporáneo.  En este artículo se analiza el uso de la identidad maya por un grupo empresarial  de gran poder económico. Tiene el propósito de problematizar en torno a la economía de la identidad entre los pueblos mayas en Quintana Roo, México, como uno de los ejemplos más acabados sobre el uso de las culturas indígenas por  el capital turístico.  Con ello se busca llamar la atención sobre la uso instrumental de la identidad étnica por parte de las empresas turísticas que forman parte de las grandes cadenas globales del ocio y del espectáculo.