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Causes of Graft Loss over 10 Years in CsA-Treated Patients. Recurrent disease 6% . Other 3%. Acute Rejection 11% . PNF 5%. Vascular 8%. Death 27%. CAN 40%. Marcén R et al. Transplantation 2001; 72:57  62. Presentation techniques Some personal advice. I. Performance

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causes of graft loss over 10 years in csa treated patients
Causes of Graft Loss over 10 Years in CsA-Treated Patients

Recurrent

disease

6%

Other

3%

Acute

Rejection

11%

PNF

5%

Vascular

8%

Death

27%

CAN

40%

Marcén R et al. Transplantation 2001; 72:5762.

presentation techniques some personal advice

Presentation techniquesSome personal advice

  • I. Performance
  • II. Manuscript
  • III. Slides
presentation techniques some personal advice1

Presentation techniquesSome personal advice

  • I. Performance
  • II. Manuscript
  • III. Slides
i performance

I. Performance

  • Never turn your back on the audience
  • Always look at the audience
  • (and the laptop)
i performance1

I. Performance

  • Never turn your back on the audience
  • Always look at the audience
  • (and the laptop)
  • Never use the laser pointer
  • Always use your slides to make your point
causes of graft loss over 10 years in csa treated patients1
Causes of Graft Loss over 10 Years in CsA-Treated Patients

Recurrent

disease

6%

Other

3%

Acute

Rejection

11%

PNF

5%

Vascular

8%

Death

27%

CAN

40%

Marcén R et al. Transplantation 2001; 72:5762.

causes of graft loss over 10 years in csa treated patients2
Causes of Graft Loss over 10 Years in CsA-Treated Patients

Recurrent

disease

6%

Other

3%

Acute

Rejection

11%

PNF

5%

Vascular

8%

Death

27%

CVD

CNI-

nephrotox

CAN

40%

Marcén R et al. Transplantation 2001; 72:57-62.

metabolic toxicities of immunosuppressive drugs
Metabolic Toxicities of Immunosuppressive Drugs

CsA = cyclosporine A; Tac = tacrolimus; Ster = corticosteroids;

SRL/EVL = sirolimus/everolimus; AZA = azathioprine

Adapted from Danovitch GM. Transplant Rev 2000; 14:65–81.

metabolic toxicities of immunosuppressive drugs1
Metabolic Toxicities of Immunosuppressive Drugs

CsA = cyclosporine A; Tac = tacrolimus; Ster = corticosteroids;

SRL/EVL = sirolimus/everolimus; AZA = azathioprine

Adapted from Danovitch GM. Transplant Rev 2000; 14:65–81.

metabolic toxicities of immunosuppressive drugs2
Metabolic Toxicities of Immunosuppressive Drugs

CsA = cyclosporine A; Tac = tacrolimus; Ster = corticosteroids;

SRL/EVL = sirolimus/everolimus; AZA = azathioprine

Adapted from Danovitch GM. Transplant Rev 2000; 14:65–81.

metabolic toxicities of immunosuppressive drugs3
Metabolic Toxicities of Immunosuppressive Drugs

CsA = cyclosporine A; Tac = tacrolimus; Ster = corticosteroids;

SRL/EVL = sirolimus/everolimus; AZA = azathioprine

Adapted from Danovitch GM. Transplant Rev 2000; 14:65–81.

metabolic toxicities of immunosuppressive drugs4
Metabolic Toxicities of Immunosuppressive Drugs

CsA = cyclosporine A; Tac = tacrolimus; Ster = corticosteroids;

SRL/EVL = sirolimus/everolimus; AZA = azathioprine

Adapted from Danovitch GM. Transplant Rev 2000; 14:65–81.

daclizumab reduces the risk of biopsy proven acute rejection bpar

0.6

0.5

0.4

0.3

0.2

0.1

0

400

0

50

100

150

200

250

300

350

450

500

Daclizumab Reduces the Risk of Biopsy-Proven Acute Rejection (BPAR)
  • Cumulative incidence of first BPAR
  • Pooled analysis of 12-month data from two pivotal trials

Placebo (n=268)

116 events

Daclizumab (n=267)

74 events

Probability

p = 0.0001

(stratified

logrank test)

Time after transplantation (days)

Ekberg H et al. Transplant Int 2000; 13:151–9.

daclizumab reduces the risk of biopsy proven acute rejection bpar1

0.6

0.5

0.4

0.3

0.2

0.1

0

400

0

50

100

150

200

250

300

350

450

500

Daclizumab Reduces the Risk of Biopsy-Proven Acute Rejection (BPAR)
  • Cumulative incidence of first BPAR
  • Pooled analysis of 12-month data from two pivotal trials

Placebo (n=268)

116 events

Daclizumab (n=267)

74 events

Probability

p = 0.0001

(stratified

logrank test)

Time after transplantation (days)

Ekberg H et al. Transplant Int 2000; 13:151–9.

i performance2

I. Performance

  • Never turn your back on the audience
  • Always look at the audience
  • Never use the laser pointer
  • Always use your slides to make your point
  • Always time your performance at home
  • 3 - 7 - 10 - 20 minutes sharp
i performance3

I. Performance

  • Never turn your back on the audience
  • Always look at the audience
  • Never use the laser pointer
  • Always use your slides to make your point
  • Always time your performance at home
  • Always prepare your opening sentences
opening sentence

Opening sentence

You will always be nervous:

Sit in the front - look back

Prepare your opening sentence

- the rest will come by itself

opening sentence1

Opening sentence

You will always be nervous:

Sit in the front - look back

Prepare your opening sentence

- the rest will come by itself

Mr chairman, ladies and gentlemen! (.)

For many years (.)

steroids have been the backbone (.)

of our manitenance IS (.)

Now is the time to challenge them (.)

opening sentence2

Opening sentence

You will always be nervous:

Sit in the front - look back

Prepare your opening sentence

- the rest will come by itself

Members and guests (.)

I thank the organizers for inviting me (.)

and I thank all of you for joining us (.)

in this symposium tonight (.)

Do not repeat the title of your talk

presentation techniques some personal advice2

Presentation techniquesSome personal advice

  • I. Performance
  • II. Manuscript
  • III. Slides
ii manuscript

II. Manuscript

  • Never read a manuscript of your talk
  • Always use your slides as the manuscript
symphony study design

150-300 ng/ml for 3 months

100-200 ng/ml thereafter

A

Normal dose CsA

MMF

Steroids

50–100 ng/ml

Daclizumab

Low dose CsA

B

MMF

Steroids

3-7 ng/ml

Daclizumab

Low dose TAC

C

MMF

Steroids

4-8 ng/ml

Daclizumab

Low dose SRL

D

MMF

Steroids

SYMPHONY Study Design

6 mo

12 mo

Tx

Ekberg H et al Am J Transpl 2006, 6 (suppl 2), #49; 83.

symphony study
Symphony study

Main inclusion criteria

  • Renal transplant recipients 18  75 years
  • Single-organ, kidney
  • Living or deceased donors

Main exclusion criteria

  • Panel reactive antibodies > 20%
  • Cold ischaemic time > 30 hours
  • History of malignancy
ii manuscript1

Never read a manuscript

  • Always use your slides as the manuscript
  • Always describe your slide immediately

II. Manuscript

calculated gfr cockcroft gault

p=0.0014

p<0.0001

p<0.0001

Calculated GFR(CockcroftGault)

100

90

80

Normal-dose CsA

65

70

59

Low-dose CsA

57

57

60

Low-dose TAC

GFR (Cockcroft Gault) (ml/min)

50

Low-dose SRL

40

30

20

10

0

12 months post-Tx

Ekberg H et al Am J Transpl 2006, 6 (suppl 2), #49; 83.

slide26

High Prevalence of

Subclinical Rejection (SCR)

  • Prevalence SCR
  • 1 mo 61 %
  • 3 mo 46 %
  • 1 yr 26 %

80

60

Prevalence (%)

40

Acute rejection

SCR (acute)

20

SCR (borderline)

0

10

0.1

0.25

0.5

1

2

3

4

5

6

7

8

9

Time after transplantation (years)

Nankivell BJ et al. N Engl J Med 2003; 349:232633.

ii manuscript2

II. Manuscript

  • Never read a manuscript
  • Always use your slides as the manuscript
  • Always describe your slide immediately
  • Never start with comments
ii manuscript3

II. Manuscript

  • Never read a manuscript
  • Always use your slides as the manuscript
  • Always describe your slide immediately
  • Never start with comments
    • let comments come last
    • make one extra slide
calculated gfr cockcroft gault1

p=0.0014

p<0.0001

p<0.0001

Calculated GFR(CockcroftGault)

100

90

80

Normal-dose CsA

65

70

59

Low-dose CsA

57

57

60

Low-dose TAC

GFR (CockcroftGault) (ml/min)

50

Low-dose SRL

40

30

No significant

difference between

CsA and Low-CsA

20

10

0

12 months post-Tx

Ekberg H et al Am J Transpl 2006, 6 (suppl 2), #49; 83.

slide30

High Prevalence of

Subclinical Rejection (SCR)

  • Prevalence SCR
  • 1 mo 61 %
  • 3 mo 46 %
  • 1 yr 26 %

80

60

Prevalence (%)

40

Acute rejection

SCR (acute)

20

SCR (borderline)

0

10

0.1

0.25

0.5

1

2

3

4

5

6

7

8

9

Time after transplantation (years)

Nankivell BJ et al. N Engl J Med 2003; 349:232633.

slide31

High Prevalence of

Subclinical Rejection (SCR)

  • Prevalence SCR
  • 1 mo 61 %
  • 3 mo 46 %
  • 1 yr 26 %

80

High risk for AR after CNI w/d

Lower risk

60

Prevalence (%)

40

Acute rejection

SCR (acute)

20

SCR (borderline)

0

10

0.1

0.25

0.5

1

2

3

4

5

6

7

8

9

Time after transplantation (years)

Nankivell BJ et al. N Engl J Med 2003; 349:2326-33.

ii manuscript4

II. Manuscript

  • Never read a manuscript
  • Always use your slides as the manuscript
  • Always describe your slide immediately

Why is this so important?

Because the audience cannot

read your slide and listento you at the same time

- > Competition

ii manuscript5

II. Manuscript

  • Never read a manuscript
  • Always use your slides as the manuscript
  • Always describe your slide immediately

- > Competition

TV news + kids

TV news + Radio news

ii manuscript6

II. Manuscript

  • Never read a manuscript
  • Always use your slides as the manuscript
  • Always describe your slide immediately
  • Always send on one channel at the time

So read your text with them first

then give your comments

TV news first, then radio

methods

Methods

  • Acute rejection was defined as biopsy-proven and treated events within 6 months after transplantation excluding borderline cases
methods1

Methods

  • Acute Rejection
    • Biopsy-proven
    • Treated patients
    • Within 6 mo.
    • Excluding Borderline
ii manuscript7

II. Manuscript

  • Never read a manuscript
  • Always use your slides as the manuscript
  • Always describe your slide immediately
  • Send on one channel at the time
  • Always use a strategy
  • (chapters, line of thoughts)
strategy

Strategy

This is a study that shows the benefit

of steroid withdrawal

… the study…

In conclusion, this study has shown

the benefit of steroid withdrawal.

  • First, say what you are going to tell us
  • Then tell us
  • Finally, say what you have told us
chapters

Chapters

  • Divide your talk into chapters
    • 1. Background
    • 2. Aim
    • 3. Method
    • 4. Results
    • 5. Conclusion
chapters1

Chapters

  • Divide your talk into chapters
    • 1. Background - 2 slides
    • 2. Aim - 1 slide
    • 3. Method - 2 slides
    • 4. Results - 3 slides
    • 5. Conclusion - 1 slide
    • 8 - 10 slides = 7 minutes
presentation techniques some personal advice3

Presentation techniquesSome personal advice

  • I. Performance
  • II. Manuscript
  • III. Slides
iii slides

III. Slides

  • Never apologize for a busy slide
      • - discard it!
  • Never say ’as you can see’
      • it means nobody can see!
slide43

Table 2. Multivariate Risk Estimates for Endpoint of Overall Graft Loss*

This is actually a slide

that was used in a congress

*Table displays main variable of interest and significant (α < .05) covariates in the model.

slide49

Creatinine levels

in posttransplant periods by CNI

Kaplan and Meier-Kriesche ATC 2004

slide50

Creatinine levels

in posttransplant periods by CNI

Kaplan and Meier-Kriesche ATC 2004

slide51

Creatinine levels

in posttransplant periods by CNI

Kaplan and Meier-Kriesche ATC 2004

iii slides1

III. Slides

  • Never apologize for a busy slide
  • Never say ’as you can see’
  • Always use simple slides
daclizumab reduces the risk of biopsy proven acute rejection bpar2

0.6

0.5

0.4

0.3

0.2

0.1

0

400

0

50

100

150

200

250

300

350

450

500

Daclizumab Reduces the Risk of Biopsy-Proven Acute Rejection (BPAR)
  • Cumulative incidence of first BPAR
  • Pooled analysis of 12-month data from two pivotal trials

Placebo (n=268)

116 events

Daclizumab (n=267)

74 events

Probability

p = 0.0001

(stratified

logrank test)

Time after transplantation (days)

Ekberg H et al. Transplant Int 2000; 13:151–9.

daclizumab prevents acute rejection

0.6

0.5

0.4

0.3

0.2

0.1

0

400

0

50

100

150

200

250

300

350

450

500

Daclizumab Prevents Acute Rejection

Pooled analysis at 12-mo. from two pivotal trials

Placebo (n=268)

Daclizumab (n=267)

Probability

p = 0.0001

Time after tx (days)

Ekberg H et al. Transplant Int 2000; 13:151–9.

iii slides2

Never apologize for a busy slide

  • Never say ’as you can see’
  • Always use simple slides
  • Think about key words

III. Slides

conclusion
Conclusion

For both LD transplants and CD paired kidneys, there was no difference in 5-year graft or patient survival to be found between primary CsA or tacrolimus therapy. There is some evidence that tacrolimus may be associated with improved renal function as compared to CsA.

Kaplan and Meier-Kriesche ATC 2004

conclusion1
Conclusion
  • For both LD transplants and CD paired kidneys, there was no difference in5-year graftor patient survival to be found between primary CsA or tacrolimus therapy.
  • There is some evidence that tacrolimus may be associated with improved renal function as compared to CsA.

Kaplan and Meier-Kriesche ATC 2004

iii slides3

III. Slides

  • Never apologize for a busy slide
  • Never say ’as you can see’
  • Always use simple slides
  • Always write like a poet - think key words
conclusion2
Conclusion
  • For both LD transplants and CD paired kidneys, there was no difference in5-year graftor patient survival to be found between primary CsA or tacrolimus therapy.
  • There is some evidence that tacrolimus may be associated with improved renal function as compared to CsA.

Not good

Kaplan and Meier-Kriesche ATC 2004

conclusion3
Conclusion

For both LD transplants and DD paired kidneys (.)

there was no difference (.)

in 5-year graft or patient survival (.)

to be found between CsA or tacrolimus therapy.

Poetry

There is some evidence (.)

that tacrolimus may be associated (.)

with improved renal function as compared to CsA.

Kaplan and Meier-Kriesche ATC 2004

conclusion4
Conclusion

For both LD transplants and CD paired kidneys,

there was no difference

in5-year graftor patient survival

to be found between CsA or tacrolimus therapy.

Poetry

Key words

There is some evidence

that tacrolimus may be associated

with improved renal function as compared to CsA.

Kaplan and Meier-Kriesche ATC 2004

conclusionary remarks conversion from cni to mmf maintenance monotherapy
Conclusionary Remarks: Conversion from CNI- to MMF- Maintenance-Monotherapy
  • Long-term observations of patients converted from CNI-to MMF-monotherapy confirm our previous early experience with this kind of an i.s. maintenance therapy as an efficacious and safe treatment after cadaveric kidney transplantation, - in particular:
  • Early amelioration of renal allograft function as well as early reduction of recipients´ high atherogenic profile (=improvement of hypertension and high blood lipids!) are not only being maintained over the years (3,4 y) after conversion but tend to improve further later on;
  • There is no evidence of late subclinically-ongoing acute rejection events as demonstrated by protocol biopsies taken 2 years after conversion in about 50 % of the patients;
  • Long-term amelioration of recipients´ atherogenic profile may let assume a reduction in morbidity and mortality due to late cerebro-cardio-vascular accidents and, thus, may contribute to an improved life expectancy of kidney-transplanted patients. Indeed,5 years after the start of the trial,there is already a trend for improved patient survival (= no patient death so far.)

Senior Lecturer at a Course

conversion from cni to mmf monotherapy
Conversion from CNI to MMF Monotherapy
  • MMF monotherapy was safe and effective
  • Continued improvement of hypertension and hyperlipidemia after CNI withdrawal
  • No subclinical rejection at 2 years
  • Improved patient survival due to less CVD
conversion from cni to mmf monotherapy1
Conversion from CNI to MMF Monotherapy
  • MMF monotherapy was safe and effective
  • Continued improvement of hypertension and hyperlipidemia after CNI withdrawal
  • No subclinical rejection at 2 years
  • Improved patient survival due to less CVD

Much better - but no Poetry

No Key Words

No spacing between paragraphs

conversion from cni to mmf monotherapy2
Conversion from CNI to MMF Monotherapy
  • MMF monotherapy was safe and effective
  • Continued improvement of hypertension and hyperlipidemia after CNI withdrawal
  • No subclinical rejection at 2 years
  • Improved patient survival due to less CVD
iii slides4

III. Slides

  • Never apologize for a busy slide
  • Never say ’as you can see’
  • Always use simple slides
  • Always write like a poet - think key words
  • Always use animation to simplify
  • (not to impress)
binet i et al polyomavirus disease under new immunosuppressive drugs transplantation 1999 67 928

Binet I et al ; Polyomavirus disease under new immunosuppressive drugsTransplantation 1999 ; 67: 928

Retrospectiv analysis of 616 Tx from 8595

No polyoma virus infection

From 9598; 5 cases with polyoma (% ??)

All had prior rejections

All switched from CsA to Tacro

4 switched from Aza to MMF

4 grafts are lost/1 has s-creat 302 mol/l

binet i et al polyomavirus disease under new immunosuppressive drugs transplantation 1999 67 9281

Binet I et al ; Polyomavirus disease under new immunosuppressive drugsTransplantation 1999 ; 67: 928

Retrospectiv analysis of 616 Tx

From 198595: No polyoma virus infection

From 199598: 5 cases with polyoma

All had prior rejections

All switched from CsA to Tacro

4 switched from Aza to MMF

4 grafts were lost

gfr and graft survival tacrolimus vs csa
GFR and Graft Survival tacrolimus vs CsA
  • Interstitial fibrosis and CAN translates into differences in GFR and graft survival:

Baboolal K, et al. Kidney Int 2002;61:686–96

gfr and graft survival tacrolimus vs csa1
GFR and Graft Survival tacrolimus vs CsA
  • Interstitial fibrosis and CAN translates into differences in GFR and graft survival:

Baboolal K, et al. Kidney Int 2002;61:686–96

gfr and graft survival tacrolimus vs csa2
GFR and Graft Survival tacrolimus vs CsA
  • Interstitial fibrosis and CAN translates into differences in GFR and graft survival:

Colours to simplify

Baboolal K, et al. Kidney Int 2002;61:686–96

a meta analysis of steroid withdrawal trials
A Meta-Analysis of steroid withdrawal trials

Acute rejection (9 studies, n=1461)

% 95% CI p

_________________________________________

AR after SRW 14 1017 <0.001

_________________________________________

Graft survival (9 studies, n=1899)

RR 95%CI

_________________________________________

RR graft failure 1.38 1.081.67 <0.012

_________________________________________

Kasiske et al, JASN 2000

iii slides5

III. Slides

  • Never apologize for a busy slide
  • Never say ’as you can see’
  • Always use simple slides
  • Always write like a poet - think key words
  • Always use animation to simplify
  • Always use colours to simplify
  • Always use the full area of the slide
presentation techniques some personal advice4

Presentation techniquesSome personal advice

  • I. Performance
  • II. Manuscript
  • III. Slides
i performance4

I. Performance

  • Never turn your back on the audience
  • Always look at the audience
  • Never use the laser pointer
  • Always use your slides to make your point
  • Always time your performance at home
  • Always prepare your opening sentences
i performance5

I. Performance

  • Never turn your back on the audience
  • Always look at the audience
  • Never use the laser pointer
  • Always use your slides to make your point
  • Always time your performance at home
  • Always prepare your opening sentences
ii manuscript8

II. Manuscript

  • Never read a manuscript
  • Always use your slides as the manuscript
  • Always describe your slide immediately
  • Always send on one channel at the time
  • Always use a strategy
ii manuscript9

II. Manuscript

  • Never read a manuscript
  • Always use your slides as the manuscript
  • Always describe your slide immediately
  • Always send on one channel at the time
  • Always use a strategy
iii slides6

III. Slides

  • Never apologize for a busy slide
  • Never say ’as you can see’
  • Always use simple slides
  • Always write like a poet - think key words
  • Always use animation to simplify
  • Always use colours to simplify
  • Always use the full area of the slide
iii slides7

III. Slides

  • Never apologize for a busy slide
  • Never say ’as you can see’
  • Always use simple slides
  • Always write like a poet - think key words
  • Always use animation to simplify
  • Always use colours to simplify
  • Always use the full area of the slide
slide85

Always be yourself

- take advantage

of your personal talents

Enjoy!

slide86

Thank you

for your attention