1. Fibrinoid necrosis in a Rhesus macaque Karen Strait, Dan Anderson, and Elizabeth Strobert Yerkes National Primate Research Center Emory University Presented at SEVPAC 2008 – Permission granted for use on SEVPAC website only

2. History Signalment: ~5 year old, male, rhesus macaque Signalment: ~5 year old, male, rhesus macaque Assigned to renal transplant study Assigned to renal transplant study Left nephrectomy followed by right nephrectomy and allogeneic renal transplant 5 months later Left nephrectomy followed by right nephrectomy and allogeneic renal transplant 5 months later Received sirolimus and Cremophor EL vehicle beginning the day of transplantation Received sirolimus and Cremophor EL vehicle beginning the day of transplantation Control Control Presented at SEVPAC 2008 – Permission granted for use on SEVPAC website only

3. History Clinical findings following renal transplant Clinical findings following renal transplant Right kidney prominent and firm Right kidney prominent and firm Scrotal edema/perineal edema, absent by post-op day 14 Scrotal edema/perineal edema, absent by post-op day 14 Intermittent diarrheal episodes, treated with appropriate antibiotics Intermittent diarrheal episodes, treated with appropriate antibiotics Occasional periorbital edema Occasional periorbital edema Thrombocytopenia at day 38 post-op Thrombocytopenia at day 38 post-op Poor appetite/weight loss at 40 days post-op Poor appetite/weight loss at 40 days post-op Animal euthanized due to a deteriorating clinical condition Animal euthanized due to a deteriorating clinical condition Presented at SEVPAC 2008 – Permission granted for use on SEVPAC website only

4. Gross Findings Presented at SEVPAC 2008 – Permission granted for use on SEVPAC website only

5. Gross findings Presented at SEVPAC 2008 – Permission granted for use on SEVPAC website only

6. Histopathology

7. Histopathology

8. Histopathology

9. Histopathology

10. Histopathology

11. Histopathology

12. Diagnosis Morphologic diagnosis: multifocal severe fibrinoid necrosis of submucosal arteries with edema and thickening of associated tissues Morphologic diagnosis: multifocal severe fibrinoid necrosis of submucosal arteries with edema and thickening of associated tissues Presented at SEVPAC 2008 – Permission granted for use on SEVPAC website only

13. Discussion Cause is undetermined Cause is undetermined Possible association with drug regimen in this animal model Possible association with drug regimen in this animal model Presented at SEVPAC 2008 – Permission granted for use on SEVPAC website only

14. Discussion Sirolimus Sirolimus Immunosuppressive/ anti-rejection drug Immunosuppressive/ anti-rejection drug Non-nephrotoxic Non-nephrotoxic Fibrinoid necrosis in GI previously reported in rhesus macaques receiving sirolimus, tacrolimus, and daclizumab to prevent renal allograft rejection – attributed to sirolimus toxicity Fibrinoid necrosis in GI previously reported in rhesus macaques receiving sirolimus, tacrolimus, and daclizumab to prevent renal allograft rejection – attributed to sirolimus toxicity Link between sirolimus and fibrinoid necrosis shown in some species, absent in others Link between sirolimus and fibrinoid necrosis shown in some species, absent in others Not seen in other transplant studies at Yerkes Not seen in other transplant studies at Yerkes Presented at SEVPAC 2008 – Permission granted for use on SEVPAC website only

15. Discussion Cremophor EL Cremophor EL Vehicle for hydrophobic drugs Vehicle for hydrophobic drugs Not inert Not inert May change pharmacological profile of drugs administered with it May change pharmacological profile of drugs administered with it Unknown interaction between Cremophor EL and sirolimus Unknown interaction between Cremophor EL and sirolimus Fibrinoid necrosis not reported with this drug Fibrinoid necrosis not reported with this drug Combination of animal model, sirolimus and Cremophor EL?? Combination of animal model, sirolimus and Cremophor EL?? Presented at SEVPAC 2008 – Permission granted for use on SEVPAC website only

16. Acknowledgements Eileen Breding Eileen Breding Evan Dessasau Evan Dessasau Presented at SEVPAC 2008 – Permission granted for use on SEVPAC website only

17. References 1. Gelderblom, H., J. Verweij, K. Nooter, A. Sparreboom. 2001. Cremophor EL: the drawbacks and advantages of vehicle selection for drug formulation. Eur J Cancer. 37(13):1590-8. 2. Montgomery, S.P., S.R. Mog, H. Xu, D.K. Tadaki, B. Hirshberg, J.D. Berning, J. Leconte, D.M. Harlan, D. Hale, A.D. Kirk. 2002. Efficacy and toxicity of a protocol using sirolimus, tacrolimus, and daclizumab in a nonhuman primate renal allotransplant model. Am J Transplant. 2(4):381-5. Presented at SEVPAC 2008 – Permission granted for use on SEVPAC website only

18. Questions?