Pharmacokinetic and pharmacodynamic correlations of cyclosporine therapy in stable renal transplant patients: evaluation of long-term target C(2)

We investigated the relationship between the pharmacokinetics and pharmacodynamics of cyclosporine in 15 stable renal transplant patients in order to define an effective and safe therapeutic range. The area under the curve of the first 4 h (AUC(0-4)), trough (C(0)) and 2 h (C(2)) levels showed median values of 1655 ng x h/ml, 114 ng/ml and 384 ng/ml, respectively. C(2) showed a strong correlation with AUC(0-4) (r=0.942, p=0.0005). C(0) correlated poorly with C(2) and AUC(0-4) (r=0.596, p=0.019 and r=0.538, p=0.031, respectively). Calcineurine activity (CNa) was 6.74% at 0 h and 3.90% at 2 h, representing significant reductions (82% and 89.6%, respectively; p<0.0005) compared with normal healthy controls (median basal value 37.4%). IL-2 production was 349 pg/ml at 0 h and 276.35 pg/ml at 2 h; both results were significantly lower (reductions of 44.5% and 56.1%, respectively; p=0.04 and 0.005) than the controls of 629.1 pg/ml. IFN-gamma at 2 h post-dose (8.16 UI/ml) was significantly lower (72.1% reduction, p=0.005) than in controls (29.2 UI/ml). There was a good correlation between CNa and IFN-gamma production, particularly at 2 h post-dose (r=0.537, p=0.007), and a fair correlation between CNa and IL-2 concentration (p=0.030, r=0.426). C(2) showed an inverse significant correlation with CNa (Spearman's p=0.000, r=-0.753), IL-2 (p=0.000, r=-0.725) and IFN-gamma (p=0.000, r=-0.701) production. In treated patients, the Emax inhibitory sigmoidal model showed that a C(2) of 279 ng/ml was needed to achieve a 50% inhibition (EC50) of IL-2 and INF-gamma production. The results demonstrated a significant inhibition of calcineurin activity and IL-2 and IFN-gamma production in patients receiving cyclosporine monotherapy compared to healthy controls. A median C(2) value of 384 ng/ml was associated with a good degree of inhibition of CNa and IL-2 and IFN-gamma synthesis, and the lack of rejection episodes and relevant toxicity.

Structure and texture of anisotropic nematic gels

Anisotropic nematic gels are prepared via in situ polymerization of diacrylate monomers in an oriented nematic liquid crystal (LC) matrix. The structure of the gels is studied from micrometer to nanometer scales by optical microscopy, small angle neutron scattering, and theta/2theta light scattering. A strong anisotropy is evidenced at all scales without electric field for both mesogenic and nonmesogenic monomers. The gel network can be pictured as an ordered but strongly distorted and polydisperse structure with two characteristic sizes: the mean size of the polymer objects and a correlation length between these objects, corresponding to the mean-size of the LC domains, which are estimated from neutron and light scattering results to be of the order of some tens of nanometers and some micrometers, respectively. Moreover, a sheet-like structure of the polymer network is evidenced. When an electric field is applied, one part of the LC switches while the other part remains anchored to the polymer network. The electric field dependence of the volume fraction of anchored LC is estimated from the analysis of the light scattering data. We emphasize systematic correlations between structure and electro-optical properties of the gels.

High frequency of a 30-bp deletion of Epstein-Barr virus latent membrane protein 1 gene in primary HIV non-Hodgkin's brain lymphomas

A characteristic 30-base pair (bp) deletion (del) in the 3' end of the Epstein-Barr virus (EBV) latent membrane protein 1 (LMP1) gene, coding for the C-terminal NF-kappa B activation domain, has been identified in various lymphoproliferative disorders and nasopharyngeal carcinomas. In the single report to date of human immunodeficiency virus primary brain lymphomas (HIV-PBLs), del-LMP1 was noted in seven cases out of nine. The present study was designed to identify this deletion in a series of 31 diffuse large B-cell HIV-PBLs, with the aim of determining its possible oncogenic action. The presence of EBV was confirmed by EBER mRNA in situ hybridization. After genomic extraction from frozen tissue, two 20-base oligonucleotide primers flanking the site of the 30-bp deletion were used. DNA sequencing of the polymerase chain reaction (PCR) products confirmed an identical segment spanning 30-bp and 69-bp, frequently associated with mutational hotspots in 19 cases (61%). A role for del-LMP1 in the oncogenic potential of EBV in systemic proliferations is a matter of debate. Its high incidence suggests that the oncogenic mechanism of LMP1 in the brain might differ significantly from that in systemic lymphoid proliferations, and might be enhanced by HIV infection.

Formation of the gut in the first two naupliar stages of Acartia clausi and Hemidiaptomus roubaui (Copepoda, Calanoida): comparative structural and ultrastructural aspects

In this study, the structure and ultrastructure of the digestive system are compared in the early larval stages (nauplii I and II) of two copepod calanoid species, Acartia clausi Giesbrecht, 1889 and Hemidiaptomus roubaui Richard, 1888. The nauplii I of both species have no functional digestive tract, which is represented initially only by a blind esophageal slit and yolky endodermal cells, which fill the most part of the naupliar body, whereas at the nauplius II stage the differentiated digestive tract becomes functional. The resorption cavity corresponding to the future midgut is progressively formed in the endodermal mass during the premolt phase; it is surrounded by differentiating epithelial cells. In the ecdysial phase the foregut has associated labral glands, the midgut young R-, B-, and R'-cells of epithelium, and there is a short open hindgut.

Pharmacokinetics and pharmacodynamics of mycophenolic acid in stable renal transplant recipients treated with low doses of mycophenolate mofetil

Suboptimal doses of mycophenolate mofetil (MMF) are frequently employed in renal transplant (Tx) patients, with drug-related side effects or low weight. The aim of this study was to compare the mycophenolic acid (MPA) pharmacokinetic profile and its pharmacodynamic effect on patients receiving either standard (2 g) or low (1.5 g or 1 g) MMF doses, in order to evaluate the therapeutic efficacy of such low doses in inhibiting IMPDH activity. Twenty-seven stable renal Tx recipients aged 18-65 years, with a post-Tx follow-up of 38.5 +/- 44.8 months (6-166 months), receiving 1 g (n = 10), 0.75 g (n = 7) and 0.5 g (n = 10) MMF twice a day in association with cyclosporine and prednisone, were included. The control group was made up of untreated healthy volunteers (n = 5). Plasma concentrations of MPA were analyzed by reverse-phase HPLC. IMPDH activity was determined in lymphocytes by the measurement of 3H release from [2,8-(3)H] hypoxantine. The mean value of areas under the concentration-time curves (AUC(0-12)) of MPA throughout the 12-h dosing interval in patients treated with 2 g was higher than the corresponding data in patients receiving 1.5 g or 1 g bid, but no statistical differences were observed between the three groups. There was no correlation between MPA-AUC(0-12) values and MMF dose (expressed in g/day or g/kg per day). Predose MPA concentrations correlated only weakly with the respective MPA-AUC(0-12) values (r2 from 0.385 to 0.655), whereas an acceptable correlation was observed between MPA Cmax and MPA-AUC(0-12) (r2 from 0.626 to 0.759) in 2 g, 1.5 g, and 1 g MMF groups. An inverse relationship between MPA concentrations and IMPDH activity was observed. In general, the maximum MPA concentration was achieved from 1 h to 2 h after dosing, and the maximum inhibition of IMPDH was also from 1 h to 2 h after dosing. The evaluation of IMPDH activity demonstrated that there was a significant statistical difference between samples from 0 to 1 h (P = 0.008) and 0 to 2 h (P = 0.04). In conclusion, concentration-time profiles of renal transplant recipients administered 0.75 g and 0.5 g twice a day are slightly lower than those from the 2 g group, but nor significantly. On the other hand, inhibition of IMPDH activity was comparable in the three groups, indicating considerable interindividual pharmacodynamic variability. Pharmacodynamic monitoring of the degree of immunosuppression and its correlation with MPA plasma concentrations will be assessed further in future studies.

Mycophenolic acid plasma concentrations: influence of comedication

Mycophenolate mofetil (MMF) in combination with cyclosporine (CsA) or Tacrolimus (TAC) has been show to be a potent immunosuppressive agent. The authors assessed the mycophenolic acid (MPA) plasma levels achieved in clinical practice and evaluated the effect of concomitant administration of CsA and TAC . One hundred forty transplant patients (kidney: 120 and lung: 20) received a triple immunosuppression regimen of CsA or TAC, prednisone and MMF. Twenty-two renal transplant patients received double therapy with MMF and prednisone. There was no correlation between MMF dose and MPA trough concentrations (r = -0.0657). The medians (range) of the MPA dose-to-concentration ratio (D/C) in the CsA and TAC groups were 0.90 (0.11-8.33) and 0.56 (0.11-14.3), respectively (p < 0.0001). According to the post transplant period (1-3, 4-6 and >6 months), D/C values were significantly lower in patients receiving MMF and TAC than those receiving MMF and CsA in all three periods. MPA levels in patients treated with MMF and CsA were significantly lower than those obtained in double therapy. The D/C ratio in CsA-treated patients, increased significantly (p = 0.0005) when CsA level increased. There was no relationship between D/C ratio and TAC blood concentrations. These results suggest that CsA exerts an influence on MPA trough levels, although further work is required to characterize the mechanism of interaction.

Reference change value for HbA1c in patients with type 2 diabetes mellitus

We estimated reference change value and steady state disease biological variation of glycohemoglobin (HbA1c) from serial measurements in 47 clinically stable type 2 diabetes patients whose home-measured capillary glucose was stable throughout the study. Whole blood HbA1c assays were performed by turbidimetric inhibition immunoassay. The analytical imprecision (coefficient of variation) was 7.1% and 5.0% for control materials with HbA1c of 5.1% and 10.7%, respectively (n=152). The sampling interval was 6 months. Patients were classified into three groups (good, acceptable and poor control) according to the American Diabetes Association (ADA) clinical practice recommendations of 1999 based on HbA1c reference interval. Steady state disease biological variation for each control group was 7.9%, 5.4% and 3.9%. HbA1c absolute reference change value was 1.42, 1.50 and 1.37%, or as relative reference change value, 29.1%, 24.4% and 17.8%, respectively. The analytical goal, defined as one-half of the biological variation, was lower than 3.9% for well-controlled patients.

Switching behavior and electro-optical properties of liquid crystals in nematic gels

Anisotropic nematic gels are prepared via in situ polymerization of diacrylate monomers in an orientated nematic liquid crystal (LC) matrix. The switching behavior of the LC molecules under electric field is probed in polarized Raman spectroscopy and straight theta-2straight theta elastic light scattering experiments. The electro-optical characteristics of the gels are directly related to the electric field dependence of the fraction of switched molecules. The electro-optical contrast relates to the coexistence of switched LC domains and LC domains anchored to the polymer network.

[Vancomycin and teicoplanin use as antibiotic prophylaxis in cardiac surgery: pharmacoeconomic study]

BACKGROUND

To assess the economical impact of vancomycin use versus teicoplanin use as antibiotic prophylaxis for patients undergoing cardiac surgery for valve replacement (VR) and coronary artery by-pass (CABS) procedures.

PATIENTS AND METHODS

This is an ancillary cost minimization analysis of a double blinded, parallel groups, randomised clinical trial (RCT), with the main objective of comparing the safety and efficacy of these antibiotics. 500 patients were included in the study; 267 in the CABS group and 233 in the VR group. The CABS patients received 1 g vancomicin or 400 mg teicoplanin, plus 150 mg netilmicin. The VR group received a second dose of each drug after extracorporeal circulation. In order to calculate the costs we considered the direct cost of the drug, the i.v. mix and the administration costs, together with personnel and structure costs. We considered two different situations: the administration of drugs within the surgical room theatre and in the medical ward.

RESULTS

The demographic data of both groups were comparable. The frequency of severe adverse drug reactions (ADR) were similar (0.4%) in both groups, as well as the post-operative infection rates (8.6%). Differences were seen in the frequencies of low severity ADRs: 20.4% in the vancomycin group and 1.6% in the teicoplanin group. When the antibiotics were administered in the surgical room, among CABS patients the costs were 8,265 pts. for the teicoplanin group and 12,005 pts. for the vancomycin group; while among VR patients, costs were respectively 11,661 pts. and 14,528 pts. Administration costs of teicoplanin and vancomycin within a medical ward setting, however, the costs were 6,740 pts. and 2,809 pts. for CABS patients, and 5,308 pts. and 10,140 pts. for VR patients, respectively.

CONCLUSIONS

The costs of antibiotic prophylaxis among cardiac surgery patients heavily depends on the setting and circumstances of drug administration. The minimization cost analysis indicates that teicoplanin is the most cost-effective option if the drug is administered within the surgical area, while vancomycin is the less costly option when administered within the medical ward. However, if the second option is to be chosen, it is necessary to assure the right plasmatic drug levels of the antibiotic at the beginning of the surgical procedure.

Assessment of mycophenolic acid-induced immunosuppression: a new approach

BACKGROUND

Mycophenolic acid (MPA), a metabolite of mycophenolate mofetil (MMF), is an immunosuppressive agent that inhibits inosine monophosphate dehydrogenase (IMPDH), a key enzyme in the ex novo synthesis of GTP. We measured IMPDH activity in peripheral blood mononuclear cells (PBMCs) from MMF-treated patients to evaluate the efficacy of MMF in individual patients.

METHODS

IMPDH activity was measured by (3)H released from [2,8-(3)H]IMP that had been formed in the cells from added [2,8-(3)H]hypoxanthine in PBMCs of 35 renal transplant recipients treated with cyclosporin A and corticoids plus MMF: 2 g (n = 10), 1.5 g (n = 7), 1 g (n = 10), or 0 g (n = 8) per day. An alternative method, based on the capacity of the patients' sera to inhibit spontaneous proliferation of the CEM cell line, was also analyzed.

RESULTS

The IMPDH activity of PBMCs in transplanted patients was highly variable. For the method based on CEM cell line proliferation: (a) cell proliferation was inhibited only in MMF-treated patients; (b) there was a clear postdose increase in inhibition; (c) inhibition was not affected by other immunosuppressants in vitro or in vivo; (d) inhibition from predose to predose sample was correlated; and (e) when the MMF dosage was <20 mg. kg(-1). day(-1), two groups of patients were identified, one that maintained a high inhibitory capacity in all dose intervals, and one with periods of low inhibitory capacity.

CONCLUSIONS

Measurement of the inhibition of CEM cell line proliferation by sera from MMF-treated patients may be useful for evaluating the relative efficacy of MMF treatment in individual patients, especially those receiving low doses of MMF.

Flicker noise measurement of HF quartz resonators

Frequency flicker of quartz resonators can be derived from the measurement of S(phi) (f), i.e., the power spectrum density of phase fluctuations phi. The interferometric method appears to be the best choice to measure the phase fluctuations of the quartz resonators because of its high sensitivity in the low power conditions, which is required for this type of resonator. Combining these two ideas, we built an instrument suitable to measure the frequency flicker floor of the quartz resonators, and we measured the stability of some 10-MHB high performance resonators as a function of the dissipated power. The stability limit of our instrument, described in terms of Allan deviation sigma(y)(tau), is of some 10(-14).

Multicenter comparison of first- and second-generation IMx tacrolimus microparticle enzyme immunoassays in liver and kidney transplantation

Tacrolimus is a potent immunosuppressive drug successfully used for baseline and rescue immunosuppression in patients after liver and kidney transplantation. Data from several clinical trials have demonstrated the efficacy of tacrolimus in the prevention of allograft rejection, even at lower concentrations in the therapeutic range (5-15 microg/L). In fact, some patients with tacrolimus levels at less than 5 microg/L have excellent hepatic or kidney function. The limit of detection of the IMx Tacrolimus I assay (TAC I; Abbott Laboratories, IL) is only 5 microg/L and that of the lower tacrolimus calibrator is 10 microg/L. The second-generation assay uses the same monoclonal antibody and the same IMx technology but offers improved sensitivity, with a dynamic range from 0 microg/L to 30 microg/L (lower calibrator, 3 microg/L). The aim of this multicenter study was to evaluate the new IMx Tacrolimus II assay (TAC II) by assessing its precision, sensitivity, performance, and correlation degree relative to the IMx TAC I assay. The study was performed at three centers in Spain. The within-run coefficients of variation (CVs) obtained for the new assay, using each of the trilevel controls in replicates of 20 during 3 consecutive days, were 8.06%, 4.38% and 5.09% at 5 microg/L, 11 microg/L, and 22 microg/L, respectively. The corresponding between-run CVs obtained measuring each of the three controls in duplicate on 10 consecutive days were 9.54%, 6.38% and 5.75%. The limit of detection, with 97.5% confidence, was 1.22 microg/L. TAC II results (Y) were compared with those from the original TAC I assay (X) analyzing 293 whole blood samples from liver (n=145) and kidney (n=148) transplant recipients. The correlation study with patient samples (using the Passing-Bablock method) was y=1.056, x + 0.017, r=0.927. No statistically significant differences were observed between assays (TAC I versus TAC II) in the mean values obtained for total patients (9.89+/-5.42 microg/L versus 10.49+/-5.63 microg/L), liver patients (9.16+/-4.79 microg/L versus 10.00+/-5.20 microg/L), and kidney patients (10.62+/-5.87 micro g/L versus 10.98+/-5.99 microg/L). The new IMx TAC II assay demonstrated the same precision and accuracy that characterized the original assay but showed improved sensitivity to the demands of tacrolimus monitoring in the lower therapeutic range of drug concentrations.

Therapeutic drug monitoring of tacrolimus in liver transplantation, phase III FK506 multicenter Spanish Study Group: a two-year follow-up

The aim of the Multicentric Liver Transplant Spanish Study was to evaluate tacrolimus therapy at the reduced, initial oral dose of 0.1 mg/kg per day to maintain the immunosuppressive potency of the drug and to avoid toxicity. The dosage of tacrolimus (D), the trough blood concentrations (C), and the evolution of the ratio (D/C) were followed up for 2 years after transplantation in 50 adult patients (38 men, 12 women) undergoing liver allograft transplantation. A total of 1732 samples were analyzed using the IMx tacrolimus method. The overall mean+/-SD concentrations were 10.84 ng/ml+/-5.32 ng/ml. During the first month, the median of the tacrolimus levels was 8.40 ng/ml, and 73.1% of the analyzed samples were within the established therapeutic range. The median oral tacrolimus dose was progressively reduced from 0.12 mg/kg per day during the first month to 0.058 mg/kg per day at the end of study period. A significant negative association was observed between the ratio of D/C and the post-transplantation period (r=-0.3624; p < 0.001). The median D/C ratio ranged from 0.0144 at the end of the first month to 0.0053 at 1 year. Significant declines in D/C were observed after the first and the third months after transplantation. The decrease in corticosteroid doses and the increase in serum albumin may explain the reduction in clearance with time.

Chiari Type I malformation and syringomyelia in unrelated patients with blepharophimosis. Report of two cases

Syringomyelia is a rare, mainly sporadic disease of the spinal cord, which is associated with 80% of cases in which a Chiari Type I malformation is also present. A mendelian transmission of syringomyelia (autosomal dominant or recessive) has been proposed in approximately 2% of reported cases. The association of syringomyelia with hereditary diseases (Noonan's syndrome, phacomatoses) has been mentioned frequently in the literature. The authors report the presence of a Chiari Type I malformation accompanied by syringomyelia in two unrelated patients affected by a familial Type II blepharophimosis-ptosis-epicanthus inversus syndrome (BPES). The first patient was a 35-year-old woman who presented with a right C-8 root paresia. The second case involved a 20-year-old man who complained of cervical radicular pain. Both belong to families in which BPES was segregated in an autosomal dominant modality, but other family members had no known neurological symptoms. To the authors' knowledge, such a combination has never been described. Perhaps the possible involvement of a genetic component in some cases of Chiari Type I-associated syringomyelia will someday be debated.

Influence of posttransplant time on dose and concentration of tacrolimus in liver transplant patients

The dosage of tacrolimus (D), the trough blood concentrations (C) and the evolution of the D/C ratio were followed for 1 year after transplantation in so adult patients (38 males and 12 females) undergoing liver allograft. A total of 1489 samples were analysed by the IMx tacrolimus method. The overall median concentration was 11.27 ng/ml. During the 1st month the median of the tacrolimus levels was 8.4 ng/ml, and 73.1% of the analysed samples were within the established therapeutic range. The median oral tacrolimus dose was progressively reduced from 0.12 mg/kg per day during the 1st month to 0.06 mg/kg per day at the end of studied period. A significant negative association was observed between the D/C ratio and the post-transplantation period (r = -0.3892; P < 0.0001). The median D/C ratio ranged from 0.0144 at 1st month to 0.0053 at 1 year. Significant D/C declines were observed after the 1st and 3rd months posttransplant. The decrease in corticosteroid doses and the increase in serum albumin may explain the reduction in clearance with time.

Comparative analysis of tacrolimus (FK506) in whole blood liver transplant recipients by PRO-TRAC enzyme-linked immunosorbent assay and microparticle enzyme immunoassay IMX methods

The macrolide tacrolimus (FK506) is a powerful immunosuppressive drug that acts early in the T-cell activation process and inhibits cytokine gene transcription. Data from several trials in liver transplantation have shown the efficacy of tacrolimus in the prevention of allograft rejection and its potent hepatotrophic effect, which could explain its great success in liver transplantation. However, tacrolimus is not devoid of adverse effects (mainly nephrotoxicity and neurotoxicity) requiring careful blood level monitoring, which is an essential aid in the adjustment of drug dosing. Several methods of analysis are available to measure tacrolimus in whole blood. A new assay based on the enzyme-linked immunosorbent assay (ELISA) technology has been developed. The INCSTAR PRO-TRAC FK506 is a sensitive immunoassay (range, 0.5 to 60 ng/ml), which uses a mouse monoclonal antibody to FK506. Samples are extracted into methanol and dried under nitrogen. The reconstituted extracts are analyzed by ELISA by using 2-h incubation. The aim of this study was to evaluate the ELISA method in routine monitoring of liver transplant patients and to compare the whole blood results with those obtained by Abbott microparticle enzyme immunoassay (MEIA) IMx. Precision studies with 20 samples from 4.37 and 17.1 ng/ml gave within-run total coefficients of variance of 14.4 and 17.4%, respectively. A total of 63 blood samples was analyzed. The mean +/- SD were 9.68 +/- 5.92 and 10.52 +/- 7.54 ng/ml by ELISA and MEIA assays, respectively. There was an acceptable correlation between the methods: ELISA = 1.419 + 0.785 MEIA; Sy x x = 2.639; r = 0.804. Serial tacrolimus measurements (n = 13) in two patients with bilirubin levels > 20 mg/dl yielded mean +/- SD (range) of 11.64 +/- 7.59 ng/ml (2.60-25.40 ng/ml) and 15.55 +/- 10.78 ng/ml (3.60-34.4 ng/mL) by ELISA and MEIA assays, respectively. These discrepancies in concentrations can result from variation in matrix or different cross-reactivities or both in the two tests. We concluded that the INCSTAR PRO-TRAC FK506 is suitable for routine whole blood tacrolimus monitoring.