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Stangou M, Marinaki S, Papachristou E, Kolovou K, Sambani E, Zerbala S, Papadea P, Balafa O, Rapsomanikis KP, Andrikos A, Manolakaki P, Papadopoulou D, Mitsopoulos E, Liakou H, Andronikidi PE, Choulitoudi V, Moustakas G, Galitsiou D, Dafnis E, Stylianou K, Stefanidis I, Golfinopoulos S, Panagoutsos S, Tsilivigkou M, Papadogianakis A, Tzanakis I, Sioulis A, Vlachakos D, Grapsa E, Spaia S, Kaperonis N, Paliouras C, Dioudis C, Papoulidou F, Apostolou T, Iatrou C, Boletis I, Goumenos D, Papagianni A. Immunosuppressive regimens based on Cyclophospamide or Calcineurin inhibitors: Comparison of their effect in the long term outcome of Primary Membranous Nephropathy. PLoS One 2019; 14:e0217116. [PMID: 31404062 PMCID: PMC6690570 DOI: 10.1371/journal.pone.0217116] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 07/22/2019] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Management of the Primary Membranous Nephropathy (PMN) usually involves administration of immunosuppressives. Cyclophosphamide (Cyclo) and Calcineurin Inhibitors (CNIs) are both widely used but only limited data exist to compare their efficacy in long term follow-up. AIM The aim of the present study was to estimate and compare long term effects of Cyclo and CNIs in patients with PMN. PATIENTS-METHODS Clinical data, histologic findings and long term outcome were retrospectively studied. The response to treatment and rate of relapse was compared between patients treated with CNIs or Cyclo based immunosuppressive regimens. RESULTS Twenty three centers participated in the study, with 752 PMN patients (Mean age 53.4(14-87) yrs, M/F 467/285), followed for 10.1±5.7 years. All patients were initially treated with Renin Angiotensin Aldosterone System inhibitors (RAASi) for at least 6 months. Based on their response and tolerance to initial treatment, patients were divided into 3 groups, group I with spontaneous remission, who had no further treatment, group II, continued on RAASi only, and group III on RAASi+immunosuppression. Immunosuppressive regimes were mainly based on CNIs or Cyclo. Frequent relapses and failure to treatment were more common between patients who had started on CNIs (n = 381) compared to those initially treated with Cyclo (n = 110), relapse rate: 25.2% vs. 6.4%, p<0.0001, and no response rate: 22.5% vs. 13.6%, p = 0.04, respectively. CONCLUSIONS Long term follow up showed that administration of Cyclo in PMN is followed by better preservation of renal function, increased response rate and less frequent relapses, compared to CNIs.
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Affiliation(s)
- Maria Stangou
- Department of Nephrology, Hippokration General Hospital, Aristotle University, Thessaloniki, Greece
| | - Smaragdi Marinaki
- Department of Nephrology, Laiko General Hospital, National and Kapodistrian University, Athens, Greece
| | | | - Kyriaki Kolovou
- Department of Nephrology, Laiko General Hospital, National and Kapodistrian University, Athens, Greece
| | - Erasmia Sambani
- Department of Nephrology, Hippokration General Hospital, Aristotle University, Thessaloniki, Greece
| | - Synodi Zerbala
- Department of Nephrology, General Hospital of Nikaia, Piraeus, Greece
| | - Panagiota Papadea
- Department of Nephrology, General Hospital of Nikaia, Piraeus, Greece
| | - Olga Balafa
- Department of Nephrology, University Hospital of Ioannina, Ioannina, Greece
| | | | - Aimilios Andrikos
- Department of Nephrology, Hatzikosta General Hospital of Ioannina, Ioannina, Greece
| | - Panagiota Manolakaki
- Department of Nephrology, Hatzikosta General Hospital of Ioannina, Ioannina, Greece
| | - Dorothea Papadopoulou
- Department of Nephrology, Papageorgiou General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Efstathios Mitsopoulos
- Department of Nephrology, Papageorgiou General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Helen Liakou
- Department of Nephrology, Hippokration General Hospital, Aristotle University, Thessaloniki, Greece
| | | | | | - George Moustakas
- Department of Nephrology, Gennimatas General Hospital of Athens, Athens, Greece
| | - Dimitra Galitsiou
- Department of Nephrology, Gennimatas General Hospital of Athens, Athens, Greece
| | - Eugene Dafnis
- Department of Nephrology, University Hospital of Heraklion, Heraklion Crete, Greece
| | - Kostas Stylianou
- Department of Nephrology, University Hospital of Heraklion, Heraklion Crete, Greece
| | - Ioannis Stefanidis
- Department of Nephrology, University Hospital of Larissa, Larissa, Greece
| | | | - Stylianos Panagoutsos
- Department of Nephrology, University Hospital of Alexandroupolis, Alexandroupoli, Greece
| | - Maria Tsilivigkou
- Department of Nephrology, Tzaneion General Hospital of Piraeus, Athens, Greece
| | | | - Ioannis Tzanakis
- Department of Nephrology, General Hospital of Chania, Chania Crete, Greece
| | - Athanasios Sioulis
- Section of Nephrology, 1st Department of Medicine, AHEPA University General Hospital, Thessaloniki, Greece
| | - Dimitrios Vlachakos
- Department of Nephrology, Attikon University Hospital, National and Kapodistrian University, Athens, Greece
| | - Eirini Grapsa
- Department of Nephrology, Aretaieio Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Sophia Spaia
- Department of Nephrology, General Hospital of Thessaloniki "Agios Pavlos", Thessaloniki, Greece
| | - Nikolaos Kaperonis
- Department of Nephrology, Hellenic Red Cross Hospital Korgialeneio-Benakeio, Athens, Greece
| | | | | | - Fani Papoulidou
- Department of Nephrology, General Hospital of Kavala, Kavala, Greece
| | | | - Christos Iatrou
- Department of Nephrology, General Hospital of Nikaia, Piraeus, Greece
| | - Ioannis Boletis
- Department of Nephrology, Laiko General Hospital, National and Kapodistrian University, Athens, Greece
| | | | - Aikaperini Papagianni
- Department of Nephrology, Hippokration General Hospital, Aristotle University, Thessaloniki, Greece
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Ponticelli C, Glassock RJ. Prevention of complications from use of conventional immunosuppressants: a critical review. J Nephrol 2019; 32:851-870. [PMID: 30927190 DOI: 10.1007/s40620-019-00602-5] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 03/21/2019] [Indexed: 01/08/2023]
Abstract
Synthetic immunosuppressive drugs are largely used in immune-related renal diseases and in kidney transplantation. Most of these drugs have a low therapeutic index (the ratio that compares the blood concentration at which a drug becomes toxic and the concentration at which the drug is effective), which means that the drug should be dosed carefully and the patient monitored frequently. In this review, we consider the categories of synthetic immunosuppressive agents more frequently and conventionally used in clinical nephrology: glucocorticoids, Aalkylating agents (cyclophosphamide, chlorambucil), purine synthesis inhibitors (azathioprine, mycophenolate salts) and calcineurin inhibitors (cyclosporine, tacrolimus). For each category the possible side effects will be reviewed, the general and specific measures to prevent or treat the adverse events will be suggested, and the more common mistakes that may increase the risk of toxicity will be described. However, the efficacy and safety of immunosuppressive agents depend not only on the pharmacologic characteristics of single drugs but can be influenced also by the clinical condition and genetic characteristics of the patient, by the typology and severity of the underlying disease and by the interaction with other concomitantly used drugs.
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Affiliation(s)
- Claudio Ponticelli
- Division of Nephrology, Istituto Scientifico Ospedale Maggiore, Milan, Italy.
- , Via Ampere 126, 20131, Milan, Italy.
| | - Richard J Glassock
- The David Geffen School of Medicine, University of California, Los Angeles, CA, USA
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Lin W, Li HY, Lin S, Zhou T. Efficacy and safety of tacrolimus vs cyclophosphamide in the therapy of patients with idiopathic membranous nephropathy: a meta-analysis. Drug Des Devel Ther 2019; 13:2179-2186. [PMID: 31308629 PMCID: PMC6613398 DOI: 10.2147/dddt.s209211] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 06/06/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND As one of the therapeutic drugs for idiopathic membranous nephropathy (IMN), tacrolimus (TAC) has not been fully vindicated for its efficacy and tolerability. A meta-analysis was performed to detect the efficacy and safety of TAC plus glucocorticoid vs cyclophosphamide (CTX) plus glucocorticoid in therapy of patients with IMN. METHODS A literature search with a pre-defined search strategy was conducted using English databases (PubMed, EMBASE, ClinicalKey and the Cochrane Library) and Chinese databases (China National Knowledge International, Wanfang, Chinese Scientific Journal Database (VIP)) from inception to Nov 19, 2018. Any high-quality randomized controlled trials (RCTs) comparing the effectiveness or safety of TAC with CTX in IMN patients were included. Data were extracted by two authors independently and analyzed using RevMan 5.3. RESULTS Four randomized controlled studies were included. In this analysis, we did not find that the statistically significant difference between TAC and CTX groups on 6-month and 12-month treatment complete remission (CR) was evident (6-month: OR=1.53, 95% CI: 0.85-2.76, P=0.15; 12-month: OR=2.17, 95% CI: 0.56-8.44, P=0.27). But TAC had better 6-month total remission (TR; total CR plus partial remission [PR]) than CTX (6-month: OR=2.62, 95% CI: 1.38-4.96, P=0.003; 12-month: OR=1.74, 95% CI: 0.29-10.48, P=0.54), and got a lower proteinuria after 6-month treatment (OR=-0.80, 95% CI: -1.53 to -0.07, P=0.03). TAC had a lower incidence rate on leucopenia than CTX, but had a tendency towards higher blood creatinine. In the meantime, tremor in TAC group was higher than that in CTX group. The differences on other adverse effects such as gastrointestinal syndrome, infection, herpes zoster, hypertension, liver function disorder and hyperglycemia were also analyzed. However, none of them were statistically significant. CONCLUSION TAC treatment could get high value of TR and had low value of proteinuria level when compared with those in CTX on 6-month treatment in therapy of patients with IMN.
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Affiliation(s)
- Wenshan Lin
- Department of Nephrology, The Second Affiliated Hospital of Shantou University Medical College, Shantou, People’s Republic of China
| | - Hong-Yan Li
- Department of Nephrology, Huadu District People’s Hospital of Guangzhou, Southern Medical University, Guangzhou, People’s Republic of China
| | - Shujun Lin
- Department of Nephrology, The Second Affiliated Hospital of Shantou University Medical College, Shantou, People’s Republic of China
| | - Tianbiao Zhou
- Department of Nephrology, The Second Affiliated Hospital of Shantou University Medical College, Shantou, People’s Republic of China
- Correspondence: Tianbiao ZhouDepartment of Nephrology, The Second Affiliated Hospital, Shantou University Medical College, No. 69 Dongsha Road, Shantou515041, People’s Republic of ChinaTel +86 136 7040 2516Email
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