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Margeta I, Mareković I, Pešut A, Zelenika M, Dorotić M, Mrnjec I, Knotek M. Evaluation of cell-mediated immune response by QuantiFERON Monitor Assay in kidney transplant recipients presenting with infective complications. Medicine (Baltimore) 2020; 99:e21010. [PMID: 32629720 PMCID: PMC7337481 DOI: 10.1097/md.0000000000021010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The net level of immunosuppression in kidney transplant recipients is difficult to assess. QuantiFERON Monitor (QFM) is an in vitro diagnostic test that detects interferon-γ (IFN-γ) release in peripheral blood. The aim of our study was to compare QFM testing results in stable kidney transplant recipients and kidney transplant recipients with infection, in a single-centre cohort.We enrolled 71 kidney transplant recipients from our transplantation centre. They were divided into 2 groups according to clinical presentation (Stable kidney transplant recipients or Infection).There were no significant differences in interferon-γ release between the 2 groups (Stable kidney transplant recipients 140.59 ± 215.28 IU/ml, Infection group 78.37 ± 197.03 IU/ml, P = .24). A further analysis revealed that kidney transplant recipients presenting with bacterial infection had significantly lower IFN-γ release when compared to stable kidney transplant recipients (26.52 ± 42.46 IU/ml vs 140.59 ± 215.28 IU/ml, P = .04).Kidney transplant recipients presenting with bacterial infection had lower IFN-γ release when compared to stable kidney transplant recipients. The QFM test may be useful as a tool to help guide immunosuppression dosing in kidney transplant recipients, but further studies are required to confirm its diagnostic value.
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Affiliation(s)
- Ivan Margeta
- Department of Nephrology, University Hospital “Merkur”
| | - Ivana Mareković
- Department of Clinical and Molecular Microbiology, University Hospital Center
- University of Zagreb, School of Medicine, Zagreb, Croatia
| | - Ana Pešut
- Department of Clinical and Molecular Microbiology, University Hospital Center
| | | | | | - Ivana Mrnjec
- Department of Nephrology, University Hospital “Merkur”
| | - Mladen Knotek
- Department of Nephrology, University Hospital “Merkur”
- University of Zagreb, School of Medicine, Zagreb, Croatia
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52
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Pallio G, Irrera N, Bitto A, Mannino F, Minutoli L, Rottura M, Pallio S, Altavilla D, Alibrandi A, Marciano MC, Righi M, Mannucci C, Arcoraci V, Squadrito F. Failure of Achieving Tacrolimus Target Blood Concentration Might Be Avoided by a Wide Genotyping of Transplanted Patients: Evidence from a Retrospective Study. J Pers Med 2020; 10:jpm10020047. [PMID: 32492825 PMCID: PMC7354451 DOI: 10.3390/jpm10020047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 05/22/2020] [Accepted: 05/29/2020] [Indexed: 01/08/2023] Open
Abstract
Precise tacrolimus treatment in transplanted patients is achieved in the clinical setting by performing therapeutic drug monitoring (TDM) and consequently adjusting therapy. The aim of this study was to retrospectively analyze the variability in tacrolimus blood levels throughout 2 years of observation in 75 transplanted patients and to investigate if tacrolimus blood levels correlate with presence of genetic polymorphisms, thus modifying tacrolimus pharmacokinetics. CYP3A5*1 (G6986A), CYP3A4*1B (A392G), CYP3A4*22, ABCB1 (C3435T; C1236T; G2677A/T), SLCO1B1 (T521C), polymorphisms were analyzed. Based on the effect of their genotypes, patients were stratified into 5 groups: (1) reduced tacrolimus metabolism (RM), (2) increased metabolism (IM), (3) transporters polymorphisms (TM), (4) metabolism and transporter polymorphisms (AM) and (5) no mutations (Wild Type, WT). The percentage of the samples out of therapeutic range was significantly higher in the IM group than in the WT group (p = 0.001), as well as compared to the TM group (p = 0.004). Only IM pattern (p = 0.015) resulted as an independent predictor of number of tacrolimus blood levels out of therapeutic range. RM pattern (p = 0.006) was inversely related to the administered dose. Therefore, genotyping could become a standard practice before tacrolimus prescription thus decreasing side effects, increasing efficacy and reducing the economic burden for the national health system.
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Affiliation(s)
- Giovanni Pallio
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125 Messina, Italy; (G.P.); (N.I.); (A.B.); (F.M.); (L.M.); (M.R.); (S.P.); (F.S.)
| | - Natasha Irrera
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125 Messina, Italy; (G.P.); (N.I.); (A.B.); (F.M.); (L.M.); (M.R.); (S.P.); (F.S.)
| | - Alessandra Bitto
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125 Messina, Italy; (G.P.); (N.I.); (A.B.); (F.M.); (L.M.); (M.R.); (S.P.); (F.S.)
| | - Federica Mannino
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125 Messina, Italy; (G.P.); (N.I.); (A.B.); (F.M.); (L.M.); (M.R.); (S.P.); (F.S.)
| | - Letteria Minutoli
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125 Messina, Italy; (G.P.); (N.I.); (A.B.); (F.M.); (L.M.); (M.R.); (S.P.); (F.S.)
| | - Michelangelo Rottura
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125 Messina, Italy; (G.P.); (N.I.); (A.B.); (F.M.); (L.M.); (M.R.); (S.P.); (F.S.)
| | - Socrate Pallio
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125 Messina, Italy; (G.P.); (N.I.); (A.B.); (F.M.); (L.M.); (M.R.); (S.P.); (F.S.)
| | - Domenica Altavilla
- Department of Biomedical, Dental, Morphological and Functional Imaging Sciences, University of Messina, Via C. Valeria, 98125 Messina, Italy; (D.A.); (M.R.); (C.M.)
| | - Angela Alibrandi
- Department of Economics Section of Statistical and Mathematical Sciences, University of Messina, Via dei Verdi, 98122 Messina, Italy;
| | - Maria Concetta Marciano
- Grande Ospedale Metropolitano: “Bianchi-Melacrino-Morelli”, Via Giuseppe Melacrino, 89124 Reggio Calabria, Italy;
| | - Maria Righi
- Department of Biomedical, Dental, Morphological and Functional Imaging Sciences, University of Messina, Via C. Valeria, 98125 Messina, Italy; (D.A.); (M.R.); (C.M.)
| | - Carmen Mannucci
- Department of Biomedical, Dental, Morphological and Functional Imaging Sciences, University of Messina, Via C. Valeria, 98125 Messina, Italy; (D.A.); (M.R.); (C.M.)
| | - Vincenzo Arcoraci
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125 Messina, Italy; (G.P.); (N.I.); (A.B.); (F.M.); (L.M.); (M.R.); (S.P.); (F.S.)
- Correspondence:
| | - Francesco Squadrito
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125 Messina, Italy; (G.P.); (N.I.); (A.B.); (F.M.); (L.M.); (M.R.); (S.P.); (F.S.)
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53
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Hannachi I, Ben Fredj N, Chadli Z, Ben Fadhel N, Ben Romdhane H, Touitou Y, Boughattas NA, Chaabane A, Aouam K. Effect of CYP3A4*22 and CYP3A4*1B but not CYP3A5*3 polymorphisms on tacrolimus pharmacokinetic model in Tunisian kidney transplant. Toxicol Appl Pharmacol 2020; 396:115000. [DOI: 10.1016/j.taap.2020.115000] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 03/18/2020] [Accepted: 04/05/2020] [Indexed: 12/16/2022]
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The First Asian Kidney Transplantation Prediction Models for Long-term Patient and Allograft Survival. Transplantation 2020; 104:1048-1057. [DOI: 10.1097/tp.0000000000002918] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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55
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Zhang M, Tajima S, Shigematsu T, Fu R, Noguchi H, Kaku K, Tsuchimoto A, Okabe Y, Egashira N, Masuda S. Donor CYP3A5 Gene Polymorphism Alone Cannot Predict Tacrolimus Intrarenal Concentration in Renal Transplant Recipients. Int J Mol Sci 2020; 21:ijms21082976. [PMID: 32340188 PMCID: PMC7215698 DOI: 10.3390/ijms21082976] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 04/20/2020] [Accepted: 04/22/2020] [Indexed: 12/12/2022] Open
Abstract
CYP3A5 gene polymorphism in recipients plays an important role in tacrolimus blood pharmacokinetics after renal transplantation. Even though CYP3A5 protein is expressed in renal tubular cells, little is known about the influence on the tacrolimus intrarenal exposure and hence graft outcome. The aim of our study was to investigate how the tacrolimus intrarenal concentration (Ctissue) could be predicted based on donor CYP3A5 gene polymorphism in renal transplant recipients. A total of 52 Japanese renal transplant patients receiving tacrolimus were enrolled in this study. Seventy-four renal biopsy specimens were obtained at 3 months and 1 year after transplantation to determine the donor CYP3A5 polymorphism and measure the Ctissue by liquid chromatography-tandem mass spectrometry (LC-MS-MS). The tacrolimus Ctissue ranged from 52 to 399 pg/mg tissue (n = 74) and was weak but significantly correlated with tacrolimus trough concentration (C0) at 3 months after transplantation (Spearman, r = 0.3560, p = 0.0096). No significant relationship was observed between the donor CYP3A5 gene polymorphism and Ctissue or Ctissue/C0. These data showed that the tacrolimus systemic level has an impact on tacrolimus renal accumulation after renal transplantation. However, donor CYP3A5 gene polymorphism alone cannot be used to predict tacrolimus intrarenal exposure. This study may be valuable for exploring tacrolimus renal metabolism and toxicology mechanism in renal transplant recipients.
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Affiliation(s)
- Mengyu Zhang
- Department of Clinical Pharmacology and Biopharmaceutics, Graduate School of Pharmaceutical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan; (M.Z.); (T.S.); (R.F.); (N.E.)
| | - Soichiro Tajima
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan;
| | - Tomohiro Shigematsu
- Department of Clinical Pharmacology and Biopharmaceutics, Graduate School of Pharmaceutical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan; (M.Z.); (T.S.); (R.F.); (N.E.)
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan;
| | - Rao Fu
- Department of Clinical Pharmacology and Biopharmaceutics, Graduate School of Pharmaceutical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan; (M.Z.); (T.S.); (R.F.); (N.E.)
| | - Hiroshi Noguchi
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan; (H.N.); (K.K.); (Y.O.)
| | - Keizo Kaku
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan; (H.N.); (K.K.); (Y.O.)
| | - Akihiro Tsuchimoto
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan;
| | - Yasuhiro Okabe
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan; (H.N.); (K.K.); (Y.O.)
| | - Nobuaki Egashira
- Department of Clinical Pharmacology and Biopharmaceutics, Graduate School of Pharmaceutical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan; (M.Z.); (T.S.); (R.F.); (N.E.)
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan;
| | - Satohiro Masuda
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan;
- Department of Pharmacy, International University of Health and Welfare Narita Hospital, 852 Hatakeda, Narita 286-0124, Japan
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, International University of Health and Welfare, 2600-1 Kita-kanemaru, Otawara 324-8501, Japan
- Correspondence: ; Tel.: +81-476-35-5600
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Correlation between Cyclosporine Blood Levels and Area under Blood Concentration Time Curve in Iraqi Bone Marrow Transplant Patients Treated with Neoral® Oral Solution. Sci Pharm 2020. [DOI: 10.3390/scipharm88010012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Cyclosporine is a potent immunosuppressive drug. It has a narrow therapeutic index, and therefore the measurement of cyclosporine’s blood concentration is essential to obtain optimal therapy. Measurement of the area under the blood concentration-time curve (AUC) is reflective of total drug exposure. However, for organ transplant patients, the measurement of AUC involves many problems and difficulties. Thus, it is more clinically acceptable to use a single blood sample as a surrogate index of total drug exposure. Fifty-four adults bone marrow transplant Iraqi patients were given cyclosporine every 12 h as prophylaxis using Neoral® oral solution. Steady-state blood concentrations were monitored for each patient at zero time and then at 1, 2, 3, 4, 6, 8, 10, and at 12 h post-dosing. Cyclosporine blood levels were determined by using AXSYM automated immuno-analyzer which is a fluorescence polarization immunoassay (FPIA). The present investigation demonstrated the best correlation between C2 and the corresponding AUC0–4h and AUC0–12h compared to other concentrations. After two months of cyclosporine therapy, no unexpected biochemical changes and adverse effects were registered. It is concluded from this study that a single blood sample obtained at 2 h post-dosing (C2) and possibly at 3 h post dosing (C3) are ideal surrogate indexes for reflecting total drug exposure, and therefore may be used in clinical practice for predicting therapeutic and toxic effects of cyclosporine.
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57
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Farouk SS, Rein JL. The Many Faces of Calcineurin Inhibitor Toxicity-What the FK? Adv Chronic Kidney Dis 2020; 27:56-66. [PMID: 32147003 DOI: 10.1053/j.ackd.2019.08.006] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Accepted: 08/01/2019] [Indexed: 02/07/2023]
Abstract
Calcineurin inhibitors (CNIs) are both the savior and Achilles' heel of kidney transplantation. Although CNIs have significantly reduced rates of acute rejection, their numerous toxicities can plague kidney transplant recipients. By 10 years, virtually all allografts will have evidence of CNI nephrotoxicity. CNIs have been strongly associated with hypertension, dyslipidemia, and new onset of diabetes after transplantation-significantly contributing to cardiovascular risk in the kidney transplant recipient. Multiple electrolyte derangements including hyperkalemia, hypomagnesemia, hypercalciuria, metabolic acidosis, and hyperuricemia may be challenging to manage for the clinician. Finally, CNI-associated tremor, gingival hyperplasia, and defects in hair growth can have a significant impact on the transplant recipient's quality of life. In this review, the authors briefly discuss the pharmacokinetics of CNI and discuss the numerous clinically relevant toxicities of commonly used CNIs, cyclosporine and tacrolimus.
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58
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Fan X, Ding X, Zhang QY. Hepatic and intestinal biotransformation gene expression and drug disposition in a dextran sulfate sodium-induced colitis mouse model. Acta Pharm Sin B 2020; 10:123-135. [PMID: 31993311 PMCID: PMC6976992 DOI: 10.1016/j.apsb.2019.12.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 10/31/2019] [Accepted: 11/07/2019] [Indexed: 12/27/2022] Open
Abstract
We examined the impact of gut inflammation on the expression of cytochrome P450 (P450) and other biotransformation genes in male mice using a dextran sulfate sodium (DSS)-induced colitis model. Several P450 isoforms, including CYP1A, CYP2B, CYP2C, and CYP3A, were down-regulated, accompanied by decreases in microsomal metabolism of diclofenac and nifedipine, in the liver and small intestine. The impact of the colitis on in vivo clearance of oral drugs varied for four different drugs tested: a small decrease for nifedipine, a relatively large decrease for lovastatin, but no change for pravastatin, and a large decrease in the absorption of cyclosporine A. To further assess the scope of influence of gut inflammation on gene expression, we performed genome-wide expression analysis using RNA-seq, which showed down-regulation of many CYPs, non-CYP phase-I enzymes, phase-II enzymes and transporters, and up-regulation of many other members of these gene families, in both liver and intestine of adult C57BL/6 mice, by DSS-induced colitis. Overall, our results indicate that gut inflammation suppresses the expression of many P450s and other biotransformation genes in the intestine and liver, and alters the pharmacokinetics for some but not all drugs, potentially affecting therapeutic efficacy or causing adverse effects in a drug-specific fashion.
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59
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Long-Term Kidney Transplant Outcomes: Role of Prolonged-Release Tacrolimus. Transplant Proc 2019; 52:102-110. [PMID: 31901329 DOI: 10.1016/j.transproceed.2019.11.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 11/02/2019] [Indexed: 01/08/2023]
Abstract
Tacrolimus has significantly improved outcomes for kidney transplant patients and remains the cornerstone of immunosuppressive therapy. While improvements in short-term outcomes in transplantation have been achieved in recent years, maintaining long-term graft survival remains a challenge in kidney transplantation. Minimizing risk factors for poor long-term kidney graft function and survival, and modifying tacrolimus regimens in the early and maintenance phases post-transplantation are essential to maintain long-term kidney transplant outcomes. Tacrolimus has a narrow therapeutic window, resulting in a tightly defined range of optimal drug exposure. Underimmunosuppression is associated with long-term risks, such as the development of donor-specific antibodies and antibody-mediated rejection, with a high possibility of a decline in kidney function and progression to graft failure. Conversely, prolonged overimmunosuppression carries a risk of drug-related adverse events. This review provides an overview of the differences in the formulation, delivery, and pharmacokinetic profiles between immediate- and prolonged-release tacrolimus and evaluates the effect of prolonged-release tacrolimus on the risk factors for poor outcomes in kidney transplantation. Recent evidence is used to provide guidance on target tacrolimus trough levels in the early and maintenance phases post-transplantation, with a view to improving long-term kidney graft function.
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60
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Alsmadi MM, Alfarah MQ, Albderat J, Alsalaita G, AlMardini R, Hamadi S, Al‐Ghazawi A, Abu‐Duhair O, Idkaidek N. The development of a population physiologically based pharmacokinetic model for mycophenolic mofetil and mycophenolic acid in humans using data from plasma, saliva, and kidney tissue. Biopharm Drug Dispos 2019; 40:325-340. [DOI: 10.1002/bdd.2206] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 09/22/2019] [Accepted: 10/09/2019] [Indexed: 02/06/2023]
Affiliation(s)
| | | | - Jawaher Albderat
- Queen Rania Abdullah Children Hospital, Royal Medical Services Amman Jordan
| | - Ghazi Alsalaita
- Queen Rania Abdullah Children Hospital, Royal Medical Services Amman Jordan
| | - Reham AlMardini
- Queen Rania Abdullah Children Hospital, Royal Medical Services Amman Jordan
| | - Salim Hamadi
- Deparment of Pharmaceutical Technology, Faculty of PharmacyUniversity of Petra Amman Jordan
| | | | - Omar Abu‐Duhair
- Deparment of Pharmaceutical Technology, Faculty of PharmacyUniversity of Petra Amman Jordan
| | - Nasir Idkaidek
- Deparment of Pharmaceutical Technology, Faculty of PharmacyUniversity of Petra Amman Jordan
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Urinary Biomarkers α-GST and π-GST for Evaluation and Monitoring in Living and Deceased Donor Kidney Grafts. J Clin Med 2019; 8:jcm8111899. [PMID: 31703290 PMCID: PMC6912502 DOI: 10.3390/jcm8111899] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 11/04/2019] [Accepted: 11/05/2019] [Indexed: 11/27/2022] Open
Abstract
The aim of this study was to analyze the value of urine α- and π-GST in monitoring and predicting kidney graft function following transplantation. In addition, urine samples from corresponding organ donors was analyzed and compared with graft function after organ donation from brain-dead and living donors. Urine samples from brain-dead (n = 30) and living related (n = 50) donors and their corresponding recipients were analyzed before and after kidney transplantation. Urine α- and π-GST values were measured. Kidney recipients were grouped into patients with acute graft rejection (AGR), calcineurin inhibitor toxicity (CNI), and delayed graft function (DGF), and compared to those with unimpaired graft function. Urinary π-GST revealed significant differences in deceased kidney donor recipients with episodes of AGR or DGF at day one after transplantation (p = 0.0023 and p = 0.036, respectively). High π-GST values at postoperative day 1 (cutoff: >21.4 ng/mg urine creatinine (uCrea) or >18.3 ng/mg uCrea for AGR or DGF, respectively) distinguished between rejection and no rejection (sensitivity, 100%; specificity, 66.6%) as well as between DGF and normal-functioning grafts (sensitivity, 100%; specificity, 62.6%). In living donor recipients, urine levels of α- and π-GST were about 10 times lower than in deceased donor recipients. In deceased donors with impaired graft function in corresponding recipients, urinary α- and π-GST were elevated. α-GST values >33.97 ng/mg uCrea were indicative of AGR with a sensitivity and specificity of 77.7% and 100%, respectively. In deceased donor kidney transplantation, evaluation of urinary α- and π-GST seems to predict different events that deteriorate graft function. To elucidate the potential advantages of such biomarkers, further analysis is warranted.
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Al Sagheer T, Enderby CY. Determining the conversion ratios for oral versus sublingual administration of tacrolimus in solid organ transplant recipients. Clin Transplant 2019; 33:e13727. [PMID: 31587353 DOI: 10.1111/ctr.13727] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 08/28/2019] [Accepted: 09/30/2019] [Indexed: 11/27/2022]
Abstract
Tacrolimus is utilized as maintenance immunosuppression in solid organ transplant (SOT). Current literature has reported conflicting conversion ratios when transitioning between oral and sublingual tacrolimus, and the exact conversion ratio has not been fully established in SOT. The purpose of this study was to determine the conversion ratios between oral and sublingual tacrolimus needed to achieve equivalent whole blood concentrations in heart, kidney, liver, and lung transplant recipients. A retrospective, single-center analysis was conducted at Mayo Clinic in Florida. One hundred and eighteen hospitalized SOT recipients who received oral and sublingual tacrolimus during the same inpatient admission from June 1, 2012, through June 1, 2017, were reviewed. The median conversion ratio of sublingual to oral tacrolimus was 1.34 (IQR: 1.03-1.93) in all SOT, 1.25 (IQR: 1.08-1.64) in heart transplant, 1.23 (IQR: 1.1-2.06) in kidney transplant, 1.64 (IQR: 1.27-2.29) in liver transplant, and 1.34 (IQR: 0.94-1.93) in lung transplant. A slightly higher dose of oral tacrolimus is needed in the majority of solid organ recipients in our population when converting between sublingual to oral tacrolimus administration.
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Affiliation(s)
| | - Cher Y Enderby
- Department of Pharmacy, Mayo Clinic, Jacksonville, Florida
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63
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Cajanding R. Immunosuppression following organ transplantation. Part 2: complications and their management. ACTA ACUST UNITED AC 2019; 27:1059-1065. [PMID: 30281349 DOI: 10.12968/bjon.2018.27.18.1059] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Advances in the care of patients who have had a solid organ transplant has led to a growing population of post-transplant patients, who are also living for longer. As a result of their longer life expectancy, transplant recipients often face a multitude of challenges, including optimising their immunosuppressive regimens and managing potential complications. Life-threatening infections, malignancies, and organ-specific toxicities are the complications post-transplant patients commonly encounter and these complications are often associated with increased morbidity and mortality, adverse graft functioning and survival, profound impairment in the patient's quality of life, and significant healthcare burden. This article, the second of two parts, gives an overview of the issues involved in the care of patients who are receiving immunosuppressants. The common complications encountered by post-transplant patients are discussed and their assessment, management, prevention and treatment explored.
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Affiliation(s)
- Ruff Cajanding
- Staff Nurse, Liver Intensive Therapy Unit, Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London
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64
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Largeau B, Guellec CBL, Longuet H, Lesne P, Bouvarel A, Préteseille L, Marquet P, Halimi JM, Büchler M, Gatault P, Noble J. Comparison of Tacrolimus Starting Doses Based on CYP3A5 Phenotype or Genotype in Kidney Transplant Recipients. Prog Transplant 2019; 29:300-308. [PMID: 31514576 DOI: 10.1177/1526924819873905] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Selection of expected phenotypes (ie, expressers/non-expressers) is currently used in CYP3A5*3 genotype-based tacrolimus dosing. The authors assessed whether a dosing regimen based on the 3 CYP3A5 genotypes may reduce the occurrence of inadequate exposure. METHODS Tacrolimus whole blood trough levels (C 0) were retrieved from a retrospective cohort of 100 kidney transplant recipients treated with a starting dose of 0.15 (non-expressers) or 0.30 (expressers) mg/kg/d. The authors evaluated the occurrence of overexposures (12 < C 0 < 20 ng/mL) or toxic concentrations (C 0 ≥ 20 ng/mL). These results were used to set up a new strategy based on the 3 distinct CYP3A5 genotypes, which relevance was evaluated in a prospective cohort of 107 patients. RESULTS In the retrospective cohort, non-expressers exhibited frequent overexposure (63.6%) or toxic C 0 (20.8%). Among expressers, none of the homozygous *1 carriers exhibited overexposure contrary to 25% of the heterozygotes. Based on these results, new tacrolimus starting doses were set at 0.10, 0.20, and 0.30 mg/kg/d for CYP3A5*3/*3, CYP3A5*1/*3, and CYP3A5*1/*1 genotypes, respectively. Tacrolimus overexposure was reduced in the CYP3A5*3/*3 group (63.6% vs 40%, P = .0038). None of the heterozygous patients exhibited toxic tacrolimus C 0. Clinical outcomes were not different between the 2 periods, whatever the genotype. Our results indicate that the best tacrolimus exposure was obtained for doses of 0.10, 0.20, and 0.20 mg/kg/d for CYP3A5*3/3, CYP3A5*1/*3, and CYP3A5*1/*1, respectively. CONCLUSIONS Our results confirm that selecting tacrolimus dosing regimen according to the expected phenotype is appropriate, but that lower than currently recommended doses may be preferable.
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Affiliation(s)
- Bérenger Largeau
- CHRU de Tours, Laboratoire de Biochimie et Biologie Moléculaire, Tours, France
| | - Chantal Barin-Le Guellec
- Université de Tours, Université de Limoges, INSERM, Individual profiling and prevention of risks with immunosuppressive therapies and transplantation (IPPRITT) - UMR 1248, CHRU de Tours, Laboratoire de Biochimie et Biologie Moléculaire, Tours, France
| | - Hélène Longuet
- CHRU de Tours, Service de Néphrologie-Hypertension artérielle, Dialyses et Transplantation Rénale, FHU SUPORT, Tours, France
| | - Philippe Lesne
- CHRU de Tours, Laboratoire de Biochimie et Biologie Moléculaire, Tours, France
| | - Antoine Bouvarel
- CHRU de Tours, Laboratoire de Biochimie et Biologie Moléculaire, Tours, France
| | - Laura Préteseille
- CHRU de Tours, Laboratoire de Biochimie et Biologie Moléculaire, Tours, France
| | - Pierre Marquet
- Université de Limoges, INSERM, Individual profiling and prevention of risks with immunosuppressive therapies and transplantation (IPPRITT) - UMR 1248, CHU de Limoges, Service de Pharmacologie et Toxicologie, FHU SUPORT, Limoges, France
| | - Jean-Michel Halimi
- Université de Tours, Transplantation, immunologie et inflammation (T2I) - EA4245, CHRU de Tours, Service de Néphrologie-Hypertension artérielle, Dialyses et Transplantation Rénale, FHU SUPORT, Tours, France
| | - Matthias Büchler
- Université de Tours, Transplantation, immunologie et inflammation (T2I) - EA4245, CHRU de Tours, Service de Néphrologie-Hypertension artérielle, Dialyses et Transplantation Rénale, FHU SUPORT, Tours, France
| | - Philippe Gatault
- Université de Tours, Transplantation, immunologie et inflammation (T2I) - EA4245, CHRU de Tours, Service de Néphrologie-Hypertension artérielle, Dialyses et Transplantation Rénale, FHU SUPORT, Tours, France
| | - Johan Noble
- CHRU de Tours, Service de Néphrologie-Hypertension artérielle, Dialyses et Transplantation Rénale, FHU SUPORT, Tours, France
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Model based development of tacrolimus dosing algorithm considering CYP3A5 genotypes and mycophenolate mofetil drug interaction in stable kidney transplant recipients. Sci Rep 2019; 9:11740. [PMID: 31409869 PMCID: PMC6692323 DOI: 10.1038/s41598-019-47876-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 07/19/2019] [Indexed: 01/10/2023] Open
Abstract
This study quantifies the interaction between tacrolimus (TAC) and mycophenolate mofetil (MMF) in kidney transplant recipients. Concentrations of TAC, mycophenolic acid (MPA), and metabolites were analyzed and relevant genotypes were determined from 32 patients. A population model was developed to estimate the effect of interaction. Concentrations of TAC were simulated in clinical scenarios and dose-adjusted trough concentrations per dose (C/D) were compared. Effect of interaction was described as the inverse exponential relationship. Major determinants of trough levels of TAC were CYP3A5 genotype and interaction with MPA. The absolute difference in C/D of TAC according to co-administered MMF was higher in CYP3A5 non-expressers (0.55 ng/mL) than in CYP3A5 expressers (0.35 ng/mL). The effect of MMF in determining the TAC exposure is more pronounced in CYP3A5 non-expressers. Based on population pharmacokinetic model, we suggest the TAC dosing algorithm considering the effects of CYP3A5 and MMF drug interaction in stable kidney transplant recipients.
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T-cell large granular lymphocyte leukemia in solid organ transplant recipients: case series and review of the literature. Int J Hematol 2019; 110:313-321. [PMID: 31250283 DOI: 10.1007/s12185-019-02682-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 05/30/2019] [Accepted: 05/31/2019] [Indexed: 10/26/2022]
Abstract
T-cell large granular lymphocyte (T-LGL) leukemia is a rare clonal proliferation of cytotoxic lymphocytes rarely described in solid organ transplant (SOT). We reviewed records from 656 kidney transplant recipients in follow-up at our Center from January 1998 to July 2017. In addition, we researched, through PubMed, further reports of T-LGL leukemia in SOT from March 1981 to December 2017. We identified six cases of T-LGL leukemia in our cohort of patients and 10 in the literature. This lymphoproliferative disorder was detected in one combined liver-kidney, one liver and 14-kidney transplant recipients. Median age at presentation was 46.5 years (IQR 39.2-56.9). The disease developed after a median age of 10 years (IQR 4.9-12) from transplantation. Anemia was the most common presentation (62.5%) followed by lymphocytosis (43.7%) and thrombocytopenia (31.2%). Splenomegaly was reported in 43.7% of the patients. Eight patients (50%) who experienced severe symptoms were treated with non-specific immunosuppressive agents. Six of them (75%) had a good outcome, whereas two (25%) remained red blood cell transfusion dependent. No cases progressed to aggressive T-LGL leukemia or died of cancer at the end of follow-up. These results suggest that T-LGL leukemia is a rare but potentially disruptive hematological disorder in the post-transplant period.
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Choudhury PS, Mukhopadhyay P, Roychowdhary A, Chowdhury S, Ghosh S. Prevalence and Predictors of "New-onset Diabetes after Transplantation" (NODAT) in Renal Transplant Recipients: An Observational Study. Indian J Endocrinol Metab 2019; 23:273-277. [PMID: 31641626 PMCID: PMC6683686 DOI: 10.4103/ijem.ijem_178_19] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE New-onset diabetes after transplantation (NODAT) develops frequently after renal transplant. The study aims at the prevalence of NODAT, predictors for developing it and therapeutic glycemic responses in NODAT. MATERIALS AND METHODS Consecutive renal transplant recipients excluding Diabetic Kidney Disease (DKD) or pretransplant diabetes were evaluated. Forty-three out of 250 persons were found to have NODAT. Ninety age-matched transplant recipients from the rest were recruited as control. Fasting blood sugar (FBS), HbA1c, lipid profile, and trough tacrolimus level (T0) were examined in all. HOMA IR C-peptide and HOMA-beta C-peptide were calculated. RESULTS Prevalence of NODAT in renal transplant recipients was 17.2% (43/250). Twenty-four (55.8%) developed early NODAT (<1 year) and 19 (44.2%) developed late NODAT (>1 year). Significantly higher pretransplant body mass index (BMI) (kg/m2) (P < 0.001), waist circumference (WC) (cm) (P < 0.001), pretransplant cholesterol (mg%) (P = 0.04), triglyceride (mg%) (P < 0.001), and FBS (mg%) (P < 0.001) were found in NODAT compared with non-NODAT. Trough tacrolimus (ng/mL) was found to be higher in NODAT (10.2 vs. 5.37, P < 0.001). Though HOMA IR was not found to be different between groups, HOMA-beta C-peptide was low in NODAT compared with non-NODAT (P = 0.03). Predictors of NODAT were WC [odds ratio (OR) = 01.15] and trough tacrolimus level (OR = 1.316). Best cut-off of WC for predicting NODAT was 87.5 cm for male and 83.5 cm for female. Best cut-off of T0 was 8.5 ng/mL. In NODAT, 9.3% were treated by lifestyle modification, 67.4% by oral hypoglycemic agents, 11.6% by insulin, and 11.6% by combined insulin and oral antidiabetic agents with HbA1c <7%. CONCLUSION NODAT in renal transplant recipients is more common in those with higher pretransplant BMI, WC, pretransplant total cholesterol, triglyceride, and FBS. Beta-cell secretory defect is more relevant as etiological factor rather than insulin resistance. Higher WC and trough tacrolimus level above 8.5 ng/mL may be important factors for predicting NODAT.
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Affiliation(s)
| | | | | | | | - Sujoy Ghosh
- Department of Endocrinology, IPGME&R, Kolkata, West Bengal, India
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Abstract
After more than 6 decades of clinical practice, the transplant community continues to research noninvasive biomarkers of solid organ injury to help improve patient care. In this review, we discuss the clinical usefulness of selective biomarkers and how they are processed at the laboratory. In addition, we organize these biomarkers based on specific aims and introduce innovative markers currently under investigation.
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Affiliation(s)
- John Choi
- Transplantation Research Center, Renal Division, Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Avenue, Boston, MA 02115, USA
| | - Albana Bano
- Transplantation Research Center, Renal Division, Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Avenue, Boston, MA 02115, USA
| | - Jamil Azzi
- Transplantation Research Center, Renal Division, Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Avenue, Boston, MA 02115, USA.
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Liu Z, Cheng J, Powell E, Macdonald G, Fawcett J, Lynch S, Martin J. Weight-based tacrolimus trough concentrations post liver transplant. Intern Med J 2019; 49:79-83. [DOI: 10.1111/imj.14043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 06/30/2018] [Accepted: 07/17/2018] [Indexed: 12/01/2022]
Affiliation(s)
- Zheng Liu
- School of Medicine and Public Health; University of Newcastle; Newcastle New South Wales Australia
- Clinical Pharmacology, Department of Medicine; The Royal Children’s Hospital; Melbourne Victoria Australia
| | - Jeffrey Cheng
- School of Medicine; University of Queensland; Brisbane Queensland Australia
- Department of Gastroenterology and Hepatology; Princess Alexandra Hospital; Brisbane Queensland Australia
| | - Elizabeth Powell
- School of Medicine; University of Queensland; Brisbane Queensland Australia
- Department of Gastroenterology and Hepatology; Princess Alexandra Hospital; Brisbane Queensland Australia
| | - Graeme Macdonald
- Department of Gastroenterology and Hepatology; Princess Alexandra Hospital; Brisbane Queensland Australia
- PA-Southside Clinical School; University of Queensland; Brisbane Queensland Australia
- Translational Research Institute; Princess Alexandra Hospital; Brisbane Queensland Australia
| | - Jonathan Fawcett
- School of Medicine; University of Queensland; Brisbane Queensland Australia
| | - Stephen Lynch
- School of Medicine; University of Queensland; Brisbane Queensland Australia
- Department of Gastroenterology and Hepatology; Princess Alexandra Hospital; Brisbane Queensland Australia
| | - Jennifer Martin
- School of Medicine and Public Health; University of Newcastle; Newcastle New South Wales Australia
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Campagne O, Mager DE, Brazeau D, Venuto RC, Tornatore KM. The impact of tacrolimus exposure on extrarenal adverse effects in adult renal transplant recipients. Br J Clin Pharmacol 2019; 85:516-529. [PMID: 30414331 DOI: 10.1111/bcp.13811] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Revised: 10/12/2018] [Accepted: 10/24/2018] [Indexed: 12/28/2022] Open
Abstract
AIMS Tacrolimus has been associated with notable extrarenal adverse effects (AEs), which are unpredictable and impact patient morbidity. The association between model-predicted tacrolimus exposure metrics and standardized extrarenal AEs in stable renal transplant recipients was investigated and a limited sampling strategy (LSS) was developed to predict steady-state tacrolimus area under the curve over a 12-h dosing period (AUCss,0-12h ). METHODS All recipients receiving tacrolimus and mycophenolic acid ≥6 months completed a 12-h cross-sectional observational pharmacokinetic-pharmacodynamic study. Patients were evaluated for the presence of individual and composite gastrointestinal, neurological, and aesthetic AEs during the study visit. The associations between AEs and tacrolimus exposure metrics generated from a published population pharmacokinetic model were investigated using a logistic regression analysis in NONMEM 7.3. An LSS was determined using a Bayesian estimation method with the same patients. RESULTS Dose-normalized tacrolimus AUCss,0-12h and apparent clearance were independently associated with diarrhoea, dyspepsia, insomnia and neurological AE ratio. Dose-normalized tacrolimus maximum concentration was significantly correlated with skin changes and acne. No AE associations were found with trough concentrations. Using limited sampling at 0, 2h; 0, 1, 4h; and 0, 1, 2, 4h provided a precise and unbiased prediction of tacrolimus AUC (root mean squared prediction error < 10%), which was not well characterized using trough concentrations only (root mean squared prediction error >15%). CONCLUSIONS Several AEs (i.e. diarrhoea, dyspepsia, insomnia and neurological AE ratio) were associated with tacrolimus dose normalized AUCss,0-12h and clearance. Skin changes and acne were associated with dose-normalized maximum concentrations. To facilitate clinical implementation, a LSS was developed to predict AUCss,0-12h values using sparse patient data to efficiently assess projected immunosuppressive exposure and potentially minimize AE manifestations.
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Affiliation(s)
- Olivia Campagne
- Department of Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA.,Faculty of Pharmacy, Universités Paris Descartes-Paris Diderot, Paris, France
| | - Donald E Mager
- Department of Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA
| | - Daniel Brazeau
- Department of Pharmaceutical Sciences, College of Pharmacy, University of New England, Portland, ME, USA
| | - Rocco C Venuto
- Erie County Medical Center, Division of Nephrology; Department of Medicine: Nephrology Division; School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Kathleen M Tornatore
- Erie County Medical Center, Division of Nephrology; Department of Medicine: Nephrology Division; School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA.,Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, Immunosuppressive Pharmacology Research Program, University at Buffalo, Buffalo, NY, USA
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Bae E, Han SS, Park DJ, Lee H, Yu MY, Kim KH, Kim MC, Cho JY, Min SI, Ha J, Kim YS, Yang SH. The level of intracellular tacrolimus in T cell is affected by CD44 +ABCB1 +activities triggered by inflammation. EUR J INFLAMM 2019. [DOI: 10.1177/2058739219845155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Rejection is an important issue in kidney transplant. Although with adequate trough level of tacrolimus, acute rejection occurs, and we are focused on these cases. We hypothesized that the lower concentration of tacrolimus in the peripheral blood mononuclear cell would be a cause of rejection; in this regard, we describe ABCB1, which regulates intracellular concentration of tacrolimus. The effect of inflammation on the intracellular concentration of tacrolimus was evaluated, as was the association between that concentration and ABCB1 and CD44 activities. Seven kidney recipients experiencing acute rejection were prospectively enrolled. Both the whole blood concentration of tacrolimus and intracellular concentration of tacrolimus were measured at the time of enrollment and after stabilization. A human T lymphoblastoid cell line (Jurkat T cell) was treated with various concentrations of tacrolimus for 21 h and then stimulated for 3 h. The levels of mRNA interleukin-2, interleukin-8, and interferon-γ decreased dose dependently by tacrolimus. Furthermore, a fluorescence-activated cell sorter was used to count cells expressing CD44 and ABCB1; changes in intracellular concentration of tacrolimus were explored after tacrolimus treatment and stimulation. Also, B6 splenocytes were tested in the same manner as previous Jurkat T cell experiments. The tacrolimus ratio of three patients was lower at the time of acute rejection than when patients were stabilized. In vitro, the intracellular concentration of tacrolimus decreased after stimulation. Under the same conditions, CD44+ABCB1+cells increased in proportion on tacrolimus treatment and stimulation. This work supports the hypothesis that inflammation reduces the intracellular tacrolimus level, possibly via drug efflux mediated by CD44+ABCB1+and inflammation could lead to acute rejection.
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Affiliation(s)
- Eunjin Bae
- Department of Internal Medicine, College of Medicine, Gyeongsang National University, Jinju, Korea
- Gyeongsang National University Changwon Hospital, Changwon, Korea
| | - Seung Seok Han
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Dong Jun Park
- Department of Internal Medicine, College of Medicine, Gyeongsang National University, Jinju, Korea
- Gyeongsang National University Changwon Hospital, Changwon, Korea
| | - Hajeong Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Mi-Yeon Yu
- Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
| | - Kyu Hong Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Min Chang Kim
- Department of Clinical Pharmacology and Therapeutics, College of Medicine, Seoul National University, Seoul, Korea
| | - Joo-Youn Cho
- Department of Clinical Pharmacology and Therapeutics, College of Medicine, Seoul National University, Seoul, Korea
| | - Sang-Il Min
- Department of Surgery, College of Medicine, Seoul National University, Seoul, Korea
| | - Jongwon Ha
- Department of Surgery, College of Medicine, Seoul National University, Seoul, Korea
| | - Yon Su Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Kidney Research Institute, Seoul National University, Seoul, Korea
| | - Seung Hee Yang
- Department of Kidney Research Institute, Seoul National University, Seoul, Korea
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The potential impact of hematocrit correction on evaluation of tacrolimus target exposure in pediatric kidney transplant patients. Pediatr Nephrol 2019; 34:507-515. [PMID: 30374607 PMCID: PMC6349786 DOI: 10.1007/s00467-018-4117-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 10/10/2018] [Accepted: 10/11/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Tacrolimus is an important immunosuppressive agent with high intra- and inter-individual pharmacokinetic variability and a narrow therapeutic index. As tacrolimus extensively accumulates in erythrocytes, hematocrit is a key factor in the interpretation of tacrolimus whole blood concentrations. However, as hematocrit values in pediatric kidney transplant patients are highly variable after kidney transplantation, translating whole blood concentration targets without taking hematocrit into consideration is theoretically incorrect. The aim of this study is to evaluate the potential impact of hematocrit correction on tacrolimus target exposure in pediatric kidney transplant patients. METHODS Data were obtained from 36 pediatric kidney transplant patients. Two hundred fifty-five tacrolimus whole blood samples were available, together responsible for 36 area under the concentration-time curves (AUCs) and trough concentrations. First, hematocrit corrected concentrations were derived using a formula describing the relationship between whole blood concentrations, hematocrit, and plasma concentrations. Subsequently, target exposure was evaluated using the converted plasma target concentrations. Ultimately, differences in interpretation of target exposure were identified and evaluated. RESULTS In total, 92% of our patients had lower hematocrit (median 0.29) than the reference value of adult kidney transplant patients. A different evaluation of target exposure for either trough level, AUC, or both was defined in 42% of our patients, when applying hematocrit corrected concentrations. CONCLUSION A critical role for hematocrit in therapeutic drug monitoring of tacrolimus in pediatric kidney transplant patients is suggested in this study. Therefore, we believe that hematocrit correction could be a step towards improvement of tacrolimus dose individualization.
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Jaeger SU, Klag T, Hoeger K, Klumpp S, Escher M, Malek N, Stange E, Wehkamp J. Tacrolimus Suppositories in Therapy-Resistant Ulcerative Proctitis. Inflamm Intest Dis 2018; 3:116-124. [PMID: 30820433 DOI: 10.1159/000493979] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 08/29/2018] [Indexed: 12/15/2022] Open
Abstract
Background Ulcerative proctitis may often be managed with topical salicylates or steroids alone, but in some patients, symptoms are persistent and severe. We analyzed the efficacy of tacrolimus suppositories in patients who had proven refractory to combined topical and systemic treatment. Methods In this retrospective analysis, ulcerative colitis activity index (CAI), side effects, co-medication and drug levels were assessed in 43 patients with distal ulcerative colitis who received suppositories containing 2 mg of tacrolimus b.i.d. as add-on medication. Results A total of 23 patients with ulcerative proctitis presented to follow-up within ≤50 days (mean 27.0 days) after suppositories were started. A decrease in CAI (from 8.0 to 5.5 points) was observed and 52.3% reached clinical remission (CAI ≤4). In total, 43 patients were available for analysis, of whom 9 had inflammation of the sigmoid colon as well. For the entire cohort, the median treatment duration was 76 days; 60% were in remission on the last documented visit. Serum measurements revealed a substantial tacrolimus level with a mean of 5.5 ng/mL. We observed one case of mild reversible acute kidney injury. Conclusions In ulcerative proctitis, adding tacrolimus suppositories can be an effective and safe option when topical mesalazine, corticoid formulations and concomitant oral or parenteral medications have failed.
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Affiliation(s)
- Simon U Jaeger
- Margarete Fischer Bosch Institute of Clinical Pharmacology, Stuttgart, Germany
| | - Thomas Klag
- Department of Internal Medicine I, University Hospital, University of Tübingen, Tübingen, Germany
| | - Katharina Hoeger
- Department of Gastroenterology and Hepatology, Robert Bosch Krankenhaus, Stuttgart, Germany
| | | | | | - Nisar Malek
- Department of Internal Medicine I, University Hospital, University of Tübingen, Tübingen, Germany
| | - Eduard Stange
- Department of Internal Medicine I, University Hospital, University of Tübingen, Tübingen, Germany
| | - Jan Wehkamp
- Department of Internal Medicine I, University Hospital, University of Tübingen, Tübingen, Germany
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Phupradit A, Vadcharavivad S, Ingsathit A, Kantachuvesiri S, Areepium N, Sra-Ium S, Auamnoy T, Sukasem C, Sumethkul V, Kitiyakara C. Impact of POR and CYP3A5 Polymorphisms on Trough Concentration to Dose Ratio of Tacrolimus in the Early Post-operative Period Following Kidney Transplantation. Ther Drug Monit 2018; 40:549-557. [PMID: 29878980 DOI: 10.1097/ftd.0000000000000542] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Tacrolimus, a critical dose drug, is widely used in transplantation. Knowing the contribution of genetic factors, which significantly influence tacrolimus variability, is beneficial in the personalization of its starting dose. The significant impact of CYP3A5*3 polymorphisms on tacrolimus exposure has been reported. Conflicting results of the additional influence of POR*28 polymorphisms on tacrolimus pharmacokinetic interindividual variability have been observed among different populations. The objective of this study was to explore the interaction between POR*28 and CYP3A5*3 polymorphisms and their main effects on tacrolimus trough concentration to dose ratios on day 7 after kidney transplantation. METHODS Two hundred sixteen adult kidney transplant recipients participated in this retrospective study. All participants received a twice daily tacrolimus regimen. Blood samples and data were collected on day 7 after transplantation. A 2-way analysis of covariance was performed. Tested covariates were age, hemoglobin, serum albumin, and prednisolone dose. RESULTS A 2 × 2 analysis of covariance revealed that the interaction between CYP3A5 polymorphisms (CYP3A5 expresser and CYP3A5 nonexpresser) and POR polymorphisms (POR*28 carrier and POR*28 noncarrier) was not significant (F(1, 209) = 2.473, P = 0.117, (Equation is included in full-text article.)= 0.012). The predicted main effect of CYP3A5 and POR polymorphisms was significant (F(1, 209) = 105.565, P < 0.001, (Equation is included in full-text article.)= 0.336 and F(1, 209) = 4.007, P = 0.047, (Equation is included in full-text article.)= 0.019, respectively). Hemoglobin, age, and steroid dose influenced log C0/dose of tacrolimus (F(1, 209) = 20.612, P < 0.001, (Equation is included in full-text article.)= 0.090; F(1, 209) = 14.360, P < 0.001, (Equation is included in full-text article.)= 0.064; and F(1, 209) = 5.512, P = 0.020, (Equation is included in full-text article.)= 0.026, respectively). CONCLUSIONS After adjusting for the influences of hemoglobin, age, and prednisolone dose, significant impacts of the CYP3A5 and POR polymorphisms on tacrolimus exposure were found. The effect of POR*28 and CYP3A5*3 polymorphisms during the very early period after kidney transplantation is independent of each other.
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Affiliation(s)
- Annop Phupradit
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
- Pharmacy Division, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Somratai Vadcharavivad
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
| | - Atiporn Ingsathit
- Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Surasak Kantachuvesiri
- Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nutthada Areepium
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
| | - Supasil Sra-Ium
- Pharmacy Division, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Titinun Auamnoy
- Faculty of Pharmaceutical Sciences, Burapha University, Chon Buri, Thailand
| | - Chonlaphat Sukasem
- Division of Pharmacogenomics and Personalized Medicine, Department of Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Vasant Sumethkul
- Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chagriya Kitiyakara
- Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Effects of clotrimazole on tacrolimus pharmacokinetics in patients with heart transplants with different CYP3A5 genotypes. Eur J Clin Pharmacol 2018; 75:67-75. [DOI: 10.1007/s00228-018-2558-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 09/14/2018] [Indexed: 01/18/2023]
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Girerd S, Schikowski J, Girerd N, Duarte K, Busby H, Gambier N, Ladrière M, Kessler M, Frimat L, Aarnink A. Impact of reduced exposure to calcineurin inhibitors on the development of de novo DSA: a cohort of non-immunized first kidney graft recipients between 2007 and 2014. BMC Nephrol 2018; 19:232. [PMID: 30219043 PMCID: PMC6139146 DOI: 10.1186/s12882-018-1014-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 08/24/2018] [Indexed: 12/15/2022] Open
Abstract
Background In low-immunological risk kidney transplant recipients (KTRs), reduced exposure to calcineurin inhibitor (CNI) appears particularly attractive for avoiding adverse events, but may increase the risk of developing de novo Donor Specific Antibodies (dnDSA). Methods CNI exposure was retrospectively analyzed in 247 non-HLA immunized first KTRs by taking into account trough levels (C0) collected during follow-up. Reduced exposure to CNI was defined as follows: C0 less than the lower limit of the international targets for ≥50% of follow-up. Results During a mean follow-up of 5.0 ± 2.0 years, 39 patients (15.8%) developed dnDSA (MFI ≥1000). Patients with DSA were significantly younger (46.6 ± 13.8 vs. 51.7 ± 14.0 years, p = 0.039), received more frequently poorly-matched grafts (59% with 6–8 A-B-DR-DQ HLA mismatches vs. 34.6%, p = 0.016) and had more frequently a reduced exposure to CNI (92.3% vs. 62.0%, p = 0.0002). Reduced exposure to CNI was associated with an increased risk of dnDSA (multivariable HR = 9.77, p = 0.002). Reduced exposure to CNI had no effect on patient survival, graft loss from any cause including death, or post-transplant cancer. Conclusions Even in a low-immunological risk population, reduced exposure to CNI is associated with increased risk of dnDSA. Benefits and risks of under-immunosuppression must be carefully evaluated before deciding on CNI minimization.
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Affiliation(s)
- S Girerd
- Service de Néphrologie et Transplantation rénale, CHRU Nancy Brabois, Vandoeuvre-les-, Nancy, France. .,INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Université de Lorraine, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France.
| | - J Schikowski
- Service de Néphrologie et Transplantation rénale, CHRU Nancy Brabois, Vandoeuvre-les-, Nancy, France
| | - N Girerd
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Université de Lorraine, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France
| | - K Duarte
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Université de Lorraine, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France
| | - H Busby
- Service d'Anatomie pathologique, CHRU Nancy Brabois, Vandœuvre-lès-Nancy, France
| | - N Gambier
- Service de Pharmacologie-Toxicologie, CHRU Nancy Brabois, Vandœuvre-lès-Nancy, France
| | - M Ladrière
- Service de Néphrologie et Transplantation rénale, CHRU Nancy Brabois, Vandoeuvre-les-, Nancy, France
| | - M Kessler
- Service de Néphrologie et Transplantation rénale, CHRU Nancy Brabois, Vandoeuvre-les-, Nancy, France
| | - L Frimat
- Service de Néphrologie et Transplantation rénale, CHRU Nancy Brabois, Vandoeuvre-les-, Nancy, France
| | - A Aarnink
- Laboratoire d'Histocompatibilité, CHRU Nancy Brabois, Vandœuvre-lès-Nancy, France
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Alfano G, Fontana F, Colaci E, Franceschini E, Ligabue G, Messerotti A, Bettelli F, Grottola A, Gennari W, Potenza L, Guaraldi G, Mussini C, Luppi M, Cappelli G. Immunophenotypic profile and clinical outcome of monoclonal B-cell lymphocytosis in kidney transplantation. Clin Transplant 2018; 32:e13338. [PMID: 30074641 DOI: 10.1111/ctr.13338] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Revised: 04/09/2018] [Accepted: 06/23/2018] [Indexed: 12/17/2022]
Abstract
Monoclonal B-cell lymphocytosis (MBL) is a lymphoproliferative disorder characterized by clonal expansion of a B-cell population in peripheral blood of otherwise healthy subjects. MBL is divided into CLL (chronic lymphocytic leukemia)-like, atypical CLL-like and non-CLL MBL. The aim of this study was to evaluate immunophenotypic characteristics and clinical outcomes of MBL in kidney transplant (KT) recipients. We retrospectively evaluated 593 kidney transplant (KT) recipients in follow-up at our center. Among them, 157 patients underwent peripheral blood flow cytometry for different clinical indications. A 6-color panel flow cytometry was used to diagnose MBL. This condition was detected in 5 of 157 KT recipients. Immunophenotypic characterization of MBL showed four cases of non-CLL MBL and one case of CLL-like MBL. At presentation, median age was 65 years (range 61-73). After a median follow-up of 3.1 years (95%CI; 1.1-5) from diagnosis, patients did not progress either to CLL or to lymphoma. The disorder did not increase the risk of malignancy, severe infections, graft loss and mortality among our KT recipients. Surprisingly, all cases were also affected by concomitant monoclonal gammopathy of undetermined significance, which did not progress to multiple myeloma during follow-up. In conclusion, our data suggest that MBL is an age-related disorder, with non-CLL MBL being the most common subtype among KT recipients.
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Affiliation(s)
- Gaetano Alfano
- Section of Nephrology, Surgical, Medical and Dental Department of Morphological Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliero - Universitaria Policlinico, Modena, Italy
| | - Francesco Fontana
- Section of Nephrology, Surgical, Medical and Dental Department of Morphological Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliero - Universitaria Policlinico, Modena, Italy
| | - Elisabetta Colaci
- Section of Hematology, Surgical, Medical and Dental Department of Morphological Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliero - Universitaria Policlinico, Modena, Italy
| | - Erica Franceschini
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Azienda Ospedaliero - Universitaria Policlinico, Modena, Italy
| | - Giulia Ligabue
- Section of Nephrology, Surgical, Medical and Dental Department of Morphological Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliero - Universitaria Policlinico, Modena, Italy
| | - Andrea Messerotti
- Section of Hematology, Surgical, Medical and Dental Department of Morphological Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliero - Universitaria Policlinico, Modena, Italy
| | - Francesca Bettelli
- Section of Hematology, Surgical, Medical and Dental Department of Morphological Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliero - Universitaria Policlinico, Modena, Italy
| | - Antonella Grottola
- Microbiology and Virology Unit, Azienda Ospedaliero - Universitaria Policlinico, Modena, Italy
| | - William Gennari
- Microbiology and Virology Unit, Azienda Ospedaliero - Universitaria Policlinico, Modena, Italy
| | - Leonardo Potenza
- Section of Hematology, Surgical, Medical and Dental Department of Morphological Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliero - Universitaria Policlinico, Modena, Italy
| | - Giovanni Guaraldi
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Azienda Ospedaliero - Universitaria Policlinico, Modena, Italy
| | - Cristina Mussini
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Azienda Ospedaliero - Universitaria Policlinico, Modena, Italy
| | - Mario Luppi
- Section of Hematology, Surgical, Medical and Dental Department of Morphological Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliero - Universitaria Policlinico, Modena, Italy
| | - Gianni Cappelli
- Section of Nephrology, Surgical, Medical and Dental Department of Morphological Sciences, University of Modena and Reggio Emilia, Azienda Ospedaliero - Universitaria Policlinico, Modena, Italy
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Beardslee T, Draper A, Kudchadkar R. Tacrolimus for the treatment of immune-related adverse effects refractory to systemic steroids and anti-tumor necrosis factor α therapy. J Oncol Pharm Pract 2018; 25:1275-1281. [DOI: 10.1177/1078155218793709] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Tyler Beardslee
- Department of Pharmacy, Winship Cancer Institute, Emory University, Druid Hills, USA
| | - Amber Draper
- Department of Pharmacy, Winship Cancer Institute, Emory University, Druid Hills, USA
| | - Ragini Kudchadkar
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Druid Hills, USA
- Hematology and Medical Oncology Fellowship Program, Winship Cancer Institute, Emory University, Druid Hills, USA
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79
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Garaix F, Stern M, Lamy FX, Dubel L, Kamar N. Tacrolimus Granules for Oral Suspension as Post-Transplant Immunosuppression in Routine Medical Practice in France: The OPTIMOD Study. Ann Transplant 2018; 23:561-571. [PMID: 30093607 PMCID: PMC6248292 DOI: 10.12659/aot.908522] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background Different pharmaceutical forms of oral tacrolimus allow tailored administration. The granular formulation facilitates accurate dose adjustment of tacrolimus according to patient characteristics, such as weight, or potential concomitant drug interactions. Currently, there are no data describing the use of tacrolimus granules in transplant recipients in France. Material/Methods OPTIMOD was a 6-month prospective, observational multicenter study that aimed to describe patient characteristics and conditions of use of tacrolimus granules. The 25 participating centers enrolled patients at time of tacrolimus granules initiation and were to collect patient and treatment data at initiation and after 6 months of follow-up. All analyses were descriptive. Results Of 61 patients included, 55.7% were children (mainly kidney graft recipients) and 44.3% were adults (mostly lung graft recipients). Overall, 24.6% of patients (all children) initiated tacrolimus granules immediately post-transplant; the remaining 75.4% converted to tacrolimus granules from ciclosporin or immediate-release tacrolimus hard capsules. The main reasons for initiating tacrolimus granules, irrespective of whether first- or second-line therapy, were to offset potential drug–drug interactions in adults by adjusting dose, and to adapt to the particular needs of children as patients. Most patients (78.7%) underwent ≥1 dose modification during follow-up. Eleven rejection episodes occurred during follow-up, of which none led to graft loss. The adverse-event profile of the tacrolimus granules was similar to that of other tacrolimus formulations and 7 treatment-related adverse events were recorded. Conclusions Results suggest that tacrolimus granules are well tolerated and effective in preventing transplant rejection when administered in routine practice in France.
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Affiliation(s)
- Florentine Garaix
- Department of Paediatric Nephrology, Hôpital La Timone, Marseille, France
| | - Marc Stern
- Department of Pulmonology, Hôpital Foch, Suresnes, France
| | | | - Laurence Dubel
- Department of Scientific and Medical Affairs Transplantation, Astellas France, Levallois-Perret Cedex, France
| | - Nassim Kamar
- Department of Nephrology, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
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80
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Zhu W, Xue L, Peng H, Duan Z, Zheng X, Cao D, Wen J, Wei X. Tacrolimus population pharmacokinetic models according to CYP3A5/CYP3A4/POR genotypes in Chinese Han renal transplant patients. Pharmacogenomics 2018; 19:1013-1025. [PMID: 30040022 DOI: 10.2217/pgs-2017-0139] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To develop a population pharmacokinetic (PK) model of tacrolimus in Chinese Han renal transplant population and establish the influence of different covariates (especially different CYP3A5/3A4/POR genotype) on PK properties. Materials & methods: Trough tacrolimus concentrations, clinical characteristics and CYP3A5/CYP3A4/POR genotypes were collected from 141 adult renal transplant recipients after transplantation. The population PK analysis was carried out using the nonlinear mixed-effect modeling software NONMEM version 3.4.2. Results: Tacrolimus PK profiles exhibited high interpatient variability. A two compartment model with first-order input and elimination described the tacrolimus PK profiles in the studied population. Among the genotypes, only CYP3A5 genotype was confirmed to have clinical significance. Conclusion: Our final model confirmed that CYP3A5*3 plays a more significant role in tacrolimus PK and could affect the blood concentrations and CL/F (clearance rate/bioavailbility). This model is expected to help to improve individualized tacrolimus dosing.
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Affiliation(s)
- Wan Zhu
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, 330031, PR China
- Department of Pharmacy, Medical School of Nanchang University, Nanchang, 330031, PR China
| | - Ling Xue
- Department of Clinical Pharmacology, The First Affiliated Hospital of Soochow University, Suzhou, 215006, PR China
| | - Hongwei Peng
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, 330031, PR China
| | - Zhouping Duan
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, 330031, PR China
| | - Xuelian Zheng
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, 330031, PR China
| | - Duanwen Cao
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, 330031, PR China
| | - Jinhua Wen
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, 330031, PR China
| | - Xiaohua Wei
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, 330031, PR China
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81
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Transplant phenomapping: A move toward personalized immunosuppression. J Heart Lung Transplant 2018; 37:943-944. [DOI: 10.1016/j.healun.2018.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 05/09/2018] [Accepted: 05/16/2018] [Indexed: 01/06/2023] Open
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Krzyżowska K, Kolonko A, Giza P, Chudek J, Więcek A. No Significant Influence of Reduced Initial Tacrolimus Dose on Risk of Underdosing and Early Graft Function in Older and Overweight Kidney Transplant Recipients. Transplant Proc 2018; 50:1755-1759. [PMID: 30056895 DOI: 10.1016/j.transproceed.2018.02.108] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 02/06/2018] [Accepted: 02/19/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Nowadays, a reduced initial daily dose of tacrolimus (Tac) (0.1-0.15 mg/kg) is recommended for the majority of kidney transplant recipients (KTRs). The aim of the study was to analyze the safety of such a regimen, including the risk of first inadequately low Tac blood level, acute rejection (AR) occurrence, or early graft dysfunction. METHODS In 2011, we introduced a modified (0.1-0.15 mg/kg/d) initial Tac dosing regimen in older (>55 years) and/or overweight KTRs. To assure the safety of this protocol, we monitored the risk of inadequately low blood Tac level (<6 ng/mL) and incidence of AR or delayed graft function (DGF). The historical cohort with the higher Tac dosing regimen (0.2 mg/kg/d, n = 208) served as a control group. RESULTS The mean Tac daily dose in 78 KTRs (group with reduced dosing) was 0.133 (95% confidence interval [CI], 0.130-0.136) mg/kg and was significantly lower than the standard, previously prescribed dose of 0.195 (95% CI, 0.194-0.197) mg/kg. Of note, induction therapy was employed twice more often in the reduced Tac dosing group. The dose reduction resulted in a slight, nonsignificant decrease in first Tac trough level. The percentages of patients with first Tac troughs <6 ng/mL (5.1% vs 4.8%), AR (6.4% vs 5.8%), and DGF (25.6% vs 31.2%) were similar in the reduced and standard dosing groups. CONCLUSION The currently recommended reduction in Tac initial dosing does not increase the risk of inadequate immunosuppression and does not affect the early graft function. Regardless of Tac dose reduction, there is still a substantial risk of Tac overdosing in older or overweight KTRs.
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Affiliation(s)
- K Krzyżowska
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
| | - A Kolonko
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland.
| | - P Giza
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
| | - J Chudek
- Department of Internal Diseases and Oncological Chemotherapy, Medical University of Silesia, Katowice, Poland
| | - A Więcek
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
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Effect of Age and Allele Variants of CYP3A5, CYP3A4, and POR Genes on the Pharmacokinetics of Cyclosporin A in Pediatric Renal Transplant Recipients From Serbia. Ther Drug Monit 2018; 39:589-595. [PMID: 29135906 DOI: 10.1097/ftd.0000000000000442] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The interindividual variability of cyclosporin A (CsA) pharmacokinetics might be explained by heterogeneity in the cytochrome P450 3A (CYP3A) subfamily. Altered CYP3A enzyme activity was associated with variant allele of P450 oxidoreductase gene (POR*28). The aim of this study was to assess the impact of age, CYP3A5*3, CYP3A4*22, and POR*28 alleles on CsA pharmacokinetics in pediatric renal transplant recipients. METHODS Renal transplant patients receiving CsA (n = 47) were genotyped for CYP3A5*3, CYP3A4*22, and POR*28. RESULTS CYP3A5 nonexpressers had higher overall dose-adjusted predose concentration (C0/dose; ng/mL per mg/kg) compared with expressers (31.48 ± 12.75 versus 22.44 ± 7.12, P = 0.01). CYP3A5 nonexpressers carrying POR*28 allele had a lower overall dose-adjusted concentration (C2/dose) than those with POR*1/*1 genotype (165.54 ± 70.40 versus 210.55 ± 79.98, P = 0.02), with age as covariate. Children aged 6 years and younger had a lower overall C0/dose (18.82 ± 4.72 versus 34.19 ± 11.89, P = 0.001) and C2/dose (106.75 ± 26.99 versus 209.20 ± 71.57, P < 0.001) compared with older children. Carriers of CYP3A5*3 allele aged ≤6 years required higher dose of CsA and achieved lower C0/dose and C2/dose, at most time points, than older carriers of this allele. Carriers of POR*28 allele aged ≤6 years required higher doses of CsA, whereas they achieved lower C0/dose and C2/dose, at most time points, in comparison to older carriers of this allele. The significant effect of age (P < 0.002) and CYP3A5 variation (P < 0.02) was shown for overall C0/dose, whereas age (P < 0.00001) and POR variation (P = 0.05) showed significant effect on C2/dose. Regression summary for overall C2/dose in patients aged 6 years younger showed a significant effect of both CYP3A5 and POR variations (P < 0.016). CONCLUSIONS Younger age, POR*28 allele, and CYP3A5*3 allele were associated with higher CsA dosing requirements and lower concentration/dose ratio. Pretransplant screening of relevant polymorphisms in accordance with age should be considered to adjust therapy.
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84
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Wring S, Murphy G, Atiee G, Corr C, Hyman M, Willett M, Angulo D. Clinical Pharmacokinetics and Drug-Drug Interaction Potential for Coadministered SCY-078, an Oral Fungicidal Glucan Synthase Inhibitor, and Tacrolimus. Clin Pharmacol Drug Dev 2018; 8:60-69. [PMID: 29947477 DOI: 10.1002/cpdd.588] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 05/16/2018] [Indexed: 12/26/2022]
Abstract
SCY-078 is an orally bioavailable triterpenoid glucan synthase inhibitor in clinical development as an intravenous and oral treatment of fungal infections caused by Candida and Aspergillus species. This was a sequential, single-center, open-label phase 1 study to assess the drug-drug interaction potential between SCY-078 and tacrolimus during concomitant administration in healthy subjects. In cohort 1, period 1, subjects received a single oral dose of tacrolimus 2 mg in the fasted state. In period 2 after a ≥15 day washout, subjects received a single loading dose of SCY-078 1250 mg on day 1 followed by maintenance doses of SCY-780 750 mg on days 2 through 8. On day 3 of period 2, subjects also received a single dose of tacrolimus 2 mg concurrent with SCY-078. In cohort 2, subjects received a loading dose of SCY-078 1250 mg on day 1 followed by maintenance doses of SCY-780 750 mg on days 2 and 3. Pharmacokinetic (PK) parameters were compared to assess both the impact of steady-state SCY-078 on tacrolimus and the impact of tacrolimus on the PK of steady-state SCY-078. The concurrent coadministration of tacrolimus and SCY-078 had no effect on the maximum blood levels of tacrolimus, as evidenced by no change in maximum concentration of drug in blood plasma and a 1.4-fold increase in total area under the plasma drug concentration-time curve. The concurrent coadministration of tacrolimus and SCY-078 resulted in a weaker interaction than typically observed with the azole class of antifungals. The current data indicate that an initial dose adjustment for tacrolimus may not be warranted when combined with SCY-078, as the modest increase in exposure is less than the therapeutic window, although tacrolimus monitoring, as with addition of any new medication, is recommended. These results support the coadministration of SCY-078 and tacrolimus.
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85
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Zhang X, Lin G, Tan L, Li J. Current progress of tacrolimus dosing in solid organ transplant recipients: Pharmacogenetic considerations. Biomed Pharmacother 2018; 102:107-114. [DOI: 10.1016/j.biopha.2018.03.054] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 02/27/2018] [Accepted: 03/09/2018] [Indexed: 12/11/2022] Open
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86
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Campagne O, Mager DE, Brazeau D, Venuto RC, Tornatore KM. Tacrolimus Population Pharmacokinetics and Multiple CYP3A5 Genotypes in Black and White Renal Transplant Recipients. J Clin Pharmacol 2018; 58:1184-1195. [PMID: 29775201 DOI: 10.1002/jcph.1118] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 02/13/2018] [Indexed: 01/08/2023]
Abstract
Tacrolimus exhibits inter-patient pharmacokinetic variability attributed to CYP3A5 isoenzymes and the efflux transporter, P-glycoprotein. Most black renal transplant recipients require higher tacrolimus doses compared to whites to achieve similar troughs when race-adjusted recommendations are used. An established guideline provides tacrolimus genotype dosing recommendations based on CYP3A5*1(W/T) and loss of protein function variants: CYP3A5*3 (rs776746), CYP3A5*6 (rs10264272), CYP3A5*7 (rs41303343) and may provide more comprehensive race-adjusted dosing recommendations. Our objective was to develop a tacrolimus population pharmacokinetic model evaluating demographic, clinical, and genomic factors in stable black and white renal transplant recipients. A secondary objective investigated race-based tacrolimus regimens and genotype-specific dosing. Sixty-seven recipients receiving oral tacrolimus and mycophenolic acid ≥6 months completed a 12-hour pharmacokinetic study. CYP3A5*3,*6,*7 and ABCB1 1236C>T, 2677G>T/A, 3435C>T polymorphisms were characterized. Patients were classified as extensive, intermediate, and poor metabolizers using a novel CYP3A5*3*6*7 metabolic composite. Modeling and simulation was performed with computer software (NONMEM 7.3, ICON Development Solutions; Ellicott City, Maryland). A 2-compartment model with first-order elimination and absorption with lag time best described the data. The CYP3A5*3*6*7 metabolic composite was significantly associated with tacrolimus clearance (P value < .05), which was faster in extensive (mean: 45.0 L/hr) and intermediate (29.5 L/hr) metabolizers than poor metabolizers (19.8 L/hr). Simulations support CYP3A5*3*6*7 genotype-based tacrolimus dosing to enhance general race-adjusted regimens, with dose increases of 1.5-fold and 2-fold, respectively, in intermediate and extensive metabolizers for comparable exposures to poor metabolizers. This model offers a novel approach to determine tacrolimus dosing adjustments that maintain comparable therapeutic exposure between black and white recipients with different CYP3A5 genotypes.
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Affiliation(s)
- Olivia Campagne
- Department of Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA.,Faculty of Pharmacy, Universités Paris Descartes-Paris Diderot, Paris, France
| | - Donald E Mager
- Department of Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA
| | - Daniel Brazeau
- Department of Pharmaceutical Sciences, College of Pharmacy, University of New England, Portland, ME, USA
| | - Rocco C Venuto
- Erie County Medical Center, Division of Nephrology, Department of Medicine, School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Kathleen M Tornatore
- Erie County Medical Center, Division of Nephrology, Department of Medicine, School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA.,Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, Immunosuppressive Pharmacology Research Program, Translational Pharmacology Research Core, NYS Center of Excellence in Bioinformatics and Life Sciences, University at Buffalo, Buffalo, NY, USA
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87
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Salis F, Descalzo AB, Benito-Peña E, Moreno-Bondi MC, Orellana G. Highly Fluorescent Magnetic Nanobeads with a Remarkable Stokes Shift as Labels for Enhanced Detection in Immunoassays. SMALL (WEINHEIM AN DER BERGSTRASSE, GERMANY) 2018; 14:e1703810. [PMID: 29665269 DOI: 10.1002/smll.201703810] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 01/30/2018] [Indexed: 06/08/2023]
Abstract
Fluorescence immunoassays are popular for achieving high sensitivity, but they display limitations in biological samples due to strong absorption of light, background fluorescence from matrix components, or light scattering by the biomacromolecules. A powerful strategy to overcome these problems is introduced here by using fluorescent magnetic nanobeads doped with two boron-dipyrromethane dyes displaying intense emission in the visible and near-infrared regions, respectively. Careful matching of the emission and absorption features of the dopants leads to a virtual Stokes shift larger than 150 nm achieved by an intraparticle Förster resonance energy transfer (FRET) process between the donor and the acceptor dyes. Additionally, the magnetic properties of the fluorescent beads allow preconcentration of the sample. To illustrate the usefulness of this approach to increase the sensitivity of fluorescence immunoassays, the novel nanoparticles are employed as labels for quantification of the widely used Tacrolimus (FK506) immunosuppressive drug. The FRET-based competitive inhibition immunoassay yields a limit of detection (LOD) of 0.08 ng mL-1 , with a dynamic range (DR) of 0.15-2.0 ng mL-1 , compared to a LOD of 2.7 ng mL-1 and a DR between 4.1 and 130 ng mL-1 for the immunoassay carried out with direct excitation of the acceptor dye.
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Affiliation(s)
- Francesca Salis
- Department of Organic Chemistry, Faculty of Chemistry, Complutense University of Madrid (UCM), 28040, Madrid, Spain
| | - Ana B Descalzo
- Department of Organic Chemistry, Faculty of Chemistry, Complutense University of Madrid (UCM), 28040, Madrid, Spain
| | - Elena Benito-Peña
- Department of Analytical Chemistry, Faculty of Chemistry, Complutense University of Madrid (UCM), 28040, Madrid, Spain
| | - María C Moreno-Bondi
- Department of Analytical Chemistry, Faculty of Chemistry, Complutense University of Madrid (UCM), 28040, Madrid, Spain
| | - Guillermo Orellana
- Department of Organic Chemistry, Faculty of Chemistry, Complutense University of Madrid (UCM), 28040, Madrid, Spain
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Chen L, Prasad GVR. CYP3A5 polymorphisms in renal transplant recipients: influence on tacrolimus treatment. PHARMACOGENOMICS & PERSONALIZED MEDICINE 2018; 11:23-33. [PMID: 29563827 PMCID: PMC5846312 DOI: 10.2147/pgpm.s107710] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Tacrolimus is a commonly used immunosuppressant after kidney transplantation. It has a narrow therapeutic range and demonstrates wide interindividual variability in pharmacokinetics, leading to potential underimmunosuppression or toxicity. Genetic polymorphism in CYP3A5 enzyme expression contributes to differences in tacrolimus bioavailability between individuals. Individuals carrying one or more copies of the wild-type allele *1 express CYP3A5, which increases tacrolimus clearance. CYP3A5 expressers require 1.5 to 2-fold higher tacrolimus doses compared to usual dosing to achieve therapeutic blood concentrations. Individuals with homozygous *3/*3 genotype are CYP3A5 nonexpressers. CYP3A5 nonexpression is the most frequent phenotype in most ethnic populations, except blacks. Differences between CYP3A5 genotypes in tacrolimus disposition have not translated into differences in clinical outcomes, such as acute rejection and graft survival. Therefore, although genotype-based dosing may improve achievement of therapeutic drug concentrations with empiric dosing, its role in clinical practice is unclear. CYP3A5 genotype may predict differences in absorption of extended-release and immediate-release oral formulations of tacrolimus. Two studies found that CYP3A5 expressers require higher doses of tacrolimus in the extended-release formulation compared to immediate release. CYP3A5 genotype plays a role in determining the impact of interacting drugs, such as fluconazole, on tacrolimus pharmacokinetics. Evidence conflicts regarding the impact of CYP3A5 genotype on risk of nephrotoxicity associated with tacrolimus. Further study is required.
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Affiliation(s)
- Lucy Chen
- Kidney Transplant Program, St Michael's Hospital, Toronto, ON, Canada
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Which Kidney Transplant Recipients Can Benefit from the Initial Tacrolimus Dose Reduction? BIOMED RESEARCH INTERNATIONAL 2018; 2018:4573452. [PMID: 29651435 PMCID: PMC5831822 DOI: 10.1155/2018/4573452] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 01/01/2018] [Indexed: 01/24/2023]
Abstract
Background Observational data suggest that the fixed initial recommended tacrolimus (Tc) dosing (0.2 mg/kg/day) results in supratherapeutic drug levels in some patients during the early posttransplant period. The aim of the study was to analyze a wide panel of patient-related factors and their interactions which increase the risk for first Tc blood level > 15 ng/ml. Materials and Methods We performed a retrospective analysis of 488 consecutive adult kidney transplant recipients who were initially treated with triple immunosuppressive regimen containing tacrolimus twice daily. The analysis included the first assessment of Tc trough blood levels and several demographic, anthropometric, laboratory, and comedication data. Results The multiple logistic regression analysis showed that age > 55 years, BMI > 24.6 kg/m2, blood hemoglobin concentration > 9.5 g/dl, and the presence of anti-HCV antibodies independently increased the risk for first Tc level > 15 ng/ml. The relative risk (RR) for first tacrolimus level > 15 ng/ml was 1.88 (95% CI 1.35–2.64, p < 0.001) for patients with one risk factor and 2.81 (2.02–3.89, p < 0.001) for patients with two risk factors. Conclusions Initial tacrolimus dose reduction should be considered in older, overweight, or obese kidney transplant recipients and in subjects with anti-HCV antibodies. Moreover, dose reduction of tacrolimus is especially important in patients with coexisting multiple risk factors.
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Hamandi B, Fegbeutel C, Silveira FP, Verschuuren EA, Younus M, Mo J, Yan J, Ussetti P, Chin-Hong PV, Solé A, Holmes-Liew CL, Billaud EM, Grossi PA, Manuel O, Levine DJ, Barbers RG, Hadjiliadis D, Aram J, Singer LG, Husain S. Voriconazole and squamous cell carcinoma after lung transplantation: A multicenter study. Am J Transplant 2018; 18:113-124. [PMID: 28898527 DOI: 10.1111/ajt.14500] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 08/04/2017] [Accepted: 08/30/2017] [Indexed: 01/25/2023]
Abstract
This study evaluated the independent contribution of voriconazole to the development of squamous cell carcinoma (SCC) in lung transplant recipients, by attempting to account for important confounding factors, particularly immunosuppression. This international, multicenter, retrospective, cohort study included adult patients who underwent lung transplantation during 2005-2008. Cox regression analysis was used to assess the effects of voriconazole and other azoles, analyzed as time-dependent variables, on the risk of developing biopsy-confirmed SCC. Nine hundred lung transplant recipients were included. Median follow-up time from transplantation to end of follow-up was 3.51 years. In a Cox regression model, exposure to voriconazole alone (adjusted hazard ratio 2.39, 95% confidence interval 1.31-4.37) and exposure to voriconazole and other azole(s) (adjusted hazard ratio 3.45, 95% confidence interval 1.07-11.06) were associated with SCC compared with those unexposed after controlling for important confounders including immunosuppressants. Exposure to voriconazole was associated with increased risk of SCC of the skin in lung transplant recipients. Residual confounding could not be ruled out because of the use of proxy variables to control for some confounders. Benefits of voriconazole use when prescribed to lung transplant recipients should be carefully weighed versus the potential risk of SCC. EU PAS registration number: EUPAS5269.
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Affiliation(s)
- B Hamandi
- Department of Pharmacy, University Health Network, Toronto, ON, Canada
| | - C Fegbeutel
- Department of Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - F P Silveira
- Division of Infectious Diseases, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - E A Verschuuren
- Department of Pulmonary Diseases, University Hospital Groningen, Groningen, the Netherlands
| | | | - J Mo
- Pfizer Inc., New York, NY, USA
| | - J Yan
- Pfizer Inc., New York, NY, USA
| | - P Ussetti
- Respiratory Department, Hospital Puerta de Hierro, Madrid, Spain
| | - P V Chin-Hong
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - A Solé
- Respiratory Department, University and Polytechnic Hospital La Fe, Universidad de Valencia, Valencia, Spain
| | - C L Holmes-Liew
- Lung Research, Hanson Institute, and Department of Thoracic Medicine, Royal Adelaide Hospital, Adelaide, Australia
| | - E M Billaud
- Service de Pharmacologie, AP-HP, Hôpital Européen G Pompidou, Paris, France
| | - P A Grossi
- Infectious Diseases Department, University of Insubria, Varese, Italy
| | - O Manuel
- Infectious Diseases Service and Transplantation Center, University Hospital of Lausanne, Lausanne, Switzerland
| | - D J Levine
- Division of Pulmonary and Critical Care Medicine, University of Texas Health Science Center San Antonio, San Antonio, TX, USA
| | - R G Barbers
- Division of Pulmonary and Critical Care, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - D Hadjiliadis
- Department of Medicine, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - J Aram
- Pfizer Inc., New York, NY, USA
| | - L G Singer
- Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada
| | - S Husain
- Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada
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91
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The combination of CYP3A4*22 and CYP3A5*3 single-nucleotide polymorphisms determines tacrolimus dose requirement after kidney transplantation. Pharmacogenet Genomics 2017; 27:313-322. [DOI: 10.1097/fpc.0000000000000296] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Goldsmith PM, Bottomley MJ, Okechukwu O, Ross VC, Ghita R, Wandless D, Falconer SJ, Papachristos S, Nash P, Androshchuk V, Clancy M. Impact of intrapatient variability (IPV) in tacrolimus trough levels on long-term renal transplant function: multicentre collaborative retrospective cohort study protocol. BMJ Open 2017; 7:e016144. [PMID: 28756385 PMCID: PMC5642769 DOI: 10.1136/bmjopen-2017-016144] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION High intrapatient variability (IPV) in tacrolimus trough levels has been shown to be associated with higher rates of renal transplant failure. There is no consensus on what level of IPV constitutes a risk of graft loss. The establishment of such a threshold could help to guide clinicians in identifying at-risk patients to receive targeted interventions to improve IPV and thus outcomes. METHODS AND ANALYSIS A multicentre Transplant Audit Collaborative has been established to conduct a retrospective study examining tacrolimus IPV and renal transplant outcomes. Patients in receipt of a renal transplant at participating centres between 2009 and 2014 and fulfilling the inclusion criteria will be included in the study. The aim is to recruit a minimum of 1600 patients with follow-up spanning at least 2 years in order to determine a threshold IPV above which a renal transplant recipient would be considered at increased risk of graft loss. The study also aims to determine any national or regional trends in IPV and any demographic associations. ETHICS AND DISSEMINATION Consent will not be sought from patients whose data are used in this study as no additional procedures or information will be required from participants beyond that which would normally take place as part of clinical care. The study will be registered locally in each participating centre in line with local research and development protocols. It is anticipated that the results of this audit will be disseminated locally, in participating NHS Trusts, through national and international meetings and publications in peer-reviewed journals.
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Affiliation(s)
- Petra M Goldsmith
- Renal Transplant Unit, Royal Liverpool University Hospitals NHS Trust, Liverpool, UK
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Matthew J Bottomley
- Department of Nephrology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Okidi Okechukwu
- Department of Transplantation, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Victoria C Ross
- Department of Transplantation, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Ryan Ghita
- Department of Transplantation, NHS Greater Glasgow and Clyde, Glasgow, UK
| | | | | | - Stavros Papachristos
- Department of Transplantation, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Philip Nash
- Department of Nephrology, King's College Hospital NHS Foundation Trust, London, UK
| | - Vitaliy Androshchuk
- Department of Nephrology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Marc Clancy
- Department of Transplantation, NHS Lothian, Edinburgh, UK
- School of Medicine, Dentistry and Surgery, University of Glasgow, Glasgow, UK
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93
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Tacrolimus Blood Level Fluctuation Predisposes to Coexisting BK Virus Nephropathy and Acute Allograft Rejection. Sci Rep 2017; 7:1986. [PMID: 28512328 PMCID: PMC5434044 DOI: 10.1038/s41598-017-02140-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 04/06/2017] [Indexed: 12/18/2022] Open
Abstract
BK virus nephropathy (BKVN) and allograft rejection are two distinct disease entities which occur at opposite ends of the immune spectrum. However, they coexist in renal transplant recipients. Predisposing factors for this coexistence remain elusive. We identified nine biopsy-proven BKVN patients with coexisting acute rejection, and 21 patients with BKVN alone. We retrospectively analyzed the dosage and blood concentrations of immunosuppressants during the 3-month period prior to the renal biopsy between the two patient groups. Compared to the BKVN alone group, renal function was noticeably worse in the coexistence group (p = 0.030). Regarding the dose and average drug level of immunosuppressants, there was no difference between the two groups. Interestingly, the coefficient of variance of tacrolimus trough blood level was noticeably higher during the 3-month period prior to the renal biopsy in the coexistence group (p = 0.010). Our novel findings suggest that a higher variability of tacrolimus trough level may be associated with the coexistence of BKVN and acute rejection. Since the prognosis is poor and the treatment is challenging in patients with coexisting BKVN and acute rejection, transplant clinicians should strive to avoid fluctuations in immunosuppressant drug levels in patients with either one of these two disease entities.
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Practical Recommendations for Long-term Management of Modifiable Risks in Kidney and Liver Transplant Recipients: A Guidance Report and Clinical Checklist by the Consensus on Managing Modifiable Risk in Transplantation (COMMIT) Group. Transplantation 2017; 101:S1-S56. [PMID: 28328734 DOI: 10.1097/tp.0000000000001651] [Citation(s) in RCA: 197] [Impact Index Per Article: 28.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Short-term patient and graft outcomes continue to improve after kidney and liver transplantation, with 1-year survival rates over 80%; however, improving longer-term outcomes remains a challenge. Improving the function of grafts and health of recipients would not only enhance quality and length of life, but would also reduce the need for retransplantation, and thus increase the number of organs available for transplant. The clinical transplant community needs to identify and manage those patient modifiable factors, to decrease the risk of graft failure, and improve longer-term outcomes.COMMIT was formed in 2015 and is composed of 20 leading kidney and liver transplant specialists from 9 countries across Europe. The group's remit is to provide expert guidance for the long-term management of kidney and liver transplant patients, with the aim of improving outcomes by minimizing modifiable risks associated with poor graft and patient survival posttransplant.The objective of this supplement is to provide specific, practical recommendations, through the discussion of current evidence and best practice, for the management of modifiable risks in those kidney and liver transplant patients who have survived the first postoperative year. In addition, the provision of a checklist increases the clinical utility and accessibility of these recommendations, by offering a systematic and efficient way to implement screening and monitoring of modifiable risks in the clinical setting.
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Béland MA, Lapointe I, Noël R, Côté I, Wagner E, Riopel J, Latulippe E, Désy O, Béland S, Magee CN, Houde I, De Serres SA. Higher calcineurin inhibitor levels predict better kidney graft survival in patients with de novo
donor-specific anti-HLA antibodies: a cohort study. Transpl Int 2017; 30:502-509. [DOI: 10.1111/tri.12934] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 01/23/2017] [Accepted: 01/31/2017] [Indexed: 01/10/2023]
Affiliation(s)
- Marc-Antoine Béland
- Transplantation Unit; Renal Division; Department of Medicine; Faculty of Medicine; University Health Center of Quebec; Laval University; Quebec QC Canada
| | - Isabelle Lapointe
- Transplantation Unit; Renal Division; Department of Medicine; Faculty of Medicine; University Health Center of Quebec; Laval University; Quebec QC Canada
| | - Réal Noël
- Transplantation Unit; Renal Division; Department of Medicine; Faculty of Medicine; University Health Center of Quebec; Laval University; Quebec QC Canada
| | - Isabelle Côté
- Transplantation Unit; Renal Division; Department of Medicine; Faculty of Medicine; University Health Center of Quebec; Laval University; Quebec QC Canada
| | - Eric Wagner
- Immunology and Histocompatibility Laboratory; Faculty of Medicine; University Health Center of Quebec; Laval University; Quebec QC Canada
| | - Julie Riopel
- Department of Pathology; Faculty of Medicine; University Health Center of Quebec; Laval University; Quebec QC Canada
| | - Eva Latulippe
- Department of Pathology; Faculty of Medicine; University Health Center of Quebec; Laval University; Quebec QC Canada
| | - Olivier Désy
- Transplantation Unit; Renal Division; Department of Medicine; Faculty of Medicine; University Health Center of Quebec; Laval University; Quebec QC Canada
| | - Stéphanie Béland
- Transplantation Unit; Renal Division; Department of Medicine; Faculty of Medicine; University Health Center of Quebec; Laval University; Quebec QC Canada
| | - Ciara N. Magee
- Department of Nephrology & Renal Transplantation; UCL Centre for Nephrology; Royal Free London NHS Foundation Trust; London UK
| | - Isabelle Houde
- Transplantation Unit; Renal Division; Department of Medicine; Faculty of Medicine; University Health Center of Quebec; Laval University; Quebec QC Canada
| | - Sacha A. De Serres
- Transplantation Unit; Renal Division; Department of Medicine; Faculty of Medicine; University Health Center of Quebec; Laval University; Quebec QC Canada
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Pensi D, De Nicolò A, Pinon M, Pisciotta C, Calvo PL, Nonnato A, Romagnoli R, Tandoi F, Di Perri G, D'Avolio A. First UHPLC-MS/MS method coupled with automated online SPE for quantification both of tacrolimus and everolimus in peripheral blood mononuclear cells and its application on samples from co-treated pediatric patients. JOURNAL OF MASS SPECTROMETRY : JMS 2017; 52:187-195. [PMID: 28098395 DOI: 10.1002/jms.3909] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 12/20/2016] [Accepted: 01/12/2017] [Indexed: 06/06/2023]
Abstract
Tacrolimus (TAC, FK-506) and everolimus (EVE, RAD001) are immunosuppressors used to treat pediatric patients undergoing liver transplantation. Their hematic TDM by liquid chromatography became standard practice. However, it does not always reflect concentrations at their active site. Our aim was to develop and validate a new method for the simultaneous TAC and EVE quantification into target cells: peripheral blood mononuclear cells (PBMCs). Peripheral blood mononuclear cells were collected using cell preparation tubes; cells number and mean cell volume were evaluated by an automatic cell counter. TAC and EVE were quantified using UHPLC-MS/MS coupled with an automated online solid-phase extraction platform. Chromatographic run was performed on an Acquity UPLC® BEH C18 1.7 μm (2.1 × 50 mm) column at 45 °C, for 6 min at 0.5 ml/min. Mobile phases were water and methanol, both with 2 mm ammonium acetate and 1 ml/l formic acid). XBridge® C8 10 μm (1 × 10 mm) SPE cartridges were used, and the internal standard was ascomycin. Following Food and Drug Administration guidelines, method validation resulted in high sensitivity and specificity. Calibration curves were linear (r2 = 0.998) and intra-day and inter-day imprecision and inaccuracy were <15%. A reproducible matrix effect was observed, with a good recovery for all compounds. Drug amounts in 15 'real' PBMCs samples from five pediatric patients in co-treatment resulted within the calibration range (0.039-5 ng). Concentrations from each patient were standardized using their evaluated mean cell volume: intra-PBMCs concentration was meanly 19.23 and 218.61 times higher than the hematic one for TAC and EVE, respectively. This method might be useful in clinical routine, giving reliable data on drugs concentration at the active site. Copyright © 2017 John Wiley & Sons, Ltd.
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Affiliation(s)
- Debora Pensi
- Unit of Infectious Diseases, Department of Medical Sciences, University of Turin, Amedeo di Savoia Hospital (Laboratory of Clinical Pharmacology and Pharmacogenetics#), Turin, Italy
| | | | - Michele Pinon
- Unit of Pediatric Gastroenterology and Hepatology, University of Turin, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Clarissa Pisciotta
- Unit of Infectious Diseases, Department of Medical Sciences, University of Turin, Amedeo di Savoia Hospital (Laboratory of Clinical Pharmacology and Pharmacogenetics#), Turin, Italy
| | - Pier Luigi Calvo
- Unit of Pediatric Gastroenterology and Hepatology, University of Turin, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Antonello Nonnato
- Clinical Biochemistry Unit, Department of Diagnostic Laboratory, A.O.U. Città della Salute e della Scienza Hospital, Turin, Italy
| | - Renato Romagnoli
- Liver Transplantation Center, General Surgery 2U, A.O.U. Cittàdella Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Francesco Tandoi
- Liver Transplantation Center, General Surgery 2U, A.O.U. Cittàdella Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Giovanni Di Perri
- Unit of Infectious Diseases, Department of Medical Sciences, University of Turin, Amedeo di Savoia Hospital (Laboratory of Clinical Pharmacology and Pharmacogenetics#), Turin, Italy
| | - Antonio D'Avolio
- Unit of Infectious Diseases, Department of Medical Sciences, University of Turin, Amedeo di Savoia Hospital (Laboratory of Clinical Pharmacology and Pharmacogenetics#), Turin, Italy
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Ericson JE, Zimmerman KO, Gonzalez D, Melloni C, Guptill JT, Hill KD, Wu H, Cohen-Wolkowiez M. A Systematic Literature Review Approach to Estimate the Therapeutic Index of Selected Immunosuppressant Drugs After Renal Transplantation. Ther Drug Monit 2017; 39:13-20. [PMID: 28081041 PMCID: PMC5235278 DOI: 10.1097/ftd.0000000000000364] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Drugs that exhibit close margins between therapeutic and toxic blood concentrations are considered to have a narrow therapeutic index (NTI). The Food and Drug Administration has proposed that NTI drugs should have more stringent bioequivalence standards for approval of generic formulations. However, many immunosuppressant drugs do not have a well-defined therapeutic index (TI). METHODS We sought to determine whether safety, efficacy, and pharmacokinetic data obtained from the medical literature through a comprehensive literature search could be used to estimate the TI of cyclosporine, tacrolimus, and sirolimus. In this analysis, we considered TI ≤2 as a criterion to define a drug as having an NTI. RESULTS Published literature indicates that cyclosporine has a TI of 2-3, which falls just short of our criteria to be classified as having an NTI. We found sirolimus and tacrolimus to have a therapeutic range of 5-12 ng/mL and of 5-20 ng/mL, respectively, but were unable to calculate the TI. CONCLUSIONS Although the current literature does not provide a clear indication that these drugs have an NTI, the routine use of therapeutic drug monitoring in clinical practice suggests that more stringent testing of their pharmacokinetic and pharmacodynamic properties should be performed before the approval of generic formulations.
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Affiliation(s)
- Jessica E. Ericson
- Departments of Pediatrics, Pennsylvania State University, Hershey, PA
- Duke Clinical Research Institute, Durham, NC
| | - Kanecia O. Zimmerman
- Duke Clinical Research Institute, Durham, NC
- Department of Pediatrics, Duke University, Durham, NC
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
| | | | | | - Kevin D. Hill
- Duke Clinical Research Institute, Durham, NC
- Department of Pediatrics, Duke University, Durham, NC
| | - Huali Wu
- Duke Clinical Research Institute, Durham, NC
| | - Michael Cohen-Wolkowiez
- Duke Clinical Research Institute, Durham, NC
- Department of Pediatrics, Duke University, Durham, NC
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Pretransplant Tacrolimus Dose Requirements Predict Early Posttransplant Dose Requirements in Blood Group AB0-Incompatible Kidney Transplant Recipients. Ther Drug Monit 2016; 38:217-22. [PMID: 26630539 DOI: 10.1097/ftd.0000000000000266] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND The aim of this study was to investigate whether pretransplant tacrolimus (Tac) dose requirements of patients scheduled to undergo living donor kidney transplantation correlate with posttransplantation dose requirements. METHODS The predictive value of Tac dose requirements (defined as the ratio of the Tac predose concentration, C0, divided by the total daily Tac dose, D) pretransplantation on this same parameter posttransplantation was assessed retrospectively in a cohort of 57 AB0-incompatible kidney transplant recipients. These patients started immunosuppressive therapy 14 days before transplant surgery. All patients were using a stable dose of glucocorticoids and were at steady-state Tac exposure before transplantation. RESULTS Tac dose requirements immediately before transplantation (C0/Dbefore) explained 63% of the Tac dose requirements on day 3 after transplantation: r = 0.633 [F (1, 44) = 75.97, P < 0.01]. No other clinical and demographic variables predicted Tac dose requirements early after transplantation. CONCLUSIONS Steady-state Tac dose requirement before transplantation largely predicted posttransplantation Tac dose requirements in AB0-incompatible kidney transplant recipients. The importance of this finding is that the posttransplantation Tac dose can be individualized based on a patient's pretransplantation Tac concentration/dose ratio. Pretransplant Tac phenotyping therefore has the potential to improve transplantation outcomes.
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Evaluation of the New Siemens Tacrolimus Assay on the Dimension EXL Integrated Chemistry System Analyzer: Comparison With an Ultra-Performance Liquid Chromatography–Tandem Mass Spectrometry Method. Ther Drug Monit 2016; 38:808-812. [DOI: 10.1097/ftd.0000000000000331] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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100
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Zimmerman KO, Wu H, Greenberg R, Hill K, Patel UD, Ku L, Gonzalez D, Hornik C, Jiang W, Zheng N, Melloni C, Cohen-Wolkowiez M. Therapeutic Drug Monitoring, Electronic Health Records, and Pharmacokinetic Modeling to Evaluate Sirolimus Drug Exposure-Response Relationships in Renal Transplant Patients. Ther Drug Monit 2016; 38:600-6. [PMID: 27259059 PMCID: PMC5025355 DOI: 10.1097/ftd.0000000000000313] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Sirolimus, an immunosuppressive agent used in renal transplantation, can prevent allograft rejection. Identification of the therapeutic index (the ratio of minimum toxic concentration to minimum therapeutic concentration) for immunosuppresants is necessary to optimize the care of patients and set standards for bioequivalence evaluation of sirolimus products. However, the therapeutic index for sirolimus has been inconsistently defined, potentially because of inconsistencies in sirolimus exposure-response relationships. METHODS The authors used retrospective therapeutic drug monitoring data from the electronic health records of patients treated in a tertiary health care system from 2008 to 2014 to (1) develop a population pharmacokinetic (PK) model, (2) use the model to simulate sirolimus concentrations, and (3) characterize the exposure-response relationship. Using Wilcoxon rank-sum and Fisher exact tests, the authors determined relationships between sirolimus exposure and adverse events (AEs) (anemia, leukopenia, thrombocytopenia, hyperlipidemia, and decline in renal function) and the composite efficacy end point of graft loss or rejection. RESULTS The developed 2-compartment population PK model showed appropriate goodness of fit. In a late-phase (>12 months), postrenal transplant population of 27 inpatients, the authors identified statistically significant relationships between 83 simulated peak and trough sirolimus concentrations and outcomes: graft loss or rejection (P = 0.018) and decline in renal function (P = 0.006), respectively. CONCLUSIONS Use of therapeutic drug monitoring results and PK modeling permitted correlation of sirolimus concentrations with graft loss or rejection and decline in renal function. However, the method was limited in its assessment of other AEs. To better evaluate sirolimus exposure-response relationships, the method should be applied to a larger sample of newly transplanted patients with a higher propensity toward AEs or efficacy failure.
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Affiliation(s)
- Kanecia O. Zimmerman
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Huali Wu
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Rachel Greenberg
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kevin Hill
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Uptal D. Patel
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Lawrence Ku
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Christoph Hornik
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Wenlei Jiang
- Office of Generic Drugs, US Food and Drug Administration, Silver Spring, MD, USA
| | - Nan Zheng
- Office of Generic Drugs, US Food and Drug Administration, Silver Spring, MD, USA
| | - Chiara Melloni
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Michael Cohen-Wolkowiez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
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