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Friend P, Russ G, Oberbauer R, Murgia MG, Tufveson G, Chapman J, Blancho G, Mota A, Grandaliano G, Campistol JM, Brault Y, Burke JT. Incidence of anemia in sirolimus-treated renal transplant recipients: the importance of preserving renal function. Transpl Int 2007; 20:754-60. [PMID: 17565578 DOI: 10.1111/j.1432-2277.2007.00506.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Sirolimus (SRL) has a concentration-related effect on hematopoiesis. In this study, 430 renal transplant recipients were randomized (1:1) 3 months post-transplantation to continue SRL-cyclosporine (CsA)-steroids (ST) or to have CsA withdrawn (SRL-ST). Over 5 years, on therapy calculated glomerular filtration rate (GFR), hematological indices, erythropoietin (EPO) use, and rates of mild, moderate, and severe anemia were determined. Longitudinal analyses using linear mixed models examined covariates predicting hemoglobin (Hgb) levels. Mean Hgb was significantly lower with SRL-ST at 6 months; but subsequently became significantly higher (at 2 years, 129 vs. 135 g/l, SRL-CsA-ST vs. SRL-ST, P<0.001). Mean corpuscular volume was low with both therapies, and significantly lower with SRL-ST. EPO use was similar in the two groups, approximately 30% during the first year and 10% thereafter. The incidence of anemia was significantly higher with SRL-CsA-ST>or=2 years. At year 5, only 39.1% of SRL-CsA-ST patients had normal Hgb vs. 68.5% of SRL-ST patients. GFR and recipient age as well as the interaction term x treatment time were significant covariates predicting Hgb. CsA withdrawal followed by SRL immunotherapy resulted in significantly less anemia than SRL-CsA-ST, despite twofold higher SRL exposure. This suggests that the improvement in GFR accompanying CsA withdrawal may mitigate the effect of SRL on hematopoiesis. (ClinicalTrials.gov number: NCT00428064).
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153
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Guerra G, Srinivas TR, Meier-Kriesche HU. Calcineurin inhibitor-free immunosuppression in kidney transplantation. Transpl Int 2007; 20:813-27. [PMID: 17645419 DOI: 10.1111/j.1432-2277.2007.00528.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The introduction of calcineurin inhibitors (CNI) revolutionized kidney transplantation (KTx). Exceptionally low acute rejection rates and excellent graft survival could be achieved with CNI-based (cyclosporine and tacrolimus) immunosuppressive protocols. However, despite short-term success, long-term graft attrition continues to be a significant problem, thus leaving clinicians looking for possible interventions. CNI nephrotoxicity is but one of numerous factors that may be contributing to long-term damage in transplant kidneys. Therefore, newer immunosuppressive agents such as mycophenolate mofetil and sirolimus (Rapa) have raised the possibility of withdrawing or avoiding CNIs altogether. Protocols exploring these options have gained greater attention over the last few years. Herein, we review studies addressing either CNI withdrawal or CNI avoidance strategies as well as discuss the risks versus benefits of these protocols. Given the accumulated experience to date, in our opinion, the use of CNIs as a part of immunosuppressive regimens remains the proven standard of care for renal transplant patients. The long-term safety and efficacy of CNI withdrawal and avoidance strategies need to be further validated in controlled clinical trials.
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Affiliation(s)
- Giselle Guerra
- Division of Nephrology, Hypertension and Transplantation, College of Medicine, University of Florida, Gainesville, FL 32610-0224, USA
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154
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Legendre C, Brault Y, Morales JM, Oberbauer R, Altieri P, Riad H, Mahony J, Messina M, Pussell B, Martínez JG, Lelong M, Burke JT, Neylan JF. Factors influencing glomerular filtration rate in renal transplantation after cyclosporine withdrawal using sirolimus-based therapy: a multivariate analysis of results at five years. Clin Transplant 2007; 21:330-6. [PMID: 17488381 DOI: 10.1111/j.1399-0012.2007.00645.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Changes in calculated glomerular filtration rate (GFR) from baseline to five yr were analyzed in relation to risk factors among renal transplant recipients. At three months after transplantation (baseline), 430 eligible patients receiving sirolimus (SRL), cyclosporine (CsA), and steroids (ST) were randomly assigned (1:1) to continue SRL-CsA-ST or have CsA withdrawn and SRL trough levels increased (SRL-ST group). For each risk factor, changes from baseline were compared within each treatment using a t-test and between treatments using ANCOVA. Univariate then multivariate robust linear regression analyses were also performed. In the SRL-ST group, changes from baseline were not significantly different for any risk factor. With the exception of cold ischemia time >24 h, GFR values declined significantly for all risk factors in SRL-CsA-ST patients. For all risk factors, except second transplant or cold ischemia time >24 h, renal function was significantly different between groups. By order of significance in the multivariate analysis, treatment (p < 0.001), donor age (p < 0.001), proteinuria (p < 0.001), and biopsy-confirmed rejection (p = 0.010) were significant predictors of GFR change from baseline. In conclusion, patients with risk factors for reduced renal function benefit from SRL maintenance therapy without CsA vs. those remaining on CsA.
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155
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Campbell MS, Rai J, Kozin E, Bloom RD, Markmann JF, Olthoff KM, Shaked A, Rajender Reddy K. Effects of sirolimus vs. calcineurin inhibitors on renal dysfunction after orthotopic liver transplantation. Clin Transplant 2007; 21:377-84. [PMID: 17488388 DOI: 10.1111/j.1399-0012.2006.00653.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Small uncontrolled series have suggested that sirolimus favorably impacts renal function after orthotopic liver transplantation (OLT). We sought to retrospectively compare renal dysfunction between cohorts exposed to sirolimus-based and calcineurin inhibitor-based immunosuppression. We retrospectively studied 79 patients converted to sirolimus-based immunosuppression and 100 control subjects continued on calcineurin inhibitor-based immunosuppression after OLT at our institution from 2000 to 2005. We collected clinical, demographic, and medication history. Renal dysfunction was defined as two or more wk of creatinine > or =2.0 mg/dL. Cohorts were compared using Kaplan-Meier survival analysis and Cox proportional hazards modeling. Patients began sirolimus a median 83 d post-OLT and were followed on the medication for median 359 d. Patients in both the sirolimus and calcineurin inhibitor cohorts had median creatinine 1.2 mg/dL at study entry. Sirolimus-based immunosuppression was associated with a 1.8 (0.8-4.3, p = 0.17) hazards ratio for renal dysfunction. Adjusting for presence of hepatocellular carcinoma, combined kidney/liver transplantation, and age, the hazards ratio was 2.0 (0.8-4.8, p = 0.13). These point estimates were not substantially altered after subgroup analysis of sirolimus as the lone immunosuppressant, duration of exposure, and time between OLT and sirolimus conversion. In conclusion, our retrospective, controlled study showed that conversion to sirolimus after OLT did not protect against renal dysfunction. The effect of sirolimus on renal function will need to be prospectively evaluated in a prospective, randomized trial.
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Affiliation(s)
- Mical S Campbell
- Division of Gastroenterology, Penn Liver Transplant Center, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA
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156
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Wali RK, Mohanlal V, Ramos E, Blahut S, Drachenberg C, Papadimitriou J, Dinits M, Joshi A, Philosophe B, Foster C, Cangro C, Nogueira J, Cooper M, Bartlett ST, Weir MR. Early withdrawal of calcineurin inhibitors and rescue immunosuppression with sirolimus-based therapy in renal transplant recipients with moderate to severe renal dysfunction. Am J Transplant 2007; 7:1572-83. [PMID: 17511682 DOI: 10.1111/j.1600-6143.2007.01825.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Mammalian Target-of-Rapamycin inhibitors (mTOR inhibitors) can be used to replace the calcineurin inhibitors (CNIs) to prevent progression in chronic kidney disease (CKD) following organ transplantation. Discontinuation of tacrolimus in 136 recipients of kidney transplants with progressive renal dysfunction significantly decreased the rate of loss of estimated glomerular filtration rate (eGFR, mL/min/1.73 m(2)) (pre-intervention vs. post-intervention slopes, -0.013 vs. -0.002, p < 0.0001). Discontinuation of tacrolimus was associated with a sustained and significant improvement in graft function (pre-eGFR vs. post-eGFR; 26.0 +/- 1.1 vs. 47.4 +/- 2.1, p < 0.0001) in 74% of patients. This intervention was ineffective if the mean and (median) values of creatinine (mg/dL) and eGFR were 3.8 +/- 0.2 (3.4) and 18.4 +/- 1.9 (22.4), respectively, at the time of conversion therapy. During the follow-up (range, 1.5-34.6, months), a total of 13 patients had their first acute rejection following the conversion therapy, an annual incidence of less than 10% and none of these episodes resulted in graft loss. The salutary effects of sirolimus therapy following discontinuation of tacrolimus in patients with moderate to severe graft dysfunction due to allograft nephropathy even in high-risk patients improves kidney function and prevents acute rejection.
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Affiliation(s)
- R K Wali
- Division of Nephrology, Department of Medicine, Unniversity of Maryland School of Medicine, Baltimore, MD, USA.
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157
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Cibrik D, Meier-Kriesche HU, Bresnahan B, Wu YM, Klintmalm G, Kew CE, Kuo PC, Whelchel J, Cohen D, Baliga P, Akalin E, Benedetti E, Wright F, Lieberman B, Ulbricht B, Jensik S. Renal function with cyclosporine C2 monitoring, enteric-coated mycophenolate sodium and basiliximab: a 12-month randomized trial in renal transplant recipients. Clin Transplant 2007; 21:192-201. [PMID: 17425744 DOI: 10.1111/j.1399-0012.2006.00622.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Cyclosporine exposure, as estimated by the area under the curve (AUC), predicts outcomes in renal transplantation. Cyclosporine concentration at two h post-dose (C(2)) has been shown to be the most reliable, single-point surrogate marker for AUC. The objective of this study was to measure renal function beyond month 2 post-transplant using two different C(2) maintenance targets in combination with enteric-coated mycophenolate sodium (EC-MPS), corticosteroids, and basiliximab induction. METHODS In this open-label, multicenter trial, renal transplant recipients entered one of two randomized groups at day 61 post-transplant: group A (higher-C(2) range) or group B (lower-C(2) range). RESULTS Patients (164) were recruited, and 141 patients were entered the randomized groups (group A, n = 66; group B, n = 75). At 12 months, the mean calculated creatinine clearance was significantly greater in group B than in group A (79.2 vs. 71.0 mL/min, p < 0.05). Biopsy-proven acute rejection occurred in 14.7% patients in group B and in 24.2% patients in group A (n.s.). During the 12-month trial, 17.7% patients discontinued EC-MPS because of adverse events. Group B (44.0%) had fewer serious adverse events when compared with group A (62.1%; p = 0.04). Overall patient and graft survival were 99.4% and 95.7% respectively. Among 99 high-risk patients (i.e., African-American race, previous transplant, PRA >35% or >4 HLA mismatches), mean creatinine clearance at 12 months was 65.6 mL/min and biopsy-proven rejection occurred in 20.2% patients. CONCLUSIONS Low cyclosporine C(2) levels are associated with improved renal function compared with higher C(2) levels when used in conjunction with EC-MPS, steroids and basiliximab induction. EC-MPS with low cyclosporine C(2) levels, corticosteroids and basiliximab provides excellent renal function with good efficacy even in high-risk patients.
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Affiliation(s)
- Diane Cibrik
- Department of Internal Medicine, Division of Nephrology, University of Michigan, Ann Arbor, MI 48109, USA.
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158
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Abstract
Sirolimus is a mammalian target of rapamycin (mTOR) inhibitor that inhibits cell cycle progression and has proven to be a potent immunosuppressive agent for use in solid organ transplant recipients. The drug was initially studied as an adjunct to ciclosporin (cyclosporine) to prevent acute rejection in kidney transplant recipients. Subsequent studies have shown efficacy when combined with a variety of other immunosuppressive agents. The most common adverse effects of sirolimus are hyperlipidaemia and myelosuppression. The drug has unique antiatherogenic and antineoplastic properties, and may promote immunological tolerance and reduce the incidence of chronic allograft nephropathy. Although sirolimus is relatively non-nephrotoxic when administered as monotherapy, it pharmacodynamically enhances the toxicity of calcineurin inhibitors. Ironically, the drug has been used to facilitate calcineurin inhibitor-free protocols designed to preserve renal function after solid organ transplantation. Whether sirolimus can be used safely over the long term with low doses of calcineurin inhibitors requires further study. The use of sirolimus as a corticosteroid-sparing agent also remains to be proven in controlled trials. Postmarketing studies have revealed a number of unforeseen adverse effects including impaired wound healing and possibly proteinuria, oedema, pneumonitis and thrombotic microangiopathy. Overall, sirolimus is a powerful agent when used judiciously with other available immunosuppressants. As is true for all immunosuppressive drugs available for treatment of solid organ transplant recipients, the efficacy of the drug must be balanced against its considerable adverse effects.
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Affiliation(s)
- Joshua J Augustine
- The Department of Medicine and the Transplantation Service, Case Western Reserve University, and University Hospitals of Cleveland, Cleveland, Ohio, USA
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159
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Abstract
As survival increases after liver transplantation, common issues that arise involve immunosuppression-related complications and primary health care. Proper emphasis on the prevention and treatment of post-liver transplant complications, such as diabetes mellitus, dyslipidemia, renal dysfunction, osteoporosis, and obesity, requires careful screening and long-term surveillance to minimize the progression of these complications. Active involvement by internists and subspecialists is necessary and a multidisciplinary approach should be undertaken. Liver transplantation should be viewed as a lifelong commitment by both patient and physician.
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Affiliation(s)
- Lawrence U Liu
- Division of Liver Diseases, Department of Medicine, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1104, New York, NY 10029, USA.
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160
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Scherer MN, Banas B, Mantouvalou K, Schnitzbauer A, Obed A, Krämer BK, Schlitt HJ. Current concepts and perspectives of immunosuppression in organ transplantation. Langenbecks Arch Surg 2007; 392:511-23. [PMID: 17450373 DOI: 10.1007/s00423-007-0188-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2007] [Accepted: 02/26/2007] [Indexed: 01/27/2023]
Abstract
BACKGROUND While early surgical success made organ transplantation possible in the 1950s and 1960s, the breakthrough in clinical organ transplantation was achieved through the discovery and invention of modern immunosuppressive agents in the early/mid-1980s. Especially during the 1990 s, a large array of immunosuppressants has expanded the armamentarium used to prevent and treat allograft rejection, resulting in an excellent short-term and an acceptable long-term outcome. However, these drugs have potent but still non-specific immunosuppressive properties and frequently show severe acute and chronic side effects, sometimes questioning the overall success. CONCEPTS/TRENDS As the "Holy-Grail" of the transplant community, the induction of "true donor-specific tolerance" has not been achieved yet; current immunosuppressive strategies, in particular in Europe, include "individually tailored immunosuppressive" protocols, mostly based on specific immunologic and non-immunologic risk factors. These protocols allow for optimal immunosuppressive protocols for each patient group according to their needs by choosing the most suitable, well-tolerated combination of agents and the most effective doses to avoid acute rejection episodes (incidence and severity) and minimise drug-related toxicity to reduce long-term drug-related morbidity and mortality. Nevertheless, transplant recipient are still being forced to take a life-long course of chemical immunosuppressive agents to keep their graft, knowing about the possible life-threatening side effects. SUMMARY We review current trends of immunosuppressive protocols in liver and kidney transplantation, focusing on calcineurin-inhibitor-sparing protocols, mammalian-target-of-rapamycin (mTOR) inhibitor based-protocols and corticosteroid-avoidance protocols, being aware of the fact, that most of these strategies could be applicable for other transplanted organs, too. Finally, we describe future trends and new developments that are rising on the horizon.
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Affiliation(s)
- Marcus N Scherer
- Klinik und Poliklinik für Chirurgie und Transplantation, Klinikum der Universität Regensburg, Franz-Josef-Strauss-Allee 11, 93042, Regensburg, Germany
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161
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Copeland JWGV, Beaumont BW, Merrilees MJ, Pilmore HL. Epithelial-to-Mesenchymal Transition of Human Proximal Tubular Epithelial Cells: Effects of Rapamycin, Mycophenolate, Cyclosporin, Azathioprine, and Methylprednisolone. Transplantation 2007; 83:809-14. [PMID: 17414716 DOI: 10.1097/01.tp.0000255680.71816.aa] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Epithelial-to-mesenchymal transition (EMT) of renal proximal tubular epithelial cells (PTEC) into myofibroblasts is an important step in the pathogenesis of chronic allograft nephropathy. The effects of commonly used immunosuppressives in renal transplantation on EMT are not known. PTEC were cultured in transforming growth factor-beta to induce EMT. The effects of the immunosuppressives on cell morphology and alpha-smooth muscle actin were studied by phase contrast microscopy, immunocytochemistry, and western blotting. The effects on versican were studied by [S] labeling and polyacrylamide gel electrophoresis. Rapamycin and mycophenolate mofetil (MMF) prevented EMT and moreover returned myofibroblasts to PTEC morphology. These immunosuppressives also reduced versican production by both PTEC and myofibroblasts. Cyclosporine A, azathioprine, and methylprednisolone were less effective than rapamycin and MMF. Moreover, these immunosuppressives did not decrease versican. Rapamycin and MMF have a greater inhibitory effect on EMT in vitro than older immunosuppressives and may result in less fibrosis and a better long-term allograft survival.
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162
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Crutchlow MF, Bloom RD. Transplant-associated hyperglycemia: a new look at an old problem. Clin J Am Soc Nephrol 2007; 2:343-55. [PMID: 17699434 DOI: 10.2215/cjn.03671106] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
New-onset diabetes has long been recognized as a common complication of kidney transplantation, promoting cardiovascular disease, death, and graft failure. Studies in recent years have begun to highlight the very high posttransplantation prevalence of the prediabetic states of impaired fasting glucose and impaired glucose tolerance and the significant repercussions of these states on cardiovascular health. Therefore, the overall burden of transplant-associated hyperglycemia (TAH), which encompasses new-onset diabetes and the prediabetic states, is far greater than previously appreciated. The kidney transplant population is predisposed to insulin resistance and to additional insults of hypertension and hyperlipidemia that, together with hyperglycemia, compose the metabolic syndrome and promote atherosclerosis. When recipients with an underlying, frequently nonmodifiable predisposition to glucose dysregulation encounter transplant-specific, often modifiable, diabetogenic exposures, TAH manifests. Aggressive screening will effectively detect TAH, whereas risk factor modification, lifestyle intervention, and, when appropriate, drug therapy may decrease its impact. Topics of future investigation should include the use of emerging diabetes therapies and avenues for the prevention and reversal of TAH.
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Affiliation(s)
- Michael F Crutchlow
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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163
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Abstract
Sirolimus is a potent immunosuppressant drug with a novel mechanism of action. It inhibits the mammalian target of rapamycin (mTOR) and blocks the cell cycle of various cell types, including T- and B-lymphocytes. Sirolimus is widely used as a maintenance immunosuppressive agent in organ transplantation. Also, a potentially benefit of this valuable drug in some immunologic and malignant diseases is currently under scrutiny.Classical side effects: hematological (anaemia, leucopenia, thrombocytopenia), hypercholesterolemia, arthralgias, extremity oedema and impaired wound healing have been frequently associated with the use of sirolimus. Additionally with its increased use, transplant professionals are encountering a variety of previously unreported and potentially more severe side effects.Here, we review the most recent data on sirolimus unexpected side effects (with an emphasis on pulmonary and renal toxicity), its use in renal transplantation and its new potential therapeutic indications (chronic glomerulopathies, polycystic kidney disease, different types of cancer). A brief description of the current knowledge of sirolimus therapeutic drug monitoring, methods of analysis, pharmacokinetics and drug interactions with calcineurin inhibitors is also included.
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Affiliation(s)
- Irina Buhaescu
- Dialysis and Renal Transplantation Center, Parhon University Hospital, Iasi, Romania.
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164
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Mulay AV, Cockfield S, Stryker R, Fergusson D, Knoll GA. Conversion from calcineurin inhibitors to sirolimus for chronic renal allograft dysfunction: a systematic review of the evidence. Transplantation 2007; 82:1153-62. [PMID: 17102766 DOI: 10.1097/01.tp.0000237101.58974.43] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Conversion from a calcineurin inhibitor to sirolimus has been used as a strategy to improve deteriorating renal allograft function but the efficacy and safety of this intervention is unknown. METHODS We performed a systematic review of studies that involved conversion from a calcineurin inhibitor to sirolimus in kidney transplantation. The search yielded five randomized trials (n=1,040 patients) and 25 nonrandomized studies (n=977 patients). RESULTS In the randomized trials, conversion to sirolimus improved short-term creatinine clearance (weighted mean difference 6.4 mL/min; 95% CI 1.9 to 11.0) compared to controls. In the nonrandomized studies, renal function improved or stabilized in 66% (95% CI 61% to 72%), creatinine clearance improved (weighted mean change 5.7 mL/min; 95% CI 1.4 to 10.1), cholesterol increased (weighted mean change 20.8 mg/dL; 95% CI 11.2 to 30.4) and triglycerides increased (weighted mean change 40.1 mg/dL; 95% CI 18.6 to 61.7). Sirolimus was discontinued by 28% of patients (95% CI 0 to 59%) in the randomized trials and 17% (95% CI 12 to 22%) in the nonrandomized trials. CONCLUSION Conversion to sirolimus is associated with an improvement in short-term renal function. However, given the discontinuation rate and potential side effects, adequately powered randomized trials with longer follow-up of hard outcomes are needed to determine whether this strategy leads to a lasting benefit in the clinical care of transplant recipients.
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Affiliation(s)
- Atul V Mulay
- Division of Nephrology, Kidney Research Center, Ottawa Health Research Institute, Ottawa, Ontario, Canada
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165
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Gordois A, Nobes M, Toohey M, Russ G. Cost-effectiveness of sirolimus therapy with early cyclosporin withdrawal vs. long-term cyclosporin therapy in Australia. Clin Transplant 2007; 20:526-36. [PMID: 16842533 DOI: 10.1111/j.1399-0012.2006.00518.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Cyclosporin (CsA) is Australia's most widely used immunosuppressant following renal transplantation. Randomized clinical trials demonstrate that sirolimus use for immunosuppression is associated with significantly lower incidence rates of nephrotoxicity and chronic graft rejection, and lower serum creatinine levels, suggesting long-term benefits if used as a replacement therapy for CsA. The cost-effectiveness of replacing CsA with sirolimus after 2-4 months (as approved by Australian regulatory authorities) was assessed relative to continued CsA plus low-dose sirolimus. A Markov model simulated outcomes over a patient's lifetime from initial transplant. Costs, measured in Australian dollars from the perspective of the Australian healthcare system, included immunosuppressants, dialysis, and inpatient and outpatient treatment. In a cohort with a mean age of 45 yr, the mean lifetime cost per patient is $39,052 greater with the study therapy. However, an average of 272 chronic graft rejections and 91 regrafts are prevented per 1000 patients. The mean predicted survival benefit is 2.086 life-years, or 0.938 quality-adjusted life-years (QALYs) when utility weights and discounting are incorporated. The incremental cost per QALY gained with the study therapy was $41,613. Cost-effectiveness was most sensitive to model duration and dialysis cost. Sirolimus is a cost-effective alternative to CsA for the long-term treatment of patients undergoing renal transplantation.
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166
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Taler SJ. Transplant Hypertension. Hypertension 2007. [DOI: 10.1016/b978-1-4160-3053-9.50036-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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167
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Mathis AS, Jin S, Friedman GS, Peng F, Carl SM, Knipp GT. The Pharmacodynamic Effects of Sirolimus andSirolimus-Calcineurin Inhibitor Combinations on Macrophage Scavenger and Nuclear Hormone Receptors. J Pharm Sci 2007; 96:209-22. [PMID: 17016853 DOI: 10.1002/jps.20751] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Sirolimus (SIR) alone or in combination with cyclosporine (CsA) or tacrolimus (TAC) are used in solid organ transplantation, but uncertainty remains regarding their respective atherogenic potentials. METHODS THP-1 cells were cultured as macrophages and then treated with plasma trough and peak concentration doses of SIR, SIR/CsA or SIR/TAC to assess the time- and dose-dependent mRNA or protein expression of selected atherogenic genes. The selected atherogenic genes included: the macrophage scavenger receptors (MSRs) CD36, CD68, scavenger receptor (SR)-A, SR-BII, and LOX-1; the nuclear hormone receptors peroxisome proliferator activated receptor gamma (PPARgamma) and liver-X-receptor alpha (LXRalpha); and the cholesterol efflux transporter (ABCA-1). RESULTS SIR-mediated changes in mRNA included the upregulation of ABCA1, downregulation of CD68, SR-A and SR-BII, and concentration- and/or time-dependent effects on CD36, LOX-1, PPARgamma, and LXRalpha that did not translate into significant protein changes. With SIR/CsA, the protein expressions of PPARgamma and ABCA-1 were downregulated at 8 h. In contrast, with SIR/TAC, PPARgamma, and ABCA-1 protein expressions were upregulated at 8 h. CONCLUSIONS Combination results differed from findings with SIR alone, supporting the observed clinical phenotype with calcineurin inhibitors. These findings may provide a rationale for the development of novel drug delivery strategies to mitigate adverse pharmacodynamic responses.
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Affiliation(s)
- A Scott Mathis
- Department of Pharmacy, Saint Barnabas Medical Center, 94 Old Short Hills Road, Livingston, New Jersey 07039, USA
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168
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Rodrigo E, Fernández-Fresnedo G, Castañeda O, Arias M. Estimation of renal function in adult kidney transplant recipients by equations. Transplant Rev (Orlando) 2007. [DOI: 10.1016/j.trre.2007.01.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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169
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Martinez-Mier G, Mendez-Lopez MT, Budar-Fernandez LF, Estrada-Oros J, Franco-Abaroa R, George-Micelli E, Rios-Martinez L, Mendez-Machado GF. Living Related Kidney Transplantation Without Calcineurin Inhibitors: Initial Experience in a Mexican Center. Transplantation 2006; 82:1533-6. [PMID: 17164728 DOI: 10.1097/01.tp.0000235823.09788.f6] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We performed a prospective randomized trial comparing sirolimus/mycophenolate mofetil (MMF)/prednisone to cyclosporine/MMF/prednisone and selected induction therapy with basiliximab. Twenty patients received sirolimus (10 mg loading dose followed by 3 mg/m body surface area/day, keeping 24-hr trough levels at 10-15 ng/mL for six months and 5-10 ng/mL thereafter. Twenty-one patients began cyclosporine (4 to 8 mg/kg/day, keeping 12-hour trough levels at 150-300 ng/mL for 6 months and 100-200 ng/mL afterwards). Mean follow up was 15.8 months. One-year patient and graft survival was similar in both groups (>90%). Acute rejection rate was 16.6% in the sirolimus group and 5.2% in the cyclosporine group (P=NS). There were no differences in mean serum creatinine between groups. No patients who received basiliximab and had sirolimus target levels suffered acute rejection at one year. The sirolimus group had significantly higher cholesterol and triglycerides. A calcineurin inhibitor-free regimen using sirolimus produces comparable one-year transplant outcomes in living related kidney transplants compared to a calcineurin inhibitor regimen.
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Affiliation(s)
- Gustavo Martinez-Mier
- Department of Organ Transplantation, IMSS Adolfo Ruiz Cortines National Medical Center, Veracruz, Mexico.
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170
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Samaniego M, Becker BN, Djamali A. Drug Insight: maintenance immunosuppression in kidney transplant recipients. ACTA ACUST UNITED AC 2006; 2:688-99. [PMID: 17124526 DOI: 10.1038/ncpneph0343] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2006] [Accepted: 09/11/2006] [Indexed: 12/31/2022]
Abstract
Kidney transplantation is the treatment of choice for patients with end-stage renal disease, in part because of ongoing efforts towards improving immunosuppressive strategies. Although calcineurin inhibitors remain the mainstay of immunosuppression in kidney transplant recipients, within this class of drug there has been a shift from use of ciclosporin to use of tacrolimus. Mycophenolate mofetil and mycophenolate sodium are now the antimetabolites of choice. A new class of drugs (inhibitors of mammalian target of rapamycin) that includes sirolimus is being increasingly used in stable kidney transplant recipients. New data, however, indicate that a more cautious approach to the use of this drug is warranted. Many transplant centers are now using steroid avoidance, minimization and withdrawal protocols. The impact of these different drugs and therapeutic strategies on outcomes has to be weighed against their immunosuppressive benefit. As more and more community-based nephrologists and primary care physicians are becoming involved in the care of stable kidney transplant recipients, it is important for these clinicians to familiarize themselves with novel immunosuppressive drugs and their pharmacokinetic properties.
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Affiliation(s)
- Millie Samaniego
- Nephrology Section, Department of Medicine, University of Wisconsin Madison, 3034 Fish Hatchery Road, Suite B, Madison, WI 53713, USA
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171
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Abstract
It is important to determine when to use and when to avoid calcineurin inhibitors (CNIs). CNIs are associated with kidney dysfunction in some, but not all, transplant recipients. CNI-sparing protocols have their own drug-specific limitations. Two major clinical series suggest the benefit of routine CNI-sparing approaches, but our review suggests weaknesses in both. Ongoing studies are needed to determine which subgroups of recipients will benefit from CNIs.
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Affiliation(s)
- A J Matas
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA.
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172
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173
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Hazzan M, Buob D, Labalette M, Provot F, Glowacki F, Hoffmann M, Copin MC, Noel C. Assessment of the risk of chronic allograft dysfunction after renal transplantation in a randomized cyclosporine withdrawal trial. Transplantation 2006; 82:657-62. [PMID: 16969289 DOI: 10.1097/01.tp.0000229424.11872.a0] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND We report the two-year follow-up of a trial comparing the three-month postgraft discontinuation of either cyclosporine (CsA) or mycophenolate mofetil (MMF) from a triple-drug regimen after de novo renal transplantation. METHODS One hundred and eight patients were enrolled in this study and randomized to be withdrawn from CsA (MMF group, n=54) or MMF (CsA group, n=54). RESULTS Despite an increased risk of acute rejection and a lower, but nonsignificant, two-year graft survival, CsA withdrawal induced a sustained improvement of the renal function. At one year, the chronic allograft damage index was similar in both the MMF and CsA groups. However, CsA elimination resulted in a higher incidence of C4d deposits, irrespective of the occurrence of a prior acute rejection. While this finding could suggest a risk of chronic rejection in the MMF group, the outcome did not appear to be related to the C4d status. Moreover, logistic regression analysis showed that only two factors, acute rejection and the one-year glomerular filtration rate level, were predictive of a significant decline of the renal function at two years. CONCLUSIONS These results point out the need to secure the minimization of the calcineurin inhibitors after renal transplantation, in order to reduce the risk of acute rejection in these patients, because this strategy allows the improvement of the one-year renal function which is predictive of a chronic allograft dysfunction.
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Affiliation(s)
- Marc Hazzan
- Nephrology Department, Regional Hospital of Lille, France.
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174
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Yang H. Maintenance immunosuppression regimens: conversion, minimization, withdrawal, and avoidance. Am J Kidney Dis 2006; 47:S37-51. [PMID: 16567240 DOI: 10.1053/j.ajkd.2005.12.045] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2005] [Accepted: 12/18/2005] [Indexed: 02/08/2023]
Abstract
A wide choice of drug combinations is available to clinicians for immunosuppression regimens for their kidney transplant patients. Although many protocols have minimized early graft loss, the optimal long-term regimen is unknown. Recent studies clearly showed that cardiovascular death is now the leading cause of graft loss. Strategies must be developed that address this risk while keeping immunologic events low. Transplant physicians have focused on exploring regimens that minimize or avoid the use of corticosteroids. Studies also have started to explore protocols that minimize calcineurin inhibitor therapy.
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Affiliation(s)
- Harold Yang
- Transplantation Services, PinnacleHealth System, Harrisburg, PA 17105-8700, USA.
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175
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Gaston RS. Current and evolving immunosuppressive regimens in kidney transplantation. Am J Kidney Dis 2006; 47:S3-21. [PMID: 16567239 DOI: 10.1053/j.ajkd.2005.12.047] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2005] [Accepted: 12/14/2005] [Indexed: 02/06/2023]
Abstract
The advent of novel immunosuppressive agents with increased potency now offers multiple treatment options for transplant physicians. However, variable efficacy, drug-drug interactions, and adverse effects associated with long-term immunosuppression continue to complicate the clinical management of kidney transplant recipients. Currently, investigators are challenged to develop regimens that take into account not only efficacy, but also dosing, monitoring, safety, and patient quality of life. Recent research has focused on evaluating new combinations of approved agents that seek to improve outcomes by improving control of immunologic events with fewer complications. This article reviews current practice and recent studies to give all health care providers who manage kidney transplant recipients a better understanding of current regimens and general trends in immunosuppressive therapy.
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Affiliation(s)
- Robert S Gaston
- Division of Nephrology, University of Alabama, School of Medicine, Birmingham, AL, USA.
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176
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Martínez-Mier G, Méndez-López MT, Estrada-Oros J, Budar-Fernandez LF, Soto-González JI, Méndez-Machado GF, Viñas Dozal JC. Conversion from calcineurin inhibitor to sirolimus for renal function deterioration in kidney allograft recipients. Arch Med Res 2006; 37:635-8. [PMID: 16740435 DOI: 10.1016/j.arcmed.2005.12.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2005] [Accepted: 12/15/2005] [Indexed: 12/13/2022]
Abstract
BACKGROUND Calcineurin inhibitors play an important role in chronic allograft dysfunction. Sirolimus is an interesting alternative in renal transplant patients because it is less nephrotoxic than calcineurin inhibitors. METHODS A chart review of the clinical outcome of kidney transplant patients converted to sirolimus with progressive allograft dysfunction is reported herein. Fifteen patients (average age: 32.3 years, 44 months mean time of conversion) were included. Indication for conversion was a >20% increase in serum creatinine over the last 6 months or progression to the range of 2-4.5 mg/dL. Patients underwent abrupt cessation of cyclosporine and sirolimus addition at 2-5 mg/day. RESULTS Concomitant immunosuppression remained unchanged during conversion. Targeted sirolimus level was 8-12 ng/mL. Serum creatinine dropped from pre-conversion level of 2.75 +/- 0.83 to 2.14 +/- 0.67 and 1.97 +/- 0.66 mg/dL at 3 and 6 months (p <0.05). There was a significant decrease in blood urea nitrogen, hemoglobin and serum calcium at 3 months post-conversion as well as serum calcium and potassium at 6 months post-conversion (p <0.05). There were no rejection episodes. Patient and graft survival was 100% with three infectious complications. CONCLUSIONS Monitored sirolimus conversion with sharp withdrawal of calcineurin inhibitor is an alternative for patients with deteriorating renal function and chronic allograft nephropathy.
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Affiliation(s)
- Gustavo Martínez-Mier
- Department of Organ Transplantation, School of Medicine, Universidad Cristobal Colon, Veracruz, Mexico.
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177
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Mathew TH, Van Buren C, Kahan BD, Butt K, Hariharan S, Zimmerman JJ. A comparative study of sirolimus tablet versus oral solution for prophylaxis of acute renal allograft rejection. J Clin Pharmacol 2006; 46:76-87. [PMID: 16397287 DOI: 10.1177/0091270005282628] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
This multicenter, open-label study compared the efficacy, safety, and pharmacokinetic parameters of sirolimus (rapamycin) tablet and liquid formulations for prevention of efficacy failure. A total of 477 renal allograft recipients were randomly assigned (1:1) to receive either tablet or solution formulations of sirolimus for 12 months, plus cyclosporine (CsA) and steroids. Pharmacokinetic parameters were analyzed based on trough concentrations and 24-hour pharmacokinetic profiles. There were no significant differences in efficacy failure at 3 or 12 months between tablet and solution groups. Graft survival, patient survival, rate of first biopsy-confirmed acute rejection, time to and severity of acute rejection, and laboratory parameters were not significantly different between groups. Mean steady-state sirolimus and CsA pharmacokinetic parameters on days 30 and 90 were not significantly different by formulation, except for longer sirolimus t(max) after tablet administration. Multivariate logistic regression analysis indicated that low sirolimus C(min,TN) and more human leukocyte antigen mismatches were predictors of acute rejection. The tablet and solution formulations of sirolimus demonstrated therapeutic equivalence.
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Affiliation(s)
- Timothy H Mathew
- Clinical Pharmacology Department, A3042, Wyeth Research, 500 Arcola Road, Collegeville, PA 19426, USA
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178
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Campistol JM, Eris J, Oberbauer R, Friend P, Hutchison B, Morales JM, Claesson K, Stallone G, Russ G, Rostaing L, Kreis H, Burke JT, Brault Y, Scarola JA, Neylan JF. Sirolimus therapy after early cyclosporine withdrawal reduces the risk for cancer in adult renal transplantation. J Am Soc Nephrol 2006; 17:581-9. [PMID: 16434506 DOI: 10.1681/asn.2005090993] [Citation(s) in RCA: 399] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Sirolimus (SRL) is a mammalian target of rapamycin inhibitor that, in contrast to cyclosporine (CsA), has been shown to inhibit rather than promote cancers in experimental models. At 3 mo +/- 2 wk after renal transplantation, 430 of 525 enrolled patients were randomly assigned to remain on SRL-CsA-steroids (ST) or to have CsA withdrawn and SRL troughs increased two-fold (SRL-ST). Median times to first skin and nonskin malignancies were compared between treatments using a survival analysis. Mean annualized rates of skin malignancy were calculated, and the relative risk was determined using a Poisson model. Malignancy-free survival rates for nonskin malignancies were compared using Kaplan-Meier estimates and the log-rank test. At 5 yr, the median time to a first skin carcinoma was delayed (491 versus 1126 d; log-rank test, P = 0.007), and the risk for an event was significantly lower with SRL-ST therapy (relative risk SRL-ST to SRL-CsA-ST 0.346; 95% confidence interval 0.227 to 0.526; P < 0.001, intention-to-treat analysis). The relative risks for both basal and squamous cell carcinomas were significantly reduced. Kaplan-Meier estimates of nonskin cancer were 9.6 versus 4.0% (SRL-CsA-ST versus SRL-ST; P = 0.032, intention-to-treat analysis). Nonskin cancers included those of the lung, larynx, oropharynx, kidney, gastrointestinal tract, prostate, breast, thyroid, and cervix as well as glioma, liposarcoma, astrocytoma, leukemia, lymphoma, and Kaposi's sarcoma. Patients who received SRL-based, calcineurin inhibitor-free therapy after CsA withdrawal at month 3 had a reduced incidence of both skin and nonskin malignancies at 5 yr after renal transplantation compared with those who received SRL therapy combined with CsA. Longer follow-up and additional trials are needed to confirm these promising results.
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179
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Pengel L, Barcena L, Morris PJ. Registry of randomized controlled trials in transplantation: January 1 to June 30, 2005. Transplantation 2006; 81:1071-86. [PMID: 16641590 DOI: 10.1097/01.tp.0000221632.63426.5c] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Liset Pengel
- Centre for Evidence in Transplantation, Clinical Effectiveness Unit, Royal College of Surgeons of England and London School of Hygiene and Tropical Medicine, University of London, London, UK
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180
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Watson CJ, Bradley JA. Sirolimus and everolimus: inhibitors of mammalian target of rapamycin in liver transplantation. Transplant Rev (Orlando) 2006. [DOI: 10.1016/j.trre.2006.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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181
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Kaplan B. Overcoming Barriers to Long-Term Graft Survival. Am J Kidney Dis 2006; 47:S52-64. [PMID: 16567241 DOI: 10.1053/j.ajkd.2005.12.044] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2005] [Accepted: 12/09/2005] [Indexed: 12/30/2022]
Abstract
Although short-term kidney graft survival has improved in recent years, the focus has shifted to the challenge of improving long-term graft survival. Acute rejection, chronic allograft nephropathy, and cardiovascular disease are associated with graft loss and patient death. Reducing the potential for such posttransplantation complications may improve long-term graft survival. In addition, gaining a better understanding of the role that various immunosuppressive therapies have in decreasing the risk for graft injury will help clinicians make better-informed decisions about appropriate treatment regimens for individual kidney transplant recipients.
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Affiliation(s)
- Bruce Kaplan
- Department of Medicine, University of Illinois College of Medicine, Chicago, IL 60612-7315, USA.
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182
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Rodriguez AE, Granada JF, Rodriguez-Alemparte M, Vigo CF, Delgado J, Fernandez-Pereira C, Pocovi A, Rodriguez-Granillo AM, Schulz D, Raizner AE, Palacios I, O'Neill W, Kaluza GL, Stone G. Oral rapamycin after coronary bare-metal stent implantation to prevent restenosis: the Prospective, Randomized Oral Rapamycin in Argentina (ORAR II) Study. J Am Coll Cardiol 2006; 47:1522-9. [PMID: 16630986 DOI: 10.1016/j.jacc.2005.12.052] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2005] [Revised: 11/24/2005] [Accepted: 12/13/2005] [Indexed: 11/22/2022]
Abstract
OBJECTIVES The purpose of this study was to assess the role of oral rapamycin in decreased restenosis after bare metal stent implantation. BACKGROUND Small observational studies suggest that the administration of oral rapamycin reduces angiographic restenosis after bare metal stent implantation. METHODS Between September 2003 and September 2004, 100 patients were randomized to either oral rapamycin (6-mg loading dose given 2.7 h before intervention followed by 3 mg/day for 14 days) plus diltiazem 180 mg/day or no therapy after the implantation of a coronary bare metal stent design. The primary study end point was incidence of angiographic binary restenosis and late loss at nine months. The secondary end points were target lesion revascularization, target vessel revascularization, and incidence of major adverse cardiovascular events at 1 year. RESULTS Angiographic follow-up was completed in 87% of patients. In the rapamycin group, the drug was well tolerated (26% minor side effects) and was maintained in 96% of patients. At 9 months, the in-segment binary restenosis was reduced by 72% (11.6% rapamycin vs. 42.8% no-therapy group, p = 0.001) and the in-stent binary restenosis was reduced by 65% (12% rapamycin vs. 34.6% no-therapy group, p = 0.009). The in-segment late loss was also significantly reduced with oral therapy (0.66 vs. 1.13 mm, respectively; 43% reduction, p < 0.001). At 1 year, patients in the oral rapamycin group also showed a significantly lower incidence of target vessel revascularization (8.3% vs. 38%, respectively, p < 0.001), target lesion revascularization (7.6% vs. 37.2%, respectively, p < 0.001), and major adverse cardiovascular events (20% vs. 44%, respectively, p = 0.018). CONCLUSIONS This randomized, controlled, and unblinded study showed that the administration of oral rapamycin during 14 days after stent implantation significantly reduces angiographic and clinical parameters of restenosis.
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183
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Djamali A, Samaniego M, Muth B, Muehrer R, Hofmann RM, Pirsch J, Howard A, Mourad G, Becker BN. Medical Care of Kidney Transplant Recipients after the First Posttransplant Year. Clin J Am Soc Nephrol 2006; 1:623-40. [PMID: 17699268 DOI: 10.2215/cjn.01371005] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Kidney transplantation is the treatment of choice for patients with ESRD. Despite improvements in short-term patient and graft outcomes, there has been no major improvement in long-term outcomes. The use of kidney allografts from expanded-criteria donors, polyoma virus nephropathy, underimmunosuppression, and incomplete functional recovery after rejection episodes may play a role in the lack of improvement in long-term outcomes. Other factors, including cardiovascular disease, infections, and malignancies, also shorten patient survival and therefore reduce the functional life of an allograft. There is a need for interventions that improve long-term outcomes in kidney transplant recipients. These patients are a unique subset of patients with chronic kidney disease. Therefore, interventions need to address disease progression, comorbid conditions, and patient mortality through a multifaceted approach. The Kidney Disease Outcomes Quality Initiative from the National Kidney Foundation, the European Best Practice Guidelines, and the forthcoming Kidney Disease: Improving Global Outcomes clinical practice guidelines can serve as a cornerstone of this approach. The unique aspects of chronic kidney disease in the transplant recipient require the integration of specific transplant-oriented problems into this care schema and a concrete partnership among transplant centers, community nephrologists, and primary care physicians. This article reviews the contemporary aspects of care for these patients.
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Affiliation(s)
- Arjang Djamali
- Department of Medicine, Nephrology Section, University of Wisconsin Madison, School of Medicine, 3034 Fish Hatchery Road, Suite B, Madison, WI 53713, USA.
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184
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Sanchez EQ, Martin AP, Ikegami T, Uemura T, Narasimhan G, Goldstein RM, Levy MF, Chinnakotla S, Dawson S, Randall HB, Saracino G, Klintmalm GB, Klintmaim GB. Sirolimus conversion after liver transplantation: improvement in measured glomerular filtration rate after 2 years. Transplant Proc 2006; 37:4416-23. [PMID: 16387135 DOI: 10.1016/j.transproceed.2005.10.019] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2005] [Indexed: 01/09/2023]
Abstract
METHODS We reviewed our prospectively maintained database of 2005 liver transplantations. Therapy was either started de novo or converted from calcineurin inhibitors (CNIs) to sirolimus as the main immunosuppressive agent for nephrotoxicity or rejection. Glomerular filtration rate (GFR) was determined with iodine 125-labeled sodium isthalamate (Glofil-125), and serum creatinine concentration was obtained before and 3 months after transplantation, and yearly in both groups. Sirolimus levels were 10 to 15 ng/mL in patients at less than 3 months after transplantations and 5 to 10 ng/mL in the remaining patients. All patients received mycophenolate mofetil as maintenance therapy. RESULTS Data for 29 patients in the de novo group and 35 in the conversion group were reviewed. Patients in the de novo group demonstrated an acute cellular rejection rate of 17.2%, 40% of which were steroid resistant. In this group, 48.2% discontinuation of sirolimus was necessary because of adverse effects. Patients in the conversion group demonstrated an acute cellular rejection rate of 2.8% and a 34.3% rate of sirolimus discontinuation. Seventeen (56.7%) patients at 1 year and 8 (44.4%) patients at 2 years demonstrated continued improvement in GFR. In the conversion group, case-control analysis did not demonstrate a significant difference in GFR and serum creatinine concentration (P > .05) at 1 and 2 years after conversion. At the time of review, no patients in the conversion group required hemodialysis. CONCLUSIONS Conversion to sirolimus therapy is an effective strategy in improving renal function in patients with CNI-induced nephrotoxicity and can be done without increased rejection. Most of our patients (65.7%) tolerated sirolimus conversion. Of these, 56.7% and 44.4% demonstrated continued increase in GFR with the CNI-free regimen at 1 and 2 years, respectively. Long-term, large-population, prospective, randomized, controlled studies should further validate these results.
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Affiliation(s)
- E Q Sanchez
- Transplantation Services, Baylor University Medical Center, Dallas, Texas 75246, USA.
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185
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Olyaei AJ, Demattos AM, Bennett WM. Cardiovascular complications of immunosuppressive agents in renal transplant recipients. Expert Opin Drug Saf 2006; 4:29-44. [PMID: 15709896 DOI: 10.1517/14740338.4.1.29] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Fatal and nonfatal cardiovascular events are the most important cause of graft loss in patients with a functioning graft following transplantation. The available data indicate that transplant patients have a high prevalence of hypertension, hyperlipidaemia and new onset diabetes mellitus after transplantation. The aetiology and pathogenesis of post-transplant hypertension, hyperlipidaemia and diabetes are multifactorial. In addition, disease of the native kidney and recurrence of renal disease can contribute to the development of cardiovascular disease in transplant recipients. Most transplant patients are at risk of clinically important drug-drug interactions involving immunosuppressive agents. Adverse reactions and drug-drug interactions should not be neglected when selecting an agent for treatment of cardiovascular risk factors in transplant recipients.
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Affiliation(s)
- Ali J Olyaei
- Oregon Health Sciences University, Division of Nephrology, Hypertension, 3181 SW Sam Jackson Park Road, Mail Code CR9-4 Portland, Oregon 97201, USA.
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186
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Abstract
This review seeks to apply a decision-making algorithm to establish whether clinical pharmacokinetic monitoring (CPM) of sirolimus (rapamycin) in solid organ transplantation is indicated in specific patient populations. The need for CPM of sirolimus, although a regulatory requirement in Europe, has not yet been firmly established in North America and other parts of the world. Sirolimus has demonstrated immunosuppressive efficacy in renal, pancreatic islet cell, liver and heart transplant recipients. The pharmacological response of immunosuppressive therapy with sirolimus cannot be readily evaluated; however, a relationship between trough blood sirolimus concentrations, area under the plasma concentration-time curve (AUC) and the incidence of rejection has been proposed. Furthermore, sirolimus can be measured in whole blood by several assays--high-performance liquid chromatography with detection by tandem mass spectrometry, or with ultraviolet detection, radioreceptor assay or microparticle enzyme immunoassay. Both experimental animal and clinical data suggest that adverse events and their associated severity are correlated with blood concentrations. To prevent rejection and minimise toxicity, a therapeutic range of 4-12 microg/L (measured via chromatographic assays) is recommended when sirolimus is used in conjunction with ciclosporin. If ciclosporin therapy is discontinued, a target trough range of 12-20 microg/L is recommended. Sirolimus pharmacokinetics display large inter- and intrapatient variability, which may change in specific patient populations due to disease states or concurrent immunosuppressants or other interacting drugs. Due to the long half-life of sirolimus, dosage adjustments would ideally be based on trough levels obtained more than 5-7 days after initiation of therapy or dosage change. Once the initial dose titration is complete, monitoring sirolimus trough concentrations weekly for the first month and every 2 weeks for the second month appears to be appropriate. After the first 2 months of dose titration, routine CPM of sirolimus is not necessary in all patients, but may be warranted to achieve target concentrations in certain populations of patients, but the frequency of further monitoring remains to be determined and should be individualised.
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Affiliation(s)
- Sunita Bond Stenton
- Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia, Canada
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187
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Russ G, Segoloni G, Oberbauer R, Legendre C, Mota A, Eris J, Grinyó JM, Friend P, Lawen J, Hartmann A, Schena FP, Lelong M, Burke JT, Neylan JF. Superior outcomes in renal transplantation after early cyclosporine withdrawal and sirolimus maintenance therapy, regardless of baseline renal function. Transplantation 2006; 80:1204-11. [PMID: 16314787 DOI: 10.1097/01.tp.0000178393.78084.9b] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND It has become increasingly important to refine therapeutic strategies according to individual patient characteristics. We evaluated the long-term impact of renal function at the time of withdrawing cyclosporine (CsA) in renal allograft recipients receiving sirolimus (SRL), CsA, and steroids (ST). METHODS At 3 months+/-2 weeks, 430 of 525 patients were eligible to be randomized to remain on triple-therapy (SRL-CsA-ST, n=215) or to have CsA withdrawn (SRL-ST, n=215). Patients were divided into quartiles according to their baseline (last value before randomization) calculated GFR: <or=45 ml/min (quartile 1, n=104), >45 to 56 ml/min (quartile 2, n=105), >56 to 67 ml/min (quartile 3, n=112), and >67 ml/min (quartile 4, n=107). All data were included (ITT analysis). RESULTS At 4 years, calculated GFR for SRL-CsA-ST vs. SRL-ST was 22.1 vs. 37.7 ml/min (P=0.017), 38.6 vs. 56.6 ml/min (P<0.001), 50.7 vs. 66.8 ml/min (P=0.006), and 62.7 vs. 71.4 ml/min (P=0.436), for quartiles 1 to 4, respectively. Death-censored graft loss ranged from 21.2% vs. 7.7% (SRL-CsA-ST vs. SRL-ST, P=0.092) in quartile 1 to 5.5% vs. 1.9% (P=0.618) in quartile 4. The incidence of death and biopsy-confirmed acute rejection also decreased with increasing baseline GFR, but was not significantly different between treatments. Overall, more patients remained on therapy in the SRL-ST group (46.3% vs. 57.9%, P=0.020). CONCLUSIONS Early and complete withdrawal of CsA from a combination of SRL, CsA, and steroids was preferable to continuing on this regimen, regardless of baseline renal function. The benefit was most marked in patients with a baseline calculated GFR<or=45 ml/min.
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Affiliation(s)
- Graeme Russ
- The Queen Elizabeth Hospital, Woodville, South Australia, Australia., and Hospitais da Universidade de Coimbra, Coimbra, Portugal.
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188
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Lisik W, Kahan BD. Individualization of Immunosuppressive Therapy. II. Sirolimus as a Less Nephrotoxic Alternative to Calcineurin Inhibitors. Transplant Proc 2006; 38:69-73. [PMID: 16504667 DOI: 10.1016/j.transproceed.2006.01.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The nephrotoxic effects of chronic administration of calcineurin inhibitors have created a demand for a potent immunosuppressive drug free of this side effect. Sirolimus (SRL) clearly displays fewer and a lesser degree of adverse effects on renal function by itself. However, in combination with calcineurin antagonists, it tends to augment the nephrotoxicity due, at least in part, to a pharmacokinetic interaction. The use of SRL for de novo immunosuppression (even with adjunctive mycophenolate mofetil) is probably not sufficient to avert alloimmune reactions. A useful combination with SRL can be achieved by reducing calcineurin inhibitor exposure by 80% for immediately functioning kidneys or by delaying its inception until renal graft recovery. SRL proffers additional benefits as an inhibitor of endothelial and smooth muscle cell proliferation, serving as the foundation of chronic immunosuppressive therapy.
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Affiliation(s)
- W Lisik
- Division of Immunology and Organ Transplantation, The University of Texas Health Science Center, 6431 Fannin, Houston, TX 77030, USA
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189
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Spinelli GA, Felipe CR, Machado PG, Garcia R, Casarini DE, Moreira SR, Park SI, Tedesco-Silva H, Medina-Pestana JO. Relationship of cyclosporin and sirolimus blood concentrations regarding the incidence and severity of hyperlipidemia after kidney transplantation. Braz J Med Biol Res 2006; 39:19-30. [PMID: 16400461 DOI: 10.1590/s0100-879x2006000100003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The influence of drug concentrations on the development of persistent posttransplant hyperlipidemia was investigated in 82 patients who received cyclosporin A (CsA) and prednisone plus sirolimus (SRL) (52) or azathioprine (AZA) (30) during the first year after transplantation. Blood levels of CsA and SRL, daily doses of AZA and prednisone, and cholesterol, triglyceride, and glucose concentrations were determined during each visit (pretransplant and 30, 60, 90, 120, 180, and 360 days posttransplant). Persistent hyperlipidemia was defined as one-year average steady-state cholesterol (CavCHOL) or triglyceride (CavTG) concentrations above 240 and 200 mg/dL, respectively. Mean cholesterol and triglyceride concentrations increased after transplantation (P < 0.01) and were higher in patients receiving SRL compared to AZA (P < 0.001). Patients receiving SRL showed a significantly higher number of cholesterol (> 229 or > 274 mg/dL) and triglyceride (> 198 or > 282 mg/dL) determinations in the upper interquartile ranges. CsA and SRL interquartile ranges correlated with cholesterol concentrations (P = 0.001) whereas only SRL interquartile ranges correlated with triglyceride concentrations (P < 0.0001). Only pretransplant cholesterol concentration > 205 mg/dL was independently associated with development of persistent hypercholesterolemia (CavCHOL > 240 mg/dL, relative risk (RR) = 20, CI 3.8-104.6, P = 0.0004) whereas pretransplant triglyceride concentration > 150 mg/dL (RR = 7.2, CI 1.6-32.4, P = 0.01) or > 211 mg/dL (RR = 19.8, CI 3.6-107.9, P = 0.0006) and use of SRL (RR = 3, CI 1.0-8.8, P = 0.0049) were independently associated with development of persistent hypertriglyceridemia (CavTG > 200 mg/dL). Persistent hypercholesterolemia was more frequent among patients with higher pretransplant cholesterol concentrations and was dependent on both CsA and SRL concentrations. Persistent hypertriglyceridemia was more frequent among patients with higher pretransplant triglyceride concentrations and was dependent on SRL concentrations.
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Affiliation(s)
- G A Spinelli
- Divisão de Nefrologia, Hospital do Rim e Hipertensão, Universidade Federal de São Paulo, São Paulo, SP, Brazil
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190
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Pascual J, Boletis IN, Campistol JM. Everolimus (Certican) in renal transplantation: a review of clinical trial data, current usage, and future directions. Transplant Rev (Orlando) 2006. [DOI: 10.1016/j.trre.2005.10.005] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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191
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Stratta P, Canavese C, Quaglia M, Balzola F, Bobbio M, Busca A, Franchello A, Libertucci D, Mazzucco G. Posttransplantation chronic renal damage in nonrenal transplant recipients. Kidney Int 2005; 68:1453-63. [PMID: 16164622 DOI: 10.1111/j.1523-1755.2005.00558.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The growing problem of relentless deterioration of renal function in patients who undergo transplantation of nonrenal solid organs is bound to have an increasingly important impact as it may not only worsen patient morbidity and mortality but also increase transplantation costs. METHODS We reviewed the literature in order to provide a sum of the most important data on the incidence, clinical picture, renal pathology pattern, damage mechanisms, and risk factors, along with strategies for prevention and treatment of chronic renal damage following nonrenal solid organ transplantation. RESULTS Literature data report that 10% to 80% of transplanted patients have some degree of renal dysfunction and that they share a common clinical picture characterized by relentless asymptomatic progression, frequent hypertension, mild urinary abnormalities, and pathology features of vascular, glomerular, tubular, and interstitial involvement. These changes are very similar to those reported for chronic nephrotoxicity from calcineurin inhibitors. The occurrence of end-stage renal disease (ESRD) requiring chronic dialysis has been reported in up to 20% of nonrenal transplant recipients. Although there are some organ-specific differences, a group of common risk factors has been recognized, including the use of calcineurin inhibitors as immunosuppressive agents, age, pretransplantation renal function, intraoperative/perioperative factors, concomitant use of other nephrotoxic drugs, infections, and posttransplantation acute renal failure. CONCLUSION Calcineurin inhibitor-induced nephrotoxicity is a growing problem and, as the age of recipients of nonrenal organs is increasing, this problem is destined to increase. It would therefore be advisable for nephrologists to share their experiences in immunomodulation with other specialties, so as to favor the cautious extension of calcineurin inhibitor-sparing protocols to the area of life-saving transplants.
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Affiliation(s)
- Piero Stratta
- Department of Nephro-Urology of the Avogadro University, Maggiore Hospital, Novara, Italy.
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192
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Waid T. Tacrolimus as secondary intervention vs. cyclosporine continuation in patients at risk for chronic renal allograft failure. Clin Transplant 2005; 19:573-80. [PMID: 16146546 DOI: 10.1111/j.1399-0012.2005.00389.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Chronic renal allograft failure (CRAF) is the leading cause of graft loss post-renal transplantation. This study evaluated the efficacy and safety of tacrolimus as secondary intervention in cyclosporine-treated kidney transplantation patients with impaired allograft function as indicated by elevated serum creatinine (SCr) levels. METHODS Patients receiving cyclosporine-based immunosuppression who had an elevated SCr at least 3 months post-renal transplantation were enrolled. Treatment allocation was 2:1 to switch to tacrolimus or continue cyclosporine. This analysis was performed after 2 yr; patients will be followed for an additional 3 yr. RESULTS There were 186 enrolled and evaluable patients. On baseline biopsy, 90% of patients had chronic allograft nephropathy. Baseline median SCr was 2.5 mg/dL in both treatment groups. For patients with graft function at month 24, SCr had decreased to 2.3 mg/dL in the tacrolimus-treated patients and increased to 2.6 mg/dL in the cyclosporine-treated patients (p = 0.01). Acute rejection occurred in 4.8% of tacrolimus-treated patients and 5.0% of cyclosporine-treated patients during follow-up. Two-year allograft survival was comparable between groups (tacrolimus 69%, cyclosporine 67%; p = 0.70). Tacrolimus-treated patients had significantly lower cholesterol and low-density lipoprotein levels and also had fewer new-onset infections. Cardiac conditions developed in significantly fewer tacrolimus-treated patients (5.6%) than cyclosporine-treated patients (24.3%; p = 0.004). Glucose levels and the incidences of new-onset diabetes and new-onset hyperglycemia did not differ between treatment groups. CONCLUSIONS Conversion from cyclosporine to tacrolimus results in improved renal function and lipid profiles, and significantly fewer cardiovascular events with no differences in the incidence of acute rejection or new-onset hyperglycemia.
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Affiliation(s)
- Thomas Waid
- Transplant Center, University of Kentucky Medical Center, Lexington, KY 40536-0084, USA. twaid.pop.uky.edu
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193
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Taylor AL, Watson CJE, Bradley JA. Immunosuppressive agents in solid organ transplantation: Mechanisms of action and therapeutic efficacy. Crit Rev Oncol Hematol 2005; 56:23-46. [PMID: 16039869 DOI: 10.1016/j.critrevonc.2005.03.012] [Citation(s) in RCA: 292] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2004] [Revised: 02/25/2005] [Accepted: 03/04/2005] [Indexed: 01/09/2023] Open
Abstract
Effective immunosuppression is an essential pre-requisite for successful organ transplantation and improvements in outcome after transplantation have to a large extent been dependent on developments in immunosuppressive therapy. Here we provide an overview of the different immunosuppressive agents currently used in solid organ transplantation. A historical perspective on the development of immunosuppression for organ transplantation is followed by a review of the individual agents, with a focus on their mechanism of action and efficacy. Steroids, anti-proliferative agents (azathioprine and mycophenolate), calcineurin inhibitors (cyclosporine and tacrolimus) and TOR inhibitors (sirolimus and everolimus) are discussed along with both polyclonal and monoclonal antibody preparations. Many of the key clinical trials that underpin current clinical usage of these agents are described and side-effects of the different agents are highlighted. Finally, a number of newer agents still in various stages of clinical development are briefly considered.
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Affiliation(s)
- Anna L Taylor
- University of Cambridge, Department of Surgery, Box 202, Addenbrookes, Hospital, Hills Road, Cambridge CB2 2QQ, UK
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194
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Randomized Trials According to Intervention and Organ:. Transplantation 2005. [DOI: 10.1097/00007890-200512150-00002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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195
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Abstract
Renal transplantation is the best therapeutic option for patients with end-stage renal disease. Although short-term results are excellent, long-term graft survival has not improved substantially in recent times. Chronic allograft nephropathy (CAN) and death with a functioning graft are the most important causes of graft loss. Recent evidence shows that nephrotoxicity of calcineurin inhibitors contributes to CAN, and the introduction of non-nephrotoxic drugs such as mycophenolate mofetil (MMF) and mammalian target of rapamycin inhibitors may provide new immunosuppressive strategies to improve long-term results after renal transplantation. MMF decreases the risk of developing chronic allograft failure and is useful for treating established CAN, because it has a beneficial effect on allograft fibrosis. Treatment with sirolimus (SRL), a basic immunosuppressive drug given in association with MMF, may offer better renal function, decrease the prevalence of CAN, and downregulate expression of genes responsible for the progression of CAN than treatment with cyclosporine A (CsA). SRL also permits an early elimination of CsA from SRL-CsA-steroid regimens and shows better renal function and improved renal histology without risk of rejection. Notably, this approach improves graft survival at 4 years. Further multicenter studies are needed to determine whether both approaches produce similar results by comparing immunosuppression caused by SRL-based and tacrolimus (TAC)-based treatments. Because TAC is the most commonly used anticalcineurin drug, it is important to compare the effects of steroid-TAC-SRL treatment with and without elimination of TAC. Finally, although caution is needed, the use of non-nephrotoxic immunosuppressive treatment may change the natural history of CAN.
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Affiliation(s)
- Jose M Morales
- Renal Transplant Unit, Nephrology Department, Hospital 12 de Octubre, Madrid, Spain.
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196
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Sennesael JJ, Bosmans JL, Bogers JP, Verbeelen D, Verpooten GA. Conversion from Cyclosporine to Sirolimus in Stable Renal Transplant Recipients. Transplantation 2005; 80:1578-85. [PMID: 16371929 DOI: 10.1097/01.tp.0000184623.35773.6a] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Conversion from cyclosporine (CsA) to sirolimus (SRL) has mainly been done in clinical conditions warranting calcineurin inhibitor discontinuation. Little is known about the clinical outcome of conversion in renal transplant recipients without transplant dysfunction. METHODS This prospective, open-label, multicentric pilot study evaluates the safety and efficacy of converting patients with stable renal function from CsA to SRL. RESULTS Forty stable patients on CsA, mycophenolate mofetil (MMF) (1.5 g/day), and steroids (ST) were converted at 7.6+/-1.4 months after renal transplantation. At 1 year, graft and patient survival was 100% and the incidence of acute rejection 5%. Calculated glomerular filtration rate (GFR) increased from 54+/-18 to 66+/-16 ml/min (P<0.0001). Blood pressure remained unchanged. A gradual increase in the incidence and severity of proteinuria was observed from month 6 onwards with de novo proteinuria in 30% of the patients at 1 year. Protein excretion was below 1 g/day in 12.5%, between 1 and 3 g/day in 17.5% and above 3 g/day in 7.5% of the proteinuric cohort (P=0.0043, compared to baseline). No predictors could be identified for the development of proteinuria. All patients had a reduction in protein excretion following renin-angiotensin blockade and were continued on SRL. CONCLUSION Conversion of stable renal transplant recipients from a CsA-MMF-ST to a SRL-MMF-ST regimen is safe and results in improved renal function but is associated with the development of proteinuria in 30% of the patients requiring renin-angiotensin blockade.
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Affiliation(s)
- Jacques J Sennesael
- Renal Unit, Academisch Ziekenhuis, Vrije Universiteit Brussel, Laarbeeklaan 101, B-1090 Brussels, Belgium.
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197
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Afzali B, Taylor AL, Goldsmith DJA. What we CAN do about chronic allograft nephropathy: Role of immunosuppressive modulations. Kidney Int 2005; 68:2429-43. [PMID: 16316321 DOI: 10.1111/j.1523-1755.2005.00720.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Given the potency of modern immunosuppressive agents, kidney transplantation across alloantingen barriers is a routine phenomenon with excellent 1-year graft survival in most centers. However, the improvement in 1-year graft survival has not been matched by improvements in long-term graft function and chronic allograft nephropathy (CAN) remains the second commonest cause of graft attrition over time. Calcineurin inhibitors, namely cyclosporine A (CyA) and tacrolimus, have been implicated as causal agents in the development of the fibrotic processes that are the hallmarks of CAN. Many studies have, therefore, concentrated on the improvement of long term graft function through the modulation of immunosuppressive therapy. It is the purpose of this review to describe and appraise the available evidence for the prevention and management of CAN through modulation of immunosuppressive agents.
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Affiliation(s)
- Behdad Afzali
- Department of Renal Medicine and Transplantion, Guy's Hospital, London, United Kingdom
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198
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Morales JM, Dominguez-Gil B. Cardiovascular risk profile with the new immunosuppressive combinations after renal transplantation. J Hypertens 2005; 23:1609-16. [PMID: 16093902 DOI: 10.1097/01.hjh.0000180159.81640.2f] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Cardiovascular disease remains the main cause of death among kidney transplant patients. Cardiovascular risk burden already present at the moment of transplantation is substantially worsened by chronic use of immunosuppressants. On the other hand, chronic allograft nephropathy, a clinical-pathological result of immunological and non-immunological damage of the graft, is the main cause of graft loss in the long-term. Among the non-immunological factors contributing to the development of chronic allograft nephropathy, cardiovascular risk factors also seem to play a role. In the present review, we analyse the impact of the different immunosuppressive medications on cardiovascular risk factors after renal transplantation, including renal function.
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Affiliation(s)
- José M Morales
- Renal Transplant Unit, Nephrology Department, Hospital 12 de Octubre, Carretera de Andalucia Km 5,400, 28041 Madrid, Spain
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199
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Diekmann F, Gutierrez-Dalmau A, Torregrosa JV, Oppenheimer F, Campistol JM. Sirolimus Monotherapy: Feasible Immunosuppression for Long-Term Follow-up of Kidney Transplantation???A Pilot Experience. Transplantation 2005; 80:1344-8. [PMID: 16314805 DOI: 10.1097/01.tp.0000176479.35275.18] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Chronic allograft nephropathy (CAN), cardiovascular mortality, and posttransplant malignancy are complications of conventional immunosuppression after kidney transplantation. The aim was to study feasibility of sirolimus (SRL) maintenance monotherapy in a pilot experience. All patients with SRL monotherapy of at least 6 months follow-up were included. In 19 patients, age 58 (34-74) years, SRL monotherapy was introduced 98.1 (49-193) months after transplantation by withdrawing concomitant immunosuppressants from protocols already including SRL or introducing SRL and withdrawing other immunosuppressants. Follow-up is 20.0 (6-41) months. One patient died from hepatocellular carcinoma, diagnosed before SRL monotherapy, with functioning graft. No rejections occurred. SRL trough concentration was 10.7 (4.6-16.1) microg/L. Creatinine (1.77 [1.0-2.9] mg/dL vs. 1.68 [0.8-3.3] mg/dL after 6 months, 1.97 [0.8-4.6] mg/dL at last follow-up; P=NS). Proteinuria increased tendentially (333 [67-893] vs. 890 [46-4011] mg/day). No significant changes of hemoglobin, triglycerides, or cholesterol occurred. SRL monotherapy late after kidney transplantation is feasible in selected patients.
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Affiliation(s)
- Fritz Diekmann
- Department of Nephrology and Kidney Transplantation, Hospital Clínic and Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.
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200
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Thaunat O, Beaumont C, Chatenoud L, Lechaton S, Mamzer-Bruneel MF, Varet B, Kreis H, Morelon E. Anemia after Late Introduction of Sirolimus May Correlate with Biochemical Evidence of a Chronic Inflammatory State. Transplantation 2005; 80:1212-9. [PMID: 16314788 DOI: 10.1097/01.tp.0000179106.07382.6a] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND The responsibility of sirolimus (SRL) for postrenal transplant anemia has never been proven, because SRL is usually combined with myelotoxic drugs, and because of the high incidence of anemia in the posttransplant period. METHODS We retrospectively analyzed anemia in 46 renal transplant recipients, who had been switched from calcineurin inhibitors to SRL for biopsy-proven chronic allograft nephropathy. RESULTS The mean decrease in hemoglobin (Hb) after SRL introduction was 2.8 g/dl. The 24 patients, whose Hb fell by >or=2 g/dl, displayed microcytic aregenerative anemia with low serum iron despite high ferritinemia, consistent with anemia of chronic inflammatory states. Fibrinogen and CRP levels increased in these patients after sirolimus introduction. We subsequently focused our study on eight patients without confounding factors of anemia. Anemia improved in all eight after SRL withdrawal. IL6 and TNFalpha at the nadir of anemia were significantly higher than before SRL introduction and after its withdrawal. Decreases in Hb correlated with increases in proinflammatory cytokine levels in a linear regression model. Unchanged serum IL10 levels measured at the nadir of anemia were discordant with the inflammatory state. CONCLUSIONS Late introduction of SRL may induce anemia and correlates with biochemical evidence of a chronic inflammatory state possibly due to defective IL10-dependent inflammatory autoregulation.
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Affiliation(s)
- Olivier Thaunat
- Department of Renal Transplantation, Hôpital Necker Enfants-Malades, Paris, France.
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