1
|
Righi I, Barone I, Rosso L, Morlacchi LC, Rossetti V, Caffarena G, Limanaqi F, Palleschi A, Clerici M, Trabattoni D. Immunopathology of lung transplantation: from infection to rejection and vice versa. Front Immunol 2024; 15:1433469. [PMID: 39286256 PMCID: PMC11402714 DOI: 10.3389/fimmu.2024.1433469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Accepted: 08/14/2024] [Indexed: 09/19/2024] Open
Abstract
Lung transplantation offers a lifesaving option for patients with end-stage lung disease, but it is marred by a high risk of post-transplant infections, particularly involving multidrug-resistant bacteria, Cytomegalovirus, and fungal pathogens. This elevated infection rate, the highest among solid organ transplants, poses a significant challenge for clinicians, particularly within the first year post-transplantation, where infections are the leading cause of mortality. The direct exposure of lung allografts to the external environment exacerbates this vulnerability leading to constant immune stimulation and consequently to an elevated risk of triggering alloimmune responses to the lung allograft. The necessity of prolonged immunosuppression to prevent allograft rejection further complicates patient management by increasing susceptibility to infections and neoplasms, and complicating the differentiation between rejection and infection, which require diametrically opposed management strategies. This review explores the intricate balance between preventing allograft rejection and managing the heightened infection risk in lung transplant recipients.
Collapse
Affiliation(s)
- Ilaria Righi
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Ivan Barone
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Lorenzo Rosso
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Letizia Corinna Morlacchi
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Valeria Rossetti
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giovanni Caffarena
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Department of Thoracic Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Fiona Limanaqi
- Department of Biomedical and Clinical Sciences (DIBIC), University of Milan, Milan, Italy
| | - Alessandro Palleschi
- Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Mario Clerici
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Fondazione Don C. Gnocchi IRCCS, Milan, Italy
| | - Daria Trabattoni
- Department of Biomedical and Clinical Sciences (DIBIC), University of Milan, Milan, Italy
| |
Collapse
|
2
|
Mohib O, Vanderhulst J, Catalano C, Roussoulières A, Knoop C, Lemoine A, Baudoux T. Variables Associated With Hyperkalemic Renal Tubular Acidosis in Solid Organ Transplant Recipients. Cureus 2024; 16:e55379. [PMID: 38434606 PMCID: PMC10908377 DOI: 10.7759/cureus.55379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2024] [Indexed: 03/05/2024] Open
Abstract
INTRODUCTION The occurrence of hyperkalemic renal tubular acidosis (RTA) in the post-transplantation period is likely underestimated, and its identification remains important to offer adequate medical management. Transplant recipients frequently present with clinical and biological characteristics that may be associated with the occurrence of this complication. METHODS This was a single-center retrospective study that compared transplanted patients with hyperkalemic RTA and a control group to identify variables associated with the occurrence of this complication. Fisher's exact test and the Mann-Whitney test, followed by multivariate logistic regression, were applied to test whether there was a significant association between hyperkalemic RTA and different variables. RESULTS Kidney and heart transplant recipients were at greater risk of developing RTA than lung transplant recipients (p = 0.016). There was also a significant association between the development of RTA and kalemia (p < 0.01), chloremia (p < 0.01), and bicarbonatemia (p < 0.01). The significant impact of these last three variables was confirmed by the results of the multivariate logistic regression. Residual serum tacrolimus levels (p = 0.13) and creatinine levels (p = 0.17) of renal transplant patients were not significantly associated with hyperkalemic RTA. CONCLUSION The type of transplanted organ, kalemia, chloremia, and bicarbonatemia were significantly associated with the occurrence of hyperkalemic RTA. This study calls into question certain approaches to managing this complication proposed in a number of case reports, such as reducing the target serum residual of tacrolimus or discontinuing trimethoprim-sulfamethoxazole (TMP-SMX) in favor of another antibiotic prophylactic agent, potentially exposing patients to graft rejection and opportunistic infections.
Collapse
Affiliation(s)
- Othmane Mohib
- Department of Nephrology, Cliniques Universitaires de Bruxelles - Hôpital (CUB) Erasme, Brussels, BEL
| | - Julien Vanderhulst
- Internal Medicine, Centre Hospitalier Universitaire (CHU) Brugmann, Brussels, BEL
| | - Concetta Catalano
- Department of Nephrology, Cliniques Universitaires de Bruxelles - Hôpital (CUB) Erasme, Brussels, BEL
| | - Ana Roussoulières
- Department of Cardiology, Cliniques Universitaires de Bruxelles - Hôpital (CUB) Erasme, Brussels, BEL
| | - Christiane Knoop
- Department of Pulmonology, Cliniques Universitaires de Bruxelles - Hôpital (CUB) Erasme, Brussels, BEL
| | - Alain Lemoine
- Department of Nephrology, Cliniques Universitaires de Bruxelles - Hôpital (CUB) Erasme, Brussels, BEL
| | - Thomas Baudoux
- Department of Nephrology, Cliniques Universitaires de Bruxelles - Hôpital (CUB) Erasme, Brussels, BEL
| |
Collapse
|
3
|
Dellgren G, Lund TK, Raivio P, Leuckfeld I, Svahn J, Holmberg EC, Olsen PS, Halme M, Fiane A, Lindstedt S, Riise GC, Magnusson J. Effect of once-per-day tacrolimus versus twice-per-day ciclosporin on 3-year incidence of chronic lung allograft dysfunction after lung transplantation in Scandinavia (ScanCLAD): a multicentre randomised controlled trial. THE LANCET. RESPIRATORY MEDICINE 2024; 12:34-44. [PMID: 37703908 DOI: 10.1016/s2213-2600(23)00293-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 07/23/2023] [Accepted: 07/25/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Evidence is low regarding the choice of calcineurin inhibitor for immunosuppression after lung transplantation. We aimed to compare the use of tacrolimus once per day with ciclosporin twice per day according to the current definition of chronic lung allograft dysfunction (CLAD) after lung transplantation. METHODS ScanCLAD is an investigator-initiated, open-label, multicentre, randomised, controlled trial in Scandinavia evaluating whether an immunosuppressive protocol based on anti-thymocyte globulin induction followed by tacrolimus (once per day), mycophenolate mofetil, and corticosteroids reduces the incidence of CLAD after de novo lung transplantation compared with a protocol using ciclosporin (twice per day), mycophenolate mofetil, and corticosteroids. Patients aged 18-70 years who were scheduled to undergo double lung transplantation were randomly allocated (1:1) to receive either oral ciclosporin (2-3 mg/kg before transplantation and 3 mg/kg [twice per day] from postoperative day 1) or oral tacrolimus (0·05-0·1 mg/kg before transplantation and 0·1-0·2 mg/kg from postoperative day 1). The primary endpoint was CLAD at 36 months post transplantation, determined by repeated lung function tests and adjudicated by an independent committee, and was assessed with a competing-risks analysis with death and re-transplantation as competing events. The primary outcome was assessed in the modified intention-to-treat (mITT) population, defined as those who underwent transplantation and received at least one dose of study drug. This study is registered at ClinicalTrials.gov (NCT02936505) and EudraCT (2015-004137-27). FINDINGS Between Oct 21, 2016, and July 10, 2019, 383 patients were screened for eligibility. 249 patients underwent double lung transplantation and received at least one dose of study drug, and were thus included in the mITT population: 125 (50%) in the ciclosporin group and 124 (50%) in the tacrolimus group. The mITT population consisted of 138 (55%) men and 111 (45%) women, with a mean age of 55·2 years (SD 10·2), and no patients were lost to follow-up. In the mITT population, CLAD occurred in 48 patients (cumulative incidence 39% [95% CI 31-48]) in the ciclosporin group and 16 patients (13% [8-21]) in the tacrolimus group at 36 months post transplantation (hazard ratio [HR] 0·28 [95% CI 0·15-0·52], log-rank p<0·0001). Overall survival did not differ between groups at 3 years in the mITT population (74% [65-81] for ciclosporin vs 79% [70-85] for tacrolimus; HR 0·72 [95% CI 0·41-1·27], log-rank p=0·25). However, in the per protocol CLAD population (those in the mITT population who also had at least one post-baseline lung function test allowing assessment of CLAD), allograft survival was significantly better in the tacrolimus group (HR 0·49 [95% CI 0·26-0·91], log-rank p=0·021). Adverse events totalled 1516 in the ciclosporin group and 1459 in the tacrolimus group. The most frequent adverse events were infection (453 events), acute rejection (165 events), and anaemia (129 events) in the ciclosporin group, and infection (568 events), anaemia (108 events), and acute rejection (98 events) in the tacrolimus group. 112 (90%) patients in the ciclosporin group and 108 (87%) in the tacrolimus group had at least one serious adverse event. INTERPRETATION Immunosuppression based on use of tacrolimus once per day significantly reduced the incidence of CLAD compared with use of ciclosporin twice per day. These findings support the use of tacrolimus as the first choice of calcineurin inhibitor after lung transplantation. FUNDING Astellas, the ALF-agreement, Scandiatransplant Organization, and Heart Centre Research Committee, Rigshospitalet, Denmark.
Collapse
Affiliation(s)
- Göran Dellgren
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden; Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Thomas Kromann Lund
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Peter Raivio
- Department of Cardiac Surgery, Heart and Lung Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Inga Leuckfeld
- Department of Respiratory Medicine, Oslo University Hospital, Oslo, Norway
| | - Johan Svahn
- Department of Pulmonology and Allergology, Skåne University Hospital, Lund, Sweden
| | - Erik C Holmberg
- Department of Oncology, Institute of Clinical Sciences, University of Gothenburg, Sweden
| | - Peter Skov Olsen
- Department of Thoracic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Maija Halme
- Department of Pulmonology, Heart and Lung Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Arnt Fiane
- Department of Cardiothoracic Surgery, Oslo University Hospital, Oslo, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Sandra Lindstedt
- Department of Cardiothoracic Surgery, Skåne University Hospital, Lund, Sweden
| | - Gerdt C Riise
- Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Pulmonology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jesper Magnusson
- Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Pulmonology, Sahlgrenska University Hospital, Gothenburg, Sweden
| |
Collapse
|
4
|
Erdman J, Wolfram J, Nimke D, Croy R, Wang X, Weaver T, Schladt D, Fitzsimmons WE. Pediatric Lung Transplant Outcomes Based on Immunosuppressive Regimen at Discharge: Retrospective Cohort Study Using Real-World Evidence From the US Scientific Registry of Transplant Recipients. Transplant Proc 2023; 55:1692-1705. [PMID: 37438193 DOI: 10.1016/j.transproceed.2023.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 04/17/2023] [Accepted: 05/16/2023] [Indexed: 07/14/2023]
Abstract
BACKGROUND This retrospective analysis of the US Scientific Registry of Transplant Recipients was undertaken to obtain real-world evidence concerning the efficacy and safety of tacrolimus-based immunosuppression in pediatric lung transplant recipients to support a supplemental New Drug Application. METHODS Overall, 725 pediatric recipients of a primary deceased-donor lung transplant between January 1, 1999, and December 31, 2017, were followed for up to 3 years post-transplant based on an immunosuppressive regimen at hospital discharge: immediate-release tacrolimus (TAC)+mycophenolate mofetil (MMF), TAC+azathioprine (AZA), cyclosporine (CsA)+MMF, or CsA+AZA. The primary outcome was the composite endpoint of graft failure or death (all-cause) at 1 year post-transplant, calculated by Kaplan-Meier analysis. RESULTS The use of TAC+MMF increased over time. During 2010 to 2017, 91.7% of pediatric lung transplant recipients were receiving TAC+MMF at the time of discharge. The proportion of recipients continuing their discharge regimen at 1 year post-transplant was 83.7% with TAC+MMF and 40.4% to 59.7% with the other regimens. Cumulative incidence of the composite endpoint of graft failure or death at 1 year post-transplant was 7.7% with TAC+MMF, 13.9% with TAC+AZA, 8.9% with CsA+MMF, and 9.1% with CsA+AZA. There was no significant difference in the risk of graft failure or death at 1 year post-transplant between groups from 1999 to 2005 (the only era when adequate numbers on each regimen allowed statistical comparison). No increase in hospitalization for infection or malignancy was seen with TAC+MMF. CONCLUSION The real-world evidence from the US database of transplant recipients supported the Food and Drug Administration's approval of tacrolimus-based maintenance immunosuppression in pediatric lung transplant recipients.
Collapse
Affiliation(s)
- Jay Erdman
- Medical Specialties Therapeutic Area, Astellas Pharma, Inc, Northbrook, Illinois
| | - Josephine Wolfram
- Real World Data & Evidence, Advanced Informatics and Analytics, Astellas Pharma Europe BV, Leiden, Netherlands
| | - David Nimke
- Real World Evidence-Americas, Advanced Informatics and Analytics, Astellas Pharma, Inc, Northbrook, Illinois
| | - Richard Croy
- Data Science, Astellas Pharma, Inc, Northbrook, Illinois
| | - Xuegong Wang
- Global Medical Lead, Medical Specialties, Astellas Pharma, Inc, Northbrook, Illinois
| | - Tim Weaver
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - David Schladt
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - William E Fitzsimmons
- College of Pharmacy, Department of Pharmacy Systems, Outcomes, and Policy, University of Illinois, Chicago, Illinois.
| |
Collapse
|
5
|
Nelson J, Alvey N, Bowman L, Schulte J, Segovia M, McDermott J, Te HS, Kapila N, Levine DJ, Gottlieb RL, Oberholzer J, Campara M. Consensus recommendations for use of maintenance immunosuppression in solid organ transplantation: Endorsed by the American College of Clinical Pharmacy, American Society of Transplantation, and the International Society for Heart and Lung Transplantation. Pharmacotherapy 2022; 42:599-633. [DOI: 10.1002/phar.2716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 03/29/2022] [Accepted: 04/08/2022] [Indexed: 12/17/2022]
Affiliation(s)
- Joelle Nelson
- Department of Pharmacotherapy and Pharmacy Services University Health San Antonio Texas USA
- Pharmacotherapy Education and Research Center University of Texas Health San Antonio San Antonio Texas USA
- Department of Pharmacy, Pharmacotherapy Division, College of Pharmacy The University of Texas at Austin Austin Texas USA
| | - Nicole Alvey
- Department of Pharmacy Rush University Medical Center Chicago Illinois USA
- Science and Pharmacy Roosevelt University College of Health Schaumburg Illinois USA
| | - Lyndsey Bowman
- Department of Pharmacy Tampa General Hospital Tampa Florida USA
| | - Jamie Schulte
- Department of Pharmacy Services Thomas Jefferson University Hospital Philadelphia Pennsylvania USA
| | | | - Jennifer McDermott
- Richard DeVos Heart and Lung Transplant Program, Spectrum Health Grand Rapids Michigan USA
- Department of Medicine, Michigan State University College of Human Medicine Grand Rapids Michigan USA
| | - Helen S. Te
- Liver Transplantation, Center for Liver Diseases, Department of Medicine University of Chicago Medical Center Chicago Illinois USA
| | - Nikhil Kapila
- Department of Transplant Hepatology Duke University Hospital Durham North Carolina USA
| | - Deborah Jo Levine
- Division of Critical Care Medicine, Department of Medicine The University of Texas Health Science Center at San Antonio San Antonio Texas USA
| | - Robert L. Gottlieb
- Baylor University Medical Center and Baylor Scott and White Research Institute Dallas Texas USA
| | - Jose Oberholzer
- Department of Surgery/Division of Transplantation University of Virginia Charlottesville Virginia USA
| | - Maya Campara
- Department of Surgery University of Illinois Chicago Chicago Illinois USA
- Department of Pharmacy Practice University of Illinois Chicago Chicago Illinois USA
| |
Collapse
|
6
|
Evans RA, Walter KS, Lobo LJ, Coakley R, Doligalski CT. Pharmacotherapy of chronic lung allograft dysfunction post lung transplantation. Clin Transplant 2022; 36:e14770. [PMID: 35801376 DOI: 10.1111/ctr.14770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 05/30/2022] [Accepted: 07/05/2022] [Indexed: 11/30/2022]
Abstract
Chronic lung allograft dysfunction (CLAD) remains the primary cause of death in lung transplant recipients (LTRs) in spite of improvements in immunosuppression management. Despite advances in knowledge regarding the pathogenesis of CLAD, treatments that are currently available are usually ineffective and delay progression of disease at best. There are currently no evidence-based guidelines for the optimal treatment of CLAD, and management varies widely across transplant centers. Additionally, there are minimal publications available to summarize data for currently available therapies and outcomes in LTRs. We identified the major domains of the medical management of CLAD and conducted a comprehensive search of PubMed and Embase databases to identify articles published from inception to December 2021 related to CLAD in LTRs. Studies published in English pertaining to the pharmacologic prevention and treatment of CLAD were included; highest priority was given to prospective, randomized, controlled trials if available. Prospective observational and retrospective controlled trials were prioritized next, followed by retrospective uncontrolled studies, case series, and finally case reports if the information was deemed to be pertinent. Reference lists of qualified publications were also reviewed to find any other publications of interest that were not found on initial search. In the absence of literature published in the aforementioned databases, additional articles were identified by reviewing abstracts presented at the International Society for Heart and Lung Transplantation and American Transplant Congress annual meetings between 2010-2021. This document serves to provide a comprehensive review of the literature and considerations for the prevention and medical management of CLAD. This article is protected by copyright. All rights reserved.
Collapse
Affiliation(s)
- Rickey A Evans
- Department of Pharmacy, University of Kentucky Healthcare, Lexington, KY, USA
| | - Krysta S Walter
- Department of Pharmacy, Michigan Medicine, Ann Arbor, MI, USA
| | | | | | | |
Collapse
|
7
|
Erdman J, Wolfram J, Nimke D, Croy R, Wang X, Weaver T, Schladt D, Fitzsimmons WE. Lung Transplant Outcomes in Adults in the United States: Retrospective Cohort Study Using Real-world Evidence from the SRTR. Transplantation 2022; 106:1233-1242. [PMID: 34974456 PMCID: PMC9128622 DOI: 10.1097/tp.0000000000004011] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 10/28/2021] [Accepted: 10/28/2021] [Indexed: 11/12/2022]
Abstract
BACKGROUND The Scientific Registry of Transplant Recipients was retrospectively analyzed to provide real-world evidence of the efficacy and safety of tacrolimus-based immunosuppressive regimens in adult lung transplant recipients in the United States. METHODS Adult recipients (N = 25 355; ≥18 y) of a primary deceased-donor lung transplant between January 1, 1999, and December 31, 2017, were followed for 3 y posttransplant based on immunosuppressive regimen at discharge: immediate-release tacrolimus (TAC) + mycophenolate mofetil (MMF), TAC + azathioprine (AZA), cyclosporine (CsA) + MMF, or CsA + AZA. The primary outcome was the composite endpoint of graft failure or death (all-cause) at 1 y posttransplant (calculated via a modified Kaplan-Meier method). RESULTS Discharge immunosuppressive regimens in lung transplant recipients changed over time, with a substantial increase in the use of TAC + MMF. TAC + MMF was the most common immunosuppressive regimen (received by 61.0% of individuals at discharge). The cumulative incidence of graft failure or death at 1 y posttransplant in adult lung transplant patients receiving TAC + MMF was 8.6% (95% confidence interval 8.1-9.1). Risk of graft failure or death was significantly higher in adults receiving CsA + MMF or CsA + AZA compared with TAC + MMF, with no significant difference seen between TAC + MMF and TAC + AZA. TAC + MMF had the highest continued use at 1 y posttransplant (72.0% versus 35.4%-51.5% for the other regimens). There was no increase in the rate of infection or malignancy in the TAC + MMF group. CONCLUSIONS Real-world evidence from the most comprehensive database of transplant recipients in the United States supports the use of TAC in combination with MMF or AZA as maintenance immunosuppression in adult lung transplant recipients.
Collapse
Affiliation(s)
- Jay Erdman
- Medical Specialties Therapeutic Area, Astellas Pharma, Inc., Northbrook, IL
| | - Josephine Wolfram
- Real World Data & Evidence, Advanced Informatics and Analytics, Astellas Pharma Europe BV, Leiden, The Netherlands
| | - David Nimke
- Real World Evidence–Americas, Advanced Informatics and Analytics, Astellas Pharma, Inc., Northbrook, IL
| | - Richard Croy
- Data Science, Astellas Pharma, Inc., Northbrook, IL
| | - Xuegong Wang
- Global Medical Lead, Medical Specialties, Astellas Pharma, Inc., Northbrook, IL
| | - Tim Weaver
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN
| | - David Schladt
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN
| | - William E. Fitzsimmons
- Department of Pharmacy Systems, Outcomes, and Policy, College of Pharmacy, University of Illinois, Chicago, IL
| |
Collapse
|
8
|
Immunosuppression in Lung Transplantation. Handb Exp Pharmacol 2021; 272:139-164. [PMID: 34796380 DOI: 10.1007/164_2021_548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Immunosuppression in lung transplantation is an area devoid of robust clinical data. This chapter will review the history of immunosuppression in lung transplantation. Additionally, it will evaluate the three classes of induction, maintenance, and rescue immunosuppression in detail. Induction immunosuppression in lung transplantation aims to decrease incidence of lung allograft rejection, however infectious risk must be considered when determining if induction is appropriate and which agent is most favorable. Similar to other solid organ transplant patient populations, a multi-drug approach is commonly prescribed for maintenance immunosuppression to minimize single agent drug toxicities. Emphasis of this review is placed on key medication considerations including dosing, adverse effects, and drug interactions. Clinical considerations will be reviewed per drug class given available literature. Finally, acute cellular, antibody mediated, and chronic rejection are reviewed.
Collapse
|
9
|
A Safety and Tolerability Study of Thin Film Freeze-Dried Tacrolimus for Local Pulmonary Drug Delivery in Human Subjects. Pharmaceutics 2021; 13:pharmaceutics13050717. [PMID: 34068391 PMCID: PMC8153550 DOI: 10.3390/pharmaceutics13050717] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 04/28/2021] [Accepted: 05/07/2021] [Indexed: 11/26/2022] Open
Abstract
Due to the low and erratic bioavailability of oral tacrolimus (TAC), the long-term survival rate following lung transplantation remained low compared to other solid organs. TAC was reformulated and developed as inhaled formulations by thin film freezing (TFF). Previous studies reported that inhaled TAC combined with 50% w/w lactose (LAC) was safe and effective for the treatment of lung transplant rejection in rodent models. In this study, we aimed to investigate the safety and tolerability of TFF TAC-LAC in human subjects. The formulation can be delivered to the lung as colloidal dispersions after reconstitution and as a dry powder. Healthy subjects inhaled TAC-LAC colloidal dispersions at 3 mg TAC/dose via a vibrating mesh nebulizer in the first stage of this study and TAC-LAC dry powder at 3 mg TAC/dose via a single dose dry powder inhaler in the second stage. Our results demonstrated that oral inhalation of TAC-LAC colloidal dispersions and dry powder exhibited low systemic absorption. Additionally, they were well-tolerated with no changes in CBC, liver, kidney, and lung functions. Only mild adverse side effects (e.g., cough, throat irritation, distaste) were observed. In summary, pulmonary delivery of TFF TAC-LAC would be a safe and promising therapy for lung transplant recipients.
Collapse
|
10
|
Li D, Duan Q, Weinkauf J, Kapasi A, Varughese R, Hirji A, Lien D, Meyer S, Laing B, Nagendran J, Halloran K. Azithromycin prophylaxis after lung transplantation is associated with improved overall survival. J Heart Lung Transplant 2020; 39:1426-1434. [PMID: 33041181 DOI: 10.1016/j.healun.2020.09.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 08/25/2020] [Accepted: 09/11/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Azithromycin prophylaxis (AP) in lung transplant recipients has been shown to reduce the composite end-point of death or chronic lung allograft dysfunction (CLAD) onset but without a clear effect on overall survival. Our program began using AP in 2010. We sought to evaluate the association between AP and survival and the risk of CLAD and baseline lung allograft dysfunction (BLAD). METHODS We studied double lung recipients transplanted between 2004 and 2016. We defined AP as chronic use of azithromycin initiated before CLAD onset. We analyzed the association between AP and death or retransplant using Cox regression with adjustment for potential confounders. We further used Cox and logistic models to assess the relationship between AP and post-transplant CLAD onset and BLAD, respectively. RESULTS A total of 445 patients were included, and 344 (77%) received AP (median time from transplant: 51 days). Patients receiving AP were more likely to receive induction with interleukin-2 receptor antagonists (57% vs 35%; p < 0.001). AP was associated with improved survival (hazard ratio [HR]: 0.59; 95% confidence interval [CI]: 0.42-0.82; p = 0.0020) in our fully adjusted model, with a reduced adjusted risk of BLAD (odds ratio: 0.53; 95% CI: 0.33-0.85; p = 0.0460) but no clear reduction in the adjusted risk of CLAD (HR: 0.69; 95% CI: 0.47-1.03; p = 0.0697). CONCLUSIONS AP is associated with improved survival after lung transplantation, potentially through improved baseline function. These findings build on prior trial results and suggest that AP is beneficial for lung transplant recipients.
Collapse
Affiliation(s)
- David Li
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Qiuli Duan
- Health Services Statistical & Analytical Methods, Alberta Health Services, Edmonton, Alberta, Canada
| | - Justin Weinkauf
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Ali Kapasi
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Rhea Varughese
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Alim Hirji
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Dale Lien
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Steven Meyer
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Bryce Laing
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Jayan Nagendran
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Kieran Halloran
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
| |
Collapse
|
11
|
Sahakijpijarn S, Moon C, Ma X, Su Y, Koleng JJ, Dolocan A, Williams RO. Using thin film freezing to minimize excipients in inhalable tacrolimus dry powder formulations. Int J Pharm 2020; 586:119490. [PMID: 32603840 DOI: 10.1016/j.ijpharm.2020.119490] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 05/27/2020] [Accepted: 05/28/2020] [Indexed: 02/09/2023]
Abstract
We investigated the feasibility of preparing high-potency tacrolimus dry powder for inhalation using thin film freezing (TFF). We found that using ultra-rapid freezing can increase drug loading up to 95% while maintaining good aerosol performance. Drug loading affected the specific surface area and moisture sorption of TFF formulations, but it did not affect the chemical stability, physical stability, and dissolution of tacrolimus. Tacrolimus remained amorphous after storage at 40 °C/75% RH, and 25 °C/60% RH for up to 6 months. Lactose functioned as a bulking agent, and it had little to no effect as a stabilizer for amorphous tacrolimus due to a lack of interaction between the drug and excipient. Additionally, the aerosol performance of TFF tacrolimus/lactose (95/5) did not significantly change after six months of storage at 25 °C/60% RH. For processing parameters, the solids content and the processing temperature did not affect the aerosol performance of tacrolimus. Furthermore, both low- and high-resistance RS01 showed optimal and consistent aerosol performance over the 1-4 kPa pressure drop range. In conclusion, TFF is a suitable technology for producing inhalable powder that contain high drug loading and have less flow rate dependence.
Collapse
Affiliation(s)
- Sawittree Sahakijpijarn
- The University of Texas at Austin, College of Pharmacy, Division of Molecular Pharmaceutics and Drug Delivery, Austin, TX, USA
| | - Chaeho Moon
- The University of Texas at Austin, College of Pharmacy, Division of Molecular Pharmaceutics and Drug Delivery, Austin, TX, USA; TFF Pharmaceuticals, Inc., Austin, TX, USA
| | - Xiangyu Ma
- The University of Texas at Austin, College of Pharmacy, Division of Molecular Pharmaceutics and Drug Delivery, Austin, TX, USA
| | - Yongchao Su
- Merck Research Laboratories, Merck & Co., Inc., Kenilworth, NJ, USA
| | | | - Andrei Dolocan
- The University of Texas at Austin, Texas Materials Institute, Austin, TX, USA
| | - Robert O Williams
- The University of Texas at Austin, College of Pharmacy, Division of Molecular Pharmaceutics and Drug Delivery, Austin, TX, USA.
| |
Collapse
|
12
|
Abstract
Lung transplantation is a viable option for those with end-stage lung disease which is evidenced by the continued increase in the number of lung transplantations worldwide. However, patients and clinicians are constantly faced with acute and chronic rejection, infectious complications, drug toxicities, and malignancies throughout the lifetime of the lung transplant recipient. Conventional maintenance immunosuppression therapy consisting of a calcineurin inhibitor (CNI), anti-metabolite, and corticosteroids have become the standard regimen but newer agents and modalities continue to be developed. Here we will review induction agents, maintenance immunosuppressives, adjunctive therapies and other strategies to improve long-term outcomes.
Collapse
Affiliation(s)
- Paul A Chung
- Division of Pulmonary and Critical Care, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA
| | - Daniel F Dilling
- Division of Pulmonary and Critical Care, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA
| |
Collapse
|
13
|
Panchabhai TS, Chaddha U, McCurry KR, Bremner RM, Mehta AC. Historical perspectives of lung transplantation: connecting the dots. J Thorac Dis 2018; 10:4516-4531. [PMID: 30174905 DOI: 10.21037/jtd.2018.07.06] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Lung transplantation is now a treatment option for many patients with end-stage lung disease. Now 55 years since the first human lung transplant, this is a good time to reflect upon the history of lung transplantation, to recognize major milestones in the field, and to learn from others' unsuccessful transplant experiences. James Hardy was instrumental in developing experimental thoracic transplantation, performing the first human lung transplant in 1963. George Magovern and Adolph Yates carried out the second human lung transplant a few days later. With a combined survival of only 26 days for these first 2 lung transplant recipients, the specialty of lung transplantation clearly had a long way to go. The first "successful" lung transplant, in which the recipient survived for 10.5 months, was reported by Fritz Derom in 1971. Ten years later, Bruce Reitz and colleagues performed the first successful en bloc transplantation of the heart and one lung with a single distal tracheal anastomosis. In 1988, Alexander Patterson performed the first successful double lung transplant. The modern technique of sequential double lung transplantation and anastomosis performed at the mainstem bronchus level was originally described by Henri Metras in 1950, but was not reintroduced into the field until Pasque reported it again in 1990. Since then, lung transplantation has seen landmark changes: evolving immunosuppression regimens, clarifying the definition of primary graft dysfunction (PGD), establishing the lung allocation score (LAS), introducing extracorporeal membrane oxygenation (ECMO) as a bridge to transplant, allowing donation after cardiac death, and implementing ex vivo perfusion, to name a few. This article attempts to connect the historical dots in this field of research, with the hope that our effort helps summarize what has been achieved, and identifies opportunities for future generations of transplant pulmonologists and surgeons alike.
Collapse
Affiliation(s)
- Tanmay S Panchabhai
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Udit Chaddha
- Department of Pulmonary and Critical Care Medicine, Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
| | - Kenneth R McCurry
- Department of Cardiothoracic Surgery, Sydell and Arnold Miller Family Heart and Vascular Institute
| | - Ross M Bremner
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Atul C Mehta
- Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
14
|
|
15
|
Abstract
Immunosuppressive therapy is arguably the most important component of medical care after lung transplantation. The goal of immunosuppression is to prevent acute and chronic rejection while maximizing patient survival and long-term allograft function. However, the benefits of immunosuppressive therapy must be balanced against the side effects and major toxicities of these medications. Immunosuppressive agents can be classified as induction agents, maintenance therapies, treatments for acute rejection and chronic rejection and antibody directed therapies. Although induction therapy remains an area of controversy in lung transplantation, it is still used in the majority of transplant centers. On the other hand, maintenance immunosuppression is less contentious; but, unfortunately, since the creation of three-drug combination therapy, including a glucocorticoid, calcineurin inhibitor and anti-metabolite, there have been relatively modest improvements in chronic maintenance immunosuppressive regimens. The presence of HLA antibodies in transplant candidates and development of de novo antibodies after transplantation remain a major therapeutic challenge before and after lung transplantation. In this chapter we review the medications used for induction and maintenance immunosuppression along with their efficacy and side effect profiles. We also review strategies and evidence for HLA desensitization prior to lung transplantation and management of de novo antibody formation after transplant. Finally, we review immune tolerance and the future of lung transplantation to limit the toxicities of conventional immunosuppressive therapy.
Collapse
Affiliation(s)
- Luke J Benvenuto
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, New York, USA
| | - Michaela R Anderson
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, New York, USA
| | - Selim M Arcasoy
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, New York, USA
| |
Collapse
|
16
|
Abstract
Immunosuppression management after lung transplantation continues to evolve, with an increasing number of agents available for use in various combinations allowing for more choice and individualization of immunosuppressive therapy. Therapeutic developments have led to improved outcomes including lower acute rejection rates and improved survival. However, a one size fits all approach for any immunosuppressive strategy may not be best suited to the individual patient and ultimately patient specific factors must be considered when designing the immunosuppressive regimen. Recipient factors including age, race, co-morbidities, immunologic risk, genetic polymorphisms, concomitant and previous pharmacotherapy, and overall immunosuppression burden should be considered. There are several significant drug-drug interactions with select immunosuppressive agents utilized in lung transplant pharmacotherapy that must be considered when choosing and devising a dosing strategy for an individual immunosuppressive agent. Herein, considerations for immunosuppression management in the individual patient will be reviewed.
Collapse
Affiliation(s)
- Jennifer K McDermott
- Richard DeVos Heart and Lung Transplant Program, Spectrum Health, Grand Rapids, Michigan.,Michigan State University College of Human Medicine, Grand Rapids, Michigan
| | - Reda E Girgis
- Michigan State University College of Human Medicine, Grand Rapids, Michigan
| |
Collapse
|
17
|
Van Herck A, Verleden SE, Vanaudenaerde BM, Verleden GM, Vos R. Prevention of chronic rejection after lung transplantation. J Thorac Dis 2017; 9:5472-5488. [PMID: 29312757 DOI: 10.21037/jtd.2017.11.85] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Long-term survival after lung transplantation (LTx) is limited by chronic rejection (CR). Therapeutic strategies for CR have been largely unsuccessful, making prevention of CR an important and challenging therapeutic approach. In the current review, we will discuss current clinical evidence regarding prevention of CR after LTx.
Collapse
Affiliation(s)
- Anke Van Herck
- Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism & Ageing (CHROMETA), Division of Respiratory Diseases, KU Leuven, Leuven, Belgium
| | - Stijn E Verleden
- Department of Chronic Diseases, Metabolism & Ageing (CHROMETA), Division of Respiratory Diseases, KU Leuven, Leuven, Belgium
| | - Bart M Vanaudenaerde
- Department of Chronic Diseases, Metabolism & Ageing (CHROMETA), Division of Respiratory Diseases, KU Leuven, Leuven, Belgium
| | - Geert M Verleden
- Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism & Ageing (CHROMETA), Division of Respiratory Diseases, KU Leuven, Leuven, Belgium
| | - Robin Vos
- Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism & Ageing (CHROMETA), Division of Respiratory Diseases, KU Leuven, Leuven, Belgium
| |
Collapse
|
18
|
Koutsokera A, Royer PJ, Antonietti JP, Fritz A, Benden C, Aubert JD, Tissot A, Botturi K, Roux A, Reynaud-Gaubert ML, Kessler R, Dromer C, Mussot S, Mal H, Mornex JF, Guillemain R, Knoop C, Dahan M, Soccal PM, Claustre J, Sage E, Gomez C, Magnan A, Pison C, Nicod LP. Development of a Multivariate Prediction Model for Early-Onset Bronchiolitis Obliterans Syndrome and Restrictive Allograft Syndrome in Lung Transplantation. Front Med (Lausanne) 2017; 4:109. [PMID: 28770204 PMCID: PMC5511826 DOI: 10.3389/fmed.2017.00109] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 06/30/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Chronic lung allograft dysfunction and its main phenotypes, bronchiolitis obliterans syndrome (BOS) and restrictive allograft syndrome (RAS), are major causes of mortality after lung transplantation (LT). RAS and early-onset BOS, developing within 3 years after LT, are associated with particularly inferior clinical outcomes. Prediction models for early-onset BOS and RAS have not been previously described. METHODS LT recipients of the French and Swiss transplant cohorts were eligible for inclusion in the SysCLAD cohort if they were alive with at least 2 years of follow-up but less than 3 years, or if they died or were retransplanted at any time less than 3 years. These patients were assessed for early-onset BOS, RAS, or stable allograft function by an adjudication committee. Baseline characteristics, data on surgery, immunosuppression, and year-1 follow-up were collected. Prediction models for BOS and RAS were developed using multivariate logistic regression and multivariate multinomial analysis. RESULTS Among patients fulfilling the eligibility criteria, we identified 149 stable, 51 BOS, and 30 RAS subjects. The best prediction model for early-onset BOS and RAS included the underlying diagnosis, induction treatment, immunosuppression, and year-1 class II donor-specific antibodies (DSAs). Within this model, class II DSAs were associated with BOS and RAS, whereas pre-LT diagnoses of interstitial lung disease and chronic obstructive pulmonary disease were associated with RAS. CONCLUSION Although these findings need further validation, results indicate that specific baseline and year-1 parameters may serve as predictors of BOS or RAS by 3 years post-LT. Their identification may allow intervention or guide risk stratification, aiming for an individualized patient management approach.
Collapse
Affiliation(s)
- Angela Koutsokera
- Division of Pulmonary Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), University of Lausanne, Lausanne, Switzerland
| | - Pierre J Royer
- Institut du thorax, INSERM UMR 1087/CNRS UMR 6291, CHU de Nantes, Université de Nantes, Nantes, France
| | - Jean P Antonietti
- Division of Pulmonary Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), University of Lausanne, Lausanne, Switzerland
| | | | - Christian Benden
- Division of Pulmonary Medicine, University Hospital Zurich, Zurich, Switzerland
| | - John D Aubert
- Division of Pulmonary Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), University of Lausanne, Lausanne, Switzerland
| | - Adrien Tissot
- Institut du thorax, INSERM UMR 1087/CNRS UMR 6291, CHU de Nantes, Université de Nantes, Nantes, France
| | - Karine Botturi
- Institut du thorax, INSERM UMR 1087/CNRS UMR 6291, CHU de Nantes, Université de Nantes, Nantes, France
| | - Antoine Roux
- Pneumology, Adult CF Center and Lung transplantation Department, Foch Hospital, Université Versailles Saint-Quentin-en-Yvelines, UPRES EA220, Suresnes, France
| | - Martine L Reynaud-Gaubert
- Pulmonary Medicine, CF Center and Lung Transplantation Department, Centre Hospitalier Universitaire Nord, CNRS UMR 6236 Aix-Marseille Université, Marseille, France
| | - Romain Kessler
- Lung Transplant Center, Hôpitaux universitaires de Strasbourg, Strasbourg, France
| | - Claire Dromer
- Service des Maladies respiratoires, Hôpital Haut Lévèque, Pessac, France
| | - Sacha Mussot
- Service de Chirurgie Thoracique, Vasculaire et Transplantation Cardiopulmonaire, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| | - Hervé Mal
- Service de Pneumologie et Transplantation pulmonaire, Hôpital Bichat, Université Denis Diderot, INSERM UMR1152, Paris, France
| | | | | | - Christiane Knoop
- Department of Chest Medicine, Erasme University Hospital, Brussels, Belgium
| | | | - Paola M Soccal
- Division of Pulmonary Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Johanna Claustre
- Clinique Universitaire de Pneumologie, Pôle Thorax et Vaisseaux, CHU Grenoble, INSERM 1055, Université Grenoble Alpes, Grenoble, France
| | - Edouard Sage
- Thoracic Surgery Department, Foch Hospital, Université Versailles Saint-Quentin-en-Yvelines, UPRES EA220, Suresnes, France
| | - Carine Gomez
- Pulmonary Medicine, CF Center and Lung Transplantation Department, Centre Hospitalier Universitaire Nord, CNRS UMR 6236 Aix-Marseille Université, Marseille, France
| | - Antoine Magnan
- Institut du thorax, INSERM UMR 1087/CNRS UMR 6291, CHU de Nantes, Université de Nantes, Nantes, France
| | - Christophe Pison
- Clinique Universitaire de Pneumologie, Pôle Thorax et Vaisseaux, CHU Grenoble, INSERM 1055, Université Grenoble Alpes, Grenoble, France
| | - Laurent P Nicod
- Division of Pulmonary Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), University of Lausanne, Lausanne, Switzerland
| | | |
Collapse
|
19
|
Affiliation(s)
- Todd L. Astor
- Division of Pulmonary and Critical Care Sciences, Lung Transplant Program, University of Colorado Health Sciences Center, Denver, Colorado, USA
| | - David Weill
- Division of Pulmonary and Critical Care Sciences, Lung Transplant Program, University of Colorado Health Sciences Center, Denver, Colorado, USA
| |
Collapse
|
20
|
Risks and Epidemiology of Infections After Lung or Heart–Lung Transplantation. TRANSPLANT INFECTIONS 2016. [PMCID: PMC7123746 DOI: 10.1007/978-3-319-28797-3_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Nowadays, lung transplantation is an established treatment option of end-stage pulmonary parenchymal and vascular disease. Post-transplant infections are a significant contributor to overall morbidity and mortality in the lung transplant recipient that, in turn, are higher than in other solid organ transplant recipients. This is likely due to several specific factors such as the constant exposure to the outside environment and the colonized native airway, and the disruption of usual mechanisms of defense including the cough reflex, bronchial circulation, and lymphatic drainage. This chapter will review the common infections that develop in the lung or heart–lung transplant recipient, including the general risk factors for infection in this population, and specific features of prophylaxis and treatment for the most frequent bacterial, viral, and fungal infections. The effects of infection on lung transplant rejection will also be discussed.
Collapse
|
21
|
Erratic tacrolimus exposure, assessed using the standard deviation of trough blood levels, predicts chronic lung allograft dysfunction and survival. J Heart Lung Transplant 2015; 34:1442-8. [DOI: 10.1016/j.healun.2015.05.028] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Revised: 04/02/2015] [Accepted: 05/28/2015] [Indexed: 12/16/2022] Open
|
22
|
Abstract
PURPOSE OF REVIEW Immunosuppression regimens have helped improve rejection episodes following lung transplantation, but long-term outcomes are still not comparable with cardiac, hepatic, or renal transplantation. This review summarizes the immunobiology that contributes to rejection events and future opportunities in outcomes on the basis of providing optimized delivery of the immunosuppression based on immune-monitoring techniques, taking into account individual patient pharmacokinetics and phenotypic variance. RECENT FINDINGS Drug toxicities, narrow therapeutic drug monitoring windows, and current immunoassays currently do not assist in detecting the global degree of immunosuppression. The currently available randomized control trials for induction therapy or maintenance therapies do not provide additional benefits compared with previously reported retrospective trials. To push beyond the current barriers, transplant teams are focusing on the role of pharmacokinetics, assessing phenotypic variable to potentially modify to quadruple therapy and using extracorporeal photopheresis. SUMMARY Conventional practice for the choices of immunosuppression is being evaluated on the basis of randomized control trials as opposed to retrospective studies or single-center trials. The future direction of immunosuppression will be continued by dynamic processes taking into consideration measures to improve tolerance, reducing treatment burden, and providing the best level of evidence while accounting for rejection, infections, renal function, and other comorbidities.
Collapse
|
23
|
Chen C, Zhao X, Chen L, Jin Y, Zhao ZK, Suh JW. Effect of overexpression of endogenous and exogenous Streptomyces antibiotic regulatory proteins on tacrolimus (FK506) production in Streptomyces sp. KCCM11116P. RSC Adv 2015. [DOI: 10.1039/c4ra15038d] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Overexpression of SARPs enhanced FK506 production in Streptomyces sp. KCCM1116P. The endogenous SARPs improved production titer, whereas the exogenous SARP enhanced productivity at the early fermentation stage.
Collapse
Affiliation(s)
- Chao Chen
- School of Life Science and Biotechnology
- Dalian University of Technology
- Dalian 116024
- China
| | - Xinqing Zhao
- School of Life Science and Biotechnology
- Dalian University of Technology
- Dalian 116024
- China
- School of Life Science and Biotechnology
| | - Liangyu Chen
- School of Life Science and Biotechnology
- Dalian University of Technology
- Dalian 116024
- China
| | - Yingyu Jin
- Division of Bioscience and Bioinformatics
- Myongji University
- Yongin 449-728
- South Korea
| | - Zongbao K. Zhao
- Department of Biotechnology
- Dalian Institute of Chemical Physics
- Chinese Academy of Sciences
- Dalian 116023
- China
| | - Joo-Won Suh
- Division of Bioscience and Bioinformatics
- Myongji University
- Yongin 449-728
- South Korea
| |
Collapse
|
24
|
Launay D, Savale L, Berezne A, Le Pavec J, Hachulla E, Mouthon L, Sitbon O, Lambert B, Gaudric M, Jais X, Stephan F, Hatron PY, Lamblin N, Vignaux O, Cottin V, Farge D, Wallaert B, Guillevin L, Simonneau G, Mercier O, Fadel E, Dartevelle P, Humbert M, Mussot S. Lung and heart-lung transplantation for systemic sclerosis patients. A monocentric experience of 13 patients, review of the literature and position paper of a multidisciplinary Working Group. Presse Med 2014; 43:e345-63. [DOI: 10.1016/j.lpm.2014.01.020] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Accepted: 01/23/2014] [Indexed: 12/14/2022] Open
|
25
|
Wang YB, Watts AB, Peters JI, Liu S, Batra A, Williams RO. In vitro and in vivo performance of dry powder inhalation formulations: comparison of particles prepared by thin film freezing and micronization. AAPS PharmSciTech 2014; 15:981-93. [PMID: 24824172 DOI: 10.1208/s12249-014-0126-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Accepted: 04/10/2014] [Indexed: 11/30/2022] Open
Abstract
Recently, inhaled immunosuppressive agents have attracted increasing attention for maintenance therapy following lung transplantation. The rationale for this delivery approach includes a more targeted and localized delivery to the diseased site with reduced systemic exposure, potentially leading to decreased adverse side effects. In this study, the in vitro and in vivo performance of an amorphous formulation prepared by thin film freezing (TFF) and a crystalline micronized formulation produced by milling was compared for tacrolimus (TAC). Despite the relatively large geometric size, the TFF-processed formulation was capable of achieving deep lung delivery due to its low-density, highly porous, and brittle characteristics. When emitted from a Miat® monodose inhaler, TFF-processed TAC formulations exhibited a fine particle fraction (FPF) of 83.3% and a mass median aerodynamic diameter (MMAD) of 2.26 μm. Single-dose 24-h pharmacokinetic studies in rats demonstrated that the TAC formulation prepared by TFF exhibited higher pulmonary bioavailability with a prolonged retention time in the lung, possibly due to decreased clearance (e.g., macrophage phagocytosis), compared to the micronized TAC formulation. Additionally, TFF formulation generated a lower systemic TAC concentration with smaller variability than the micronized formulation following inhalation, potentially leading to reduced side effects related to the drug in systemic circulation.
Collapse
|
26
|
Snell GI, Paraskeva MA, Levvey BJ, Westall GP. Immunosuppression for lung transplant recipients. ACTA ACUST UNITED AC 2014. [DOI: 10.1007/s13665-014-0081-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
|
27
|
Abstract
The enduring success of lung transplantation is built on the use of immunosuppressive drugs to stop the immune system from rejecting the newly transplanted lung allograft. Most patients receive a triple-drug maintenance immunosuppressive regimen consisting of a calcineurin inhibitor, an antiproliferative and corticosteroids. Induction therapy with either an antilymphocyte monoclonal or an interleukin-2 receptor antagonist are prescribed by many centres aiming to achieve rapid inhibition of recently activated and potentially alloreactive T lymphocytes. Despite this generic approach acute rejection episodes remain common, mandating further fine-tuning and augmentation of the immunosuppressive regimen. While there has been a trend away from cyclosporine and azathioprine towards a preference for tacrolimus and mycophenolate mofetil, this has not translated into significant protection from the development of chronic lung allograft dysfunction, the main barrier to the long-term success of lung transplantation. This article reviews the problem of lung allograft rejection and the evidence for immunosuppressive regimens used both in the short- and long-term in patients undergoing lung transplantation.
Collapse
|
28
|
Snell GI, Westall GP, Levvey BJ, Jaksch P, Keshavjee S, Hoopes CW, Ahya V, Mehta A, Trulock EP. A randomized, double-blind, placebo-controlled, multicenter study of rabbit ATG in the prophylaxis of acute rejection in lung transplantation. Am J Transplant 2014; 14:1191-8. [PMID: 24618385 DOI: 10.1111/ajt.12663] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Revised: 01/07/2014] [Accepted: 01/07/2014] [Indexed: 01/25/2023]
Abstract
ATG-Fresenius S (ATG-F) is a polyclonal anti-human-T-lymphocyte immunoglobulin preparation that has been clinically developed to prevent episodes of acute cellular rejection. This study evaluated the efficacy and safety of ATG-F at doses of 5 and 9 mg/kg versus placebo in adult recipients of a primary lung allograft. The primary efficacy composite end point was defined as death, graft loss, acute rejection and/or loss to follow-up within 12 months of transplantation. The interim analysis showed the ATG-F 5 mg/kg treatment to be inefficacious, and it would be impossible to enroll enough patients to power the study to show a difference between the 9 mg/kg arm and the placebo arm. Therefore, the main focus of the study shifted to the safety end points and a descriptive analysis of the primary end point. At 12 months posttransplant, the efficacy failure rate was not significantly different between the ATG-F 9 mg/kg group and the placebo group (40.2% vs. 36.7%, respectively). This large study did not demonstrate a significant reduction in acute cellular rejection, graft loss or death with single-dose induction therapy with ATG-F within the first year after lung transplantation.
Collapse
Affiliation(s)
- G I Snell
- Lung Transplant Service, Department of Allergy, Immunology and Respiratory Medicine, The Alfred Hospital, Melbourne, Australia
| | | | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Prado e Silva M, Soto SF, Almeida FM, Limonete TTK, Parra ERC, Jatene FB, Pêgo-Fernandes PM, Pazetti R. Immunosuppression effects on airway mucociliary clearance: comparison between two triple therapies. Ann Thorac Surg 2013; 96:473-7. [PMID: 23806228 DOI: 10.1016/j.athoracsur.2013.04.069] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 04/15/2013] [Accepted: 04/16/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND Tacrolimus and mycophenolate have now become the most widely used combination for maintenance immunosuppressive regimens after lung transplantation in comparison with cyclosporine and azathioprine. However, limited information is available with respect to their effects on cells, other than those from the immunologic compartment. We hypothesized that different triple therapies could have different effects on airway mucociliary clearance, playing an important role in respiratory infections observed after lung transplantation. METHODS Ninety rats were assigned to three groups (n = 30 each): control = vehicle, therapy 1 = tacrolimus + mycophenolate + prednisone, and therapy 2 = cyclosporine + azathioprine + prednisone. After 7, 15, or 30 days of treatment by gavage, the animals were killed and the following parameters were studied: mucus transportability, ciliary beating frequency, mucociliary transport velocity, and neutral and acid mucus production. RESULTS There was a significant decrease in ciliary beating frequency, mucociliary transport velocity, and neutral mucus production in all immunosuppressed animals; indeed, both therapies, mainly therapy 1, caused an increase in acid mucus production for as long as 15 days of treatment. CONCLUSIONS Both triple therapies impaired airway mucociliary clearance of rats, but therapy 1 had a more deleterious effect. These data suggest that these undesirable effects can contribute to the high incidence of respiratory infections observed in patients undergoing lung transplantation.
Collapse
Affiliation(s)
- Maristela Prado e Silva
- Laboratory of Thoracic Surgery Research-LIM61, Department of Cardiopneumology, Heart Institute (InCor), Hospital das Clinicas, São Paulo, Brazil
| | | | | | | | | | | | | | | |
Collapse
|
30
|
Weigt SS, DerHovanessian A, Wallace WD, Lynch JP, Belperio JA. Bronchiolitis obliterans syndrome: the Achilles' heel of lung transplantation. Semin Respir Crit Care Med 2013; 34:336-51. [PMID: 23821508 PMCID: PMC4768744 DOI: 10.1055/s-0033-1348467] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Lung transplantation is a therapeutic option for patients with end-stage pulmonary disorders. Unfortunately, chronic lung allograft dysfunction (CLAD), most commonly manifest as bronchiolitis obliterans syndrome (BOS), continues to be highly prevalent and is the major limitation to long-term survival. The pathogenesis of BOS is complex and involves alloimmune and nonalloimmune pathways. Clinically, BOS manifests as airway obstruction and dyspnea that are classically progressive and ultimately fatal; however, the course is highly variable, and distinguishable phenotypes may exist. There are few controlled studies assessing treatment efficacy, but only a minority of patients respond to current treatment modalities. Ultimately, preventive strategies may prove more effective at prolonging survival after lung transplantation, but their remains considerable debate and little data regarding the best strategies to prevent BOS. A better understanding of the risk factors and their relationship to the pathological mechanisms of chronic lung allograft rejection should lead to better pharmacological targets to prevent or treat this syndrome.
Collapse
Affiliation(s)
- S Samuel Weigt
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California 90095, USA.
| | | | | | | | | |
Collapse
|
31
|
Penninga L, Penninga EI, Møller CH, Iversen M, Steinbrüchel DA, Gluud C. Tacrolimus versus cyclosporin as primary immunosuppression for lung transplant recipients. Cochrane Database Syst Rev 2013:CD008817. [PMID: 23728681 DOI: 10.1002/14651858.cd008817.pub2] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Lung transplantation is a well-accepted treatment for people with most end-stage lung diseases. Although both tacrolimus and cyclosporin are used as primary immunosuppressive agents in lung transplant recipients, it is unclear which of these drugs is better in reducing rejection and death without causing adverse effects. OBJECTIVES To assess the benefits and harms of tacrolimus versus cyclosporin for primary immunosuppression in lung transplant recipients. SEARCH METHODS We searched the Cochrane Renal Group's Specialised Register to 10 April 2013 through contact with the Trials Search Co-ordinator using search terms relevant to this review. We also searched Science Citation Index Expanded and the Transplant Library to 20 April 2013. SELECTION CRITERIA We included all randomised controlled trials (RCT) that compared any dose and duration of administration of tacrolimus versus cyclosporin as primary immunosuppressive treatment in lung transplant recipients. Our selection criteria required that all included patients received the same additional immunosuppressive therapy within each study. DATA COLLECTION AND ANALYSIS Three authors extracted data. For dichotomous data we used risk ratio (RR) and used mean difference (MD) for continuous data, each with 95% confidence intervals (CI). Methodological components of the included studies were used to assess risk of systematic errors (bias). Trial sequential analysis was used to assess risk of random errors (play of chance). MAIN RESULTS We included three studies that enrolled a total of 413 adult patients that compared tacrolimus with microemulsion or oral solution cyclosporin. All studies were found to be at high risk of bias. Tacrolimus seemed to be significantly superior to cyclosporin regarding the incidence of bronchiolitis obliterans syndrome (RR 0.46, 95% CI 0.29 to 0.74), lymphocytic bronchitis score (MD -0.60, 95% CI -1.04 to -0.16), treatment withdrawal (RR 0.27, 95% CI 0.16 to 0.46), and arterial hypertension (RR 0.67, 95% CI 0.50 to 0.89). However, the finding for arterial hypertension was not confirmed when analysed using a random-effects model (RR 0.54, 95% CI 0.17 to 1.73). Furthermore, trial sequential analysis found that none of the meta-analyses reached the required information sizes and cumulative Z-curves did not cross trial sequential monitoring boundaries. Diabetes mellitus occurred more frequently among people in the tacrolimus group compared with the cyclosporin group when the fixed-effect model was applied (RR 4.24, 95% CI 1.58 to 11.40), but no difference was found when the random-effects model was used for analysis (RR 4.43, 95% CI 0.75 to 26.05). Again, trial sequential analysis found that the required information threshold was not reached and cumulative Z-curve did not cross the trial sequential monitoring boundary. No significant difference between treatment groups was observed regarding mortality (RR 1.06, 95% CI 0.75 to 1.49), incidence of acute rejection (RR 0.89, 95% CI 0.77 to 1.03), numbers of infections/100 patient-days (MD -0.15, 95% CI -0.30 to 0.00), cancer (RR 0.21, 95% CI 0.04 to 1.16), kidney dysfunction (RR 1.41, 95% CI 0.93 to 2.14), kidney failure (RR 1.57, 95% CI 0.28 to 8.94), neurotoxicity (RR 7.06, 95% CI 0.37 to 135.19), and hyperlipidaemia (RR 0.60, 95% CI 0.30 to 1.20). Trial sequential analysis showed the required information thresholds were not reached for any of these outcome measures. AUTHORS' CONCLUSIONS Tacrolimus may be superior to cyclosporin regarding bronchiolitis obliterans syndrome, lymphocytic bronchitis, treatment withdrawal, and arterial hypertension, but may be inferior regarding development of diabetes. No difference in mortality and acute rejection was observed between patients treated with tacrolimus and cyclosporin. There were few studies comparing tacrolimus and cyclosporin after lung transplantation, and the numbers of patients and events in the included studies were limited. Furthermore, the included studies were deemed to be at high risk of bias. Hence, more RCTs are needed to assess the results of the present review. Such studies ought to be conducted with low risks of systematic errors (bias) and of random errors (play of chance).
Collapse
Affiliation(s)
- Luit Penninga
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital,Copenhagen, Denmark. .
| | | | | | | | | | | |
Collapse
|
32
|
Lee JT, Whitson BA, Kelly RF, D'Cunha J, Dunitz JM, Hertz MI, Shumway SJ. Calcineurin inhibitors and Clostridium difficile infection in adult lung transplant recipients: the effect of cyclosporine versus tacrolimus. J Surg Res 2013; 184:599-604. [PMID: 23566442 DOI: 10.1016/j.jss.2013.03.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Revised: 03/01/2013] [Accepted: 03/13/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND Tacrolimus (FK506) has a superior immunosuppressive effect compared with cyclosporine (CSA) without a significant increase in generalized infectious complications. Differences in specific infections such as Clostridium difficile (CDI) have not been reported. We investigated the relationship between calcineurin inhibitors and CDI, hypothesizing that choice of calcineurin inhibitor (CSA or FK506) after lung transplantation would have no effect on the incidence of CDI. METHODS We performed a retrospective chart review of lung transplant recipients between June 1, 2000, and December 31, 2005, at a single institution. Positive CDI assays through December 11, 2011, were also recorded. We used Student's t- and chi-squared tests (α = 0.05) to compare CSA and FK506 groups. We calculated adjusted hazard ratios for CDI using Cox proportional hazard models. RESULTS We identified 217 lung transplant recipients: 106 patients in the CSA group and 111 patients in the FK506 group. A total of 31 patients (27.9%) in the FK506 group developed CDI postoperatively compared with 20 patients (18.9%) in the CSA group (P = 0.16). The adjusted hazard ratio for CDI in the FK506 group was not significantly higher (1.53; 95% confidence interval, 0.78-2.98). There was no significant difference in the intensive care unit or total length of stay, in-hospital incidence rate, time to first CDI episode, or recurrence rate between groups. CONCLUSIONS The CDI rates were not significantly higher in the FK506 group than the CSA group in our study. These data are consistent with previous studies on FK506 that show no increase in infectious complications over CSA, and demonstrate its continued safety in lung transplantation.
Collapse
Affiliation(s)
- Janet T Lee
- Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota 55455, USA.
| | | | | | | | | | | | | |
Collapse
|
33
|
Zur ISHLT-Leitlinie: Immunsuppression nach Herztransplantation. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2013. [DOI: 10.1007/s00398-012-0981-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
34
|
|
35
|
Baughman RP, Meyer KC, Nathanson I, Angel L, Bhorade SM, Chan KM, Culver D, Harrod CG, Hayney MS, Highland KB, Limper AH, Patrick H, Strange C, Whelan T. Monitoring of nonsteroidal immunosuppressive drugs in patients with lung disease and lung transplant recipients: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2012; 142:e1S-e111S. [PMID: 23131960 PMCID: PMC3610695 DOI: 10.1378/chest.12-1044] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2012] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVES Immunosuppressive pharmacologic agents prescribed to patients with diffuse interstitial and inflammatory lung disease and lung transplant recipients are associated with potential risks for adverse reactions. Strategies for minimizing such risks include administering these drugs according to established, safe protocols; monitoring to detect manifestations of toxicity; and patient education. Hence, an evidence-based guideline for physicians can improve safety and optimize the likelihood of a successful outcome. To maximize the likelihood that these agents will be used safely, the American College of Chest Physicians established a committee to examine the clinical evidence for the administration and monitoring of immunosuppressive drugs (with the exception of corticosteroids) to identify associated toxicities associated with each drug and appropriate protocols for monitoring these agents. METHODS Committee members developed and refined a series of questions about toxicities of immunosuppressives and current approaches to administration and monitoring. A systematic review was carried out by the American College of Chest Physicians. Committee members were supplied with this information and created this evidence-based guideline. CONCLUSIONS It is hoped that these guidelines will improve patient safety when immunosuppressive drugs are given to lung transplant recipients and to patients with diffuse interstitial lung disease.
Collapse
Affiliation(s)
| | - Keith C Meyer
- University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | - Luis Angel
- University of Texas Health Sciences, San Antonio, TX
| | | | - Kevin M Chan
- University of Michigan Health Systems, Ann Arbor, MI
| | | | | | - Mary S Hayney
- University of Wisconsin School of Pharmacy, Madison, WI
| | | | | | | | | | | |
Collapse
|
36
|
Treede H, Glanville AR, Klepetko W, Aboyoun C, Vettorazzi E, Lama R, Bravo C, Knoop C, Aubert JD, Reichenspurner H. Tacrolimus and cyclosporine have differential effects on the risk of development of bronchiolitis obliterans syndrome: Results of a prospective, randomized international trial in lung transplantation. J Heart Lung Transplant 2012; 31:797-804. [DOI: 10.1016/j.healun.2012.03.008] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Revised: 03/11/2012] [Accepted: 03/27/2012] [Indexed: 10/28/2022] Open
|
37
|
Abstract
Immunosuppressive therapy has contributed significantly to improved survival after solid organ transplantation. Nevertheless, treatment-related adverse events and persistently high risk of chronic graft rejection remain major obstacles to long-term survival after lung transplantation. The development of new agents, refinements in techniques to monitor immunosuppression, and enhanced understanding of transplant immunobiology are essential for further improvements in outcome. In this article, conventional immunosuppressive regimens, novel approaches to preventing graft rejection, and investigational agents for solid organ transplantation are reviewed.
Collapse
Affiliation(s)
- Timothy Floreth
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago Medical Center, Chicago, IL 60637, USA
| | | | | |
Collapse
|
38
|
Mangi AA, Mason DP, Nowicki ER, Batizy LH, Murthy SC, Pidwell DJ, Avery RK, McCurry KR, Pettersson GB, Blackstone EH. Predictors of Acute Rejection After Lung Transplantation. Ann Thorac Surg 2011; 91:1754-62. [DOI: 10.1016/j.athoracsur.2011.01.076] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2010] [Revised: 01/19/2011] [Accepted: 01/21/2011] [Indexed: 11/25/2022]
|
39
|
Immunosuppression-induced bronchial epithelial–mesenchymal transition: A potential contributor to obliterative bronchiolitis. J Thorac Cardiovasc Surg 2011; 141:523-30. [DOI: 10.1016/j.jtcvs.2010.10.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2010] [Revised: 09/24/2010] [Accepted: 10/03/2010] [Indexed: 11/22/2022]
|
40
|
Watts AB, Peters JI, Talbert RL, O'Donnell KP, Coalson JJ, Williams RO. Preclinical evaluation of tacrolimus colloidal dispersion for inhalation. Eur J Pharm Biopharm 2010; 77:207-15. [PMID: 21130874 DOI: 10.1016/j.ejpb.2010.11.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2010] [Revised: 11/22/2010] [Accepted: 11/22/2010] [Indexed: 01/14/2023]
Abstract
Substantial improvements in transplant therapy have been made in the past four decades resulting in the acceptance of organ transplantation as a viable treatment for late-stage disease and organ failure. More recently, lung transplantation has gained acceptance; however, high incidence of chronic rejection and opportunistic infections has limited success rates in comparison with other transplant procedures. To achieve more targeted therapy, pulmonary administration of nebulized tacrolimus (TAC) colloidal dispersion once daily for 28 consecutive days in Sprague Dawley (SD) rats has been investigated for safety and systemic elimination. A liquid dispersion of colloidal TAC and lactose (1:1 ratio by weight) was aerosolized using a vibrating mesh nebulizer and administered via a nose-only dosing chamber. Blood chemistry and histological comparisons to saline-dosed animals showed no clinically significant differences in liver and kidney function or lung tissue damage. Maximum blood and lung concentrations sampled 1h after the final dose showed TAC concentrations of 10.1 ± 1.4 ng/mL and 1758.7 ± 80.0 ng/g, respectively. Twenty-four hours after the final dose, systemic TAC concentrations measured 1.0 ± 0.5 ng/mL, which is well below clinically accepted trough concentrations (5-15 ng/mL) for maintenance therapy, and therefore, would not be expected to induce toxic side effects. The propensity for pulmonary retention seen when compared to single dose lung levels may be due to macrophage uptake and the lipophilic nature of TAC. Additionally, three month stability testing of TAC powder for reconstitution showed no changes in amorphous nature or drug potency when stored at ambient conditions. TAC colloidal dispersion proved to be non-toxic when administered by pulmonary inhalation to SD rats over 28 days while providing therapeutic concentrations locally. This delivery strategy may prove safe and effective for the prevention of lung allograft rejection in lung transplant recipients.
Collapse
Affiliation(s)
- Alan B Watts
- University of Texas at Austin, Austin, TX 78712, USA
| | | | | | | | | | | |
Collapse
|
41
|
Groves S, Galazka M, Johnson B, Corcoran T, Verceles A, Britt E, Todd N, Griffith B, Smaldone GC, Iacono A. Inhaled cyclosporine and pulmonary function in lung transplant recipients. J Aerosol Med Pulm Drug Deliv 2010; 23:31-9. [PMID: 19580368 DOI: 10.1089/jamp.2009.0748] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Chronic rejection, manifesting as bronchiolitis obliterans, is the leading cause of death in lung transplant recipients. In our previously reported double-blinded, placebo-controlled trial comparing inhaled cyclosporine (ACsA) to aerosol placebo, the rate of bronchiolitis-free survival improved. However, an independent analysis of pulmonary function, a secondary endpoint of the trial, was not performed. We sought to determine the effect of ACsA, in addition to systemic immunosuppression, on pulmonary function. METHODS From 1998-2001, 58 patients were randomly assigned to inhale either 300 mg of ACsA (28 patients) or placebo aerosol (30 patients) 3 days a week for the first 2 years after transplantation. Longitudinal changes in pulmonary function of ACsA patients were compared to aerosol placebo patients. In another analysis, the rate of decline from 6-month maximum FEV(1) in randomized patients was compared to the rate of decline in patients receiving conventional immunosuppression from the Novartis transplant database (644 patients, 12 centers worldwide, transplanted from 1990-1995). RESULTS The average duration of ACsA and aerosol placebo was 400 days +/- 306 and 433 +/- 256, respectively. The change in FEV(1) of ACsA patients (adjusted for Cytomegalovirus (CMV) mismatch and transplant type, followed for a maximum duration of 4.6 years) was superior to the aerosol placebo controls (9.0 +/- 71.4 mL/year vs. -107.9 +/- 55.3, p = 0.007). The FEF(25-75) decreased by -220.3 +/- 117.7 L/(second x year) vs. -412.2 +/- 139.2, p = 0.07, respectively. Similarly, percent FEV(1) decline from maximal values was improved in ACsA patients compared to aerosol placebo and Novartis controls (ACsA -0.43 +/- 1.12%/year vs. aerosol placebo -4.08 +/- 1.4, p = 0.04; ACsA vs. Novartis -4.7 +/- 0.31, p = 0.007). Single-lung recipients receiving ACsA showed improvement in FEV(1) compared to Novartis controls (FEV(1) -0.8 +/- 1.8%/year vs. -4.94 +/- 0.4, p = 0.03) but double-lung recipients showed improvement compared to aerosol placebo controls only (FEV(1) -0.28 +/- 1.22%/year vs. -8.53 +/- 5.95, p = 0.048). CONCLUSIONS In this single center trial, ACsA appears to ameliorate important pulmonary function parameters in lung transplant recipients compared to aerosol placebo and historical control patients. Single- and double-lung transplant recipients may not respond uniformly to treatment, and ongoing randomized trials in lung transplant recipients using ACsA may help elucidate our findings.
Collapse
Affiliation(s)
- Soleyah Groves
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine , Baltimore, Maryland, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
42
|
Tacrolimus versus cyclosporine for adult lung transplant recipients: a meta-analysis. Transplant Proc 2009; 41:1821-4. [PMID: 19545736 DOI: 10.1016/j.transproceed.2008.11.016] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2008] [Accepted: 11/14/2008] [Indexed: 11/23/2022]
Abstract
BACKGROUND Tacrolimus and cyclosporine are the 2 major immunosuppressants for lung transplantation. Several studies have compared these 2 drugs, but the outcomes were not consistent. The aim of this meta-analysis of randomized controlled trials (RCTs) was to compare the beneficial and harmful effects of tacrolimus and cyclosporine as the primary immunosuppressant for lung transplant recipients. METHODS We conducted searches of electronic databases and manual bibliographies. We performed a meta-analysis of all RCTs comparing tacrolimus with cyclosporine as primary immunosuppression for lung transplant recipients. Extracted, pooled data for mortality, acute rejection, withdrawals, and adverse events were analyzed using Mantel-Haenszel tests with a random effects model. RESULTS Three RCTs including 297 patients were assessed in this study. Mortality at 1 year or more was comparable between lung recipients treated with tacrolimus and cyclosporine (odds ratio [OR], 0.94; 95% confidence interval [CI], 0.42-2.10; P = .88). Tacrolimus-treated patients experienced fewer incidences of acute rejection (MD = -0.14; 95% CI, -0.28 to -0.01; P = .04). Pooled analysis showed a trend toward a lower risk of bronchiolitis obliterans syndrome (BOS) among tacrolimus-treated patients, although it did not reach significances (OR, 0.53; 95% CI, 0.25-1.12; P = .10). Fewer patients stopped tacrolimus than cyclosporine (OR, 0.12; 95% CI, 0.03-0.48; P = .003). The rate of new-onset diabetes was higher among the tacrolimus group (OR, 3.69; 95% CI, 1.17-11.62; P = .03). The incidence of hypertension and renal dysfunction were comparable in these 2 groups (OR, 0.24; 95% CI, 0.03-1.70; P = .15; and OR, 1.67; 95% CI, 0.70-3.96; P = .25, respectively). There was a trend toward lower risk of malignancy in tacrolimus-treated patients, although it did not reach significance either (OR, 0.19; 95% CI, 0.03-1.13; P = .07). The incidence of infection was comparable in these 2 groups (MD = -0.29, 95% CI, -0.68 to 0.11; P = .16). CONCLUSION Using tacrolimus as primary immunosuppressant for lung transplant recipient resulted in comparable survival and reduction in acute rejection episodes when compared with cyclosporine.
Collapse
|
43
|
Watts AB, Cline AM, Saad AR, Johnson SB, Peters JI, Williams RO. Characterization and pharmacokinetic analysis of tacrolimus dispersion for nebulization in a lung transplanted rodent model. Int J Pharm 2009; 384:46-52. [PMID: 19782740 DOI: 10.1016/j.ijpharm.2009.09.040] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2009] [Revised: 09/17/2009] [Accepted: 09/18/2009] [Indexed: 11/27/2022]
Abstract
Lung transplantation animal models have been well established and enabled the investigation of a variety of new pharmacotherapeutic strategies for prevention of lung allograft rejection. Direct administration of immunosuppressive agents to the lung is a commonly investigated approach; however, can prove challenging due to the poor solubility of the drug molecule, the tortuous pathways of the lung periphery, and the limited number of excipients approved for inhalation. In this study, we aimed to evaluate a solubility enhancing formulation of tacrolimus for localized therapy in a lung transplanted rat model and determine the extent of drug absorption into systemic circulation. Characterization of the nebulized tacrolimus dispersion for nebulization showed a fine particle fraction (FPF) of 46.1% and a mass median aerodynamic diameter (MMAD) of 4.06 microm. After single dose administration to transplanted and non-transplanted rats, a mean peak transplanted lung concentration of 399.8+/-29.2 ng/g and mean peak blood concentration of 4.88+/-1.6 ng/mL were achieved. It is theorized that enhanced lung retention of tacrolimus is due to lipophilic associations with bronchial tissue and phospholipid surfactants in lung fluid. These findings indicate that tacrolimus dispersion for nebulization can achieve highly localized therapy for lung transplant recipients.
Collapse
Affiliation(s)
- Alan B Watts
- The University of Texas at Austin, College of Pharmacy, 1 University Station A1920, Austin, TX 78712, USA
| | | | | | | | | | | |
Collapse
|
44
|
Immunosuppressive therapy in lung transplantation: state of the art. Eur J Cardiothorac Surg 2009; 35:1045-55. [DOI: 10.1016/j.ejcts.2009.02.035] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2008] [Revised: 02/03/2009] [Accepted: 02/20/2009] [Indexed: 11/21/2022] Open
|
45
|
Celik MR, Lederer DJ, Wilt J, Eser D, Bacchetta M, D'Ovidio F, Sonett JR, Arcasoy SM. Tacrolimus and azathioprine versus cyclosporine and mycophenolate mofetil after lung transplantation: a retrospective cohort study. J Heart Lung Transplant 2009; 28:697-703. [PMID: 19560698 DOI: 10.1016/j.healun.2009.04.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2008] [Revised: 03/11/2009] [Accepted: 04/07/2009] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND The efficacy and safety of different combinations of immunosuppressive regimens after lung transplantation are unknown. METHODS We examined 120 consecutive transplant recipients between July 2001 and July 2005, of whom 37 received cyclosporine and mycophenolate mofetil (Cyc/MMF) and 83 received tacrolimus and azathioprine (Tac/Aza) as the initial immunosuppressive regimen along with an interleukin-2 antagonist induction therapy. The primary outcome was the rate of histologically confirmed acute rejection. RESULTS The rate of acute rejection did not vary by treatment regimen (0.42 vs 0.34 episodes per 100 person-days in Cyc/MMF and Tac/Aza groups, respectively, p = 0.22). The mean cumulative lymphocytic bronchiolitis score was greater in the Cyc/MMF group (1.8 +/- 1.9) compared with the Tac/Aza group (1.2 +/- 2.0; p = 0.03). Pulmonary function at 1 year was better in the Tac/Aza group, even when adjusted for recipient age, gender, and transplant procedure. Survival and the rate of bronchiolitis obliterans syndrome did not vary by group. CONCLUSIONS Outcomes after lung transplantation did not meaningfully vary between those assigned to Cyc/MMF compared with Tac/Aza combined with IL-2 inhibitor induction therapy.
Collapse
Affiliation(s)
- Muhammet R Celik
- Department of Surgery, College of Physicians and Surgeons, Columbia University Medical Center, New York, New York
| | | | | | | | | | | | | | | |
Collapse
|
46
|
Watts AB, Williams RO, Peters JI. Recent Developments in Drug Delivery to Prolong Allograft Survival in Lung Transplant Patients. Drug Dev Ind Pharm 2009; 35:259-71. [DOI: 10.1080/03639040802282904] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
|
47
|
Neurohr C, Huppmann P, Zimmermann G, Leuchte H, Baumgartner R, Hatz R, Frey L, Uberfuhr P, Bittmann I, Behr J, Reichart B. Tacrolimus and mycophenolate mofetil as first line immunosuppression after lung transplantation. Transpl Int 2009; 22:635-43. [PMID: 19207186 DOI: 10.1111/j.1432-2277.2009.00843.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The optimal maintenance therapy after lung transplantation remains to be established. The aim of this study was to analyse the impact of tacrolimus and mycophenolate mofetil (MMF) as first line immunosuppression on long-term survival and Bronchiolitis Obliterans Syndrome (BOS). From January 1996 through December 2006, all 155 recipients receiving tacrolimus and MMF as maintenance immunosuppression were included in this study. Tacrolimus and MMF was discontinued in 36 patients (23.2%). The overall survival rates were 91.6% at 6 months, 86.4% at 1 year, 74.9% at 3 years, 60.3% at 5 years and 32.4% at 10 years. The overall freedom from acute rejection was 74.6%, 63.2% and 59.4% at 1, 3, and 5 years respectively. The overall BOS-free survival was 95.6% at 1 year, 88.4% at 3 years, 69.5% at 5 years and 30.5% at 10 years. The development of BOS > or = 1 was associated with a significantly increased risk of death and reduced long-term survival. The combination of tacrolimus and MMF offers safe and reliable maintenance immunosuppression after lung transplantation. However, substantial improvements of long-term survival and freedom from BOS might only be achieved by a change in organ allocation policies and patient management beyond differential immunosuppressive protocols.
Collapse
Affiliation(s)
- Claus Neurohr
- Department of Int. Medicine I, Division of Pulmonary Diseases, Klinikum Grosshadern, Ludwig-Maximilians University, Munich, Germany.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
48
|
Sato M, Keshavjee S. Bronchiolitis obliterans syndrome: alloimmune-dependent and -independent injury with aberrant tissue remodeling. Semin Thorac Cardiovasc Surg 2008; 20:173-82. [PMID: 18707652 DOI: 10.1053/j.semtcvs.2008.05.002] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2008] [Indexed: 12/21/2022]
Abstract
Long-term success in lung transplantation continues to be challenged by chronic graft dysfunction, which is manifest as bronchiolitis obliterans syndrome (BOS). The mechanisms of BOS involve both immune-mediated pathways (rejection, autoimmune-like mechanisms), and alloimmune-independent pathways (infection, aspiration, ischemia, primary graft failure), which lead to a fibroproliferative responses. BOS correlates histologically with obliterative bronchiolitis in terminal bronchioles and evidence of aberrant remodeling in the airway epithelium, vasculature, stroma, and lymphoid system. A potentially important mechanism that supports the progressive and therapy-resistant nature of BOS is a continuous cycle of ongoing injury and aberrant remodeling. Namely, anatomical and functional abnormalities induce and exacerbate immune-mediated and alloimmune-independent pathways through various mechanisms (e.g., epithelial remodeling decreases mucociliary clearance that exacerbates aspiration-related injury). From this viewpoint, we review current therapeutic strategies and revisit the role of transplant surgeons in attenuating the initial transplant-related injuries to prevent the lung grafts from entering the remodeling-injury cycle.
Collapse
Affiliation(s)
- Masaaki Sato
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | |
Collapse
|
49
|
Ramos A. [Infections in the immunocompromised host. What is the role of the medications?]. REUMATOLOGIA CLINICA 2008; 4 Suppl 2:1-6. [PMID: 21794556 DOI: 10.1016/s1699-258x(08)76160-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Infections in patients with connective tissue diseases (CTD) are associated to considerable morbidity and mortality. Some patients with CTD suffer a certain degree of immune deregulation inherent to their rheumatic disease. Other factors such as advanced age, and the coexistence of other chronic diseases such as diabetes mellitus can also lead to the development of infection. Glucocoticosteroids induce a reduction in the synthesis of most of the known cytokines, an alteration in the migration of leukocytes from the blood with an alteration in antigen presentation and an abnormal cytotoxic response. Immunosuppresants fundamentally affect cellular immunity and its effect is related to the duration of treatment and dose. There is a clear relationship between the use of anti-TNF drugs and the reactivation of tuberculosis. Its clinical and histological manifestations are frequently atypical. In those cases in which active tuberculosis is suspected, anti-TNF must be suspended until infection is ruled out. Prophylactic treatment when faced with Pneumocystis jiroveci with cotrimoxazole has been recommended in patients that receive steroids and immunosuppressants, especially if the agent employed is cyclophosphmide or if lymphopenia develops.
Collapse
Affiliation(s)
- Antonio Ramos
- Unidad de Enfermedades Infecciosas-Medicina Interna. Hospital Universitario Puerta de Hierro. Universidad Autónoma de Madrid. Madrid. España
| |
Collapse
|
50
|
Lung Transplantation. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_88] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|