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Long-term, Prolonged-release Tacrolimus-based Immunosuppression in De Novo Liver Transplant Recipients: 5-year Prospective Follow-up of Patients in the DIAMOND Study. Transplant Direct 2021; 7:e722. [PMID: 34263020 PMCID: PMC8274734 DOI: 10.1097/txd.0000000000001166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 03/08/2021] [Accepted: 03/09/2021] [Indexed: 01/27/2023] Open
Abstract
Background Immunosuppression with calcineurin inhibitors (CNIs) is reportedly associated with risk of renal impairment in liver transplant recipients. It is believed that this can be mitigated by decreasing initial exposure to CNIs or delaying CNI introduction until 3-4 d posttransplantation. The ADVAGRAF studied in combination with mycophenolate mofetil and basiliximab in liver transplantation (DIAMOND) trial evaluated different administration strategies for prolonged-release tacrolimus (PR-T). Methods DIAMOND was a 24-wk, open-label, phase 3b trial in de novo liver transplant recipients randomized to: PR-T 0.2 mg/kg/d (Arm 1); PR-T 0.15-0.175 mg/kg/d plus basiliximab (Arm 2); or PR-T 0.2 mg/kg/d delayed until day 5 posttransplant plus basiliximab (Arm 3). In a 5-y follow-up, patients were maintained on an immunosuppressive regimen according to standard clinical practice (NCT02057484). Primary endpoint: graft survival (Kaplan-Meier analysis). Results Follow-up study included 856 patients. Overall graft survival was 84.6% and 73.5% at 1 and 5 y post transplant, respectively. Five-year rates for Arms 1, 2, and 3 were 74.7%, 71.5%, and 74.5%, respectively. At 5 y, death-censored graft survival in the entire cohort was 74.7%. Overall graft survival in patients remaining on PR-T for ≥30 d was 79.1%. Graft survival in patients who remained on PR-T at 5 y was 87.3%. Patient survival was 86.6% at 1 y and 76.3% at 5 y, with survival rates similar in the 3 treatment arms at 5 y. Estimated glomerular filtration rate at the end of the 24-wk initial study and 5 y posttransplant was 62.1 and 61.5 mL/min/1.73 m2, respectively, and was similar between the 3 treatment arms at 5 y. Overall, 18 (2.9%) patients had ≥1 adverse drug reaction, considered possibly related to PR-T in 6 patients. Conclusions In the DIAMOND study patient cohort, renal function, graft survival, and patient survival were similar between treatment arms at 5 y posttransplant.
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Population pharmacogenetic pharmacokinetic modeling for flip-flop phenomenon of enteric-coated mycophenolate sodium in kidney transplant recipients. Eur J Clin Pharmacol 2014; 70:1211-9. [DOI: 10.1007/s00228-014-1728-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Accepted: 08/01/2014] [Indexed: 01/06/2023]
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Gao X, Ma Y, Sun L, Chen D, Mei C, Xu C. Cyclosporine A for the treatment of refractory nephrotic syndrome with renal dysfunction. Exp Ther Med 2013; 7:447-450. [PMID: 24396423 PMCID: PMC3881069 DOI: 10.3892/etm.2013.1446] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 12/04/2013] [Indexed: 11/25/2022] Open
Abstract
Cyclosporine A (CsA) is an immunosuppressant agent and is utilized as a second-line drug therapy for refractory nephrotic syndrome (RNS). In general, the use of CsA is strictly controlled in patients with an estimated glomerular filtration rate (eGFR) <30–40 ml/min/1.73 m2, and little is known about the safety and efficacy of CsA treatment in patients with RNS complicated by renal dysfunction. In the present study, the clinical data of 10 patients with RNS and renal dysfunction, who received CsA treatment between 2000 and 2009 in the Kidney Institute of PLA, were reviewed retrospectively. Pathologically, these patients included six cases with minimal change, two cases of diffuse mesangial proliferation and two cases of focal segmental glomerulosclerosis. Six months subsequent to the initiation of the CsA treatment, six patients achieved complete remission, two patients achieved remarkable remission and two patients achieved partial remission. Renal function was improved in all patients as represented by the improvement in the eGFR (28.6±3.8 ml/min/1.73 m2 prior to treatment versus 99.3±21.9 ml/min/1.73 m2 6 months subsequent to treatment). Few adverse CsA-related events were observed. These results suggest that renal dysfunction is not an absolute contraindication for CsA treatment in patients with RNS. The use of CsA is safe and efficacious and may, in certain cases, improve renal function in patients with RNS and renal impairment.
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Affiliation(s)
- Xiang Gao
- Department of Medicine, Kidney Institute of PLA, Changzheng Hospital, Second Military Medical University, Shanghai 200003, P.R. China
| | - Yiyi Ma
- Department of Medicine, Kidney Institute of PLA, Changzheng Hospital, Second Military Medical University, Shanghai 200003, P.R. China
| | - Lijun Sun
- Department of Medicine, Kidney Institute of PLA, Changzheng Hospital, Second Military Medical University, Shanghai 200003, P.R. China
| | - Dongping Chen
- Department of Medicine, Kidney Institute of PLA, Changzheng Hospital, Second Military Medical University, Shanghai 200003, P.R. China
| | - Changlin Mei
- Department of Medicine, Kidney Institute of PLA, Changzheng Hospital, Second Military Medical University, Shanghai 200003, P.R. China
| | - Chenggang Xu
- Department of Medicine, Kidney Institute of PLA, Changzheng Hospital, Second Military Medical University, Shanghai 200003, P.R. China
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Beckebaum S, Cicinnati VR, Radtke A, Kabar I. Calcineurin inhibitors in liver transplantation - still champions or threatened by serious competitors? Liver Int 2013; 33:656-65. [PMID: 23442173 DOI: 10.1111/liv.12133] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2012] [Accepted: 01/29/2013] [Indexed: 12/14/2022]
Abstract
Current strategies for immunosuppression in liver transplant (LT) recipients include the design of protocols targeting a more individualized approach to reduce risk factors such as renal failure, cardiovascular complications and malignancies. Renal injury in LT recipients may be often multifactorial and is associated with increased risk of post-transplant morbidity and mortality. The quest for low toxicity immunosuppressive regimens has been challenging and resulted in CNI minimization protocols or CNI withdrawal and conversion to mycophenolate mofetil (MMF) and/or mammalian target of rapamycin inhibitor-based immunosuppressive regimens. Use of antibody induction to delay CNI administration may be an option in particular in immunocompromized, critically ill patients with high MELD scores. Protocols including MMF introduction and concomitant CNI minimization have the potential to recover renal function even in the medium and long term after LT. We review on hot topics in the prevention and management of acute and chronic renal injury in LT patients. For this purpose, we present and critically discuss results from immunosuppressive studies published in the current literature or presented at recent LT meetings.
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Affiliation(s)
- Susanne Beckebaum
- Department of Transplant Medicine, Muenster University Hospital, Muenster, Germany.
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Saner FH, Cicinnati VR, Sotiropoulos G, Beckebaum S. Strategies to prevent or reduce acute and chronic kidney injury in liver transplantation. Liver Int 2012; 32:179-88. [PMID: 21745304 DOI: 10.1111/j.1478-3231.2011.02563.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Acute kidney injury (AKI) has a major impact on short- and long-term survival in liver transplant (LT) patients. There is no currently accepted uniform definition of AKI, which would facilitate standardization of the care of patients with AKI and to improve and enhance collaborative research efforts. New promising biomarkers such as neutrophil gelatinase-associated lipocalin or kidney injury molecule-1 have been developed for the prevention of delayed AKI treatment. Early dialysis has been shown to be beneficial in patients with AKI stage III according to the classification of the Acute Kidney Injury Network, whereas treatment with loop diuretics or dopamine is associated with worse outcome. The mainstay for the prevention of AKI seems to be avoidance of volume depletion and maintenance of a mean arterial pressure >65 mmHg. Although the aetiology of chronic kidney disease in transplant recipients may be multifactorial, calcineurin-inhibitor (CNI)-induced nephrotoxicity significantly contributes to the development of renal dysfunction over time after LT. The delayed introduction of CNI at minimal doses has shown to be safe and effective for the preservation of kidney function. Other strategies to overcome CNI nephrotoxicity include CNI minimization protocols or CNI withdrawal and conversion to mycophenolate mofetil or the mammalian target of rapamycin inhibitor-based immunosuppressive regimens. However, CNI avoidance may bear a higher rejection risk. Thus, more results from randomized-controlled studies are urgently warranted to determine which drug combinations are the most beneficial approaches for the potential introduction of CNI-free immunosuppressive regimens.
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Affiliation(s)
- Fuat H Saner
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, Essen, Germany
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Kong Y, Wang D, Shang Y, Liang W, Ling X, Guo Z, He X. Calcineurin-inhibitor minimization in liver transplant patients with calcineurin-inhibitor-related renal dysfunction: a meta-analysis. PLoS One 2011; 6:e24387. [PMID: 21931704 PMCID: PMC3170329 DOI: 10.1371/journal.pone.0024387] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Accepted: 08/08/2011] [Indexed: 12/13/2022] Open
Abstract
Background Introduction of calcineurin-inhibitor (CNI) has made transplantation a miracle in the past century. However, the side effects of long-term use of CNI turn out to be one of the major challenges in the current century. Among these, renal dysfunction attracts more and more attention. Herein, we undertook a meta-analysis to evaluate the efficacy and safety of calcineurin-inhibitor (CNI) minimization protocols in liver transplant recipients with CNI-related renal dysfunction. Methods We included randomized trials with no year and language restriction. All data were analyzed using random effect model by Review Manager 5.0. The primary endpoints were glomerular filtration rate (GFR), serum creatinine level (sCr) and creatinine clearance rate (CrCl), and the secondary endpoints were acute rejection episodes, incidence of infection and patient survival at the end of follow-up. Results GFR was significantly improved in CNI minimization group than in routine CNI regimen group (Z = 5.45, P<0.00001; I2 = 0%). Likely, sCr level was significantly lower in the CNI minimization group (Z = 2.84, P = 0.005; I2 = 39%). However, CrCl was not significantly higher in the CNI minimization group (Z = 1.59, P = 0.11; I2 = 0%). Both acute rejection episodes and patient survival were comparable between two groups (rejection: Z = 0.01, P = 0.99; I2 = 0%; survival: Z = 0.28, P = 0.78; I2 = 0%, respectively). However, current CNI minimization protocols may be related to a higher incidence of infections (Z = 3.06, P = 0.002; I2 = 0%). Conclusion CNI minimization can preserve or even improve renal function in liver transplant patients with renal impairment, while sharing similar short term acute rejection rate and patient survival with routine CNI regimen.
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Affiliation(s)
- Yuan Kong
- Organ Transplant Center, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Dongping Wang
- Organ Transplant Center, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yushu Shang
- Organ Transplant Center, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wenhua Liang
- Organ Transplant Center, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiaoting Ling
- Organ Transplant Center, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhiyong Guo
- Organ Transplant Center, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- * E-mail: (ZG); (XH)
| | - Xiaoshun He
- Organ Transplant Center, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- * E-mail: (ZG); (XH)
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Basiliximab induction and delayed calcineurin inhibitor initiation in liver transplant recipients with renal insufficiency. Transplantation 2011; 91:1254-60. [PMID: 21617588 DOI: 10.1097/tp.0b013e318218f0f5] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Renal insufficiency (RI) is common after liver transplantation (LT) and may worsen due to calcineurin inhibitor (CNI) use. We compared LT outcomes using basiliximab induction and delayed CNI initiation to controls with a standard CNI regimen in patients with peri-LT RI. METHODS All adults transplanted January 2004 to December 2007 with peri-LT RI (hemodialysis or creatinine ≥1.5 within 1 week of LT) were included in a retrospective nonrandomized cohort. Outcomes including 30-day and 1-year patient and graft survival and renal function were compared between basiliximab and control groups. RESULTS Two hundred twenty-nine patients (102 basiliximab, 127 controls) were analyzed, mean age 54 years, 72% men, 54% with hepatitis C virus. Mean model for end-stage liver disease (28.2 vs. 20.0; P<0.001) and creatinine (1.9 vs. 1.6; P=0.001) were higher and more patients were on hemodialysis at LT (29% vs. 6%; P<0.001) in the basiliximab group. 30-day patient (99% vs. 97%; P=0.26) and graft survival (98% vs. 95%; P=0.17), 1-year patient (87% vs. 87%; P=0.89) and graft survival (86% vs. 82%; P=0.37), mean creatinine at 1-year (1.5 vs. 1.5 mg/dL; P=0.82), and treated acute rejection (6% vs. 6%; P=0.90) were similar between basiliximab and control groups, respectively. In multivariable logistic regression, basiliximab was not significantly associated with 30-day (odds ratio, 0.10; P=0.11) or 1-year (odds ratio, 0.97; P=0.94) survival, controlling for age, previous LT, model for end-stage liver disease, and hepatitis C virus. CONCLUSIONS Basiliximab induction resulted in 30-day and 1-year patient, graft and renal outcomes comparable with a control group receiving standard CNI-based immunosuppression. Antibody induction with delayed CNI should be further studied prospectively.
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Kornberg A, Küpper B, Thrum K, Krause B, Büchler P, Kornberg J, Sappler A, Altendorf-Hofmann A, Wilberg J, Friess H. Sustained renal response to mycophenolate mofetil and CNI taper promotes survival in liver transplant patients with CNI-related renal dysfunction. Dig Dis Sci 2011; 56:244-51. [PMID: 20824504 DOI: 10.1007/s10620-010-1386-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2010] [Accepted: 08/04/2010] [Indexed: 12/22/2022]
Abstract
AIM The aim of this trial was to evaluate the impact of conversion from a calcineurin-inhibitor (CNI)-based immunosuppressive regimen to mycophenolate mofetil (MMF) and reduced-dose CNI on long-term renal function and survival in a series of 63 liver transplant patients with CNI-induced renal dysfunction. METHODS CNI dosage was significantly tapered after introduction of 2,000 mg MMF per day. Renal function was assessed by determination of serum creatinine levels and calculated creatinine clearance (CCl). The impact of relevant clinical parameters on renal function and survival post-conversion was analyzed by univariate and multivariate analysis. RESULTS At 60 months post-conversion, mean creatinine level had significantly declined from 197.2±58.3 μmol/l at baseline to 160.0±76.5 μmol/l, and mean CCl has significantly increased from 38.4±13.4 ml/min at baseline to 47.9±21.1 ml/min (p<0.001), respectively. Forty-six patients (73.1%) demonstrated sustained renal response to modified immunosuppression. Full-dose MMF medication (p=0.006) and the early conversion (p=0.02) were identified as independent predictors of persistent renal function improvement. Sustained renal response to MMF plus reduced-dose CNI was identified as the most relevant independent promoter of long-term survival (hazard ratio 6.9). Five-year survival rate post-conversion was 93.9% in renal responders and 64.3% in renal non-responders (log rank<0.001). CONCLUSIONS Sustained renal response to MMF and CNI dose reduction promotes long-term survival in liver transplant patients with CNI-induced renal dysfunction.
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Affiliation(s)
- A Kornberg
- Department of Surgery, Klinikum Rechts der Isar, TU Munich, Ismaningerstr. 22, 81675, Munich, Germany.
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9
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Conversion to combined mycophenolate mofetil and low-dose calcineurin inhibitor therapy for renal dysfunction in liver transplant patients: never too late? Dig Dis Sci 2011; 56:4-6. [PMID: 21049289 PMCID: PMC3010221 DOI: 10.1007/s10620-010-1449-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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10
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Combined Mycophenolate Mofetil and Minimal Dose Calcineurin Inhibitor Therapy in Liver Transplant Patients: Clinical Results of a Prospective Randomized Study. Transplant Proc 2009; 41:2567-9. [DOI: 10.1016/j.transproceed.2009.06.152] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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11
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Neuberger JM, Mamelok RD, Neuhaus P, Pirenne J, Samuel D, Isoniemi H, Rostaing L, Rimola A, Marshall S, Mayer AD. Delayed introduction of reduced-dose tacrolimus, and renal function in liver transplantation: the 'ReSpECT' study. Am J Transplant 2009; 9:327-36. [PMID: 19120077 DOI: 10.1111/j.1600-6143.2008.02493.x] [Citation(s) in RCA: 200] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
We report a multicenter, prospective, randomized, open-label trial investigating the effect of lower levels and delayed introduction of tacrolimus on renal function in liver transplant recipients. Adult patients with good renal function undergoing primary liver transplant were randomized to either: group A (standard-dose tacrolimus [target trough levels >10 ng/mL] and corticosteroids; n = 183); group B (mycophenolate mofetil [MMF] 2g/day, reduced-dose tacrolimus [target trough levels </=8 ng/mL], and corticosteroids; n = 170); group C (daclizumab induction, MMF, reduced-dose tacrolimus delayed until the fifth day posttransplant and corticosteroids, n = 172). The primary endpoint was change from baseline in estimated glomerular filtration rate (eGFR) at 52 weeks. The eGFR decreased by 23.61, 21.22 and 13.63 mL/min in groups A, B and C, respectively (A vs C, p = 0.012; A vs B, p = 0.199). Renal dialysis was required less frequently in group C versus group A (4.2% vs. 9.9%; p = 0.037). Biopsy-proven acute rejection rates were 27.6%, 29.2% and 19.0%, respectively. Patient and graft survival was similar. In conclusion, daclizumab induction, MMF, corticosteroids and delayed reduced-dose tacrolimus was associated with less nephrotoxicity than therapy with standard-dose tacrolimus and corticosteroids without compromising efficacy or tolerability.
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Affiliation(s)
- J M Neuberger
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK.
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12
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Kornberg A, Küpper B, Wilberg J, Tannapfel A, Thrum K, Bärthel E, Hommann M, Settmacher U. Conversion to mycophenolate mofetil for modulating recurrent hepatitis C in liver transplant recipients. Transpl Infect Dis 2007; 9:295-301. [PMID: 17511824 DOI: 10.1111/j.1399-3062.2007.00228.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND The aim of this study was to analyze the influence of cyclosporine A (CsA) taper in conjunction with mycophenolate mofetil (MMF) therapy on recurrent hepatitis C virus (HCV) in liver transplant patients. PATIENTS AND METHODS Nineteen liver recipients with serologically and morphologically confirmed recurrent HCV were included in this study. After MMF introduction up to a maximum dose of 2000 mg/day, CsA dose was significantly tapered. In the control group immunosuppression remained unchanged. Allograft function and morphology, viral loads, and renal function were analyzed continuously. RESULTS MMF treatment was well tolerated without risk of rejection. Allograft fibrosis progressed in 6 patients of the MMF group (66.6%) and none (0%) of the controls at 12-month biopsy (P=0.005). Moreover, aminotransferases and viral loads increased slightly in the MMF-treated patients. Renal function improved significantly (serum creatinine: 239.3+/-90.2 micromol/L vs. 175.8+/-46.0 micromol/L; P=0.008) in the treatment group, while deteriorating (serum creatinine: 156.8+/-44.6 micromol/L vs. 214.8+/-120.1 micromol/L; P=0.06) in the controls. CONCLUSION MMF introduction allows a safe CsA taper in HCV-positive liver transplant patients and results in significant improvement of renal function. However, there seems to be a risk of marked progression of HCV-induced allograft injury.
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Affiliation(s)
- A Kornberg
- Department of General, Visceral and Vascular Surgery, Friedrich-Schiller-University, Jena, Germany.
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13
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Cicinnati VR, Yu Z, Klein CG, Sotiropoulos GC, Saner F, Malagó M, Frilling A, Gerken G, Broelsch CE, Beckebaum S. Clinical trial: switch to combined mycophenolate mofetil and minimal dose calcineurin inhibitor in stable liver transplant patients--assessment of renal and allograft function, cardiovascular risk factors and immune monitoring. Aliment Pharmacol Ther 2007; 26:1195-208. [PMID: 17944734 DOI: 10.1111/j.1365-2036.2007.03466.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Calcineurin inhibitor (CNI)-related nephrotoxicity significantly contributes to chronic renal failure after liver transplantation. METHODS In this prospective study, liver transplantation patients with renal dysfunction were randomized either to receive mycophenolate mofetil (MMF) followed by stepwise reduction of CNI with defined minimal CNI-trough levels (MMF group), or to continue their maintenance CNI dose (control group). Immune monitoring was performed in a subgroup of the patients. RESULTS In the MMF group (n = 50), renal function assessed by serum creatinine improved >10% in 62% of patients, was stable in 36% and deteriorated >10% in 2% after 12 months compared with baseline values. Mean serum creatinine levels (+/- s.d.) significantly decreased from 1.90 +/- 0.44 mg/dL to 1.61 +/- 0.39 mg/dL and the corresponding calculated glomerular filtration rate significantly increased from 38.8 +/- 9.6 mL/min/1.73 m(2) to 47.0 +/- 11.8 mL/min/1.73 m(2) over a 12-month follow-up period. Blood pressure and levels of liver enzymes significantly decreased. In the control group (n = 25), there were no significant changes with respect to the investigated parameters. The MMF group had significantly lower numbers of circulating cytotoxic T cells compared with the controls; whereas regulatory T cells significantly increased. CONCLUSION Combined MMF and minimal dose CNI therapy after liver transplantation is nephroprotective and may promote allograft tolerance.
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Affiliation(s)
- V R Cicinnati
- Department of Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany
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Abstract
PURPOSE OF REVIEW Recent attention in liver transplantation has focused on equity in organ allocation and management of posttransplant complications. RECENT FINDINGS Adoption of the model for end-stage liver disease for liver allocation has been successful in implementing a system based on medical urgency rather than waiting time. Refinements are being studied in improving the prediction of mortality and improving transplant benefit by balancing pretransplant mortality and posttransplant survival. Emerging literature is examining expansion of the current criteria for transplantation of hepatocellular carcinoma and the role of neoadjuvant therapy. Chronic renal dysfunction after liver transplantation is a source of considerable morbidity. Nephron-sparing immunosuppression regimens are emerging with encouraging results. Hepatitis C virus infection is difficult to differentiate histologically from rejection, although newer markers are being developed. Antiviral and immunosuppressive strategies for reducing the severity of hepatitis C virus recurrence are discussed. Alcohol relapse is common after liver transplant in alcoholic liver disease patients and can lead to worse outcomes. SUMMARY Organ allocation tends to evolve under the model for end-stage liver disease with a focus on maximizing transplant benefit. Hepatitis C virus, hepatocellular carcinoma, chronic renal dysfunction and alcohol relapse are major challenges, and continued research in these areas will undoubtedly lead to better outcomes for transplant recipients.
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Affiliation(s)
- Adnan Said
- Section of Gastroenterology and Hepatology, University of Wisconsin-Madison, School of Medicine and Public Health, Madison, WI 53792, USA.
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Akamatsu N, Sugawara Y, Tamura S, Matsui Y, Kaneko J, Makuuchi M. Efficacy of mycofenolate mofetil for steroid-resistant acute rejection after living donor liver transplantation. World J Gastroenterol 2006; 12:4870-2. [PMID: 16937470 PMCID: PMC4087622 DOI: 10.3748/wjg.v12.i30.4870] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To discuss the use of mycophenolate mofetil (MMF) as an immunosuppressant in steroid resistant rejection after liver transplantation.
METHODS: The clinical records of 260 adult patients who underwent living donor liver transplantation (LDLT) were reviewed. Tacrolimus and methylprednisolone were used for primary immunosuppression. Acute rejection was first treated with steroids. When steroid resistance occurred, the patient was treated with a combination of steroids and MMF. Anti-T-cell monoclonal antibody was administered to patients who were not responsive to steroids in combination with MMF.
RESULTS: A total of 90 (35%) patients developed acute rejection. The median interval time from transplantation to the first episode was 15 d. Fifty-four patients were steroid resistant. Forty-four patients were treated with MMF and the remaining 10 required anti-T-cell monoclonal antibody treatment. Progression to chronic rejection was observed in one patient. Bone marrow suppression and gastrointestinal symptoms were the most common side effects associated with MMF use. There was no significant increase in opportunistic infections.
CONCLUSION: Our results demonstrate that MMF is a potent and safe immunosuppressive agent for rescue therapy in patients with acute rejection after LDLT.
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Affiliation(s)
- Nobuhisa Akamatsu
- Artificial Organ and Transplantation Division, Department of Surgery, University of Tokyo, Japan
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16
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Abstract
PURPOSE OF REVIEW Recent attention in liver transplantation has focused on equity in organ allocation and management of post-transplant complications. RECENT FINDINGS Adoption of the model for end-stage liver disease (MELD) for liver allocation has been successful in implementing a system based on medical urgency rather than waiting time. Refinements are being studied in reducing geographic disparities and improving transplant benefit by balancing pre-transplant mortality and post-transplant survival. With hepatocellular carcinoma becoming a bigger proportion of liver transplants since MELD, emerging literature is examining expansion of the current criteria for transplantation of hepatocellular carcinoma. Hepatitis C virus infection is associated with worse patient and graft survival post-transplantation than other liver diseases. The optimal timing and delivery of current antiviral therapy and immunosuppressive strategies in reducing the severity of hepatitis C virus recurrence post-transplantation are discussed. Chronic renal dysfunction after liver transplantation is a source of considerable morbidity. Nephron-sparing immunosuppression regimens are emerging with encouraging results. SUMMARY Organ allocation tends to evolve under MELD with a focus on reducing geographic disparities and maximizing transplant benefit. Hepatitis C virus, hepatocellular carcinoma and chronic renal dysfunction are a major challenge and continued research in these areas will undoubtedly lead to better outcomes for transplant recipients.
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Affiliation(s)
- Adnan Said
- Section of Gastroenterology and Hepatology, University of Wisconsin-Madison, School of Medicine and Public Health, 53792, USA.
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