Cardiovascular and renal interactions between cyclosporine and NSAIDs: Underlying mechanisms and clinical relevance

Cyclosporine: Immunosuppressive effects, entwined toxicity, and clinical modulations of an organ transplant drug

The discovery and use of cyclosporine since its inception into the clinics in the '70s and up have played a crucial role in advancing transplant therapy, and containment of the immune-based rejections. The drug has improved the high rates of acute rejections and has supported early graft survival. However, the long-term survival of renal allografts is still less prevalent, and an in-depth analysis, as well as reported findings led us to believe that there is a chronic irreversible component to the drug, that is tackled through its metabolites, and that causes toxicity, which has led to new therapies, including monoclonal antibody-based medications. A recap of the immunosuppressive effects, and entwined toxicity of the drug, now relegated primarily to bone marrow early transplants, is being overviewed for the past protocols that were used to minimize, and avoid, or use this calcineurin inhibitor class of drug, cyclosporine, in combination with other drugs. The current review circumvents the cyclosporine's mechanism of action, pathophysiology, cytochrome roles, and other factors associated with acute and chronic toxicity developments. The review also attempts to find conclusive strategies reported in the recent studies to avoid its toxic side effects, and develop a safe-use strategy for the drug. Gastrointestinal decontamination, supporting the airway, monitoring for signs of respiratory insufficiency, monitoring for severe reactions, such as seizures, need for administration of oxygen, and avoiding the administration of drugs, that increase the blood levels of the cyclosporine, are beneficial interventions, when encountering cyclosporine toxicity cases. The constrained therapeutic outcomes have also led to redesign, and making use of combined formulations to reassess the pharmacokinetics of the drug.

Causal effects of rheumatoid arthritis or ankylosing spondylitis on membranous nephropathy: a two-sample Mendelian randomization study

Background

Membranous nephropathy (MN) is the leading cause of adult-onset nephrotic syndrome, with primary MN of unclear cause accounting for 80% of cases. Retrospective clinical research reported that MN occurring in rheumatoid arthritis (RA) and ankylosing spondylitis (AS) patients was triggered by nephrotoxic drugs or of unknown cause. However, whether RA or AS itself increases the risk of developing MN is unknown.

Methods

We conducted mendelian randomization (MR) analysis to evaluate the causal effects of RA or AS on MN using genome-wide association study (GWAS) statistics. The inverse variance weighted (IVW) method was the primary analysis, and several supplementary analyses and sensitivity analyses were performed to test the causal estimates.

Results

We obtained 30 valid instrumental variables (IVs) of RA and 16 valid IVs of AS from large-scale open-access GWASs. The genetically predicted RA significantly increased the risk of MN [IVW odds ratios (OR) = 1.327, 95% confidence interval (CI) = (1.124, 1.565), P = 8.051 × 10-4]. Three supplementary MR analyses provided the consistent positive causal effect of RA on MN (all P < 0.05). No horizontal pleiotropy was detected by MR Egger intercept analysis (P = 0.411). However, the genetically predicted AS had no causal effect on MN by IVW and supplementary analysis (all P > 0.05).

Conclusions

Genetically predicted RA could increase the risk of MN, but genetically predicted AS was not associated with MN. Screening for kidney involvement in RA patients should be noted, and active treatment of RA will reduce the public health burden of MN.

Provider-directed analgesia for dental pain

INTRODUCTION

Extraction of impacted molar teeth is a common procedure performed by oral surgeons and general dentists, with postoperative pain being a significant adverse event post-surgery. If mismanaged, pain can lead to complications that impact oral and systemic health. The current scourge of the opioid epidemic has ushered in a new era of provider-directed analgesic (PDA) therapy in dentistry.

AREAS COVERED

This article provides an in-depth review on the major pharmacological and therapeutic properties of established and alternative analgesics used to manage dental pain.

EXPERT OPINION

Substantial evidence-based literature shows combination of a non-steroidal anti-inflammatory drug (NSAID; e.g. ibuprofen) and acetaminophen provides superior pain relief than single-agent or combination opioid regimens. However, there are clinical scenarios (e.g. severe pain) when short-course opioid prescription is appropriate in select patients, in which a 2-3-day treatment duration is typically sufficient. Alternative agents (e.g. caffeine, gabapentin, phytotherapies), typically in combination with established agents, can mitigate postoperative dental pain. Some evidence suggests preemptive therapies (e.g. corticosteroids, NSAIDs) reduce amounts of postsurgical analgesic consumption and might lessen opioid prescription burden. In summary, this comprehensive review provides an opportune update on the evolving landscape of pharmacotherapy for acute postsurgical dental pain, informing best practices for PDA in the dental setting.

Tracking Peripheral Artery Motion and Vascular Resistance with a Multi-Modal Wearable Sensor Under Pressure Perturbations

Peripheral artery status is a key physiological indicator of the body's cardiovascular response to both acute and chronic medical conditions. In this paper, peripheral artery behavior is tracked non-invasively by combining a photo plethysmograph (PPG) sensor and a piezoelectric (polyvinylidene difluoride, PVDF) sensor, while applying an outside pressure-varying cuff. A simple mechanical model for the local artery and tissue captures time- and pressure-dependent features present in the PPG and PVDF signals with respect to applied cuff pressure, during maneuvers applied to multiple swine subjects to perturb blood pressure and vascular resistance. These behaviors provide insight into feasibility and robustness of cardiovascular property identification by multi-modal non-invasive wearable sensing. This is found to help refine non-invasive blood pressure measurements and estimation of systemic vascular resistance (SVR) and blood pressure (BP) using selected features of sensor amplitude versus applied cuff pressure.

Distinct effects of calcineurin dependent and independent immunosuppressants on endotoxaemia-induced nephrotoxicity in rats: Role of androgens

Evidence suggests that immunosuppressant therapies protect against harmful effects of endotoxaemia. In this study, we tested whether calcineurin-dependent (cyclosporine/tacrolimus) and -independent (sirolimus) immunosuppressants variably influence nephrotoxicity induced by endotoxaemia and whether this interaction is modulated by testosterone. We investigated the effects of immunosuppressants on renal histopathological, biochemical and inflammatory profiles in endotoxic male rats and the role of androgenic state in the interaction. Six-hour treatment of rats with lipopolysaccharide (LPS, 3 mg/kg) increased (i) serum urea/creatinine, (ii) width of proximal/distal tubules, (iii) tubular degeneration and vacuolation, (iv) Western protein expressions of renal toll-like receptor 4, monocyte chemoattractant protein-1, and NADPH oxidase-2, and (v) serum tumour necrosis factor-α and myeloperoxidase. These endotoxic manifestations were intensified and eliminated upon concurrent exposure to cyclosporine and sirolimus, respectively. The cyclosporine actions appear to be a class rather than a drug effect because similar exacerbation of LPS nephrotoxicity was observed in rats treated with tacrolimus, another calcineurin inhibitor (CNI). Moreover, the deteriorated renal outcomes in LPS/tacrolimus-treated rats were reduced after castration or androgen receptor blockade by flutamide. The data suggest opposite effects for calcineurin-dependent (exaggeration) and -independent immunosuppressants (amelioration) on renal defects of endotoxaemia and implicate androgenic pathways in the worsened endotoxic renal profile induced by CNIs.

Concomitant tacrolimus and ketorolac therapy in pediatric liver transplant recipients: Teaching old dogma new tricks

Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ketorolac, are effective analgesic medications, but concerns for nephrotoxicity have limited their role for pain control following pediatric liver transplantation (LT). Calcineurin inhibitors (CNIs) and NSAIDs share a similar mechanism of nephrotoxicity, and concomitant administration is traditionally discouraged. A retrospective review of pediatric LT recipients was conducted between 1/1/2015 and 12/31/2019 at a single center. Patients were stratified based on receipt of ketorolac. The primary outcome was the incidence of acute kidney injury (AKI). Secondary outcomes included serum creatinine, urine output, estimated glomerular filtration rate, bleeding incidence, oral morphine milligram equivalents, and hospital length of stay (LOS). The incidence of AKI was similar between the two groups with 25.8% of patients in the ketorolac group versus 29.2% of patients in the nonketorolac group (p = .475) meeting criteria in the first 10 days post-transplant. Opioid requirements were less in the ketorolac group (p < .001), who also demonstrated shorter LOS compared with nonketorolac patients (p = .033). Concurrent CNI and ketorolac use did not result in an increased incidence of AKI in the early post-LT period and resulted in significantly lower opioid requirements along with a decreased hospital LOS.

Long-term Assessment of NSAID Prescriptions and Potential Nephrotoxicity Risk in Adult Kidney Transplant Recipients

BACKGROUND

Nonsteroidal anti-inflammatory drug (NSAID) use is recommended to be avoided in kidney transplantation, with a paucity of studies assessing their safety within this population. This study aims to use a large cohort of Veterans Affairs (VA) kidney transplantation recipients to assess the risk of acute kidney injury (AKI) with NSAID use.

METHODS

This is a 10-year longitudinal cohort study of adult kidney transplant recipients retrospectively followed in the VA system from 2001 to 2010 that assessed for risk of AKI with NSAID prescriptions. NSAID prescriptions, patient characteristics, and estimated glomerular filtration rates were abstracted from the VA comprehensive electronic health record. NSAID exposure was assessed by duration, dosage, and type. AKI events were defined by ≥50% decrease in estimated glomerular filtration rate. Risk was estimated using longitudinal multivariable generalized logistic regression model.

RESULTS

About 5100 patients were included with a total of 29 980 years of follow-up; 671 NSAID prescriptions in 273 (5.4%) patients (2.24 per 100 patient-y) with 472 (70%) high dose were identified. High-dose NSAID prescriptions were associated with 2.83 (95% confidence interval [CI], 1.55-5.19; P < 0.001) higher odds of AKI events within a given year; low dose was not associated with AKI (odds ratio, 1.93; 95 % CI, 0.95-6.02; P = 0.256). One 7-day NSAID course was associated with 5% higher odds of increasing AKI events, whereas chronic use (≥180 d) was associated with 3.25 (95% CI, 1.78-5.97; P < 0.001) higher odds of AKI.

CONCLUSIONS

Prescriptions for NSAIDs were uncommon in this cohort but were associated with a significant increase in the risk of AKI, which was impacted by higher NSAID dose and longer NSAID durations.

Spectrum and prognosis of renal histopathological lesions in 56 Chinese patients with rheumatoid arthritis with renal involvement

The objective of the study was to evaluate the characteristics and prognosis of 56 patients with rheumatoid arthritis (RA)-associated renal involvement by retrospective review of their renal biopsy specimens. Included in this cross-sectional study were 56 RA patients with renal involvement, in whom renal biopsy was performed to analyze the histological pattern and renal prognosis. IgA nephropathy (IgAN) was detected in 48.2% of the 56 included patients as the most common renal histological pattern, followed by membranous nephropathy (MN) in 23.2% cases, focal segmental glomerular sclerosis (FSGS) in 19.6% cases, chronic interstitial nephritis (CIN) in 5.4% cases, membranoproliferative glomerulonephritis (MPGN) in 1.8% cases, and non-IgA mesangial proliferative glomerulonephritis in 1.8% cases. No significant relationship was observed between the histopathologic type and the RA duration, joint deformity or treatment. Renal dysfunction was mainly found in IgAN patients, and MN occurred more frequently in older patients. Renal function decline occurred in two IgAN patients, one with FSGS and the other with MPGN. Another CIN patient progressed to dialysis during the follow-up period. The patients with renal function decline had a significantly higher level of serum creatinine at presentation. The high percentage of glomeruli sclerosis and interstitial fibrosis/tubular atrophy was also related to renal function decline. IgAN was the major RA-associated renal histological lesion in our series. Renal biopsy can provide useful information about the histological pattern and renal prognosis and therefore should be considered in RA patients with renal involvement.

Protective effect of royal jelly against diclofenac-induced hepato-renal damage and gastrointestinal ulcerations in rats

Objective

Evaluation of traditionally used royal jelly (RJ) for the management of hepato-renal damage and gastrointestinal ulcerations caused by diclofenac.

Methods

Forty adult male Wistar rats were allocated into four groups. Rats of the 1^st group received only saline and served as normal group. The remaining 3 groups received diclofenac (50 mg/kg/day, I.P.) for 7 days. Group 2 served as diclofenac-control group. Groups 3 and 4 received RJ (150 and 300 mg/kg/day, P.O.) respectively for 30 days. Twenty-four hours after the last treatment, blood samples were collected, rats were sacrificed, and livers, kidneys, stomachs & intestines were harvested. Stomachs and intestines were tested for ulcer counts. Serum levels of AST, ALT, creatinine and urea were investigated. Hepatic, renal, gastric and intestinal tissue contents of myeloperoxidase (MPO) and prostaglandin-E2 (PGE2) were measured. Histopathological examinations were also performed followed by immunohistochemical determination of cyclooxygenase-2 (COX-2) and inducible nitric oxide synthase (iNOS) expression.

Results

Diclofenac administration caused significant deterioration of all the above mentioned parameters. RJ improved hepatic and renal functions. Gastric and intestinal ulcer counts were significantly ameliorated. Hepatic, renal, gastric and intestinal tissue PGE-2 contents and COX-2 expression were significantly elevated. RJ also significantly reduced MPO content and iNOS expression as compared to diclofenac-control group. Improvements of the histopathological pictures of hepatic, renal, gastric and intestinal tissues were also apparent.

Conclusion

The study demonstrates promising protective effects of RJ against diclofenac-induced hepato-renal damage and gastrointestinal ulceration in rats.

Direct in situ labeling of target drugs with a fluorophore probe to improve MALDI-MS detection sensitivity in micro-liter plasma

Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used for symptomatic relief from fever, inflammation, and chronic pain associated with a variety of human disorders. Long-term usage of these drugs can result in severe syndromes; hence, their dose should be controlled carefully and their side effects such as Stevens–Johnson syndrome, toxic epidermal necrolysis, phototoxicity, acute interstitial nephritis, gastrointestinal bleeding, cardiovascular diseases, and liver injury should be considered. Furthermore, the widely used combination of NSAIDs as over-the-counter (OTC) drugs with other drugs leads to adverse drug–drug interactions. Therefore, development of a throughput method to rapidly screen 20 NSAIDs in biological samples is necessary to safeguard human health. In this work, we selected a suitable fluorophore probe coupled with in situ micro-labeling (<2 min) on stainless plate for the fast detection of NSAIDs in plasma samples at the micro-liter level (5 μL) without complicated sample preparation and separation. Every step undertaken in the protocol was also at the micro-liter level; thus, a small amount of blood collected from the human finger will suffice to determine the drug concentration in blood using the proposed method. Furthermore, the proposed method we developed was also matched the modern trends of green analytical chemistry towards miniaturization of analytical methodologies.