1
|
Bellini A, Finocchietti M, Rosa AC, Nordio M, Ferroni E, Massari M, Spila Alegiani S, Masiero L, Bedeschi G, Cardillo M, Lucenteforte E, Piccolo G, Leoni O, Pierobon S, Ledda S, Garau D, Davoli M, Addis A, Belleudi V. Effectiveness and safety of immunosuppressive regimens used as maintenance therapy in kidney transplantation: The CESIT study. PLoS One 2024; 19:e0295205. [PMID: 38165971 PMCID: PMC10760756 DOI: 10.1371/journal.pone.0295205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 11/16/2023] [Indexed: 01/04/2024] Open
Abstract
Maintenance immunosuppressive therapy used in kidney transplantation typically involves calcineurin inhibitors, such as tacrolimus or cyclosporine, in combination with mycophenolate or mechanistic target of rapamycin (mTORi) with or without corticosteroids. An Italian retrospective multicentre observational study was conducted to investigate the risk-benefit profile of different immunosuppressive regimens. We identified all subjects who underwent kidney transplant between 2009 and 2019, using healthcare claims data. Patients on cyclosporine and tacrolimus-based therapies were matched 1:1 based on propensity score, and effectiveness and safety outcomes were compared using Cox models (HR; 95%CI). Analyses were also conducted comparing mTORi versus mycophenolate among tacrolimus-treated patients. Patients treated with cyclosporine had a higher risk of rejection or graft loss (HR:1.69; 95%CI:1.16-2.46) and a higher incidence of severe infections (1.25;1.00-1.55), but a lower risk of diabetes (0.66;0.47-0.91) compared to those treated with tacrolimus. Among tacrolimus users, mTORi showed non-inferiority to MMF in terms of mortality (1.01;0.68-1.62), reject/graft loss (0.61;0.36-1.04) and severe infections (0.76;0.56-1.03). In a real-life setting, tacrolimus-based immunosuppressive therapy appeared to be superior to cyclosporine in reducing rejection and severe infections, albeit with an associated increased risk of diabetes. The combination of tacrolimus and mTORi may represent a valid alternative to the combination with mycophenolate, although further studies are needed to confirm this finding.
Collapse
Affiliation(s)
- Arianna Bellini
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | | | | | | | | | - Marco Massari
- National Centre for Drug Research and Evaluation, Istituto Superiore Di Sanità, Rome, Italy
| | | | - Lucia Masiero
- Italian National Transplant Centre, Istituto Superiore di Sanità, Rome, Italy
| | - Gaia Bedeschi
- Italian National Transplant Centre, Istituto Superiore di Sanità, Rome, Italy
| | - Massimo Cardillo
- Italian National Transplant Centre, Istituto Superiore di Sanità, Rome, Italy
| | - Ersilia Lucenteforte
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Olivia Leoni
- Department of Health of Lombardy Region, Epidemiology Observatory, Milan, Italy
| | | | - Stefano Ledda
- General Directorate for Health, Sardinia Region, Italy
| | | | - Marina Davoli
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Antonio Addis
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Valeria Belleudi
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | | |
Collapse
|
2
|
Qayyum S, Shahid K. Comparative Safety and Efficacy of Immunosuppressive Regimens Post-kidney Transplant: A Systematic Review. Cureus 2023; 15:e43903. [PMID: 37746361 PMCID: PMC10512192 DOI: 10.7759/cureus.43903] [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: 08/22/2023] [Indexed: 09/26/2023] Open
Abstract
Immunosuppressive agents are used post-organ transplant to prevent acute rejection and graft losses. Tacrolimus, the most widely used immunosuppressive agent for kidney transplant recipients, has unfavorable side effects such as new-onset diabetes after transplant, nephrotoxicity, and electrolyte imbalances. Other drug groups such as the mammalian target of rapamycin (mTOR) inhibitors, belatacept, and bleselumab have been used to either substitute calcineurin inhibitors or reduce their exposure. This systematic analysis reviews evidence from randomized controlled trials to compare the safety and efficacy of various immunosuppressive regimens for kidney transplant recipients. An in-depth methodical search was conducted across PubMed, Cochrane Library, and Mendeley. PRISMA 2020 guidelines were followed for this study. Randomized controlled trials comparing varying regimens were included in this study. While there was no difference in safety and efficacy between once-daily and twice-daily tacrolimus, mTOR inhibitors showed to be a viable option for a reduced tacrolimus exposure regimen. Calcineurin inhibitor avoidance and early steroid withdrawal regimens both showed increased rates of rejection. Based on these findings, a regimen containing once-daily tacrolimus and an mTOR inhibitor with or without corticosteroid is a viable immunosuppressive regimen post-kidney transplant. Further trials, especially ones with longer follow-up periods, are needed to explore these regimens' long-term safety and efficacy.
Collapse
Affiliation(s)
- Shahid Qayyum
- Nephrology, Diaverum Dialysis Center, Wadi Al Dawasir, SAU
| | - Kamran Shahid
- Internal Medicine/Family Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| |
Collapse
|
3
|
El Hennawy HM, Faifi ASA, El Nazer W, Mahedy A, Kamal A, Al Faifi IS, Abdulmalik H, Safar O, Zaitoun MF, Fahmy AE. Calcineurin Inhibitors Nephrotoxicity Prevention Strategies With Stress on Belatacept-Based Rescue Immunotherapy: A Review of the Current Evidence. Transplant Proc 2021; 53:1532-1540. [PMID: 34020797 DOI: 10.1016/j.transproceed.2021.03.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 03/10/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND A traditional narrative review was performed to evaluate clinical studies that have examined the clinical implications, risk factors, and prevention of calcineurin inhibitors (CNIs) nephrotoxicity with stress on a belatacept-based rescue regimen. METHODS The Cochrane Library, PubMed/MEDLINE, EBSCO (Academic Search Ultimate), ProQuest (Central), and Excerpta Medical databases and Google scholar were searched using the keywords (CNI AND Nephrotoxicity prevention) OR ("Calcineurin inhibitor" AND Nephrotoxicity) OR (Tacrolimus AND Nephrotoxicity) OR (Ciclosporin AND Nephrotoxicity) OR (cyclosporine AND Nephrotoxicity) OR (Belatacept) OR (CNI Conversion) for the period from 1990 to 2020. Fifty-five related articles and reviews were found. CONCLUSION A better understanding of the mechanisms underlying calcineurin inhibitor nephrotoxicity could help in the individualization of therapy for and prevention of CNI nephrotoxicity. Identification of high-risk patients for CNI nephrotoxicity before renal transplantation enables better use and selection of immunosuppression with reduced adverse effects and, eventually, successful treatment of the kidney recipients. Belatacept conversion is a good and safe option in patients with deteriorating renal function attributed to CNI nephrotoxicity.
Collapse
Affiliation(s)
- Hany M El Hennawy
- Transplant Surgery Section, Surgery Department, Armed Forces Hospital-Southern Regions, Khamis Mushayt, Saudi Arabia.
| | - Abdullah S Al Faifi
- Transplant Surgery Section, Surgery Department, Armed Forces Hospital-Southern Regions, Khamis Mushayt, Saudi Arabia
| | - Weam El Nazer
- Nephrology Department, Armed Forces Hospital-Southern Regions, Khamis Mushayt, Saudi Arabia
| | - Ahmed Mahedy
- Nephrology Department, Armed Forces Hospital-Southern Regions, Khamis Mushayt, Saudi Arabia
| | - Ahmed Kamal
- Nephrology Department, Armed Forces Hospital-Southern Regions, Khamis Mushayt, Saudi Arabia
| | - Ibrahim S Al Faifi
- Department of Family Medicine, Armed Forces Hospital-Southern Regions, Khamis Mushayt, Saudi Arabia
| | - Hana Abdulmalik
- Department of Surgery, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Omar Safar
- Department of Urology, Armed Forces Hospital-Southern Regions, Khamis Mushayt, Saudi Arabia
| | - Mohammad F Zaitoun
- Department of Pharmacy, Armed Forces Hospital-Southern Regions, Khamis Mushayt, Saudi Arabia
| | - Ahmed E Fahmy
- Department of Surgery, Division of Transplantation, North Shore University Hospital, Northwell Health, Manhasset, New York
| |
Collapse
|
4
|
Cucchiari D, Ríos J, Molina-Andujar A, Montagud-Marrahi E, Revuelta I, Ventura-Aguiar P, Piñeiro GJ, De Sousa-Amorim E, Esforzado N, Cofán F, Torregrosa JV, Ugalde-Altamirano J, Ricart MJ, Rovira J, Torres F, Solè M, Campistol JM, Diekmann F, Oppenheimer F. Combination of calcineurin and mTOR inhibitors in kidney transplantation: a propensity score analysis based on current clinical practice. J Nephrol 2019; 33:601-610. [PMID: 31853792 DOI: 10.1007/s40620-019-00675-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Accepted: 11/18/2019] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The TRANSFORM study demonstrated that an immunosuppression based on a combination of calcineurin inhibitors and de-novo mTOR inhibitors (mTORi) is safe and effective in kidney transplant recipients. However, data that validate this approach in clinical practice are currently missing. MATERIALS AND METHODS Analysis of 401 kidney transplant recipients transplanted from June 2013 to December 2016. All patients received tacrolimus with prednisone in combination with either mycophenolate (n = 186) or mTORi (either everolimus or sirolimus, n = 215). A propensity score to receive mTORi was calculated based on the inverse probability of treatment weighting (IPTW) from the following parameters: age and sex of donor and recipient, BMI, previous transplants, diabetes, cPRA, dialysis before transplantation, dialysis vintage, type of donor, ABO-incompatibility, HLA-mismatches, induction and ischemia time. Median follow-up was 2.6 [1.9; 3.7] years. RESULTS Cox-regression analysis suggests good results for mTORi versus MPA in terms of 1-year biopsy-proven acute rejection (BPAR, P = 0.063), 1-year graft loss (P = 0.025) and patient survival (P < 0.001). Results observed for BPAR and graft failure were largely attributed to those patients that would have been excluded by the TRANSFORM because of some exclusion criteria (52.9% of the population, P = 0.003 for 1-year BPAR and P = 0.040 for graft loss). In patients who met selection criteria for TRANSFORM, no effect of treatment for BPAR or graft failure was observed, while the beneficial effect on overall survival persisted. CONCLUSIONS In a real-life setting, a protocol based on de-novo mTORi with tacrolimus and prednisone could be employed as a standard immunosuppressive regimen and was associated with good outcomes.
Collapse
Affiliation(s)
- David Cucchiari
- Renal Transplant Unit, Hospital Clínic, Carrer Villaroel 170, 08023, Barcelona, Spain.
| | - José Ríos
- Medical Statistics Core Facility, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Biostatistics Unit, Faculty of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Alicia Molina-Andujar
- Renal Transplant Unit, Hospital Clínic, Carrer Villaroel 170, 08023, Barcelona, Spain
| | | | - Ignacio Revuelta
- Renal Transplant Unit, Hospital Clínic, Carrer Villaroel 170, 08023, Barcelona, Spain
- Laboratori Experimental de Nefrologia I Trasplantament (LENIT), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Red de Investigación Renal (REDINREN), Madrid, Spain
| | - Pedro Ventura-Aguiar
- Renal Transplant Unit, Hospital Clínic, Carrer Villaroel 170, 08023, Barcelona, Spain
| | - Gastón J Piñeiro
- Renal Transplant Unit, Hospital Clínic, Carrer Villaroel 170, 08023, Barcelona, Spain
| | - Erika De Sousa-Amorim
- Renal Transplant Unit, Hospital Clínic, Carrer Villaroel 170, 08023, Barcelona, Spain
| | - Nuria Esforzado
- Renal Transplant Unit, Hospital Clínic, Carrer Villaroel 170, 08023, Barcelona, Spain
| | - Frederic Cofán
- Renal Transplant Unit, Hospital Clínic, Carrer Villaroel 170, 08023, Barcelona, Spain
| | | | | | - Maria José Ricart
- Renal Transplant Unit, Hospital Clínic, Carrer Villaroel 170, 08023, Barcelona, Spain
| | - Jordi Rovira
- Laboratori Experimental de Nefrologia I Trasplantament (LENIT), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Red de Investigación Renal (REDINREN), Madrid, Spain
| | - Ferran Torres
- Medical Statistics Core Facility, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Biostatistics Unit, Faculty of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Manel Solè
- Pathology Unit, Hospital Clínic, Barcelona, Spain
| | - Josep M Campistol
- Renal Transplant Unit, Hospital Clínic, Carrer Villaroel 170, 08023, Barcelona, Spain
| | - Fritz Diekmann
- Renal Transplant Unit, Hospital Clínic, Carrer Villaroel 170, 08023, Barcelona, Spain.
- Laboratori Experimental de Nefrologia I Trasplantament (LENIT), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.
- Red de Investigación Renal (REDINREN), Madrid, Spain.
| | - Frederic Oppenheimer
- Renal Transplant Unit, Hospital Clínic, Carrer Villaroel 170, 08023, Barcelona, Spain
| |
Collapse
|
5
|
Hahn D, Hodson EM, Hamiwka LA, Lee VWS, Chapman JR, Craig JC, Webster AC. Target of rapamycin inhibitors (TOR-I; sirolimus and everolimus) for primary immunosuppression in kidney transplant recipients. Cochrane Database Syst Rev 2019; 12:CD004290. [PMID: 31840244 PMCID: PMC6953317 DOI: 10.1002/14651858.cd004290.pub3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Kidney transplantation is the therapy of choice for many patients with end-stage kidney disease (ESKD) with an improvement in survival rates and satisfactory short term graft survival. However, there has been little improvement in long-term survival. The place of target of rapamycin inhibitors (TOR-I) (sirolimus, everolimus), which have different modes of action from other commonly used immunosuppressive agents, in kidney transplantation remains uncertain. This is an update of a review first published in 2006. OBJECTIVES To evaluate the short and long-term benefits and harms of TOR-I (sirolimus and everolimus) when used in primary immunosuppressive regimens for kidney transplant recipients. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 20 September 2019 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register were identified through searches of CENTRAL, MEDLINE and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA All randomised controlled trials (RCTs) and quasi-RCTs in which drug regimens, containing TOR-I commenced within seven days of transplant, were compared to alternative drug regimens, were included without age restriction, dosage or language of report. DATA COLLECTION AND ANALYSIS Three authors independently assessed study eligibility, risk of bias, and extracted data. Results were reported as risk ratios (RR) with 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) with 95% CI for continuous outcomes. Statistical analyses were performed using the random-effects model. The certainty of the evidence was assessed using GRADE MAIN RESULTS: Seventy studies (17,462 randomised participants) were included; eight studies included two comparisons to provide 78 comparisons. Outcomes were reported at six months to three years post transplant. Risk of bias was judged to be low for sequence generation in 25 studies, for allocation concealment in 23 studies, performance bias in four studies, detection bias in 65 studies, attrition bias in 45 studies, selective reporting bias in 48 studies, and for other potential bias in three studies. Risk of bias was judged to be at high risk of bias for sequence generation in two studies, allocation concealment in two studies, performance bias in 61 studies, detection bias in one study, attrition bias in four studies, for selective reporting bias in 11 studies and for other potential risk of bias in 46 studies. Compared with CNI and antimetabolite, TOR-I with antimetabolite probably makes little or no difference to death (RR 1.31, 95% CI 0.87 to 1.98; 19 studies) or malignancies (RR 0.86, 95% CI 0.50 to 1.48; 10 studies); probably increases graft loss censored for death (RR 1.32, 95% CI 0.96 to 1.81; 15 studies), biopsy-proven acute rejection (RR 1.60, 95% CI 1.25 to 2.04; 15 studies), need to change treatment (RR 2.42, 95% CI 1.88 to 3.11; 14 studies) and wound complications (RR 2.56, 95% CI 1.94 to 3.36; 12 studies) (moderate certainty evidence); but reduces CMV infection (RR 0.43, 95% CI 0.29 to 0.63; 13 studies) (high certainty evidence). Compared with antimetabolites and CNI, TOR-I with CNI probably makes little or no difference to death (RR 1.06, 95% CI 0.84 to 1.33; 31 studies), graft loss censored for death (RR 1.09, 95% CI 0.82 to 1.45; 26 studies), biopsy-proven acute rejection (RR 0.95, 95% CI 0.81 to 1.12; 24 studies); and malignancies (RR 0.83, 95% CI 0.64 to 1.07; 17 studies); probably increases the need to change treatment (RR 1.56, 95% CI 1.28 to 1.90; 25 studies), and wound complications (RR 1.56, 95% CI 1.28 to 1.91; 17 studies); but probably reduces CMV infection (RR 0.44, 95% CI 0.34 to 0.58; 25 studies) (moderate certainty evidence). Lower dose TOR-I and standard dose CNI compared with higher dose TOR-I and reduced dose CNI probably makes little or no difference to death (RR 1.07, 95% CI 0.64 to 1.78; 9 studies), graft loss censored for death (RR 1.09, 95% CI 0.54 to 2.20; 8 studies), biopsy-proven acute rejection (RR 0.87, 95% CI 0.67 to 1.13; 8 studies), and CMV infection (RR 1.42, 95% CI 0.78 to 2.60; 5 studies) (moderate certainty evidence); and may make little or no difference to wound complications (RR 0.95, 95% CI 0.53 to 1.71; 3 studies), malignancies (RR 1.04, 95% CI 0.36 to 3.04; 7 studies), and the need to change treatments (RR 1.18, 95% CI 0.58 to 2.42; 5 studies) (low certainty evidence). Lower dose of TOR-I compared with higher doses probably makes little or no difference to death (RR 0.84, 95% CI 0.67 to 1.06; 13 studies), graft loss censored for death (RR 0.92, 95% CI 0.71 to 1.19; 12 studies), biopsy-proven acute rejection (RR 1.26, 95% CI 1.10 to 1.43; 11 studies), CMV infection (RR 0.87, 95% CI 0.63 to 1.21; 9 studies), wound complications (RR 0.92, 95% CI 0.66 to 1.29; 7 studies), and malignancy (RR 0.84, 95% CI 0.54 to 1.32; 10 studies) (moderate certainty evidence); and may make little or no difference to the need to change treatments (RR 0.91, 95% CI 0.78 to 1.05; 10 studies) (low certainty evidence). It is uncertain whether sirolimus and everolimus differ in their effects on kidney function and lipid levels because the certainty of the evidence is very low based on a single small study with only three months of follow-up. AUTHORS' CONCLUSIONS In studies with follow-up to three years, TOR-I with an antimetabolite increases the risk of graft loss and acute rejection compared with CNI and an antimetabolite. TOR-I with CNI potentially offers an alternative to an antimetabolite with CNI as rates of graft loss and acute rejection are similar between interventions and TOR-I regimens are associated with a reduced risk of CMV infections. Wound complications and the need to change immunosuppressive medications are higher with TOR-I regimens. While further new studies are not required, longer-term follow-up data from participants in existing methodologically robust RCTs are needed to determine how useful immunosuppressive regimens, which include TOR-I, are in maintaining kidney transplant function and survival beyond three years.
Collapse
Affiliation(s)
- Deirdre Hahn
- The Children's Hospital at WestmeadDepartment of NephrologyLocked Bag 4001WestmeadNSWAustralia2145
| | - Elisabeth M Hodson
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchLocked Bag 4001WestmeadNSWAustralia2145
| | - Lorraine A Hamiwka
- University of Calgary/Alberta Children's HospitalDepartment of Medicine/Pediatrics2888 Shaganappi Trail NW Children's HospitalCalgaryAlbertaCanadaT3B 6A8
| | - Vincent WS Lee
- Westmead & Blacktown HospitalsDepartment of Renal MedicineDarcy RdWestmeadNSWAustralia2145
- The University of Sydney at WestmeadCentre for Transplant and Renal Research, Westmead Millennium InstituteWestmeadAustralia
| | - Jeremy R Chapman
- Westmead Millennium Institute, The University of Sydney at WestmeadCentre for Transplant and Renal ResearchDarcy RdWestmeadNSWAustralia2145
| | - Jonathan C Craig
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchLocked Bag 4001WestmeadNSWAustralia2145
- Flinders UniversityCollege of Medicine and Public HealthAdelaideSAAustralia5001
| | - Angela C Webster
- The University of Sydney at WestmeadCentre for Transplant and Renal Research, Westmead Millennium InstituteWestmeadAustralia
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
| | | |
Collapse
|
6
|
|
7
|
Karpe KM, Talaulikar GS, Walters GD. Calcineurin inhibitor withdrawal or tapering for kidney transplant recipients. Cochrane Database Syst Rev 2017; 7:CD006750. [PMID: 28730648 PMCID: PMC6483545 DOI: 10.1002/14651858.cd006750.pub2] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Calcineurin inhibitors (CNI) can reduce acute transplant rejection and immediate graft loss but are associated with significant adverse effects such as hypertension and nephrotoxicity which may contribute to chronic rejection. CNI toxicity has led to numerous studies investigating CNI withdrawal and tapering strategies. Despite this, uncertainty remains about minimisation or withdrawal of CNI. OBJECTIVES This review aimed to look at the benefits and harms of CNI tapering or withdrawal in terms of graft function and loss, incidence of acute rejection episodes, treatment-related side effects (hypertension, hyperlipidaemia) and death. SEARCH METHODS We searched the Cochrane Kidney and Transplant Specialised Register to 11 October 2016 through contact with the Information Specialist using search terms relevant to this review. Studies contained in the Specialised Register are identified through search strategies specifically designed for CENTRAL, MEDLINE, and EMBASE; handsearching conference proceedings; and searching the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA All randomised controlled trials (RCTs) where drug regimens containing CNI were compared to alternative drug regimens (CNI withdrawal, tapering or low dose) in the post-transplant period were included, without age or dosage restriction. DATA COLLECTION AND ANALYSIS Two authors independently assessed studies for eligibility, risk of bias, and extracted data. Results were expressed as risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI). MAIN RESULTS We included 83 studies that involved 16,156 participants. Most were open-label studies; less than 30% of studies reported randomisation method and allocation concealment. Studies were analysed as intent-to-treat in 60% and all pre-specified outcomes were reported in 54 studies. The attrition and reporting bias were unclear in the remainder of the studies as factors used to judge bias were reported inconsistently. We also noted that 50% (47 studies) of studies were funded by the pharmaceutical industry.We classified studies into four groups: CNI withdrawal or avoidance with or without substitution with mammalian target of rapamycin inhibitors (mTOR-I); and low dose CNI with or without mTOR-I. The withdrawal groups were further stratified as avoidance and withdrawal subgroups for major outcomes.CNI withdrawal may lead to rejection (RR 2.54, 95% CI 1.56 to 4.12; moderate certainty evidence), may make little or no difference to death (RR 1.09, 95% CI 0.96 to 1.24; moderate certainty), and probably slightly reduces graft loss (RR 0.85, 95% CI 0.74 to 0.98; low quality evidence). Hypertension was probably reduced in the CNI withdrawal group (RR 0.82, 95% CI 0.71 to 0.95; low certainty), while CNI withdrawal may make little or no difference to malignancy (RR 1.10, 95% CI 0.93 to 1.30; low certainty), and probably makes little or no difference to cytomegalovirus (CMV) (RR 0.87, 95% CI 0.52 to 1.45; low certainty)CNI avoidance may result in increased acute rejection (RR 2.16, 95% CI 0.85 to 5.49; low certainty) but little or no difference in graft loss (RR 0.96, 95% CI 0.79 to 1.16; low certainty). Late CNI withdrawal increased acute rejection (RR 3.21, 95% CI 1.59 to 6.48; moderate certainty) but probably reduced graft loss (RR 0.84, 95% CI 0.72 to 0.97, low certainty).Results were similar when CNI avoidance or withdrawal was combined with the introduction of mTOR-I; acute rejection was probably increased (RR 1.43; 95% CI 1.15 to 1.78; moderate certainty) and there was probably little or no difference in death (RR 0.96; 95% CI 0.69 to 1.36, moderate certainty). mTOR-I substitution may make little or no difference to graft loss (RR 0.94, 95% CI 0.75 to 1.19; low certainty), probably makes little of no difference to hypertension (RR 0.86, 95% CI 0.64 to 1.15; moderate), and probably reduced the risk of cytomegalovirus (CMV) (RR 0.60, 95% CI 0.44 to 0.82; moderate certainty) and malignancy (RR 0.69, 95% CI 0.47 to 1.00; low certainty). Lymphoceles were increased with mTOR-I substitution (RR 1.45, 95% CI 0.95 to 2.21; low certainty).Low dose CNI combined with mTOR-I probably increased glomerular filtration rate (GFR) (MD 6.24 mL/min, 95% CI 3.28 to 9.119; moderate certainty), reduced graft loss (RR 0.75, 95% CI 0.55 to 1.02; moderate certainty), and made little or no difference to acute rejection (RR 1.13 ; 95% CI 0.91 to 1.40; moderate certainty). Hypertension was decreased (RR 0.98, 95% CI 0.80 to 1.20; low certainty) as was CMV (RR 0.41, 95% CI 0.16 to 1.06; low certainty). Low dose CNI plus mTOR-I makes probably makes little of no difference to malignancy (RR 1.22, 95% CI 0.42 to 3.53; low certainty) and may make little of no difference to death (RR 1.16, 95% CI 0.71 to 1.90; moderate certainty). AUTHORS' CONCLUSIONS CNI avoidance increased acute rejection and CNI withdrawal increases acute rejection but reduced graft loss at least over the short-term. Low dose CNI with induction regimens reduced acute rejection and graft loss with no major adverse events, also in the short-term. The use of mTOR-I reduced CMV infections but increased the risk of acute rejection. These conclusions must be tempered by the lack of long-term data in most of the studies, particularly with regards to chronic antibody-mediated rejection, and the suboptimal methodological quality of the included studies.
Collapse
Affiliation(s)
- Krishna M Karpe
- Canberra HospitalRenal ServicesYamba DriveGarranACTAustralia2605
- Australian National University Medical SchoolActonACTAustralia2601
| | - Girish S Talaulikar
- Canberra HospitalRenal ServicesYamba DriveGarranACTAustralia2605
- Australian National University Medical SchoolActonACTAustralia2601
| | - Giles D Walters
- Canberra HospitalRenal ServicesYamba DriveGarranACTAustralia2605
- Australian National University Medical SchoolActonACTAustralia2601
| | | |
Collapse
|
8
|
Peng T, Chang X, Wang J, Zhen J, Yang X, Hu Z. Protective effects of tacrolimus on podocytes in early diabetic nephropathy in rats. Mol Med Rep 2017; 15:3172-3178. [PMID: 28339051 DOI: 10.3892/mmr.2017.6354] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2015] [Accepted: 12/05/2016] [Indexed: 11/05/2022] Open
Abstract
The aim of the present study was to investigate the protective effect of tacrolimus on early podocyte damage in rats with diabetic nephropathy (DN). A total of 38 normal male Sprague‑Dawley rats were randomly divided into four groups: Normal control group (group N; n=8), DN group (n=10), tacrolimus (FK506) treatment group (group F; n=10), benazepril (Lotensin) treatment group (group L; n=10). The rats in groups DN, F and L were administered with streptozotocin (STZ; 60 mg/kg) by intraperitoneal injection to establish the diabetic rat model. After 4 weeks, the diabetic rat model was established, and rats in the different groups were administered intragrastically with the respective drugs. Blood glucose (BS), body weight (BW) and 24‑h urine protein were detected every 4 weeks, serum creatinine (SCr), blood urea nitrogen (BUN) and kidney weight/body weight (KW/BW) were measured at the end of the 8 weeks of drug treatment. Renal pathological changes were observed under a light microscope and electron microscope. Expression of nephrin, which is a podocyte‑specific marker, was detected using western blot analysis. The results showed that the levels of SCr, BUN, KW/BW and 24‑h urine protein in groups D, F and L were significantly higher, compared with those in group N (P<0.05). No significant differences were found between groups F and L for the above indicators, with the exception of BS. However, all indices were significantly lower, compared with those in group DN (P<0.05). Renal pathological expression was normal in group N under light microscopy. There were significant increases in the glomerular volume, proliferative mesangial cells, width of the mesangial area and thickness of the basement membrane in group DN, however, all the above pathological characteristics were reduced in groups F and L, compared with group DN (P<0.05). No significant difference was found between groups F and L. A widened glomerular basement membrane, and disorder, widening and fusion of podocyte processes were observed under the electron microscope in group DN, however, these were reduced in groups F and L, compared with group DN (P<0.05). The results of the western blot analysis showed that the expression of nephrin decreased by 60.1% in group DN, compared with group N, and significant recovery in the expression of nephrin was observed in groups F and L (P<0.05). Tacrolimus reduced urinary protein and slowed the progression of DN, partially by recovering the protein expression of nephrin in the renal tissue of diabetic rats, and maintaining the integrity of the structure and function of podocytes.
Collapse
Affiliation(s)
- Tao Peng
- Department of Nephrology, Shandong University Qilu Hospital, Jinan, Shandong 250012, P.R. China
| | - Xiangdi Chang
- Department of Nephrology, Affiliated Hospital of Binzhou Medical School, Yantai, Shandong 264003, P.R. China
| | - Jie Wang
- Department of Nephrology, Liaocheng People's Hospital, Liaocheng, Shandong 252000, P.R. China
| | - Junhui Zhen
- Department of Pathology, Shandong University Qilu Hospital, Jinan, Shandong 250012, P.R. China
| | - Xiangdong Yang
- Department of Nephrology, Shandong University Qilu Hospital, Jinan, Shandong 250012, P.R. China
| | - Zhao Hu
- Department of Nephrology, Shandong University Qilu Hospital, Jinan, Shandong 250012, P.R. China
| |
Collapse
|
9
|
Impact on Autophagy and Ultraviolet B Induced Responses of Treatment with the MTOR Inhibitors Rapamycin, Everolimus, Torin 1, and pp242 in Human Keratinocytes. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2017; 2017:5930639. [PMID: 28400912 PMCID: PMC5376460 DOI: 10.1155/2017/5930639] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 01/15/2017] [Accepted: 02/13/2017] [Indexed: 12/21/2022]
Abstract
The mechanistic target of Rapamycin (MTOR) protein is a crucial signaling regulator in mammalian cells that is extensively involved in cellular biology. The function of MTOR signaling in keratinocytes remains unclear. In this study, we detected the MTOR signaling and autophagy response in the human keratinocyte cell line HaCaT and human epidermal keratinocytes treated with MTOR inhibitors. Moreover, we detected the impact of MTOR inhibitors on keratinocytes exposed to the common carcinogenic stressors ultraviolet B (UVB) and UVA radiation. As a result, keratinocytes were sensitive to the MTOR inhibitors Rapamycin, everolimus, Torin 1, and pp242, but the regulation of MTOR downstream signaling was distinct. Next, autophagy induction only was observed in HaCaT cells treated with Rapamycin. Furthermore, we found that MTOR signaling was insensitive to UVB but sensitive to UVA radiation. UVB treatment also had no impact on the inhibition of MTOR signaling by MTOR inhibitors. Finally, MTOR inhibition by Rapamycin, everolimus, or pp242 did not affect the series of biological events in keratinocytes exposed to UVB, including the downregulation of BiP and PERK, activation of Histone H2A and JNK, and cleavage of caspase-3 and PARP. Our study demonstrated that MTOR inhibition in keratinocytes cannot always induce autophagy, and the MTOR pathway does not play a central role in the UVB triggered cellular response.
Collapse
|
10
|
Rummo OO, Carmellini M, Rostaing L, Oberbauer R, Christiaans MHL, Mousson C, Langer RM, Citterio F, Charpentier B, Brown M, Kazeem G, Lehner F. ADHERE: randomized controlled trial comparing renal function inde novokidney transplant recipients receiving prolonged-release tacrolimus plus mycophenolate mofetil or sirolimus. Transpl Int 2016; 30:83-95. [DOI: 10.1111/tri.12878] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 05/09/2016] [Accepted: 10/14/2016] [Indexed: 12/30/2022]
Affiliation(s)
- Oleg O. Rummo
- Republican Scientific and Practical Center (RSPC) for Organ and Tissue Transplantation; Minsk Belarus
| | - Mario Carmellini
- Department of Medical, Surgical and Neuroscience; Policlinico Santa Maria alle Scotte; University of Siena; Siena Italy
| | - Lionel Rostaing
- Department of Nephrology, Dialysis and Organ Transplantation; Toulouse University Hospital; INSERM U563, IFR-BMT, CHU Purpan; Toulouse France
| | - Rainer Oberbauer
- Department of Internal Medicine III, Nephrology and Dialysis; Medical University of Vienna; Vienna Austria
| | - Maarten H. L. Christiaans
- Department of Internal Medicine/Division of Nephrology; Maastricht University Medical Center; Maastricht The Netherlands
| | - Christiane Mousson
- Department of Nephrology-Transplantation; University Hospital; Dijon France
| | - Robert M. Langer
- Department of Transplantation and Surgery; Semmelweis University; Budapest Hungary
| | - Franco Citterio
- Department of Surgery, Renal Transplantation; Catholic University; Rome Italy
| | - Bernard Charpentier
- Department of Nephrology, Dialysis and Transplantation; University Hospital of Bicêtre; Le Kremlin Bicetre France
| | - Malcolm Brown
- Medical Affairs - Global; Astellas Pharma; Northbrook IL USA
| | | | - Frank Lehner
- General, Visceral and Transplantation Surgery; Hannover Medical School; Hannover Germany
| | | |
Collapse
|
11
|
Knight SR, Hussain S. Variability in the reporting of renal function endpoints in immunosuppression trials in renal transplantation: time for consensus? Clin Transplant 2016; 30:1584-1590. [DOI: 10.1111/ctr.12861] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2016] [Indexed: 01/05/2023]
Affiliation(s)
- Simon R. Knight
- Nuffield Department of Surgical Sciences; University of Oxford; Oxford UK
- Centre for Evidence in Transplantation; Clinical Effectiveness Unit; Royal College of Surgeons of England; London UK
| | - Samia Hussain
- Nuffield Department of Surgical Sciences; University of Oxford; Oxford UK
- Centre for Evidence in Transplantation; Clinical Effectiveness Unit; Royal College of Surgeons of England; London UK
| |
Collapse
|
12
|
Sawinski D, Trofe-Clark J, Leas B, Uhl S, Tuteja S, Kaczmarek JL, French B, Umscheid CA. Calcineurin Inhibitor Minimization, Conversion, Withdrawal, and Avoidance Strategies in Renal Transplantation: A Systematic Review and Meta-Analysis. Am J Transplant 2016; 16:2117-38. [PMID: 26990455 DOI: 10.1111/ajt.13710] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 12/28/2015] [Accepted: 01/07/2016] [Indexed: 01/25/2023]
Abstract
Despite their clinical efficacy, concerns about calcineurin inhibitor (CNI) toxicity make alternative regimens that reduce CNI exposure attractive for renal transplant recipients. In this systematic review and meta-analysis, we assessed four CNI immunosuppression strategies (minimization, conversion, withdrawal, and avoidance) designed to reduce CNI exposure and assessed the impact of each on patient and allograft survival, acute rejection and renal function. We evaluated 92 comparisons from 88 randomized controlled trials and found moderate- to high-strength evidence suggesting that minimization strategies result in better clinical outcomes compared with standard-dose regimens; moderate-strength evidence indicating that conversion to a mammalian target of rapamycin inhibitor or belatacept was associated with improved renal function but increased rejection risk; and moderate- to high-strength evidence suggesting planned CNI withdrawal could result in improved renal function despite an association with increased rejection risk. The evidence base for avoidance studies was insufficient to draw meaningful conclusions. The applicability of the review is limited by the large number of studies examining cyclosporine-based strategies and low-risk populations. Additional research is needed with tacrolimus-based regimens and higher risk populations. Moreover, research is necessary to clarify the effect of induction and adjunctive agents in alternative immunosuppression strategies and should include more comprehensive and consistent reporting of patient-centered outcomes.
Collapse
Affiliation(s)
- D Sawinski
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - J Trofe-Clark
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,Department of Pharmacy Services, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - B Leas
- Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, PA
| | - S Uhl
- ECRI Institute, Plymouth Meeting, PA
| | - S Tuteja
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | | | - B French
- Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - C A Umscheid
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, PA.,Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| |
Collapse
|
13
|
Zhao DQ, Li SW, Sun QQ. Sirolimus-Based Immunosuppressive Regimens in Renal Transplantation: A Systemic Review. Transplant Proc 2016; 48:3-9. [PMID: 26915834 DOI: 10.1016/j.transproceed.2016.01.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Revised: 12/24/2015] [Accepted: 01/05/2016] [Indexed: 12/30/2022]
Abstract
Sirolimus (SRL)-based immunosuppressive regimens have been used for preventing rejection after kidney transplantation. This review analyzes their merits and demerits compared with other conventional regimes from the aspects of acute rejection rate, graft function, as well as patient/graft survival rates. In general, SRL is mostly recommended to be used as conversion therapy from calcineurin inhibitor (CNI) after kidney transplantation in most studies. Minimization or withdrawal of cyclosporine A (CsA) could also be considered when it was combined with SRL. SRL can replace mycophenolate mofetil (MMF), and the CNI dose should be reduced appropriately in this setting. Quadruple maintenance regimens containing SRL need future study to clarify their superiority. De novo use of low-dose CNI combined with SRL has no apparent merits and thus is not recommended. De novo use of standard-dose CNI combined with SRL followed by maintenance, de novo use of CNI-free regimens, as well as SRL use in delayed graft function (DGF) patients who spare antibody induction and postpone CNI administration should also be avoided. SRL supports steroids withdrawal after kidney transplantation, and SRL combined with tacrolimus is recommended in this setting. Loading dose is recommended when initiating SRL treatment and its trough blood level should be routinely monitored.
Collapse
Affiliation(s)
- D Q Zhao
- Kidney Transplantation Department, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - S W Li
- Kidney Transplantation Department, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Q Q Sun
- Kidney Transplantation Department, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.
| |
Collapse
|
14
|
Tedesco Silva H, Rosso Felipe C, Medina Pestana JO. Reviewing 15 years of experience with sirolimus. Transplant Res 2015; 4:6. [PMID: 27293553 PMCID: PMC4895289 DOI: 10.1186/s13737-015-0028-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Here, we review 15 years of clinical use of sirolimus in our transplant center, in context with the developing immunosuppressive strategies use worldwide. The majority of studies were conducted in de novo kidney transplant recipients, using sirolimus (SRL) in combination with calcineurin inhibitors (CNIs). We also explored steroid (ST) or CNI-sparing therapies, including CNI minimization, elimination, or conversion strategies in combination with mycophenolate (MMF/MPS). Pooled long-term outcomes were comparable with those obtained with CNI and antimetabolite combination. Surprisingly, there are still several areas that need further investigation to improve the risk/benefit profile of SRL in kidney transplantation, including pharmacokinetic/pharmacodynamic drug-to-drug interaction with cyclosporine (CsA) or tacrolimus (TAC), mechanisms of SRL-associated adverse reactions and combinations with other drugs such as belatacept and once-daily TAC, possibly leading to improved long-term adherence. These studies, along with others investigating the benefits of SRL associated lower viral infections and malignancies, are essential as we do not expect the introduction of new immunosuppressive drugs in the near future.
Collapse
Affiliation(s)
- Helio Tedesco Silva
- Nephrology Division, Hospital do Rim, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Claudia Rosso Felipe
- Nephrology Division, Hospital do Rim, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Jose Osmar Medina Pestana
- Nephrology Division, Hospital do Rim, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| |
Collapse
|
15
|
Kloster-Jensen K, Vethe NT, Bremer S, Abadpour S, Korsgren O, Foss A, Bergan S, Scholz H. Intracellular sirolimus concentration is reduced by tacrolimus in human pancreatic islets in vitro. Transpl Int 2015; 28:1152-61. [DOI: 10.1111/tri.12617] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Revised: 02/09/2015] [Accepted: 06/01/2015] [Indexed: 12/16/2022]
Affiliation(s)
- Kristine Kloster-Jensen
- Department of Transplantation Medicine; Oslo University Hospital; Norway
- Institute for Surgical Research; University of Oslo; Norway
| | - Nils Tore Vethe
- Department of Pharmacology; Oslo University Hospital; Norway
| | - Sara Bremer
- Department of Medical Biochemistry; Oslo University Hospital; Norway
| | - Shadab Abadpour
- Department of Transplantation Medicine; Oslo University Hospital; Norway
- Institute for Surgical Research; University of Oslo; Norway
| | - Olle Korsgren
- Department of Immunology Genetics and Pathology, Science for Life Laboratory; Uppsala University; Sweden
| | - Aksel Foss
- Department of Transplantation Medicine; Oslo University Hospital; Norway
- Institute for Surgical Research; University of Oslo; Norway
- Faculty of Medicine; University of Oslo; Norway
| | - Stein Bergan
- Department of Pharmacology; Oslo University Hospital; Norway
- School of Pharmacy; University of Oslo; Norway
| | - Hanne Scholz
- Department of Transplantation Medicine; Oslo University Hospital; Norway
- Institute for Surgical Research; University of Oslo; Norway
| |
Collapse
|