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Mohamed ME, Saqr A, Staley C, Onyeaghala G, Teigen L, Dorr CR, Remmel RP, Guan W, Oetting WS, Matas AJ, Israni AK, Jacobson PA. Pharmacomicrobiomics: Immunosuppressive Drugs and Microbiome Interactions in Transplantation. Transplantation 2024; 108:1895-1910. [PMID: 38361239 PMCID: PMC11327386 DOI: 10.1097/tp.0000000000004926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
The human microbiome is associated with human health and disease. Exogenous compounds, including pharmaceutical products, are also known to be affected by the microbiome, and this discovery has led to the field of pharmacomicobiomics. The microbiome can also alter drug pharmacokinetics and pharmacodynamics, possibly resulting in side effects, toxicities, and unanticipated disease response. Microbiome-mediated effects are referred to as drug-microbiome interactions (DMI). Rapid advances in the field of pharmacomicrobiomics have been driven by the availability of efficient bacterial genome sequencing methods and new computational and bioinformatics tools. The success of fecal microbiota transplantation for recurrent Clostridioides difficile has fueled enthusiasm and research in the field. This review focuses on the pharmacomicrobiome in transplantation. Alterations in the microbiome in transplant recipients are well documented, largely because of prophylactic antibiotic use, and the potential for DMI is high. There is evidence that the gut microbiome may alter the pharmacokinetic disposition of tacrolimus and result in microbiome-specific tacrolimus metabolites. The gut microbiome also impacts the enterohepatic recirculation of mycophenolate, resulting in substantial changes in pharmacokinetic disposition and systemic exposure. The mechanisms of these DMI and the specific bacteria or communities of bacteria are under investigation. There are little or no human DMI data for cyclosporine A, corticosteroids, and sirolimus. The available evidence in transplantation is limited and driven by small studies of heterogeneous designs. Larger clinical studies are needed, but the potential for future clinical application of the pharmacomicrobiome in avoiding poor outcomes is high.
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Affiliation(s)
- Moataz E Mohamed
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN
| | - Abdelrahman Saqr
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN
| | | | - Guillaume Onyeaghala
- Hennepin Healthcare Research Institute, Minneapolis, MN
- Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Levi Teigen
- Department of Food Science and Nutrition, University of Minnesota, St Paul, MN
| | - Casey R Dorr
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN
- Hennepin Healthcare Research Institute, Minneapolis, MN
- Department of Medicine, University of Minnesota, Minneapolis, MN
- Department of Medicine, Hennepin Healthcare, Minneapolis, MN
| | - Rory P Remmel
- Department of Medicinal Chemistry, College of Pharmacy, University of Minnesota, Minneapolis, MN
| | - Weihua Guan
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - William S Oetting
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN
| | - Arthur J Matas
- Department of Surgery, University of Minnesota, Minneapolis, MN
| | - Ajay K Israni
- Hennepin Healthcare Research Institute, Minneapolis, MN
- Department of Medicine, Hennepin Healthcare, Minneapolis, MN
- Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN
| | - Pamala A Jacobson
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN
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Przybyciński J, Drożdżal S, Wilk A, Dziedziejko V, Szumilas K, Pawlik A. The Effect of the Gut Microbiota on Transplanted Kidney Function. Int J Mol Sci 2023; 24:ijms24021260. [PMID: 36674775 PMCID: PMC9866452 DOI: 10.3390/ijms24021260] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 11/23/2022] [Accepted: 01/06/2023] [Indexed: 01/10/2023] Open
Abstract
The intestinal microflora is extremely important, not only in the processes of absorption, digestion and biosynthesis of vitamins, but also in shaping the immune and cognitive functions of the human body. Several studies demonstrate a correlation between microbiota composition and such events as graft rejection, kidney interstitial fibrosis, urinary tract infections, and diarrhoea or graft tolerance. Some of those changes might be directly linked with pathologies such as colonization with pathogenic bacterial strains. Gut microbiota composition also plays an important role in metabolic complications and viral infections after transplantation. From the other side, gut microbiota might induce graft tolerance by promotion of T and B regulatory cells. Graft tolerance induction is still an extremely important issue regarding transplantology and might allow the reduction or even avoidance of immunosuppressive treatment. Although there is a rising evidence of the pivotal role of gut microbiota in aspects of kidney transplantation there is still a lack of knowledge on the direct mechanisms of microbiota action. Furthermore, some of those negative effects could be reversed by probiotics of faecal microbiota trapoinsplantation. While diabetes and hypertension as well as BKV and CMV viremia are common and important complications of transplantation, both worsening the graft function and causing systemic injuries, it opens up potential clinical treatment options. As has been also suggested in the current review, some bacterial subsets exhibit protective properties. However, currently, there is a lack of evidence on pro- and prebiotic supplementation in kidney transplant patients. In the current review, we describe the effect of the microbiota on the transplanted kidney in renal transplant recipients.
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Affiliation(s)
- Jarosław Przybyciński
- Department of Nephrology, Transplantology and Internal Medicine, Pomeranian Medical University, 70-111 Szczecin, Poland
| | - Sylwester Drożdżal
- Department of Nephrology, Transplantology and Internal Medicine, Pomeranian Medical University, 70-111 Szczecin, Poland
| | - Aleksandra Wilk
- Department of Histology and Embryology, Pomeranian Medical University, 70-111 Szczecin, Poland
| | - Violetta Dziedziejko
- Department of Biochemistry and Medical Chemistry, Pomeranian Medical University, 70-111 Szczecin, Poland
| | - Kamila Szumilas
- Department of Physiology, Pomeranian Medical University in Szczecin, 70-111 Szczecin, Poland
| | - Andrzej Pawlik
- Department of Physiology, Pomeranian Medical University in Szczecin, 70-111 Szczecin, Poland
- Correspondence:
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Teng F, Zhang W, Wang W, Chen J, Liu S, Li M, Li L, Guo W, Wei H. Population pharmacokinetics of tacrolimus in Chinese adult liver transplant patients. Biopharm Drug Dispos 2022; 43:76-85. [PMID: 35220592 DOI: 10.1002/bdd.2311] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 01/23/2022] [Accepted: 02/03/2022] [Indexed: 12/27/2022]
Abstract
Tacrolimus is widely used in organ transplantation to prevent rejection. However, the narrow therapeutic window and the large inter-and intra-individual variability in the pharmacokinetics (PK) of tacrolimus make it difficult for individualization of dosing. This study aimed at developing a population pharmacokinetic model for estimating the oral clearance of tacrolimus in Chinese liver transplant patients, and identifying factors that contribute to the PK variability of tacrolimus. Data of 151 liver transplant patients who received tacrolimus were analyzed in this study. The population PK model was analyzed and the covariates including population demographic and biochemical characteristics, drug combination, and genetic polymorphism were explored using non-linear mixed-effects modeling approach. A single-compartment population PK model was developed, and the final model was CL/F = (14.6-2.38 × cytochrome P450 (CYP) 3A5-3.72 × WZC+1.04 × (POD/9)+2.48 × COR) × Exp(ηi ), where CYP3A5 was 1 for CYP3A5*3/*3, Wuzhi Capsule (WZC) was 1 when patients took tacrolimus combined with WZC, otherwise it was 0, corticosteroids (COR) was 1 when patients take tacrolimus combined with COR, otherwise, it was 0, POD was the post-operative day. Visual inspection and bootstrap indicated that the final model was stable and robust. In this study, we developed the first tacrolimus population PK model in Chinese adult liver transplant patients. We first determined the influence of WZC on tacrolimus in these people, which could provide useful PK information for the drug combination of tacrolimus and WZC. We also revealed the influence of genetic polymorphism of CYP3A5, POD, and a combination of COR on tacrolimus PK. Therefore, these significant factors should be taken into consideration in optimizing dosage regimens.
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Affiliation(s)
- Fei Teng
- Institute of Organ Transplantation, Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Weiyue Zhang
- School of Nursing, Beijing University of Chinese Medicine, Beijing, China
| | - Wei Wang
- Medical Guarantee Center, Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Jiani Chen
- Medical Guarantee Center, Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Shiyi Liu
- Medical Guarantee Center, Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Mingming Li
- Medical Guarantee Center, Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Lujin Li
- Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Wenyuan Guo
- Institute of Organ Transplantation, Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Hua Wei
- Medical Guarantee Center, Second Affiliated Hospital of Naval Medical University, Shanghai, China
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Dumond C, Aulagnon F, Etienne I, Heng AE, Bougnoux ME, Favennec L, Kamar N, Iriart X, Pereira B, Büchler M, Desoubeaux G, Kaminski H, Lussac-Sorton F, Gargala G, Anglicheau D, Poirier P, Scemla A, Garrouste C. Epidemiological and clinical study of microsporidiosis in French kidney transplant recipients from 2005 to 2019: TRANS-SPORE registry. Transpl Infect Dis 2021; 23:e13708. [PMID: 34324771 DOI: 10.1111/tid.13708] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 06/29/2021] [Accepted: 07/01/2021] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Microsporidiosis is an emerging opportunistic infection in renal transplantation (RT) recipients. We aimed to describe its clinical presentation and treatment. MATERIALS AND METHODS We collected microsporidiosis cases identified in RT recipients between 2005 and 2019 in six French centers from the Crystal, Divat and Astre prospective databases. RESULTS We report 68 RT recipients with intestinal microsporidiosis; the patients were predominantly male (61.8%), with a median age of 58 (46-69) years. Infection occurred at a median time of 3 (0.8-6.8) years posttransplant. Only Enterocytozoon bieneusi was found. Microsporidiosis manifested as diarrhea (98.5% of patients) with weight loss (72.1%) and acute renal injury (57.4%) without inflammatory biological parameters. The therapeutic approaches were no treatment (N = 9), reduction of the immunosuppressive regimen (∆IS) (N = 22), fumagillin alone (N = 9), fumagillin and ∆IS (N = 19), and albendazole or nitazoxanide and ∆IS (N = 9). Overall clinical remission was observed in 60 patients (88.2%). We observed no acute kidney rejection, renal transplant failure, or death within 6 months after microsporidiosis. CONCLUSION E. bieneusi is an underestimated opportunistic pathogen in RT recipients, and infection with E. bieneusi leads to diarrhea with important dehydration and acute renal injury. The treatment is based on the reduction of the immunosuppressive regimen and the administration of fumagillin if available.
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Affiliation(s)
- Clément Dumond
- Department of Nephrology, 3iHP, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Florence Aulagnon
- Department of Nephrology and Kidney Transplantation, Assistance Publique-Hôpitaux de Paris, Necker Hospital, Paris, France
| | - Isabelle Etienne
- Department of Nephrology, Rouen University Hospital, Rouen, France
| | - Anne-Elisabeth Heng
- Department of Nephrology, 3iHP, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Marie-Elisabeth Bougnoux
- Department of Parasitology, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Loic Favennec
- Department of Parasitology, Rouen University Hospital, University of Rouen, Mont-Saint-Aignan, France
| | - Nassim Kamar
- Department of Nephrology and Organ Transplantation, Toulouse Rangueil University Hospital, Center for Pathophysiology of Toulouse Purpan, Paul Sabatier University, Toulouse, France
| | - Xavier Iriart
- Service de Parasitologie-Mycologie, CHU Toulouse, Hôpital Purpan, Toulouse, France.,Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity), CNRS UMR5051, INSERM UMR1291, UPS, Université Toulouse, Toulouse, France
| | - Bruno Pereira
- Biostatistics Unit (DRCI), Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Mathias Büchler
- Department of Nephrology and Clinical Immunology, Tours University Hospital, Tours, France
| | - Guillaume Desoubeaux
- Department of Parasitology-Mycology- Tropical Medicine, Tours University Hospital, Tours, France
| | - Hannah Kaminski
- Department of Nephrology, Bordeaux University Hospital, Bordeaux, France
| | | | - Gilles Gargala
- Department of Parasitology, Rouen University Hospital, University of Rouen, Mont-Saint-Aignan, France
| | - Dany Anglicheau
- Department of Nephrology and Kidney Transplantation, Assistance Publique-Hôpitaux de Paris, Necker Hospital, Paris, France
| | - Philippe Poirier
- Department of Parasitology, Clermont-Ferrand University Hospital, 3iHP, Clermont-Ferrand, INSERM, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Anne Scemla
- Department of Nephrology and Kidney Transplantation, Assistance Publique-Hôpitaux de Paris, Necker Hospital, Paris, France
| | - Cyril Garrouste
- Department of Nephrology, 3iHP, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
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- Department of Nephrology, 3iHP, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
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Efficacy and Safety of Switching to Azathioprine for Mycophenolate-Induced Diarrhea in Renal Transplant Recipients. Transplant Proc 2021; 53:1951-1956. [PMID: 34274119 DOI: 10.1016/j.transproceed.2021.06.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 06/14/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Diarrhea is a common adverse effect of mycophenolate treatment in renal transplant recipients. In patients with mycophenolate-induced diarrhea, one option is to switch to mycophenolate to azathioprine. In this study, we aimed to define the safety and efficacy of switching from mycophenolate to azathioprine for mycophenolate-related diarrhea in renal transplant recipients. METHODS A total of 177 patients, 59 of whom were switched to azathioprine because of diarrhea and 118 of whom comprised a matched control group without diarrhea and continued mycophenolate treatment participated in this study. We analyzed the effect of switching to azathioprine from mycophenolate on amelioration of diarrhea and graft survival. RESULTS We observed that 89.8% of patients who switched to azathioprine because of diarrhea had improved diarrhea complaints. Patients switched to azathioprine because of diarrhea had lower glomerular filtration rates (P < .001) and higher proteinuria (P < .001) compared with the control group before the switch. Patients switched to azathioprine compared with a subgroup of 59 control patients were matched to patients switched to azathioprine in terms of baseline renal function and proteinuria in addition to demographic parameters had higher 10-year graft loss compared with patients who continued mycophenolate (P = .03). Particularly in patients with a glomerular filtration rate <30 mL/min at the time of conversion, the risk of early graft loss was high. CONCLUSIONS Although switching from mycophenolate to azathioprine was an effective approach to improve diarrhea, this approach is associated with increased risk of graft loss.
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Chavant A, Gautier-Veyret E, Chhun S, Guilhaumou R, Stanke-Labesque F. [Pharmacokinetic changes related to acute infection. Examples from the SARS-CoV-2 pandemic]. Therapie 2020; 76:319-333. [PMID: 33129512 PMCID: PMC7833468 DOI: 10.1016/j.therap.2020.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/18/2020] [Accepted: 10/12/2020] [Indexed: 01/08/2023]
Abstract
The knowledge of factors of pharmacokinetic variability is important in order to personalize pharmacological treatment, particularly for drugs with a narrow therapeutic range for which pharmacological therapeutic monitoring is recommended. Inflammation is a protective response against acute infections and injuries that contributes to intra- and inter-individual variability in drug exposure by modulating the activity of enzymes involved in drug metabolism, and by altering the binding of drugs to plasma proteins. The understanding of the impact of inflammation on drug metabolism and the related clinical consequences allow to better take into consideration the effect of inflammation on the variability of drug exposure. We first summarized the molecular mechanisms by which inflammation contributes to the inhibition of drug metabolism enzymes. We then presented an updated overview of the consequences of the outcome of acute infectious event on pharmacokinetic exposure of drugs with a narrow therapeutic range and that are substrates of cytochrome P450, and the related clinical consequences. Finally, in the context of the COVID-19 pandemic, we reported examples of drug overexposures in COVID- 19 infected patients.
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Affiliation(s)
- Anaëlle Chavant
- Laboratoire de pharmacologie-pharmacogénétique-toxicologie, pôle de biologie et pathologie, CHU Grenoble Alpes, 38700 La Tronche, France
| | - Elodie Gautier-Veyret
- Laboratoire de pharmacologie-pharmacogénétique-toxicologie, pôle de biologie et pathologie, CHU Grenoble Alpes, 38700 La Tronche, France; University Grenoble Alpes, Inserm, CHU Grenoble Alpes, HP2, 38043 Grenoble, France
| | - Stéphanie Chhun
- UFR de médecine Paris centre, 75015 Paris, France; Institut Necker-Enfants Malades (INEM), Inserm U1151-CNRS UMR 8253, 75015 Paris, France; Laboratoire d'immunologie biologique, département médico universitaire BioPhyGen, hôpital universitaire Necker-enfants malades, AP-HP, 75015 Paris, France
| | - Romain Guilhaumou
- Unité de pharmacologie clinique et pharmacovigilance AP-HM, 13354 Marseille, France; Aix Marseille Univ, Inserm, INS Inst Neurosci Syst, 13354 Marseille, France
| | - Françoise Stanke-Labesque
- Laboratoire de pharmacologie-pharmacogénétique-toxicologie, pôle de biologie et pathologie, CHU Grenoble Alpes, 38700 La Tronche, France; University Grenoble Alpes, Inserm, CHU Grenoble Alpes, HP2, 38043 Grenoble, France.
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7
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Sikma MA, Hunault CC, Van Maarseveen EM, Huitema ADR, Van de Graaf EA, Kirkels JH, Verhaar MC, Grutters JC, Kesecioglu J, De Lange DW. High Variability of Whole-Blood Tacrolimus Pharmacokinetics Early After Thoracic Organ Transplantation. Eur J Drug Metab Pharmacokinet 2020; 45:123-134. [PMID: 31745812 PMCID: PMC6994432 DOI: 10.1007/s13318-019-00591-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background and Objective Oral tacrolimus is initiated perioperatively in heart and lung transplantation patients. There have been few studies on oral tacrolimus pharmacokinetics early post-transplantation, even though tacrolimus-related toxicity may occur early, potentially leading to morbidity and mortality. Therefore, we aimed to study the pharmacokinetics of oral tacrolimus in thoracic organ recipients during the first days after transplantation. Methods We conducted a pharmacokinetic study in 30 thoracic organ transplants at intensive care at the University Medical Center Utrecht in the first week post-transplantation. Twelve-hour whole-blood tacrolimus profiles were examined using high-performance liquid chromatography tandem mass spectrometry (HPLC–MS/MS) and analysed via population pharmacokinetic modelling. Results The concentration–time profiles showed high variability. Concentrations at 12 h were outside the target range in 69% of the cases. A two-compartment model with mixed first-order and zero-order absorption adequately described tacrolimus concentrations. The typical value of the apparent clearance was 19.6 L/h (95% CI 16.2–22.9), and the apparent distribution volumes of central and peripheral compartments, V1 and V2, were 231 L (95% CI 199–267) and 521 L (95% CI 441–634), respectively. Inter-occasion (dose-to-dose) variability far exceeded the interindividual variability (IIV), with an estimated variability in relative bioavailability of 55% (95% CI 48.5–64.4). Conclusions The high variability of tacrolimus pharmacokinetics early after thoracic organ transplantation is largely due to excessive variability in bioavailability, making individualised dosing based on measured concentrations futile. To bypass this bioavailability issue, we suggest administering tacrolimus intravenously and aiming below the upper therapeutic range early post-transplantation. Clinical Trial Registraion: NTR 3912/EudraCT 2012-001909-24. Electronic supplementary material The online version of this article (10.1007/s13318-019-00591-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Maaike A Sikma
- Department of Intensive Care and Dutch Poisons Information Center, University Medical Center Utrecht, Utrecht University, F06.149, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands.
| | - Claudine C Hunault
- Dutch Poisons Information Center, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Erik M Van Maarseveen
- Department of Clinical Pharmacy, Princess Máxima Center, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands.,Department of Clinical Pharmacy, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Alwin D R Huitema
- Department of Clinical Pharmacy, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands.,Department of Pharmacy and Pharmacology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Ed A Van de Graaf
- Department of Lung Transplantation, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Johannes H Kirkels
- Department of Cardiology, Heart Transplantation, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Marianne C Verhaar
- Department of Nephrology and Hypertension, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Jan C Grutters
- Department of Lung Transplantation, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands.,Department of Pulmonology, St. Antonius Hospital, Nieuwegein, Utrecht, The Netherlands
| | - Jozef Kesecioglu
- Department of Intensive Care, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Dylan W De Lange
- Dutch Poisons Information Center and Department of Intensive Care, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
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Degraeve AL, Moudio S, Haufroid V, Chaib Eddour D, Mourad M, Bindels LB, Elens L. Predictors of tacrolimus pharmacokinetic variability: current evidences and future perspectives. Expert Opin Drug Metab Toxicol 2020; 16:769-782. [PMID: 32721175 DOI: 10.1080/17425255.2020.1803277] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION In kidney transplantation, tacrolimus (TAC) is at the cornerstone of current immunosuppressive strategies. Though because of its narrow therapeutic index, it is critical to ensure that TAC levels are maintained within this sharp window through reactive adjustments. This would allow maximizing efficiency while limiting drug-associated toxicity. However, TAC high intra- and inter-patient pharmacokinetic (PK) variability makes it more laborious to accurately predict the appropriate dosage required for a given patient. AREAS COVERED This review summarizes the state-of-the-art knowledge regarding drug interactions, demographic and pharmacogenetics factors as predictors of TAC PK. We provide a scoring index for each association to grade its relevance and we present practical recommendations, when possible for clinical practice. EXPERT OPINION The management of TAC concentration in transplanted kidney patients is as critical as it is challenging. Recommendations based on rigorous scientific evidences are lacking as knowledge of potential predictors remains limited outside of DDIs. Awareness of these limitations should pave the way for studies looking at demographic and pharmacogenetic factors as well as gut microbiota composition in order to promote tailored treatment plans. Therapeutic approaches considering patients' clinical singularities may help allowing to maintain appropriate concentration of TAC.
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Affiliation(s)
- Alexandra L Degraeve
- Integrated Pharmacometrics, Pharmacogenomics and Pharmacokinetics (PMGK), Louvain Drug Research Institute (LDRI), Université Catholique De Louvain , Brussels, Belgium.,Metabolism and Nutrition Research Group (Mnut), Louvain Drug Research Institute (LDRI), Université Catholique De Louvain , Brussels, Belgium
| | - Serge Moudio
- Integrated Pharmacometrics, Pharmacogenomics and Pharmacokinetics (PMGK), Louvain Drug Research Institute (LDRI), Université Catholique De Louvain , Brussels, Belgium.,Louvain Centre for Toxicology and Applied Pharmacology (LTAP), Institut De Recherche Expérimentale Et Clinique (IREC), Université Catholique De Louvain , Brussels, Belgium
| | - Vincent Haufroid
- Louvain Centre for Toxicology and Applied Pharmacology (LTAP), Institut De Recherche Expérimentale Et Clinique (IREC), Université Catholique De Louvain , Brussels, Belgium.,Department of Clinical Chemistry, Cliniques Universitaires Saint-Luc , Brussels, Belgium
| | - Djamila Chaib Eddour
- Kidney and Pancreas Transplantation Unit, Cliniques Universitaires Saint-Luc , Brussels, Belgium
| | - Michel Mourad
- Kidney and Pancreas Transplantation Unit, Cliniques Universitaires Saint-Luc , Brussels, Belgium
| | - Laure B Bindels
- Metabolism and Nutrition Research Group (Mnut), Louvain Drug Research Institute (LDRI), Université Catholique De Louvain , Brussels, Belgium
| | - Laure Elens
- Integrated Pharmacometrics, Pharmacogenomics and Pharmacokinetics (PMGK), Louvain Drug Research Institute (LDRI), Université Catholique De Louvain , Brussels, Belgium.,Louvain Centre for Toxicology and Applied Pharmacology (LTAP), Institut De Recherche Expérimentale Et Clinique (IREC), Université Catholique De Louvain , Brussels, Belgium
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Murakami T, Bodor E, Bodor N. Modulation of expression/function of intestinal P-glycoprotein under disease states. Expert Opin Drug Metab Toxicol 2019; 16:59-78. [DOI: 10.1080/17425255.2020.1701653] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
| | | | - Nicholas Bodor
- Bodor Laboratories, Miami, FL, USA
- College of Pharmacy, University of Florida, Gainesville, FL, USA
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10
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Therapeutic Drug Monitoring of Tacrolimus-Personalized Therapy: Second Consensus Report. Ther Drug Monit 2019; 41:261-307. [DOI: 10.1097/ftd.0000000000000640] [Citation(s) in RCA: 227] [Impact Index Per Article: 45.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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11
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Brunet M, van Gelder T, Åsberg A, Haufroid V, Hesselink DA, Langman L, Lemaitre F, Marquet P, Seger C, Shipkova M, Vinks A, Wallemacq P, Wieland E, Woillard JB, Barten MJ, Budde K, Colom H, Dieterlen MT, Elens L, Johnson-Davis KL, Kunicki PK, MacPhee I, Masuda S, Mathew BS, Millán O, Mizuno T, Moes DJAR, Monchaud C, Noceti O, Pawinski T, Picard N, van Schaik R, Sommerer C, Vethe NT, de Winter B, Christians U, Bergan S. Therapeutic Drug Monitoring of Tacrolimus-Personalized Therapy: Second Consensus Report. Ther Drug Monit 2019. [DOI: 10.1097/ftd.0000000000000640
expr 845143713 + 809233716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
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Abstract
In June 2015, an outbreak of cryptosporidiosis with 35 cases (23 probable and 12 laboratory-confirmed) occurred among 191 attendees of a residential rehabilitation holiday for paediatric organ transplant patients (n = 49) and their families at a hotel in Somogy county, Hungary. The overall attack rate was 18%. Most of the cases were transplanted children who experienced severe acute disease and required adjustment to their tacrolimus immunosuppression. A retrospective case-control study suggested an association between recreational water exposures and illness: cases were seven times more likely than controls to have swum in the children's pool (odds ratio 7.17; 95% confidence interval 2.9–17.2; P < 0.0001) and five times more likely to have used the jetted whirlpool (odds ratio 5.25; 95% confidence interval 2.1–13.1; P < 0.0001). This was the first outbreak of cryptosporidiosis in Hungary and it is especially unfortunate that it affected vulnerable children who experienced severe symptoms. Cryptosporidium presents specific infection control difficulties in treated recreational water venues; the link to a whirlpool is unusual and highlights the importance of the age-appropriate use of these facilities and reminding users not to immerse their heads or swallow the water. Cryptosporidiosis is more commonly linked to children’ pools where improved bather hygiene and promoting exclusion of diarrhoea cases could help to avoid similar outbreaks.
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Immunosuppressive drugs and the gastrointestinal tract in renal transplant patients. Transplant Rev (Orlando) 2018; 33:55-63. [PMID: 30473173 DOI: 10.1016/j.trre.2018.11.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 11/07/2018] [Accepted: 11/10/2018] [Indexed: 12/26/2022]
Abstract
Gastrointestinal (GI) discomfort is common after renal transplantation and can be caused by the use of various immunosuppressive drugs. GI symptoms affect the quality of life, lead to an impaired graft survival and an increased mortality. Moreover, diseases and disturbances of the GI tract also affect the pharmacokinetics of immunosuppressive drugs. This review addresses the interaction between immunosuppressive agents and GI disorders. The GI tract is involved in the metabolism of several immunosuppressive drugs. Calcineurin inhibitors, mTor inhibitors, and corticosteroids are subjected to metabolism by the intestinal cytochrome P450 (CYP3A) and by the drug efflux pump ABCB1. Mycophenolate is partly metabolized in the stomach and intestine and undergoes enterohepatic recirculation. Gastrointestinal disturbances can lead to a modified exposure to immunosuppressive drugs. In the first and second part of this review, we focus on the role of the GI tract in the pharmacokinetics of the immunosuppressive drugs and how to adjust immunosuppressive therapy in patients with vomiting, need for tube feeding, delayed gastric emptying, intestinal resection, and diarrhea. In the third part, we review the GI adverse effects of the various immunosuppressive drugs, with special attention for diarrhea and dyspepsia. Finally, we discuss the effects of drugs used for relief of GI complaints on the exposure to immunosuppressive agents.
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14
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Cryptosporidiosis Treated With Nitazoxanide in Intestinal Transplantation. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2016. [DOI: 10.1097/ipc.0000000000000332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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15
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Lee JR, Muthukumar T, Dadhania D, Taur Y, Jenq RR, Toussaint NC, Ling L, Pamer E, Suthanthiran M. Gut microbiota and tacrolimus dosing in kidney transplantation. PLoS One 2015; 10:e0122399. [PMID: 25815766 PMCID: PMC4376942 DOI: 10.1371/journal.pone.0122399] [Citation(s) in RCA: 118] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Accepted: 01/13/2015] [Indexed: 12/14/2022] Open
Abstract
Tacrolimus dosing to establish therapeutic levels in recipients of organ transplants is a challenging task because of much interpatient and intrapatient variability in drug absorption, metabolism, and disposition. In view of the reported impact of gut microbial species on drug metabolism, we investigated the relationship between the gut microbiota and tacrolimus dosing requirements in this pilot study of adult kidney transplant recipients. Serial fecal specimens were collected during the first month of transplantation from 19 kidney transplant recipients who either required a 50% increase from initial tacrolimus dosing during the first month of transplantation (Dose Escalation Group, n=5) or did not require such an increase (Dose Stable Group, n=14). We characterized bacterial composition in the fecal specimens by deep sequencing of the PCR amplified 16S rRNA V4-V5 region and we investigated the hypothesis that gut microbial composition is associated with tacrolimus dosing requirements. Initial tacrolimus dosing was similar in the Dose Escalation Group and in the Stable Group (4.2±1.1 mg/day vs. 3.8±0.8 mg/day, respectively, P=0.61, two-way between-group ANOVA using contrasts) but became higher in the Dose Escalation Group than in the Dose Stable Group by the end of the first transplantation month (9.6±2.4 mg/day vs. 3.3±1.5 mg/day, respectively, P<0.001). Our systematic characterization of the gut microbial composition identified that fecal Faecalibacterium prausnitzii abundance in the first week of transplantation was 11.8% in the Dose Escalation Group and 0.8% in the Dose Stable Group (P=0.002, Wilcoxon Rank Sum test, P<0.05 after Benjamini-Hochberg correction for multiple hypotheses). Fecal Faecalibacterium prausnitzii abundance in the first week of transplantation was positively correlated with future tacrolimus dosing at 1 month (R=0.57, P=0.01) and had a coefficient±standard error of 1.0±0.6 (P=0.08) after multivariable linear regression. Our novel observations may help further explain inter-individual differences in tacrolimus dosing to achieve therapeutic levels.
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Affiliation(s)
- John R. Lee
- Department of Medicine, Division of Nephrology and Hypertension, Weill Cornell Medical College, New York, New York, United States of America
- Department of Transplantation Medicine, New York Presbyterian Hospital—Weill Cornell Medical Center, New York, New York, United States of America
- * E-mail:
| | - Thangamani Muthukumar
- Department of Medicine, Division of Nephrology and Hypertension, Weill Cornell Medical College, New York, New York, United States of America
- Department of Transplantation Medicine, New York Presbyterian Hospital—Weill Cornell Medical Center, New York, New York, United States of America
| | - Darshana Dadhania
- Department of Medicine, Division of Nephrology and Hypertension, Weill Cornell Medical College, New York, New York, United States of America
- Department of Transplantation Medicine, New York Presbyterian Hospital—Weill Cornell Medical Center, New York, New York, United States of America
| | - Ying Taur
- Department of Medicine, Infectious Diseases Services, Memorial Sloan Kettering Cancer Center, New York, New York, United States of America
- Lucille Castori Center for Microbes, Inflammation and Cancer, Memorial Sloan Kettering Cancer Center, New York, New York, United States of America
- Weill Cornell Medical College, New York, New York, United States of America
| | - Robert R. Jenq
- Lucille Castori Center for Microbes, Inflammation and Cancer, Memorial Sloan Kettering Cancer Center, New York, New York, United States of America
- Weill Cornell Medical College, New York, New York, United States of America
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York, United States of America
| | - Nora C. Toussaint
- Department of Medicine, Infectious Diseases Services, Memorial Sloan Kettering Cancer Center, New York, New York, United States of America
| | - Lilan Ling
- Lucille Castori Center for Microbes, Inflammation and Cancer, Memorial Sloan Kettering Cancer Center, New York, New York, United States of America
| | - Eric Pamer
- Department of Medicine, Infectious Diseases Services, Memorial Sloan Kettering Cancer Center, New York, New York, United States of America
- Lucille Castori Center for Microbes, Inflammation and Cancer, Memorial Sloan Kettering Cancer Center, New York, New York, United States of America
- Weill Cornell Medical College, New York, New York, United States of America
| | - Manikkam Suthanthiran
- Department of Medicine, Division of Nephrology and Hypertension, Weill Cornell Medical College, New York, New York, United States of America
- Department of Transplantation Medicine, New York Presbyterian Hospital—Weill Cornell Medical Center, New York, New York, United States of America
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