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Combarel D, Geraud A, Gougis P. Reply to: "Therapeutic Drug Monitoring of Oral Oncology Drugs: Another Example of Maslow's Hammer" and "Therapeutic Drug Monitoring of Oral Oncology Drugs: Finding the Right Nails". Clin Pharmacol Ther 2024. [PMID: 38970295 DOI: 10.1002/cpt.3367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Accepted: 06/23/2024] [Indexed: 07/08/2024]
Affiliation(s)
- David Combarel
- Pharmacology Department, Gustave Roussy, Villejuif, France
- Faculty of Pharmacy, Paris-Saclay University, Chatenay-Malabry, France
| | - Arthur Geraud
- Department of Medical Oncology, Institut Paoli-Calmettes, Marseille, France
- Department of Cancer Medicine, Gustave Roussy, Villejuif, France
| | - Paul Gougis
- Department of Pharmacology and Clinical Investigation Center (CIC-1901), Pitié-Salpêtrière Hospital, AP-HP Sorbonne Université, Paris, France
- INSERM, CIC-1901 and UMR-S 1166, Sorbonne Université Médecine, Paris, France
- Oncology Department, APHP-Sorbonne Université, Cancer Institute (IUC), Paris, France
- Residual Tumor & Response to Treatment Laboratory, RT2Lab, INSERM, U932 Immunity and Cancer, Curie Institute, Université Paris, Paris, France
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2
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Meganck S, Raevens S, Ferdinande K, Verhelst X, Hoorens A, Degroote H, Geerts A, Van Vlierberghe H. Recurrent rejections after liver transplantation for hepatocellular carcinoma with stem cell features in an adult patient. Acta Clin Belg 2024:1-8. [PMID: 38961614 DOI: 10.1080/17843286.2024.2376304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 07/01/2024] [Indexed: 07/05/2024]
Abstract
Patients with hepatoblastoma featuring carcinoma characteristics have better outcomes after liver transplantation, than after chemotherapy and resection. Possibly this should be extrapolated to aggressive subtypes of hepatocellular carcinomas in non-cirrhotic livers, where early liver transplantation might also be indicated. However, the risks associated with liver transplantation and immunosuppressive treatment after liver transplantation are once again demonstrated by this case of a 32-year-old women with a negative personal and familial history of liver diseases. She underwent transplantation (DBD) for a hepatocellular carcinoma with stem cell features (HCC-HS; an aggressive 'hepatoblast subtype' of hepatocellular carcinoma) after chemotherapeutical downstaging techniques failed to sufficiently downstage the tumor. Despite being on conventional immunosuppressive regimens (tacrolimus and mycophenolate mofetil with initial corticosteroids tapered), this patient still developed two severe rejection episodes, one of which necessitated retransplantation (DCD). Both episodes were preceded by alterations in tacrolimus trough levels, either intentionally, when tacrolimus was reduced within a nephroprotective regimen, or unintentionally, when rifampicin, a CYP3A4 inducer, significantly lowered the trough levels. Together, these episodes stress the importance of therapeutic drug monitoring of tacrolimus. Furthermore, the patient experienced an everolimus-linked drug-induced thrombotic microangiopathy, underwent multiple ERCPs for an anastomotic stricture and only one and a half year after the first liver transplantation she already suffers from long-term immunosuppressive-related side effects such as impaired glucose tolerance, hypertension and a potential cardiomyopathy. At present, she is still alive and experienced no recurrence of her primary tumor. Her case underscores the significant challenges in post-liver transplantation care.
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Affiliation(s)
- S Meganck
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Gent, Belgium
| | - S Raevens
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Gent, Belgium
| | - K Ferdinande
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Gent, Belgium
| | - X Verhelst
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Gent, Belgium
| | - A Hoorens
- Department of Pathology, Ghent University Hospital, Gent, Belgium
| | - H Degroote
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Gent, Belgium
| | - A Geerts
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Gent, Belgium
| | - H Van Vlierberghe
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Gent, Belgium
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3
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Xie W, Fan S, Liu R, Yan W, Su C, Zheng K, Wang X, Wang Z. Tacrolimus intra-patient variability measures and its associations with allograft clinical outcomes in kidney transplantation. Transplant Rev (Orlando) 2024; 38:100842. [PMID: 38537484 DOI: 10.1016/j.trre.2024.100842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 03/14/2024] [Accepted: 03/15/2024] [Indexed: 06/16/2024]
Abstract
AIMS Tacrolimus (Tac) is commonly prescribed in solid organ transplantation to prevent immune-mediated damage to the graft. However, its pharmacokinetics show substantial variability between and within patients. Intra-patient variability of tacrolimus (Tac-IPV) has emerged as a novel marker to predict transplant outcomes. Numerous studies report varying associations between Tac-IPV and clinical outcomes, with Tac-IPV measures showing wide discrepancies among these studies. This inconsistency could be a significant factor that influences the various outcomes reported in different studies. Our review comprehensively assesses the relationship between various Tac-IPV measures and their associations with clinical outcomes in transplant patients. METHODS A comprehensive literature search was conducted using the PubMed and Embase databases, covering the period from 2004 to March 31, 2023. The search focused on studies that examined the relationship between Tac-IPV and clinical outcomes in kidney transplantation (KT). The inclusion criteria were specific to studies addressing Tac-IPV, including measures such as standard deviation (SD), coefficient of variation (CV), time-weighted coefficient of variability (CV), mean absolute deviation (MAD), and Tac variability score (TVS). Clinical outcomes included the development of de novo donor-specific antibodies (dnDSA), rejection episodes, graft loss, and graft failure. RESULTS Among the 33 studies that met the inclusion criteria, a notable proportion presented conflicting findings in their assessment of various Tac-IPV measures regarding dnDSA, rejection episodes, graft loss, and graft failure. CONCLUSIONS Most studies have identified a correlation between high Tac-IPV and poor clinical outcomes; however, this relationship is multifactorial. Influencing factors include the metabolic status of KT patients, the timing of Tac-IPV calculations, and the criteria for defining high and low Tac-IPV thresholds, including the size and selection method. CV, MAD, and TWCV are the metrics that are most frequently used to determine Tac-IPV. Additionally, most of the methods for establishing Tac-IPV thresholds typically employ receiver operating characteristic (ROC) curves and median values. It is also notable that studies examining the clinical significance of Tac-IPV often include tacrolimus levels measured six months after kidney transplantation.
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Affiliation(s)
- Wenmin Xie
- Department of Pharmacy, Shanghai Changhai Hospital, Naval Medical University, Shanghai, People's Republic of China; College of life sciences and Biopharmaceuticals, Shenyang Pharmaceutical University, Shenyang, People's Republic of China
| | - Shupan Fan
- Department of Pharmacy, Shanghai Changhai Hospital, Naval Medical University, Shanghai, People's Republic of China; Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Naval Medical University, Shanghai, People's Republic of China
| | - Ruolin Liu
- Department of Pharmacy, Shanghai Changhai Hospital, Naval Medical University, Shanghai, People's Republic of China; College of life sciences and Biopharmaceuticals, Shenyang Pharmaceutical University, Shenyang, People's Republic of China
| | - Wencheng Yan
- Department of Pharmacy, Shanghai Changhai Hospital, Naval Medical University, Shanghai, People's Republic of China; School of Pharmacy, Bengbu Medical University, Bengbu, People's Republic of China
| | - Chengxin Su
- Department of Pharmacy, Shanghai Changhai Hospital, Naval Medical University, Shanghai, People's Republic of China; College of life sciences and Biopharmaceuticals, Shenyang Pharmaceutical University, Shenyang, People's Republic of China
| | - Kaile Zheng
- Department of Pharmacy, Shanghai Changhai Hospital, Naval Medical University, Shanghai, People's Republic of China; School of Pharmacy, Bengbu Medical University, Bengbu, People's Republic of China
| | - Xuebin Wang
- Department of pharmacy, Shanghai Children's Hospital, School of medicine, Shanghai Jiao Tong University, Shanghai, People's Republic of China.
| | - Zhuo Wang
- Department of Pharmacy, Shanghai Changhai Hospital, Naval Medical University, Shanghai, People's Republic of China; College of life sciences and Biopharmaceuticals, Shenyang Pharmaceutical University, Shenyang, People's Republic of China; Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Naval Medical University, Shanghai, People's Republic of China; School of Pharmacy, Bengbu Medical University, Bengbu, People's Republic of China.
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4
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Wang X, Liu Z, Chen J, Chai Y, Shao X, Xie W, Zheng K, You J, Wang Z, Feng M. Impact of intra-patient variability of tacrolimus on allograft function and CD4 + /CD8 + ratio in kidney transplant recipients: a retrospective single-center study. Int J Clin Pharm 2024:10.1007/s11096-024-01726-w. [PMID: 38814512 DOI: 10.1007/s11096-024-01726-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 03/12/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND Tacrolimus is a critical component of immunosuppressive therapy for kidney transplant recipients. Intra-patient variation (IPV) of tacrolimus levels affects the function of transplanted kidney. AIM This study aimed to investigate the impact of tacrolimus IPV on kidney function, examine its association with post-transplant duration, and assess its effect on the immune status of transplant recipients. METHOD This retrospective study was conducted from January 2016 to February 2022. IPV was evaluated using the coefficient of variation (CV) of tacrolimus trough levels from 6 to 48 months after transplantation. Patients were divided into low- and high-IPV groups based on the median CV. Significant differences in kidney function, CD4 + /CD8 + ratio, and post-transplant duration between these groups were analyzed. RESULTS Among 189 patients, tacrolimus IPV showed a strong correlation with serum creatinine clearance rate (Ccr) and estimated glomerular filtration rate (eGFR) (p < 0.05). Tacrolimus IPV was significantly correlated with post-transplant duration in only two patients (p < 0.05). Using a median CV of 15.4% to categorize patients, the high IPV group, compared to the low IPV group, exhibited significantly higher eGFR at 6-9 months (p < 0.05), lower Ccr at 9-12 months (p < 0.05), and reduced Ccr and eGFR at 15-18 months (p < 0.05). Six months after transplantation, the high IPV group had a significantly lower CD4 + /CD8 + ratio than the low IPV group (p < 0.05). CONCLUSION This study highlights the significant impact of tacrolimus IPV on transplant kidney function and immune status in transplant patients at various post-transplantation intervals.
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Affiliation(s)
- Xuebin Wang
- Department of Biological Medicines and Shanghai Engineering Research Center of Immunotherapeutics, Fudan University School of Pharmacy, 826 Zhangheng Road, Pudong New District, Shanghai, 201203, People's Republic of China
- Department of Pharmacy, Shanghai Changhai Hospital, Naval Medical University, 168 Changhai Road, Shanghai, 200433, People's Republic of China
- Department of Pharmacy, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200062, People's Republic of China
| | - Zhengyue Liu
- Department of Pharmacy, Shanghai Changhai Hospital, Naval Medical University, 168 Changhai Road, Shanghai, 200433, People's Republic of China
| | - Jingxia Chen
- Department of Pharmacy, Shanghai Changhai Hospital, Naval Medical University, 168 Changhai Road, Shanghai, 200433, People's Republic of China
| | - Yuhui Chai
- Department of Pharmacy, Shanghai Changhai Hospital, Naval Medical University, 168 Changhai Road, Shanghai, 200433, People's Republic of China
| | - Xueqing Shao
- Department of Pharmacy, Shanghai Changhai Hospital, Naval Medical University, 168 Changhai Road, Shanghai, 200433, People's Republic of China
| | - Wenmin Xie
- Department of Pharmacy, Shanghai Changhai Hospital, Naval Medical University, 168 Changhai Road, Shanghai, 200433, People's Republic of China
| | - Kaile Zheng
- Department of Pharmacy, Shanghai Changhai Hospital, Naval Medical University, 168 Changhai Road, Shanghai, 200433, People's Republic of China
- School of Pharmacy, Bengbu Medical University, Bengbu, 233030, Anhui, People's Republic of China
| | - Jia You
- Department of Pharmacy, Shanghai Changhai Hospital, Naval Medical University, 168 Changhai Road, Shanghai, 200433, People's Republic of China
- School of Pharmacy, Bengbu Medical University, Bengbu, 233030, Anhui, People's Republic of China
| | - Zhuo Wang
- Department of Pharmacy, Shanghai Changhai Hospital, Naval Medical University, 168 Changhai Road, Shanghai, 200433, People's Republic of China
| | - Meiqing Feng
- Department of Biological Medicines and Shanghai Engineering Research Center of Immunotherapeutics, Fudan University School of Pharmacy, 826 Zhangheng Road, Pudong New District, Shanghai, 201203, People's Republic of China.
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Poudel S, Gupta S, Saigal S. Basics and Art of Immunosuppression in Liver Transplantation. J Clin Exp Hepatol 2024; 14:101345. [PMID: 38450290 PMCID: PMC10912712 DOI: 10.1016/j.jceh.2024.101345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 01/09/2024] [Indexed: 03/08/2024] Open
Abstract
Liver transplantation is one of the most challenging areas in the medical field. Despite that, it has already been established as a standard treatment option, especially in decompensated cirrhosis and selected cases of hepatocellular carcinoma and acute liver failure. Complications due to graft rejection, including mortality and morbidity, have greatly improved over time due to better immunosuppressive agents and management protocols. Currently, immunosuppression in liver transplant patients makes use of the best possible combinations of effective agents to achieve optimal immunosuppression for long-term graft survival. Induction agents are no longer used routinely, and the aim is to provide minimal immunosuppression in the maintenance phase. Currently available immunosuppressive agents are mainly classified as biological and pharmacological agents. Though the protocols may vary among the centers and over time, the basics of effective use usually remain similar. Most protocols use the combination of multiple agents with different mechanisms of action to reduce the dose and minimize the side effects. Along with the improvement in operative and perioperative techniques, this art of immunosuppression has contributed to the recent progress made in the outcomes of liver transplants. In this review, we will discuss the various types of immunosuppressive agents currently in use, the different protocols of immunosuppression used, and the art of optimal use for achieving maximum immunosuppression without increasing toxicity. We will also discuss the practical aspects of various immunosuppression regimens, including drug monitoring, and briefly discuss the concepts of immunosuppression minimization and withdrawal.
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Affiliation(s)
- Shekhar Poudel
- Fellow Transplant Hepatology, Centre for Liver and Biliary Sciences, Max Super Specialty Hospital, Saket, New Delhi, India
| | - Subhash Gupta
- Liver Transplant and Gastrointestinal Surgery, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Sanjiv Saigal
- Principal Director and Head, Transplant Hepatology, Centre for Liver and Biliary Sciences, Max Super Specialty Hospital, Saket, New Delhi, India
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Rodríguez-Espinosa D, Broseta JJ, Montagud-Marrahí E, Arana C, Ferrer J, Cuatrecasas M, Garcia-Criado Á, Amor AJ, Diekmann F, Ventura-Aguiar P. Tacrolimus's Time Below Therapeutic Range Is Associated With Acute Pancreatic Graft Rejection and the Development of De Novo Donor-specific Antibodies. Transpl Int 2024; 37:12591. [PMID: 38694489 PMCID: PMC11062183 DOI: 10.3389/ti.2024.12591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 03/11/2024] [Indexed: 05/04/2024]
Abstract
Tacrolimus is pivotal in pancreas transplants but poses challenges in maintaining optimal levels due to recipient differences. This study aimed to explore the utility of time spent below the therapeutic range and intrapatient variability in predicting rejection and de novo donor-specific antibody (dnDSA) development in pancreas graft recipients. This retrospective unicentric study included adult pancreas transplant recipients between January 2006 and July 2020. Recorded variables included demographics, immunosuppression details, HLA matching, biopsy results, dnDSA development, and clinical parameters. Statistical analysis included ROC curves, sensitivity, specificity, and predictive values. A total of 131 patients were included. Those with biopsy-proven acute rejection (BPAR, 12.2%) had more time (39.9% ± 24% vs. 25.72% ± 21.57%, p = 0.016) and tests (41.95% ± 13.57% vs. 29.96% ± 17.33%, p = 0.009) below therapeutic range. Specific cutoffs of 31.5% for time and 34% for tests below the therapeutic range showed a high negative predictive value for BPAR (93.98% and 93.1%, respectively). Similarly, patients with more than 34% of tests below the therapeutic range were associated with dnDSA appearance (38.9% vs. 9.4%, p = 0.012; OR 6.135, 1.346-27.78). In pancreas transplantation, maintaining optimal tacrolimus levels is crucial. Suboptimal test percentages below the therapeutic range prove valuable in identifying acute graft rejection risk.
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Affiliation(s)
- Diana Rodríguez-Espinosa
- Department of Nephrology and Renal Transplantation, Hospital Clínic de Barcelona, Barcelona, Spain
- Laboratori Experimental de Nefrologia I Trasplantament (LENIT), Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - José Jesús Broseta
- Department of Nephrology and Renal Transplantation, Hospital Clínic de Barcelona, Barcelona, Spain
- Laboratori Experimental de Nefrologia I Trasplantament (LENIT), Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Enrique Montagud-Marrahí
- Department of Nephrology and Renal Transplantation, Hospital Clínic de Barcelona, Barcelona, Spain
- Laboratori Experimental de Nefrologia I Trasplantament (LENIT), Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Carolt Arana
- Department of Nephrology and Renal Transplantation, Hospital Clínic de Barcelona, Barcelona, Spain
- Laboratori Experimental de Nefrologia I Trasplantament (LENIT), Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Joana Ferrer
- Department of Hepatobiliopancreatic Surgery and Liver Transplant, Hospital Clínic, Barcelona, Spain
| | | | | | - Antonio J. Amor
- Diabetes Unit, Department of Endocrinology and Nutrition, Hospital Clínic Barcelona, Barcelona, Spain
| | - Fritz Diekmann
- Department of Nephrology and Renal Transplantation, Hospital Clínic de Barcelona, Barcelona, Spain
- Laboratori Experimental de Nefrologia I Trasplantament (LENIT), Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Pedro Ventura-Aguiar
- Department of Nephrology and Renal Transplantation, Hospital Clínic de Barcelona, Barcelona, Spain
- Laboratori Experimental de Nefrologia I Trasplantament (LENIT), Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
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7
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Charlès L, Lupon E, Sheth T, Camuzard O, Lellouch AG, Shende C, Farquharson S, Safa K, Cetrulo CL. Immunosuppressant drug monitor: A non-invasive device to measure tacrolimus level in the saliva of transplanted patients. Int J Pharm 2024; 653:123858. [PMID: 38286196 DOI: 10.1016/j.ijpharm.2024.123858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 01/22/2024] [Accepted: 01/24/2024] [Indexed: 01/31/2024]
Abstract
Solid organ and vascularized composite allograft transplantation are pivotal in enhancing both life expectancy and quality of life. However, the significant risk of donor tissue rejection requires lifelong immunosuppressive therapy. Tacrolimus, a common component of immunosuppressive regimens, offers effectiveness in preventing organ rejection but poses challenges due to its narrow therapeutic window and toxicity, making it essential to carefully monitor its concentration. Tacrolimus trough levels are currently measured in blood, requiring frequent blood draws from patients, and results are available after 3 to 6 h. To address the need for a fast, minimally-invasive, and simple method to monitor tacrolimus concentrations, we have assessed a new device for at-home analysis, the Immunosuppressant Drug Monitor (IDM) that can extract, identify and quantify tacrolimus in saliva within 15 min. We included males and females hospitalized at Massachusetts General Hospital Transplant Unit, between the ages of 21 and 65 years, and treated with Tacrolimus. Informed consent, demographic and treatment data were collected. Each subject was asked to provide a 5 mL saliva sample that was de-identified and processed by the IDM, while a 5 mL blood sample was drawn and supplied to the MGH clinical lab for analysis by the current standard, immunoassays. The predicted tacrolimus concentration found in saliva was compared to the blood trough level results. 62 samples from 31 different patients were obtained. The male to female ratio and ethnicity distribution were well balanced. The majority of patients were within 30 days of initiating tacrolimus treatment. After IDM calibration and exclusion, 21 samples were measured by the IDM. Using an exponential function fit, the IDM showed a correlation of R2 = 0.39 between the saliva Test Line absorption and the measured tacrolimus concentration in blood, with an average absolute error of 1.8 ng/mL. Our results demonstrate a clear correlation between blood and saliva measurements. The IDM provided promising results to monitor immunosuppressant drug concentrations in patients after transplantation. Future larger studies will further develop the correlation, and the IDM's potential impact on patient outcomes.
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Affiliation(s)
- Laura Charlès
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Elise Lupon
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Plastic and Reconstructive Surgery, Institut Universitaire Locomoteur et du Sport, Pasteur 2 Hospital, University Côte d'Azur, Nice, France; Department of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Tia Sheth
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Olivier Camuzard
- Department of Plastic and Reconstructive Surgery, Institut Universitaire Locomoteur et du Sport, Pasteur 2 Hospital, University Côte d'Azur, Nice, France.
| | - Alexandre G Lellouch
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, MA, USA; Innovative Therapies in Haemostasis, INSERM UMR-S 1140, University of Paris, Paris F-75006, France.
| | - Chetan Shende
- Real-Time Analyzers Inc., 362 Industrial Park Road, Unit 8, Middletown, CT 06457, USA.
| | - Stuart Farquharson
- Real-Time Analyzers Inc., 362 Industrial Park Road, Unit 8, Middletown, CT 06457, USA.
| | - Kassem Safa
- Division of Nephrology & Transplant Center, Massachusetts General Hospital, Boston, MA, USA.
| | - Curtis L Cetrulo
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, MA, USA.
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8
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Chen F, Yong JK, Shen C, Zhou T, Feng M, Wan P, Luo Y, Lin H, Qian Y, Xia Q. High intra-patient variability of tacrolimus within post-operative 1 month predicted worse 1-year outcomes in pediatric liver transplant recipients. Eur J Clin Pharmacol 2024:10.1007/s00228-024-03663-z. [PMID: 38502358 DOI: 10.1007/s00228-024-03663-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 03/04/2024] [Indexed: 03/21/2024]
Abstract
BACKGROUND The pharmacokinetics of tacrolimus (TAC) show high intra-patient variability (IPV), which is associated with poor long-term outcomes following adult liver transplantation (LT). However, this relationship remains to be confirmed in pediatric liver transplant (PLT) recipients. The present study aimed to investigate the association between TAC IPV and grafts or patient outcomes after pediatric liver transplantion. METHODS This retrospective study included 848 PLT recipients (including infants) between January, 2016, and June, 2021. The IPV of TAC concentrations was estimated by calculating the coefficient of variation (CV) of trough concentrations in whole blood within 1 month after transplantation. Patients were categorized into two groups, low IPV (CV < 45%) and high IPV (CV ≥ 45%), based on the third quartile of the CV distribution. RESULTS A total of 848 patients were included in our study. The low CV group included 614 patients, with a mean TAC trough concentration of 8.59 ± 1.65 ng/ml and a median CV of 32.37%. In contrast, the high CV group included 214 patients, the mean TAC trough concentration and median CV were 8.81 ± 2.00 ng/ml and 54.88%, respectively. The median hospital duration was significantly higher in the high CV group (22 days vs. 20 days, P = 0.01). Univariate analysis was performed to evaluate the significant differences in 1-year recipient survival (P = 0.041) and 1-year graft survival (P = 0.005) between the high- and low-CV groups. Moreover, high CV (HR 2.316, 95%CI 1.026-5.231, P = 0.043) and persistent EBV viremia (HR 13.165, 95%CI 3.090-56.081, P < 0.001) were identified as independent risk factors for 1- year mortality after PLT. CONCLUSIONS PLT recipients with high TAC trough concentration of CV in the first month were associated with poor 1-year outcomes. This CV calculation provides a valuable strategy to monitor TAC exposure.
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Affiliation(s)
- Fang Chen
- Department of Pharmacy, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200127, People's Republic of China
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, No. 1630 Dongfang Road, Shanghai, 200127, People's Republic of China
| | - June-Kong Yong
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, No. 1630 Dongfang Road, Shanghai, 200127, People's Republic of China
| | - Chuan Shen
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, No. 1630 Dongfang Road, Shanghai, 200127, People's Republic of China
| | - Tao Zhou
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, No. 1630 Dongfang Road, Shanghai, 200127, People's Republic of China
| | - Mingxuan Feng
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, No. 1630 Dongfang Road, Shanghai, 200127, People's Republic of China
| | - Ping Wan
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, No. 1630 Dongfang Road, Shanghai, 200127, People's Republic of China
| | - Yi Luo
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, No. 1630 Dongfang Road, Shanghai, 200127, People's Republic of China
| | - Houwen Lin
- Department of Pharmacy, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200127, People's Republic of China
| | - Yongbing Qian
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, No. 1630 Dongfang Road, Shanghai, 200127, People's Republic of China.
| | - Qiang Xia
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, No. 1630 Dongfang Road, Shanghai, 200127, People's Republic of China.
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9
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Kim JJ, Lawless L, Marshall D, Maxted A, Lunn A, Mallik M, Williams A. Pharmacokinetics of Envarsus in pediatric kidney transplant recipients - phase 1 pilot conversion study. Pediatr Transplant 2024; 28:e14703. [PMID: 38433334 DOI: 10.1111/petr.14703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 01/10/2024] [Accepted: 01/22/2024] [Indexed: 03/05/2024]
Abstract
INTRODUCTION Tacrolimus is the standard immunosuppressant for pediatric kidney transplants and is routinely administered twice daily (BD-tac). Envarsus (LCP-tac), an extended-release formulation, is approved for adults but not for pediatric patients. METHODS We conducted a pilot open-label phase 1 study in stable pediatric kidney transplant recipients (age < 18 at the time of study). Our primary objective was to compare the pharmacokinetics (Pk) of LCP-tac versus BD-tac. We conducted two 24-h Pk studies: pre-conversion (BD-tac) and 4 weeks post-conversion to LCP-tac. Patients were followed for 6 months, with the option to continue LCP-tac. RESULTS Five patients completed the study, with no returns to BD-tac. Median age was 15 years (range 11-17). LCP-tac exhibited an extended-release profile versus the bimodal profile of BD-tac. Time to maximum concentration was delayed (5 h vs. 1 h), and maximum concentration was lower (9.9 ng/mL vs. 14.4 ng/mL). Tacrolimus area under the curve (24 h) was comparable (141 ± 46.5 ng/mL vs. 164 ± 27.8 ng/mL). No new safety concerns arose. There were no rejection and no difference in eGFR at the study's end (1.5 mL/min/1.73 m2 , range - 1.7 to 2.3 mL/min/1.73 m2 ). Concentration/dose ratio was higher in LCP-tac (1.8 ± 0.64 vs. 0.8 ± 0.39). The final conversion ratio was 0.6 (BD-tac: LCP-tac). CONCLUSION Our pilot study confirms the extended-release Pk profile and improved absorption of LCP-tac compared to BD-tac. A larger study is needed to further evaluate the population Pk characteristics in children.
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Affiliation(s)
- Jon Jin Kim
- Department of Paediatric Nephrology, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Department of Surgery, University of Cambridge, Cambridge, UK
| | - Laura Lawless
- Research and Innovation, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - David Marshall
- Department of Clinical Biochemistry, Wythenshawe Hospital, Manchester, UK
| | - Andrew Maxted
- Department of Paediatric Nephrology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Andrew Lunn
- Department of Paediatric Nephrology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Meeta Mallik
- Department of Paediatric Nephrology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Alun Williams
- Department of Paediatric Nephrology, Nottingham University Hospitals NHS Trust, Nottingham, UK
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10
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Pan B, Li Y, Wang X, Ou Y, Heng G, Liu X, Jiang D, Liu W, Huang Y, Hu F, Xu Z, Chen Z, Zhang L, Zhang C. Adequate cumulative exposure to tacrolimus and low tacrolimus variability decrease the incidence of biliary complications after liver transplantation. Int Immunopharmacol 2024; 128:111461. [PMID: 38176344 DOI: 10.1016/j.intimp.2023.111461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 12/25/2023] [Accepted: 12/26/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Nonearly biliary complications (BCs) after liver transplantation (LT) are highly associated with immunological status. Tacrolimus is the main immunosuppressant. Whether and how tacrolimus bioavailability affects BCs is unclear. METHODS LT recipients receiving tacrolimus-free immunosuppressants or developing BCs within 3 months after LT were excluded. Tacrolimus-related variables included trough concentration (C0), variability and cumulative exposure to tacrolimus (CET). Receiver operating characteristic (ROC) curves defined cutoff values of CET and variability. The values divided patients into adequate and low CET groups, also high and low-variability groups. Inverse probability of treatment weighting (IPTW) was used to reduce bias. Logistic regression identified risk factors. Kaplan-Meier curves were generated for survival comparison. RESULTS 409 patients were enrolled, and 39 (9.5 %) suffered from BCs. The mean C0 values were 6.9 and 7.2 ng/mL in the BCs and BCs-free groups, respectively. CET within 3 postoperative months was 550.0 and 608.6 ng.day/mL, while the tacrolimus variability was 0.4 and 0.3, respectively. The cutoff values for CET within 3 months and variability predicting BCs were 660.5 and 0.54, respectively. Multivariable logistic regression revealed that low CET within 3 months (p = 0.005, p = 0.002) and high variability (p < 0.001, p < 0.001) were associated with BCs before and after IPTW. Appropriate CET and low variability were associated with better overall survival (p = 0.009 and 0.029). Subgroup analysis indicated that long cold ischemia time (CIT), high bilirubin and low CET had a higher relative risk and raised the incidence of BCs. CONCLUSIONS Adequate CET and low variability of tacrolimus ameliorated nonearly BCs incidence and improved survival.
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Affiliation(s)
- Bi Pan
- Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Shapingba District, Chongqing City, China
| | - Yuancheng Li
- Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Shapingba District, Chongqing City, China
| | - Xiaojun Wang
- Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Shapingba District, Chongqing City, China
| | - Yanjiao Ou
- Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Shapingba District, Chongqing City, China
| | - Gang Heng
- Department of general surgery, PLA Middle Military Command General Hospital, Wuchang District, Wuhan Province, China
| | - Xingchao Liu
- Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Qingyang District, Sichuan Province, China
| | - Di Jiang
- Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Shapingba District, Chongqing City, China
| | - Wei Liu
- Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Shapingba District, Chongqing City, China
| | - Yixian Huang
- Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Shapingba District, Chongqing City, China
| | - Feng Hu
- Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Shapingba District, Chongqing City, China
| | - Zeliang Xu
- Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Shapingba District, Chongqing City, China
| | - Zhiyu Chen
- Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Shapingba District, Chongqing City, China.
| | - Leida Zhang
- Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Shapingba District, Chongqing City, China.
| | - Chengcheng Zhang
- Department of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University (Army Medical University), Shapingba District, Chongqing City, China.
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11
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Reineke M, Morath C, Speer C, Rudek M, Bundschuh C, Klein JA, Mahler CF, Kälble F, Nusshag C, Beimler J, Zeier M, Bartenschlager R, Schnitzler P, Benning L. Dynamics of torque teno virus load in kidney transplant recipients with indication biopsy and therapeutic modifications of immunosuppression. Front Med (Lausanne) 2024; 11:1337367. [PMID: 38327708 PMCID: PMC10847215 DOI: 10.3389/fmed.2024.1337367] [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] [Received: 11/12/2023] [Accepted: 01/04/2024] [Indexed: 02/09/2024] Open
Abstract
Following kidney transplantation, lifelong immunosuppressive therapy is essential to prevent graft rejection. On the downside, immunosuppression increases the risk of severe infections, a major cause of death among kidney transplant recipients (KTRs). To improve post-transplant outcomes, adequate immunosuppressive therapy is therefore a challenging but vital aspect of clinical practice. Torque teno virus load (TTVL) was shown to reflect immune competence in KTRs, with low TTVL linked to an elevated risk for rejections and high TTVL associated with infections in the first year post-transplantation. Yet, little is known about the dynamics of TTVL after the first year following transplantation and how TTVL changes with respect to short-term modifications in immunosuppressive therapy. Therefore, we quantified TTVL in 106 KTRs with 108 clinically indicated biopsies, including 65 biopsies performed >12 months post-transplantation, and correlated TTVL to histopathology. In addition, TTVL was quantified at 7, 30, and 90 days post-biopsy to evaluate how TTVL was affected by changes in immunosuppression resulting from interventions based on histopathological reporting. TTVL was highest in patients biopsied between 1 and 12 months post-transplantation (N = 23, median 2.98 × 107 c/mL) compared with those biopsied within 30 days (N = 20, median 7.35 × 103 c/mL) and > 1 year post-transplantation (N = 65, median 1.41 × 104 c/mL; p < 0.001 for both). Patients with BK virus-associated nephropathy (BKVAN) had significantly higher TTVL than patients with rejection (p < 0.01) or other pathologies (p < 0.001). When converted from mycophenolic acid to a mTOR inhibitor following the diagnosis of BKVAN, TTVL decreased significantly between biopsy and 30 and 90 days post-biopsy (p < 0.01 for both). In KTR with high-dose corticosteroid pulse therapy for rejection, TTVL increased significantly between biopsy and 30 and 90 days post-biopsy (p < 0.05 and p < 0.01, respectively). Of note, no significant changes were seen in TTVL within 7 days of changes in immunosuppressive therapy. Additionally, TTVL varied considerably with time since transplantation and among individuals, with a significant influence of age and BMI on TTVL (p < 0.05 for all). In conclusion, our findings indicate that TTVL reflects changes in immunosuppressive therapy, even in the later stages of post-transplantation. To guide immunosuppressive therapy based on TTVL, one should consider inter- and intraindividual variations, as well as potential confounding factors.
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Affiliation(s)
- Marvin Reineke
- Department of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Christian Morath
- Department of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
- German Center for Infection Research, DZIF, Heidelberg Partner Site, Heidelberg, Germany
| | - Claudius Speer
- Department of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
- Department of Molecular Medicine Partnership Unit Heidelberg, European Molecular Biology Laboratory, Heidelberg, Germany
| | - Markus Rudek
- Department of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Christian Bundschuh
- Medical Faculty Heidelberg, Department of Infectious Diseases, Virology, Heidelberg University, Heidelberg, Germany
| | - Julian A.F. Klein
- Medical Faculty Heidelberg, Department of Infectious Diseases, Virology, Heidelberg University, Heidelberg, Germany
| | - Christoph F. Mahler
- Department of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Florian Kälble
- Department of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Christian Nusshag
- Department of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Jörg Beimler
- Department of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Zeier
- Department of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Ralf Bartenschlager
- German Center for Infection Research, DZIF, Heidelberg Partner Site, Heidelberg, Germany
- Medical Faculty Heidelberg, Department of Infectious Diseases, Molecular Virology, Center for Integrative Infectious Diseases Research, Heidelberg University, Heidelberg, Germany
- Division Virus-Associated Carcinogenesis, German Cancer Research Center, Heidelberg, Germany
| | - Paul Schnitzler
- German Center for Infection Research, DZIF, Heidelberg Partner Site, Heidelberg, Germany
- Medical Faculty Heidelberg, Department of Infectious Diseases, Virology, Heidelberg University, Heidelberg, Germany
| | - Louise Benning
- Department of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
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12
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Sharma A, Verma S, Mirzai S, Viswanathan V, Kapoor S, Hariharan S, Dew MA, Puttarajappa CM. Implementing a self-reported immunosuppression adherence questionnaire to screen for non-adherence in routine care of kidney transplant recipients. Clin Transplant 2024; 38:e15157. [PMID: 37792310 DOI: 10.1111/ctr.15157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 09/20/2023] [Accepted: 09/24/2023] [Indexed: 10/05/2023]
Abstract
INTRODUCTION Self-reported measures of immunosuppression adherence have been largely examined in research settings. METHODS In this single center study of 610 kidney transplant recipients, we examined if a voluntary, non-anonymous self-report measure could identify non-adherence in a routine clinic setting and how patients perceived such a measure. Non-adherence was measured using the Basel Assessment of Adherence to Immunosuppressive Medications Scale (BAASIS) and patient perception was elicited using a customized questionnaire. RESULTS Non-responders to the survey (15%) were younger, more likely to be black, and less likely to have had a pre-emptive transplant. Among complete responders (n = 485), 38% reported non-adherence with non-adherent patients being younger (54 y vs. 60 y; p = .01), less likely to have been on dialysis pre-transplant (59% vs. 68%; p = .04), further out from transplant (37 vs. 22 months; p < .001) and had more rejections in the preceding year (8% vs. 3%; p = .02). Self-reported non-adherence was associated with higher calcineurin inhibitor intra-patient variability (27.4% vs. 24.5%; p = .02), but not with donor-specific antibody detection (27.8% vs. 21.2%, p = .15). Of patients providing feedback (n = 500), the majority of patients felt comfortable reporting adherence (92%), that the survey was relevant to their visit (71%), and that the survey did not interfere with their clinic visit (88%). CONCLUSION In summary, a self-reported questionnaire during clinic visits identified immunosuppression non-adherence in a significant proportion of patients and was well received by patients. Integrating self-report measures into routine post-transplant care may enable early identification of non-adherence.
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Affiliation(s)
- Akhil Sharma
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Medicine, Renal-Electrolyte Division, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Siddharth Verma
- Department of Medicine, Renal-Electrolyte Division, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Saeid Mirzai
- Department of Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Vignesh Viswanathan
- Department of Medicine, Renal-Electrolyte Division, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sanjana Kapoor
- Department of Medicine, Renal-Electrolyte Division, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sundaram Hariharan
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Medicine, Renal-Electrolyte Division, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Mary Amanda Dew
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Chethan M Puttarajappa
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Medicine, Renal-Electrolyte Division, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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13
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Wang CB, Zhang YJ, Zhao MM, Zhao L. Dosage optimization of tacrolimus based on the glucocorticoid dose and pharmacogenetics in adult patients with systemic lupus erythematosus. Int Immunopharmacol 2023; 124:110866. [PMID: 37678026 DOI: 10.1016/j.intimp.2023.110866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/25/2023] [Accepted: 08/26/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND The purpose of the study was to develop a genotype-incorporated population pharmacokinetic (PPK) model of tacrolimus (TAC) in adults with systemic lupus erythematosus (SLE) to investigate the factors influencing TAC pharmacokinetics and to develop an individualized dosing regimen based on the model. In addition, a non-genotype-incorporated model was also established to assess its predictive performance compared to the genotype-incorporated model. METHODS A total of 365 trough concentrations from 133 adult SLE patients treated with TAC were collected to develop a genotype-incorporated PPK model and a non-genotype-incorporated PPK model of TAC using a nonlinear mixed-effects model (NONMEM). External validation of the two models was performed using data from an additional 29 patients. Goodness-of-fit diagnostic plots, bootstrap method, and normalized predictive distribution error test were used to validate the predictive performance and stability of the final models. The goodness-of-fit of the two final models was compared using the Akaike information criterion (AIC). The dosing regimen was optimized using Monte Carlo simulations based on the developed optimal model. RESULTS The typical value of the apparent clearance (CL/F) of TAC estimated in the final genotype-incorporated model was 14.3 L h-1 with inter-individual variability of 27.6%. CYP3A5 polymorphism and coadministered medication were significant factors affecting TAC-CL/F. CYP3A5 rs776746 GG genotype carriers had only 77.3% of the TAC-CL/F of AA or AG genotype carriers. Omeprazole reduced TAC-CL/F by 3.7 L h-1 when combined with TAC, while TAC-CL/F increased nonlinearly as glucocorticoid dose increased. Similar findings were demonstrated in the non-genotype-incorporated PPK model. Comparing these two models, the genotype-incorporated PPK model was superior to the non-genotype-incorporated PPK model (AIC = 643.19 vs. 657.425). Monte Carlo simulation based on the genotype-incorporated PPK model indicated that CYP3A5 rs776746 AA or AG genotype carriers required a 1/2-1 fold higher dose of TAC than GG genotype carriers to achieve the target concentration. And as the daily dose of prednisone increases, the dose of TAC required to reach the target concentration increases appropriately. CONCLUSIONS We developed the first pharmacogenetic-based PPK model of TAC in adult patients with SLE and proposed a dosing regimen based on glucocorticoid dose and CYP3A5 genotype according to the model, which could facilitate individualized dosing for TAC.
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Affiliation(s)
- Cheng-Bin Wang
- Department of Pharmacy, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Yu-Jia Zhang
- Department of Pharmacy, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Ming-Ming Zhao
- Department of Pharmacy, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China.
| | - Limei Zhao
- Department of Pharmacy, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China.
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14
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Kim H, Han A, Ahn S, Min SK, Ha J, Min S. Association of high intra-patient variability in tacrolimus exposure with calcineurin inhibitor nephrotoxicity in kidney transplantation. Sci Rep 2023; 13:16502. [PMID: 37783764 PMCID: PMC10545770 DOI: 10.1038/s41598-023-43755-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 09/27/2023] [Indexed: 10/04/2023] Open
Abstract
Tacrolimus intra-patient variability (IPV) is a novel predictive marker for long-term kidney transplantation outcomes. We examined the association between IPV and calcineurin inhibitor (CNI) nephrotoxicity and the impact of pharmacogenes on CNI nephrotoxicity and IPV. Among kidney transplant recipients at our hospital between January 2013 and December 2015, the records of 80 patients who underwent 1-year protocol renal allograft biopsy and agreed to donate blood samples for genetic analysis were retrospectively reviewed. The cohort was divided into the low and high IPV groups based on a coefficient variability cutoff value (26.5%). In multivariate analysis, the IPV group was involved in determining CNI nephrotoxicity (HR 4.55; 95% CI 0.05-0.95; p = 0.043). The 5-year graft survival was superior in the low IPV group than in the high IPV group (100% vs 92.4% respectively, p = 0.044). Analysis of the time above therapeutic range (TATR) showed higher CNI nephrotoxicity in the high IPV with high TATR group than in the low IPV with low TATR group (35.7% versus 6.7%, p = 0.003). Genetic analysis discovered that CYP3A4 polymorphism (rs2837159) was associated with CNI nephrotoxicity (HR 28.23; 95% CI 2.2-355.9; p = 0.01). In conclusion, high IPV and CYP3A4 polymorphisms (rs2837159) are associated with CNI nephrotoxicity.
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Affiliation(s)
- Hyokee Kim
- Department of Surgery, Korea University College of Medicine, Seoul, South Korea
| | - Ahram Han
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Sanghyun Ahn
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Seung-Kee Min
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Jongwon Ha
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Sangil Min
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea.
- Division of Transplantation and Vascular Surgery, Department of Surgery, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul, 03080, South Korea.
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15
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An S, Lee S, Rhu J, Kim JM, Choi GS, Joh JW. Safety and Efficacy of Conversion to Once-Daily Tacrolimus from Twice-Daily Tacrolimus in Pediatric Liver Transplant Recipients. J Pediatr Surg 2023; 58:2054-2058. [PMID: 37277238 DOI: 10.1016/j.jpedsurg.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 04/21/2023] [Accepted: 05/07/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND Nonadherence to immunosuppression is the most common cause of late acute rejection in pediatric liver transplant (LT) recipients. A prolonged-release once-daily tacrolimus formulation was developed to improve adherence and long-term allograft survival. METHODS We screened 179 pediatric LT recipients who converted from twice-daily tacrolimus (TD-TAC) to once-daily tacrolimus (OD-TAC) between February 2011 and September 2019. RESULTS One hundred seventy-nine recipients converted to OD-TAC and were followed for 18 months. 152 OD-TAC-converted recipients (84.9%) experienced uneventful follow-up, while 21 recipients showed LFT elevation. Four recipients had biopsy-proven acute rejection within six months of conversion, all of which were successfully treated with steroid pulse. 166 recipients (92.7%) remain on OD-TAC and 13 (7.3%) were switched back to TD-TAC. The mean tacrolimus trough level significantly decreased three months following conversion (3.14 ± 1.9 ng/mL) compared with pre-conversion levels (3.69 ± 1.98 ng/mL). Mean tacrolimus trough levels remained unchanged from 3 months to 12 months following conversion. Percent coefficient of variation of tacrolimus trough levels decreased significantly from 32.5 ± 16.4 ng/mL to 27.5 ± 15.6 ng/mL after conversion to OD-TAC, reflecting a decrease in variation of tacrolimus trough levels following conversion. CONCLUSIONS Conversion to OD-TAC in pediatric LT recipients with stable graft function is safe and effective. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- SungHyo An
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sanghoon Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
| | - Jinsoo Rhu
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jong Man Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Gyu-Seong Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jae-Won Joh
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Morais MC, Soares ME, Costa G, Guerra L, Vaz N, Codes L, Bittencourt PL. Impact of tacrolimus intra-patient variability in adverse outcomes after organ transplantation. World J Transplant 2023; 13:254-263. [PMID: 37746041 PMCID: PMC10514747 DOI: 10.5500/wjt.v13.i5.254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 07/31/2023] [Accepted: 08/11/2023] [Indexed: 09/15/2023] Open
Abstract
Tacrolimus (Tac) is currently the most common calcineurin-inhibitor employed in solid organ transplantation. High intra-patient variability (IPV) of Tac (Tac IPV) has been associated with an increased risk of immune-mediated rejection and poor outcomes after kidney transplantation. Few data are available concerning the impact of high Tac IPV in non-kidney transplants. However, even in kidney transplantation, there is still a controversy whether high Tac IPV is indeed detrimental in respect to graft and/or patient survival. This may be due to different methods employed to evaluate IPV and distinct time frames adopted to assess graft and patient survival in those reports published up to now in the literature. Little is also known about the influence of high Tac IPV in the development of other untoward adverse events, update of the current knowledge regarding the impact of Tac IPV in different outcomes following kidney, liver, heart, lung, and pancreas tran splantation to better evaluate its use in clinical practice.
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Affiliation(s)
- Maria Clara Morais
- School of Medicine, Bahiana School of Medicine and Public Health, Salvador 40290-000, Bahia, Brazil
| | - Maria Eduarda Soares
- School of Medicine, Federal University of Bahia, Salvador 40110-100, Bahia, Brazil
| | - Gabriela Costa
- School of Medicine, Bahiana School of Medicine and Public Health, Salvador 40290-000, Bahia, Brazil
| | - Laura Guerra
- School of Medicine, Bahiana School of Medicine and Public Health, Salvador 40290-000, Bahia, Brazil
| | - Nayana Vaz
- School of Medicine, Bahiana School of Medicine and Public Health, Salvador 40290-000, Bahia, Brazil
- Unit of Gastroenterology and Hepatology, Portuguese Hospital, Salvador 40130-030, Bahia, Brazil
| | - Liana Codes
- School of Medicine, Bahiana School of Medicine and Public Health, Salvador 40290-000, Bahia, Brazil
- Unit of Gastroenterology and Hepatology, Portuguese Hospital, Salvador 40130-030, Bahia, Brazil
| | - Paulo Lisboa Bittencourt
- School of Medicine, Bahiana School of Medicine and Public Health, Salvador 40290-000, Bahia, Brazil
- Unit of Gastroenterology and Hepatology, Portuguese Hospital, Salvador 40130-030, Bahia, Brazil
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Degraeve AL, Haufroid V, Loriot A, Gatto L, Andries V, Vereecke L, Elens L, Bindels LB. Gut microbiome modulates tacrolimus pharmacokinetics through the transcriptional regulation of ABCB1. MICROBIOME 2023; 11:138. [PMID: 37408070 DOI: 10.1186/s40168-023-01578-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 05/17/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND Following solid organ transplantation, tacrolimus (TAC) is an essential drug in the immunosuppressive strategy. Its use constitutes a challenge due to its narrow therapeutic index and its high inter- and intra-pharmacokinetic (PK) variability. As the contribution of the gut microbiota to drug metabolism is now emerging, it might be explored as one of the factors explaining TAC PK variability. Herein, we explored the consequences of TAC administration on the gut microbiota composition. Reciprocally, we studied the contribution of the gut microbiota to TAC PK, using a combination of in vivo and in vitro models. RESULTS TAC oral administration in mice resulted in compositional alterations of the gut microbiota, namely lower evenness and disturbance in the relative abundance of specific bacterial taxa. Compared to controls, mice with a lower intestinal microbial load due to antibiotics administration exhibit a 33% reduction in TAC whole blood exposure and a lower inter-individual variability. This reduction in TAC levels was strongly correlated with higher expression of the efflux transporter ABCB1 (also known as the p-glycoprotein (P-gp) or the multidrug resistance protein 1 (MDR1)) in the small intestine. Conventionalization of germ-free mice confirmed the ability of the gut microbiota to downregulate ABCB1 expression in a site-specific fashion. The functional inhibition of ABCB1 in vivo by zosuquidar formally established the implication of this efflux transporter in the modulation of TAC PK by the gut microbiota. Furthermore, we showed that polar bacterial metabolites could recapitulate the transcriptional regulation of ABCB1 by the gut microbiota, without affecting its functionality. Finally, whole transcriptome analyses pinpointed, among others, the Constitutive Androstane Receptor (CAR) as a transcription factor likely to mediate the impact of the gut microbiota on ABCB1 transcriptional regulation. CONCLUSIONS We highlight for the first time how the modulation of ABCB1 expression by bacterial metabolites results in changes in TAC PK, affecting not only blood levels but also the inter-individual variability. More broadly, considering the high number of drugs with unexplained PK variability transported by ABCB1, our work is of clinical importance and paves the way for incorporating the gut microbiota in prediction algorithms for dosage of such drugs. Video Abstract.
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Affiliation(s)
- Alexandra L Degraeve
- Department of Integrated PharmacoMetrics, PharmacoGenomics and PharmacoKinetics, Louvain Drug Research Institute, Université catholique de Louvain, Brussels, Belgium
- Metabolism and Nutrition Research Group, Louvain Drug Research Institute, Université catholique de Louvain, Brussels, Belgium
| | - Vincent Haufroid
- Louvain centre for Toxicology and Applied Pharmacology, Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Brussels, Belgium
- Department of Clinical Chemistry, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Axelle Loriot
- Computational Biology and Bioinformatics Unit (CBIO), de Duve Institute, Université catholique de Louvain, Brussels, Belgium
| | - Laurent Gatto
- Computational Biology and Bioinformatics Unit (CBIO), de Duve Institute, Université catholique de Louvain, Brussels, Belgium
| | - Vanessa Andries
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium
- VIB-UGent Center for Inflammation Research, Ghent, Belgium
- Ghent Gut Inflammation Group (GGIG), Ghent, Belgium
| | - Lars Vereecke
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium
- VIB-UGent Center for Inflammation Research, Ghent, Belgium
- Ghent Gut Inflammation Group (GGIG), Ghent, Belgium
| | - Laure Elens
- Department of Integrated PharmacoMetrics, PharmacoGenomics and PharmacoKinetics, Louvain Drug Research Institute, Université catholique de Louvain, Brussels, Belgium
- Louvain centre for Toxicology and Applied Pharmacology, Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Brussels, Belgium
| | - Laure B Bindels
- Metabolism and Nutrition Research Group, Louvain Drug Research Institute, Université catholique de Louvain, Brussels, Belgium.
- WELBIO department, WEL Research Institute, Wavre, Belgium.
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18
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Wang CB, Zhang YJ, Zhao MM, Zhao LM. Population pharmacokinetic analyses of tacrolimus in non-transplant patients: a systematic review. Eur J Clin Pharmacol 2023:10.1007/s00228-023-03503-6. [PMID: 37261481 DOI: 10.1007/s00228-023-03503-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 04/30/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND AND OBJECTIVES Tacrolimus (TAC) has been increasingly used in patients with non-transplant settings. Because of its large between-subject variability, several population pharmacokinetic (PPK) studies have been performed to facilitate individualized therapy. This review summarized published PPK models of TAC in non-transplant patients, aiming to clarify factors affecting PKs of TAC and identify the knowledge gap that may require further research. METHODS The PubMed, Embase databases, and Cochrane Library, as well as related references, were searched from the time of inception of the databases to February 2023, to identify TAC population pharmacokinetic studies modeled in non-transplant patients using a non-linear mixed-effects modeling approach. RESULTS Sixteen studies, all from Asian countries (China and Korea), were included in this study. Of these studies, eleven and four were carried out in pediatric and adult patients, respectively. One-compartment models were the commonly used structural models for TAC. The apparent clearance (CL/F) of TAC ranged from 2.05 to 30.9 L·h-1 (median of 14.9 L·h-1). Coadministered medication, genetic factors, and weight were the most common covariates affecting TAC-CL/F, and variability in the apparent volume of distribution (V/F) was largely explained by weight. Coadministration with Wuzhi capsules reduced CL/F by about 19 to 43%. For patients with CYP3A5*1*1 and *1*3 genotypes, the CL/F was 39-149% higher CL/F than patients with CYP3A5*1*1. CONCLUSION The optimal TAC dosage should be adjusted based on the patient's co-administration, body weight, and genetic information (especially CYP3A5 genotype). Further studies are needed to assess the generalizability of the published models to other ethnic groups. Moreover, external validation should be frequently performed to improve the clinical practicality of the models.
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Affiliation(s)
- Cheng-Bin Wang
- Department of Pharmacy, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, 110004, Liaoning Province, People's Republic of China
| | - Yu-Jia Zhang
- Department of Pharmacy, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, 110004, Liaoning Province, People's Republic of China
| | - Ming-Ming Zhao
- Department of Pharmacy, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, 110004, Liaoning Province, People's Republic of China
| | - Li-Mei Zhao
- Department of Pharmacy, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, 110004, Liaoning Province, People's Republic of China.
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19
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Montano-Loza AJ, Rodríguez-Perálvarez ML, Pageaux GP, Sanchez-Fueyo A, Feng S. Liver transplantation immunology: Immunosuppression, rejection, and immunomodulation. J Hepatol 2023; 78:1199-1215. [PMID: 37208106 DOI: 10.1016/j.jhep.2023.01.030] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 12/30/2022] [Accepted: 01/30/2023] [Indexed: 05/21/2023]
Abstract
Outcomes after liver transplantation have continuously improved over the past decades, but long-term survival rates are still lower than in the general population. The liver has distinct immunological functions linked to its unique anatomical configuration and to its harbouring of a large number of cells with fundamental immunological roles. The transplanted liver can modulate the immunological system of the recipient to promote tolerance, thus offering the potential for less aggressive immunosuppression. The selection and adjustment of immunosuppressive drugs should be individualised to optimally control alloreactivity while mitigating toxicities. Routine laboratory tests are not accurate enough to make a confident diagnosis of allograft rejection. Although several promising biomarkers are being investigated, none of them is sufficiently validated for routine use; hence, liver biopsy remains necessary to guide clinical decisions. Recently, there has been an exponential increase in the use of immune checkpoint inhibitors due to the unquestionable oncological benefits they provide for many patients with advanced-stage tumours. It is expected that their use will also increase in liver transplant recipients and that this might affect the incidence of allograft rejection. Currently, the evidence regarding the efficacy and safety of immune checkpoint inhibitors in liver transplant recipients is limited and cases of severe allograft rejection have been reported. In this review, we discuss the clinical relevance of alloimmune disease, the role of minimisation/withdrawal of immunosuppression, and provide practical guidance for using checkpoint inhibitors in liver transplant recipients.
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Affiliation(s)
- Aldo J Montano-Loza
- Division of Gastroenterology and Liver Unit, University of Alberta, Edmonton, AB, Canada.
| | - Manuel L Rodríguez-Perálvarez
- Department of Hepatology and Liver Transplantation, Hospital Universitario Reina Sofía, Universidad de Córdoba, IMIBIC, Córdoba, Spain; CIBER de Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - George-Philippe Pageaux
- Liver Transplantation Unit, Digestive Department, Saint Eloi University Hospital, University of Montpellier, 34295, Montpellier Cedex 5, France
| | - Alberto Sanchez-Fueyo
- Institute of Liver Studies, King's College London University and King's College Hospital, London, United Kingdom
| | - Sandy Feng
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
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Wagner-Skacel J, Fink N, Kahn J, Dalkner N, Jauk E, Bengesser S, Mairinger M, Schüssler G, Pieh C, Stadlbauer V, Kirsch AH, Zitta S, Rosenkranz AR, Fickert P, Schemmer P. Improving adherence to immunosuppression after liver or kidney transplantation in individuals with impairments in personality functioning – A randomized controlled single center feasibility study. Front Psychol 2023; 14:1150548. [PMID: 36968754 PMCID: PMC10033957 DOI: 10.3389/fpsyg.2023.1150548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 02/20/2023] [Indexed: 03/11/2023] Open
Abstract
IntroductionAlthough adherence to immunosuppressive medication is the key factor for long-term graft survival today, 20–70% of transplant recipients are non-adherent to their immunosuppressive medication.ObjectiveA prospective, randomized, controlled single-center feasibility study was designed to evaluate the impact of a step guided multicomponent interprofessional intervention program for patients after kidney or liver transplantation on adherence to their immunosuppressive medication in daily clinical practice.Materials and methodsThe intervention consisted of group therapy and daily training as well as individual sessions in a step guided approach. The primary endpoint of the study was adherence to immunosuppression as assessed with the “Basel Assessment of Adherence to Immunosuppressive Medications Scale” (BAASIS). The coefficient of variation (CV%) of Tacrolimus (TAC) through levels and the level of personality functioning was a secondary endpoint. We conducted six monthly follow-up visits.ResultsForty-one age- and sex-matched patients [19 females, 58.5 (SD = 10.56) years old, 22 kidney- and 19 liver transplantation] were randomized to the intervention- (N = 21) or control-group (N = 20). No differences between intervention- and control groups were found in the primary endpoint adherence and CV% of TAC. However, in further exploratory analyses, we observed that individuals with higher impairments in personality functioning showed higher CV% of TAC in the controls. The intervention might compensate personality-related susceptibility to poor adherence as evident in CV% of TAC.DiscussionThe results of the feasibility study showed that this intervention program was highly accepted in the clinical setting. The Intervention group could compensate higher CV% of TAC after liver or kidney transplantation in individuals with lower levels of personality functioning and non-adherence.Clinical trial registrationClinicalTrials.gov, identifier NCT04207125.
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Affiliation(s)
- Jolana Wagner-Skacel
- Department of Medical Psychology, Psychosomatics, and Psychotherapy, Medical University of Graz, Graz, Austria
- University Transplant Center Graz, Medical University of Graz, Graz, Austria
| | - Nadja Fink
- University Transplant Center Graz, Medical University of Graz, Graz, Austria
- Division of Abdominal, Visceral, and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Judith Kahn
- University Transplant Center Graz, Medical University of Graz, Graz, Austria
- Division of Abdominal, Visceral, and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Nina Dalkner
- Department of Psychiatry and Psychotherapeutic Medicine, Medical University of Graz, Graz, Austria
| | - Emanuel Jauk
- Department of Medical Psychology, Psychosomatics, and Psychotherapy, Medical University of Graz, Graz, Austria
| | - Susanne Bengesser
- Department of Psychiatry and Psychotherapeutic Medicine, Medical University of Graz, Graz, Austria
| | - Marco Mairinger
- Department of Psychiatry and Psychotherapeutic Medicine, Medical University of Graz, Graz, Austria
| | - Gerhard Schüssler
- Department of Medical Psychology, Psychosomatics, and Psychotherapy, Medical University of Graz, Graz, Austria
| | - Christoph Pieh
- Department of Psychosomatic Medicine, University for Continuing Education Krems, Krems an der Donau, Austria
| | - Vanessa Stadlbauer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Alexander H. Kirsch
- University Transplant Center Graz, Medical University of Graz, Graz, Austria
- Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- *Correspondence: Alexander H. Kirsch,
| | - Sabine Zitta
- University Transplant Center Graz, Medical University of Graz, Graz, Austria
- Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Alexander R. Rosenkranz
- University Transplant Center Graz, Medical University of Graz, Graz, Austria
- Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Peter Fickert
- University Transplant Center Graz, Medical University of Graz, Graz, Austria
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Peter Schemmer
- University Transplant Center Graz, Medical University of Graz, Graz, Austria
- Division of Abdominal, Visceral, and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
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21
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Vaisbourd Y, Dahhou M, Zhang X, Sapir-Pichhadze R, Cardinal H, Johnston O, Blydt-Hansen TD, Tibbles LA, Hamiwka L, Urschel S, Birk P, Bissonnette J, Matsuda-Abedini M, BScPhm JH, Schiff J, Phan V, De Geest S, Allen U, Avitzur Y, Mital S, Foster BJ. Differences in medication adherence by sex and organ type among adolescent and young adult solid organ transplant recipients. Pediatr Transplant 2023; 27:e14446. [PMID: 36478059 DOI: 10.1111/petr.14446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 10/26/2022] [Accepted: 11/11/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Identification of differences in medication adherence by sex or organ type may help in planning interventions to optimize outcomes. We compared immunosuppressive medication adherence between males and females, and between kidney, liver and heart transplant recipients. METHODS This multicenter study of prevalent kidney, liver and heart transplant recipients 14-25 years assessed adherence 3 times (0, 3, 6 months post-enrollment) with the BAASIS self-report tool. At each visit, participants were classified as adherent if they missed no doses in the prior 4 weeks and non-adherent otherwise. Adherence was also assessed using the coefficient of variation (CV) of tacrolimus trough levels; CV < 30% was classified as adherent. We used multivariable mixed effects logistic regression models adjusted for potential confounders to compare adherence by sex and by organ. RESULTS Across all visits, males (n = 150, median age 20.4 years, IQR 17.2-23.3) had lower odds of self-reported adherence than females (n = 120, median age 19.8 years, IQR 17.1-22.7) (OR 0.41, 95% CI 0.21-0.80) but higher odds of adherence by tacrolimus CV (OR 2.50, 95% CI 1.30-4.82). No significant differences in adherence (by self-report or tacrolimus CV) were noted between the 184 kidney, 58 liver, and 28 heart recipients. CONCLUSION Females show better self-reported adherence than males but greater variability in tacrolimus levels. Social desirability bias, more common in females than males, may contribute to better self-reported adherence among females. Higher tacrolimus variability among females may reflect biologic differences in tacrolimus metabolism between males and females rather than sex differences in adherence. There were no significant differences in adherence by organ type.
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Affiliation(s)
| | - Mourad Dahhou
- Research Institute of The McGill University Health Centre, Quebec, Canada
| | - Xun Zhang
- Research Institute of The McGill University Health Centre, Quebec, Canada
| | - Ruth Sapir-Pichhadze
- Research Institute of The McGill University Health Centre, Quebec, Canada.,Department of Medicine, McGill University, Quebec, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Quebec, Canada
| | | | - Olwyn Johnston
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Tom D Blydt-Hansen
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lee Anne Tibbles
- Department of Medicine and Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Lorraine Hamiwka
- Department of Paediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Simon Urschel
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Patricia Birk
- Section of Pediatric Nephrology, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Mina Matsuda-Abedini
- Department of Pediatrics, The Hospital for Sick Children and The University of Toronto, Toronto, Ontario, Canada
| | - Jennifer Harrison BScPhm
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada.,Ajmera Transplant Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | - Jeffrey Schiff
- Ajmera Transplant Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | | | - Sabina De Geest
- Department Public Health, Institute of Nursing Science, University of Basel, Basel, Switzerland.,Department of Primary Care and Public Health, Academic Center of Nursing and Midwifery, KU Leuven, Leuven, Belgium
| | - Upton Allen
- Department of Pediatrics, The Hospital for Sick Children and The University of Toronto, Toronto, Ontario, Canada
| | - Yaron Avitzur
- Department of Pediatrics, The Hospital for Sick Children and The University of Toronto, Toronto, Ontario, Canada
| | - Seema Mital
- Department of Pediatrics, The Hospital for Sick Children and The University of Toronto, Toronto, Ontario, Canada
| | - Bethany J Foster
- Department of Pediatrics, McGill University, Quebec, Canada.,Research Institute of The McGill University Health Centre, Quebec, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Quebec, Canada
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22
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Sugawara K, Fukuda T, Kishimoto Y, Oka D, Yoshii T, Hara H, Uemura Y, Kawashima Y, Kanda H, Motoi N. Influences of intratumoral heterogeneity on assessment of tumor microenvironment in esophageal squamous cell carcinoma. Cancer Sci 2023; 114:1180-1191. [PMID: 36424361 PMCID: PMC9986096 DOI: 10.1111/cas.15665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 11/02/2022] [Accepted: 11/15/2022] [Indexed: 11/26/2022] Open
Abstract
The intratumoral heterogeneity (ITH) of the tumor microenvironment (TME) has yet to be addressed in esophageal squamous cell carcinoma (ESCC). Here, we studied the ITH of CD8 and PD-L1 status in ESCC, and examined the potential of the tumor surface for representing the TME. In total, 67 surgically resected clinical Stage II ESCC specimens were analyzed. The CD8-cell density, PD-L1 tumor proportion score (TPS), and combined positive score (CPS) were calculated in three (superficial, middle, and deep) areas of each specimen. ITH was quantified by distance-standardized coefficient variations of the three values. The CD8 and PD-L1 status of each area was dichotomized and tumor-surface capabilities for predicting the entire tumor status were estimated. Variables were compared according to the presence of neoadjuvant chemotherapy (NAC). The ITH, especially PD-L1 heterogeneity, differed markedly among specimens. The concordance rates of CD8 and PD-L1 (CPS and TPS) status among the three different areas were 71.6%, 74.6%, and 73.1%, respectively. The sensitivity and the specificity of the tumor surface for predicting the CD8 status of the whole tumor were high, especially in the NAC- group (both 1.0). The tumor surface also showed high capabilities for representing the whole PD-L1 status, while yielding moderate positive predictive values (0.70). The ITH degrees and predictive capabilities did not differ according to NAC. Taken together, the ITH of CD8 and PD-L1 differed among ESCC specimens, while not being markedly affected by NAC. The use of a biopsy specimen from the tumor surface might be feasible for TME evaluation.
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Affiliation(s)
- Kotaro Sugawara
- Department of Gastroenterological Surgery, Saitama Cancer Center, Saitama, Japan
| | - Takashi Fukuda
- Department of Gastroenterological Surgery, Saitama Cancer Center, Saitama, Japan
| | - Yutaka Kishimoto
- Department of Gastroenterological Surgery, Saitama Cancer Center, Saitama, Japan
| | - Daiji Oka
- Department of Gastroenterological Surgery, Saitama Cancer Center, Saitama, Japan
| | - Takako Yoshii
- Department of Gastroenterology, Saitama Cancer Center, Saitama, Japan
| | - Hiroki Hara
- Department of Gastroenterology, Saitama Cancer Center, Saitama, Japan
| | - Yukari Uemura
- Biostatistics Section, Department of Data Science, Center for Clinical Sciences, National Center for Global Health and Medicine, Tokyo, Japan
| | - Yoshiyuki Kawashima
- Department of Gastroenterological Surgery, Saitama Cancer Center, Saitama, Japan
| | - Hiroaki Kanda
- Department of Pathology, Saitama Cancer Center, Saitama, Japan
| | - Noriko Motoi
- Department of Pathology, Saitama Cancer Center, Saitama, Japan
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23
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Ilan Y. Making use of noise in biological systems. PROGRESS IN BIOPHYSICS AND MOLECULAR BIOLOGY 2023; 178:83-90. [PMID: 36640927 DOI: 10.1016/j.pbiomolbio.2023.01.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 12/07/2022] [Accepted: 01/09/2023] [Indexed: 01/12/2023]
Abstract
Disorder and noise are inherent in biological systems. They are required to provide systems with the advantages required for proper functioning. Noise is a part of the flexibility and plasticity of biological systems. It provides systems with increased routes, improves information transfer, and assists in response triggers. This paper reviews recent studies on noise at the genome, cellular, and whole organ levels. We focus on the need to use noise in system engineering. We present some of the challenges faced in studying noise. Optimizing the efficiency of complex systems requires a degree of variability in their functions within certain limits. Constrained noise can be considered a method for improving system robustness by regulating noise levels in continuously dynamic settings. The digital pill-based artificial intelligence (AI)-based platform is the first to implement second-generation AI comprising variability-based signatures. This platform enhances the efficacy of the therapeutic regimens. Systems requiring variability and mechanisms regulating noise are mandatory for understanding biological functions.
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Affiliation(s)
- Yaron Ilan
- Hebrew University, Faculty of Medicine, Department of Medicine, Hadassah Medical Center, POB 1200, IL91120, Jerusalem, Israel.
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24
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Song X, Liu F, Gao H, Yan M, Zhang F, Zhao J, Qin Y, Li Y, Zhang Y. Compare the performance of multiple machine learning models in predicting tacrolimus concentration for infant patients with living donor liver transplantation. Pediatr Transplant 2023; 27:e14379. [PMID: 36039686 DOI: 10.1111/petr.14379] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 07/20/2022] [Accepted: 08/02/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND This study aims to establish multiple ML models and compare their performance in predicting tacrolimus concentration for infant patients who received LDLT within 3 months after transplantation. METHODS Retrospectively collected basic information and relevant biochemical indicators of included infant patients. CMIA was used to determine tacrolimus C0 . PCR was used to determine the donors' and recipients' CYP3A5 genotypes. Multivariate stepwise regression analysis and stepwise elimination covariates were used for covariates selection. Thirteen machine learning algorithms were applied for the development of prediction models. APE, the ratio of the APE ≤3 ng ml-1 and ideal rate (the proportion of the predicted value with a relative error of 30% or less) were used to evaluate the predictive performance of the model. RESULTS A total of 163 infant patients were included in this study. In the case of the optimal combination of covariates, the Ridge model had the lowest APE, 2.01 (0.85, 3.35 ng ml-1 ). The highest ratio of the APE ≤3 ng ml-1 was the LAR model (71.77%). And the Ridge model showed the highest ideal rate (55.05%). For the Ridge model, GRWR was the most important predictor. CONCLUSIONS Compared with other ML models, the Ridge model had good predictive performance and potential clinical application.
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Affiliation(s)
- XueWu Song
- First Central Clinical College of Tianjin Medical University, Tianjin, China
| | - FangHao Liu
- College of Computer Science, Tianjin Key Laboratory of Network and Data Security Technology, Nankai University, Tianjin, China
| | - HuiEr Gao
- Department of Pharmacy, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin, China
| | - MeiLing Yan
- Department of Pharmacy, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin, China
| | - FeiYu Zhang
- First Central Clinical College of Tianjin Medical University, Tianjin, China
| | - Jia Zhao
- First Central Clinical College of Tianjin Medical University, Tianjin, China
| | - YinPeng Qin
- Department of Pharmacy, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin, China
| | - Yue Li
- College of Computer Science, KLMDASR, Key Laboratory for Medical Data Analysis and Statistical Research, Nankai University, Tianjin, China
| | - Yi Zhang
- Department of Pharmacy, Tianjin First Central Hospital, School of Medicine, Nankai University, Tianjin, China
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25
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Choi S, Hong Y, Jung SH, Kang G, Ghim JR, Han S. Pharmacokinetic Model Based on Stochastic Simulation and Estimation for Therapeutic Drug Monitoring of Tacrolimus in Korean Adult Transplant Recipients. Ther Drug Monit 2022; 44:729-737. [PMID: 35830880 PMCID: PMC9648981 DOI: 10.1097/ftd.0000000000001006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 11/10/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND Tacrolimus shows high variability in inter- and intraindividual pharmacokinetics (PK); therefore, it is important to develop an appropriate model for accurate therapeutic drug monitoring (TDM) procedures. This study aimed to develop a pharmacokinetic model for tacrolimus that can be used for TDM procedures in Korean adult transplant recipients by integrating published models with acquired real-world TDM data and evaluating clinically meaningful covariates. METHODS Clinical data of 1829 trough blood samples from 269 subjects were merged with simulated data sets from published models and analyzed using a nonlinear mixed-effect model. The stochastic simulation and estimation (SSE) method was used to obtain the final parameter estimates. RESULTS The final estimated values for apparent clearance, the volume of distribution, and absorption rate were 21.2 L/h, 510 L, and 3.1/h, respectively. The number of postoperative days, age, body weight, and type of transplant organs were the major clinical factors affecting tacrolimus PK. CONCLUSIONS A tacrolimus PK model that can incorporate published PK models and newly collected data from the Korean population was developed using the SSE method. Despite the limitations in model development owing to the nature of TDM data, the SSE method was useful in retrieving complete information from the TDM data by integrating published PK models while maintaining the variability of the model.
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Affiliation(s)
- Suein Choi
- Pharmacometrics Institute for Practical Education and Training (PIPET), College of Medicine, The Catholic University of Korea
- Department of Pharmacology, College of Medicine, The Catholic University of Korea
| | - Yunjeong Hong
- Pharmacometrics Institute for Practical Education and Training (PIPET), College of Medicine, The Catholic University of Korea
- Department of Pharmacology, College of Medicine, The Catholic University of Korea
| | - Sook-Hyun Jung
- Catholic Clinical Research Coordinating Center, Seoul, Korea
| | - Gaeun Kang
- Division of Clinical Pharmacology, Chonnam National University Hospital, Gwangju; and
| | - Jong-Ryul Ghim
- Department of Pharmacology and Pharmacogenomics Research Center, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Seunghoon Han
- Pharmacometrics Institute for Practical Education and Training (PIPET), College of Medicine, The Catholic University of Korea
- Department of Pharmacology, College of Medicine, The Catholic University of Korea
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Intrapatient Variability (IPV) and the Blood Concentration Normalized by the Dose (C/D Ratio) of Tacrolimus-Their Correlations and Effects on Long-Term Renal Allograft Function. Biomedicines 2022; 10:biomedicines10112860. [PMID: 36359380 PMCID: PMC9687762 DOI: 10.3390/biomedicines10112860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 11/02/2022] [Accepted: 11/04/2022] [Indexed: 11/11/2022] Open
Abstract
Tacrolimus, in combination with mycophenolate mofetil and glucocorticoids, is the basis of immunosuppressive therapy after renal transplantation. Tacrolimus intrapatient variability (IPV) and the blood concentration normalized by the dose (concentration/dose ratio, C/D ratio) both have an effect on the function of the transplanted kidney. In this study, we examined whether the metabolism rate affected IPV, whether the C/D ratio value was stable in the long-term follow-up, and whether it could be used for IPV measurements. In addition, our study population was examined for the effect of the C/D ratio and IPV on long-term renal function. The C/D ratio and IPV were examined in 170 patients at appointments held at 3, 6, 12 and 24 months after RTx. The average time post renal transplantation was 70 months. Renal function defined as creatinine concentration at the last appointment was examined. Results: the mean C/D ratio in the study group was 1.63. A negative correlation between the C/D ratio and creatinine concentration at the end of the follow-up was observed. Between the C/D ratio < and ≥1.63 groups, significant differences in creatinine concentration at the last appointment were found. No relationship was identified between the mean C/D ratio and IPV. The C/D ratio values increased significantly over a longer post-transplant period (12, 24, 60 and 120 m). We did not find a correlation between the mean IPV and the creatinine concentration from the last appointment. Our study group was divided into terciles according to IPV, while no renal graft function differences were found at the same appointment. Conclusion: the C/D ratio is useful for assessing the effects of the metabolism rate of tacrolimus on the long-term renal graft function. The C/D ratio does not affect the IPV value. IPV calculated from variability of the C/D ratio does not influence transplanted kidney function. The C/D changes over time.
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Barreda P, Cañamero L, Boya M, García-Saiz MDM, Valero R, Belmar L, Kislikova M, De Cos MA, Ruiz JC, Rodrigo E. Lower Time in Therapeutic Range Relates to a Worse Kidney Graft Outcome. Transplant Proc 2022; 54:2446-2449. [DOI: 10.1016/j.transproceed.2022.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 07/23/2022] [Accepted: 09/02/2022] [Indexed: 12/23/2022]
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Zhu H, Wang M, Xiong X, Du Y, Li D, Wang Z, Ge W, Zhu Y. Plasma metabolomic profiling reveals factors associated with dose-adjusted trough concentration of tacrolimus in liver transplant recipients. Front Pharmacol 2022; 13:1045843. [PMID: 36386159 PMCID: PMC9659571 DOI: 10.3389/fphar.2022.1045843] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 10/13/2022] [Indexed: 07/30/2023] Open
Abstract
Inter- and intrapatient variability of tacrolimus exposure is a vital prognostic risk factor for the clinical outcome of liver transplantation. New factors or biomarkers characterizing tacrolimus disposition is essential for optimal dose prediction in recipients of liver transplant. The aim of the study was to identify potential plasma metabolites associated with the dose-adjusted trough concentration of tacrolimus in liver transplant recipients by using a global metabolomic approach. A total of 693 plasma samples were collected from 137 liver transplant recipients receiving tacrolimus and regular therapeutic drug monitoring. Untargeted metabolomic analysis was performed by ultraperformance liquid chromatography-quadrupole time-of-flight mass spectrometry. Univariate and multivariate analyses with a mixed linear model were conducted, and the results showed that the dose-adjusted tacrolimus trough concentration was associated with 31 endogenous metabolites, including medium- and long-chain acylcarnitines such as stearoylcarnitine (β = 0.222, p = 0.001), microbiota-derived uremic retention solutes such as indolelactic acid (β = 0.194, p = 0.007), bile acids such as taurohyodeoxycholic acid (β = -0.056, p = 0.002), and steroid hormones such as testosterone (β = 0.099, p = 0.001). A multiple linear mixed model including 11 metabolites and clinical information was established with a suitable predictive performance (correlation coefficient based on fixed effects = 0.64 and correlation coefficient based on fixed and random effects = 0.78). These data demonstrated that microbiota-derived uremic retention solutes, bile acids, steroid hormones, and medium- and long-chain acylcarnitines were the main metabolites associated with the dose-adjusted trough concentration of tacrolimus in liver transplant recipients.
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Affiliation(s)
- Huaijun Zhu
- Department of Pharmacology, School of Pharmacy, Fudan University, Shanghai, China
- Department of Pharmacy, the Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
- Nanjing Medical Center for Clinical Pharmacy, Nanjing, China
| | - Min Wang
- Department of Pharmacy, the Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
- Nanjing Medical Center for Clinical Pharmacy, Nanjing, China
| | - Xiaofu Xiong
- Department of Pharmacy, the Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yao Du
- Department of Pharmacy, the Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
- Nanjing Medical Center for Clinical Pharmacy, Nanjing, China
| | - Danying Li
- Department of Pharmacy, the Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
- Nanjing Medical Center for Clinical Pharmacy, Nanjing, China
| | - Zhou Wang
- State Key Laboratory of Quality Research in Chinese Medicine and School of Pharmacy, Macau University of Science and Technology, Macau, China
| | - Weihong Ge
- Department of Pharmacy, the Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
- Nanjing Medical Center for Clinical Pharmacy, Nanjing, China
| | - Yizhun Zhu
- Department of Pharmacology, School of Pharmacy, Fudan University, Shanghai, China
- State Key Laboratory of Quality Research in Chinese Medicine and School of Pharmacy, Macau University of Science and Technology, Macau, China
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Comparison of Tacrolimus Intra-Patient Variability during 6-12 Months after Kidney Transplantation between CYP3A5 Expressers and Nonexpressers. J Clin Med 2022; 11:jcm11216320. [PMID: 36362548 PMCID: PMC9658797 DOI: 10.3390/jcm11216320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 10/19/2022] [Accepted: 10/24/2022] [Indexed: 12/05/2022] Open
Abstract
A high intra-patient variability (IPV) of tacrolimus exposure is associated with poor long-term kidney transplantation outcomes. To assess the influence of cytochrome P450 (CYP) 3A5 genetic polymorphisms on tacrolimus IPV, 188 clinically stable kidney transplant recipients, who had received an immediate-release tacrolimus-based immunosuppressive regimen, were enrolled in this retrospective cohort study. Genotyping of CYP3A5*3 (rs776746) was performed and 110 (58.5%) were identified as CYP3A5 expressers and 78 (41.5%) as nonexpressers. Whole blood tacrolimus concentrations were analyzed by chemiluminescent microparticle immunoassay. Dose-adjusted trough tacrolimus concentrations (C0/D) measured at months 6, 9, and 12 were used to determine IPV. There were no significant differences in the IPV estimated by the coefficient of variation, the IPV calculated by mean absolute deviation method, and the proportions of recipients with the IPV estimated by the coefficient of variation of 30% or more between CYP3A5 expressers and nonexpressers (p = 0.613, 0.686, and 0.954, respectively). Tacrolimus C0/D in CYP3A5 expressers was approximately half of those in nonexpressers, overall (p < 0.001). In both CYP3A5 expressers and nonexpressers, tacrolimus C0/D increased gradually from month 6 to month 12 (p = 0.021). There was no evidence that the CYP3A5 polymorphisms significantly influence tacrolimus IPV during the 6 to 12 months after kidney transplantation.
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Kostalova B, Mala-Ladova K, Sulkova SD, Denhaerynck K, De Geest S, Maly J. Comparison of different methods to assess tacrolimus concentration intra-patient variability as potential marker of medication non-adherence. Front Pharmacol 2022; 13:973564. [PMID: 36313323 PMCID: PMC9609782 DOI: 10.3389/fphar.2022.973564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 09/30/2022] [Indexed: 11/22/2022] Open
Abstract
Background and objective: Non-adherence to tacrolimus commonly manifests as low drug concentrations and/or high intra-patient variability (IPV) of concentrations across multiple measurements. We aimed to compare several methods of tacrolimus IPV calculation and evaluate how well each reflects blood concentration variation due to medication non-adherence in kidney transplant recipients. Methods: This Czech single-center retrospective longitudinal study was conducted in 2019. All outpatients ≥18 years of age, ≥3 months post-transplant, and on tacrolimus-based regimens were approached. After collecting seven consecutive tacrolimus concentrations we asked participating patients to self-report adherence to immunosuppressants (BAASIS© scale). The IPV of tacrolimus was calculated as the medication level variability index (MLVI), the coefficient of variation (CV), the time-weighted CV, and via nonlinearly modeled dose-corrected trough levels. These patient-level variables were analyzed using regression analysis. Detected nonlinearities in the dose-response curve were controlled for by adding tacrolimus dosing and its higher-order terms as covariates, along with self-reported medication adherence levels. Results: Of 243 patients using tacrolimus, 42% (n = 102) reported medication non-adherence. Non-adherence was associated with higher CVs, higher time-weighted CVs, and lower dose-corrected nonlinearly modeled trough levels; however, it was not associated with MLVIs. All of the significant operationalizations suggested a weak association that was similar across the applied methods. Discussion and conclusion: Implementation non-adherence was reflected by higher CV or time-weighted CV and by lower blood concentrations of tacrolimus. As an additional tool for identifying patients at risk for non-adherence, simple IPV calculations incorporated into medical records should be considered in everyday clinical practice.
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Affiliation(s)
- Barbora Kostalova
- Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Kralove, Charles University, Hradec Kralove, Czechia
| | - Katerina Mala-Ladova
- Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Kralove, Charles University, Hradec Kralove, Czechia
| | - Sylvie Dusilova Sulkova
- Department of Nephrology, University Hospital Hradec Kralove and Faculty of Medicine Hradec Kralove, Charles University, Hradec Kralove, Czechia
| | - Kris Denhaerynck
- Department Public Health, Institute of Nursing Science, University of Basel, Basel, Switzerland
| | - Sabina De Geest
- Department Public Health, Institute of Nursing Science, University of Basel, Basel, Switzerland
- Academic Center for Nursing and Midwifery, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Josef Maly
- Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Kralove, Charles University, Hradec Kralove, Czechia
- *Correspondence: Josef Maly,
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31
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Choi JS, Ko H, Kim HK, Chung C, Han A, Min SK, Ha J, Kang HG, Ha IS, Min S. Effects of tacrolimus intrapatient variability and CYP3A5 polymorphism on the outcomes of pediatric kidney transplantation. Pediatr Transplant 2022; 26:e14297. [PMID: 35466485 DOI: 10.1111/petr.14297] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 03/16/2022] [Accepted: 04/07/2022] [Indexed: 12/17/2022]
Abstract
BACKGROUND The intrapatient variability (IPV) of tacrolimus (Tac) is associated with the long-term outcome of kidney transplantation. The CYP3A single-nucleotide polymorphism (SNP) may affect the IPV of Tac. We investigated the impact of IPV and genetic polymorphism in pediatric patients who received kidney transplantation. METHODS A total of 202 pediatric renal transplant recipients from 2000 to 2016 were analyzed retrospectively. The IPV was calculated between 6 and 12 months after surgery. Among these patients, CYP3A5 polymorphism was analyzed in 67 patients. RESULTS The group with high IPV had a significantly higher rate of de novo donor-specific human leukocyte antigen antibodies (dnDSA) development (35.7% vs. 16.7%, p = .003). The high IPV group also had a higher incidence of T-cell-mediated rejection (TCMR; p < .001). The high IPV had no significant influence on Epstein-Barr virus, cytomegalovirus, and BK virus viremia but was associated with the incidence of posttransplant lymphoproliferative disorders (p = .003). Overall, the graft survival rate was inferior in the high IPV group (p < .001). The CYP3A5 SNPs did not significantly affect the IPV of Tac. In the CYP3A5 expressor group, however, the IPV was significantly associated with the TCMR-free survival rate (p < .001). CONCLUSION The IPV of Tac had a significant impact on dnDSA development, occurrence of acute TCMR, and graft failure in pediatric patients who received renal transplantation. CYP3A5 expressors with high IPV of Tac showed worse outcomes, while the CYP3A5 polymorphism had no impact on IPV of Tac.
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Affiliation(s)
- Jin Sun Choi
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hyunmin Ko
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hyo Kee Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Chris Chung
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Ahram Han
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Seung-Kee Min
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jongwon Ha
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.,Transplantation Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Hee Gyung Kang
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Il Soo Ha
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Sangil Min
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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Brunet M, Pastor-Anglada M. Insights into the Pharmacogenetics of Tacrolimus Pharmacokinetics and Pharmacodynamics. Pharmaceutics 2022; 14:pharmaceutics14091755. [PMID: 36145503 PMCID: PMC9503558 DOI: 10.3390/pharmaceutics14091755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 07/28/2022] [Accepted: 08/10/2022] [Indexed: 11/27/2022] Open
Abstract
The influence of pharmacogenetics in tacrolimus pharmacokinetics and pharmacodynamics needs further investigation, considering its potential in assisting clinicians to predict the optimal starting dosage and the need for a personalized adjustment of the dose, as well as to identify patients at a high risk of rejection, drug-related adverse effects, or poor outcomes. In the past decade, new pharmacokinetic strategies have been developed to improve personalized tacrolimus treatment. Several studies have shown that patients with tacrolimus doses C0/D < 1 ng/mL/mg may demonstrate a greater incidence of drug-related adverse events and infections. In addition, C0 tacrolimus intrapatient variability (IPV) has been identified as a potential biomarker to predict poor outcomes related to drug over- and under-exposure. With regard to tacrolimus pharmacodynamics, inconsistent genotype-phenotype relationships have been identified. The aim of this review is to provide a concise summary of currently available data regarding the influence of pharmacogenetics on the clinical outcome of patients with high intrapatient variability and/or a fast metabolizer phenotype. Moreover, the role of membrane transporters in the interindividual variability of responses to tacrolimus is critically discussed from a transporter scientist’s perspective. Indeed, the relationship between transporter polymorphisms and intracellular tacrolimus concentrations will help to elucidate the interplay between the biological mechanisms underlying genetic variations impacting drug concentrations and clinical effects.
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Affiliation(s)
- Mercè Brunet
- Farmacologia i Toxicologia, Servei de Bioquímica i Genètica Molecular, Centre de Diagnòstic Biomèdic. Hospital Clínic de Barcelona, Universitat de Barcelona, 08036 Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pí i Sunyer (IDIBAPS), 08036 Barcelona, Spain
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBEREHD), 28029 Madrid, Spain
- Correspondence: (M.B.); (M.P.-A.)
| | - Marçal Pastor-Anglada
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBEREHD), 28029 Madrid, Spain
- Molecular Pharmacology and Experimental Therapeutics (MPET), Departament de Bioquímica i Biomedicina Molecular, Institut de Biomedicina, Universitat de Barcelona (IBUB), 08028 Barcelona, Spain
- Institut de Recerca Sant Joan de Déu (IRSJD), 08950 Esplugues de Llobregat, Spain
- Correspondence: (M.B.); (M.P.-A.)
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Yu KW, Li BL, Yuan YS, Liao JM, Li WK, Dong H, Ke PF, Jin X, Chen L, Zhao JJ, Wang H, Cao SW, Chen WY, Huang XZ, Zhao BB, Kang CM. A modified LC-MS/MS method for the detection of whole blood tacrolimus and its clinical value in Chinese kidney transplant patients. Heliyon 2022; 8:e10214. [PMID: 36042743 PMCID: PMC9420483 DOI: 10.1016/j.heliyon.2022.e10214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 06/12/2022] [Accepted: 08/03/2022] [Indexed: 11/26/2022] Open
Abstract
Background For patients who treated with tacrolimus after kidney transplant, therapeutic drug monitoring is essential to improve their prognosis. However, previous detection methods have limitations, such as the overestimation and unacceptable bias in the immunoassays. Precision medicine has been challenged. The liquid chromatography-tandem mass spectrometry (LC-MS/MS) method is recognized as the gold standard due to its accuracy and specificity, but lack of throughput and complex process limits its clinical application. Therefore, an accurate, simple and high throughput method for tacrolimus monitoring is needed for clinical practice. Methods A modified LC-MS/MS method was introduced and validated. Whole blood samples were prepared by a one-step protein precipitation method. Chromatographic separation was achieved using a Phenomenex Kinetex 2.6 μm XB-C18 2.1 × 50 mm column with a total run time of 3.5 min to avoid matrix effect. An electrospray ionization source (ESI) was used in positive ion multiple reaction monitoring (MRM) mode for mass spectrometric detection. In order to protect the mass spectrometer, only part of the sample after LC separation was allowed to enter the mass spectrum, through a two HPLC systems coupled one mass spectrometry design. In this way, the instrument throughput is also improved and realizing the detection of 2 samples within 3.5 min and carried out a shorter analyzing time for each sample of 1.75 min. Additionally, we calculated tacrolimus-intrapatient variant (Tac-IPV) based on this modified method and assessed the prognostic value of Tac-IPV in Chinese kidney transplant patients. Results The LC-MS/MS was modified by streamlining the procedure and increasing the throughput. The method proved to be accurate and reproducible with all performance parameters suitably meeting the clinical requirements over a calibration ranged from 0.37 to 42.90 ng/mL. Parameters such as linearity, limit of quantification (LoQ) and dilution integrity were validated with a clinical reportable range from 0.37 to 343.20 ng/mL, which was particularly useful for high drug concentrations patients (rare but very serious). Both cross-contamination and matrix effects were negligible. Clinical data of 83 patients showed that Tac-IPV was associated with poor kidney transplant outcome in Chinese (Hazard Ratio (HR) = 3.96, 4.75; 95% Cl: 1.10–14.21, 1.23–18.36; P < 0.05). Conclusions This modified LC-MS/MS method possessed high throughput and simple sample preparation, allowing it to meet daily clinical needs. At the same time, Tac-IPV based on this modified LC-MS/MS had excellent prognostic value in kidney transplantation. These advantages have great significance for the individualized treatment of Chinese kidney transplant patients and broad application of Tac-IPV.
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Affiliation(s)
- Ke-Wei Yu
- Department of Laboratory Medicine, Second Clinical Medical College, Guangzhou University of Traditional Chinese Medicine, China
| | - Bing-Ling Li
- Guangzhou KingMed Center for Clinical Laboratory Co., Ltd., KingMed College of Laboratory Medical of Guangzhou Medical University, Guangzhou, Guangdong 510120, China
| | - Ying-Shi Yuan
- Department of Laboratory Medicine, Second Clinical Medical College, Guangzhou University of Traditional Chinese Medicine, China
| | - Jia-Min Liao
- Department of Laboratory Medicine, Second Clinical Medical College, Guangzhou University of Traditional Chinese Medicine, China
| | - Wei-Kang Li
- Department of Laboratory Medicine, Second Clinical Medical College, Guangzhou University of Traditional Chinese Medicine, China
| | - Heng Dong
- Guangzhou KingMed Center for Clinical Laboratory Co., Ltd., KingMed College of Laboratory Medical of Guangzhou Medical University, Guangzhou, Guangdong 510120, China
| | - Pei-Feng Ke
- Department of Laboratory Medicine, Second Clinical Medical College, Guangzhou University of Traditional Chinese Medicine, China
| | - Xing Jin
- Department of Laboratory Medicine, Second Clinical Medical College, Guangzhou University of Traditional Chinese Medicine, China
| | - Lu Chen
- Department of Laboratory Medicine, Second Clinical Medical College, Guangzhou University of Traditional Chinese Medicine, China
| | - Jing-Jing Zhao
- Department of Laboratory Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, China
| | - Heng Wang
- Department of Laboratory Medicine, Second Clinical Medical College, Guangzhou University of Traditional Chinese Medicine, China
| | - Shun-Wang Cao
- Department of Laboratory Medicine, Second Clinical Medical College, Guangzhou University of Traditional Chinese Medicine, China
| | - Wei-Ye Chen
- Department of Laboratory Medicine, Second Clinical Medical College, Guangzhou University of Traditional Chinese Medicine, China
| | - Xian-Zhang Huang
- Department of Laboratory Medicine, Second Clinical Medical College, Guangzhou University of Traditional Chinese Medicine, China.,Department of Laboratory Medicine, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, Guangdong 510120, China
| | - Bei-Bei Zhao
- Guangzhou KingMed Center for Clinical Laboratory Co., Ltd., KingMed College of Laboratory Medical of Guangzhou Medical University, Guangzhou, Guangdong 510120, China
| | - Chun-Min Kang
- Department of Laboratory Medicine, Second Clinical Medical College, Guangzhou University of Traditional Chinese Medicine, China.,Department of Laboratory Medicine, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, Guangdong 510120, China
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Seitz A, Mounsey K, Hughes P, Cullen K, Welberry Smith M, Daga S, Carter C, Clark B, Baker R. Isolated Pre-existing HLA-DP Donor-Specific Antibodies are Associated With Poorer Outcomes in Renal Transplantation. Kidney Int Rep 2022; 7:2251-2263. [PMID: 36217531 PMCID: PMC9546735 DOI: 10.1016/j.ekir.2022.07.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 07/08/2022] [Accepted: 07/11/2022] [Indexed: 12/01/2022] Open
Abstract
Introduction The importance of donor-specific antibodies (DSAs) in renal transplantation has long been recognized, but the significance of human leukocyte antigen (HLA)-DP antibodies remains less clear. We performed a retrospective single center study of renal transplants with pre-existing isolated HLA-DP-DSAs to assess clinical outcomes. Methods Twenty-three patients with isolated HLA-DP-DSAs were compared with 3 control groups as follows: standard immunological risk (calculated reaction frequency [cRF] < 85%, no current or historical DSA, no repeat mismatched antigens with previous transplants, n = 46), highly sensitized (cRF > 85%, n = 27), and patients with HLA-DP antibodies that were not donor-specific (n = 18). Univariate and multivariate analyses were performed comparing antibody-mediated rejection (ABMR)-free and graft survival. Factors in the final multivariable models included patient group, % cRF, B-cell flow crossmatch (BFXM) positivity and regrafts. Results Over a median follow-up of 1197 days, 65% of HLA-DP-DSA patients had ABMR on indication biopsies, and 30% of HLA-DP-DSA patients lost their graft. Pre-existing HLA-DP DSAs remained the single factor associated with ABMR after multivariable analysis (hazard ratio [HR] = 9.578, P = 0.012). Patients with HLA-DP DSAs had increased microvascular scores (P = 0.0346) and worse transplant glomerulopathy (P = 0.015) on biopsy compared with the standard immunological risk group. Furthermore, flow crossmatch (FXM) positivity did not help inform on the risk of graft failure or ABMR in patients with preformed DP-DSA. Conclusion Transplants with pre-existing HLA-DP-DSAs should be considered high risk. Routine laboratory tests are unable to further risk stratify these patients. Recipients should be considered for intensified immunosuppression and closely monitored.
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Affiliation(s)
- Adrienne Seitz
- Renal Transplant Unit, St James’s University Hospital, Leeds, UK
- Transplant Immunology, St James’s University Hospital, Leeds, UK
- Correspondence: Adrienne Seitz, Renal Transplant Unit, St James's University Hospital, Leeds, UK.
| | | | - Pamela Hughes
- Transplant Immunology, St James’s University Hospital, Leeds, UK
| | - Katherine Cullen
- Transplant Immunology, St James’s University Hospital, Leeds, UK
| | | | - Sunil Daga
- Renal Transplant Unit, St James’s University Hospital, Leeds, UK
| | - Clive Carter
- Transplant Immunology, St James’s University Hospital, Leeds, UK
| | - Brendan Clark
- Transplant Immunology, St James’s University Hospital, Leeds, UK
| | - Richard Baker
- Renal Transplant Unit, St James’s University Hospital, Leeds, UK
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Combined Analysis of HLA Class II Eplet Mismatch and Tacrolimus Levels for the Prediction of De Novo Donor Specific Antibody Development in Kidney Transplant Recipients. Int J Mol Sci 2022; 23:ijms23137357. [PMID: 35806362 PMCID: PMC9267119 DOI: 10.3390/ijms23137357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 06/29/2022] [Accepted: 06/29/2022] [Indexed: 02/05/2023] Open
Abstract
We investigated whether HLA class II eplet mismatch was related to dnDSA development and analyzed its combined impact with tacrolimus levels for kidney transplantation outcomes. A total of 347 kidney transplants were included. HLA Matchmaker was used for the single molecular eplet, total eplet, antibody (Ab)-verified eplet mismatch analyses, and Ab-verified single molecular analysis to identify HLA-DR/DQ molecular thresholds for the risk of dnDSA development. A time-weighted tacrolimus trough level (TAC-C0) of 5 ng/mL and a TAC-C0 time-weighted coefficient variability (TWCV) of 20% were applied to find the combined effects on dnDSA development. A high level of mismatch for single molecular eplet (DQ ≥ 10), total eplet (DQ ≥ 12), Ab-verified eplet (DQ ≥ 4), and Ab-verified single molecular eplet (DQ ≥ 4) significantly correlated with HLA class II dnDSA development. Class II dnDSA developed mostly in patients with low TAC-C0 and high eplet mismatch. In the multivariable analyses, low TAC-C0 and high eplet mismatch showed the highest hazard ratio for the development of dnDSA. No significant combined effect was observed in dnDSA development according to TWCV. In conclusion, the determination of HLA class II eplet mismatch may improve the risk stratification for dnDSA development, especially in conjunction with tacrolimus trough levels.
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Mendoza Rojas A, Hesselink DA, van Besouw NM, Dieterich M, de Kuiper R, Baan CC, van Gelder T. High Tacrolimus Intrapatient Variability and Subtherapeutic Immunosuppression are Associated With Adverse Kidney Transplant Outcomes. Ther Drug Monit 2022; 44:369-376. [PMID: 35394988 PMCID: PMC9083489 DOI: 10.1097/ftd.0000000000000955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 11/12/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Kidney transplant recipients with high intrapatient variability (IPV) in tacrolimus (Tac) exposure experience more rejection and reduced graft survival. To understand the underlying pathophysiology of this association, the authors investigated whether patients with high tacrolimus IPV have a more activated immune system than patients with low IPV. In addition, exposure to tacrolimus and mycophenolic acid (MPA) was studied in relation to rejection and graft survival. METHODS At the time of patient inclusion (5-7 years post-transplantation), the frequency of donor-reactive cells was determined by enzyme-linked immunosorbent assay, and the development of donor-specific anti-Human Leukocyte Antigen antibodies (DSA) was measured by Luminex Single Antigen assay. Tacrolimus IPV was retrospectively calculated between 6 and 12 months and the exposure to tacrolimus and MPA was determined between 1 and 5 years post-transplantation. RESULTS A total of 371 kidney transplant recipients were included in this study, of whom 56 developed a rejection episode after 12 months and 60 experienced graft failure after 5-7 years. No correlations were found between tacrolimus IPV or immunosuppression exposure and the number of donor-reactive cells after 5 years of transplantation. DSA were detected more often in patients with low exposure to both tacrolimus and MMF [4/21 (19%) versus 17/350 (4.9%), P = 0.04]. In this cohort, neither tacrolimus IPV nor low overall immunosuppression exposure was associated with a higher incidence of rejection. However, regression analysis showed that a higher tacrolimus IPV was associated with an increased incidence of graft failure (odds ratio = 1.03, P = 0.02). CONCLUSIONS This study verifies the relationship between high tacrolimus IPV and impaired kidney allograft survival in long-term follow-up. DSA was also found to be more prevalent in patients with subtherapeutic concentrations of tacrolimus and MPA. An increased prevalence of donor-specific alloreactivity is yet to be demonstrated in patients with high IPV.
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Affiliation(s)
- Aleixandra Mendoza Rojas
- Department of Internal Medicine—Nephrology and Transplantation, Erasmus MC Transplantation Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Erasmus MC Transplant Institute, Rotterdam, the Netherlands; and
| | - Dennis A. Hesselink
- Department of Internal Medicine—Nephrology and Transplantation, Erasmus MC Transplantation Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Erasmus MC Transplant Institute, Rotterdam, the Netherlands; and
| | - Nicole M. van Besouw
- Department of Internal Medicine—Nephrology and Transplantation, Erasmus MC Transplantation Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Erasmus MC Transplant Institute, Rotterdam, the Netherlands; and
| | - Marjolein Dieterich
- Department of Internal Medicine—Nephrology and Transplantation, Erasmus MC Transplantation Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Erasmus MC Transplant Institute, Rotterdam, the Netherlands; and
| | - Ronella de Kuiper
- Department of Internal Medicine—Nephrology and Transplantation, Erasmus MC Transplantation Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Erasmus MC Transplant Institute, Rotterdam, the Netherlands; and
| | - Carla C. Baan
- Department of Internal Medicine—Nephrology and Transplantation, Erasmus MC Transplantation Institute, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Erasmus MC Transplant Institute, Rotterdam, the Netherlands; and
| | - Teun van Gelder
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, the Netherlands
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Friebus-Kardash J, Nela E, Möhlendick B, Kribben A, Siffert W, Heinemann FM, Eisenberger U. Development of De Novo Donor-specific HLA Antibodies and AMR in Renal Transplant Patients Depends on CYP3A5 Genotype. Transplantation 2022; 106:1031-1042. [PMID: 34241984 PMCID: PMC9038248 DOI: 10.1097/tp.0000000000003871] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 06/09/2021] [Accepted: 06/09/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND The single-nucleotide polymorphism CYP3A5 rs776746 is related to a reduction in the metabolizing activity of the CYP3A5 enzyme. People carrying at least one copy of the wild-type allele, defined as CYP3A5 expressers, exhibit higher clearance and lower trough concentrations of tacrolimus than homozygous nonexpressers, and this difference may affect alloimmunization and allograft function. METHODS We retrospectively studied 400 kidney transplant recipients treated with a tacrolimus-based immunosuppression regimen to detect CYP3A5 genotype, de novo formation of HLA antibodies and donor-specific antibodies (DSAs), and clinical outcome up to 5 y after transplant. RESULTS We found that 69 (17%) of the 400 patients were CYP3A5 expressers. During the first 3 y after transplant, CYP3A5 expressers tended to have lower tacrolimus trough levels than nonexpressers, although their tacrolimus dosage was as much as 80% higher. De novo DSAs were found more frequently in CYP3A5 expressers than in nonexpressers (13/69 [19%] versus 33/331 [10%], P = 0.02). De novo DSA-free survival rates (P = 0.02) were significantly lower for expressers than for nonexpressers. CYP3A5 genotype had no effect on allograft failure, but CYP3A5 expressers exhibited a significantly higher frequency of antibody-mediated rejection. CYP3A5 expresser status was an independent risk factor for the development of de novo DSAs (relative risk, 2.34, P = 0.01). CONCLUSIONS Early detection of CYP3A5 expressers, enabling genotype-based dose adjustment of tacrolimus immediately after renal transplant, may be a useful strategy for reducing the risk of de novo DSA production and antibody-mediated rejection.
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Affiliation(s)
- Justa Friebus-Kardash
- Department of Nephrology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Ejona Nela
- Department of Nephrology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Birte Möhlendick
- Institute of Pharmacogenetics, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Andreas Kribben
- Department of Nephrology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Winfried Siffert
- Institute of Pharmacogenetics, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Falko Markus Heinemann
- Institute for Transfusion Medicine, Transplantation Diagnostics, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Ute Eisenberger
- Department of Nephrology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
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Dopazo C, Bilbao I, García S, Gómez-Gavara C, Caralt M, Campos-Varela I, Castells L, Hidalgo E, Moreso F, Montoro B, Charco R. High intrapatient variability of tacrolimus exposure associated with poorer outcomes in liver transplantation. Clin Transl Sci 2022; 15:1544-1555. [PMID: 35373449 PMCID: PMC9199878 DOI: 10.1111/cts.13276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 03/03/2022] [Accepted: 03/14/2022] [Indexed: 11/29/2022] Open
Abstract
Tacrolimus (TAC) is a dose‐dependent immunosuppressor with considerable intrapatient variability (IPV) in its pharmacokinetics. The aim of this work is to ascertain the association between TAC IPV at 6 months after liver transplantation (LT) and patient outcome. This single‐center cohort study retrospectively analyzed adult patients who underwent transplantation from 2015 to 2019 who survived the first 6 months with a functioning graft. The primary end point was the patient’s probability of death and the secondary outcome was the loss of renal function between month 6 and the last follow‐up. TAC IPV was estimated by calculating the coefficient of variation (CV) of the dose‐corrected concentration (C0/D) between the third and sixth months post‐LT. Of the 140 patients who underwent LT included in the study, the low‐variability group (C0/D CV < 27%) comprised 105 patients and the high‐variability group (C0/D CV ≥ 27%) 35 patients. One‐, 3‐, and 5‐year patient survival rates were 100%, 82%, and 72% in the high‐variability group versus 100%, 97%, and 93% in the low‐variability group, respectively (p = 0.005). Moreover, significant impaired renal function was observed in the high‐variability group at 1 year (69 ± 16 ml/min/1.73 m2 vs. 78 ± 16 ml/min/1.73 m2, p = 0.004) and at 2 years post‐LT (69 ± 17 ml/min/1.73 m2 vs. 77 ± 15 ml/min/1.73 m2, p = 0.03). High C0/D CV 3–6 months remained independently associated with worse survival (hazard ratio = 3.57, 95% CI = 1.32–9.67, p = 0.012) and loss of renal function (odds ratio = 3.47, 95% CI = 1.30–9.20, p = 0.01). Therefore, high IPV between the third and sixth months appears to be an early and independent predictor of patients with poorer liver transplant outcomes.
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Affiliation(s)
- Cristina Dopazo
- Department of HPB Surgery and Transplants, Hospital Universitario Vall d´Hebron, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Itxarone Bilbao
- Department of HPB Surgery and Transplants, Hospital Universitario Vall d´Hebron, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Sonia García
- Department of Pharmacy, Barcelona Hospital Campus, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Concepción Gómez-Gavara
- Department of HPB Surgery and Transplants, Hospital Universitario Vall d´Hebron, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Mireia Caralt
- Department of HPB Surgery and Transplants, Hospital Universitario Vall d´Hebron, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Isabel Campos-Varela
- Liver Unit, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autónoma de Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Lluis Castells
- Liver Unit, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autónoma de Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Ernest Hidalgo
- Department of HPB Surgery and Transplants, Hospital Universitario Vall d´Hebron, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Francisco Moreso
- Department of Nephrology, Hospital Universitario Vall d´Hebron, Barcelona, Spain
| | - Bruno Montoro
- Department of Pharmacy, Barcelona Hospital Campus, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Ramón Charco
- Department of HPB Surgery and Transplants, Hospital Universitario Vall d´Hebron, Universidad Autónoma de Barcelona, Barcelona, Spain
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Beak JA, Park MJ, Kim SY, Jhun J, Woo JS, Choi JW, Na HS, Lee SK, Choi JY, Cho ML. FK506 and Lactobacillus acidophilus ameliorate acute graft-versus-host disease by modulating the T helper 17/regulatory T-cell balance. J Transl Med 2022; 20:104. [PMID: 35216600 PMCID: PMC8881869 DOI: 10.1186/s12967-022-03303-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 02/09/2022] [Indexed: 11/10/2022] Open
Abstract
Background Graft-versus-host disease (GvHD) is a critical complication after allogeneic hematopoietic stem cell transplantation (HSCT). The immunosuppressants given to patients undergoing allogeneic HSCT disturb the microbiome and the host immune system, potentially leading to dysbiosis and inflammation, and may affect immune function and bone marrow transplantation. The intestinal microbiome is a target for the development of novel therapies for GvHD. Lactobacillus species are widely used supplements to induce production of antimicrobial and anti-inflammatory factors. Methods We determined the effect of the combination of Lactobacillus acidophilus and FK506 on GvHD following major histocompatibility complex-mismatched bone marrow transplantation. Results The combination treatment suppressed IFN-γ and IL-17-producing T cell differentiation, but increased Foxp3+Treg differentiation and IL-10 production. Also, the combination treatment and combination treated-induced Treg cells modulated the proliferation of murine alloreactive T cells in vitro. Additionally, the combination treatment upregulated Treg-related genes—Nt5e, Foxp3, Ikzf2, Nrp1 and Itgb8—in murine CD4+-T cells. The combination treatment also alleviated GvHD clinically and histopathologically by controlling the effector T cell and Treg balance in vivo. Moreover, the combination treatment decreased Th17 differentiation significantly and significantly upregulated Foxp3 and IL-10 expression in peripheral blood mononuclear cells from healthy controls and liver transplantation (LT) patients. Conclusions Therefore, the combination of L. acidophilus and FK506 is effective and safe for patients undergoing allogeneic hematopoietic stem cell transplantation.
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Affiliation(s)
- Jin-Ah Beak
- The Rheumatism Research Center, Catholic Research Institute of Medical Science, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea.,Department of Biomedicine & Health Sciences, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Min-Jung Park
- The Rheumatism Research Center, Catholic Research Institute of Medical Science, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Se-Young Kim
- The Rheumatism Research Center, Catholic Research Institute of Medical Science, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - JooYeon Jhun
- The Rheumatism Research Center, Catholic Research Institute of Medical Science, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea.,Department of Biomedicine & Health Sciences, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Jin Seok Woo
- The Rheumatism Research Center, Catholic Research Institute of Medical Science, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Jeong Won Choi
- The Rheumatism Research Center, Catholic Research Institute of Medical Science, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Hyun Sik Na
- The Rheumatism Research Center, Catholic Research Institute of Medical Science, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea.,Department of Biomedicine & Health Sciences, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Soon Kyu Lee
- Division of Hepatology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Jong Young Choi
- Division of Hepatology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Mi-La Cho
- The Rheumatism Research Center, Catholic Research Institute of Medical Science, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea. .,Department of Biomedicine & Health Sciences, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea. .,Department of Medical Lifescience, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea.
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González-Vílchez F, Crespo-Leiro MG, Delgado-Jiménez J, Pérez-Villa F, Segovia-Cubero J, Díaz-Molina B, Mirabet-Pérez S, Arizón del Prado JM, Blasco-Peiró T, Martínez-Sellés M, Almenar-Bonet L, Garrido-Bravo I, Rábago G, Vázquez de Prada JA. Impacto de la variabilidad intrapaciente en la concentración sanguínea de anticalcineurínicos en los resultados del trasplante cardiaco. Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2021.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Santulario Verdú L, García-Romero E, Díez-López C. Clinical impact of variability in blood concentrations of calcineurin inhibitors in heart transplant: a double-edged sword. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2022; 75:112-114. [PMID: 34598885 DOI: 10.1016/j.rec.2021.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 08/17/2021] [Indexed: 06/13/2023]
Affiliation(s)
- Lorena Santulario Verdú
- Departamento de Farmacia Hospitalaria, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Elena García-Romero
- Unidad de Insuficiencia Cardíaca Avanzada y Trasplante Cardíaco, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain; Departament de Medicina, Facultat de Medicina, Universitat de Barcelona, Barcelona, Spain
| | - Carles Díez-López
- Unidad de Insuficiencia Cardíaca Avanzada y Trasplante Cardíaco, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain; Departament de Medicina, Facultat de Medicina, Universitat de Barcelona, Barcelona, Spain.
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42
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Impacto clínico de la variabilidad en la concentración sanguínea de inhibidores de calcineurina en trasplante cardiaco: una espada de doble filo. Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2021.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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43
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González-Vílchez F, Crespo-Leiro MG, Delgado-Jiménez J, Pérez-Villa F, Segovia-Cubero J, Díaz-Molina B, Mirabet-Pérez S, Arizón Del Prado JM, Blasco-Peiró T, Martínez-Sellés M, Almenar-Bonet L, Garrido-Bravo I, Rábago G, Vázquez de Prada JA. Impact of intrapatient blood level variability of calcineurin inhibitors on heart transplant outcomes. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2022; 75:129-140. [PMID: 33744197 DOI: 10.1016/j.rec.2021.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 02/08/2021] [Indexed: 06/12/2023]
Abstract
INTRODUCTION AND OBJECTIVES Intrapatient blood level variability (IPV) of calcineurin inhibitors has been associated with poor outcomes in solid-organ transplant, but data for heart transplant are scarce. Our purpose was to ascertain the clinical impact of IPV in a multi-institutional cohort of heart transplant recipients. METHODS We retrospectively studied patients aged ≥18 years, with a first heart transplant performed between 2000 and 2014 and surviving≥ 1 year. IPV was assessed by the coefficient of variation of trough levels from posttransplant months 4 to 12. A composite of rejection or mortality/graft loss or rejection and all-cause mortality/graft loss between years 1 to 5 posttransplant were analyzed by Cox regression analysis. RESULTS The study group consisted of 1581 recipients (median age, 56 years; women, 21%). Cyclosporine immediate-release tacrolimus and prolonged-release tacrolimus were used in 790, 527 and 264 patients, respectively. On multivariable analysis, coefficient of variation> 27.8% showed a nonsignificant trend to association with 5-year rejection-free survival (HR, 1.298; 95%CI, 0.993-1.695; P=.056) and with 5-year mortality (HR, 1.387; 95%CI, 0.979-1.963; P=.065). Association with rejection became significant on analysis of only those patients without rejection episodes during the first year posttransplant (HR, 1.609; 95%CI, 1.129-2.295; P=.011). The tacrolimus-based formulation had less IPV than cyclosporine and better results with less influence of IPV. CONCLUSIONS IPV of calcineurin inhibitors is only marginally associated with mid-term outcomes after heart transplant, particularly with the tacrolimus-based immunosuppression, although it could play a role in the most stable recipients.
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Affiliation(s)
| | - María G Crespo-Leiro
- Servicio de Cardiología, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - Juan Delgado-Jiménez
- Servicio Cardiología y Fundación Investigación Hospital Universitario 12 de Octubre, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Félix Pérez-Villa
- Servicio de Cardiología, Hospital Clínic Universitari, Barcelona, Spain
| | - Javier Segovia-Cubero
- Servicio de Cardiología, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Madrid, Spain
| | - Beatriz Díaz-Molina
- Servicio de Cardiología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Sonia Mirabet-Pérez
- Servei de Cardiologia, Hospital Universitari Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Teresa Blasco-Peiró
- Servicio de Cardiología, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Manuel Martínez-Sellés
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Universitario Gregorio Marañón, Madrid, Spain; Facultad de Medicina, Universidad Europea, Madrid, Spain; Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Luis Almenar-Bonet
- Servicio de Cardiología, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Iris Garrido-Bravo
- Servicio de Cardiología, Hospital Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
| | - Gregorio Rábago
- Servicio de Cirugía Cardiaca, Clínica Universitaria de Navarra, Pamplona, Spain
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Tornatore KM, Meaney CJ, Attwood K, Brazeau DA, Wilding GE, Consiglio JD, Gundroo A, Chang SS, Gray V, Cooper LM, Venuto RC. Race and sex associations with tacrolimus pharmacokinetics in stable kidney transplant recipients. Pharmacotherapy 2022; 42:94-105. [PMID: 35103348 PMCID: PMC9020367 DOI: 10.1002/phar.2656] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 10/27/2021] [Accepted: 10/28/2021] [Indexed: 11/22/2022]
Abstract
Study Objective This study investigated race and sex differences in tacrolimus pharmacokinetics and pharmacodynamics in stable kidney transplant recipients. Design and Setting A cross‐sectional, open‐label, single center, 12‐h pharmacokinetic‐pharmacodynamic study was conducted. Tacrolimus pharmacokinetic parameters included area under the concentration‐time curve (AUC0–12), AUC0–4, 12‐h troughs (C12 h), maximum concentrations (Cmax), oral clearance (Cl), with dose‐normalized AUC0–12, troughs, and Cmax with standardized adverse effect scores. Statistical models were used to analyze end points with individual covariate‐adjustment including clinical factors, genotypic variants CYP3A5*3, CYP3A5*6, CYP3A5*7(CYP3A5*3*6*7) metabolic composite, and ATP binding cassette gene subfamily B member 1 (ABCB1) polymorphisms. Patients 65 stable, female and male, Black and White kidney transplant recipients receiving tacrolimus and mycophenolic acid ≥6 months post‐transplant were evaluated. Measurements and Main Results Black recipients exhibited higher tacrolimus AUC0–12 (Race: p = 0.005), lower AUC* (Race: p < 0.001; Race × Sex: p = 0.068), and higher Cl (Race: p < 0.001; Sex: p = 0.066). Greater cumulative (Sex: p < 0.001; Race × Sex: p = 0.014), neurologic (Sex: p = 0.021; Race × Sex: p = 0.005), and aesthetic (Sex: p = 0.002) adverse effects were found in females, with highest scores in Black women. In 84.8% of Black and 68.8% of White patients, the target AUC0–12 was achieved (p = 0.027). In 31.3% of White and 9.1% of Black recipients, AUC0–12 was <100 ng‧h/ml despite tacrolimus troughs in the target range (p = 0.027). The novel CYP3A5*3*6*7 metabolic composite was the significant covariate accounting for 15%–19% of tacrolimus variability in dose (p = 0.002); AUC0–12 h* (p < 0.001), and Cl (p < 0.001). Conclusions Tacrolimus pharmacokinetics and adverse effects were different among stable kidney transplant recipient groups based upon race and sex with interpatient variability associated with the CYP3A5*3*6*7 metabolic composite. More cumulative, neurologic, and aesthetic adverse effects were noted among females. Tacrolimus regimens that consider race and sex may reduce adverse effects and enhance allograft outcomes by facilitating more patients to achieve the targeted AUC0–12 h.
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Affiliation(s)
- Kathleen M. Tornatore
- Immunosuppressive Pharmacology Research Program Translational Pharmacology Research Core NYS Center of Excellence in Bioinformatics & Life Sciences Buffalo New York USA
- Pharmacy School of Pharmacy and Pharmaceutical Sciences Buffalo New York USA
- Nephrology Division Medicine School of Medicine and Biomedical Sciences Buffalo New York USA
| | - Calvin J. Meaney
- Immunosuppressive Pharmacology Research Program Translational Pharmacology Research Core NYS Center of Excellence in Bioinformatics & Life Sciences Buffalo New York USA
- Pharmacy School of Pharmacy and Pharmaceutical Sciences Buffalo New York USA
| | - Kristopher Attwood
- Biostatistics School of Public Health and Health Professions Buffalo New York USA
| | - Daniel A. Brazeau
- Department of Biomedical Sciences Joan C Edwards School of Medicine Marshall University Huntington West Virginia USA
| | - Gregory E. Wilding
- Biostatistics School of Public Health and Health Professions Buffalo New York USA
| | - Joseph D. Consiglio
- Biostatistics School of Public Health and Health Professions Buffalo New York USA
| | - Aijaz Gundroo
- Nephrology Division Medicine School of Medicine and Biomedical Sciences Buffalo New York USA
- Erie County Medical Center Buffalo New York USA
| | - Shirley S. Chang
- Nephrology Division Medicine School of Medicine and Biomedical Sciences Buffalo New York USA
- Erie County Medical Center Buffalo New York USA
| | - Vanessa Gray
- Nephrology Division Medicine School of Medicine and Biomedical Sciences Buffalo New York USA
| | - Louise M. Cooper
- Immunosuppressive Pharmacology Research Program Translational Pharmacology Research Core NYS Center of Excellence in Bioinformatics & Life Sciences Buffalo New York USA
- Pharmacy School of Pharmacy and Pharmaceutical Sciences Buffalo New York USA
| | - Rocco C. Venuto
- Nephrology Division Medicine School of Medicine and Biomedical Sciences Buffalo New York USA
- Erie County Medical Center Buffalo New York USA
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Gandolfini I, Palmisano A, Fiaccadori E, Cravedi P, Maggiore U. Detecting, preventing, and treating non-adherence to immunosuppression after kidney transplantation. Clin Kidney J 2022; 15:1253-1274. [PMID: 35756738 PMCID: PMC9217626 DOI: 10.1093/ckj/sfac017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Indexed: 11/12/2022] Open
Abstract
Medication non-adherence (MNA) is a major issue in kidney transplantation and it is associated with increased risk of rejection, allograft loss, patients’ death and higher healthcare costs. Despite its crucial importance, it is still unclear what are the best strategies to diagnose, prevent and treat MNA. MNA can be intentional (deliberate refusal to take the medication as prescribed) or unintentional (non-deliberate missing the prescribed medication). Its diagnosis may rely on direct methods, aiming at measuring drug ingestions, or indirect methods that analyse the habits of patients to adhere to correct drug dose (taking adherence) and interval (time adherence). Identifying individual risk factors for MNA may provide the basis for a personalized approach to the treatment of MNA. Randomized control trials performed so far have tested a combination of strategies, such as enhancing medication adherence through the commitment of healthcare personnel involved in drug distribution, the use of electronic reminders, therapy simplification or various multidisciplinary approaches to maximize the correction of individual risk factors. Although most of these approaches reduced MNA in the short-term, the long-term effects on MNA and, more importantly, on clinical outcomes remain unclear. In this review, we provide a critical appraisal of traditional and newer methods for detecting, preventing and treating non-adherence to immunosuppression after kidney transplantation from the perspective of the practising physician.
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Affiliation(s)
- Ilaria Gandolfini
- Department of Medicine and Surgery, University of Parma, Parma, Italy
- Nephrology Unit, University Hospital of Parma, Parma, Italy
| | | | - Enrico Fiaccadori
- Department of Medicine and Surgery, University of Parma, Parma, Italy
- Nephrology Unit, University Hospital of Parma, Parma, Italy
| | - Paolo Cravedi
- Department of Medicine, Division of Nephrology and Translational Transplant Research Center, Recanati Miller Transplant Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Umberto Maggiore
- Department of Medicine and Surgery, University of Parma, Parma, Italy
- Nephrology Unit, University Hospital of Parma, Parma, Italy
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Baghai Arassi M, Gauche L, Schmidt J, Höcker B, Rieger S, Süsal C, Tönshoff B, Fichtner A. Association of intraindividual tacrolimus variability with de novo donor-specific HLA antibody development and allograft rejection in pediatric kidney transplant recipients with low immunological risk. Pediatr Nephrol 2022; 37:2503-2514. [PMID: 35166920 PMCID: PMC9395307 DOI: 10.1007/s00467-022-05426-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 11/24/2021] [Accepted: 12/13/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Tacrolimus (Tac) intraindividual variability (TacIPV) in pediatric kidney transplant patients is only poorly understood. We investigated the impact of TacIPV on de novo donor-specific HLA antibodies (dnDSA) development and allograft rejection in Caucasian pediatric recipients of a living or deceased donor kidney with low immunological risk. METHODS This was a single-center retrospective study including 48 pediatric kidney transplant recipients. TacIPV was calculated based on coefficient of variation (CV%) 6-12 months posttransplant. TacIPV cutoff was set at the median (25%). Outcome parameters were dnDSA development and rejection episodes. RESULTS In total, 566 Tac levels were measured with median 11.0 (6.0-17.0) measurements per patient. The cutoff of 25% corresponded to the median CV% in our study cohort (25%, IQR 18-35%) and was comparable to cutoffs determined by receiver operating characteristic (ROC) curve analysis. High TacIPV was associated with higher risk of dnDSA development (HR 3.4, 95% CI 1.0-11.1, P = 0.047; Kaplan-Meier analysis P = 0.018) and any kind of rejection episodes (HR 4.1, 95% CI 1.1-14.8, P = 0.033; Kaplan-Meier analysis P = 0.010). There was a clear trend towards higher TacIPV below the age of 6 years. TacIPV (CV%) was stable over time. A TacIPV (CV%) cutoff of 30% or IPV quantification by mean absolute deviation (MAD) showed comparable results. CONCLUSIONS High TacIPV is associated with an increased risk of dnDSA development and rejection episodes > year 1 posttransplant even in patients with low immunological risk profile. Therefore, in patients with high TacIPV, potential causes should be addressed, and if not resolved, changes in immunosuppressive therapy should be considered. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Maral Baghai Arassi
- Department of Pediatrics I, University Children's Hospital Heidelberg, Heidelberg, Germany. .,Structural and Computational Biology Unit, European Molecular Biology Laboratory, Heidelberg, Germany.
| | - Laura Gauche
- Department of Pediatrics I, University Children’s Hospital Heidelberg, Heidelberg, Germany
| | - Jeremy Schmidt
- Department of Pediatrics I, University Children’s Hospital Heidelberg, Heidelberg, Germany
| | - Britta Höcker
- Department of Pediatrics I, University Children’s Hospital Heidelberg, Heidelberg, Germany
| | - Susanne Rieger
- Department of Pediatrics I, University Children’s Hospital Heidelberg, Heidelberg, Germany
| | - Caner Süsal
- Institute of Immunology, Transplantation Immunology, University Hospital Heidelberg, Heidelberg, Germany
| | - Burkhard Tönshoff
- Department of Pediatrics I, University Children’s Hospital Heidelberg, Heidelberg, Germany
| | - Alexander Fichtner
- Department of Pediatrics I, University Children’s Hospital Heidelberg, Heidelberg, Germany
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Bunthof KLW, Al-Hassany L, Nakshbandi G, Hesselink DA, van Schaik RHN, Ten Dam MAGJ, Baas MC, Hilbrands LB, van Gelder T. A randomized crossover study comparing different tacrolimus formulations to reduce intrapatient variability in tacrolimus exposure in kidney transplant recipients. Clin Transl Sci 2021; 15:930-941. [PMID: 34905302 PMCID: PMC9010272 DOI: 10.1111/cts.13206] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 10/23/2021] [Accepted: 11/17/2021] [Indexed: 12/05/2022] Open
Abstract
A high intrapatient variability (IPV) in tacrolimus exposure is a risk factor for poor long‐term outcomes after kidney transplantation. The main objective of this trial was to investigate whether tacrolimus IPV decreases after switching patients from immediate‐release (IR)‐tacrolimus to either extended‐release (ER)‐tacrolimus or LifeCyclePharma (LCP)‐tacrolimus. In this randomized, prospective, open‐label, cross‐over trial, adult kidney transplant recipients on a stable immunosuppressive regimen, including IR‐tacrolimus, were randomized for conversion to ER‐tacrolimus or LCP‐tacrolimus, and for the order in which IR‐tacrolimus and the once‐daily formulations were taken. Patients were followed 6 months for each formulation, with monthly tacrolimus predose concentration assessments to calculate the IPV. The IPV was defined as the coefficient of variation (%) of dose corrected predose concentrations. Ninety‐two patients were included for analysis of the primary outcome. No significant differences between the IPV of IR‐tacrolimus (16.6%) and the combined once‐daily formulations (18.3%) were observed (% difference +1.7%, 95% confidence interval [CI] −1.1% to ‒4.5%, p = 0.24). The IPV of LCP‐tacrolimus (20.1%) was not significantly different from the IPV of ER‐tacrolimus (16.5%, % difference +3.6%, 95% CI −0.1% to 7.3%, p = 0.06). In conclusion, the IPV did not decrease after switching from IR‐tacrolimus to either ER‐tacrolimus or LCP‐tacrolimus. These results provide no arguments to switch kidney transplant recipients from twice‐daily (IR) tacrolimus formulations to once‐daily (modified‐release) tacrolimus formulations when the aim is to lower the IPV.
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Affiliation(s)
- Kim L W Bunthof
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Internal Medicine, Bravis Hospital, Roosendaal, The Netherlands
| | - Linda Al-Hassany
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Gizal Nakshbandi
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Dennis A Hesselink
- Internal Medicine, Division of Nephrology and Transplantation, Erasmus University Medical Center, Rotterdam, The Netherlands.,Erasmus University Medical Center, Erasmus MC Transplant Institute, Rotterdam, The Netherlands
| | - Ron H N van Schaik
- Clinical Chemistry, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marc A G J Ten Dam
- Department of Internal Medicine, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Marije C Baas
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Luuk B Hilbrands
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Teun van Gelder
- Internal Medicine, Division of Nephrology and Transplantation, Erasmus University Medical Center, Rotterdam, The Netherlands.,Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
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Early Monitoring and Subsequent Gain of Tacrolimus Time-In-Therapeutic Range May Improve Clinical Outcomes After Living Kidney Transplantation. Ther Drug Monit 2021; 43:728-735. [PMID: 34780391 DOI: 10.1097/ftd.0000000000000881] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 01/16/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND The early identification of recipients at high risk of graft loss is clinically relevant after kidney transplantation. The authors explored whether the earlier monitoring of tacrolimus (Tac) time-in-therapeutic range (TTR) is predictive of and a subsequent gain in TTR improves transplant outcomes. METHODS The TTR within 3, 6, 9, and 12 months was evaluated. Multivariate Cox analyses were performed to explore when TTR was predictive of transplant outcomes. Patients were divided into 3 groups based on incremental TTR change [TTR gain (increase >10%), TTR stable (maintained within 10%), and TTR loss (decrease >10%)] and 4 groups based on predefined cutoff values [low-low (LL), low-high (LH), high-low (HL), and high-high (HH)] using 6- and 12-month TTRs. Death-censored graft loss and patient death were primary outcomes. RESULTS Nonlinear associations were observed between 6-, 9-, and 12-month TTR and death-censored graft and patient survival rates. In multivariate analysis, every 10% increase in 6-, 9-, and 12-month TTRs was associated with reduced patient death [hazard ratio (HR): 0.83; HR: 0.68; HR: 0.61, respectively] and graft loss (HR: 0.88; HR: 0.73; HR: 0.66, respectively). A nonlinear relationship was observed between transplant outcomes and incremental changes in TTR. TTR gain and stable TTR contributed to higher graft survival (HR: 0.20; HR: 0.21) and patient survival (HR: 0.14; HR: 0.15) rates than TTR loss, whereas the former 2 had comparable outcomes. Furthermore, compared with those in the HH group, the LL and HL groups had inferior graft survival (HR: 3.33; HR: 5.17) and patient survival (HR: 5.15; HR: 8.94) rates, whereas the LH group had similar outcomes (P = 0.63, P = 0.97). Nonadherence was the main controllable risk factor for low TTR. CONCLUSIONS The 6-month TTR identified patients at higher risk of worse outcomes. The subsequent gain of TTR may contribute to better transplant outcomes.
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Herden U, Sterneck M, Buchholz BM, Achilles EG, Ott A, Fischer L. A single-center, open-label, randomized cross-over study to evaluate the pharmacokinetics and bioavailability of once-daily prolonged-release formulations of tacrolimus in de novo liver transplant recipients. Immun Inflamm Dis 2021; 9:1771-1780. [PMID: 34559956 PMCID: PMC8589356 DOI: 10.1002/iid3.537] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 09/06/2021] [Accepted: 09/09/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The narrow therapeutic window of tacrolimus (Tac) requires intense drug monitoring to achieve adequate efficacy while minimizing dose-related toxicities. Once-daily formulations of Tac (LCP-Tac and PR-Tac) have been recently designed for higher bioavailability and a more consistent exposure over time, as opposed to the twice-daily, administered immediate-release formulation of Tac (IR-Tac). METHODS This single-center, open-label, randomized cross-over pharmacokinetic (PK) study compares extended-release LCP-Tac with the prolonged-release formulation of tacrolimus (PR-Tac) in adult de novo liver transplant recipients. Eligible patients were screened and randomized 1:1 to the two treatment arms up to 30 days after liver transplantation. Patients were administered either LCP-Tac or PR-Tac for 14 days followed by another 14-day time interval of the other once-daily Tac medication. A 24hr-PK profile was obtained at the end of each time interval. RESULTS Nine patients (45%) completed the study resulting in a total of 18 Tac PK profiles. Overall, the profile of the mean concentrations indicated a flattened kinetic of LCP-Tac compared to PR-Tac, especially in the first 3 h after drug intake. The average cumulative dose per day to achieve equivalent trough levels was approximately 25% lower for LCP-Tac (8.7 mg) than for PR-Tac (11.7 mg). LCP-Tac resulted in a longer tmax and fewer peak-to-trough fluctuations compared to PR-Tac. CONCLUSION Despite methodological weaknesses that limit the conclusions, we have found a more consistent drug exposure for LCP-Tac in de novo LT recipients. LCP-Tac demonstrated a greater bioavailability compared to PR-Tac.
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Affiliation(s)
- Uta Herden
- Department of Visceral TransplantationUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Martina Sterneck
- Department of MedicineUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Bettina M. Buchholz
- Department of Visceral TransplantationUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Eike G. Achilles
- Department of Visceral TransplantationUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Armin Ott
- Institute of Medical Informatics, Statistics and EpidemiologyTechnische Universität MünchenMunichGermany
| | - Lutz Fischer
- Department of Visceral TransplantationUniversity Medical Center Hamburg‐EppendorfHamburgGermany
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Effect of the Interrelation between CYP3A5 Genotype, Concentration/Dose Ratio and Intrapatient Variability of Tacrolimus on Kidney Graft Function: Monte Carlo Simulation Approach. Pharmaceutics 2021; 13:pharmaceutics13111970. [PMID: 34834385 PMCID: PMC8622919 DOI: 10.3390/pharmaceutics13111970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 11/02/2021] [Accepted: 11/04/2021] [Indexed: 12/04/2022] Open
Abstract
Background: Tacrolimus (Tac) is characterized by large between- and within-patient (IPV) variability in pharmacokinetics and exposure. Aim: This study aimed to assess and validate the effect of Tac IPV and trough concentration-to-dose ratio (C0/D) over 6–12 months on reduced estimated glomerular filtration rate (eGFR) values in the late period after kidney transplantation (Tx), applying Monte Carlo (MC) simulation. Methods: The previously published linear regression was the basis for MC simulation, performed to determine how variations in significant predictors affect the distribution of eGFR from 13 to 36 months post-transplantation. The input C0/D values were derived from CYP3A5 genotype subgroups. Results: Patients characterized by high Tac IPV and low mean C0/D over 6–12 months could have been at greater risk of lower eGFR values in a three-year period following Tx compared to the other patient groups. This effect was more pronounced in patients with a lower eGFR at the 6th month and a history of acute rejection. The proven contribution of CYP3A5 expresser genotype to low C0/D values may suggest its indirect effect on long-term graft function. Conclusion: The findings indicate that simultaneous assessment of Tac IPV, C0/D, and CYP3A5 genotype may identify patients at risk of deterioration of graft function in the long-term post-transplantation period.
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