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Bonatti HJR, Sadik KW, Krebs ED, Sifri CD, Pruett TL, Sawyer RG. Clostridium difficile-Associated Colitis Post-Transplant Is Not Associated with Elevation of Tacrolimus Concentrations. Surg Infect (Larchmt) 2017. [PMID: 28650734 DOI: 10.1089/sur.2016.180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Diarrhea is a common condition after solid organ transplant (SOT); Clostridium difficile-associated colitis (CDAC) is one of the most common infections after SOT. We documented previously that some types of enteritis are associated with an elevation of tacrolimus (TAC) trough concentrations by interfering with the drug's complex metabolism. PATIENTS AND METHODS Tacrolimus concentrations of 25 SOT recipients including 12 renal and 13 liver recipients before, during, and after CDAC were analyzed retrospectively. RESULTS Median age of the 25 patients was 54 y (range, 36-71), there were 15 males and 10 females. Clostridium difficile-associated colitis developed at a median of 55 d (range 2-4551) post-SOT. Median TAC concentrations prior to the outbreak of CDAC were 6.9 ng/mL (range, <1.5-17.2), 5.6 ng/mL (range, <1.5-13.2) during diarrhea, and 7.4 ng/mL (range, <1.5-24.3) after resolution of diarrhea (p > 0.05, NS). Treatment of CDAC consisted of metronidazole for 14 d in all cases. All patients recovered from CDAC but seven patients had CDAC relapse. CONCLUSIONS In contrast to other types of infectious diarrhea such as rotavirus enteritis and cryptosporidiosis, CDAC is not associated with an increase in TAC concentrations. This is because C. difficile causes primarily colitis as opposed to other organisms, which are associated with enteritis.
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Affiliation(s)
- Hugo J R Bonatti
- 1 Department of Surgery, University of Virginia Health System , Charlottesville, Virginia.,3 University of Maryland , Shore Regional Health, Easton, Maryland
| | - Karim W Sadik
- 1 Department of Surgery, University of Virginia Health System , Charlottesville, Virginia.,4 Guthrie, Plastic Surgery , Sayre, Pennsylvania
| | - Elizabeth D Krebs
- 1 Department of Surgery, University of Virginia Health System , Charlottesville, Virginia
| | - Costi D Sifri
- 2 Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia Health System , Charlottesville, Virginia
| | - Timothy L Pruett
- 1 Department of Surgery, University of Virginia Health System , Charlottesville, Virginia.,5 Division of Transplantation, University of Minnesota , Minneapolis, Minnesota
| | - Robert G Sawyer
- 1 Department of Surgery, University of Virginia Health System , Charlottesville, Virginia
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2
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Roda KMO, Fonseca EA, Candido HL, Benavides MR, Afonso RC, Pugliese R, Vincenzi R, Chapchap P, Seda Neto J. Simultaneous or sequential gastrectomy in pediatric liver transplant recipients. Pediatr Transplant 2016; 20:994-999. [PMID: 27412691 DOI: 10.1111/petr.12755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/08/2016] [Indexed: 01/16/2023]
Abstract
The association between LT and gastrectomy is not common. Only two studies reported the gastrectomy/LT association in children. Here, we report three children who underwent LT who required a concomitant or sequential gastrectomy for different reasons. Patient 1, a 16-yr-old boy, during the LT, underwent a partial gastrectomy due to extensive injury to the duodenum. He had a previous and unusual portoenterostomy performed in the duodenum. Bowel reconstruction was performed using an intestinal loop that was first used for the bilio-enteric anastomosis and then connected to the gastric stump. Patient 2, a 22-month-old female child, underwent a partial gastrectomy with a Roux-en-Y reconstruction during a retransplantation. She had a large perforated gastric ulcer blocked by the allograft liver. Patient 3, a 26-month-old male child, five yr after living donor LT, was submitted to a partial gastrectomy because of gastric outlet obstruction. The histopathology was compatible with eosinophilic gastritis. The association between LT and gastrectomy in the pediatric population is extremely rare. Appropriate knowledge of the previous transplantation technique is very important. Further studies are required to assess the outcomes of the different types of gastric reconstruction in pediatric recipients.
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Affiliation(s)
- Karina M O Roda
- Hepatology and Liver Transplantation, Hospital Sirio-Libanes, Sao Paulo, SP, Brazil.,A. C. Camargo Cancer Center, Sao Paulo, SP, Brazil
| | - Eduardo A Fonseca
- Hepatology and Liver Transplantation, Hospital Sirio-Libanes, Sao Paulo, SP, Brazil.,A. C. Camargo Cancer Center, Sao Paulo, SP, Brazil
| | - Helry L Candido
- Hepatology and Liver Transplantation, Hospital Sirio-Libanes, Sao Paulo, SP, Brazil.,A. C. Camargo Cancer Center, Sao Paulo, SP, Brazil
| | - Marcel R Benavides
- Hepatology and Liver Transplantation, Hospital Sirio-Libanes, Sao Paulo, SP, Brazil.,A. C. Camargo Cancer Center, Sao Paulo, SP, Brazil
| | - Rogerio C Afonso
- Hepatology and Liver Transplantation, Hospital Sirio-Libanes, Sao Paulo, SP, Brazil.,A. C. Camargo Cancer Center, Sao Paulo, SP, Brazil
| | - Renata Pugliese
- Hepatology and Liver Transplantation, Hospital Sirio-Libanes, Sao Paulo, SP, Brazil.,A. C. Camargo Cancer Center, Sao Paulo, SP, Brazil
| | - Rodrigo Vincenzi
- Hepatology and Liver Transplantation, Hospital Sirio-Libanes, Sao Paulo, SP, Brazil.,A. C. Camargo Cancer Center, Sao Paulo, SP, Brazil
| | - Paulo Chapchap
- Hepatology and Liver Transplantation, Hospital Sirio-Libanes, Sao Paulo, SP, Brazil
| | - Joao Seda Neto
- Hepatology and Liver Transplantation, Hospital Sirio-Libanes, Sao Paulo, SP, Brazil. .,A. C. Camargo Cancer Center, Sao Paulo, SP, Brazil.
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3
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The tacrolimus metabolism rate influences renal function after kidney transplantation. PLoS One 2014; 9:e111128. [PMID: 25340655 PMCID: PMC4207775 DOI: 10.1371/journal.pone.0111128] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Accepted: 09/22/2014] [Indexed: 12/11/2022] Open
Abstract
The effective calcineurin inhibitor (CNI) tacrolimus (Tac) is an integral part of the standard immunosuppressive regimen after renal transplantation (RTx). However, as a potent CNI it has nephrotoxic potential leading to impaired renal function in some cases. Therefore, it is of high clinical impact to identify factors which can predict who is endangered to develop CNI toxicity. We hypothesized that the Tac metabolism rate expressed as the blood concentration normalized by the dose (C/D ratio) is such a simple predictor. Therefore, we analyzed the impact of the C/D ratio on kidney function after RTx. Renal function was analyzed 1, 2, 3, 6, 12 and 24 months after RTx in 248 patients with an immunosuppressive regimen including basiliximab, tacrolimus, mycophenolate mofetil and prednisolone. According to keep the approach simple, patients were split into three C/D groups: fast, intermediate and slow metabolizers. Notably, compared with slow metabolizers fast metabolizers of Tac showed significantly lower estimated glomerular filtration rate (eGFR) values at all the time points analyzed. Moreover, fast metabolizers underwent more indication renal biopsies (p = 0.006) which revealed a higher incidence of CNI nephrotoxicity (p = 0.015) and BK nephropathy (p = 0.024) in this group. We herein identified the C/D ratio as an easy calculable risk factor for the development of CNI nephrotoxicity and BK nephropathy after RTx. We propose that the simple C/D ratio should be taken into account early in patient's risk management strategies.
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Bonatti H, Barroso LF, Sawyer RG, Kotton CN, Sifri CD. Cryptosporidium enteritis in solid organ transplant recipients: multicenter retrospective evaluation of 10 cases reveals an association with elevated tacrolimus concentrations. Transpl Infect Dis 2012; 14:635-48. [PMID: 22340660 DOI: 10.1111/j.1399-3062.2012.00719.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2011] [Revised: 11/04/2011] [Accepted: 01/09/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND Cryptosporidial enteritis, a diarrheal infection of the small intestine caused by the apicomplexan protozoa Cryptosporidium, is infrequently recognized in transplant recipients from developed countries. METHODS A retrospective review of all cases of cryptosporidiosis in solid organ transplant (SOT) recipients at 2 centers from January 2001 to October 2010 was performed and compared with transplant recipients with community-onset Clostridium difficile infection (CDI). A literature search was performed with regard to reported cases of cryptosporidiosis in SOT recipients. RESULTS Eight renal, 1 liver, and 1 lung transplant recipient were diagnosed with cryptosporidiosis at median 46.0 months (interquartile range [IQR] 25.2-62.8) following SOT. Symptoms existed for a median 14 days (IQR 10.5-14.8) before diagnosis. For the 9 patients receiving tacrolimus (TAC), mean TAC levels increased from 6.3 ± 1.1 to 21.3 ± 9.2 ng/mL (P = 0.0007) and median serum creatinine increased temporarily from 1.3 (IQR 1.1-1.7) to 2.4 (IQR 2.0-4.6) mg/dL (P = 0.008). By comparison, 8 SOT recipients (6 kidney, 2 liver) hospitalized with community-onset CDI had a mean TAC level of 10.8 ± 2.8 ng/dL during disease compared with 9.2 ± 2.3 ng/mL at baseline (P = 0.07) and had no change in median creatinine. All patients recovered from Cryptosporidium enteritis after receiving various chemotherapeutic regimens. CONCLUSIONS Cryptosporidiosis should be recognized as an important cause of diarrhea after SOT and is associated with elevated TAC levels and acute kidney injury. Increased TAC levels may reflect altered drug metabolism in the small intestine.
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Affiliation(s)
- H Bonatti
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
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Rogers CC, Alloway RR, Alexander JW, Cardi M, Trofe J, Vinks AA. Pharmacokinetics of mycophenolic acid, tacrolimus and sirolimus after gastric bypass surgery in end-stage renal disease and transplant patients: a pilot study. Clin Transplant 2008; 22:281-91. [PMID: 18482049 DOI: 10.1111/j.1399-0012.2007.00783.x] [Citation(s) in RCA: 138] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Promising data regarding the safety and efficacy of gastric bypass surgery (GBS) as an option to address obesity in the transplant population are emerging. The data lack on how GBS may alter the pharmacokinetics (PK) of modern immunosuppression. The objective of this study was to describe the alterations in the PK of modern immunosuppressants and the GBS population. METHODS Data are presented on six subjects who participated in this trial--four were on dialysis and two were renal transplant recipients. Dialysis-dependent bypass subjects received a single dose of 6 mg of sirolimus, two 4-mg doses of tacrolimus and two 1000-mg doses of mycophenolate mofetil (MMF) over the 24-h study period. Transplant recipients continued their current regimen. Maximum plasma concentration (C(max)), time to reach the maximum plasma concentration (T(max)) and the area under the plasma concentration vs. time curve (AUC(0-12) and AUC(0-infinity) where appropriate) were calculated for tacrolimus, sirolimus, mycophenolic acid (MPA) and mycophenolic acid glucuronide (MPAG). RESULTS Significant inter-patient variability in the C(max), T(max) and AUC of tacrolimus, sirolimus MPA and MPAG was observed. A notable difference in the AUC:dose ratio for tacrolimus was seen when comparing data with published data in the non-bypass population. Similar differences in PK were seen with sirolimus, MPA and MPAG. CONCLUSIONS When comparing the PK of sirolimus, tacrolimus, MPA and MPAG to published PK data in the non-bypass population, significant differences are observed. It is likely that transplant recipients with GBS would need higher doses of tacrolimus, sirolimus and MMF to provide similar exposure to a non-bypass patient.
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Affiliation(s)
- Christin C Rogers
- University of Cincinnati, Department of Surgery, Cincinnati, OH 45267-0585, USA
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Nishi K, Ishii T, Wada M, Amae S, Sano N, Nio M, Hayashi Y. The colon displays an absorptive capacity of tacrolimus. Transplant Proc 2004; 36:364-6. [PMID: 15050160 DOI: 10.1016/j.transproceed.2003.12.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE In our previous study, blood levels of orally administered tacrolimus were significantly higher in short bowel piglets than in control animals. It has been reported that the blood levels of tacrolimus are influenced by the metabolic activity of intestinal CYP3A4. If tacrolimus may be absorbed in the colon, direct administration of drug into this organ might be useful to augment bioavailability since the expression of CYP3A4 is low at this site. In the present study we evaluated the absorptive capacity of tacrolimus in the colon. MATERIALS AND METHODS Piglets were divided into four groups: groups 1 and 2 were controls (n = 11 and 3, respectively); group 3 underwent resection of the entire small intestine (n = 8); and group 4 had a catheter placed in the cecum (n = 4). In groups 1 and 3, tacrolimus was administered orally; in group 2 it was given intravenously; and in group 4 it was injected into cecum through the catheter from postoperative days 3 to 7. On day 7, blood samples were obtained for drug measurements to calculate the area under the concentration time curve (AUC) values. RESULTS The trough level and AUC values of tacrolimus in group 4 as well as in group 3 were significantly higher than those in group 1. In Group 4 animals showed a 60-minute time to peak concentration. CONCLUSIONS Tacrolimus is absorbed by the colon. Since the blood levels were not influenced by the metabolic activity in the graft bowel, direct administration of tacrolimus into the colon might be useful in small intestinal transplantation.
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Affiliation(s)
- K Nishi
- Department of Pediatric Surgery, Tohoku University School of Medicine, Sendai, Japan.
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Nishi K, Ishii T, Wada M, Amae S, Sano N, Nio M, Hayashi Y. The expression of intestinal CYP3A4 in the piglet model. Transplant Proc 2004; 36:361-3. [PMID: 15050159 DOI: 10.1016/j.transproceed.2003.12.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE In our previous study, the blood levels of tacrolimus were higher in the short bowel and small bowel transplantation models than those in controls. Metabolism by intestinal cytochrome p450 3A4 (CYP3A4) has been reported to influence the blood level of orally administered tacrolimus. We performed immunohistochemistry to examine the localization of intestinal CYP3A4. MATERIALS AND METHODS Twenty-four piglets were divided into three groups: group 1 were controls (n = 11); group 2, ileal resection of 2/3 proximal small intestine (n = 5); and group 3, total small intestinal resection followed by 1/3 allotransplantation of ileum (n = 8). Tacrolimus was orally administered from postoperative days 3 to 7. On day 7, blood samplings were performed for the trough level and the calculation of area under the concentration time curve (AUC). Intestinal specimens from the jejunum, ileum, colon, and ileal graft were obtained on days 0 and 10 for immunohistochemistry of CYP3A4. RESULTS The trough and AUC values in group 2 were significantly higher than those in group 1. Furthermore those measurements in group 3 animals were higher than in group 2 (trough levels: 2.5 +/- 1.7, 11.2 +/- 2.1, 16.3 +/- 2.7 ng/mL and AUC values: 126 +/- 90, 319 +/- 155, 546 +/- 117 ng. h/mL). The expression levels of CYP3A4 were, jejunum > ileum > ileal graft > colon. CONCLUSIONS The intensity and extent of CYP3A4 staining diminished in the ileal graft showing an inverse correlation to the blood concentrations.
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Affiliation(s)
- K Nishi
- Department of Pediatric Surgery, Tohoku University School of Medicine, Sendai, Japan.
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8
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Berengue JI, López-Espinosa JA, Ortega-López J, Sánchez-Sánchez L, Castilla-Valdes P, Asensio-Llorente M, Margarit-Creixell C. Two- to three-fold increase in blood tacrolimus (FK506) levels during diarrhea in liver-transplanted children. Clin Transplant 2003; 17:249-53. [PMID: 12780676 DOI: 10.1034/j.1399-0012.2003.00043.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The diagnosis and treatment of diarrhea in liver transplant recipients often pose a challenge owing to the variety of infectious and non-infectious causes. However, diagnosis is principally focused on ruling out an infectious etiology. Tacrolimus, an immunosuppressive agent generally used after liver transplantation, is absorbed mainly from the duodenum through the upper jejunum. It can be assumed that metabolism of the drug will be influenced by diarrhea. METHODS Four liver transplant recipients who developed an episode of acute gastroenteritis. Infectious etiology was confirmed; trough tacrolimus levels were measured before, during and after gastroenteritis. RESULTS All patients presented a two- to three-fold increase in blood tacrolimus levels after the onset of gastroenteritis. CONCLUSIONS Until the role played by the intestine in the metabolism of tacrolimus is fully understood, it is prudent to recommend early dose reduction of tacrolimus and careful monitoring of trough levels during diarrheal disorders of any nature in pediatric liver-transplanted patients.
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Sano N, Nio M, Ishii T, Amae S, Wada M, Nishi K, Endo N, Hayashi Y, Ohi R. Oral FK 506 blood levels are elevated in pig short bowel model: further investigations with co-administration of an intestinal CYP3A4 inhibitor. Transplant Proc 2002; 34:1050-1. [PMID: 12034301 DOI: 10.1016/s0041-1345(02)02708-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- N Sano
- Department of Pediatric Surgery, Tohoku University School of Medicine, Sendai, Japan
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Frühwirth M, Fischer H, Simma B, Ellemunter H. Elevated tacrolimus trough levels in association with mycophenolate mofetil-induced diarrhea: a case report. Pediatr Transplant 2001; 5:132-4. [PMID: 11328552 DOI: 10.1034/j.1399-3046.2001.005002132.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The combination of tacrolimus (TAC) and mycophenolate mofetil (MMF) is frequently used for immunosuppression after organ transplantation (Tx), but the pharmacokinetics and interactions between the two drugs are poorly elucidated. We describe here the increase of TAC trough levels during MMF-induced diarrhea in a 8-yr-old boy after kidney Tx. Early dose reduction of TAC, together with short-term monitoring of TAC trough levels in the presence of diarrhea, is recommended.
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Affiliation(s)
- M Frühwirth
- Department of Pediatrics, University Hospital Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria.
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