1
|
Carrara F, Gaspari F, Trillini M, Peracchi T, Fidone D, Stucchi N, Ferrari S, Cugini D, Perico N, Parvanova A, Remuzzi G, Ruggenenti P. GFR measurement in patients with CKD: Performance and feasibility of simplified iohexol plasma clearance techniques. PLoS One 2024; 19:e0306935. [PMID: 39018289 PMCID: PMC11253958 DOI: 10.1371/journal.pone.0306935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 06/25/2024] [Indexed: 07/19/2024] Open
Abstract
Implementing shortened one-compartment iohexol plasma clearance models for GFR measurement is crucial since the gold standard inulin renal clearance technique and the reference two-compartment, 10-hour, 16-samplings iohexol plasma clearance method are clinically unfeasible. Inulin may precipitate anaphylactic shock. Four-hour and 8-hour one-compartment iohexol plasma clearance models with Bröchner-Mortensen correction provide accurate GFR measurements in patients with estimated GFR (eGFR) > or ≤40 mL/min/1.73m2, respectively. We compared the performance of the simplified 5-hour, 4-samplings, two-compartment population pharmacokinetic model (popPK) with the performance of the reference two-compartment 10-hour iohexol method in 16 patients with GFR 15.2 to 56.5 mL/min/1.73 m2. We also compared the performance of shortened (5, 6 and 7-hour) one-compartment models with the performance of the standard 8-hour one-compartment model in 101 patients with eGFR ≤40 mL/min/1.73 m2. The performance of popPK and shortened methods versus reference methods was evaluated by total deviation index (TDI), concordance correlation coefficient (CCC) and coverage probability (CP). TDI <10%, CCC ≥0.9 and CP >90% indicated adequate performance. TDI, CCC and CP of popPK were 11.11%, 0.809 and 54.10%, respectively. All shortened, one-compartment models overestimated the GFR (p <0.0001 for all) as compared to the 8-hour model. TDI, CCC and CP were 7.02%, 0.815, and 75.80% for the 7-hour model, 7.26%, 0.803, and 74.20% for the 6-hour model, and 8.85%, 0.729 and 64.70% for the 5-hour model. The agreement of popPK model was comparable to that obtained with the Chronic-Kidney-Disease-Collaboration-Epidemiology (CKD-Epi) and the Modification-of-Diet-in-Renal-Disease (MDRD) serum-creatinine based equations for GFR estimation. PopPK model is remarkably unreliable for GFR measurement in stage III-IV CKD patients. In patients with eGFR ≤40 mL/min/1.73m2, shortened one-compartment models, in particular the 5-hour model, are less performant than the reference 8-hour model. For accurate GFR measurements, the iohexol plasma clearance should be measured with appropriate protocols. Over-simplified procedures should be avoided.
Collapse
Affiliation(s)
- Fabiola Carrara
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases “Aldo e Cele Daccò”, Bergamo, Italy
| | - Flavio Gaspari
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases “Aldo e Cele Daccò”, Bergamo, Italy
| | - Matias Trillini
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases “Aldo e Cele Daccò”, Bergamo, Italy
| | - Tobia Peracchi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases “Aldo e Cele Daccò”, Bergamo, Italy
| | - Diego Fidone
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases “Aldo e Cele Daccò”, Bergamo, Italy
| | - Nadia Stucchi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases “Aldo e Cele Daccò”, Bergamo, Italy
| | - Silvia Ferrari
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases “Aldo e Cele Daccò”, Bergamo, Italy
| | - Daniela Cugini
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases “Aldo e Cele Daccò”, Bergamo, Italy
| | - Norberto Perico
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases “Aldo e Cele Daccò”, Bergamo, Italy
| | - Aneliya Parvanova
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases “Aldo e Cele Daccò”, Bergamo, Italy
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases “Aldo e Cele Daccò”, Bergamo, Italy
| | - Piero Ruggenenti
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases “Aldo e Cele Daccò”, Bergamo, Italy
- Unit of Nephrology, Azienda Socio-Sanitaria Territoriale (ASST) Papa Giovanni XXIII, Bergamo, Italy
| |
Collapse
|
2
|
Zhu LJ, Lin H, Wu XT, Shi SH, Qiao X. Analysis of risk factors and prognosis of diarrhea after renal transplantation. Technol Health Care 2024; 32:2069-2080. [PMID: 38393930 DOI: 10.3233/thc-230579] [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] [Indexed: 02/25/2024]
Abstract
BACKGROUND Diarrhea is a prevalent complication after renal transplantation. OBJECTIVE To examine the risk factors for diarrhea after renal transplantation, evaluate their combined predictive values, and analyze the prognosis. METHODS Clinical data of patients who underwent allogeneic renal transplantation in the Second People's Hospital of Shanxi Province from January 2019 to March 2020 were retrospectively analyzed, cases were screened and grouped, independent risk factors for diarrhea after renal transplantation were analyzed by univariate analysis and multivariate analysis, and their predictive value was evaluated by receiver operating characteristic (ROC) curve. The survival time of recipient grafts in diarrhea and non-diarrhea groups were evaluated by Kaplan-Meier and log-rank test. RESULTS We included 166 recipients in the study and the incidence of diarrhea was 25.9%; univariate and logistic regression multivariate analyses revealed that independent risk factors for diarrhea in recipients were that the type of renal transplant donor was DCD (donation after circulatory death), immunity induction was onducted with basiliximab + antithymocyte globulin (ATG), and ATG alone, the type of mycophenolic acid (MPA) used was mycophenolate mofetil capsules, and delayed graft function (DGF) occurred after transplantation. The ROC curve indicated that the combination of the four factors had good accuracy in predicting the occurrence of diarrhea in recipients. The graft survival rate two years after the operation in the diarrhea group was significantly lower than that in the non-diarrhea group. CONCLUSION Diarrhea affected the two-year survival rate of the graft. The type of donor, immunity induction scheme, and the type of MPA and DGF were independent risk factors for diarrhea in recipients, and the combination of the four factors had good prognostic prediction value.
Collapse
Affiliation(s)
- Li-Jun Zhu
- Department of Kidney Transplantation and Dialysis Center, The Second People's Hospital of Shanxi Province, Taiyuan, Shanxi, China
- Department of Kidney Transplantation and Dialysis Center, The Second People's Hospital of Shanxi Province, Taiyuan, Shanxi, China
| | - Hui Lin
- Department of Nephrology, The Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
- Department of Kidney Transplantation and Dialysis Center, The Second People's Hospital of Shanxi Province, Taiyuan, Shanxi, China
| | - Xiao-Tong Wu
- Department of Kidney Transplantation and Dialysis Center, The Second People's Hospital of Shanxi Province, Taiyuan, Shanxi, China
| | - Shao-Hua Shi
- Department of Kidney Transplantation and Dialysis Center, The Second People's Hospital of Shanxi Province, Taiyuan, Shanxi, China
| | - Xi Qiao
- Department of Nephrology, The Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| |
Collapse
|
3
|
The Mycophenolate-based Immunosuppressive Regimen Is Associated With Increased Mortality in Kidney Transplant Patients With COVID-19. Transplantation 2022; 106:e441-e451. [PMID: 35765133 PMCID: PMC9521389 DOI: 10.1097/tp.0000000000004251] [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] [Indexed: 02/04/2023]
Abstract
BACKGROUND The chronic use of immunosuppressive drugs is a key risk factor of death because of coronavirus disease 2019 (COVID-19) in kidney transplant recipients (KTRs), although no evident association between the class of immunosuppressive and outcomes has been observed. Thus, we aimed to compare COVID-19-associated outcomes among KTRs receiving 3 different immunosuppressive maintenance regimes. METHODS This study included data from 1833 KTRs with COVID-19 diagnosed between March 20 and April 21 extracted from the national registry before immunization. All patients were taking calcineurin inhibitor associated with mycophenolate acid (MPA, n = 1258), azathioprine (AZA, n = 389), or mammalian targets of rapamycin inhibitors (mTORi, n = 186). Outcomes within 30 and 90 d were assessed. RESULTS Compared with patients receiving MPA, the 30-d (79.9% versus 87.9% versus 89.2%; P < 0.0001) and 90-d (75% versus 83.5% versus 88.2%; P < 0.0001) unadjusted patient survivals were higher in those receiving AZA or mTORi, respectively. Using adjusted multivariable Cox regression, compared with patients receiving AZA, the use of MPA was associated with a higher risk of death within 30 d (adjusted hazard ratio [aHR], 1.70; 95% confidence interval [CI], 1.21-2.40; P = 0.003), which was not observed in patients using mTORi (aHR, 0.78; 95% CI, 0.45-1.35; P = 0.365). At 90 d, although higher risk of death was confirmed in patients receiving MPA (aHR, 1.46; 95% CI, 1.09-1.98; P = 0.013), a reduced risk was observed in patients receiving mTORi (aHR, 0.59; 95% CI, 0.35-0.97; P = 0.04) compared with AZA. CONCLUSIONS This national cohort data suggest that, in KTRs receiving calcineurin inhibitor and diagnosed with COVID-19, the use of MPA was associated with higher risk of death, whereas mTORi use was associated with lower risk of death.
Collapse
|
4
|
Nelson J, Alvey N, Bowman L, Schulte J, Segovia M, McDermott J, Te HS, Kapila N, Levine DJ, Gottlieb RL, Oberholzer J, Campara M. Consensus recommendations for use of maintenance immunosuppression in solid organ transplantation: Endorsed by the American College of Clinical Pharmacy, American Society of Transplantation, and the International Society for Heart and Lung Transplantation. Pharmacotherapy 2022; 42:599-633. [DOI: 10.1002/phar.2716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 03/29/2022] [Accepted: 04/08/2022] [Indexed: 12/17/2022]
Affiliation(s)
- Joelle Nelson
- Department of Pharmacotherapy and Pharmacy Services University Health San Antonio Texas USA
- Pharmacotherapy Education and Research Center University of Texas Health San Antonio San Antonio Texas USA
- Department of Pharmacy, Pharmacotherapy Division, College of Pharmacy The University of Texas at Austin Austin Texas USA
| | - Nicole Alvey
- Department of Pharmacy Rush University Medical Center Chicago Illinois USA
- Science and Pharmacy Roosevelt University College of Health Schaumburg Illinois USA
| | - Lyndsey Bowman
- Department of Pharmacy Tampa General Hospital Tampa Florida USA
| | - Jamie Schulte
- Department of Pharmacy Services Thomas Jefferson University Hospital Philadelphia Pennsylvania USA
| | | | - Jennifer McDermott
- Richard DeVos Heart and Lung Transplant Program, Spectrum Health Grand Rapids Michigan USA
- Department of Medicine, Michigan State University College of Human Medicine Grand Rapids Michigan USA
| | - Helen S. Te
- Liver Transplantation, Center for Liver Diseases, Department of Medicine University of Chicago Medical Center Chicago Illinois USA
| | - Nikhil Kapila
- Department of Transplant Hepatology Duke University Hospital Durham North Carolina USA
| | - Deborah Jo Levine
- Division of Critical Care Medicine, Department of Medicine The University of Texas Health Science Center at San Antonio San Antonio Texas USA
| | - Robert L. Gottlieb
- Baylor University Medical Center and Baylor Scott and White Research Institute Dallas Texas USA
| | - Jose Oberholzer
- Department of Surgery/Division of Transplantation University of Virginia Charlottesville Virginia USA
| | - Maya Campara
- Department of Surgery University of Illinois Chicago Chicago Illinois USA
- Department of Pharmacy Practice University of Illinois Chicago Chicago Illinois USA
| |
Collapse
|
5
|
Chocair PR, Neves PDMDM, Mohrbacher S, Neto MP, Sato VAH, Oliveira ÉS, Barbosa LV, Bales AM, da Silva FP, Cuvello-Neto AL, Duley JA. Case Report: Azathioprine: An Old and Wronged Immunosuppressant. Front Immunol 2022; 13:903012. [PMID: 35757730 PMCID: PMC9226564 DOI: 10.3389/fimmu.2022.903012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 05/12/2022] [Indexed: 12/02/2022] Open
Abstract
Mycophenolate rapidly substituted azathioprine (AZA) in transplant immunosuppression regimens since the 1990s, when early clinical trials indicated better outcomes, although opposite results were also observed. However, none of these trials used the well-established optimization methods for AZA dosing, namely, thiopurine methyltransferase pharmacogenetics combined with monitoring of the thiopurine metabolites 6-thioguanine nucleotides (6-TGN) and 6-methylmercaptopurine (6-MMP). Resistance to optimize AZA therapy remains today in transplant therapy, despite the fact that thiopurine metabolite testing is being used by other medical disciplines with evident improvement in clinical results. In a previous analysis, we found that active 6-TGN metabolites were not detectable in about 30% of kidney transplant patients under continuous use of apparently adequate azathioprine dosage, which demonstrates the need to monitor these metabolites for therapeutic optimization. Two of four case studies presented here exemplifies this fact. On the other hand, some patients have toxic 6-TGN levels with a theoretically appropriate dose, as seen in the other two case studies in this presentation, constituting one more important reason to monitor the AZA dose administered by its metabolites. This analysis is not intended to prove the superiority of one immunosuppressant over another, but to draw attention to a fact: there are thousands of patients around the world receiving an inadequate dose of azathioprine and, therefore, with inappropriate immunosuppression. This report is also intended to draw attention, to clinicians using thiopurines, that allopurinol co-therapy with AZA is a useful therapeutic pathway for those patients who do not adequately form active thioguanine metabolites.
Collapse
Affiliation(s)
- Pedro R Chocair
- Internal Medicine and Nephrology Service, Hospital Alemão Oswaldo Cruz, Sao Paulo, Brazil
| | | | - Sara Mohrbacher
- Internal Medicine and Nephrology Service, Hospital Alemão Oswaldo Cruz, Sao Paulo, Brazil
| | | | - Victor A H Sato
- Internal Medicine and Nephrology Service, Hospital Alemão Oswaldo Cruz, Sao Paulo, Brazil
| | - Érico S Oliveira
- Internal Medicine and Nephrology Service, Hospital Alemão Oswaldo Cruz, Sao Paulo, Brazil
| | - Leonardo V Barbosa
- Internal Medicine and Nephrology Service, Hospital Alemão Oswaldo Cruz, Sao Paulo, Brazil
| | - Alessandra M Bales
- Internal Medicine and Nephrology Service, Hospital Alemão Oswaldo Cruz, Sao Paulo, Brazil
| | | | - Américo L Cuvello-Neto
- Internal Medicine and Nephrology Service, Hospital Alemão Oswaldo Cruz, Sao Paulo, Brazil
| | - John A Duley
- School of Pharmacy, The University of Queensland, Woolloongabba, QLD, Australia
| |
Collapse
|
6
|
Efficacy and Safety of Switching to Azathioprine for Mycophenolate-Induced Diarrhea in Renal Transplant Recipients. Transplant Proc 2021; 53:1951-1956. [PMID: 34274119 DOI: 10.1016/j.transproceed.2021.06.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 06/14/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Diarrhea is a common adverse effect of mycophenolate treatment in renal transplant recipients. In patients with mycophenolate-induced diarrhea, one option is to switch to mycophenolate to azathioprine. In this study, we aimed to define the safety and efficacy of switching from mycophenolate to azathioprine for mycophenolate-related diarrhea in renal transplant recipients. METHODS A total of 177 patients, 59 of whom were switched to azathioprine because of diarrhea and 118 of whom comprised a matched control group without diarrhea and continued mycophenolate treatment participated in this study. We analyzed the effect of switching to azathioprine from mycophenolate on amelioration of diarrhea and graft survival. RESULTS We observed that 89.8% of patients who switched to azathioprine because of diarrhea had improved diarrhea complaints. Patients switched to azathioprine because of diarrhea had lower glomerular filtration rates (P < .001) and higher proteinuria (P < .001) compared with the control group before the switch. Patients switched to azathioprine compared with a subgroup of 59 control patients were matched to patients switched to azathioprine in terms of baseline renal function and proteinuria in addition to demographic parameters had higher 10-year graft loss compared with patients who continued mycophenolate (P = .03). Particularly in patients with a glomerular filtration rate <30 mL/min at the time of conversion, the risk of early graft loss was high. CONCLUSIONS Although switching from mycophenolate to azathioprine was an effective approach to improve diarrhea, this approach is associated with increased risk of graft loss.
Collapse
|
7
|
Ruggenenti P, Cravedi P, Gotti E, Plati A, Marasà M, Sandrini S, Bossini N, Citterio F, Minetti E, Montanaro D, Sabadini E, Tardanico R, Martinetti D, Gaspari F, Villa A, Perna A, Peraro F, Remuzzi G. Mycophenolate mofetil versus azathioprine in kidney transplant recipients on steroid-free, low-dose cyclosporine immunosuppression (ATHENA): A pragmatic randomized trial. PLoS Med 2021; 18:e1003668. [PMID: 34166370 PMCID: PMC8224852 DOI: 10.1371/journal.pmed.1003668] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 05/23/2021] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND We compared protection of mycophenolate mofetil (MMF) and azathioprine (AZA) against acute cellular rejection (ACR) and chronic allograft nephropathy (CAN) in kidney transplant recipients on steroid-free, low-dose cyclosporine (CsA) microemulsion maintenance immunosuppression. METHODS AND FINDINGS ATHENA, a pragmatic, prospective, multicenter trial conducted by 6 Italian transplant centers, compared the outcomes of 233 consenting recipients of a first deceased donor kidney transplant induced with low-dose thymoglobulin and basiliximab and randomized to MMF (750 mg twice/day, n = 119) or AZA (75 to 125 mg/day, n = 114) added-on maintenance low-dose CsA microemulsion and 1-week steroid. In patients without acute clinical or subclinical rejections, CsA dose was progressively halved. Primary endpoint was biopsy-proven CAN. Analysis was by intention to treat. Participants were included between June 2007 and July 2012 and followed up to August 2016. Between-group donor and recipient characteristics, donor/recipient mismatches, and follow-up CsA blood levels were similar. During a median (interquartile range (IQR)) follow-up of 47.7 (44.2 to 48.9) months, 29 of 87 biopsied patients on MMF (33.3%) versus 31 of 88 on AZA (35.2%) developed CAN (hazard ratio (HR) [95% confidence interval (CI)]: 1.147 (0.691 to 1.904, p = 0.595). Twenty and 21 patients on MMF versus 34 and 14 on AZA had clinical [HR (95% CI): 0.58 (0.34 to 1.02); p = 0.057) or biopsy-proven subclinical [HR (95% CI): 1.49 (0.76 to 2.92); p = 0.249] ACR, respectively. Combined events [HR (95% CI): 0.85 (0.56 to 1.29); p = 0.438], patient and graft survival, delayed graft function (DGF), 3-year glomerular filtration rate (GFR) [53.8 (40.6;65.7) versus 49.8 (36.8;62.5) mL/min/1.73 m2, p = 0.50], and adverse events (AEs) were not significantly different between groups. Chronicity scores other than CAN predict long-term graft outcome. Study limitations include small sample size and unblinded design. CONCLUSIONS In this study, we found that in deceased donor kidney transplant recipients on low-dose CsA and no steroids, MMF had no significant benefits over AZA. This finding suggests that AZA, due to its lower costs, could safely replace MMF in combination with minimized immunosuppression. TRIAL REGISTRATION ClinicalTrials.gov NCT00494741; EUDRACT 2006-005604-14.
Collapse
Affiliation(s)
- Piero Ruggenenti
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
- Unit of Nephrology and Dialysis, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Paolo Cravedi
- Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Eliana Gotti
- Unit of Nephrology and Dialysis, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Annarita Plati
- Unit of Nephrology and Dialysis, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Maddalena Marasà
- Unit of Nephrology and Dialysis, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Silvio Sandrini
- Unit of Nephrology, ASST degli Spedali Civili di Brescia, Brescia, Italy
| | - Nicola Bossini
- Unit of Nephrology, ASST degli Spedali Civili di Brescia, Brescia, Italy
| | - Franco Citterio
- Unit of Kidney Transplantation, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Enrico Minetti
- Unit of Nephrology, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Domenico Montanaro
- SOC di Nefrologia, Dialisi e Trapianto Renale della Azienda Ospedaliero Universitaria “S. Maria della Misericordia,” Udine, Italy
| | - Ettore Sabadini
- Unit of Nephrology and Dialysis, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Regina Tardanico
- Unit of Nephrology, ASST degli Spedali Civili di Brescia, Brescia, Italy
| | - Davide Martinetti
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Flavio Gaspari
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Alessandro Villa
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Annalisa Perna
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Francesco Peraro
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
- * E-mail:
| |
Collapse
|
8
|
Melo Bisneto AVD, Oliveira LCD, Silva Fernandes A, Silva LS, Véras JH, Cardoso CG, E Silva CR, de Moraes Filho AV, Carneiro CC, Chen-Chen L. Recombinogenic, genotoxic, and cytotoxic effects of azathioprine using in vivo assays. JOURNAL OF TOXICOLOGY AND ENVIRONMENTAL HEALTH. PART A 2021; 84:261-271. [PMID: 33372579 DOI: 10.1080/15287394.2020.1864692] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Azathioprine (Aza) is a purine antimetabolite immunosuppressant that is widely employed for immunosuppressive therapy in post-transplant recipients or patients with autoimmune diseases. Chronic use of immunosuppressants might produce several side effects, including a high rate of neoplasms in these patients. Considering that genotoxic effects are associated with an increased risk of developing cancer, the aim of this study was to examine the recombinogenic, genotoxic, and cytotoxic effects of Aza using Somatic Mutation and Recombination Test (SMART) in Drosophila melanogaster, as well as comet and micronucleus assays in mouse bone marrow cells. Further, the adverse effects of Aza were determined in mouse hepatic and renal tissues using histopathological analysis. Data demonstrated that Aza induced significant increased genotoxicity in D. melanogaster and mouse bone marrow cells at all concentrations tested. Homologous recombination was the predominant genotoxic event noted for the first time to be initiated by Aza in SMART. In histopathological analysis, Aza did not show any marked toxic activity in mouse hepatic and renal tissues. Therefore, the high rate of neoplasms reported in patients with long-term use of Aza may be attributed, at least partially, to the genotoxic action of this drug.
Collapse
Affiliation(s)
- A V D Melo Bisneto
- Laboratory of Radiobiology and Mutagenesis, Department of Genetics, Institute of Biological Sciences, Campus Samambaia, Federal University of Goiás, Goiânia, Brazil
| | - L C D Oliveira
- Laboratory of Radiobiology and Mutagenesis, Department of Genetics, Institute of Biological Sciences, Campus Samambaia, Federal University of Goiás, Goiânia, Brazil
| | - A Silva Fernandes
- Laboratory of Radiobiology and Mutagenesis, Department of Genetics, Institute of Biological Sciences, Campus Samambaia, Federal University of Goiás, Goiânia, Brazil
| | - L S Silva
- Laboratory of Radiobiology and Mutagenesis, Department of Genetics, Institute of Biological Sciences, Campus Samambaia, Federal University of Goiás, Goiânia, Brazil
| | - J H Véras
- Laboratory of Radiobiology and Mutagenesis, Department of Genetics, Institute of Biological Sciences, Campus Samambaia, Federal University of Goiás, Goiânia, Brazil
| | - C G Cardoso
- Department of Morphology, Institute of Biological Sciences, Campus Samambaia, Federal University of Goiás, Goiânia, Brazil
| | - Carolina R E Silva
- Department of Morphology, Institute of Biological Sciences, Campus Samambaia, Federal University of Goiás, Goiânia, Brazil
| | - A V de Moraes Filho
- Institute of Health Sciences, Alfredo Nasser University, Aparecida de Goiânia, Brazil
| | - C C Carneiro
- Institute of Health Sciences, Universidade Paulista, Campus Flamboyant, Goiânia, Brazil
| | - L Chen-Chen
- Laboratory of Radiobiology and Mutagenesis, Department of Genetics, Institute of Biological Sciences, Campus Samambaia, Federal University of Goiás, Goiânia, Brazil
| |
Collapse
|
9
|
de Paula MI, Bowring MG, Shaffer AA, Garonzik-Wang J, Bessa AB, Felipe CR, Cristelli MP, Massie AB, Medina-Pestana J, Segev DL, Tedesco-Silva H. Decreased incidence of acute rejection without increased incidence of cytomegalovirus (CMV) infection in kidney transplant recipients receiving rabbit anti-thymocyte globulin without CMV prophylaxis - a cohort single-center study. Transpl Int 2021; 34:339-352. [PMID: 33314321 PMCID: PMC8573716 DOI: 10.1111/tri.13800] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 09/28/2020] [Accepted: 12/07/2020] [Indexed: 01/05/2023]
Abstract
Induction therapy with rabbit anti-thymocyte globulin (rATG) in low-risk kidney transplant recipients (KTR) remains controversial, given the associated increased risk of cytomegalovirus (CMV) infection. This natural experiment compared 12-month clinical outcomes in low-risk KTR without CMV prophylaxis (January/3/13-September/16/15) receiving no induction or a single 3 mg/kg dose of rATG. We used logistic regression to characterize delayed graft function (DGF), negative binomial to characterize length of hospital stay (LOS), and Cox regression to characterize acute rejection (AR), CMV infection, graft loss, death, and hospital readmissions. Recipients receiving 3 mg/kg rATG had an 81% lower risk of AR (aHR 0.14 0.190.25 , P < 0.001) but no increased rate of hospital readmissions because of infections (0.68 0.911.21 , P = 0.5). There was no association between 3 mg/kg rATG and CMV infection/disease (aHR 0.86 1.101.40 , P = 0.5), even when the analysis was stratified according to recipient CMV serostatus positive (aHR 0.94 1.251.65 , P = 0.1) and negative (aHR 0.28 0.571.16 , P = 0.1). There was no association between 3 mg/kg rATG and mortality (aHR 0.51 1.253.08 , P = 0.6), and graft loss (aHR 0.34 0.731.55 , P = 0.4). Among low-risk KTR receiving no CMV pharmacological prophylaxis, 3 mg/kg rATG induction was associated with a significant reduction in the incidence of AR without an increased risk of CMV infection, regardless of recipient pretransplant CMV serostatus.
Collapse
Affiliation(s)
- Mayara Ivani de Paula
- Department of Nephrology, Hospital do Rim, Universidade Federal de São Paulo, São Paulo, Brazil
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mary Grace Bowring
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ashton A. Shaffer
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | | | - Adrieli Barros Bessa
- Department of Nephrology, Hospital do Rim, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Claudia Rosso Felipe
- Department of Nephrology, Hospital do Rim, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | - Allan B. Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Jose Medina-Pestana
- Department of Nephrology, Hospital do Rim, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Helio Tedesco-Silva
- Department of Nephrology, Hospital do Rim, Universidade Federal de São Paulo, São Paulo, Brazil
| |
Collapse
|
10
|
Marisiddappa L, Sathish R, Kedlaya P, Nagaraj V, Kruthika DM. Graft and survival outcome in renal transplant patients receiving cyclosporine and azathioprine versus tacrolimus and mycophenolate mofetil: A single-center retrospective observational study. INDIAN JOURNAL OF TRANSPLANTATION 2021. [DOI: 10.4103/ijot.ijot_33_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
11
|
Abstract
Primary Sjögren's syndrome (pSS) is a systemic autoimmune disease with exocrine gland dysfunction and multi-organ involvement. Currently, there is an increasing trend toward non-steroid therapy for the treatment of autoimmune diseases. Some biological agents or immunosuppressive drugs may be the ideal choices. In real-world practice, as patients have severe systemic complications or organ damage, they will have a bad prognosis even if they are treated with high-dose steroids and strong immunosuppressive drugs. However, if we can start early intervention and prevent progressive development in advance, the patient may have a good prognosis. Mycophenolate is an immunosuppressive drug with minor side effects. Here, we conduct a systemic review and find supporting evidence that patients with pSS benefit from early mycophenolate therapy. Mycophenolate may be the first-line treatment for pSS patients in the future.
Collapse
Affiliation(s)
- Weiqian Chen
- Division of Rheumatology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Jin Lin
- Division of Rheumatology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
| |
Collapse
|
12
|
Change in the dynamics of the catalytic action of azathioprine on the electroreduction process of Bi(III) ions under the influence of surfactants in the context of controlled drug release. J Electroanal Chem (Lausanne) 2020. [DOI: 10.1016/j.jelechem.2020.114033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
13
|
Gomes RM, Barbosa WB, Godman B, Costa JDO, Ribeiro Junior NG, Simão Filho C, Cherchiglia ML, Acurcio FDA, Guerra Júnior AA. Effectiveness of Maintenance Immunosuppression Therapies in a Matched-Pair Analysis Cohort of 16 Years of Renal Transplant in the Brazilian National Health System. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E1974. [PMID: 32192172 PMCID: PMC7142921 DOI: 10.3390/ijerph17061974] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 03/09/2020] [Accepted: 03/11/2020] [Indexed: 12/11/2022]
Abstract
The maintenance of patients with renal transplant typically involves two or more drugs to prevent rejection and prolong graft survival. The calcineurin inhibitors (CNI) are the most commonly recommended medicines in combinations with others. While immunosuppressive treatment regimens are well established, there is insufficient long-term effectiveness data to help guide future management decisions. The study analyzes the effectiveness of treatment regimens containing CNI after renal transplantation during 16 years of follow-up with real-world data from the Brazilian National Health System (SUS). This was a retrospective study of 2318 SUS patients after renal transplantion. Patients were propensity score-matched (1:1) by sex, age, type and year of transplantation. Kaplan-Meier analysis was used to estimate the cumulative probabilities of survival. A Cox proportional hazard model was used to evaluate factors associated with progression to graft loss. Multivariable analysis, adjusted for diabetes mellitus and race/color, showed a greater risk of graft loss for patients using tacrolimus plus mycophenolate compared to patients treated with cyclosporine plus azathioprine. In conclusion, this Brazilian real-world study, with a long follow-up period using matched analysis for relevant clinical features and the representativeness of the sample, demonstrated improved long-term effectiveness for therapeutic regimens containing cyclosporine plus azathioprine. Consequently, we recommend that protocols and clinical guidelines for renal transplantation should consider the cyclosporine plus azathioprine regimen as a potential first line option, along with others.
Collapse
Affiliation(s)
- Rosângela Maria Gomes
- Department of Social Pharmacy, College of Pharmacy, Federal University of Minas Gerais, Belo Horizonte 31270-901, Brazil
- SUS Collaborating Centre—Technology Assessment & Excellence in Health, College of Pharmacy, Federal University of Minas Gerais, Belo Horizonte 31270-901, Brazil
- Programa de Pós-graduação em Medicamentos e Assistência Farmacêutica, Departamento de Farmácia Social, Faculdade de Farmácia, Universidade Federal de Minas Gerais—UFMG. Av. Presidente Antônio Carlos, 6627 Campus Pampulha, Belo Horizonte, MG 31270-901 Brazil
| | - Wallace Breno Barbosa
- Department of Social Pharmacy, College of Pharmacy, Federal University of Minas Gerais, Belo Horizonte 31270-901, Brazil
- SUS Collaborating Centre—Technology Assessment & Excellence in Health, College of Pharmacy, Federal University of Minas Gerais, Belo Horizonte 31270-901, Brazil
| | - Brian Godman
- Strathclyde Institute of Pharmacy and Biomedical Sciences, Strathclyde University, Glasgow G4 ORE, UK
- Department of Laboratory Medicine, Division of Clinical Pharmacology, Karolinska Institute, Karolinska University Hospital Huddinge, SE-141 86 Stockholm, Sweden
- Health Economics Centre, Liverpool University Management School, Chatham Street, Liverpool L69 7ZH, UK
- School of Pharmacy, Sefako Makgatho Health Sciences University, Ga-Rankuwa, South Africa
| | - Juliana de Oliveira Costa
- SUS Collaborating Centre—Technology Assessment & Excellence in Health, College of Pharmacy, Federal University of Minas Gerais, Belo Horizonte 31270-901, Brazil
- Department of Preventive and Social Medicine, College of Medicine, Federal University of Minas Gerais, Belo Horizonte 31270-901, Brazil
| | - Nélio Gomes Ribeiro Junior
- SUS Collaborating Centre—Technology Assessment & Excellence in Health, College of Pharmacy, Federal University of Minas Gerais, Belo Horizonte 31270-901, Brazil
| | - Charles Simão Filho
- Department of Surgery, College of Medicine, Federal University of Minas Gerais, Belo Horizonte 31270-901, Brazil
| | - Mariângela Leal Cherchiglia
- Department of Preventive and Social Medicine, College of Medicine, Federal University of Minas Gerais, Belo Horizonte 31270-901, Brazil
| | - Francisco de Assis Acurcio
- Department of Social Pharmacy, College of Pharmacy, Federal University of Minas Gerais, Belo Horizonte 31270-901, Brazil
- SUS Collaborating Centre—Technology Assessment & Excellence in Health, College of Pharmacy, Federal University of Minas Gerais, Belo Horizonte 31270-901, Brazil
| | - Augusto Afonso Guerra Júnior
- Department of Social Pharmacy, College of Pharmacy, Federal University of Minas Gerais, Belo Horizonte 31270-901, Brazil
- SUS Collaborating Centre—Technology Assessment & Excellence in Health, College of Pharmacy, Federal University of Minas Gerais, Belo Horizonte 31270-901, Brazil
| |
Collapse
|
14
|
USTA M, ERSOY A, AYAR Y. Effect of conversion from azathioprine to mycophenolate mofetil on renal function in stable kidney transplant recipients. TURKISH JOURNAL OF INTERNAL MEDICINE 2019. [DOI: 10.46310/tjim.632066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
|
15
|
Impact of Adopting Routine Luminex-Based Pretransplant Assessment of HLA Antibodies on Clinical Practice and Outcomes in Kidney Transplantation. Transplant Proc 2019; 51:2241-2244. [DOI: 10.1016/j.transproceed.2019.01.147] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 01/21/2019] [Indexed: 01/06/2023]
|
16
|
An Y, Zhang H, Liu Z. Individualizing Therapy in Lupus Nephritis. Kidney Int Rep 2019; 4:1366-1372. [PMID: 31701046 PMCID: PMC6829184 DOI: 10.1016/j.ekir.2019.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 08/06/2019] [Accepted: 08/12/2019] [Indexed: 12/14/2022] Open
Abstract
The ideal therapeutic approach for lupus nephritis (LN) is to quickly achieve a complete remission and maintain that response long-term while minimizing drug toxicity, and prevent tissue damage and death. The combination therapy consisting of multiple medications is aimed at incorporating drugs with complementary actions at reduced doses to achieve additive or synergistic therapeutic effects while minimizing toxicity. Here, we review the available evidence using combination therapies (triple therapy) and how such strategies can improve therapeutic efficacy in LN, which will mainly focus on the combination of high-dose corticosteroids with mycophenolate mofetil (MMF) and a calcineurin inhibitor (CNI) at low dose. We discuss the rationale, efficacy, and safety of the therapy, as well as its molecular mechanisms. We also discuss the questions raised from the trials and briefly describe emerging approaches developed on the basis of combination therapy, and these advances that promise to improve on the standard-of-care treatments and toward individual therapy in LN.
Collapse
Affiliation(s)
- Yu An
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Haitao Zhang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Zhihong Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| |
Collapse
|
17
|
Fu J, Wang Z, Lee K, Wei C, Liu Z, Zhang M, Zhou M, Cai M, Zhang W, Chuang PY, Ma'ayan A, He JC, Liu Z. Transcriptomic analysis uncovers novel synergistic mechanisms in combination therapy for lupus nephritis. Kidney Int 2018; 93:416-429. [PMID: 29102373 DOI: 10.1016/j.kint.2017.08.031] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 08/08/2017] [Accepted: 08/17/2017] [Indexed: 02/03/2023]
Abstract
A recent clinical study showed that combination therapy consisting of mycophenolate mofetil, tacrolimus and steroids was shown to be more effective in achieving complete remission in patients with severe forms of lupus nephritis than conventional therapy consisting of intravenous cyclophosphamide and steroids. To explore the underlying molecular and cellular mechanisms of increased efficacy of the combination therapy regimen, we employed a mouse model of lupus nephritis, MRL/lpr mice, and treated them with monotherapies of prednisone, mycophenolate mofetil, or tacrolimus, or with their combination. Consistent with previous clinical findings, combination therapy markedly improved renal outcome compared to the monotherapies in mice with lupus nephritis. Transcriptomic analysis of their kidneys revealed distinct molecular pathways that were differentially regulated in combination therapy versus monotherapies. Combination therapy not only provided additive immunosuppressive effects, but also induced gene expression and molecular pathways to confer enhanced renoprotection. Specifically, combination therapy inhibited TLR7 expression in the kidneys of mice with lupus nephritis; combination of tacrolimus and mycophenolate mofetil led to better stabilization of the podocyte actin cytoskeleton through the reciprocal regulation of RhoA and Rac1 activities. Combination therapy strongly suppressed the IL-6/Stat3 pathway. These findings were further validated in renal biopsy samples from patients with lupus nephritis before and after treatments with mycophenolate mofetil, tacrolimus or combination therapy. Thus, our study further supports the earlier clinical finding and further provides insights into the molecular basis for increased efficacy of combination therapy.
Collapse
Affiliation(s)
- Jia Fu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Zichen Wang
- Department of Pharmacological Sciences, Mount Sinai Center for Bioinformatics, BD2K-LINCS Data Coordination and Integration Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kyung Lee
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Chengguo Wei
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Zhengzhao Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Mingchao Zhang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Minlin Zhou
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Minchao Cai
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Nephrology, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Weijia Zhang
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Peter Y Chuang
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Avi Ma'ayan
- Department of Pharmacological Sciences, Mount Sinai Center for Bioinformatics, BD2K-LINCS Data Coordination and Integration Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - John Cijiang He
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Renal Program, James J Peters VA Medical Center, Bronx, New York, USA.
| | - Zhihong Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China.
| |
Collapse
|
18
|
Jones-Hughes T, Snowsill T, Haasova M, Coelho H, Crathorne L, Cooper C, Mujica-Mota R, Peters J, Varley-Campbell J, Huxley N, Moore J, Allwood M, Lowe J, Hyde C, Hoyle M, Bond M, Anderson R. Immunosuppressive therapy for kidney transplantation in adults: a systematic review and economic model. Health Technol Assess 2018; 20:1-594. [PMID: 27578428 DOI: 10.3310/hta20620] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND End-stage renal disease is a long-term irreversible decline in kidney function requiring renal replacement therapy: kidney transplantation, haemodialysis or peritoneal dialysis. The preferred option is kidney transplantation, followed by immunosuppressive therapy (induction and maintenance therapy) to reduce the risk of kidney rejection and prolong graft survival. OBJECTIVES To review and update the evidence for the clinical effectiveness and cost-effectiveness of basiliximab (BAS) (Simulect(®), Novartis Pharmaceuticals UK Ltd) and rabbit anti-human thymocyte immunoglobulin (rATG) (Thymoglobulin(®), Sanofi) as induction therapy, and immediate-release tacrolimus (TAC) (Adoport(®), Sandoz; Capexion(®), Mylan; Modigraf(®), Astellas Pharma; Perixis(®), Accord Healthcare; Prograf(®), Astellas Pharma; Tacni(®), Teva; Vivadex(®), Dexcel Pharma), prolonged-release tacrolimus (Advagraf(®) Astellas Pharma), belatacept (BEL) (Nulojix(®), Bristol-Myers Squibb), mycophenolate mofetil (MMF) (Arzip(®), Zentiva; CellCept(®), Roche Products; Myfenax(®), Teva), mycophenolate sodium (MPS) (Myfortic(®), Novartis Pharmaceuticals UK Ltd), sirolimus (SRL) (Rapamune(®), Pfizer) and everolimus (EVL) (Certican(®), Novartis) as maintenance therapy in adult renal transplantation. METHODS Clinical effectiveness searches were conducted until 18 November 2014 in MEDLINE (via Ovid), EMBASE (via Ovid), Cochrane Central Register of Controlled Trials (via Wiley Online Library) and Web of Science (via ISI), Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects and Health Technology Assessment (The Cochrane Library via Wiley Online Library) and Health Management Information Consortium (via Ovid). Cost-effectiveness searches were conducted until 18 November 2014 using a costs or economic literature search filter in MEDLINE (via Ovid), EMBASE (via Ovid), NHS Economic Evaluation Database (via Wiley Online Library), Web of Science (via ISI), Health Economic Evaluations Database (via Wiley Online Library) and the American Economic Association's electronic bibliography (via EconLit, EBSCOhost). Included studies were selected according to predefined methods and criteria. A random-effects model was used to analyse clinical effectiveness data (odds ratios for binary data and mean differences for continuous data). Network meta-analyses were undertaken within a Bayesian framework. A new discrete time-state transition economic model (semi-Markov) was developed, with acute rejection, graft function (GRF) and new-onset diabetes mellitus used to extrapolate graft survival. Recipients were assumed to be in one of three health states: functioning graft, graft loss or death. RESULTS Eighty-nine randomised controlled trials (RCTs), of variable quality, were included. For induction therapy, no treatment appeared more effective than another in reducing graft loss or mortality. Compared with placebo/no induction, rATG and BAS appeared more effective in reducing biopsy-proven acute rejection (BPAR) and BAS appeared more effective at improving GRF. For maintenance therapy, no treatment was better for all outcomes and no treatment appeared most effective at reducing graft loss. BEL + MMF appeared more effective than TAC + MMF and SRL + MMF at reducing mortality. MMF + CSA (ciclosporin), TAC + MMF, SRL + TAC, TAC + AZA (azathioprine) and EVL + CSA appeared more effective than CSA + AZA and EVL + MPS at reducing BPAR. SRL + AZA, TAC + AZA, TAC + MMF and BEL + MMF appeared to improve GRF compared with CSA + AZA and MMF + CSA. In the base-case deterministic and probabilistic analyses, BAS, MMF and TAC were predicted to be cost-effective at £20,000 and £30,000 per quality-adjusted life-year (QALY). When comparing all regimens, only BAS + TAC + MMF was cost-effective at £20,000 and £30,000 per QALY. LIMITATIONS For included trials, there was substantial methodological heterogeneity, few trials reported follow-up beyond 1 year, and there were insufficient data to perform subgroup analysis. Treatment discontinuation and switching were not modelled. FUTURE WORK High-quality, better-reported, longer-term RCTs are needed. Ideally, these would be sufficiently powered for subgroup analysis and include health-related quality of life as an outcome. CONCLUSION Only a regimen of BAS induction followed by maintenance with TAC and MMF is likely to be cost-effective at £20,000-30,000 per QALY. STUDY REGISTRATION This study is registered as PROSPERO CRD42014013189. FUNDING The National Institute for Health Research Health Technology Assessment programme.
Collapse
Affiliation(s)
- Tracey Jones-Hughes
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Tristan Snowsill
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Marcela Haasova
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Helen Coelho
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Louise Crathorne
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Chris Cooper
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Ruben Mujica-Mota
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Jaime Peters
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Jo Varley-Campbell
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Nicola Huxley
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Jason Moore
- Exeter Kidney Unit, Royal Devon and Exeter Foundation Trust Hospital, Exeter, UK
| | - Matt Allwood
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Jenny Lowe
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Chris Hyde
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Martin Hoyle
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Mary Bond
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| | - Rob Anderson
- Peninsula Technology Assessment Group (PenTAG), University of Exeter, Exeter, UK
| |
Collapse
|
19
|
Chang VS, Chodosh J, Papaliodis GN. Chronic Ocular Complications of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: The Role of Systemic Immunomodulatory Therapy. Semin Ophthalmol 2016; 31:178-87. [PMID: 26959145 DOI: 10.3109/08820538.2015.1114841] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare, but potentially blinding diseases that affect the skin and mucous membranes. Although the cutaneous manifestations tend to be self-limited and resolve without sequelae, the chronic ocular complications associated with SJS/TEN can persist despite local therapy. Poor understanding of the underlying pathophysiology and lack of a standardized clinical approach have resulted in a paucity of data in regards to suitable treatment options. Inflammatory cellular infiltration and elevated levels of ocular surface cytokines in the conjunctival specimens of affected patients give credence to an underlying immunogenic etiology. Furthermore, the presence of ongoing ocular surface inflammation and progressive conjunctival fibrosis in the absence of exogenous aggravating factors suggest a possible role for systemic immunomodulatory therapy (IMT). We review in detail the proposed immunogenesis underlying chronic ocular SJS/TEN and the possible utility of systemic IMT.
Collapse
Affiliation(s)
- Victoria S Chang
- a Department of Ophthalmology , Harvard Medical School, Massachusetts Eye and Ear Infirmary , Boston , Massachusetts , USA
| | - James Chodosh
- a Department of Ophthalmology , Harvard Medical School, Massachusetts Eye and Ear Infirmary , Boston , Massachusetts , USA
| | - George N Papaliodis
- a Department of Ophthalmology , Harvard Medical School, Massachusetts Eye and Ear Infirmary , Boston , Massachusetts , USA
| |
Collapse
|
20
|
Thierry A, Le Meur Y, Ecotière L, Abou-Ayache R, Etienne I, Laurent C, Vuiblet V, Colosio C, Bouvier N, Aldigier JC, Rerolle JP, Javaugue V, Gand E, Bridoux F, Essig M, Hurault de Ligny B, Touchard G. Minimization of maintenance immunosuppressive therapy after renal transplantation comparing cyclosporine A/azathioprine or cyclosporine A/mycophenolate mofetil bitherapy to cyclosporine A monotherapy: a 10-year postrandomization follow-up study. Transpl Int 2016; 29:23-33. [PMID: 26729582 DOI: 10.1111/tri.12627] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Revised: 04/13/2015] [Accepted: 06/15/2015] [Indexed: 11/28/2022]
Abstract
Long-term outcomes in renal transplant recipients withdrawn from steroid and submitted to further minimization of immunosuppressive regimen after 1 year are lacking. In this multicenter study, 204 low immunological risk kidney transplant recipients were randomized 14.2 ± 3.7 months post-transplantation to receive either cyclosporine A (CsA) + azathioprine (AZA; n = 53), CsA + mycophenolate mofetil (MMF; n = 53), or CsA monotherapy (n = 98). At 3 years postrandomization, the occurrence of biopsy for graft dysfunction was similar in bitherapy and monotherapy groups (21/106 vs. 26/98; P = 0.25). At 10 years postrandomization, patients' survival was 100%, 94.2%, and 95.8% (P = 0.25), and death-censored graft survival was 94.9%, 94.7%, and 95.2% (P = 0.34) in AZA, MMF, and CsA groups, respectively. Mean estimated glomerular filtration rate was 70.4 ± 31.1, 60.1 ± 22.2, and 60.1 ± 19.0 ml/min/1.73 m(2), respectively (P = 0.16). The incidence of biopsy-proven acute rejection was 1.4%/year in the whole cohort. None of the patients developed polyomavirus-associated nephropathy. The main cause of graft loss (n = 12) was chronic antibody-mediated rejection (n = 6). De novo donor-specific antibodies were detected in 13% of AZA-, 21% of MMF-, and 14% of CsA-treated patients (P = 0.29). CsA monotherapy after 1 year is safe and associated with prolonged graft survival in well-selected renal transplant recipient (ClinicalTrials.gov number: 980654).
Collapse
Affiliation(s)
- Antoine Thierry
- Service de Néphrologie-Hémodialyse-Transplantation rénale, CHU de Poitiers, Poitiers, France.,Institut National de la Santé et de la Recherche Médicale U1082, Poitiers, France
| | | | - Laure Ecotière
- Service de Néphrologie-Hémodialyse-Transplantation rénale, CHU de Poitiers, Poitiers, France
| | - Ramzi Abou-Ayache
- Service de Néphrologie-Hémodialyse-Transplantation rénale, CHU de Poitiers, Poitiers, France
| | | | | | | | | | | | | | | | - Vincent Javaugue
- Service de Néphrologie-Hémodialyse-Transplantation rénale, CHU de Poitiers, Poitiers, France
| | - Elise Gand
- Service de Néphrologie-Hémodialyse-Transplantation rénale, CHU de Poitiers, Poitiers, France
| | - Frank Bridoux
- Service de Néphrologie-Hémodialyse-Transplantation rénale, CHU de Poitiers, Poitiers, France
| | - Marie Essig
- Service de Néphrologie, CHRU, Limoges, France
| | | | - Guy Touchard
- Service de Néphrologie-Hémodialyse-Transplantation rénale, CHU de Poitiers, Poitiers, France.,Institut National de la Santé et de la Recherche Médicale U1082, Poitiers, France
| |
Collapse
|
21
|
Haller MC, Royuela A, Nagler EV, Pascual J, Webster AC. Steroid avoidance or withdrawal for kidney transplant recipients. Cochrane Database Syst Rev 2016; 2016:CD005632. [PMID: 27546100 PMCID: PMC8520739 DOI: 10.1002/14651858.cd005632.pub3] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Steroid-sparing strategies have been attempted in recent decades to avoid morbidity from long-term steroid intake among kidney transplant recipients. Previous systematic reviews of steroid withdrawal after kidney transplantation have shown a significant increase in acute rejection. There are various protocols to withdraw steroids after kidney transplantation and their possible benefits or harms are subject to systematic review. This is an update of a review first published in 2009. OBJECTIVES To evaluate the benefits and harms of steroid withdrawal or avoidance for kidney transplant recipients. SEARCH METHODS We searched the Cochrane Kidney and Transplant Specialised Register to 15 February 2016 through contact with the Information Specialist using search terms relevant to this review. SELECTION CRITERIA All randomised and quasi-randomised controlled trials (RCTs) in which steroids were avoided or withdrawn at any time point after kidney transplantation were included. DATA COLLECTION AND ANALYSIS Assessment of risk of bias and data extraction was performed by two authors independently and disagreement resolved by discussion. Statistical analyses were performed using the random-effects model and dichotomous outcomes were reported as relative risk (RR) and continuous outcomes as mean difference (MD) with 95% confidence intervals. MAIN RESULTS We included 48 studies (224 reports) that involved 7803 randomised participants. Of these, three studies were conducted in children (346 participants). The 2009 review included 30 studies (94 reports, 5949 participants). Risk of bias was assessed as low for sequence generation in 19 studies and allocation concealment in 14 studies. Incomplete outcome data were adequately addressed in 22 studies and 37 were free of selective reporting.The 48 included studies evaluated three different comparisons: steroid avoidance or withdrawal compared with steroid maintenance, and steroid avoidance compared with steroid withdrawal. For the adult studies there was no significant difference in patient mortality either in studies comparing steroid withdrawal versus steroid maintenance (10 studies, 1913 participants, death at one year post transplantation: RR 0.68, 95% CI 0.36 to 1.30) or in studies comparing steroid avoidance versus steroid maintenance (10 studies, 1462 participants, death at one year after transplantation: RR 0.96, 95% CI 0.52 to 1.80). Similarly no significant difference in graft loss was found comparing steroid withdrawal versus steroid maintenance (8 studies, 1817 participants, graft loss excluding death with functioning graft at one year after transplantation: RR 1.17, 95% CI 0.72 to 1.92) and comparing steroid avoidance versus steroid maintenance (7 studies, 1211 participants, graft loss excluding death with functioning graft at one year after transplantation: RR 1.09, 95% CI 0.64 to 1.86). The risk of acute rejection significantly increased in patients treated with steroids for less than 14 days after transplantation (7 studies, 835 participants: RR 1.58, 95% CI 1.08 to 2.30) and in patients who were withdrawn from steroids at a later time point after transplantation (10 studies, 1913 participants, RR 1.77, 95% CI 1.20 to 2.61). There was no evidence to suggest a difference in harmful events, such as infection and malignancy, in adult kidney transplant recipients. The effect of steroid withdrawal in children is unclear. AUTHORS' CONCLUSIONS This updated review increases the evidence that steroid avoidance and withdrawal after kidney transplantation significantly increase the risk of acute rejection. There was no evidence to suggest a difference in patient mortality or graft loss up to five year after transplantation, but long-term consequences of steroid avoidance and withdrawal remain unclear until today, because prospective long-term studies have not been conducted.
Collapse
Affiliation(s)
- Maria C Haller
- Medical University ViennaSection for Clinical Biometrics, Center for Medical Statistics, Informatics and Intelligent SystemsSpitalgasse 23ViennaAustriaA‐1090
- Krankenhaus Elisabethinen LinzDepartment for Internal Medicine III, Nephrology & Hypertension Diseases, Transplantation Medicine & RheumatologyFadingerstrasse 1LinzAustria4040
- Ghent University HospitalEuropean Renal Best Practice (ERBP), guidance issuing body of the European Renal Association – European Dialysis and Transplant Association (ERA‐EDTA), Methods Support TeamGhentBelgium
| | - Ana Royuela
- Hospital Ramon y CajalCIBER Epidemiologia y Salud Publica (CIBERESP)Ctra. Colmenar km, 9.1MadridSpain28047
- Instituto de Investigación Puerta de Hierro (IDIPHIM)Clinical Biostatistics UnitC/ Joaquín Rodrigo, 2Edif. Laboratorio. Planta 0.MajadahondaMadridSpain28222
| | - Evi V Nagler
- Ghent University HospitalEuropean Renal Best Practice (ERBP), guidance issuing body of the European Renal Association – European Dialysis and Transplant Association (ERA‐EDTA), Methods Support TeamGhentBelgium
- Ghent University HospitalRenal Division, Department of Internal MedicineDe Pintelaan 185GhentBelgium9000
| | - Julio Pascual
- Hospital del Mar‐IMIMDepartment of NephrologyPasseig Maritim 25‐29BarcelonaSpain08003
| | - Angela C Webster
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
- The University of Sydney at WestmeadCentre for Transplant and Renal Research, Westmead Millennium InstituteWestmeadNSWAustralia2145
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
| | | |
Collapse
|
22
|
Implications of Clinical Mycophenolate Mofetil Dose According to Individual Body Weight in Japanese Renal Transplant Recipients. Transplant Proc 2016; 48:35-41. [PMID: 26915840 DOI: 10.1016/j.transproceed.2015.11.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Revised: 11/05/2015] [Accepted: 11/18/2015] [Indexed: 11/20/2022]
Abstract
BACKGROUND Mycophenolate mofetil (MMF) is generally administered at a fixed dose of 0.5-1.5 g/d without considering individual body weight (BW) in Japanese renal transplant outpatients receiving maintenance therapy. We aimed to investigate the implications of the area under the curve of mycophenolic acid (MPA AUC):MMF dose ratio by individual BW and suggest the index of MMF dose according to individual BW. METHODS Forty-three Japanese patients who received a renal transplant ≥6 months before the study were enrolled. Blood samples were collected at 4 time points: at predose, 20 minutes, 1 hour, and 3 hours after MMF administration. RESULTS The mean ± standard deviation MMF dose, MPA AUC, and BW of all patients were 581 ± 207 mg/d, 36.2 ± 18.7 μg·h/mL, and 56.3 ± 11.1 kg, respectively. Patients with a lower BW tended to have a higher MPA AUC:MMF dose ratio than patients with a higher BW. There was a significant correlation between the MMF dose:BW ratios and MPA AUC (r(2) = 0.330; P < .01). The rate of MPA AUC between 30 and 60 μg·h/mL with the MMF dose:BW ratio of 10-16 mg/kg was 73.7%. CONCLUSION Individual BW seems to affect the MPA AUC:MMF dose ratio; therefore, we need to consider individual BW when deciding on a MMF dose. The MMF dose:BW ratio of 10-16 mg/kg could predict MPA AUC between 30 and 60 μg·h/mL with a probability of approximately 75%. Therefore, it could be a useful index for outpatients, because it is difficult to draw blood frequently from such patients.
Collapse
|
23
|
van Gelder T, Hesselink DA. Mycophenolate revisited. Transpl Int 2016; 28:508-15. [PMID: 25758949 DOI: 10.1111/tri.12554] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 02/03/2015] [Accepted: 03/06/2015] [Indexed: 12/11/2022]
Abstract
The patent of mycophenolate mofetil (MMF) has expired, and for enteric-coated mycophenolate sodium (EC-MPS), this will happen in 2017. In the twenty years these drugs have been used, they have become extremely popular. In this review, the reasons for the popularity of mycophenolate are discussed, including the benefits compared to azathioprine. MMF and EC-MPS are therapeutically equivalent. Although neither is considered to be a narrow therapeutic index drug, this should not lead to careless switching between the innovator drug and generic formulations, or between one generic formulation and another. The pipeline of new immunosuppressive drugs is dry, and it is very likely that we will be using mycophenolate for many more years to come as a first-line immunosuppressive drug in our transplant population. Whether or not the development of donor-specific anti-HLA antibodies is related to drug exposure (mycophenolic acid concentrations) remains to be investigated.
Collapse
Affiliation(s)
- Teun van Gelder
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center, Rotterdam, The Netherlands; Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | | |
Collapse
|
24
|
González F, Valjalo R. Combining cytochrome P-450 3A4 modulators and cyclosporine or everolimus in transplantation is successful. World J Transplant 2015; 5:338-347. [PMID: 26722662 PMCID: PMC4689945 DOI: 10.5500/wjt.v5.i4.338] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 08/10/2015] [Accepted: 09/18/2015] [Indexed: 02/05/2023] Open
Abstract
AIM: To describe the long term follow-up of kidney allograft recipients receiving ketoconazole with calcineurin inhibitors (CNI) alone or combined with everolimus.
METHODS: This is an open-label, prospective observational clinical trial in low immunologic risk patients who, after signing an Institutional Review Board approved consent form, were included in one of two groups. The first one (n = 59) received everolimus (target blood level, 3-8 ng/mL) and the other (n = 114) azathioprine 2 mg/kg per day or mycophenolate mofetyl (MMF) 2 g/d. Both groups also received tapering steroids, the cytochrome P-450 3A4 (CYP3A4) modulator, ketoconazole 50-100 mg/d, and cyclosporine with C0 targets in the everolimus group of 200-250 ng/mL in 1 mo, 100-125 ng/mL in 2 mo, and 50-65 ng/mL thereafter, and in the azathioprine or MMF group of 250-300 ng/mL in 1 mo, 200-250 ng/mL in 2 mo, 180-200 ng/mL until 3-6 mo, and 100-125 ng/mL thereafter. Clinical visits were performed monthly the first year and quarterly thereafter by treating physicians and all data was extracted by the investigators.
RESULTS: The clinical characteristics of these two cohorts were similar. During the follow up (66 + 31 mo), both groups showed comparable clinical courses, but the biopsy proven acute rejection rate during the full follow-up period seemed to be lower in the everolimus group (20% vs 36%; P = 0.04). The everolimus group did not show a higher surgical complication rate than the other group. By the end of the follow-up period, the everolimus group tended to show a higher glomerular filtration rate. Nevertheless, we found no evidence of a consistent negative slope of the temporal allograft function estimated by the modification of the diet in renal disease formula in any of both groups. At 6 years of follow-up, the uncensored and death-censored graft survivals were 91% and 93%, and 91% and 83% in the everolimus plus cyclosporine, and cyclosporine alone groups, respectively. The addition of ketoconazole saved 80% of cyclosporine and 56% of everolimus doses.
CONCLUSION: Combining CYP3A4 modulators with CNI or mammalian target of rapamycin inhibitor, in low immunological risk kidney transplant recipients is feasible, effective, safe and affordable even in the long term.
Collapse
|
25
|
Rogers J, Katari R, Gifford S, Tamburrini R, Edgar L, Voigt MR, Murphy SV, Igel D, Mancone S, Callese T, Colucci N, Mirzazadeh M, Peloso A, Zambon JP, Farney AC, Stratta RJ, Orlando G. Kidney transplantation, bioengineering and regeneration: an originally immunology-based discipline destined to transition towards ad hoc organ manufacturing and repair. Expert Rev Clin Immunol 2015; 12:169-82. [PMID: 26634874 DOI: 10.1586/1744666x.2016.1112268] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Kidney transplantation (KT), as a modality of renal replacement therapy (RRT), has been shown to be both economically and functionally superior to dialysis for the treatment of end-stage renal disease (ESRD). Progress in KT is limited by two major barriers: a) a chronic and burgeoning shortage of transplantable organs and b) the need for chronic immunosuppression following transplantation. Although ground-breaking advances in transplant immunology have improved patient survival and graft durability, a new pathway of innovation is needed in order to overcome current obstacles. Regenerative medicine (RM) holds the potential to shift the paradigm in RRT, through organ bioengineering. Manufactured organs represent a potentially inexhaustible source of transplantable grafts that would bypass the need for immunosuppressive drugs by using autologous cells to repopulate extracellular matrix (ECM) scaffolds. This overview discusses the current status of renal transplantation while reviewing the most promising innovations in RM therapy as applied to RRT.
Collapse
Affiliation(s)
- Jeffrey Rogers
- a Department of Surgery , Wake Forest University , Winston Salem , NC , USA
| | - Ravi Katari
- b Wake Forest University School of Medicine , Winston Salem , NC , USA
| | - Sheyna Gifford
- c Annenberg School for Communication & Journalism , University of Southern California , Los Angeles , CA , USA
| | | | - Lauren Edgar
- b Wake Forest University School of Medicine , Winston Salem , NC , USA
| | - Marcia R Voigt
- b Wake Forest University School of Medicine , Winston Salem , NC , USA
| | - Sean V Murphy
- d Wake Forest Institute for Regenerative Medicine , Winston Salem , NC , USA
| | - Daniel Igel
- b Wake Forest University School of Medicine , Winston Salem , NC , USA
| | - Sara Mancone
- b Wake Forest University School of Medicine , Winston Salem , NC , USA
| | - Tyler Callese
- b Wake Forest University School of Medicine , Winston Salem , NC , USA
| | - Nicola Colucci
- a Department of Surgery , Wake Forest University , Winston Salem , NC , USA
| | - Majid Mirzazadeh
- e Department of Urology , Wake Forest University , Winston Salem , NC , USA
| | - Andrea Peloso
- f Department of General Surgery , University of Pavia , Pavia , Italy
| | - Joao Paulo Zambon
- d Wake Forest Institute for Regenerative Medicine , Winston Salem , NC , USA
| | - Alan C Farney
- a Department of Surgery , Wake Forest University , Winston Salem , NC , USA
| | - Robert J Stratta
- a Department of Surgery , Wake Forest University , Winston Salem , NC , USA
| | - Giuseppe Orlando
- a Department of Surgery , Wake Forest University , Winston Salem , NC , USA
| |
Collapse
|
26
|
Wagner M, Earley AK, Webster AC, Schmid CH, Balk EM, Uhlig K. Mycophenolic acid versus azathioprine as primary immunosuppression for kidney transplant recipients. Cochrane Database Syst Rev 2015; 2015:CD007746. [PMID: 26633102 PMCID: PMC10986644 DOI: 10.1002/14651858.cd007746.pub2] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Modern immunosuppressive regimens after kidney transplantation usually use a combination of two or three agents of different classes to prevent rejection and maintain graft function. Most frequently, calcineurin-inhibitors (CNI) are combined with corticosteroids and a proliferation-inhibitor, either azathioprine (AZA) or mycophenolic acid (MPA). MPA has largely replaced AZA as a first line agent in primary immunosuppression, as MPA is believed to be of stronger immunosuppressive potency than AZA. However, treatment with MPA is more costly, which calls for a comprehensive assessment of the comparative effects of the two drugs. OBJECTIVES This review of randomised controlled trials (RCTs) aimed to look at the benefits and harms of MPA versus AZA in primary immunosuppressive regimens after kidney transplantation. Both agents were compared regarding their efficacy for maintaining graft and patient survival, prevention of acute rejection, maintaining graft function, and their safety, including infections, malignancies and other adverse events. Furthermore, we investigated potential effect modifiers, such as transplantation era and the concomitant immunosuppressive regimen in detail. SEARCH METHODS We searched Cochrane Kidney and Transplant's Specialised Register (to 21 September 2015) through contact with the Trials' Search Co-ordinator using search terms relevant to this review. SELECTION CRITERIA All RCTs about MPA versus AZA in primary immunosuppression after kidney transplantation were included, without restriction on language or publication type. DATA COLLECTION AND ANALYSIS Two authors independently determined study eligibility, assessed risk of bias and extracted data from each study. Statistical analyses were performed using the random-effects model and the results were expressed as risk ratio (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes with 95% confidence intervals (CI). MAIN RESULTS We included 23 studies (94 reports) that involved 3301 participants. All studies tested mycophenolate mofetil (MMF), an MPA, and 22 studies reported at least one outcome relevant for this review. Assessment of methodological quality indicated that important information on factors used to judge susceptibility for bias was infrequently and inconsistently reported.MMF treatment reduced the risk for graft loss including death (RR 0.82, 95% CI 0.67 to 1.0) and for death-censored graft loss (RR 0.78, 95% CI 0.62 to 0.99, P < 0.05). No statistically significant difference for MMF versus AZA treatment was found for all-cause mortality (16 studies, 2987 participants: RR 0.95, 95% CI 0.70 to 1.29). The risk for any acute rejection (22 studies, 3301 participants: RR 0.65, 95% CI 0.57 to 0.73, P < 0.01), biopsy-proven acute rejection (12 studies, 2696 participants: RR 0.59, 95% CI 0.52 to 0.68) and antibody-treated acute rejection (15 studies, 2914 participants: RR 0.48, 95% CI 0.36 to 0.65, P < 0.01) were reduced in MMF treated patients. Meta-regression analyses suggested that the magnitude of risk reduction of acute rejection may be dependent on the control rate (relative risk reduction (RRR) 0.34, 95% CI 0.10 to 1.09, P = 0.08), AZA dose (RRR 1.01, 95% CI 1.00 to 1.01, P = 0.10) and the use of cyclosporin A micro-emulsion (RRR 1.27, 95% CI 0.98 to 1.65, P = 0.07). Pooled analyses failed to show a significant and meaningful difference between MMF and AZA in kidney function measures.Data on malignancies and infections were sparse, except for cytomegalovirus (CMV) infections. The risk for CMV viraemia/syndrome (13 studies, 2880 participants: RR 1.06, 95% CI 0.85 to 1.32) was not statistically significantly different between MMF and AZA treated patients, whereas the likelihood of tissue-invasive CMV disease was greater with MMF therapy (7 studies, 1510 participants: RR 1.70, 95% CI 1.10 to 2.61). Adverse event profiles varied: gastrointestinal symptoms were more likely in MMF treated patients and thrombocytopenia and elevated liver enzymes were more common in AZA treatment. AUTHORS' CONCLUSIONS MMF was superior to AZA for improvement of graft survival and prevention of acute rejection after kidney transplantation. These benefits must be weighed against potential harms such as tissue-invasive CMV disease. However, assessment of the evidence on safety outcomes was limited due to rare events in the observation periods of the studies (e.g. malignancies) and inconsistent reporting and definitions (e.g. infections, adverse events). Thus, balancing benefits and harms of the two drugs remains a major task of the transplant physician to decide which agent the individual patient should be started on.
Collapse
Affiliation(s)
- Martin Wagner
- University Hospital WürzburgDepartment of Medicine I, Division of NephrologyOberdürrbacher Str. 6WürzburgGermany97080
- University of WürzburgInstitute of Clinical Epidemiology and BiometryWürzburgGermany
| | - Amy K Earley
- Tufts Medical CenterInstitute for Clinical Research and Health Policy Studies800 Washington StBostonMAUSA02113
| | - Angela C Webster
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
- The University of Sydney at WestmeadCentre for Transplant and Renal Research, Westmead Millennium InstituteWestmeadNSWAustralia2145
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
| | - Christopher H Schmid
- Brown University School of Public HealthCenter for Evidence‐based MedicineProvidenceRIUSA02912
| | - Ethan M Balk
- Brown University School of Public HealthCenter for Evidence‐based MedicineProvidenceRIUSA02912
| | - Katrin Uhlig
- Tufts University School of MedicineDepartment of Medicine, Division of Nephrology750 Washington StBox 391BostonMAUSA02111
| | | |
Collapse
|
27
|
Chapal M, Foucher Y, Marguerite M, Neau K, Papuchon E, Daguin P, Morélon E, Mourad G, Cassuto E, Ladrière M, Legendre C, Giral M. PREventing Delayed Graft Function by Driving Immunosuppressive InduCtion Treatment (PREDICT-DGF): study protocol for a randomized controlled trial. Trials 2015; 16:282. [PMID: 26099226 PMCID: PMC4477597 DOI: 10.1186/s13063-015-0807-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Accepted: 06/11/2015] [Indexed: 11/17/2022] Open
Abstract
Background In kidney transplantation, the use of Anti-Thymocyte Globulins (ATG) as induction therapy has been described as a possible treatment for reducing the prevalence of Delayed Graft Function (DGF). ATG possesses pharmaceutical proprieties that could help control the lesions caused by ischemia reperfusion injury. However, other studies have questioned this potential protective effect. We hypothesized that the benefits related to ATG for reducing DGF prevalence may be higher and more consistently recognized if only patients with high DGF risk are considered. We recently proposed a scoring system entitled DGFS (Delayed Graft Function Score) for such stratification of kidney transplant recipients according to their risk of DGF. Using the DGFS calculation, we aim to determine whether a short course of ATG can decrease the incidence of DGF in comparison with Basiliximab in kidney transplant recipients with low immunological risk but high DGF risk. Methods We conduct a phase IV, open label, randomized, multicentric and prospective study, to compare ATG in parallel with a control group treated by Basiliximab. The 1:1 randomized allocation of patients between groups is stratified on the clinical center, and on the hypothermic machine-perfusion device. We aimed to include a total of 384 patients to achieve a statistical power at 0.80. The study was initiated at the Nantes University hospital in July 2014, with data collection continuing until April 2018, and publication of the results proposed for 2019. Discussion The main expected benefits of this study are i) the reduction of unjustified ATG over-prescriptions associated with serious adverse events, ii) the reduction of chance losses related to ATG under-prescription, iii) the decrease in the incidence of DGF which was described as a risk factor of graft failure and patient death, and iv) the reduction in hospitalization duration and number of post transplantation dialysis sessions, both being associated with reduced medical costs. In conclusion, the current study is innovative by proposing a more efficient and personalized induction therapy. Trial registration The study was registered in the Clinical Trials Registry (#NCT02056938, February 5, 2014), and in the European Clinical Trials Database (EudraCT #2014-000332-42, January 30, 2014).
Collapse
Affiliation(s)
- Marion Chapal
- ITUN and Inserm U1064, Nantes University, 30 Boulevard Jean Monnet, Nantes, 44035, France.
| | - Yohann Foucher
- ITUN and Inserm U1064, Nantes University, 30 Boulevard Jean Monnet, Nantes, 44035, France. .,SPHERE (EA4275), Nantes University, Nantes, France. .,Délégation à la recherche clinique et à l'innovation, CHU Nantes, Nantes, France.
| | - Monique Marguerite
- Délégation à la recherche clinique et à l'innovation, CHU Nantes, Nantes, France.
| | - Karine Neau
- Délégation à la recherche clinique et à l'innovation, CHU Nantes, Nantes, France.
| | - Emmanuelle Papuchon
- ITUN and Inserm U1064, Nantes University, 30 Boulevard Jean Monnet, Nantes, 44035, France.
| | - Pascal Daguin
- ITUN and Inserm U1064, Nantes University, 30 Boulevard Jean Monnet, Nantes, 44035, France.
| | - Emmanuel Morélon
- Néphrologie, Transplantation et Immunologie Clinique, Hôpital Edouard Herriot, Lyon, France.
| | - Georges Mourad
- Service de Néphrologie, Dialyse et Transplantation, Hôpital Lapeyronie and Université Montpellier I, Montpellier, France.
| | | | - Marc Ladrière
- Service de Transplantation Rénale, CHU Brabois, Nancy, France.
| | - Christophe Legendre
- Service de Transplantation Rénale et de Soins Intensifs, Hôpital Necker, APHP and Universités Paris Descartes et Sorbonne Paris Cité, Paris, France.
| | - Magali Giral
- ITUN and Inserm U1064, Nantes University, 30 Boulevard Jean Monnet, Nantes, 44035, France. .,SPHERE (EA4275), Nantes University, Nantes, France. .,Centre d'Investigation Clinique en Biothérapie, Nantes University Hospital, Nantes, France. .,CENTAURE Fondation, Nantes, France.
| |
Collapse
|
28
|
Basu B, Pandey R, Mahapatra TKS, Mondal N, Schaefer F. WITHDRAWN: Efficacy and Safety of Mycophenolate Mofetil Versus Levamisole in Children and Adolescents With Idiopathic Nephrotic Syndrome: Results of a Randomized Clinical Trial. Am J Kidney Dis 2015:S0272-6386(15)00762-3. [PMID: 26071057 DOI: 10.1053/j.ajkd.2015.04.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 04/28/2015] [Indexed: 11/11/2022]
Abstract
This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.
Collapse
Affiliation(s)
- Biswanath Basu
- Division of Pediatric Nephrology, NRS Medical College & Hospital, Kolkata, India; Department of Pediatrics, NRS Medical College & Hospital, Kolkata, India
| | - Rajendra Pandey
- Department of Nephrology, Institute of Post Graduate Medical Education & Research, Kolkata, India
| | - T K S Mahapatra
- Department of Pediatrics, NRS Medical College & Hospital, Kolkata, India
| | - Nirmal Mondal
- Department of Community Medicine & Statistics, NRS Medical College & Hospital, Kolkata, India
| | - Franz Schaefer
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
| |
Collapse
|
29
|
Remuzzi G. West Meets East. KIDNEY DISEASES (BASEL, SWITZERLAND) 2015; 1:4-7. [PMID: 27536660 PMCID: PMC4934798 DOI: 10.1159/000382038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 04/05/2015] [Indexed: 11/19/2022]
Affiliation(s)
- Giuseppe Remuzzi
- IRCCS - Mario Negri Institute for Pharmacological Research, and Department of Medicine, Azienda Ospedaliera, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| |
Collapse
|
30
|
Fisher JD, Acharya AP, Little SR. Micro and nanoparticle drug delivery systems for preventing allotransplant rejection. Clin Immunol 2015; 160:24-35. [PMID: 25937032 DOI: 10.1016/j.clim.2015.04.013] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 04/21/2015] [Accepted: 04/23/2015] [Indexed: 12/20/2022]
Abstract
Despite decades of advances in transplant immunology, tissue damage caused by acute allograft rejection remains the primary cause of morbidity and mortality in the transplant recipient. Moreover, the long-term sequelae of lifelong immunosuppression leaves patients at risk for developing a host of other deleterious conditions. Controlled drug delivery using micro- and nanoparticles (MNPs) is an effective way to deliver higher local doses of a given drug to specific tissues and cells while mitigating systemic effects. Herein, we review several descriptions of MNP immunotherapies aimed at prolonging allograft survival. We also discuss developments in the field of biomimetic drug delivery that use MNP constructs to induce and recruit our bodies' own suppressive immune cells. Finally, we comment on the regulatory pathway associated with these drug delivery systems. Collectively, it is our hope the studies described in this review will help to usher in a new era of immunotherapy in organ transplantation.
Collapse
Affiliation(s)
- James D Fisher
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA; School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; The Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA; The McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Abhinav P Acharya
- The McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Chemical and Petroleum Engineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Steven R Little
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA; The McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Chemical and Petroleum Engineering, University of Pittsburgh, Pittsburgh, PA, USA; Department of Immunology, University of Pittsburgh, Pittsburgh, PA, USA.
| |
Collapse
|
31
|
Gentile G, Somma C, Gennarini A, Mastroluca D, Rota G, Lacanna F, Locatelli B, Remuzzi G, Ruggenenti P. Low-dose RATG with or without basiliximab in renal transplantation: a matched-cohort observational study. Am J Nephrol 2015; 41:16-27. [PMID: 25612603 DOI: 10.1159/000371728] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 12/18/2014] [Indexed: 01/11/2023]
Abstract
BACKGROUND/AIMS In renal transplantation, peri-operative low-dose rabbit-antithymocyte-globulin (RATG) plus basiliximab induction prevented acute allograft rejection more effectively than post-operative RATG plus basiliximab induction. We investigated the specific antirejection contribution of basiliximab in this context. METHODS This single-center, observational, matched-cohort study evaluated allograft rejections (primary outcome), steroid exposure and side effects, GFR (iohexol plasma clearance) and treatment costs in 16 deceased-donor renal transplant recipients induced with RATG (0.5 mg/kg/day) and 32 age-, gender- and treatment-matched reference-patients given RATG plus basiliximab (20 mg on days 0 and 4). RESULTS Induction was well tolerated. At 18 months, 8 patients (50%) vs. 3 reference-patients (9.4%) rejected the graft [HR (95% CI): 6.53 (1.73-24.70), p = 0.006]. Difference was significant (p < 0.01) even after adjusting for recipient/donor age and gender, cold ischemia time and HLA mismatches. There were 1 antibody-mediated rejection and 2 moderate cellular rejections in patients vs. none in reference-patients (p = 0.032). The median (interquartile range) prednisone cumulative dose was remarkably higher in patients than reference-patients [4.78 (1.12-6.10) vs. 0.19 (0.18-3.81) grams, p = 0.002]. Three patients vs. 24 reference-patients were off-steroid at study end (p < 0.001). Three patients vs. no reference-patient developed new-onset diabetes (p = 0.003). Both inductions similarly depleted B-cells. Outcomes of AZA- vs. MMF-treated participants were similar. GFR was similar in all groups. Compared to MMF, AZA therapy saved ≈ EUR 2,500/year and by month 14.3 post-transplant compensated basiliximab costs. CONCLUSION In renal transplantation, basiliximab plus peri-operative low-dose RATG more efficiently prevented allograft rejection than RATG monotherapy, and minimized steroid exposure and toxicity. AZA- vs MMF-based maintenance immunosuppression largely compensated the extra costs of basiliximab.
Collapse
Affiliation(s)
- Giorgio Gentile
- IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Clinical Research Center for Rare Diseases 'Aldo e Cele Daccò', Bergamo, Italy
| | | | | | | | | | | | | | | | | |
Collapse
|
32
|
Abstract
Diarrhea is a frequent but overlooked complication of kidney transplantation. Diarrhea is repeatedly neglected, often considered by patients and clinicians an unavoidable side effect of immunosuppressive regimens. It is, however, associated with a significant impairment in life quality. Severe and chronic posttransplant diarrhea may lead to dehydration, malabsorption, rehospitalization, immunosuppression, noncompliance, and a greater risk of graft loss and death. There is thus a need to optimize and standardize the management of posttransplant diarrhea with consistent diagnostic and therapeutic strategies. A recent study has suggested that the increased sensitivity of molecular tools might help in early pathogen identification and guidance of antimicrobial treatment. Most bacterial and protozoan infections are readily curable with appropriate antimicrobial agents; cryptosporidiosis and C. difficile infections may however be complicated by relapsing courses. In addition, identification of enteric viral genomes in stool has further reduced posttransplant diarrhea of unknown origin. Chronic norovirus-related posttransplant diarrhea, arising from the interplay of the virus and immunosuppressive drugs, has emerged as a new challenge in the field. Prospective and controlled studies are necessary to evaluate the efficacy and safety of innovative anti-norovirus therapeutics, as well as optimal immunosuppressive regimens, to enable viral clearance while preventing rejection and donor-specific antibody formation. This review seeks to provide a basis for the design of future clinical prospective studies.
Collapse
|
33
|
Rutkowski B, Bzoma B, Dębska-Ślizień A, Chamienia A. Generic formulation of mycophenolate mofetil (Myfenax) in de novo renal transplant recipients: results of 12-month observation. Transplant Proc 2014; 46:2683-8. [PMID: 25380894 DOI: 10.1016/j.transproceed.2014.09.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND The aim of this study was to show the preliminary outcomes of transplantation in patients treated with the generic formulation of mycophenolate mofetil (Myfenax, Teva). MATERIALS AND METHODS Over the past 4 years, 60 patients received generic mycophenolate mofetil (Myfenax) after renal transplantation at the Gdansk Transplantology Center. During the same time period, another 273 kidney transplantations were performed in our department, and these patients were treated with other formulations of mycophenolate (CellCept [Roche], Myfortic, or mycophenolate mofetil-Apotex) as a part of the immunosuppressive plan. Thirty of the Myfenax patients received a pair of kidneys from the same donor and received original mycophenolate mofetil CellCept with observation for at least 12 months. RESULTS The outcomes of the renal transplantations in both groups (Myfenax vs pair) were good, with satisfactory function of grafts. One case of graft loss was reported in the Myfenax group (renal vein thrombosis, graftectomy 5 days after transplantation). There was no difference in the incidence of acute renal graft rejection in either group. Moderate adverse reactions to immunosuppression were observed in both groups. On the other hand, a comparison between the 60 patients with Myfenax and the 273 other patients with other formulations of mycophenolate revealed no differences in the incidence of acute renal graft rejection, delayed graft function, graft loss, and death. CONCLUSIONS There were no differences in the incidence of acute renal graft rejection, delayed graft function, graft loss, and death in patients with Myfenax vs original CellCept and other formulations of mycophenolate. To confirm its complete biological and pharmacokinetic equivalence with the reference medicine, long-term, randomized observations carried out on larger renal transplant patients groups are needed.
Collapse
Affiliation(s)
- B Rutkowski
- Department of Nephrology, Transplantology, and Internal Medicine, Medical University of Gdańsk, Gdańsk, Poland.
| | - B Bzoma
- Department of Nephrology, Transplantology, and Internal Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - A Dębska-Ślizień
- Department of Nephrology, Transplantology, and Internal Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - A Chamienia
- Department of Nephrology, Transplantology, and Internal Medicine, Medical University of Gdańsk, Gdańsk, Poland
| |
Collapse
|
34
|
Garattini S, Perico N. Drug development: how academia, industry and authorities interact. Nat Rev Nephrol 2014; 10:602-10. [PMID: 25092151 DOI: 10.1038/nrneph.2014.133] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Unfortunately, abundant examples could be given of pitfalls in the current drug development paradigm-including in the design, conduct and evaluation of phase III clinical trials. This article discusses issues of particular relevance to clinical trials in nephrology, including the inappropriate use of placebo, publication of reports that emphasize potential treatment benefits over adverse reactions, the sometimes dubious impartiality of independent guidelines, and inadequate recruitment of elderly patients. This Perspectives article aims to highlight and summarize the flaws in the current drug development process, while suggesting a way forward that equally satisfies the requirements of academia, patients and the pharmaceutical industry. We suggest improvements to the drug development process and related legislation that intend to balance public needs with commercial aims and ensure effective drug evaluation by regulatory authorities.
Collapse
Affiliation(s)
- Silvio Garattini
- IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico) Istituto di Ricerche Farmacologiche "Mario Negri", via Giuseppe La Masa 19, 20156 Milan, Italy
| | - Norberto Perico
- IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico) Istituto di Ricerche Farmacologiche "Mario Negri", via Giuseppe La Masa 19, 20156 Milan, Italy
| |
Collapse
|
35
|
Mihovilović K, Maksimović B, Kocman B, Guštin D, Vidas Ž, Bulimbašić S, Ljubanović DG, Matovinović MS, Knotek M. Effect of mycophenolate mofetil on progression of interstitial fibrosis and tubular atrophy after kidney transplantation: a retrospective study. BMJ Open 2014; 4:e005005. [PMID: 24993756 PMCID: PMC4091392 DOI: 10.1136/bmjopen-2014-005005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES Chronic transplant dysfunction after kidney transplantation is a major reason of kidney graft loss and is caused by immunological and non-immunological factors. There is evidence that mycophenolate mofetil (MMF) may exert a positive effect on renal damage in addition to immunosuppression, by its direct antifibrotic properties. The aim of our study was to retrospectively investigate the role of MMF doses on progression of chronic allograft dysfunction and fibrosis and tubular atrophy (IF/TA). SETTING Retrospective, cohort study. PARTICIPANTS Patients with kidney transplant in a tertiary care institution. This is a retrospective cohort study that included 79 patients with kidney and kidney-pancreas transplantation. Immunosuppression consisted of anti-interleukin 2 antibody induction, MMF, a calcineurin inhibitor±steroids. PRIMARY OUTCOME MEASURES An association of average MMF doses over 1 year post-transplant with progression of interstitial fibrosis (Δci), tubular atrophy (Δct) and estimated-creatinine clearance (eCrcl) at 1 year post-transplant was evaluated using univariate and multivariate analyses. RESULTS A higher average MMF dose was significantly independently associated with better eCrcl at 1 year post-transplant (b=0.21±0.1, p=0.04). In multiple regression analysis lower Δci (b=-0.2±0.09, p=0.05) and Δct (b=-0.29±0.1, p=0.02) were independently associated with a greater average MMF dose. There was no correlation between average MMF doses and incidence of acute rejection (p=0.68). CONCLUSIONS A higher average MMF dose over 1 year is associated with better renal function and slower progression of IF/TA, at least partly independent of its immunosuppressive effects.
Collapse
Affiliation(s)
- Karlo Mihovilović
- Renal Division, Department of Medicine, Clinical Hospital Merkur, Zagreb, Croatia
| | - Bojana Maksimović
- Renal Division, Department of Medicine, Clinical Hospital Merkur, Zagreb, Croatia
| | - Branislav Kocman
- Department of Surgery, Clinical Hospital Merkur, Zagreb, Croatia
| | - Denis Guštin
- Department of Anaesthesiology, Clinical Hospital Merkur, Zagreb, Croatia
| | - Željko Vidas
- Department of Urology, Clinical Hospital Merkur, Zagreb, Croatia
| | - Stela Bulimbašić
- Department of Pathology, Clinical Hospital Dubrava, Zagreb, Croatia
| | - Danica Galešić Ljubanović
- Department of Pathology, Clinical Hospital Dubrava, Zagreb, Croatia
- University of Zagreb School of Medicine, Zagreb, Croatia
| | | | - Mladen Knotek
- Renal Division, Department of Medicine, Clinical Hospital Merkur, Zagreb, Croatia
- University of Zagreb School of Medicine, Zagreb, Croatia
| |
Collapse
|
36
|
Murray B, Hawes E, Lee RA, Watson R, Roederer MW. Genes and beans: pharmacogenomics of renal transplant. Pharmacogenomics 2014; 14:783-98. [PMID: 23651025 DOI: 10.2217/pgs.13.68] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Advances in the management of patients after solid organ transplantation have led to dramatic decreases in rates of acute rejection, but long-term graft and patient survival have remained unchanged. Individualized therapy after transplant will ideally provide adequate immunosuppression while limiting the adverse effects of drug therapy that significantly impact graft survival. Therapeutic drug monitoring represents the best approximation of individualized drug therapy in transplant at this time; however, obtaining pharmacogenomic data in transplant patients has the potential to enhance our current practice. Polymorphisms of target genes that impact pharmacokinetics have been identified for most immunosuppressants, including tacrolimus, cyclosporine, mycophenolate, azathioprine and sirolimus. In the future, pre-emptive assessment of a patient's genetic profile may inform drug selection and provide information on specific doses that will improve efficacy and limit toxicity.
Collapse
Affiliation(s)
- Brian Murray
- Critical Care Clinical Specialist, UNC Hospitals & Clinics, 101 Manning Drive, CB #7600, Chapel Hill, NC 27599-7600, USA.
| | | | | | | | | |
Collapse
|
37
|
Chang C. Unmet needs in the treatment of autoimmunity: from aspirin to stem cells. Autoimmun Rev 2014; 13:331-46. [PMID: 24462645 DOI: 10.1016/j.autrev.2014.01.052] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2013] [Indexed: 12/26/2022]
Abstract
As rheumatologic diseases became understood to be autoimmune in nature, the drugs used to treat this group of conditions has evolved from herbal or plant derived anti-inflammatory agents, such as salicylates, quinine and colchicine to the many recently approved biological response modifiers. These new drugs, especially the anti-tumor necrosis factor agents, have shown remarkable efficacy in autoimmune diseases, and there are new agents under investigation that will provide additional treatment options. In between, the world was introduced to cortisone and all of its derivatives, as chemical synthesis led to better, more efficacious drugs with lesser side effects. Disease modifying anti-rheumatic agents have actually been around since the first half of the 20th century, but only began to be used in the treatment of autoimmune diseases in the 1970s and 1980s. One advantage is that they have been invaluable in their ability to offer "steroid sparing" to decrease the adverse effects of steroids. Research over the past decade has resulted in a new class of drugs that influence cytokine regulatory pathways such as the Janus associated kinase inhibitors. The promise of personalized medicine now permeates current research into new pharmacological agents for the treatment of autoimmune disease. The new appreciation for the gene-environment interaction in the pathogenesis of most diseases especially those as heterogeneous as autoimmune diseases, has led to our focus on targeted therapies. Add to that the new knowledge of epigenetics and how changes in DNA and histone structure affect expression of genes that can play a role in immune signaling, and we now have a new exciting frontier for cutting edge drug development. The history of treatment of autoimmune diseases is really only a little over a century, but so much has changed, leading to increasing lifespans and improved quality of life of those who suffer from these ailments.
Collapse
Affiliation(s)
- Christopher Chang
- Division of Allergy and Immunology, Thomas Jefferson University, Nemours/A.I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE 19803, USA.
| |
Collapse
|
38
|
Maripuri S, Kasiske BL. The role of mycophenolate mofetil in kidney transplantation revisited. Transplant Rev (Orlando) 2013; 28:26-31. [PMID: 24321304 DOI: 10.1016/j.trre.2013.10.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Accepted: 10/21/2013] [Indexed: 01/20/2023]
Abstract
Since its regulatory approval in 1995, mycophenolate mofetil (MMF) has largely replaced azathioprine (AZA) as the anti-metabolite immunosuppressive of choice in kidney transplantation. While the initial industry-sponsored clinical trials suggested strong reductions in the incidence of acute rejection in the first six months post transplantation, long-term follow-up studies have failed to demonstrate a similar degree of benefit in overall graft and patient survival. In addition, several subsequent studies have raised questions on the potential attenuating effects of calcineurin inhibitor choice on MMF efficacy when compared to AZA. This review will revisit the question of whether the available evidence continues to support the superiority of MMF over AZA in kidney transplantation outcomes while comprehensively reviewing the available evidence from clinical trial data, systematic reviews, and registry studies.
Collapse
Affiliation(s)
- Saugar Maripuri
- Division of Nephrology, Department of Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | | |
Collapse
|
39
|
Abstract
The first successful kidney transplantation between monozygotic identical twins did not require any immunosuppressive drugs. Clinical application of azathioprine and glucocorticosteroids allowed the transfer of organs between genetically disparate donors and recipients. Transplantation is now the standard of care, a life-saving procedure for patients with failed organs. Progress in our understanding of the immunobiology of rejection has been translated to the development of immunosuppressive agents targeting T cells, B cells, plasma cells, costimulatory signals, complement products, and antidonor antibodies. Modern immunopharmacologic interventions have contributed to the clinical success observed following transplantation but challenges remain in personalizing immunosuppressive therapy.
Collapse
Affiliation(s)
- Choli Hartono
- Division of Nephrology and Hypertension, Departments of Medicine and Transplantation Medicine, New York Presbyterian Hospital-Weill Cornell Medical College, New York, New York 10065
| | | | | |
Collapse
|
40
|
Cristelli M, Tedesco-Silva H, Medina-Pestana J, Franco M. Safety profile comparing azathioprine and mycophenolate in kidney transplant recipients receiving tacrolimus and corticosteroids. Transpl Infect Dis 2013; 15:369-78. [DOI: 10.1111/tid.12095] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Revised: 08/16/2012] [Accepted: 01/08/2013] [Indexed: 11/26/2022]
Affiliation(s)
- M.P. Cristelli
- Transplant Division; Hospital do Rim e Hipertensão; UNIFESP; São Paulo; SP; Brazil
| | - H. Tedesco-Silva
- Transplant Division; Hospital do Rim e Hipertensão; UNIFESP; São Paulo; SP; Brazil
| | - J.O. Medina-Pestana
- Transplant Division; Hospital do Rim e Hipertensão; UNIFESP; São Paulo; SP; Brazil
| | - M.F. Franco
- Transplant Division; Hospital do Rim e Hipertensão; UNIFESP; São Paulo; SP; Brazil
| |
Collapse
|
41
|
Kwon O, Cho JH, Choi JY, Park SH, Kim YL, Kim HK, Huh S, Kim CD. Long-term Outcome of Azathioprine Versus Mycophenolate Mofetil in Cyclosporine-Based Immunosuppression in Kidney Transplantation: 10 Years of Experience at a Single Center. Transplant Proc 2013; 45:1487-90. [DOI: 10.1016/j.transproceed.2013.02.046] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Revised: 01/30/2013] [Accepted: 02/06/2013] [Indexed: 10/26/2022]
|
42
|
Lee RA, Gabardi S. Current trends in immunosuppressive therapies for renal transplant recipients. Am J Health Syst Pharm 2013; 69:1961-75. [PMID: 23135563 DOI: 10.2146/ajhp110624] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
PURPOSE Current trends in immunosuppressive therapies for renal transplant recipients are reviewed. SUMMARY The common premise for immunosuppressive therapies in renal transplantation is to use multiple agents to work on different immunologic targets. The use of a multidrug regimen allows for pharmacologic activity at several key steps in the T-cell replication process and lower dosages of each individual agent, thereby producing fewer drug-related toxicities. In general, there are three stages of clinical immunosuppression: induction therapy, maintenance therapy, and treatment of an established acute rejection episode. Only immunosuppressive therapies used for maintenance therapy are discussed in detail in this review. The most common maintenance immunosuppressive agents can be divided into five classes: (1) the calcineurin inhibitors (CNIs) (cyclosporine and tacrolimus), (2) costimulation blockers (belatacept), (3) mammalian target of rapamycin inhibitors (sirolimus and everolimus), (4) antiproliferatives (azathioprine and mycophenolic acid derivatives), and (5) corticosteroids. Immunosuppressive regimens vary among transplantation centers but most often include a CNI and an adjuvant agent, with or without corticosteroids. Selection of appropriate immunosuppressive regimens should be patient specific, taking into account the medications' pharmacologic properties, adverse-event profile, and potential drug-drug interactions, as well as the patient's preexisting diseases, risk of rejection, and medication regimen. CONCLUSION Advancements in transplant immunosuppression have resulted in a significant reduction in acute cellular rejection and a modest increase in long-term patient and graft survival. Because the optimal immunosuppression regimen is still unknown, immunosuppressant use should be influenced by institutional preference and tailored to the immunologic risk of the patient and adverse-effect profile of the drug.
Collapse
Affiliation(s)
- Ruth-Ann Lee
- Department of Pharmacy, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC 27599-7574, USA.
| | | |
Collapse
|
43
|
Banerjee B, Musk M, Sutanto EN, Yerkovich ST, Hopkins P, Knight DA, Lindsey-Temple S, Stick SM, Kicic A, Chambers DC. Regional differences in susceptibiity of bronchial epithelium to mesenchymal transition and inhibition by the macrolide antibiotic azithromycin. PLoS One 2012; 7:e52309. [PMID: 23284981 PMCID: PMC3528745 DOI: 10.1371/journal.pone.0052309] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2012] [Accepted: 11/16/2012] [Indexed: 12/11/2022] Open
Abstract
Objective Dysregulated repair following epithelial injury is a key forerunner of disease in many organs, and the acquisition of a mesenchymal phenotype by the injured epithelial cells (epithelial to mesenchymal transition, EMT) may serve as a source of fibrosis. The macrolide antibiotic azithromycin and the DNA synthesis inhibitor mycophenolate are in clinical use but their mechanism of action remains unknown in post-transplant bronchiolitis obliterans syndrome (BOS). Here we determined if regional variation in the EMT response to TGFβ1 underlies the bronchiolocentric fibrosis leading to BOS and whether EMT could be inhibited by azithromycin or mycophenolate. Methods/Results We found that small and large airway epithelial cells from stable lung transplant patients underwent EMT when stimulated with TGFβ1, however mesenchymal protein expression was higher and loss of epithelial protein expression more complete in small airway epithelial cells. This regional difference was not mediated by changes in expression of the TGFβRII or Smad3 activation. Azithromycin potentially inhibited EMT in both small and large airway epithelial cells by inhibiting Smad3 expression, but not activation. Conclusion Collectively, these observations provide a biologic basis for a previously unexplained but widely observed clinical phenomena, and a platform for the development of new approaches to fibrotic diseases.
Collapse
Affiliation(s)
- Balarka Banerjee
- School of Paediatrics and Child Health, the University of Western Australia, Nedlands, Western Australia, Australia
- School of Medicine and Pharmacology, the University of Western Australia, Nedlands, Western Australia, Australia
- Western Australia Lung Transplant Program, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Michael Musk
- Western Australia Lung Transplant Program, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Erika N. Sutanto
- Telethon Institute for Child Health Research, Centre for Child Health Research, the University of Western Australia, Subiaco, Western Australia, Australia
| | | | - Peter Hopkins
- School of Medicine, The University of Queensland, Herston, Queensland, Australia
| | - Darryl A. Knight
- University of British Columbia, James Hogg Research Centre for Cardiovascular and Pulmonary Research, Vancouver, British Columbia, Canada
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Suzanna Lindsey-Temple
- Centre for Asthma and Allergy Research Institute (CAARR) The Lung Institute of Western Australia, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Stephen M. Stick
- School of Paediatrics and Child Health, the University of Western Australia, Nedlands, Western Australia, Australia
- Department of Respiratory Medicine, Princess Margaret Hospital for Children, Perth, Western Australia, Australia
- Telethon Institute for Child Health Research, Centre for Child Health Research, the University of Western Australia, Subiaco, Western Australia, Australia
| | - Anthony Kicic
- School of Paediatrics and Child Health, the University of Western Australia, Nedlands, Western Australia, Australia
- Department of Respiratory Medicine, Princess Margaret Hospital for Children, Perth, Western Australia, Australia
- Telethon Institute for Child Health Research, Centre for Child Health Research, the University of Western Australia, Subiaco, Western Australia, Australia
| | - Daniel C. Chambers
- School of Medicine, The University of Queensland, Herston, Queensland, Australia
- Queensland Lung Transplant Service, The Prince Charles Hospital, Brisbane, Queensland, Australia
- * E-mail:
| |
Collapse
|
44
|
Honarbakhsh N, Rouini MR, Lesan-Pezeshki M, Javadi MR, Karimzadeh I, Mohebbi N, Gholami K. Mycophenolic Acid pharmacokinetics early after kidney transplant. EXP CLIN TRANSPLANT 2012; 11:112-7. [PMID: 23176542 DOI: 10.6002/ect.2012.0094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES To determine the mycophenolic acid pharmacokinetic profile early after transplant in Iranian kidney graft recipients. MATERIALS AND METHODS A cross-sectional study was performed during 6 months in 31 patients who recently had kidney transplant and received fixed doses of mycophenolate mofetil (2 g/d). The plasma levels of mycophenolic acid were determined by high performance liquid chromatography. RESULTS The mean first mycophenolic acid peak level was 10 ± 5 mg/L. The mean mycophenolic acid area under the curve was 26 ± 19 mgh/L and apparent clearance was 57 ± 55 L/h. The mycophenolic acid area under the curve values of only 8 patients (26%) were within the therapeutic range (30-60 mgh/L). The first, second, and third mycophenolic acid peak levels correlated significantly with mycophenolic acid area under the curve (P < .05). Mycophenolic acid concentration at 10 hours had the highest correlation with mycophenolic acid area under the curve (r=0.962; P < .05). No statistically significant differences were evident in the mean mycophenolic acid area under the curve between men and women. CONCLUSIONS There was a high degree of variation between different patients in mycophenolic acid pharmacokinetics early after kidney transplant.
Collapse
Affiliation(s)
- Nazanin Honarbakhsh
- Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, Tehran, Iran
| | | | | | | | | | | | | |
Collapse
|
45
|
Obi Y, Ichimaru N, Kato T, Kaimori JY, Okumi M, Yazawa K, Rakugi H, Nonomura N, Isaka Y, Takahara S. A single daily dose enhances the adherence to immunosuppressive treatment in kidney transplant recipients: a cross-sectional study. Clin Exp Nephrol 2012; 17:310-5. [PMID: 23089939 DOI: 10.1007/s10157-012-0713-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Accepted: 10/02/2012] [Indexed: 01/13/2023]
Abstract
BACKGROUND Nonadherence to treatment regimens for immunosuppressive agents is one of the major risk factors for allograft failure in kidney transplant recipients. The aim of this study was to estimate the relative effect of daily dosing on treatment adherence, not to identify how patients are non-adherent, in long-term kidney transplant recipients. METHODS In January 2009, a cross-sectional, anonymous, and voluntary questionnaire survey was given to kidney transplant recipients who regularly visited Inoue Hospital. A self-reporting questionnaire underestimates nonadherence, but we reasoned that the effect of the dosing regimen should be estimated with relative accuracy by using the generalized ordered logit/partial proportional hazard odds model given that the distribution patterns in the degree of nonadherence have been shown to be similar with other measures. RESULTS Of 336 eligible patients, 312 (92.9 %) participated in this study. Two hundred seventy-four patients (87.8 %) were more than 3 years post-transplant. Univariate analysis revealed that a single daily dose was significantly associated with better adherence. After controlling for age, sex, time since transplantation, and the number of prescribed drugs, the effect of a single daily dose still remained significant [odds ratio, 0.40 (95 % confidence interval, 0.19-0.81); p = 0.011]. Several sensitivity analyses yielded similar results. CONCLUSIONS To our knowledge, this is the first report that, in long-term kidney transplant recipients, a single daily regimen-one of few modifiable factors-might improve treatment adherence and allograft survival.
Collapse
Affiliation(s)
- Yoshitsugu Obi
- Department of Geriatric Medicine and Nephrology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | | | | | | | | | | | | | | | | | | |
Collapse
|
46
|
Ladrière M. [Current indications of azathioprine in nephrology]. Nephrol Ther 2012; 9:8-12. [PMID: 23022291 DOI: 10.1016/j.nephro.2012.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2011] [Revised: 08/09/2012] [Accepted: 08/10/2012] [Indexed: 10/27/2022]
Abstract
Azathioprine is an immunosuppressive agent belonging to the antimetabolite family whose action blocks purine synthesis. It inhibits lymphocyte proliferation. In recent years, several trials have clarified the role of this compound used for three main indications: lupus glomerulonephritis, necrotizing vasculitis associated with antineutrophil cytoplasmic antibodies and renal involvement, and kidney transplantation. This review of the literature details practical conditions for the use of azathioprine in these three situations.
Collapse
Affiliation(s)
- Marc Ladrière
- Service de néphrologie-hémodialyse-transplantation, CHU Brabois Adultes, rue du Morvan, 54511 Vandœuvre-lès-Nancy, France.
| |
Collapse
|
47
|
|
48
|
A randomized trial with steroids and antithymocyte globulins comparing cyclosporine/azathioprine versus tacrolimus/mycophenolate mofetil (CATM2) in renal transplantation. Transplantation 2012; 93:437-43. [PMID: 22228415 DOI: 10.1097/tp.0b013e31824215b7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The best immunosuppressive regimen in benefit-risk ratio in renal transplantation is debated. Nowadays, tacrolimus (Tac) and mycophenolate mofetil (MMF) are considered more efficient than cyclosporine A (CsA) and MMF, but recent studies have challenged this assumption. METHODS We conducted a monocentric, prospective, open-labeled, randomized, and controlled trial comparing CsA/azathioprine (Aza) versus Tac/MMF in 289 kidney transplant recipients treated with antithymocyte globulins and prednisone. Primary outcome was the number of patients with clinically suspected acute rejection at 1 year. Secondary outcomes were the number of patients with biopsy-proven acute rejection (BPAR), estimated glomerular filtration rate (eGFR), patient and graft survivals, and adverse events at 1 and 3 years. RESULTS During the first year, 21 patients had clinically suspected acute rejection with CsA/Aza (14.4%) vs. 11 (7.7%) with Tac/MMF (P=0.07). BPAR, including borderline, was more frequent in the CsA/Aza group (14.4%) than in the Tac/MMF group (5.6%; P=0.013). At 1 year, patient and graft survivals were not different, and eGFR was 48±1 in the CsA/Aza group and 53±1 mL/min/1.73 m in the Tac/MMF group (P=0.007). There was no significant difference in diabetes after transplantation (16.8% and 18.8%, respectively). CONCLUSIONS With antithymocyte globulins and steroids, clinically suspected acute rejections did not differ between CsA/Aza and Tac/MMF arms. Analysis of secondary endpoints showed a lower rate of BPAR, including border line, and a higher eGFR in the Tac/MMF group. CsA/Aza allowed a low acute rejection rate, but Tac/MMF seemed as a better regimen regarding severe secondary outcomes.
Collapse
|
49
|
Coelho T, Tredger M, Dhawan A. Current status of immunosuppressive agents for solid organ transplantation in children. Pediatr Transplant 2012; 16:106-22. [PMID: 22360399 DOI: 10.1111/j.1399-3046.2012.01644.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Immunosuppression after organ transplantation is complex and ever evolving. Over the past two decades, newer immunosuppressive agents have been introduced with an aim to provide better patient and graft survival. Improved therapeutic strategies have been developed offering the option to use combinations of drugs with non-overlapping toxicities. There are, however, only a few clinical studies with robust data to rationalize the use of these agents in children. This review will discuss the newer immunosuppressive agents used for solid organ transplant, their current status in post-transplant management and prevention of allograft rejection.
Collapse
Affiliation(s)
- Tracy Coelho
- Paediatric Liver GI and Nutrition Centre, King's College Hospital, King's College London School of Medicine, London, UK
| | | | | |
Collapse
|
50
|
Esterberg E, Acharya NR. Corticosteroid-sparing therapy: practice patterns among uveitis specialists. J Ophthalmic Inflamm Infect 2011; 2:21-8. [PMID: 22057810 PMCID: PMC3302992 DOI: 10.1007/s12348-011-0047-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2011] [Accepted: 10/20/2011] [Indexed: 12/19/2022] Open
Abstract
Purpose This study aims to determine uveitis specialists’ practice patterns, preferences, and perceptions of corticosteroid-sparing therapies for the initial treatment of chronic noninfectious uveitis. Methods A survey was distributed to the American Uveitis Society and Proctor email listservs in order to restrict the respondents to specialists who likely have extensive experience in the use of immunomodulatory therapy. Topics included effectiveness, usage, and preferences related to seven immunomodulatory treatments. Results Among the 45 responders, the majority (59%) had greater than 10 years of experience treating uveitis. Methotrexate was the most commonly used initial therapy for anterior, intermediate, and posterior/panuveitis (85%, 57%, and 37%), and the most preferred for anterior (55%). Mycophenolate mofetil was the most preferred for intermediate (35%) and posterior/panuveitis (42%). Primary reasons not to prescribe a treatment were effectiveness for azathioprine, safety/tolerability for cyclosporine and cyclophosphamide, and a mixture of cost, safety/tolerability, and difficulty of administration for the biologic drugs. Conclusions Within the group of highly experienced uveitis specialists, methotrexate is still the most commonly used initial treatment. Although newer biologic drugs are seen as effective, they are not commonly used, or even preferred, as initial corticosteroid-sparing treatment.
Collapse
Affiliation(s)
- Elizabeth Esterberg
- F.I. Proctor Foundation, University of California San Francisco, Room S309, 513 Parnassus Avenue, San Francisco, CA, 94143-0412, USA
| | | |
Collapse
|