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Grosyeux C, Alla A, Barbé F, Dubourg LD, Chardon L, Guéant JL, Frimat L, Oussalah A, Vrillon I. The EKFC equation outperforms the CKD-EPI and CKiD equations for GFR estimation in adolescent and young adult kidney transplant patients. Nephrology (Carlton) 2024; 29:680-687. [PMID: 38803085 DOI: 10.1111/nep.14328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 04/28/2024] [Accepted: 05/17/2024] [Indexed: 05/29/2024]
Abstract
AIM This study evaluated the bias and accuracy of the CKD-EPI/CKiD and EKFC equations compared with the reference exogenous tracer-based assessment of glomerular filtration rate (GFR) in adult and pediatric patients according to their renal transplant status. METHODS We assessed the bias and P30 accuracy of the CKD-EPI/CKiD and EKFC equations compared with iohexol-based GFR measurement. RESULTS In the overall population (n = 59), the median age was 29 years (IQR, 16.0-46.0) and the median measured GFR was 73.9 mL/min/1.73m2 (IQR, 57.3-84.6). Among non-kidney transplant patients, the median was 77.7 mL/min/1.73m2 (IQR, 59.3-86.5), while among kidney transplant patients, it was 60.5 mL/min/1.73m2 (IQR, 54.2-66.8). The bias associated with the EKFC and CKD-EPI/CKiD equations was significantly higher among kidney transplant patients than among non-kidney transplant patients, with a difference between medians (Hodges-Lehmann) of +10.4 mL/min/1.73m2 (95% CI, 2.2-18.9; p = .02) for the EKFC and +12.1 mL/min/1.73m2 (95% CI, 4.2-21.4; p = .006) for the CKD-EPI/CKiD equations. In multivariable analysis, kidney transplant status emerged as an independent factor associated with a bias of >3.4 mL/min/1.73m2 (odds ratio, 7.7; 95% CI, 1.4-43.3; p = .02) for the EKFC equation and a bias of >13.4 mL/min/1.73m2 (odds ratio, 15.0; 95% CI, 2.6-85.7; p = .002) for the CKD-EPI/CKiD equations. CONCLUSION In our study, which included adolescent and young adult kidney transplant patients, both the CKD-EPI/CKiD and EKFC equations tended to overestimate the measured glomerular filtration rate, with the EKFC equation exhibiting less bias. Renal transplant status significantly influenced the degree of estimation bias.
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Affiliation(s)
- Chloé Grosyeux
- Pediatric Nephrology Department, University Hospital of Nancy, Nancy, France
| | - Asma Alla
- Department of Nephrology, University of Lorraine, Nancy, France
| | - Françoise Barbé
- Department of Molecular Medicine, Division of Biochemistry, Molecular Biology, and Nutrition, University Hospital of Nancy, Nancy, France
- Reference Center for Inborn Errors of Metabolism (ORPHA67872), University Hospital of Nancy, Nancy, France
| | - Laurence Derain Dubourg
- Nephrology, Dialysis, Hypertension and Functional Renal Exploration, Edouard Herriot Hospital, Hospices Civils de Lyon and Université Lyon 1, Lyon, France
| | - Laurence Chardon
- Department of Biology and Hormonology, Lyon-Est Hospital, Bron, France
| | - Jean-Louis Guéant
- Department of Molecular Medicine, Division of Biochemistry, Molecular Biology, and Nutrition, University Hospital of Nancy, Nancy, France
- Reference Center for Inborn Errors of Metabolism (ORPHA67872), University Hospital of Nancy, Nancy, France
- INSERM UMR_S 1256, Nutrition, Genetics, and Environmental Risk Exposure (NGERE), Nancy, France
| | - Luc Frimat
- Department of Nephrology, University of Lorraine, Nancy, France
- INSERM CIC-EC CIE6, University of Lorraine, Nancy, France
| | - Abderrahim Oussalah
- Department of Molecular Medicine, Division of Biochemistry, Molecular Biology, and Nutrition, University Hospital of Nancy, Nancy, France
- Reference Center for Inborn Errors of Metabolism (ORPHA67872), University Hospital of Nancy, Nancy, France
- INSERM UMR_S 1256, Nutrition, Genetics, and Environmental Risk Exposure (NGERE), Nancy, France
| | - Isabelle Vrillon
- Pediatric Nephrology Department, University Hospital of Nancy, Nancy, France
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Zheng X, Ouyang X, Cheng C, Rong L, Chen L, Mo Y, Jiang X. Efficacy and safety of multi-target therapy in children with lupus nephritis. Pediatr Res 2023; 94:2040-2046. [PMID: 37488301 DOI: 10.1038/s41390-023-02747-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 05/12/2023] [Accepted: 07/09/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND To analyze the efficacy and safety of multi-target therapy in children with lupus nephritis (LN). METHODS In our retrospective study from January 2009 to December 2021, the multi-target therapy of glucocorticoids, MMF and tacrolimus was adopted as induction therapy or re-induction therapy for 36 LN children who had combined proliferative and membranous LN or for who were ineffective to combination therapy of glucocorticoids with IV-CYC or MMF for at least 6 months. The clinical and pathological data were collected and analyzed. RESULTS The levels of 24-h urinary protein, anti-dsDNA antibody and SLE disease activity index were decreased, while the levels of albumin and complement 3 were increased after multi-target therapy. More than 90% of LN children achieved partial or complete remission within 6 months. In terms of adverse effects, there was no significant difference between the level of eGFR before and after multi-target therapy. During the follow-up period, four children had infection, two children had hyperuricemia, and one child had liver dysfunction. All of them improved after symptomatic therapy. CONCLUSIONS Multi-target therapy could be an effective treatment option with minimal adverse effects for LN children who are refractory to initial first-line induction therapies or had combined proliferative and membranous LN. IMPACT The multi-target therapy of glucocorticoids, mycophenolate mofetil and tacrolimus was adopted in 36 children with lupus nephritis. Multi-target therapy could be an effective treatment option for lupus nephritis children who are refractory to initial first-line induction therapies or had combined proliferative and membranous lupus nephritis. Adverse effects of multi-target therapy were infrequent and minimal that can be improved by symptomatic therapy.
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Affiliation(s)
- Xiaohong Zheng
- Department of Pediatric Nephrology and Rheumatology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiaojun Ouyang
- Department of Pediatric Nephrology and Rheumatology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Cheng Cheng
- Department of Pediatric Nephrology and Rheumatology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Liping Rong
- Department of Pediatric Nephrology and Rheumatology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Lizhi Chen
- Department of Pediatric Nephrology and Rheumatology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ying Mo
- Department of Pediatric Nephrology and Rheumatology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.
| | - Xiaoyun Jiang
- Department of Pediatric Nephrology and Rheumatology, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.
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3
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Odenwald MA, Roth HF, Reticker A, Segovia M, Pillai A. Evolving challenges with long-term care of liver transplant recipients. Clin Transplant 2023; 37:e15085. [PMID: 37545440 DOI: 10.1111/ctr.15085] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 07/17/2023] [Accepted: 07/23/2023] [Indexed: 08/08/2023]
Abstract
The number of liver transplants (LT) performed worldwide continues to rise, and LT recipients are living longer post-transplant. This has led to an increasing number of LT recipients requiring lifelong care. Optimal care post-LT requires careful attention to both the allograft and systemic issues that are more common after organ transplantation. Common causes of allograft dysfunction include rejection, biliary complications, and primary disease recurrence. While immunosuppression prevents rejection and reduces incidences of some primary disease recurrence, it has detrimental systemic effects. Most commonly, these include increased incidences of metabolic syndrome, various malignancies, and infections. Therefore, it is of utmost importance to optimize immunosuppression regimens to prevent allograft dysfunction while also decreasing the risk of systemic complications. Institutional protocols to screen for systemic disease and heightened clinical suspicion also play an important role in providing optimal long-term post-LT care. In this review, we discuss these common complications of LT as well as unique considerations when caring for LT recipients in the years after transplant.
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Affiliation(s)
- Matthew A Odenwald
- Department of Medicine, Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago Medicine, Chicago, USA
| | - Hannah F Roth
- Department of Medicine, Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago Medicine, Chicago, USA
| | - Anesia Reticker
- Department of Pharmacy, University of Chicago Medicine, Chicago, USA
| | - Maria Segovia
- Department of Medicine, Section of Gastroenterology, Duke University School of Medicine, Durham, USA
| | - Anjana Pillai
- Department of Medicine, Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago Medicine, Chicago, USA
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4
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Zhao L, Yang Y, Xu H, Leng W, Xu G. Efficacy and safety of tacrolimus-based treatment for non-rapidly progressive IgA nephropathy. Front Pharmacol 2023; 14:1189608. [PMID: 37274107 PMCID: PMC10232819 DOI: 10.3389/fphar.2023.1189608] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 05/10/2023] [Indexed: 06/06/2023] Open
Abstract
In this study, we aimed to evaluate the efficacy and safety of tacrolimus-based treatment for immunoglobulin A nephropathy (IgAN). We retrospectively reviewed 127 adult patients with primary IgAN with 24 h urine total protein quantity (24 h UTP) ≥ 1 g and serum creatinine ≤3 mg/dL. All patients were divided into tacrolimus (TAC) and control (non-TAC) groups according to the treatment strategy. Proteinuria remission, remission rate, and adverse events were compared between the two groups. Among the 127 patients, 61 received TAC-based treatment and 66 received non-TAC treatment. TAC group exhibited a more rapid decline in proteinuria than the non-TAC group at 3, 9, and 12 months (p = 0.049, 0.001, and 0.018, respectively). Remission rates at 1, 3, 6, 9, and 12 months were 41.0, 68.9, 80.3, 90.2, and 88.5%, respectively, in the TAC group. These rates were higher than those in the control group at 3, 9, and 12 months (p = 0.030, 0.008, and 0.026, respectively). Complete remission rates at 1, 3, 6, 9, and 12 months were 6.56, 19.7, 37.7, 54.1, and 62.3%, respectively, in the TAC group. These rates were higher than those in the control group at 9 and 12 months (p = 0.013 and 0.008, respectively). The estimated mean time to complete remission was significantly shorter in the TAC group than in the control group (p = 0.028). TAC did not increase the incidence of adverse events. In conclusion, TAC accelerated proteinuria remission in patients with non-rapidly progressive IgAN with no increased risk of adverse events. Further prospective randomized controlled trials are necessary to validate our findings.
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Affiliation(s)
- Lijuan Zhao
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University of PLA, Xi’an, China
| | - Yanyan Yang
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University of PLA, Xi’an, China
- Department of Nephrology, Shaanxi University of Chinese Medicine, Xianyang, Shaanxi, China
| | - Hao Xu
- M.S. in Biostatistics, Columbia University Mailman School of Public Health, New York, NY, United States
| | - Wei Leng
- Department of Nephrology, Shaanxi University of Chinese Medicine, Xianyang, Shaanxi, China
| | - Guoshuang Xu
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University of PLA, Xi’an, China
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5
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Oreschak K, Saba LM, Rafaels N, Ambardekar AV, Deininger KM, Page RL, Lindenfeld J, Aquilante CL. Association Between Variants in Calcineurin Inhibitor Pharmacokinetic and Pharmacodynamic Genes and Renal Dysfunction in Adult Heart Transplant Recipients. Front Genet 2021; 12:658983. [PMID: 33868389 PMCID: PMC8047196 DOI: 10.3389/fgene.2021.658983] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 03/15/2021] [Indexed: 11/30/2022] Open
Abstract
Background: The goal of the study was to assess the relationship between single nucleotide variants (SNVs) in calcineurin inhibitor (CNI) pharmacokinetic and pharmacodynamic genes and renal dysfunction in adult heart transplant (HTx) recipients. Methods: This retrospective analysis included N = 192 patients receiving a CNI at 1-year post-HTx. Using a candidate gene approach, 93 SNVs in eight pharmacokinetic and 35 pharmacodynamic genes were chosen for investigation. The primary outcome was renal dysfunction 1-year after HTx, defined as an estimated glomerular filtration rate (eGFR) <45 ml/min/1.73m2. Results: Renal dysfunction was present in 28.6% of patients 1-year after HTx. Two SNVs [transforming growth factor beta 1 (TGFB1) rs4803455 C > A and phospholipase C beta 1 (PLCB1) rs170549 G > A] were significantly associated with renal dysfunction after accounting for a false discovery rate (FDR) of 20%. In a multiple-SNV adjusted model, variant A allele carriers of TGFB1 rs4803455 had lower odds of renal dysfunction compared to C/C homozygotes [odds ratio (OR) 0.28, 95% CI 0.12-0.62; p = 0.002], whereas PLCB1 rs170549 variant A allele carriers had higher odds of the primary outcome vs. patients with the G/G genotype (OR 2.66, 95% CI 1.21-5.84, p = 0.015). Conclusion: Our data suggest that genetic variation in TGFB1 and PLCB1 may contribute to the occurrence of renal dysfunction in HTx recipients receiving CNIs. Pharmacogenetic markers, such as TGFB1 rs4803455 and PLCB1 rs170549, could help identify patients at increased risk of CNI-associated renal dysfunction following HTx, potentially allowing clinicians to provide more precise and personalized care to this population.
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Affiliation(s)
- Kris Oreschak
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, United States
| | - Laura M. Saba
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, United States
| | - Nicholas Rafaels
- Division of Biomedical Informatics and Personalized Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, United States
| | - Amrut V. Ambardekar
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, United States
| | - Kimberly M. Deininger
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, United States
| | - Robert L. Page
- Division of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, United States
| | - JoAnn Lindenfeld
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Christina L. Aquilante
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, United States
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6
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Shiraishi Y, Amiya E, Hatano M, Katsuki T, Bujo C, Tsuji M, Nitta D, Maki H, Ishida J, Kagami Y, Endo M, Kimura M, Ando M, Shimada S, Kinoshita O, Ono M, Komuro I. Impact of tacrolimus versus cyclosporin A on renal function during the first year after heart transplant. ESC Heart Fail 2020; 7:1842-1849. [PMID: 32445260 PMCID: PMC7373882 DOI: 10.1002/ehf2.12749] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 04/02/2020] [Accepted: 04/24/2020] [Indexed: 12/22/2022] Open
Abstract
AIMS Nephrotoxicity of calcineurin inhibitors (CNIs) is associated with adverse events in patients undergoing heart transplant (HTx), although studies directly comparing tacrolimus (TAC) versus cyclosporin A (CsA), especially in combination with everolimus and low-dose CNIs approach, are limited. Thus, we sought to investigate the associations of TAC and CsA with clinical outcomes in HTx recipients, with specific focus on renal function. METHODS AND RESULTS From August 2007 to February 2017, 72 consecutive patients (39 treated with TAC vs. 33 with CsA) receiving de novo HTx in a single transplant centre were retrospectively evaluated. We used the instrumental variable method to account for unmeasured confounding. The study outcomes were percentage change in estimated glomerular filtration rates (eGFR) (safety endpoint) and biopsy-proven acute rejection (efficacy endpoint) within the first year after HTx. The enrolled patients (median age 40 years) were predominantly men (68%). There were no significant differences in baseline characteristics, including eGFR (64.8 [45.7-96.4] mL/min/1.73 m2 in TAC vs. 65.6 [57.9-83.0] mL/min/1.73 m2 for CsA; P = 0.48), other than sex (male, 49% for TAC vs. 91% for CsA; P < 0.001) between the two groups. Within the first year after HTx, 23 (59%) in the TAC group switched mycophenolate mofetil to everolimus, whereas 16 (48%) in the CsA group (P = 0.52). At 12 months, the rates of mortality and end-stage renal disease requiring renal replacement therapies were both 0%. In the instrumental variable analysis, no differences in renal function as well as graft rejection for 1 year after HTx existed between the TAC and CsA groups. These results were similar when taking into account of everolimus use. CONCLUSIONS Irrespective of everolimus use with low-dose CNIs, our analysis using the instrumental variable method showed no differences in renal function as well as graft rejection during the first year after HTx between HTx recipients who received TAC or CsA.
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Affiliation(s)
- Yasuyuki Shiraishi
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Eisuke Amiya
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Therapeutic Strategy for Heart Failure, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masaru Hatano
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Therapeutic Strategy for Heart Failure, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Toshiomi Katsuki
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Chie Bujo
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masaki Tsuji
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Daisuke Nitta
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hisataka Maki
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Junichi Ishida
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yukie Kagami
- Department of Organ Transplantation, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Miyoko Endo
- Department of Organ Transplantation, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Mitsutoshi Kimura
- Department of Cardiovascular Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masahiko Ando
- Department of Cardiovascular Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shogo Shimada
- Department of Cardiovascular Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Osamu Kinoshita
- Department of Cardiovascular Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Minoru Ono
- Department of Cardiovascular Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Issei Komuro
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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7
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Sharma P, Sun Y, Neal J, Erley J, Shen J, Tischer S, Sonnenday CJ, Park JM. Renal Outcomes of Liver Transplantation Recipients Receiving Standard Immunosuppression and Early Renal Sparing Immunosuppression: A Retrospective Single Center Study. Transplant Direct 2019; 5:e480. [PMID: 31579808 PMCID: PMC6739043 DOI: 10.1097/txd.0000000000000917] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 05/24/2019] [Accepted: 06/03/2019] [Indexed: 12/26/2022] Open
Abstract
New-onset stage 4-5 chronic kidney disease (CKD) after liver transplantation (LT) is associated with high morbidity, mortality, and economic burden. In 2010, we instituted an early renal sparing immunosuppression (RSI) protocol for LT recipients with severe renal dysfunction (pre-LT dialysis/estimated glomerular filtration rate (eGFR)<30mL/min/1.73 m2 or post-LT acute kidney injury) consisting of 2 doses of basiliximab for induction and delaying tacrolimus to post-LT day 4-7. We examined the effect of early RSI on post-LT renal outcomes. METHODS Data on all adults who had LT between January 1, 2010, and December 12, 2014 were collected. We calculated the renal risk index (RRI) score for each LT recipient (https://rri.med.umich.edu). Primary outcome was new-onset post-LT stage 4-5 CKD. RESULTS Of 214 LT recipients, 121 (57%) received early RSI and 93 (43%) received standard immunosuppression. Cumulative incidence of new-onset stage 4-5 CKD was higher in early RSI compared with standard immunosuppression (P = 0.03). Female sex and RRI score were the significant risk factors for development of post-LT stage CKD in the entire study cohort as well as the LT recipients with RRI ≥ sixth decile (high-risk group). CONCLUSIONS Delaying tacrolimus initiation combined with basiliximab induction did not have a durable effect on long-term renal outcomes in high-risk LT recipients. Further studies are needed to identify the effective strategies to preserve renal function by targeting patients at high risk for CKD progression.
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Affiliation(s)
- Pratima Sharma
- Division of Gastroenterology and Hepatology, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Yihan Sun
- College of Pharmacy, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Joslyn Neal
- College of Pharmacy, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Jennifer Erley
- College of Pharmacy, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - James Shen
- College of Pharmacy, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Sarah Tischer
- College of Pharmacy, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Christopher J. Sonnenday
- Department of Surgery, Section of Transplantation, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Jeong M. Park
- College of Pharmacy, Michigan Medicine, University of Michigan, Ann Arbor, MI
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Zhang XJ, Ji CF, Yuan JZ, Wang L, Zhang J, Fang W, Bai DF, Hu Z. Efficacy and safety of tacrolimus-based treatment for nephrotic idiopathic membranous nephropathy in young adults: A retrospective study. Kaohsiung J Med Sci 2019; 35:633-639. [PMID: 31225949 DOI: 10.1002/kjm2.12098] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 05/16/2019] [Indexed: 11/09/2022] Open
Abstract
In China, the prevalence of idiopathic membranous nephropathy (IMN) is increasing with a younger age of onset. From January 2012 to October 2018, biopsy-proven nephrotic IMN patients aged between 15 and 40 in Taian City Central Hospital treated with tacrolimus (TAC) were retrospectively analyzed. Twelve-month follow-up data were collected. A total of 86 patients were enrolled in this study. Forty patients in the TAC group received TAC monotherapy with an initial dose of 0.05 to 0.1 mg/kg/day. Forty-six patients in the TAC + Pred group received TAC combined with oral prednisone (0.5 mg/kg/day initially). Remission rate, relapse rate, and adverse events in the two groups were assessed. Total remission (TR) rates at the end of the 3rd, 6th, and 12th month were 15%, 35%, and 77.5% (TAC group) and 28.3%, 56.5%, and 80.4% (TAC + Pred group), respectively. Compared with the TAC group, the TAC + Pred group had higher complete remission rates at the end of the 6th and 12th month, and TR rate at the 6th month was significantly higher. Twenty-four-hour urinary protein excretion, serum albumin and estimated glomerular filtration rate between the two groups were comparable during the follow-up. Decrease in proteinuria was significantly greater in the TAC + Pred group. No significant difference of relapse rate was found between the two groups. Adverse effects in the two groups were mild and controllable. Both TAC monotherapy and TAC combined with medium-dose prednisone are effective and safe for young adults with nephrotic IMN, while TAC + Pred regimen brings more benefits.
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Affiliation(s)
- Xiao-Juan Zhang
- Department of Nephrology, Qi Lu Hospital of Shandong University, Jinan, Shandong, China.,Department of Nephrology, Taian City Central Hospital, Taian, Shandong, China
| | - Cheng-Fa Ji
- Shandong New Time Pharmaceutical Co., LTD., Lunan Pharmaceutical Group Co., Ltd., Linyi, Shandong, China
| | - Jiang-Zi Yuan
- Department of Nephrology, RenJi Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lei Wang
- Department of Nephrology, Taian City Central Hospital, Taian, Shandong, China
| | - Jing Zhang
- Shandong New Time Pharmaceutical Co., LTD., Lunan Pharmaceutical Group Co., Ltd., Linyi, Shandong, China
| | - Wei Fang
- Department of Nephrology, RenJi Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Dong-Fang Bai
- Department of Nephrology, Taian City Central Hospital, Taian, Shandong, China
| | - Zhao Hu
- Department of Nephrology, Qi Lu Hospital of Shandong University, Jinan, Shandong, China
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9
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Shang SL, Cai GY, Duan SW, Li P, Li QG, Chen XM. Retrospective analysis of tacrolimus combined with Tripterygium wilfordii polyglycoside for treating idiopathic membranous nephropathy. BMC Nephrol 2018; 19:182. [PMID: 30021637 PMCID: PMC6052665 DOI: 10.1186/s12882-018-0967-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 06/26/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Idiopathic membranous nephropathy (IMN) is one of the most common adult nephrotic syndromes. Some patients with this disorder require immunosuppressive therapy. This retrospective case series was performed to assess the effects of tacrolimus (TAC) combined with Tripterygium wilfordii polyglycoside (TWG) in treating IMN. METHODS From January 2015 to August 2016, kidney-biopsy-proven IMN patients treated with TAC in the Chinese PLA General Hospital were screened. Data were retrieved from the patients' medical records. The first efficacy evaluation index was remission rate (complete remission and partial remission), and the secondary efficacy evaluation indices included relapse rate, proteinuria, serum albumin and estimated glomerular filtration rate (eGFR). Adverse events were also assessed. RESULTS The included patients' treatments were tacrolimus monotherapy (TAC group, n = 33), tacrolimus combined with methylprednisolone (MP) (TAC + MP group, n = 24) and tacrolimus combined with Tripterygium wilfordii polyglycoside (TAC + TWG group, n = 21). The remission rates of the TAC, TAC + MP, and TAC + TWG groups in the 10th month were 54.5, 62.5, and 85.7%, respectively (TAC + TWG group vs TAC group, P = 0.037, TAC + TWG group vs TAC + MP group, P = 0.125). Moreover, the complete remission rates of the TAC, TAC + MP, and TAC + TWG groups in the 10th month were 21.2, 20.8, and 57.1%, respectively (TAC + TWG group vs TAC group, P = 0.007, TAC + TWG group vs TAC + MP group, P = 0.012). Compared with the TAC group, the TAC + TWG group had a higher remission rate during these ten months (log-rank, P = 0.005). Compared with the TAC and TAC + MP groups, the TAC + TWG group had a higher complete remission rate (log-rank, P = 0.019 and log-rank, P = 0.005, respectively). CONCLUSION This retrospective study showed that TAC combined with TWG may be effective for treating IMN. Further randomized controlled trials (RCTs) are needed to assess the efficacy and safety of TAC combined with TWG.
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Affiliation(s)
- Shun-Lai Shang
- Department of Nephrology, Medical School of Chinese PLA, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Guang-Yan Cai
- Department of Nephrology, Medical School of Chinese PLA, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Shu-Wei Duan
- Department of Nephrology, Medical School of Chinese PLA, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Ping Li
- Department of Nephrology, Medical School of Chinese PLA, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Qing-Gang Li
- Department of Nephrology, Medical School of Chinese PLA, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China.
| | - Xiang-Mei Chen
- Department of Nephrology, Medical School of Chinese PLA, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China.
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Heyman SN, Abassi Z, Rosenberger C, Yaseen H, Skarjinski G, Shina A, Mathia S, Krits N, Khamaisi M. Cyclosporine A induces endothelin-converting enzyme-1: Studies in vivo and in vitro. Acta Physiol (Oxf) 2018; 223:e13033. [PMID: 29330945 DOI: 10.1111/apha.13033] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Revised: 01/04/2018] [Accepted: 01/08/2018] [Indexed: 11/27/2022]
Abstract
AIM Cyclosporine A (CsA) induces renal vasoconstriction and hypoxia and enhances the expression of endothelin-1 (ET-1) pro-hormone (pre-pro-ET-1), plausibly leading to a feed-forward loop of renal vasoconstriction, hypoxia and enhanced synthesis of the potent vasoconstrictor ET-1. Endothelin-converting enzyme (ECE)-1 cleaves big endothelin to generate endothelin (ET)-1 and is upregulated by hypoxia via hypoxia-inducible factor (HIF). We hypothesized that in addition to the direct induction of ET-1 synthesis, CsA might also intensify renal ECE-1 expression, thus contributing to enhanced ET-1 synthesis following CsA. METHODS CsA was administered to Sprague Dawley rats (120 mg/kg/SC) for 4 days, and renal HIF and ECE-1 expression were assessed with Western blots and immunostaining. Human umbilical vein endothelial cells (HUVEC) and proximal tubular cell line (HK-2) were subjected to CsA, and ECE-1 induction was evaluated using real-time mRNA PCR and Western blots. RESULTS Cyclosporine A intensified renal parenchymal ECE-1 expression in the rat kidney, particularly in distal nephron segments, along with renal hypoxia (detected by pimonidazole adducts) and HIF expression, in line with our recent observations showing episodic hypoxia in mice subjected to CsA. Furthermore, in cultured normoxic HUVEC and HK-2 cells, CsA dose-dependently induced both pre-pro-ET-1 and ECE-1 mRNA and protein expression, with enhanced ET-1 generation. CONCLUSION CsA induces ECE-1 via both hypoxic and non-hypoxic pathways. ECE-1 may contribute to increased renal ET-1 generation following CsA, participating in a feed-forward loop of renal parenchymal hypoxia and ET synthesis.
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Affiliation(s)
- S. N. Heyman
- Department of Medicine; Hadassah Hebrew University Hospital; Jerusalem Israel
| | - Z. Abassi
- Department of Physiology, Ruth and Bruce Rappaport Faculty of Medicine; Technion-IIT; Haifa Israel
- Department of Laboratory Medicine; Rambam Health Care Campus; Haifa Israel
| | - C. Rosenberger
- Department of Nephrology and Medical Intensive Care; Charité - Universitätsmedizin; Berlin Germany
| | - H. Yaseen
- Department of Medicine D; Rambam Health Care Campus; Haifa Israel
- Ruth and Bruce Rappaport Faculty of Medicine; Technion-IIT; Haifa Israel
| | - G. Skarjinski
- Department of Medicine; Hadassah Hebrew University Hospital; Jerusalem Israel
| | - A. Shina
- Department of Medicine; Hadassah Hebrew University Hospital; Jerusalem Israel
| | - S. Mathia
- Department of Nephrology and Medical Intensive Care; Charité - Universitätsmedizin; Berlin Germany
| | - N. Krits
- Department of Medicine D; Rambam Health Care Campus; Haifa Israel
- Ruth and Bruce Rappaport Faculty of Medicine; Technion-IIT; Haifa Israel
| | - M. Khamaisi
- Department of Medicine D; Rambam Health Care Campus; Haifa Israel
- Ruth and Bruce Rappaport Faculty of Medicine; Technion-IIT; Haifa Israel
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Cyclosporine before Coronary Artery Bypass Grafting Does Not Prevent Postoperative Decreases in Renal Function. Anesthesiology 2018; 128:710-717. [DOI: 10.1097/aln.0000000000002104] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Abstract
Background
Acute kidney injury is a common complication after cardiac surgery, leading to increased morbidity and mortality. One suggested cause for acute kidney injury is extracorporeal circulation–induced ischemia–reperfusion injury. In animal studies, cyclosporine has been shown to reduce ischemia–reperfusion injury in the kidneys. We hypothesized that administering cyclosporine before extracorporeal circulation could protect the kidneys in patients undergoing cardiac surgery.
Methods
The Cyclosporine to Protect Renal Function in Cardiac Surgery (CiPRICS) study was an investigator-initiated, double-blind, randomized, placebo-controlled, single-center study. The primary objective was to assess if cyclosporine could reduce acute kidney injury in patients undergoing coronary artery bypass grafting surgery with extracorporeal circulation. In the study, 154 patients with an estimated glomerular filtration rate of 15 to 90 ml · min–1 · 1.73 m–2 were enrolled. Study patients were randomized to receive 2.5 mg/kg cyclosporine or placebo intravenously before surgery. The primary endpoint was relative plasma cystatin C changes from the preoperative day to postoperative day 3. Secondary endpoints included biomarkers of kidney, heart, and brain injury.
Results
All enrolled patients were analyzed. The cyclosporine group (136.4 ± 35.6%) showed a more pronounced increase from baseline plasma cystatin C to day 3 compared to placebo (115.9 ± 30.8%), difference, 20.6% (95% CI, 10.2 to 31.2%, P < 0.001). The same pattern was observed for the other renal markers. The cyclosporine group had more patients in Risk Injury Failure Loss End-stage (RIFLE) groups R (risk), I (injury), or F (failure; 31% vs. 8%, P < 0.001). There were no differences in safety parameter distribution between groups.
Conclusions
Administration of cyclosporine did not protect coronary artery bypass grafting patients from acute kidney injury. Instead, cyclosporine caused a decrease in renal function compared to placebo that resolved after 1 month.
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Yu MY, Kim YC, Koo HS, Chin HJ. Short-term anti-proteinuric effect of tacrolimus is not related to preservation of the glomerular filtration rate in IgA nephropathy: A 5-year follow-up study. PLoS One 2017; 12:e0188375. [PMID: 29155873 PMCID: PMC5695802 DOI: 10.1371/journal.pone.0188375] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 11/05/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The immunosuppressive drug tacrolimus has the short-term effect of reducing proteinuria in patients with immunoglobulin A nephropathy (IgAN). Our study investigated the effects on proteinuria and kidney function after discontinuation of tacrolimus. METHODS Patients with biopsy-proven IgAN were included in the study and randomly divided into two treatment groups. There was a corresponding control group for each treatment group. The first group included patients treated with tacrolimus (Tac vs non-Tac group) and the second group included patients with a renin angiotensin system blocker (RASi vs non-RASi group). The Tac group received treatment for up to 16 weeks, with the administration of tacrolimus being ceased at the final visit (trial phase). We tracked the patients at 12, 24, 52, and 240 weeks (observational phase). The primary outcomes examined were the percentage change (from the trial phase to the observational phase) of time-averaged proteinuria (TA-proteinuria; g/g creatinine [cr]) and the estimated glomerular filtration rate (eGFR). Time-averaged proteinuria was defined as the average of urine protein to creatinine ratio (UPCR), measured every 3 months during both the trial and observational phases of the study. RESULTS A significant reduction in UPCR was observed in the Tac group compared to non-Tac group at the 4 and 8 week visits during the trial phase (p = 0.023 and p = 0.003, respectively). However, the difference between the Tac group and non-Tac group was not evident in the other review periods, estimated by linear mixed effect model. The percentage change in TA-proteinuria was greater in the Tac group than that in the corresponding control group (116 ± 96% vs. 63 ± 239%, p = 0.004). Therefore, during the observational phase, TA-proteinuria was not significantly different between the Tac group and the non-Tac group (1.150 ± 0.733 g/g cr vs. 1.455 ± 2.017 g/g cr, p = 0.775). The levels of eGFR throughout the observational phase were not significantly different between the two groups. Furthermore, the mean rate of eGFR change throughout both phases of the study was -6.4 ± 5.9 mL/min/1.73 m2/year in the non-Tac group and -5.4 ± 7.9 mL/min/1.73 m2/year in the Tac group (p = 0.988). CONCLUSION The anti-proteinuric effect of tacrolimus was promptly reversed 3 months after discontinuing the drug. The use of tacrolimus for a short period of time for patients with IgAN temporarily reduces proteinuria, but the data showed no long-term efficacy regarding proteinuria reduction and improvement of renal function.
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Affiliation(s)
- Mi-Yeon Yu
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Yong-Chul Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Ho Suk Koo
- Department of Internal Medicine, Inje University Seoul Paik Hospital, Seoul, Korea
| | - Ho Jun Chin
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seong-Nam, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Renal Institute, Seoul National University Medical Research Center, Seoul, Korea
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Estimating Glomerular Filtration Rate in Kidney Transplant Recipients: Comparing a Novel Equation With Commonly Used Equations in this Population. Transplant Direct 2017. [PMID: 29536033 PMCID: PMC5828695 DOI: 10.1097/txd.0000000000000742] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Background Assessment of glomerular filtration rate (GFR) is important in kidney transplantation. The aim was to develop a kidney transplant specific equation for estimating GFR and evaluate against published equations commonly used for GFR estimation in these patients. Methods Adult kidney recipients (n = 594) were included, and blood samples were collected 10 weeks posttransplant. GFR was measured by 51Cr-ethylenediaminetetraacetic acid clearance. Patients were randomized into a reference group (n = 297) to generate a new equation and a test group (n = 297) for comparing it with 7 alternative equations. Results Two thirds of the test group were males. The median (2.5-97.5 percentile) age was 52 (23-75) years, cystatin C, 1.63 (1.00-3.04) mg/L; creatinine, 117 (63-220) μmol/L; and measured GFR, 51 (29-78) mL/min per 1.73 m2. We also performed external evaluation in 133 recipients without the use of trimethoprim, using iohexol clearance for measured GFR. The Modification of Diet in Renal Disease equation was the most accurate of the creatinine-equations. The new equation, estimated GFR (eGFR) = 991.15 × (1.120sex/([age0.097] × [cystatin C0.306] × [creatinine0.527]); where sex is denoted: 0, female; 1, male, demonstrating a better accuracy with a low bias as well as good precision compared with reference equations. Trimethoprim did not influence the performance of the new equation. Conclusions The new equation demonstrated superior accuracy, precision, and low bias. The Modification of Diet in Renal Disease equation was the most accurate of the creatinine-based equations.
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Gojowy D, Adamczak M, Dudzicz S, Gazda M, Karkoszka H, Wiecek A. High Frequency of Arterial Hypertension in Patients After Liver Transplantation. Transplant Proc 2017; 48:1721-4. [PMID: 27496479 DOI: 10.1016/j.transproceed.2015.11.043] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 10/27/2015] [Accepted: 11/11/2015] [Indexed: 12/23/2022]
Abstract
BACKGROUND Cardiovascular diseases are among the most frequent causes of patient death after liver transplantation. The aim of this retrospective clinical study was to estimate the prevalence of arterial hypertension among patients after successful liver transplantation and the role of immunosuppressive drugs in the pathogenesis of hypertension in these patients. PATIENTS AND METHODS A total of 88 patients (age 47 .5 ± 12.1 years; 33 women and 55 men) who had undergone successful liver transplantation and completed 24 months follow-up were studied. The results are presented as means with standard deviations. RESULTS At 1, 12, and 24 months after liver transplantation, the prevalences of hypertension were 44.3%, 54.5%, and 62.5%, respectively. Systolic and diastolic blood pressure in these months were 124.1 ± 14.8, 132.8 ± 19.1, and 135.2 ± 17.3 mm Hg and 83.3 ± 12.0, 87.3 ± 11.1, and 87.9 ± 11.1 mm Hg, respectively. The estimated glomerular filtration rates were 77.8 ± 32.3, 80.3 ± 30.8, and 78.8 ± 29.1 mL/min/1.73 m(2), respectively. Arterial hypertension was significantly more frequent in patients treated with cyclosporine A than in those treated with tacrolimus (P = .004) or everolimus (P = .005). In patients treated with tacrolimus, a positive correlation was found between tacrolimus blood concentration and systolic blood pressure (R = 0.34; P = .01) and a negative correlation was found between estimated glomerular filtration rate and systolic blood pressure (R = -0.28; P = .02). CONCLUSIONS Based on study findings, the following conclusions were drawn: arterial hypertension occurs in more than 50% of patients after liver transplantation (significantly higher frequency than in the general population); calcineurin inhibitors may participate in the pathogenesis of arterial hypertension in patients after successful liver transplantation; and the clinical importance of these findings and the influence on cardiovascular outcome of the liver transplant recipients need further investigation.
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Affiliation(s)
- D Gojowy
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
| | - M Adamczak
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
| | - S Dudzicz
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
| | - M Gazda
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
| | - H Karkoszka
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
| | - A Wiecek
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland.
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Ederoth P, Grins E, Dardashti A, Brondén B, Metzsch C, Erdling A, Nozohoor S, Mokhtari A, Hansson MJ, Elmér E, Algotsson L, Jovinge S, Bjursten H. Ciclosporin to Protect Renal function In Cardiac Surgery (CiPRICS): a study protocol for a double-blind, randomised, placebo-controlled, proof-of-concept study. BMJ Open 2016; 6:e012299. [PMID: 27979834 PMCID: PMC5168697 DOI: 10.1136/bmjopen-2016-012299] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Acute kidney injury (AKI) after cardiac surgery is common and results in increased morbidity and mortality. One possible mechanism for AKI is ischaemia-reperfusion injury caused by the extracorporeal circulation (ECC), resulting in an opening of the mitochondrial permeability transition pore (mPTP) in the kidneys, which can lead to cell injury or cell death. Ciclosporin may block the opening of mPTP if administered before the ischaemia-reperfusion injury. We hypothesised that ciclosporin given before the start of ECC in cardiac surgery can decrease the degree of AKI. METHODS AND ANALYSIS Ciclosporin to Protect Renal function In Cardiac Surgery (CiPRICS) study is an investigator-initiated double-blind, randomised, placebo-controlled, parallel design, single-centre study performed at a tertiary university hospital. The primary objective is to assess the safety and efficacy of ciclosporin to limit the degree of AKI in patients undergoing coronary artery bypass grafting surgery. We aim to evaluate 150 patients with a preoperative estimated glomerular filtration rate of 15-90 mL/min/1.73 m2. Study patients are randomised in a 1:1 ratio to receive study drug 2.5 mg/kg ciclosporin or placebo as an intravenous injection after anaesthesia induction but before start of surgery. The primary end point consists of relative P-cystatin C changes from the preoperative day to postoperative day 3. The primary variable will be tested using an analysis of covariance method. Secondary end points include evaluation of P-creatinine and biomarkers of kidney, heart and brain injury. ETHICS AND DISSEMINATION The trial is conducted in compliance with the current version of the Declaration of Helsinki and the International Council for Harmonisation (ICH) Good Clinical Practice guidelines E6 (R1) and was approved by the Regional Ethical Review Board, Lund and the Swedish Medical Products Agency (MPA). Written and oral informed consent is obtained before enrolment into the study. TRIAL REGISTRATION NUMBER NCT02397213; Pre-results.
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Affiliation(s)
- Per Ederoth
- Department of Anesthesiology and Intensive Care, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Edgars Grins
- Department of Anesthesiology and Intensive Care, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Alain Dardashti
- Department of Anesthesiology and Intensive Care, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Björn Brondén
- Department of Anesthesiology and Intensive Care, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Carsten Metzsch
- Department of Anesthesiology and Intensive Care, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - André Erdling
- Department of Anesthesiology and Intensive Care, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Shahab Nozohoor
- Department of Cardiothoracic Surgery, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Arash Mokhtari
- Department of Cardiothoracic Surgery, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Magnus J Hansson
- Department of Mitochondrial Medicine, Clinical Sciences, Lund University, Lund, Sweden
| | - Eskil Elmér
- Department of Mitochondrial Medicine, Clinical Sciences, Lund University, Lund, Sweden
| | - Lars Algotsson
- Department of Anesthesiology and Intensive Care, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Stefan Jovinge
- Fredrik Meijer Heart and Vascular Institute Spectrum Health, MI US Van Andel Institute, Grand Rapids, Michigan, USA
- Cardiovascular Institute, Stanford University, Stanford, California, USA
| | - Henrik Bjursten
- Department of Cardiothoracic Surgery, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
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Hannah J, Casian A, D'Cruz D. Tacrolimus use in lupus nephritis: A systematic review and meta-analysis. Autoimmun Rev 2015; 15:93-101. [PMID: 26427983 DOI: 10.1016/j.autrev.2015.09.006] [Citation(s) in RCA: 109] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 09/22/2015] [Indexed: 12/21/2022]
Abstract
There is growing interest in the role of tacrolimus as a potential therapeutic agent in SLE. This systematic review and meta-analysis evaluates the evidence for tacrolimus use in the management of lupus nephritis. Thirteen controlled studies were identified (9 suitable for inclusion), using Cochrane database, SCOPUS, Web of Science and OVID (MEDLINE and EMBASE). Data on complete and partial remission rates, proteinuria reduction and adverse events was extracted and analysed using RevMan software. The meta-analysis showed that overall tacrolimus is more effective at inducing complete renal remission than IVCYC (p=0.004), but there is no significant difference compared to MMF (p=0.87). Multi-target TAC+MMF therapy is more effective than IVCYC only when partial remission is included (p=0.0006). Frequency of key adverse effects seems comparable to other agents used in the management of lupus nephritis with fewer gastrointestinal side effects, leukopenia, menstrual disorders, infections and episodes of liver dysfunction reported, but more new onset hypertension and hyperglycaemia. Mortality was lower in the tacrolimus groups, but this was not statistically significant (p=0.15). Tacrolimus may be more effective at reducing proteinuria, but again this was not statistically significant. There are no controlled trials looking at use in pregnancy or juvenile patients, however case reports suggest potential efficacy and safety. In conclusion, in moderately severe lupus nephritis, there is some evidence supporting efficacy of tacrolimus or multi-target TAC+MMF over IVCYC, but no evidence supporting tacrolimus over MMF. Tacrolimus may be more effective at reducing proteinuria, having potential implications for long-term outcome. Key limitations of this study are the lack of long-term outcome data and the lack of high quality, large, blinded controlled trials in multi-ethnic groups.
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Affiliation(s)
- Jennifer Hannah
- King's College London, Division of Immunology, Infection and Inflammatory Diseases, New Hunt's House, Guy's Campus, Great Maze Pond, London, SE1 1UL.
| | - Alina Casian
- King's College London, Division of Immunology, Infection and Inflammatory Diseases, New Hunt's House, Guy's Campus, Great Maze Pond, London, SE1 1UL.
| | - David D'Cruz
- King's College London, Division of Immunology, Infection and Inflammatory Diseases, New Hunt's House, Guy's Campus, Great Maze Pond, London, SE1 1UL. david.d'
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Moes AD, Hesselink DA, Zietse R, van Schaik RHN, van Gelder T, Hoorn EJ. Calcineurin inhibitors and hypertension: a role for pharmacogenetics? Pharmacogenomics 2014; 15:1243-51. [DOI: 10.2217/pgs.14.87] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Hypertension is a common side effect of calcineurin inhibitors (CNIs), which are drugs used to prevent rejection after transplantation. Hypertension after kidney transplantation has been associated with earlier graft failure and higher cardiovascular mortality in the recipient. Recent data indicate that enzymes and transporters involved in CNI pharmacokinetics and pharmacodynamics, including CYP3A5, ABCB1, WNK4 and SPAK, are also associated with salt-sensitive hypertension. These insights raise the question whether polymorphisms in the genes encoding these proteins increase the risk of CNI-induced hypertension. Predicting who is at risk for CNI-induced hypertension may be useful for when selecting specific interventions, including dietary salt restriction, thiazide diuretics or a CNI-free immunosuppressive regimen. This review aims to explore the pharmacogenetics of CNI-induced hypertension, highlighting the knowns and unknowns.
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Affiliation(s)
- Arthur D Moes
- Department of Internal Medicine, Nephrology & Transplantation, Erasmus Medical Center, PO Box 2040 – Room H-438, 3000 CA Rotterdam, The Netherlands
| | - Dennis A Hesselink
- Department of Internal Medicine, Nephrology & Transplantation, Erasmus Medical Center, PO Box 2040 – Room H-438, 3000 CA Rotterdam, The Netherlands
| | - Robert Zietse
- Department of Internal Medicine, Nephrology & Transplantation, Erasmus Medical Center, PO Box 2040 – Room H-438, 3000 CA Rotterdam, The Netherlands
| | - Ron HN van Schaik
- Department of Clinical Chemistry, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Teun van Gelder
- Department of Internal Medicine, Nephrology & Transplantation, Erasmus Medical Center, PO Box 2040 – Room H-438, 3000 CA Rotterdam, The Netherlands
- Department of Hospital Pharmacy, Clinical Pharmacology Unit, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Ewout J Hoorn
- Department of Internal Medicine, Nephrology & Transplantation, Erasmus Medical Center, PO Box 2040 – Room H-438, 3000 CA Rotterdam, The Netherlands
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Hiemstra JA, Liu S, Ahlman MA, Schuleri KH, Lardo AC, Baines CP, Dellsperger KC, Bluemke DA, Emter CA. A new twist on an old idea: a two-dimensional speckle tracking assessment of cyclosporine as a therapeutic alternative for heart failure with preserved ejection fraction. Physiol Rep 2013; 1:e00174. [PMID: 24744855 PMCID: PMC3970750 DOI: 10.1002/phy2.174] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 11/01/2013] [Accepted: 11/04/2013] [Indexed: 01/12/2023] Open
Abstract
We recently reported that mitochondrial dysfunction, characterized by increased mitochondrial permeability transition (MPT), was present in a translational swine model of heart failure with preserved ejection fraction (HFpEF). Cyclophilin D is a key component of the MPT pore, therefore, the purpose of this study was to test the efficacy of a novel cyclosporine (CsA) dosing scheme as a therapeutic alternative for HFpEF. Computed tomography (CT), two‐dimensional speckle tracking two‐dimensional speckle tracking (2DST), and invasive hemodynamics were used to evaluate cardiac function. CT imaging showed 14 weeks of CsA treatment caused eccentric myocardial remodeling (contrasting concentric remodeling in untreated HF animals) and elevated systemic pressures. 2DST detected left ventricular (LV) mechanics associated with systolic and diastolic dysfunction prior to the onset of significantly increased LV end diastolic pressure including: (1) decreased systolic apical rotation rate, longitudinal displacement, and longitudinal/radial/circumferential strain; (2) decreased early diastolic untwisting and longitudinal strain rate; and (3) increased late diastolic radial/circumferential mitral strain rate. LV mechanics associated with systolic and diastolic impairment was enhanced to a greater extent than seen in untreated HF animals following CsA treatment. In conclusion, CsA treatment accelerated the development of heart failure, including dilatory LV remodeling and impaired systolic and diastolic mechanics. Although our findings do not support CsA as a viable therapy for HFpEF, 2DST was effective in differentiating between progressive gradations of developing HF and detecting diastolic impairment prior to the development of overt diastolic dysfunction. We recently reported that mitochondrial dysfunction, characterized by increased mitochondrial permeability transition (MPT), was present in a translational swine model of heart failure with preserved ejection fraction (HFpEF). Cyclophilin D is a key component of the MPT pore, therefore, the purpose of this study was to test the efficacy of a novel cyclosporine (CsA) dosing scheme as a therapeutic alternative for HFpEF. CsA treatment accelerated the development of heart failure, including dilatory LV remodeling and impaired systolic and diastolic mechanics. Although our findings do not support CsA as a viable therapy for HFpEF, 2DST was effective in differentiating between progressive gradations of developing HF and detecting diastolic impairment prior to the development of overt diastolic dysfunction.
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Affiliation(s)
- Jessica A Hiemstra
- Department of Biomedical Science, University of Missouri- Columbia, Columbia, Missouri
| | - Songtao Liu
- Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, Maryland ; Molecular Biomedical Imaging Laboratory, National Institute of Biomedical Imaging and Bioengineering, Bethesda, Maryland
| | - Mark A Ahlman
- Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, Maryland ; Molecular Biomedical Imaging Laboratory, National Institute of Biomedical Imaging and Bioengineering, Bethesda, Maryland
| | - Karl H Schuleri
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Albert C Lardo
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Christopher P Baines
- Department of Biomedical Science, University of Missouri- Columbia, Columbia, Missouri ; Dalton Cardiovascular Research Center, University of Missouri- Columbia, Columbia, Missouri
| | - Kevin C Dellsperger
- Department of Medical Pharmacology and Physiology, University of Missouri- Columbia, Columbia, Missouri ; Department of Internal Medicine, University of Missouri- Columbia, Columbia, Missouri ; Center for Health Care Quality, University of Missouri- Columbia, 1600 E. RollinsW160 Veterinary Medicine, Columbia, 65211, Missouri
| | - David A Bluemke
- Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, Maryland ; Molecular Biomedical Imaging Laboratory, National Institute of Biomedical Imaging and Bioengineering, Bethesda, Maryland
| | - Craig A Emter
- Department of Biomedical Science, University of Missouri- Columbia, Columbia, Missouri
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Kim YC, Chin HJ, Koo HS, Kim S. Tacrolimus decreases albuminuria in patients with IgA nephropathy and normal blood pressure: a double-blind randomized controlled trial of efficacy of tacrolimus on IgA nephropathy. PLoS One 2013; 8:e71545. [PMID: 23977072 PMCID: PMC3747236 DOI: 10.1371/journal.pone.0071545] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Accepted: 06/24/2013] [Indexed: 12/16/2022] Open
Abstract
Background Treatment remains uncertain for IgA nephropathy patients with mild to moderate proteinuria, for whom anti-hypertensive medication or the RAS blocker is not applicable due to low blood pressure. Trial design A double blinded randomized trial. Methods The anti-proteinuric effect of tacrolimus was explored for 40 biopsy-proven mild IgA nephropathies for 16 weeks. We randomly assigned patients either to receive tacrolimus or placebo with stratification by using a renin angiotensin system blocker. The primary outcome was the percentage change of final UACR compared to the baseline value (pcUACR). Results The mean value of pcUACR at 12-week and 16-week visits (primary outcome) was decreased more in the Tac group compared to the control group (–52.0±26.4 vs –17.3±29.3%, p = 0.001). At each visit, pcUACR was also decreased more in the Tac group compared to the control group. In the Tac group, the pcUACRs were –60.2±28.2%, –62.2±33.9%, –48.5±29.8%, and –55.5±24.0%, and, in the control group, –6.8±32.2%, –2.5±35.9%, –12.7±34.2%, and –21.9±30.6%, at 4-week, 8-week, 12-week, and 16-week visits, respectively. The pre-defined secondary outcomes were better in the Tac group compared to the control group. The frequency of decrease in pcUACR and percentage change of UPCR (pcUPCR) ≥50% at 16 weeks were 65.0% (13/20) and 55.0% (11/20)in the Tac group, and 25.0% (5/20) and 15.0% (3/20), in the control group, respectively (p = 0.025 for pcUACR and p = 0.019 for pcUPCR). However, tacrolimus wasn't effective with a dose of 0.05 mg/kg/day in patients taking ARB. The adverse events were tolerable. Conclusion Tacrolimus effectively reduced proteinuria in IgA nephropathy with normal blood pressure. This suggested that tacrolimus could be an alternative to corticosteroid and RAS blocker for IgA nephropathy patients who cannot endure anti-hypertensive medication. Trial Registration Clinicaltrial.gov NCT1224028
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Affiliation(s)
- Yong-Chul Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Ho Jun Chin
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seong-Nam, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Renal Institute, Seoul National University Medical Research Center, Seoul, Korea
- * E-mail:
| | - Ho Suk Koo
- Department of Internal Medicine, Inje University Seoul Paik Hospital, Seoul, Korea
| | - Suhnggwon Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Renal Institute, Seoul National University Medical Research Center, Seoul, Korea
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Issa N, Kukla A, Ibrahim HN. Calcineurin inhibitor nephrotoxicity: a review and perspective of the evidence. Am J Nephrol 2013; 37:602-12. [PMID: 23796509 DOI: 10.1159/000351648] [Citation(s) in RCA: 161] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Accepted: 04/25/2013] [Indexed: 12/31/2022]
Abstract
BACKGROUND There is no doubt that acute calcineurin inhibitor (CNI) nephrotoxicity exists; however, chronic CNI nephrotoxicity is questionable at best. METHODS We reviewed the literature to identify original articles related to the use of CNIs in renal and nonrenal solid organ transplantation in order to examine the available evidence about their chronic nephrotoxicity and contribution to graft failure. RESULTS Early clinical experience and animal studies support the evidence of CNI nephrotoxicity. These findings evolved into the dogma that CNI nephrotoxicity is the major cause of late renal allograft failure. However, in transplanted kidneys the specific role of chronic CNI nephrotoxicity has been questioned. The emerging literature clearly highlights the lack of solid evidence for the role of CNIs as the sole and major injurious agents that cause chronic renal dysfunction and subsequent graft failure. Most of the evidence available to date is against complete CNI avoidance, and minimization appears to be a more viable strategy. It is becoming increasingly clear that the typical pathological lesions linked to chronic CNI use are highly nonspecific, and most of the chronic changes that have been attributed to chronic CNI nephrotoxicity are the consequences of previously unrecognized immunologic injuries. One needs to keep in mind that the potential risk of side effects of CNI use should be balanced against the risk of rejection. CONCLUSIONS More research should focus on addressing the true causes of chronic graft dysfunction rather than focusing on the overexaggerated contribution of CNIs to late graft loss.
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Affiliation(s)
- Naim Issa
- Division of Renal Diseases and Hypertension, University of Minnesota, Minneapolis, MN 55414, USA
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Rehman H, Krishnasamy Y, Haque K, Thurman RG, Lemasters JJ, Schnellmann RG, Zhong Z. Green tea polyphenols stimulate mitochondrial biogenesis and improve renal function after chronic cyclosporin a treatment in rats. PLoS One 2013; 8:e65029. [PMID: 23755172 PMCID: PMC3670924 DOI: 10.1371/journal.pone.0065029] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Accepted: 04/21/2013] [Indexed: 11/30/2022] Open
Abstract
Our previous studies showed that an extract from Camellia sinenesis (green tea), which contains several polyphenols, attenuates nephrotoxicity caused by cyclosporine A (CsA). Since polyphenols are stimulators of mitochondrial biogenesis (MB), this study investigated whether stimulation of MB plays a role in green tea polyphenol protection against CsA renal toxicity. Rats were fed a powdered diet containing green tea polyphenolic extract (0.1%) starting 3 days prior to CsA treatment (25 mg/kg, i.g. daily for 3 weeks). CsA alone decreased renal nuclear DNA-encoded oxidative phosphorylation (OXPHOS) protein ATP synthase-β (AS-β) by 42%, mitochondrial DNA (mtDNA)-encoded OXPHOS protein NADH dehydrogenase-3 (ND3) by 87% and their associated mRNAs. Mitochondrial DNA copy number was also decreased by 78% by CsA. Immunohistochemical analysis showed decreased cytochrome c oxidase subunit IV (COX-IV), an OXPHOS protein, in tubular cells. Peroxisome proliferator-activated receptor-γ coactivator (PGC)-1α, the master regulator of MB, and mitochondrial transcription factor-A (Tfam), the transcription factor that regulates mtDNA replication and transcription, were 42% and 90% lower, respectively, in the kidneys of CsA-treated than in untreated rats. These results indicate suppression of MB by chronic CsA treatment. Green tea polyphenols alone and following CsA increased AS-β, ND3, COX-IV, mtDNA copy number, PGC-1α mRNA and protein, decreased acetylated PGC-1α, and increased Tfam mRNA and protein. In association with suppressed MB, CsA increased serum creatinine, caused loss of brush border and dilatation of proximal tubules, tubular atrophy, vacuolization, apoptosis, calcification, and increased neutrophil gelatinase-associated lipocalin expression, leukocyte infiltration, and renal fibrosis. Green tea polyphenols markedly attenuated CsA-induced renal injury and improved renal function. Together, these results demonstrate that green tea polyphenols attenuate CsA-induced kidney injury, at least in part, through the stimulation of MB.
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Affiliation(s)
- Hasibur Rehman
- Department of Drug Discovery & Biomedical Sciences, Medical University of South Carolina, Charleston, South Carolina, United States of America
| | - Yasodha Krishnasamy
- Department of Drug Discovery & Biomedical Sciences, Medical University of South Carolina, Charleston, South Carolina, United States of America
| | - Khujista Haque
- Department of Drug Discovery & Biomedical Sciences, Medical University of South Carolina, Charleston, South Carolina, United States of America
| | - Ronald G. Thurman
- Department of Pharmacology, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - John J. Lemasters
- Department of Drug Discovery & Biomedical Sciences, Medical University of South Carolina, Charleston, South Carolina, United States of America
- Department of Biochemistry & Molecular Biology, Medical University of South Carolina, Charleston, South Carolina, United States of America
- Hollings Cancer Center, Medical University of South Carolina, Charleston, South Carolina, United States of America
| | - Rick G. Schnellmann
- Department of Drug Discovery & Biomedical Sciences, Medical University of South Carolina, Charleston, South Carolina, United States of America
- Department of Biochemistry & Molecular Biology, Medical University of South Carolina, Charleston, South Carolina, United States of America
- Hollings Cancer Center, Medical University of South Carolina, Charleston, South Carolina, United States of America
- Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina, United States of America
| | - Zhi Zhong
- Department of Drug Discovery & Biomedical Sciences, Medical University of South Carolina, Charleston, South Carolina, United States of America
- Hollings Cancer Center, Medical University of South Carolina, Charleston, South Carolina, United States of America
- Department of Pharmacology, University of North Carolina, Chapel Hill, North Carolina, United States of America
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Outcomes of tacrolimus therapy in adults with refractory membranous nephrotic syndrome: a prospective, multicenter clinical trial. Am J Med Sci 2013; 345:81-7. [PMID: 22627258 DOI: 10.1097/maj.0b013e31824ce676] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The treatment of adult refractory idiopathic membranous nephropathy with steroid and other immunosuppressant-resistant nephrotic syndrome can be a significant challenge. The authors investigated the efficacy and safety of tacrolimus (TAC) as a promising regimen. METHODS A prospective, multicenter trial was conducted in 9 nephrology centers from 2006 to 2008. Fourteen patients were enrolled. In conjunction with prednisone, TAC was started at 0.05 mg/kg/d, titrated to achieve a trough blood level of 5 to 10 ng/mL for the first 6 months, then reduced to 4 to 6 ng/mL for the subsequent 6 months. The primary endpoints included complete or partial remission. Secondary endpoints included relapse, change of clinical parameters and adverse events. RESULTS After 12 months, complete remission was achieved in 35.7% of patients and partial remission in 42.9%, yielding a response rate of 78.6%. Proteinuria, serum albumin, cholesterol, triglyceride and low-density lipoprotein were improved significantly (P < 0.001, P < 0.001, P = 0.002, P = 0.01, P = 0.004, respectively). Proteinuria and serum albumin were significantly improved (42.0% ± 13.2%, P = 0.02; 15.2% ± 4.5%, P = 0.01, respectively) even after the first month of treatment. One patient relapsed during the subsequent 6 months of follow-up. Adverse events included 2 cases of infection and 1 case each of hyperglycemia, hand tremor, sudden death (nondrug related) and diarrhea. CONCLUSIONS TAC plus prednisone may be an alternative therapeutic option for steroid and general immunosuppressant-resistant membranous nephrotic syndrome patients, with a favorable safety profile. However, given the limitation of a small number of patients in this trial, further study with a larger number and longer follow-up is needed.
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Matloff RG, Arnon R, Saland JM. The kidney in pediatric liver transplantation: an updated perspective. Pediatr Transplant 2012; 16:818-28. [PMID: 23131055 DOI: 10.1111/petr.12006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
CKD continues to detract from the success of improved survival in pediatric liver transplantation, and its presence is likely under recognized. Here we review the literature regarding the prevalence, etiology, and management of renal dysfunction in pediatric liver transplant recipients. Long-term studies suggest the prevalence of CKD to be 25-38% by 5-10 yr post-transplant. While important, sole use of serum creatinine overestimates renal function in this population. Screening for and treatment of persistent proteinuria and hypertension as well as minimization of nephrotoxic insults are the mainstays to delay or prevent CKD progression. Office-based blood pressure measures are less sensitive than ABPM, which is specifically recommended by the American Heart Association for its ability to diagnose masked hypertension in pediatric liver transplant recipients. Long-term risk of CKD is predominantly secondary to CNI toxicity. CNI minimization protocols have shown promise in slowing progression of CKD while maintaining graft function, but large-scale randomized control trials with long-term follow-up are needed.
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Affiliation(s)
- Robyn Greenfield Matloff
- Division of Pediatric Nephrology and Hypertension, Mount Sinai Medical Center, New York, NY 10029, USA
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ALK2 and BMPR2 knockdown and endothelin-1 production by pulmonary microvascular endothelial cells. Microvasc Res 2012; 85:46-53. [PMID: 23142694 DOI: 10.1016/j.mvr.2012.10.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Accepted: 10/08/2012] [Indexed: 01/15/2023]
Abstract
BACKGROUND Many cases of pulmonary arterial hypertension (PAH) are heritable and related to gene mutations in bone morphogenic receptor-2 (BMPR2). These patients consequently may have a signaling imbalance within the transforming growth factor beta (TGFβ) receptor superfamily. The causes of increased endothelin-1 (ET-1), which contributes to PAH, are unknown, and we therefore studied the contribution of various BMPs and their receptors on ET-1 production in vitro, after knockdown of BMPR2 in human pulmonary microvascular endothelial cells (HMVEC-LBl). METHODOLOGY/PRINCIPAL FINDINGS Receptor knockdown in HMVEC-LBl was performed using siRNA to BMPR2, and activin like-kinases 1 and 2 (ALK1, ALK2). ET-1 and TGFβ levels in the medium were measured by ELISA. In some experiments, cells were exposed to TGFβ or BMP7 or FK506 (tacrolimus). Using Western blotting, levels of BMPR2, endothelin ET(B) receptor, phosphorylated SMAD 2 (pSMAD 2), phosphorylated SMAD 1,5 (pSMAD 1,5), ALK1, ALK2, ALK5, TGFβ receptor 2, plasminogen activator inhibitor-1 (PAI-1) and ID1 were measured. BMPR2 knockdown significantly increased ET-1 levels. It did not affect ET(B) receptor or TGFβ levels. TGFβ increased ET-1 levels, with or without BMPR2 knockdown. BMPR2 knockdown did not affect TGFβ (pSMAD 2 and PAI-1) signaling. BMP7 increased ET-1 levels after BMPR2 knockdown but this was prevented by ALK2 knockdown as was the increase in ID1 caused by BMPR2 knockdown. FK506, which interacts with ALK2, increased ET-1 levels and ID1 levels, and this was blocked by ALK2 knockdown. CONCLUSION/SIGNIFICANCE ALK2 may be an important receptor in ET-1 production during BMPR2 knockdown.
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Abstract
This article reviews the current understanding of the mechanisms of calcineurin inhibitor-induced hypertension. Already early after the introduction of cyclosporine in the 1980s, vasoconstriction, sympathetic excitation and sodium retention by the kidney had been shown to play a role in this form of hypertension. The vasoconstrictive effects of calcineurin inhibitors are related to interference with the balance of vasoactive substances, including endothelin and nitric oxide. Until recently, the renal site of the sodium-retaining effect of calcineurin inhibitors was unknown. We and others have shown that calcineurin inhibitors increase the activity of the thiazide-sensitive sodium chloride cotransporter through an effect on the kinases WNK and SPAK. Here, we review the pertinent literature on the hypertensinogenic effects of calcineurin inhibitors, including neural, vascular and renal effects, and we propose an integrated model of calcineurin inhibitor-induced hypertension.
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Acute effects of calcineurin inhibitors on kidney allograft microperfusion visualized by contrast-enhanced sonography. Transplantation 2012; 93:1125-9. [PMID: 22470107 DOI: 10.1097/tp.0b013e31824f3dae] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Calcineurin inhibitors induce detrimental vascular remodeling, which may be one cause of chronic allograft failure. Real-time contrast-enhanced sonography (CES) is a relatively new technique in providing quantitative information on microvascular tissue perfusion in kidney allografts in more detail. The purpose of the study was to explore whether acute changes of kidney allograft microperfusion due to the administration of cyclosporine A (CsA) and tacrolimus (Tac) can be evidenced using real-time CES. METHODS In an explorative single-center clinical trial, renal parenchymal tissue perfusion of 32 stable kidney allograft recipients was evaluated with CES before and 2 hr after the intake of CsA or Tac. In addition to laboratory and clinical parameters, Doppler indices and estimated glomerular filtration rate were measured. RESULTS Although systolic and diastolic blood pressure and color Doppler indices did not significantly differ, there was a significant decrease of renal blood flow 2 hr after the intake of CsA compared with baseline (4.78±2.31 dB/s, 49%, respectively). In contrast, kidney allograft microperfusion was neither significantly reduced in patients receiving CsA paralleled by calcium channel blockers nor significantly reduced in patients receiving Tac. Furthermore, there was a significant correlation between renal blood flow obtained before drug administration and kidney function. CONCLUSIONS CES revealed a 49% reduction of kidney allograft microperfusion 2 hr after the intake of CsA, which might be abrogated by calcium channel blockers. In comparison to CsA, Tac did not result in a significant decrease of kidney blood flow.
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Fan L, Liu Q, Liao Y, Li Z, Ji Y, Yang Z, Chen J, Fu J, Zhang J, Kong Y, Fu P, Lou T, Liu Z, Yu X, Chen W. Tacrolimus is an alternative therapy option for the treatment of adult steroid-resistant nephrotic syndrome: a prospective, multicenter clinical trial. Int Urol Nephrol 2012; 45:459-68. [PMID: 22684795 DOI: 10.1007/s11255-012-0205-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2012] [Accepted: 05/15/2012] [Indexed: 11/30/2022]
Abstract
BACKGROUND The optimal therapy for adult steroid-resistant nephrotic syndrome (SRNS) remains a therapeutic challenge. We investigated the efficacy and safety of tacrolimus as a promising regimen in Chinese adult patients. METHODS A prospective, multicenter trial was conducted in 9 nephrology centers from 2006 to 2008, in patients with SRNS (defined as failure to respond to 1 mg/kg/day of prednisone for 8, and 16 weeks, in focal segmental glomerulosclerosis). Patients were treated with tacrolimus (TAC) plus prednisone for 12 months. TAC dose was titrated to achieve a target trough blood concentration of 5-10 ng/ml for the first 6 months and 4-6 ng/ml for the subsequent 6 months. The primary outcomes included complete or partial remission [complete remission (CR): proteinuria <0.3 g/24 h, with serum albumin ≥ 3.5 g/dl and stable renal function; partial remission (PR): proteinuria between 0.3 and 3.5 g/24 h and a decrease of at least 50 % from the baseline level, with serum albumin ≥ 3.0 g/dl and stable renal function]. Secondary end-points included relapse rate, changes of clinical parameters (proteinuria, serum albumin, and lipid profile) and adverse events. RESULTS Twenty-four patients with SRNS were enrolled. After 6 months of therapy, CR was achieved in 58.3 % of patients and PR in 16.7 %, yielding a final response rate of 75.0 %. The decrease in proteinuria was 43.1 ± 17.5 % after the first month of treatment (P < 0.001). Complete or PR was achieved in 6 of 8 patients with minimal change disease, 4 of 6 patients with mesangioproliferative glomerulonephritis (MsPGN), 6 of 7 patients with focal segmental glomerulosclerosis (FSGS), and all 2 patients with IgA nephropathy. Two patients (1 with MsPGN and 1 with FSGS) experienced relapses during the subsequent 6 months of follow-up. Adverse events included infection, hand tremor, diarrhea, acute reversible or persistent nephrotoxicity. CONCLUSIONS In conjunction with prednisone, TAC may be an alternative therapeutic regimen for adult SRNS patients. However, adverse events in these patients should be carefully monitored, especially at the beginning of treatment. Randomized controlled trials with longer follow-up are warranted.
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Affiliation(s)
- Li Fan
- Department of Nephrology, The First Affiliated Hospital, Key Laboratory of Nephrology, Ministry of Health of China, Sun Yat-sen University, 58# Zhongshan Road II, Guangzhou 510080, China
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Zamorano-León JJ, López-Farré AJ, Marques M, Rodríguez P, Modrego J, Segura A, Macaya C, Barrientos A. Changes by tacrolimus of the rat aortic proteome: Involvement of endothelin-1. Transpl Immunol 2012; 26:191-200. [DOI: 10.1016/j.trim.2012.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2011] [Revised: 01/03/2012] [Accepted: 02/02/2012] [Indexed: 01/31/2023]
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Chen W, Liu Q, Chen W, Tang X, Fu P, Liu F, Liao Y, Yang Z, Zhang J, Chen J, Lou T, Fu J, Kong Y, Liu Z, Li Z, Yu X. Outcomes of maintenance therapy with tacrolimus versus azathioprine for active lupus nephritis: a multicenter randomized clinical trial. Lupus 2012; 21:944-52. [PMID: 22438027 DOI: 10.1177/0961203312442259] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AIM The optimal maintenance therapy for active diffuse lupus nephritis remains to be established. In this study, we explored the efficacy and safety of tacrolimus for maintaining remission of active lupus nephritis compared to that of azathioprine. METHODS Seventy patients with biopsy-proven lupus nephritis who achieved remission were enrolled in nine nephrology centers in China from 2006 to 2008. Patients were randomized either to tacrolimus plus prednisone (n = 34) or azathioprine plus prednisone (n = 36) for six months. Tacrolimus was titrated to achieve a trough blood concentration of 4-6 ng/mL, and the dosage of azathioprine was 2 mg/kg/d. Prednisone was administered at a dose of 10 mg/d to both groups. The primary outcome was incidence of relapse. Response, clinical parameters and adverse effects were secondary endpoints. RESULTS After six months of therapy, two of the azathioprine-treated patients developed renal relapse compared to none of the tacrolimus-treated patients (p = 0.49; odds ratio, 1.06; 95% CI (0.98, 1.15)). Leucopenia (defined as < 2000 cells per cubic millimeter) was significantly more frequent in the azathioprine group than the tacrolimus group (47% vs. 9%, p < .001). CONCLUSION In conjunction with prednisone, maintenance therapy with tacrolimus and azathioprine has a similar low rate of renal relapse, and the tacrolimus regimen has a more favorable safety profile, with less leucopenia. However, since our study lacked sufficient power, longer follow-up is needed to draw final conclusions.
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Affiliation(s)
- W Chen
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, China
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Abstract
The discovery and use of cyclosporine since its inception into clinical use in the late 1970s has played a major role in the advancement of transplant medicine. While it has improved rates of acute rejection and early graft survival, data on long-term survival of renal allografts is less convincing. The finding of acute reversible nephrotoxicity and nephrotoxicity in nonrenal transplants has since led to the widely accepted view that there is a chronic more irreversible component to this agent as well. Since that time, there has been intense interest in finding protocols which seek to minimize and even avoid the use of calcineurin inhibitors altogether. We seek to review cyclosporine in terms of its mechanism of action, pathophysiologic, and histologic features associated with acute and chronic nephrotoxicity and recent studies looking to avoid its toxic side effects.
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Abstract
1. Metabolic syndrome (MS) is common after liver transplantation and has been associated with increased risks of cardiovascular disease, cardiovascular death, liver-related death, and overall mortality. 2. Immunosuppression may increase the frequency of hyperlipidemia, diabetes, and hypertension and thus increase the risk and prevalence of MS after transplantation. 3. Corticosteroids are associated with increased rates of diabetes, hypertension, and hyperlipidemia in the short term. These agents are now being used perhaps less frequently and certainly for shorter durations; therefore, the long-term effects on metabolic morbidities may be reduced. 4. Calcineurin inhibitors and mammalian target of rapamycin inhibitors affect many MS parameters to various degrees and contribute to long-term morbidity after transplantation.
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Affiliation(s)
- Kymberly D Watt
- Division of Gastroenterology and Hepatology, William J. von Liebig Transplant Center, Mayo Clinic and Foundation, Rochester, MN 55905, USA.
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Chen W, Tang X, Liu Q, Chen W, Fu P, Liu F, Liao Y, Yang Z, Zhang J, Chen J, Lou T, Fu J, Kong Y, Liu Z, Fan A, Rao S, Li Z, Yu X. Short-term Outcomes of Induction Therapy With Tacrolimus Versus Cyclophosphamide for Active Lupus Nephritis: A Multicenter Randomized Clinical Trial. Am J Kidney Dis 2011; 57:235-44. [DOI: 10.1053/j.ajkd.2010.08.036] [Citation(s) in RCA: 145] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2010] [Accepted: 10/07/2010] [Indexed: 11/11/2022]
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Differential effects of acute and sustained cyclosporine and tacrolimus on sympathetic nerve activity. J Hypertens 2010; 28:1928-34. [PMID: 20577127 DOI: 10.1097/hjh.0b013e32833c20eb] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND We studied the effect of acute and sustained cyclosporine and tacrolimus on muscle sympathetic nerve activity (MSNA) in groups of healthy male volunteers. METHODS AND RESULTS Acute cyclosporine in normal dose (2.5 mg/kg) increased MSNA from 11 +/- 6 to 19 +/- 8 bursts/min (P < 0.05). Acute cyclosporine in high dose (10 mg/kg) increased MSNA from 13 +/- 6 to 25 +/- 4 bursts/min (P < 0.05) and increased heart rate and mean arterial pressure (heart rate from 64 +/- 8 to 74 +/- 6 b.p.m., MAP from 92 +/- 10 to 105 +/- 8 mmHg; both P < 0.05). Sustained cyclosporine (2.5 mg/kg b.i.d. for 2 weeks) suppressed MSNA from 14 +/- 6 to 8 +/- 7 bursts/min (P < 0.05). Blood pressure increased from 89 +/- 6 to 98 +/- 6 mmHg (P < 0.05). Body weight increased and plasma renin activity was suppressed. Acute tacrolimus in regular dose (0.05 mg/kg) and high dose (0.20 mg/kg) had no effect on MSNA and blood pressure. Sustained tacrolimus (0.05 mg/kg b.i.d. for 2 weeks) had no effect on blood pressure, body weight and plasma renin activity, but decreased MSNA from 14 +/- 6 to 8 +/- 5 bursts/min (P < 0.05). CONCLUSION Sympathetic overactivity plays a role in the acute hypertensive action of cyclosporine. Cyclosporine given during 2 weeks increases blood pressure and suppresses MSNA, possibly by volume retention. Tacrolimus, in the presently applied dosages, does not cause hypertension or sympathetic overactivity. However, sustained tacrolimus also suppresses sympathetic activity, the reason of which is unclear.
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Desai S, Hong JC, Saab S. Cardiovascular risk factors following orthotopic liver transplantation: predisposing factors, incidence and management. Liver Int 2010; 30:948-57. [PMID: 20500807 DOI: 10.1111/j.1478-3231.2010.02274.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Liver transplantation is the standard of care for acute and chronic causes of end-stage liver disease. Advances in medical therapy and surgical techniques have led to improvement of patient and graft survival rates following orthotopic liver transplantation. However, the prevalence of post-transplant cardiovascular complications has been rising with increased life expectancy after liver transplantation. AIMS To determine the incidences, risk factors, and treatment for hypertension, hyperlipidaemia, diabetes, and obesity in the post-liver transplantation population. METHODS We performed a review of relevant studies available on the PubMed database that provided information on the incidence, risk factors and treatment for cardiovascular complications that develop in the post-liver transplantation population. RESULTS Current immunosuppressive agents have improved patient and graft survival rates. However, long-term exposure to these agents has been associated with development of systemic and metabolic complications including hypertension, hyperlipidaemia, diabetes mellitus and obesity. Cardiovascular disease remains one of the most common causes of death in liver transplant patients with functional grafts. CONCLUSIONS Liver transplant recipients have a higher risk of cardiovascular complications compared with the nontransplant population. Post-transplant cardiac risk stratification and aggressive treatment of cardiovascular complications, including modification of risk factors and tailoring of immunosuppressive regimen, is imperative to prevent serious complications.
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Affiliation(s)
- Shireena Desai
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
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Hypertension in the kidney transplant recipient. Transplant Rev (Orlando) 2010; 24:105-20. [DOI: 10.1016/j.trre.2010.02.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2010] [Accepted: 02/02/2010] [Indexed: 12/31/2022]
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El-Kenawy AEM. Investigating the Protective Effects of Astragalus Membranaceus on Nephrotoxicity in Cyclosporine A-treated Rats. ACTA ACUST UNITED AC 2010. [DOI: 10.1007/s00596-009-0136-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Charlton MR, Wall WJ, Ojo AO, Ginès P, Textor S, Shihab FS, Marotta P, Cantarovich M, Eason JD, Wiesner RH, Ramsay MA, Garcia-Valdecasas JC, Neuberger JM, Feng S, Davis CL, Gonwa TA. Report of the first international liver transplantation society expert panel consensus conference on renal insufficiency in liver transplantation. Liver Transpl 2009; 15:S1-34. [PMID: 19877213 DOI: 10.1002/lt.21877] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Abstract
The use of the calcineurin inhibitors cyclosporine and tacrolimus led to major advances in the field of transplantation, with excellent short-term outcome. However, the chronic nephrotoxicity of these drugs is the Achilles' heel of current immunosuppressive regimens. In this review, the authors summarize the clinical features and histologic appearance of both acute and chronic calcineurin inhibitor nephrotoxicity in renal and nonrenal transplantation, together with the pitfalls in its diagnosis. The authors also review the available literature on the physiologic and molecular mechanisms underlying acute and chronic calcineurin inhibitor nephrotoxicity, and demonstrate that its development is related to both reversible alterations and irreversible damage to all compartments of the kidneys, including glomeruli, arterioles, and tubulo-interstitium. The main question--whether nephrotoxicity is secondary to the actions of cyclosporine and tacrolimus on the calcineurin-NFAT pathway--remains largely unanswered. The authors critically review the current evidence relating systemic blood levels of cyclosporine and tacrolimus to calcineurin inhibitor nephrotoxicity, and summarize the data suggesting that local exposure to cyclosporine or tacrolimus could be more important than systemic exposure. Finally, other local susceptibility factors for calcineurin inhibitor nephrotoxicity are reviewed, including variability in P-glycoprotein and CYP3A4/5 expression or activity, older kidney age, salt depletion, the use of nonsteroidal anti-inflammatory drugs, and genetic polymorphisms in genes like TGF-beta and ACE. Better insight into the mechanisms underlying calcineurin inhibitor nephrotoxicity might pave the way toward more targeted therapy or prevention of calcineurin inhibitor nephrotoxicity.
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Affiliation(s)
- Maarten Naesens
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Herestraat 49, B-3000 Leuven, Belgium.
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42
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Taler SJ. Transplant Hypertension. Hypertension 2007. [DOI: 10.1016/b978-1-4160-3053-9.50036-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Tekes E, Soydan G, Tuncer M. The role of endothelin in FK506-induced vascular reactivity changes in rat perfused kidney. Eur J Pharmacol 2005; 517:92-6. [PMID: 15964565 DOI: 10.1016/j.ejphar.2005.05.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2005] [Revised: 05/20/2005] [Accepted: 05/24/2005] [Indexed: 10/25/2022]
Abstract
Tacrolimus (FK506) is an immunosuppressant agent that is widely used in transplanted patients. The aim of this study was to investigate the role of endothelin in the acute effects of FK506 on the vascular reactivity in perfused isolated rat renal and mesenteric vasculature. Left kidney/mesentery of male Wistar rats (230-300 g) were perfused by a constant flow and perfusion pressure was recorded. The responses to noradrenaline and sodium nitroprusside were obtained both in the absence and presence of FK506 (10(-7) M) or polyoxyethylene hydrogenated castor oil 60 (HCO-60 and solvent of the drug at equivalent concentrations). FK506 significantly increased the noradrenaline-induced vasoconstrictor responses in renal, but not in mesenteric vascular beds. Bosentan (10(-5) M), a nonselective endothelin ET-1 receptor antagonist given by perfusion, reversed the increase in noradrenaline responses in the kidney. Sodium nitroprusside-induced vasodilator responses in both renal and mesenteric vascular beds were significantly decreased by FK506. However, in renal vasculature, there was no significant difference between the inhibitory effects of FK506 and HCO-60, although the effect of the solvent was not significantly different from that of the control. While in the mesenteric bed, the solvent significantly inhibited nitroprusside-induced vasodilation, similar to that of FK506. The effect of FK506 on vasodilation in both vascular beds was not reversed by bosentan. Our results indicated that FK506 increased the reactivity of the renal vascular bed to noradrenaline through endothelin ET-1 receptor activation. The mechanism of impaired vasodilation due to FK506 appears to be due to its solvent action and is independent of endothelin release.
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Affiliation(s)
- Ender Tekes
- Department of Pharmacology, Faculty of Medicine, Hacettepe University, Ankara 06100, Turkey
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Neal DAJ, Brown MJ, Wilkinson IB, Alexander GJM. Mechanisms of hypertension after liver transplantation. Transplantation 2005; 79:935-40. [PMID: 15849546 DOI: 10.1097/01.tp.0000158738.00927.65] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Hypertension is the most common cardiovascular complication after liver transplantation. Systemic vasoconstriction underlies transplant hypertension, but the mechanisms contributing to this remain unresolved. Plasma renin, aldosterone, and endothelin (ET)-1 together with augmentation index, a measure of arterial stiffness, were determined before and at intervals of 1, 3, and 6 months after transplant in 32 consecutive patients accepted for liver transplantation. At 3 months, 47% of patients were hypertensive, and at 6 months, 50% of patients were hypertensive. Plasma renin and aldosterone decreased after transplantation but were no different between hypertensive and normotensive patients. Plasma ET-1 levels were elevated pretransplant and decreased at 1 month, but at 6 months, levels were elevated in hypertensive patients but not in normotensive patients (P=0.019). Augmentation index increased after transplant and was greater in the hypertensive patients compared with the normotensive patients (P=0.031). During the first 6 months, the renin-aldosterone system does not play a significant role in posttransplant hypertension. Elevation in plasma ET-1 and increases in arterial stiffness are potential important mechanisms underlying the development of hypertension after liver transplant.
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Affiliation(s)
- David A J Neal
- University Department of Medicine, Addenbrooke's Hospital, Cambridge CB2 2QQ, England, UK
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Affiliation(s)
- S C Textor
- Division of Nephrology and Hypertension, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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Abstract
After more than 20 years of cyclosporine use its nephrotoxicity remains a significant clinical problem. Cyclosporine-induced renal injury has been described in solid organs recipients and in patients treated for autoimmune diseases. It is manifested in 2 distinct and well characterized forms, acute nephrotoxicity and chronic nephrotoxicity. This communication reviews the current literature analyzing the available data about the pathogenesis and mechanisms of acute and chronic cyclosporine-induced nephrotoxicity. A working hypothesis for the possible mechanisms of chronic cyclosporine nephrotoxicity will be provided.
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Affiliation(s)
- Emmanuel A Burdmann
- Division of Nephrology, São José do Rio Preto Medical School, São José do Rio Preto, Brazil.
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Agarwala S, Culligan E, Jain A, McCauley J, Shapiro R, Chakrabarti P, Burckart G, Venkataramanan R. Evaluation of renal function in transplant patients on tacrolimus therapy. J Clin Pharmacol 2002; 42:798-805. [PMID: 12092747 DOI: 10.1177/009127002401102632] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Glomerular filtration rate (GFR), as measured by 24-hour creatinine clearance and clearance of iothalamate, and effective renal plasma flow (ERPF), as measured by the clearance of para-aminohippuric acid (PAH), were evaluated at 2 weeks, 1 month, and 3 months after transplantation in 8 renal transplant patients and at 1 month and 1 year after transplantation in 9 liver transplant patients receiving tacrolimus (Prograf) therapy. In renal transplant patients, there was a significant increase in GFR after transplantation. There was no change in GFR at 1 and 3 months as compared to 2 weeks after transplantation, while ERPF (ml/min/1.73 m2) was lower (p < 0.05) at 3 months (212+/-42) compared to 1 month (306+/-118) after transplantation. In liver transplant patients, GFR and ERPF were below normal despite normal serum creatinine concentrations, but there was no difference in GFR or ERPF at 1 month and 1 year after transplantation. Although below normal, renal function was well preserved in transplant patients while receiving chronic tacrolimus therapy over the study period. Dosage alterations ofrenally eliminated drugs may be required for drugs with a narrow therapeutic index.
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Affiliation(s)
- Sangeeta Agarwala
- Department of Pharmaceutical Sciences and Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pennsylvania 15261, USA
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Abraham KA, McGorrian C, O'Kelly P, Neligan M, Woods AE, Conlon PJ, Donohoe J. The effect of pre-existing ischaemic heart disease on renal dysfunction in cardiac transplant recipients. Am J Transplant 2002; 2:355-9. [PMID: 12118858 DOI: 10.1034/j.1600-6143.2002.20411.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Renal dysfunction is a recognized complication of cardiac transplantation and can impact on the life expectancy of an already fragile population. A large proportion of these patients require transplantation because of the consequences of ischaemic heart disease (IHD) which, in turn, is often associated with ischaemic nephropathy. We studied the effect of IHD, diagnosed prior to transplantation, on the renal function of recipients who survived more than 6months after surgery. Of the 168 patients transplanted in a single centre over 15 years, 132 were included in the study. Renal dysfunction was defined as a serum creatinine consistently above 200 micromol/L (2.26 mg/dL). Analysis confirmed that IHD was an independent risk factor for developing renal impairment. In transplant recipients with IHD, closer monitoring is warranted to detect and prevent renal dysfunction or to retard its progression.
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Klein IHHT, Abrahams A, van Ede T, Hené RJ, Koomans HA, Ligtenberg G. Different effects of tacrolimus and cyclosporine on renal hemodynamics and blood pressure in healthy subjects. Transplantation 2002; 73:732-6. [PMID: 11907418 DOI: 10.1097/00007890-200203150-00012] [Citation(s) in RCA: 116] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The side effects of cyclosporine, nephrotoxicity and hypertension, contribute to long-term renal graft failure and cardiovascular morbidity in graft recipients. It is not clear whether tacrolimus is as nephrotoxic and hypertensive as cyclosporine. Data on this subject are not consistent because of differences in dosage and duration of treatment and the presence of comorbidity in the studied patients. A comparison of both drugs with respect to renal hemodynamics and blood pressure has not been performed yet in healthy subjects. METHODS We studied blood pressure, glomerular filtration rate, and effective renal plasma flow in eight healthy subjects at baseline and after 2 weeks administration of cyclosporine and tacrolimus, in randomized order. Trough levels of either drug were within the currently recommended therapeutical range of 100-200 ng/ml for cyclosporine and 5-15 ng/ml for tacrolimus. RESULTS Tacrolimus did not influence renal hemodynamic parameters, in contrast to cyclosporine. During cyclosporine, glomerular filtration rate decreased from 98+/-9 ml/min/1.732 to 85+/-10 ml/min/1.732 (P<0.05), and ERPF decreased from 597+/-108 ml/min/1.732 to 438+/-84 ml/min/1.732 (P<0.01). Mean arterial blood pressure increased from 93+/-8 mmHg to 108+/-10 mmHg (P<0.05) during cyclosporine and remained unchanged during tacrolimus. CONCLUSIONS We conclude that tacrolimus given during 2 weeks in the currently advised dosage has no unfavorable effects on renal hemodynamics and blood pressure in healthy individuals. The use of tacrolimus in organ transplant recipients may in the long-term lead to better renal function and less cardiovascular morbidity than the use of cyclosporine.
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Affiliation(s)
- Inge H H T Klein
- Department of Nephrology and Hypertension, University Medical Center Utrecht, The Netherlands
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Affiliation(s)
- M G Crespo-Leiro
- Programa de Trasplante Cardiaco, Hospital Juan Canalejo, A Coruña, Spain
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