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Ferulic acid prevents cyclosporine-induced nephrotoxicity in rats through exerting anti-oxidant and anti-inflammatory effects via activation of Nrf2/HO-1 signaling and suppression of NF-κB/TNF-α axis. Naunyn Schmiedebergs Arch Pharmacol 2022; 395:387-395. [PMID: 35092471 DOI: 10.1007/s00210-022-02212-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 01/24/2022] [Indexed: 10/19/2022]
Abstract
Cyclosporine is one of the main immunosuppressive agents used in the treatment of autoimmune diseases or transplantation. Despite the favorable effects, cyclosporine-mediated nephrotoxicity critically restricts the clinical use of the agent. Given this, herein, we aimed to evaluate whether ferulic acid could prevent cyclosporine-mediated nephrotoxicity in rats. A total of 32 Wistar rats were chosen to be treated with cyclosporine, ferulic acid, and the combination of both agents for 21 days. To evaluate the nephron-protective mechanism of ferulic acid, the serum levels of biochemical parameters, as well as the tissue levels of several oxidative and anti-oxidative mediators, were examined. The expression and the tissue levels of nuclear factor (NF)-κB, tumor necrosis factor (TNF)-α, heme oxygenase (HO-1), and nuclear factor erythroid 2-related factor 2 (Nrf2) were evaluated using the qRT-PCR and ELISA, respectively. Our results showed while cyclosporine elevated the serum levels of renal-related markers in the rats, in the presence of ferulic acid, there was a significant reduction in the levels of urea, uric acid, creatinine, and sGOT. Moreover, we found that ferulic acid remarkably prevented cyclosporine-mediated nephrotoxicity by restoring the anti-oxidant system through activating the Nrf2/HO-1 axis. By halting the NF-κB-mediated upregulation of TNF-α, it also seems that ferulic acid prevented lymphocytes infiltration into kidney tissue and consequently suppressed inflammatory responses. Overall, the results of the present study suggest that due to the anti-oxidant and anti-inflammatory properties of ferulic acid, this agent could be used alongside cyclosporine to reduce its adverse effects on kidney tissue.
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Tombelli S, Trono C, Berneschi S, Berrettoni C, Giannetti A, Bernini R, Persichetti G, Testa G, Orellana G, Salis F, Weber S, Luppa PB, Porro G, Quarto G, Schubert M, Berner M, Freitas PP, Cardoso S, Franco F, Silverio V, Lopez-Martinez M, Hilbig U, Freudenberger K, Gauglitz G, Becker H, Gärtner C, O'Connell MT, Baldini F. An integrated device for fast and sensitive immunosuppressant detection. Anal Bioanal Chem 2021; 414:3243-3255. [PMID: 34936009 PMCID: PMC8956524 DOI: 10.1007/s00216-021-03847-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 11/22/2021] [Accepted: 12/10/2021] [Indexed: 12/17/2022]
Abstract
The present paper describes a compact point of care (POC) optical device for therapeutic drug monitoring (TDM). The core of the device is a disposable plastic chip where an immunoassay for the determination of immunosuppressants takes place. The chip is designed in order to have ten parallel microchannels allowing the simultaneous detection of more than one analyte with replicate measurements. The device is equipped with a microfluidic system, which provides sample mixing with the necessary chemicals and pumping samples, reagents and buffers into the measurement chip, and with integrated thin film amorphous silicon photodiodes for the fluorescence detection. Submicrometric fluorescent magnetic particles are used as support in the immunoassay in order to improve the efficiency of the assay. In particular, the magnetic feature is used to concentrate the antibody onto the sensing layer leading to a much faster implementation of the assay, while the fluorescent feature is used to increase the optical signal leading to a larger optical dynamic change and consequently a better sensitivity and a lower limit of detection. The design and development of the whole integrated optical device are here illustrated. In addition, detection of mycophenolic acid and cyclosporine A in spiked solutions and in microdialysate samples from patient blood with the implemented device are reported.
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Affiliation(s)
- Sara Tombelli
- Institute of Applied Physics "Nello Carrara", CNR-IFAC, Via Madonna del Piano 10, 50019, Sesto Fiorentino, Italy
| | - Cosimo Trono
- Institute of Applied Physics "Nello Carrara", CNR-IFAC, Via Madonna del Piano 10, 50019, Sesto Fiorentino, Italy.
| | - Simone Berneschi
- Institute of Applied Physics "Nello Carrara", CNR-IFAC, Via Madonna del Piano 10, 50019, Sesto Fiorentino, Italy
| | - Chiara Berrettoni
- Institute of Applied Physics "Nello Carrara", CNR-IFAC, Via Madonna del Piano 10, 50019, Sesto Fiorentino, Italy
| | - Ambra Giannetti
- Institute of Applied Physics "Nello Carrara", CNR-IFAC, Via Madonna del Piano 10, 50019, Sesto Fiorentino, Italy
| | - Romeo Bernini
- Institute for Electromagnetic Sensing of the Environment, CNR-IREA, Via Diocleziano 328, 80124, Napoli, Italy
| | - Gianluca Persichetti
- Institute for Electromagnetic Sensing of the Environment, CNR-IREA, Via Diocleziano 328, 80124, Napoli, Italy
| | - Genni Testa
- Institute for Electromagnetic Sensing of the Environment, CNR-IREA, Via Diocleziano 328, 80124, Napoli, Italy
| | - Guillermo Orellana
- Department of Organic Chemistry, Faculty of Chemistry, Universidad Complutense de Madrid, 28040, Madrid, Spain
| | - Francesca Salis
- Department of Organic Chemistry, Faculty of Chemistry, Universidad Complutense de Madrid, 28040, Madrid, Spain
| | - Susanne Weber
- Institute of Clinical Chemistry and Pathobiochemistry, Klinikum rechts der Isar, Technische Universität München, Marchioninistrasse 15, 8000, Munich, Germany
| | - Peter B Luppa
- Institute of Clinical Chemistry and Pathobiochemistry, Klinikum rechts der Isar, Technische Universität München, Marchioninistrasse 15, 8000, Munich, Germany
| | - Giampiero Porro
- Datamed Srl, Via Grandi 4/6, 20068 - Peschiera Borromeo, Milan, Italy
| | - Giovanna Quarto
- Datamed Srl, Via Grandi 4/6, 20068 - Peschiera Borromeo, Milan, Italy
| | - Markus Schubert
- Institute for Photovoltaics and Research Center SCoPE, University of Stuttgart, 70569, Stuttgart, Germany
| | - Marcel Berner
- Innovative Pyrotechnik GmbH, Steinwerkstraße 2, 71139, Ehningen, Germany
| | - Paulo P Freitas
- Instituto de Engenharia de Sistemas e Computadores-Microsistemas e Nanotecnologias, R.Alves Redol 9, 1000-027, Lisbon, Portugal
| | - Susana Cardoso
- Instituto de Engenharia de Sistemas e Computadores-Microsistemas e Nanotecnologias, R.Alves Redol 9, 1000-027, Lisbon, Portugal
| | - Fernando Franco
- Instituto de Engenharia de Sistemas e Computadores-Microsistemas e Nanotecnologias, R.Alves Redol 9, 1000-027, Lisbon, Portugal
| | - Vânia Silverio
- Instituto de Engenharia de Sistemas e Computadores-Microsistemas e Nanotecnologias, R.Alves Redol 9, 1000-027, Lisbon, Portugal
| | - Maria Lopez-Martinez
- Instituto de Engenharia de Sistemas e Computadores-Microsistemas e Nanotecnologias, R.Alves Redol 9, 1000-027, Lisbon, Portugal
| | - Urs Hilbig
- Institute for Physical and Theoretical Chemistry, Eberhard Karls University, Auf der Morgenstelle 18, 72076, Tübingen, Germany
| | - Kathrin Freudenberger
- Institute for Physical and Theoretical Chemistry, Eberhard Karls University, Auf der Morgenstelle 18, 72076, Tübingen, Germany
| | - Günter Gauglitz
- Institute for Physical and Theoretical Chemistry, Eberhard Karls University, Auf der Morgenstelle 18, 72076, Tübingen, Germany
| | - Holger Becker
- microfluidic ChipShop GmbH, Stockholmer Str. 20, 07747, Jena, Germany
| | - Claudia Gärtner
- microfluidic ChipShop GmbH, Stockholmer Str. 20, 07747, Jena, Germany
| | - Mark T O'Connell
- Cornel Medical Limited, 17 Church Walk, St Neots, Cambridgeshire, PE19 1JH, UK
| | - Francesco Baldini
- Institute of Applied Physics "Nello Carrara", CNR-IFAC, Via Madonna del Piano 10, 50019, Sesto Fiorentino, Italy
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Le suivi des patients greffés. ACTUALITES PHARMACEUTIQUES 2021. [DOI: 10.1016/j.actpha.2021.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Villeneuve C, Rousseau A, Rerolle JP, Couzi L, Kamar N, Essig M, Etienne I, Westeel PF, Büchler M, Esposito L, Thierry A, Marquet P, Monchaud C. Adherence profiles in kidney transplant patients: Causes and consequences. PATIENT EDUCATION AND COUNSELING 2020; 103:189-198. [PMID: 31447197 DOI: 10.1016/j.pec.2019.08.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 07/30/2019] [Accepted: 08/01/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE Adherence is a dynamic phenomenon and a critical determinant of transplant patients outcome. The objective of this longitudinal study was to explore adherence in kidney transplant patients followed-up for up to three years after transplantation. METHODS Adherence was repeatedly estimated using the Morisky-Green-Levine 4-Item Medication Adherence Scale, in two successive cohorts of 345 (EPIGREN) and 367 (EPHEGREN) kidney transplant recipients. Mixed effect modeling with latent processes and latent classes was used to describe adherence time-profiles. RESULTS Two latent classes were identified. The adherent class represented 85% of the patients. Patients of the poorer-adherence class displayed a lower adherence at one month (p<10-3), which worsened over time. Good adherence was associated with age >50 years, fewer depression episodes (5% vs. 13%, p = 0.001) and a better mental health component of quality of life (MCS-SF36 47 ± 11 vs. 41 ± 13, p = 0.015). Survival without acute rejection episodes was longer in the adherent class (p = 0.004). CONCLUSIONS The risk of poor adherence in renal transplant patients can be detected as early as one month post-transplantation, using appropriate and easy tools adapted to routine monitoring. PRACTICE IMPLICATIONS An early focus on vulnerable patients should allow putting into place actions in order to reduce the risk of poor outcome related to poor adherence.
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Affiliation(s)
- Claire Villeneuve
- CHU Limoges, Department of Pharmacology, Toxicology and Centre of Pharmacovigilance, F-87000 Limoges, France; INSERM, UMR-1248, F-87000 Limoges, France.
| | - Annick Rousseau
- INSERM, UMR-1248, F-87000 Limoges, France; FHU SUPORT, Limoges, F-87000, France; Univ Limoges, Faculty of Pharmacy, Department of Biophysics, F-87000 Limoges, France
| | - Jean-Phillipe Rerolle
- INSERM, UMR-1248, F-87000 Limoges, France; FHU SUPORT, Limoges, F-87000, France; Department of Nephrology, Dialysis and Transplantation, F-87000, Limoges, France
| | - Lionel Couzi
- Department of Nephrology, Transplantation, Dialysis, Centre Hospitalier Universitaire (CHU) Pellegrin, Bordeaux, France; CNRS-UMR 5164 Immuno ConcEpT, Bordeaux University, Bordeaux, France
| | - Nassim Kamar
- Department of Nephrology and Organ Transplantation, CHU Toulouse, Toulouse, France; Université Paul Sabatier, Toulouse, France; INSERM U1043, IFR-BMT, CHU Purpan, Toulouse, France
| | - Marie Essig
- INSERM, UMR-1248, F-87000 Limoges, France; FHU SUPORT, Limoges, F-87000, France; Department of Nephrology, Dialysis and Transplantation, F-87000, Limoges, France; Univ Limoges, Faculty of Medicine, F-87000 Limoges, France
| | - Isabelle Etienne
- Service de Nephrologie, Rouen University Hospital, Rouen, France
| | - Pierre-Francois Westeel
- Department of Nephrology and Kidney Transplantation, University Hospital of Amiens, Amiens, France
| | - Mathias Büchler
- FHU SUPORT, Limoges, F-87000, France; Department of Nephrology and Kidney Transplantation, University Hospital of Tours, Tours, France; François Rabelais University, EA 4245 Tours, France
| | - Laure Esposito
- Department of Nephrology and Organ Transplantation, CHU Toulouse, Toulouse, France
| | - Antoine Thierry
- FHU SUPORT, Limoges, F-87000, France; CHU Poitiers, Department of Nephrology, Dialysis and Transplantation, F-86000 Poitiers, France
| | - Pierre Marquet
- CHU Limoges, Department of Pharmacology, Toxicology and Centre of Pharmacovigilance, F-87000 Limoges, France; INSERM, UMR-1248, F-87000 Limoges, France; FHU SUPORT, Limoges, F-87000, France; Univ Limoges, Faculty of Medicine, F-87000 Limoges, France
| | - Caroline Monchaud
- CHU Limoges, Department of Pharmacology, Toxicology and Centre of Pharmacovigilance, F-87000 Limoges, France; INSERM, UMR-1248, F-87000 Limoges, France; FHU SUPORT, Limoges, F-87000, France
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Karpe KM, Talaulikar GS, Walters GD. Calcineurin inhibitor withdrawal or tapering for kidney transplant recipients. Cochrane Database Syst Rev 2017; 7:CD006750. [PMID: 28730648 PMCID: PMC6483545 DOI: 10.1002/14651858.cd006750.pub2] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Calcineurin inhibitors (CNI) can reduce acute transplant rejection and immediate graft loss but are associated with significant adverse effects such as hypertension and nephrotoxicity which may contribute to chronic rejection. CNI toxicity has led to numerous studies investigating CNI withdrawal and tapering strategies. Despite this, uncertainty remains about minimisation or withdrawal of CNI. OBJECTIVES This review aimed to look at the benefits and harms of CNI tapering or withdrawal in terms of graft function and loss, incidence of acute rejection episodes, treatment-related side effects (hypertension, hyperlipidaemia) and death. SEARCH METHODS We searched the Cochrane Kidney and Transplant Specialised Register to 11 October 2016 through contact with the Information Specialist using search terms relevant to this review. Studies contained in the Specialised Register are identified through search strategies specifically designed for CENTRAL, MEDLINE, and EMBASE; handsearching conference proceedings; and searching the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA All randomised controlled trials (RCTs) where drug regimens containing CNI were compared to alternative drug regimens (CNI withdrawal, tapering or low dose) in the post-transplant period were included, without age or dosage restriction. DATA COLLECTION AND ANALYSIS Two authors independently assessed studies for eligibility, risk of bias, and extracted data. Results were expressed as risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI). MAIN RESULTS We included 83 studies that involved 16,156 participants. Most were open-label studies; less than 30% of studies reported randomisation method and allocation concealment. Studies were analysed as intent-to-treat in 60% and all pre-specified outcomes were reported in 54 studies. The attrition and reporting bias were unclear in the remainder of the studies as factors used to judge bias were reported inconsistently. We also noted that 50% (47 studies) of studies were funded by the pharmaceutical industry.We classified studies into four groups: CNI withdrawal or avoidance with or without substitution with mammalian target of rapamycin inhibitors (mTOR-I); and low dose CNI with or without mTOR-I. The withdrawal groups were further stratified as avoidance and withdrawal subgroups for major outcomes.CNI withdrawal may lead to rejection (RR 2.54, 95% CI 1.56 to 4.12; moderate certainty evidence), may make little or no difference to death (RR 1.09, 95% CI 0.96 to 1.24; moderate certainty), and probably slightly reduces graft loss (RR 0.85, 95% CI 0.74 to 0.98; low quality evidence). Hypertension was probably reduced in the CNI withdrawal group (RR 0.82, 95% CI 0.71 to 0.95; low certainty), while CNI withdrawal may make little or no difference to malignancy (RR 1.10, 95% CI 0.93 to 1.30; low certainty), and probably makes little or no difference to cytomegalovirus (CMV) (RR 0.87, 95% CI 0.52 to 1.45; low certainty)CNI avoidance may result in increased acute rejection (RR 2.16, 95% CI 0.85 to 5.49; low certainty) but little or no difference in graft loss (RR 0.96, 95% CI 0.79 to 1.16; low certainty). Late CNI withdrawal increased acute rejection (RR 3.21, 95% CI 1.59 to 6.48; moderate certainty) but probably reduced graft loss (RR 0.84, 95% CI 0.72 to 0.97, low certainty).Results were similar when CNI avoidance or withdrawal was combined with the introduction of mTOR-I; acute rejection was probably increased (RR 1.43; 95% CI 1.15 to 1.78; moderate certainty) and there was probably little or no difference in death (RR 0.96; 95% CI 0.69 to 1.36, moderate certainty). mTOR-I substitution may make little or no difference to graft loss (RR 0.94, 95% CI 0.75 to 1.19; low certainty), probably makes little of no difference to hypertension (RR 0.86, 95% CI 0.64 to 1.15; moderate), and probably reduced the risk of cytomegalovirus (CMV) (RR 0.60, 95% CI 0.44 to 0.82; moderate certainty) and malignancy (RR 0.69, 95% CI 0.47 to 1.00; low certainty). Lymphoceles were increased with mTOR-I substitution (RR 1.45, 95% CI 0.95 to 2.21; low certainty).Low dose CNI combined with mTOR-I probably increased glomerular filtration rate (GFR) (MD 6.24 mL/min, 95% CI 3.28 to 9.119; moderate certainty), reduced graft loss (RR 0.75, 95% CI 0.55 to 1.02; moderate certainty), and made little or no difference to acute rejection (RR 1.13 ; 95% CI 0.91 to 1.40; moderate certainty). Hypertension was decreased (RR 0.98, 95% CI 0.80 to 1.20; low certainty) as was CMV (RR 0.41, 95% CI 0.16 to 1.06; low certainty). Low dose CNI plus mTOR-I makes probably makes little of no difference to malignancy (RR 1.22, 95% CI 0.42 to 3.53; low certainty) and may make little of no difference to death (RR 1.16, 95% CI 0.71 to 1.90; moderate certainty). AUTHORS' CONCLUSIONS CNI avoidance increased acute rejection and CNI withdrawal increases acute rejection but reduced graft loss at least over the short-term. Low dose CNI with induction regimens reduced acute rejection and graft loss with no major adverse events, also in the short-term. The use of mTOR-I reduced CMV infections but increased the risk of acute rejection. These conclusions must be tempered by the lack of long-term data in most of the studies, particularly with regards to chronic antibody-mediated rejection, and the suboptimal methodological quality of the included studies.
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Affiliation(s)
- Krishna M Karpe
- Canberra HospitalRenal ServicesYamba DriveGarranACTAustralia2605
- Australian National University Medical SchoolActonACTAustralia2601
| | - Girish S Talaulikar
- Canberra HospitalRenal ServicesYamba DriveGarranACTAustralia2605
- Australian National University Medical SchoolActonACTAustralia2601
| | - Giles D Walters
- Canberra HospitalRenal ServicesYamba DriveGarranACTAustralia2605
- Australian National University Medical SchoolActonACTAustralia2601
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Lee SH, Park JB, Oh CK, Kim MS, Kim SJ, Ha J. Cyclosporine Sparing Effect of Enteric-Coated Mycophenolate Sodium in De Novo Kidney Transplantation. Yonsei Med J 2017; 58:217-225. [PMID: 27873516 PMCID: PMC5122640 DOI: 10.3349/ymj.2017.58.1.217] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 01/14/2016] [Accepted: 05/30/2016] [Indexed: 01/19/2023] Open
Abstract
PURPOSE The increased tolerability of enteric-coated mycophenolate sodium (EC-MPS), compared to mycophenolate mofetil, among kidney transplant recipients has the potential to facilitate cyclosporine (CsA) minimization. Therefore, a prospective trial to determine the optimum EC-MPS dose in CsA-based immunosuppression regimens is necessary. MATERIALS AND METHODS A comparative, parallel, randomized, open-label study was performed for 140 patients from four centers to compare the efficacy and tolerability of low dose CsA with standard dose EC-MPS (the investigational group) versus standard dose CsA with low dose EC-MPS (the control group) for six months in de novo kidney transplant recipients. Graft function, the incidence of efficacy failure [biopsy-confirmed acute rejection (BCAR), death, graft loss, loss to follow-up], and adverse events were compared. RESULTS The mean estimated glomerular filtration rate (eGFR) of the investigational group at six months post-transplantation was non-inferior to that of the control group (confidence interval between 57.3 mL/min/1.73m² and 67.4 mL/min/1.73 m², p<0.001). One graft loss was reported in the control group, and no patient deaths were reported in either group. The incidence of BCAR of the investigational group was 8.7%, compared to 18.8% in the control group (p=0.137), during the study period. There were no significant differences (p>0.05) in the incidence of discontinuations and serious adverse events (SAE) between the groups. CONCLUSION CsA minimization using a standard dose of EC-MPS kept the incidence of acute rejection and additional risks as low as conventional immunosuppression and provided therapeutic equivalence in terms of renal graft function and safety issues.
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Affiliation(s)
- Su Hyung Lee
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Jae Berm Park
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Chang Kwon Oh
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Myoung Soo Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Joo Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jongwon Ha
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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Thierry A, Le Meur Y, Ecotière L, Abou-Ayache R, Etienne I, Laurent C, Vuiblet V, Colosio C, Bouvier N, Aldigier JC, Rerolle JP, Javaugue V, Gand E, Bridoux F, Essig M, Hurault de Ligny B, Touchard G. Minimization of maintenance immunosuppressive therapy after renal transplantation comparing cyclosporine A/azathioprine or cyclosporine A/mycophenolate mofetil bitherapy to cyclosporine A monotherapy: a 10-year postrandomization follow-up study. Transpl Int 2016; 29:23-33. [PMID: 26729582 DOI: 10.1111/tri.12627] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Revised: 04/13/2015] [Accepted: 06/15/2015] [Indexed: 11/28/2022]
Abstract
Long-term outcomes in renal transplant recipients withdrawn from steroid and submitted to further minimization of immunosuppressive regimen after 1 year are lacking. In this multicenter study, 204 low immunological risk kidney transplant recipients were randomized 14.2 ± 3.7 months post-transplantation to receive either cyclosporine A (CsA) + azathioprine (AZA; n = 53), CsA + mycophenolate mofetil (MMF; n = 53), or CsA monotherapy (n = 98). At 3 years postrandomization, the occurrence of biopsy for graft dysfunction was similar in bitherapy and monotherapy groups (21/106 vs. 26/98; P = 0.25). At 10 years postrandomization, patients' survival was 100%, 94.2%, and 95.8% (P = 0.25), and death-censored graft survival was 94.9%, 94.7%, and 95.2% (P = 0.34) in AZA, MMF, and CsA groups, respectively. Mean estimated glomerular filtration rate was 70.4 ± 31.1, 60.1 ± 22.2, and 60.1 ± 19.0 ml/min/1.73 m(2), respectively (P = 0.16). The incidence of biopsy-proven acute rejection was 1.4%/year in the whole cohort. None of the patients developed polyomavirus-associated nephropathy. The main cause of graft loss (n = 12) was chronic antibody-mediated rejection (n = 6). De novo donor-specific antibodies were detected in 13% of AZA-, 21% of MMF-, and 14% of CsA-treated patients (P = 0.29). CsA monotherapy after 1 year is safe and associated with prolonged graft survival in well-selected renal transplant recipient (ClinicalTrials.gov number: 980654).
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Affiliation(s)
- Antoine Thierry
- Service de Néphrologie-Hémodialyse-Transplantation rénale, CHU de Poitiers, Poitiers, France.,Institut National de la Santé et de la Recherche Médicale U1082, Poitiers, France
| | | | - Laure Ecotière
- Service de Néphrologie-Hémodialyse-Transplantation rénale, CHU de Poitiers, Poitiers, France
| | - Ramzi Abou-Ayache
- Service de Néphrologie-Hémodialyse-Transplantation rénale, CHU de Poitiers, Poitiers, France
| | | | | | | | | | | | | | | | - Vincent Javaugue
- Service de Néphrologie-Hémodialyse-Transplantation rénale, CHU de Poitiers, Poitiers, France
| | - Elise Gand
- Service de Néphrologie-Hémodialyse-Transplantation rénale, CHU de Poitiers, Poitiers, France
| | - Frank Bridoux
- Service de Néphrologie-Hémodialyse-Transplantation rénale, CHU de Poitiers, Poitiers, France
| | - Marie Essig
- Service de Néphrologie, CHRU, Limoges, France
| | | | - Guy Touchard
- Service de Néphrologie-Hémodialyse-Transplantation rénale, CHU de Poitiers, Poitiers, France.,Institut National de la Santé et de la Recherche Médicale U1082, Poitiers, France
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Sawinski D, Trofe-Clark J, Leas B, Uhl S, Tuteja S, Kaczmarek JL, French B, Umscheid CA. Calcineurin Inhibitor Minimization, Conversion, Withdrawal, and Avoidance Strategies in Renal Transplantation: A Systematic Review and Meta-Analysis. Am J Transplant 2016; 16:2117-38. [PMID: 26990455 DOI: 10.1111/ajt.13710] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 12/28/2015] [Accepted: 01/07/2016] [Indexed: 01/25/2023]
Abstract
Despite their clinical efficacy, concerns about calcineurin inhibitor (CNI) toxicity make alternative regimens that reduce CNI exposure attractive for renal transplant recipients. In this systematic review and meta-analysis, we assessed four CNI immunosuppression strategies (minimization, conversion, withdrawal, and avoidance) designed to reduce CNI exposure and assessed the impact of each on patient and allograft survival, acute rejection and renal function. We evaluated 92 comparisons from 88 randomized controlled trials and found moderate- to high-strength evidence suggesting that minimization strategies result in better clinical outcomes compared with standard-dose regimens; moderate-strength evidence indicating that conversion to a mammalian target of rapamycin inhibitor or belatacept was associated with improved renal function but increased rejection risk; and moderate- to high-strength evidence suggesting planned CNI withdrawal could result in improved renal function despite an association with increased rejection risk. The evidence base for avoidance studies was insufficient to draw meaningful conclusions. The applicability of the review is limited by the large number of studies examining cyclosporine-based strategies and low-risk populations. Additional research is needed with tacrolimus-based regimens and higher risk populations. Moreover, research is necessary to clarify the effect of induction and adjunctive agents in alternative immunosuppression strategies and should include more comprehensive and consistent reporting of patient-centered outcomes.
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Affiliation(s)
- D Sawinski
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - J Trofe-Clark
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,Department of Pharmacy Services, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - B Leas
- Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, PA
| | - S Uhl
- ECRI Institute, Plymouth Meeting, PA
| | - S Tuteja
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | | | - B French
- Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - C A Umscheid
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, PA.,Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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Shih CJ, Tarng DC, Yang WC, Yang CY. Immunosuppressant dose reduction and long-term rejection risk in renal transplant recipients with severe bacterial pneumonia. Singapore Med J 2015; 55:372-7. [PMID: 25091886 DOI: 10.11622/smedj.2014089] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Due to lifelong immunosuppression, renal transplant recipients (RTRs) are at risk of infectious complications such as pneumonia. Severe pneumonia results in respiratory failure and is life‑threatening. We aimed to examine the influence of immunosuppressant dose reduction on RTRs with bacterial pneumonia and respiratory failure. METHODS From January 2001 to January 2011, 33 of 1,146 RTRs at a single centre developed bacterial pneumonia with respiratory failure. All patients were treated using mechanical ventilation and aggressive therapies in the intensive care unit. RESULTS Average time from kidney transplantation to pneumonia with respiratory failure was 6.8 years. In-hospital mortality rate was 45.5% despite intensive care and aggressive therapies. Logistic regression analysis indicated that a high serum creatinine level at the time of admission to the intensive care unit (odds ratio 1.77 per mg/dL, 95% confidence interval 1.01-3.09; p = 0.045) was a mortality determinant. Out of the 33 patients, immunosuppressive agents were reduced in 17 (51.5%). We found that although immunosuppressant dose reduction tended to improve in-hospital mortality, this was not statistically significant. Nevertheless, during a mean follow-up period of two years, none of the survivors (n = 18) developed acute rejection or allograft necrosis. CONCLUSION In RTRs with bacterial pneumonia and respiratory failure, higher serum creatinine levels were a mortality determinant. Although temporary immunosuppressant dose reduction might not reduce mortality, it was associated with a minimal risk of acute rejection during the two-year follow-up. Our results suggest that early immunosuppressant reduction in RTRs with severe pneumonia of indeterminate microbiology may be safe even when pathogens are bacterial in nature.
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Affiliation(s)
| | | | | | - Chih-Yu Yang
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Section 2, Shih-Pai Road, Taipei 11217, Taiwan.
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Woillard JB, Lebreton V, Neely M, Turlure P, Girault S, Debord J, Marquet P, Saint-Marcoux F. Pharmacokinetic tools for the dose adjustment of ciclosporin in haematopoietic stem cell transplant patients. Br J Clin Pharmacol 2015; 78:836-46. [PMID: 24698009 DOI: 10.1111/bcp.12394] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Accepted: 03/25/2014] [Indexed: 01/15/2023] Open
Abstract
AIMS Ciclosporin A (CsA) is used in the prophylaxis and treatment of acute and chronic graft vs. host disease after haematopoietic stem cell (HSCT) transplantation. Our objective was to build and compare three independent Bayesian estimators of CsA area under the curve (AUC) using a limited sampling strategy (LSS), to assist in dose adjustment. METHODS The Bayesian estimators were developed using in parallel: two independent parametric modelling approaches (nonmem® and iterative two stage (ITS) Bayesian modelling) and the non-parametric adaptive grid method (Pmetrics®). Seventy-two full pharmacokinetic profiles (at pre-dose and 0.33, 0.66, 1, 2, 3, 4, 6, 8 and 12h after dosing) collected from 40 HSCT patients given CsA were used to build the pharmacokinetic models, while 15 other profiles (n = 7) were kept for validation. For each Bayesian estimator, AUCs estimated using the full profiles were compared with AUCs estimated using three samples. RESULTS The pharmacokinetic profiles were well fitted using a two compartment model with first order elimination, combined with a gamma function for the absorption phase with ITS and Pmetrics or an Erlang distribution with nonmem. The derived Bayesian estimators based on a C0-C1 h-C4 h sampling schedule (best LSS) accurately estimated CsA AUC(0,12 h) in the validation group (n = 15; nonmem: bias (mean ± SD)/RMSE 2.05% ± 13.31%/13.02%; ITS: 4.61% ± 10.56%/11.20%; Pmetrics: 0.30% ± 10.12%/10.47%). The dose chosen confronting the three results led to a pertinent dose proposal. CONCLUSIONS The developed Bayesian estimators were all able to predict ciclosporin AUC(0,12 h) in HSCT patients using only three blood with minimal bias and may be combined to increase the reliability of CsA dose adjustment in routine.
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Affiliation(s)
- Jean-Baptiste Woillard
- Service de Pharmacologie, Toxicologie et Pharmacovigilance, CHU Limoges, Limoges, France; INSERM UMR-S850, Univ Limoges, Limoges, France
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11
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Kamar N, Del Bello A, Belliere J, Rostaing L. Calcineurin inhibitor-sparing regimens based on mycophenolic acid after kidney transplantation. Transpl Int 2015; 28:928-37. [PMID: 25557802 DOI: 10.1111/tri.12515] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 11/16/2014] [Accepted: 12/24/2014] [Indexed: 11/30/2022]
Abstract
The use of calcineurin inhibitors (CNIs) has dramatically reduced the number of acute rejections and improved kidney allograft survival. However, CNIs can also cause kidney damage and several adverse events. This has prompted transplant physicians to use CNI-sparing regimens. CNI withdrawal, minimization, or avoidance protocols have been conducted using mycophenolic acid (MPA), and/or mammalian-target-of-rapamycin inhibitors, and/or belatacept. Herein, we review the outcomes of minimizing, withdrawing, or avoiding CNIs when giving mycophenolic acid to de novo and maintenance kidney transplant patients. Protocols on CNI withdrawal, when based on MPA without mammalian-target-of-rapamycin inhibitors (mTORi) or belatacept, in de novo and maintenance kidney transplant patients, are associated with an increased risk of acute rejection. Consequently, these strategies have been abandoned and are not recommended. Protocols on CNI minimization show a beneficial impact of kidney function and acceptable acute rejection rates mainly in patients who have been recipients of a graft for >3-5 years. However, no significant improvement to graft survival has been observed.
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Affiliation(s)
- Nassim Kamar
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse, France.,Université Paul Sabatier, Toulouse, France.,INSERM U1043, IFR-BMT, CHU Purpan, Toulouse, France
| | - Arnaud Del Bello
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse, France.,Université Paul Sabatier, Toulouse, France
| | - Julie Belliere
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse, France
| | - Lionel Rostaing
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse, France.,Université Paul Sabatier, Toulouse, France.,INSERM U1043, IFR-BMT, CHU Purpan, Toulouse, France
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Li P, Shuker N, Hesselink DA, van Schaik RHN, Zhang X, van Gelder T. Do Asian renal transplant patients need another mycophenolate mofetil dose compared with Caucasian or African American patients? Transpl Int 2014; 27:994-1004. [PMID: 24963914 DOI: 10.1111/tri.12382] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Revised: 04/22/2014] [Accepted: 06/17/2014] [Indexed: 01/01/2023]
Affiliation(s)
- Pengmei Li
- Department of Hospital Pharmacy; Erasmus Medical Center Rotterdam; Rotterdam The Netherlands
- Department of Pharmacy; China-Japan Friendship Hospital; Beijing China
| | - Nauras Shuker
- Department of Hospital Pharmacy; Erasmus Medical Center Rotterdam; Rotterdam The Netherlands
- Department of Internal Medicine; Erasmus Medical Center Rotterdam; Rotterdam The Netherlands
| | - Dennis A. Hesselink
- Department of Internal Medicine; Erasmus Medical Center Rotterdam; Rotterdam The Netherlands
| | - Ron H. N. van Schaik
- Department of Clinical Chemistry; Erasmus Medical Center Rotterdam; Rotterdam The Netherlands
| | - Xianglin Zhang
- Department of Pharmacy; China-Japan Friendship Hospital; Beijing China
| | - Teun van Gelder
- Department of Hospital Pharmacy; Erasmus Medical Center Rotterdam; Rotterdam The Netherlands
- Department of Internal Medicine; Erasmus Medical Center Rotterdam; Rotterdam The Netherlands
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13
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Cyclosporine therapeutic window evaluation by Chebyshev's inequality method in kidney recipients. Medicina (B Aires) 2014; 50:37-43. [DOI: 10.1016/j.medici.2014.05.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Accepted: 01/15/2014] [Indexed: 11/18/2022] Open
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Heemann U, Viklicky O. The role of belataceptin transplantation: results and implications of clinical trials in the context of other new biological immunosuppressant agents. Clin Transplant 2012. [DOI: 10.1111/ctr.12044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Uwe Heemann
- Department of Nephrology; Klinikum Rechts der Isar der; Technischen Universität München; München; Germany
| | - Ondrej Viklicky
- Department of Nephrology, Transplant Center; Institute for Clinical and Experimental Medicine; Prague; Czech Republic
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Einollahi B, Teimoori M, Rostami Z. Change of Cyclosporine Absorption over the Time after Kidney Transplantation. Nephrourol Mon 2012; 4:470-4. [PMID: 23573469 PMCID: PMC3614282 DOI: 10.5812/numonthly.2437] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2011] [Revised: 10/06/2011] [Accepted: 10/17/2011] [Indexed: 11/21/2022] Open
Abstract
Background Although the immunosuppressant cyclosporine (CsA) is widely used after kidney transplantation over the long term, there is still no firm consensus on the best way to monitor of CsA blood levels. Objectives Cyclosporine (CsA) assay is critical for the management of renal transplant recipients due to inter– and intra–patient variation in CsA absorption and metabolism. Patients and Methods: In a retrospective cross sectional study, blood levels of CsA (through and 2 hours post dose) measured at least 5 times during 3 years post transplantation, in 7702 kidney transplant recipients from different transplant center of Tehran, IR Iran between 2008 and 2012. Cyclosporine absorption (CA) calculated C2/C0 ratio. Results CA had a significant correlation with allograft function (P = 0.000, r =.0.285), this correlation was stronger than its relationship with C0 and C2 blood levels (P = 0.000 and P = 0.000 as well as r = 0.033 and r = 0.090, respectively). In univariate analysis during different times after transplantation, C0 and C2 blood levels significantly decreased over three years follow up (P = 0.000), (P = 0.000); While, CA reversely increases over the time (P = 0.000). In linear regression model overall CA levels had correlation with lower age of recipient (P = 0.02), hypokalemia (P = 0.001), higher level of creatinine (P = 0.02) and triglyceride (P = 0.001). Conclusions The present study shows that CsA absorption changes trough the post-transplant time and appears to increases over time in long–term period after kidney transplantation.
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Affiliation(s)
- Behzad Einollahi
- Nephrology and Urology Research Center, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
| | - Mojtaba Teimoori
- Nephrology and Urology Research Center, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
| | - Zohreh Rostami
- Nephrology and Urology Research Center, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
- Corresponding author: Zohreh Rostami, Nephrology and Urology Research Center, Baqiyatallah University of Medical Sciences, Tehran, IR Iran. Tel.: +98-81262073, Fax: +98-81262073, E-mail:
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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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Efficacy and safety of changing from cyclosporine C0 to C2 monitoring in stable recipients following renal transplantation: a prospective cohort study. Transplant Proc 2011; 43:3697-701. [PMID: 22172829 DOI: 10.1016/j.transproceed.2011.08.105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2011] [Revised: 07/23/2011] [Accepted: 08/31/2011] [Indexed: 11/22/2022]
Abstract
Cyclosporine doses can be adjusted individually to decrease the occurrence of rejection and nephrotoxic episodes using concentrations at 2 hours postdosing (C2). However, some transplantation centers still use trough concentrations (C0) to adjust cyclosporine doses among stable renal transplant recipients. We analyzed the efficacy and safety of changing from monitoring C0 to C2 among stable recipients following living relative donor renal transplantation. We enrolled 65 stable renal transplant recipients whose cyclosporine (Neoral) dosages were adjusted by C0, recording their cyclosporine C2 values. They were divided into low (<500 ng/mL, n=25), target (500-600 ng/mL, n=23), or high (>600 ng/mL, n=17) C2 groups. The cyclosporine dose was prospectively modified in the low and high C2 groups; all patients were followed for 12 months. We compared the incidences of complications among their transplanted kidneys and other organs. Among patients in the high C2 group, the C2 target value was achieved by reducing the cyclosporine dose by up to 575.0 mg (mean=33.8 mg/patient); 88.2% of patients showed stable levels of creatinine (Cr) and urea nitrogen (BUN) during the follow-up with decreased blood cholesterol and uric acid levels in some patients, while two subjects suffered acute rejection episodes. Among the low C2 group, the target value was achieved by increasing the cyclosporine dose by up to 755.0 mg (mean=30.2 mg/patient); during the follow-up with 84.0% of subjects displaying stable levels of Cr and BUN, four suffered increasing Cr and BUN values. Although most of stable recipients in this study benefited from C2 monitoring, some patients suffered rejection or nephrotoxicity episodes. One must be cautious to change from monitoring C0 to C2 in stable recipients following renal transplantation.
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Lan Z, Lian D, Liu W, Arp J, Charlton B, Ge W, Brand S, Healey D, DeBenedette M, Nicolette C, Garcia B, Wang H. Prevention of chronic renal allograft rejection by soluble CD83. Transplantation 2010; 90:1278-85. [PMID: 21079552 DOI: 10.1097/tp.0b013e318200005c] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Recombinant human soluble CD83 had previously exhibited significant immunosuppressive properties that involved interference with dendritic cell maturation in both mouse and humans, inhibition of autoimmunity in mice, and induction of antigen-specific mouse cardiac allograft tolerance when used in combination with other immunosuppressive drugs. Our current research focus turned to examining the effects of peritransplant soluble CD83 (sCD83) administration on prevention of chronic renal allograft rejection. METHODS Fisher344-to-Lewis orthotopic rat renal transplants were performed with sequential recipient killing on postoperative days (PODs) 2, 14, and 140 to examine both the acute and chronic effects of peritransplant sCD83 treatment in rat recipients. RESULTS Recipients treated with sCD83 exhibited a marked decrease in IgM and IgG deposition in the graft and antidonor antibody levels in the circulation, as early as POD14 and persisting until POD140. sCD83 treatment also reduced the infiltration of T cells and monocytes into the graft tissue and inhibited intragraft expression of MyD88 and inflammatory cytokine levels during the observation period. sCD83-treated grafts demonstrated normal histology beyond POD140, including dramatic reductions in tubular atrophy and interstitial fibrosis compared with untreated recipients. CONCLUSION We have demonstrated that peritransplant treatment with recombinant sCD83 attenuates both innate and adaptive immune responses and leads to prevention of chronic rejection in a rat renal transplant model. Because sCD83 is of human origin, the therapeutic approach used in our rodent transplant model holds significant promise for clinical transplantation.
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Affiliation(s)
- Zhu Lan
- Department of Surgery, University of Western Ontario, London, ON, Canada
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Long-Term Impact of Cyclosporin Reduction with MMF Treatment in Chronic Allograft Dysfunction: REFERENECE Study 3-Year Follow Up. J Transplant 2010; 2010. [PMID: 20706667 PMCID: PMC2913628 DOI: 10.1155/2010/402750] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2010] [Accepted: 06/24/2010] [Indexed: 12/14/2022] Open
Abstract
Calcineurin inhibitor (CNI) toxicity contributes to chronic allograft nephropathy (CAN). In the 2-year, randomized, study, we showed that 50% cyclosporin (CsA) reduction in combination with mycophenolate mofetil (MMF) treatment improves kidney function without increasing the risk for graft rejection/loss. To investigate the long-term effect of this regimen, we conducted a follow up study in 70 kidney transplant patients until 5 years after REFERENCE initiation. The improvement of kidney function was confirmed in the MMF group but not in the control group (CsA group). Four graft losses occurred, 2 in each group (graft survival in the MMF group 95.8% and 90.9% in control group). One death occurred in the control group. There was no statistically significant difference in the occurrence of serious adverse events or acute graft rejections. A limitation is the weak proportion of patient still remaining within the control group. On the other hand, REFERENCE focuses on the CsA regimen while opinions about the tacrolimus ones are still debated. In conclusion, CsA reduction in the presence of MMF treatment seems to maintain kidney function and is well tolerated in the long term.
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