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El-Bohy D, El Sharkawy M, Abo-Elazm S, Shahin S, Bchari W, Mancy A, El Hamamsy M. Esomeprazole vs pantoprazole effects on cyclosporine levels in kidney transplantation: A randomized clinical trial. Ther Apher Dial 2019; 24:591-598. [PMID: 31856374 DOI: 10.1111/1744-9987.13464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 12/14/2019] [Accepted: 12/17/2019] [Indexed: 11/30/2022]
Abstract
Renal allograft survival requires multiple immunosuppressive drugs. This strategy may lead to gastric complications that necessitate gastro-protective medications, notably, proton pump inhibitors (PPI). This study aimed to compare the influence of pantoprazole and esomeprazole on serum cyclosporine trough levels (C0 ) in renal transplant recipients (RTR). A prospective, parallel, open-label trial was conducted on 47 adult RTR receiving cyclosporine doses adjusted to attain trough concentrations of 100 to 150 μg/L, mycophenolate mofetil (MMF) 750 mg q12 hour and prednisolone at 5 mg daily at Nasser Institute, Cairo, Egypt from January to September 2016. Patients were randomized into the esomeprazole group (25) or pantoprazole group (22) receiving the same dose (40 mg once daily). The study outcomes included clinical signs of rejection and renal function decline, assessed by elevations in serum creatinine, caused by cyclosporine level variations in either of the two study groups. Renal function, C0 and CBC measurements were measured at baseline and monthly for 6 months. The mean C0 values were higher in the pantoprazole group than in the esomeprazole group in the sixth month only (P = .007). Serum creatinine level was lower in the sixth month than at baseline in the esomeprazole group (P = .004). There were no signs of rejection biochemical or clinical in any of the study groups. In conclusion, PPIs should be used with caution and doses should be titrated to reach the C0 targets in RTR, which is of more importance in pantoprazole than esomeprazole to avoid C0 level elevation or decline affecting the allograft function.
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Affiliation(s)
- Doaa El-Bohy
- Department of Clinical Pharmacy, Future University in Egypt, Cairo, Egypt
| | - Magdy El Sharkawy
- Department of Internal Medicine & Nephrology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Soheir Abo-Elazm
- Department of Pharmacology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Sara Shahin
- Department of Clinical Pharmacy, Faculty of Pharmacy, Ain Shams University, Cairo, Egypt
| | - Waleed Bchari
- Department of Internal Medicine & Nephrology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Azza Mancy
- Department of Clinical Pharmacy, Faculty of Pharmacy, Fayoum University, Fayoum, Egypt
| | - Manal El Hamamsy
- Department of Clinical Pharmacy, Faculty of Pharmacy, Ain Shams University, Cairo, Egypt
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Li LQ, Chen DN, Li CJ, Li QP, Chen Y, Fang P, Zheng P, Lu HJ, Ye DM, Wan HY, Li J, Li L. Impact of UGT2B7 and ABCC2 genetic polymorphisms on mycophenolic acid metabolism in Chinese renal transplant recipients. Pharmacogenomics 2018; 19:1323-1334. [PMID: 30345879 DOI: 10.2217/pgs-2018-0114] [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] [Indexed: 12/12/2022] Open
Abstract
AIM To evaluate genetic variants affecting mycophenolic acid (MPA) metabolism in Chinese renal transplant recipients. METHODS Total 11 SNPs of UGT1A9, UGT1A8, UGT2B7, ABCC2, ABCG2 and SLCO1B3 were genotyped in 408 Chinese renal transplant recipients. Associations between SNPs and MPA concentration/dose ratio (C0/D) were analyzed using different genetic models. Multivariate linear regression was used to analyze associations between log (C0/D) and clinical factors. Results: After adjustment by clinical factors, UGT2B7 rs7662029 was associated with log (C0/D) using a dominant (p = 0.041) and an additive (p = 0.038) model, ABCC2 rs717620 was associated with log (C0/D) using a recessive model (p = 0.019). Using additive model, SNP-SNP interactions were identified (p = 0.002) between ABCC2 rs717620 and UGT1A9 rs2741049, with interactions (p = 0.002) between ABCC2 rs717620 and UGT1A8 rs1042597. Age, albumin and serum creatinine were associated with log (C0/D). CONCLUSION rs7662029 and rs717620 may affect MPA pharmacokinetics. SNP-SNP interactions and clinical factors may have significant effects on MPA metabolism.
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Affiliation(s)
- Li-Qing Li
- Department of Medical Genetics, School of Basic Medical Sciences, Southern Medical University, Guangzhou 510515, Guangdong, PR China
| | - Di-Na Chen
- Department of Medical Genetics, School of Basic Medical Sciences, Southern Medical University, Guangzhou 510515, Guangdong, PR China
| | - Chuan-Jiang Li
- Department of Hepatobiliary Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510515, Guangdong, PR China
| | - Qing-Ping Li
- Department of Hepatobiliary Surgery, Nanfang Hospital, Southern Medical University, Guangzhou 510515, Guangdong, PR China
| | - Yan Chen
- Department of Pharmacy, Nanfang Hospital, Southern Medical University, Guangzhou 510515, Guangdong, PR China
| | - Ping Fang
- Department of Medical Genetics, School of Basic Medical Sciences, Southern Medical University, Guangzhou 510515, Guangdong, PR China
| | - Ping Zheng
- Department of Pharmacy, Nanfang Hospital, Southern Medical University, Guangzhou 510515, Guangdong, PR China
| | - Hui-Jie Lu
- Department of Medical Genetics, School of Basic Medical Sciences, Southern Medical University, Guangzhou 510515, Guangdong, PR China
| | - De-Mei Ye
- Department of Medical Genetics, School of Basic Medical Sciences, Southern Medical University, Guangzhou 510515, Guangdong, PR China
| | - Hao-Yang Wan
- Department of Medical Genetics, School of Basic Medical Sciences, Southern Medical University, Guangzhou 510515, Guangdong, PR China
| | - Jie Li
- Department of Medical Genetics, School of Basic Medical Sciences, Southern Medical University, Guangzhou 510515, Guangdong, PR China
| | - Liang Li
- Department of Medical Genetics, School of Basic Medical Sciences, Southern Medical University, Guangzhou 510515, Guangdong, PR China.,Key Laboratory of single cell technology and application in Guangzhou, Guangdong, PR China
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Cai W, Cai Q, Xiong N, Qin Y, Lai L, Sun X, Hu Y. Limited Sampling Strategy for Estimating Mycophenolic Acid Exposure on Day 7 Post-Transplant for Two Mycophenolate Mofetil Formulations Derived From 20 Chinese Renal Transplant Recipients. Transplant Proc 2018; 50:1298-1304. [PMID: 29735215 DOI: 10.1016/j.transproceed.2018.02.068] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 02/01/2018] [Accepted: 02/17/2018] [Indexed: 11/18/2022]
Abstract
PURPOSE To assess the pharmacokinetic properties of mycophenolate mofetil (MMF) dispersible tablets and capsules by the enzyme multiplied immunoassay technique (EMIT) in Chinese kidney transplant recipients in the early post-transplantation phase and to develop the equations to predict mycophenolic acid (MPA) area under the 12-hour concentration-time curve (AUC0-12h) using a limited sampling strategy (LSS). METHODS Forty patients who underwent renal transplantation from brain-dead donors were randomly divided into dispersible tablets (Sai KE Ping; Hangzhou Zhongmei Huadong Pharma) and capsules (Cellcept; Roche Pharma, Why, NSW, Australia) groups, and treated with MMF combined with combination tacrolimus and prednisone as a basic immunosuppressive regimen. Blood samples were collected before treatment (0) and at 0.5,1, 1.5, 2, 4, 6, 8, 10, and 12 hours post-treatment and 7 days after renal transplantation. Plasma MPA concentrations were measured using EMIT. LSS equations were identified using multiple stepwise linear regression analysis. RESULTS The peak concentration (Cmax) in the MMF dispersible tablets (MMFdt) group (7.0 ± 2.8) mg/L was reduced compared with that in the MMF capsules (MMFc) group (10.8 ± 6.2 mg/L; P = .012); time to peak concentration in the MMFdt group was 3.2 ± 2.3 hours, which was nonsignificantly elevated compared with that of the MMFc group (2.2 ± 1.7 hours). Three-point estimation formulas were generated by multiple linear regression for both groups: MPA-AUCMMFdt = 3.542 + 3.332C0.5h + 1.117C1.5h + 3.946C4h (adjusted r2 = 0.90, P < .001); MPA-AUCMMFc = 8.149 + 1.442C2h + 1.056C4h + 7.133C6h (adjusted r2 = 0.88, P < .001). Both predicted and measured AUCs showed good consistency. CONCLUSIONS After treatment with MMF dispersible tables or MMF capsules, the Cmax of MPA for the MMFdt group was significantly lower than that of the MMFc group; there was no significant difference in other pharmacokinetic parameters. Three-time point equations can be used as a predictable measure of the AUC0-12h of MPA.
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Affiliation(s)
- W Cai
- Department of Clinical Pharmacy, 303 Hospital of PLA, Nanning, China
| | - Q Cai
- Department of Clinical Pharmacy, 458 Hospital of PLA, Guangzhou, China
| | - N Xiong
- Guangxi Key Laboratory for Transplantation Medicine, Institute of Transplant Medicine, 303 Hospital of PLA, Nanning, China
| | - Y Qin
- Guangxi Key Laboratory for Transplantation Medicine, Institute of Transplant Medicine, 303 Hospital of PLA, Nanning, China
| | - L Lai
- Department of Pharmaceutics, Guangxi Medical University, Nanning, Guangxi, China
| | - X Sun
- Guangxi Key Laboratory for Transplantation Medicine, Institute of Transplant Medicine, 303 Hospital of PLA, Nanning, China.
| | - Y Hu
- Department of Clinical Pharmacy, 303 Hospital of PLA, Nanning, China.
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Ciftci HS, Karadeniz MS, Tefik T, Caliskan Y, Yazıcı H, Demir E, Turkmen A, Nane I, Oguz FS, Aydin F. Influence of Proton Pump Inhibitors on Mycophenolic Acid Pharmacokinetics in Patients With Renal Transplantation and the Relationship With Cytochrome 2C19 Gene Polymorphism. Transplant Proc 2017; 49:490-496. [PMID: 28340819 DOI: 10.1016/j.transproceed.2017.01.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Most patients have serious digestive complications after renal transplantation. Therefore, it is important to protect gastrointestinal function to improve the survival rate of transplant patients. Proton pump inhibitors (PPIs) such as lansoprazole and rabeprazole are widely administered to renal transplant patients with mycophenolic acid (MPA) in the perioperative period. PPIs are metabolized by cytochrome (CYP) 2C19 enzymes. Mycophenolate sodium (MYF) and mycophenolate mofetil (MMF) have been used in immunosuppression. Clinically relevant drug-drug interactions have been described between immunosuppressive drugs. In the present study, we investigated the drug interaction between MPA and lansoparazole or rabeprazole and the impact of CYP2C19 polymorphisms on these drug interactions after renal transplantation. MATERIALS AND METHODS A total of 125 renal transplant patients taking MPA derivatives between 2012 and 2016 were included in this study. The 125 patients were divided into 6 groups: MMF/tacrolimus/steroid together with lansoprazole or rabeprazole; MYF/tacrolimus/steroid together with lansoprazole or rabeprazole and without PPI. The single nucleotide polymorphisms of CYP2C19 were determined by the polymerase chain reaction-restriction fragment length polymorphism. Plasma concentrations of MPA were measured by cloned enzyme donor immunoassay. Clinical parameters such as incidence of delayed graft function and acute rejection, the rate of change of serum creatinine, toxicity, and gastrointestinal adverse effects were analyzed retrospectively. RESULTS The mean concentrations of MPA in the MYF group were higher than those in the MMF group. The mean dose-adjusted blood concentration of MPA coadministered with lansoprazole was lower than that of MPA with rabeprazole or without PPI in MMF and MYF groups (P < .05). In patients with the CYP2C19*2/*2 genotype, the mean concentrations of MMF with lansoprazole were significantly lower than those with rabeprazole with MMF or without PPI (P < .05). Gastrointestinal side effects were significantly higher in MMF with lansoprazole group than in MYF with lansoprazole group (P < .05). However, no differences were found according to genotype distribution in all groups (P > .05). CONCLUSION Polymorphisms in CYP2C19 are related to the metabolic oxidation of drugs to varying degrees. Both genetic and clinical factors in pharmacokinetics may help to make further progress toward individualized therapy to yield maximum efficacy with minimal side effects.
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Affiliation(s)
- H S Ciftci
- Department of Medical Biology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey.
| | - M S Karadeniz
- Department of Anesthesiology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - T Tefik
- Department of Urology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Y Caliskan
- Department of Nephrology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - H Yazıcı
- Department of Nephrology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - E Demir
- Department of Nephrology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - A Turkmen
- Department of Nephrology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - I Nane
- Department of Urology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - F S Oguz
- Department of Medical Biology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - F Aydin
- Department of Medical Biology, Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
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Kagaya H, Niioka T, Saito M, Inoue T, Numakura K, Habuchi T, Satoh S, Miura M. Effect of hepatic drug transporter polymorphisms on the pharmacokinetics of mycophenolic acid in patients with severe renal dysfunction before renal transplantation. Xenobiotica 2016; 47:916-922. [PMID: 27616538 DOI: 10.1080/00498254.2016.1235742] [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] [Indexed: 10/21/2022]
Abstract
1. The objective of this study was to examine the association of UGT1A9, SLCO, and ABCC polymorphisms with mycophenolic acid (MPA) pharmacokinetics in ABO blood type (ABO) incompatible patients with severe renal dysfunction pre-transplantation. 2. In all patients, on day 14 after beginning mycophenolate mofetil (MMF) treatment (1 week before transplantation) and on day 28 after renal transplantation, samples were collected just prior to and 1, 2, 3, 4, 6, 9, and 12 h after oral MMF administration. 3. The median dose-adjusted AUC0-12 of MPA after renal transplantation was significantly lower than before transplantation (57.9 versus 76.5 μg h/mL, respectively, p = 0.002). 4. Although the enterohepatic circulation of MPA pre-transplantation was extremely high (57.6%), this level was significantly reduced after renal transplantation (34.6%). 5. In the multivariate analysis, pre-transplantation, patients with the SLCO1B3 334T allele (p = 0.003), higher alanine aminotransferase (p = 0.002), and lower body weight were independently predictive for a higher dose-adjusted AUC0-12 of MPA. 6. In patients with severe renal dysfunction pre-transplantation, MPA is excreted mainly to bile from the liver, and as a consequence, the SLCO1B3 334T > G polymorphism was found to be significantly associated with MPA exposure.
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Affiliation(s)
- Hideaki Kagaya
- a Department of Pharmacy , Akita University Hospital , Akita , Japan
| | - Takenori Niioka
- a Department of Pharmacy , Akita University Hospital , Akita , Japan
| | - Mitsuru Saito
- b Department of Urology , Akita University School of Medicine , Akita , Japan , and
| | - Takamitsu Inoue
- b Department of Urology , Akita University School of Medicine , Akita , Japan , and
| | - Kazuyuki Numakura
- b Department of Urology , Akita University School of Medicine , Akita , Japan , and
| | - Tomonori Habuchi
- b Department of Urology , Akita University School of Medicine , Akita , Japan , and
| | - Shigeru Satoh
- c Center for Kidney Disease and Transplantation, Akita University Graduate School of Medicine , Akita , Japan
| | - Masatomo Miura
- a Department of Pharmacy , Akita University Hospital , Akita , Japan
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Implications of Clinical Mycophenolate Mofetil Dose According to Individual Body Weight in Japanese Renal Transplant Recipients. Transplant Proc 2016; 48:35-41. [PMID: 26915840 DOI: 10.1016/j.transproceed.2015.11.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Revised: 11/05/2015] [Accepted: 11/18/2015] [Indexed: 11/20/2022]
Abstract
BACKGROUND Mycophenolate mofetil (MMF) is generally administered at a fixed dose of 0.5-1.5 g/d without considering individual body weight (BW) in Japanese renal transplant outpatients receiving maintenance therapy. We aimed to investigate the implications of the area under the curve of mycophenolic acid (MPA AUC):MMF dose ratio by individual BW and suggest the index of MMF dose according to individual BW. METHODS Forty-three Japanese patients who received a renal transplant ≥6 months before the study were enrolled. Blood samples were collected at 4 time points: at predose, 20 minutes, 1 hour, and 3 hours after MMF administration. RESULTS The mean ± standard deviation MMF dose, MPA AUC, and BW of all patients were 581 ± 207 mg/d, 36.2 ± 18.7 μg·h/mL, and 56.3 ± 11.1 kg, respectively. Patients with a lower BW tended to have a higher MPA AUC:MMF dose ratio than patients with a higher BW. There was a significant correlation between the MMF dose:BW ratios and MPA AUC (r(2) = 0.330; P < .01). The rate of MPA AUC between 30 and 60 μg·h/mL with the MMF dose:BW ratio of 10-16 mg/kg was 73.7%. CONCLUSION Individual BW seems to affect the MPA AUC:MMF dose ratio; therefore, we need to consider individual BW when deciding on a MMF dose. The MMF dose:BW ratio of 10-16 mg/kg could predict MPA AUC between 30 and 60 μg·h/mL with a probability of approximately 75%. Therefore, it could be a useful index for outpatients, because it is difficult to draw blood frequently from such patients.
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Pazdernik M, Malek I, Koudelkova E, Sochman J, Kautzner J. Bone marrow suppression and associated consequences in patients after heart transplantation: A 6-year retrospective review. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2015; 159:372-7. [PMID: 26000773 DOI: 10.5507/bp.2015.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 04/22/2015] [Indexed: 11/23/2022] Open
Abstract
AIMS To evaluate the incidence of bone marrow suppression and consequences of MMF dose adjustment in patients within the first year after heart transplantation. METHODS Group I (n=47) was treated with a regimen currently used in patients after heart transplantation (mycophenolatemofetil - MMF, valganciclovir - VGC and trimethoprim/sulfamethoxazole - TMP-SMX). Group II (n=47) received only MMF of potentially myelotoxic medications. The myelotoxic effect and need for dose modification were assessed. The incidence of rejections and infectious episodes associated with MMF adjustment were analyzed during the first 12 months in Group I. RESULTS There was a significantly greater proportion of patients with leukopenia (leukocyte count < 4 x 10^9/L) at 3 months after orthotopic heart transplantation in Group I compared with Group II (19.1% vs 2.1%; P = 0.02). The difference in lymphopenia (lymphocyte count < 0.8 x 10^9/L) at 3 months follow-up was highly significant (38.3 % vs 6.4 %; P = 0.0002). MMF was modified due to bone marrow suppression or severe infection in 63.8% patients in Group I and in only 8.5% of patients in Group II (P < 0.001). Reducing or stopping MMF was not associated with increased rejections. In Group I, at least 1 episode of higher degree cellular or humoral rejection occurred in 35% of patients with the standard MMF dosage compared with only 26% in patients with modified MMF (P = 0.0534). CONCLUSIONS Addition of VGC+TMP-SMX to current immunosuppressive medication regimen in patients after heart transplantation is associated with significant lymphocytopenia and leukopenia. Importantly, modification of immunosuppressive prophylaxis (reducing or stopping MMF) leads to normalization of blood count without increased incidence of rejections.
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Affiliation(s)
- Michal Pazdernik
- Department of Cardiology, Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic
| | - Ivan Malek
- Department of Cardiology, Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic
| | - Eva Koudelkova
- Department of Cardiology, Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic
| | - Jan Sochman
- Department of Cardiology, Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic
| | - Josef Kautzner
- Department of Cardiology, Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic
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Chaabane A, Aouam K, Ben Fredj N, Hammouda M, Chadly Z, El May M, Boughattas N, Skhiri H. Limited sampling strategy of mycophenolic acid in adult kidney transplant recipients: influence of the post-transplant period and the pharmacokinetic profile. J Clin Pharmacol 2013; 53:925-33. [PMID: 23813362 DOI: 10.1002/jcph.125] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Accepted: 05/25/2013] [Indexed: 11/07/2022]
Abstract
We aimed to develop an accurate and convenient LSS for predicting MPA-AUC(0-12 hours) in Tunisian adult kidney transplant recipients whose immunosuppressive regimen consisted of MMF and tacrolimus combination with regards to the post-transplant period and the pharmacokinetic profile. Each pharmacokinetic profile consisted of eight blood samples collected during the 12-hour dosing interval. The AUC(0-12 hours) was calculated according to the linear trapezoidal rule. The MPA concentrations at each sampling time were correlated by a linear regression analysis with the measured AUC(0-12). We analyzed all the developed models for their ability to estimate the MPA-AUC(0-12 hours). The best multilinear regression model for predicting the full MPA-AUC(0-12 hours) was found to be the combination of C1, C4, and C6. All the best correlated models and the most convenient ones were verified to be also applicable before 5 months after transplantation and thereafter. These models were also verified to be applicable for patients having or not the second peak in their pharmacokinetic profiles. For practical reasons we recommend a LSS using C0, C1, and C4 that provides a reasonable MPA-AUC(0-12 hours) estimation.
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Affiliation(s)
- Amel Chaabane
- Department of Pharmacology, University of Medicine, Monastir, Tunisia.
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Li J, Liu Y, Huang J, Fu Q, Chen E, Liu L, Zhang R, Huang M, Wang C. Evaluation of mycophenolic acid exposure using a limited sampling strategy in renal transplant recipients. Am J Nephrol 2013; 37:534-40. [PMID: 23689735 DOI: 10.1159/000351180] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2012] [Accepted: 03/22/2013] [Indexed: 01/22/2023]
Abstract
BACKGROUND/AIMS While there are drug exposure equation models based on limited sampling times for mycophenolate mofetil (MMF), there are few for enteric-coated mycophenolate sodium (EC-MPS), and none that studied Chinese individuals. Our objective is to generate the optimal model equations for estimation of the mycophenolic acid (MPA) area under the plasma concentration-time curve from 0 to 12 h (MPA-AUC(0-12h)) with a limited sampling strategy (LSS) for renal transplant recipients receiving EC-MPS. METHODS The pharmacokinetics in 31 Chinese renal allograft recipients treated with EC-MPS in combination with tacrolimus and steroids were determined. The model equations were generated by multiple stepwise regression analysis for estimation of the MPA-AUC. RESULTS A total of 31 patients with an average age and weight of 37.58 ± 10.9 years and 60.9 ± 10.7 kg, respectively, were included. Mean serum creatinine and glomerular filtration rate were 112.2 ± 17.7 μmol/l and 65.6 ± 14.6 ml/min, respectively. The mean values of AUC(0-12h), pre-dose MPA trough concentration (C0), maximum concentrations (C(max)), and time to reach C(max) (T(max)) were 61.17 ± 26.39 mg·h/l (range 22.9-123.0 mg·h/l), 4.98 ± 4.65 mg/l (range 0.13-20.04 mg/l), 17.54 ± 10.67 mg/l (range 4.08-42.36 mg/l), and 5.0 ± 2.6 h (range 1.0-10.5 h), respectively. The best predictive equation for estimation of MPA-AUC(0-12h) was -3.63 + 8.35 × C4 + 17.04 × C7 + 13.74 × C12 (r(2) = 0.7491), prediction bias (PE%) was 20.9 ± 20.37, and prediction precision (APE%) was 3.66 ± 29.20. CONCLUSIONS This model provides an effective approach for estimation of full MPA-AUC(0-12h) in Chinese adult renal allograft recipients treated with EC-MPS and tacrolimus.
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Affiliation(s)
- Jun Li
- Department of Transplantation, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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10
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A possible simplification for the estimation of area under the curve (AUC₀₋₁₂) of enteric-coated mycophenolate sodium in renal transplant patients receiving tacrolimus. Ther Drug Monit 2011; 33:165-70. [PMID: 21383656 DOI: 10.1097/ftd.0b013e31820c16f8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Enteric-coated mycophenolate sodium (EC-MPS) is widely used in renal transplantation. With a delayed absorption profile, it has not been possible to develop limited sampling strategies to estimate area under the curve (mycophenolic acid [MPA] AUC₀₋₁₂), which have limited time points and are completed in 2 hours. We developed and validated simplified strategies to estimate MPA AUC₀₋₁₂ in an Indian renal transplant population prescribed EC-MPS together with prednisolone and tacrolimus. Intensive pharmacokinetic sampling (17 samples each) was performed in 18 patients to measure MPA AUC₀₋₁₂. The profiles at 1 month were used to develop the simplified strategies and those at 5.5 months used for validation. We followed two approaches. In one, the AUC was calculated using the trapezoidal rule with fewer time points followed by an extrapolation. In the second approach, by stepwise multiple regression analysis, models with different time points were identified and linear regression analysis performed. Using the trapezoidal rule, two equations were developed with six time points and sampling to 6 or 8 hours (8hrAUC[₀₋₁₂exp]) after the EC-MPS dose. On validation, the 8hrAUC(₀₋₁₂exp) compared with total measured AUC₀₋₁₂ had a coefficient of correlation (r²) of 0.872 with a bias and precision (95% confidence interval) of 0.54% (-6.07-7.15) and 9.73% (5.37-14.09), respectively. Second, limited sampling strategies were developed with four, five, six, seven, and eight time points and completion within 2 hours, 4 hours, 6 hours, and 8 hours after the EC-MPS dose. On validation, six, seven, and eight time point equations, all with sampling to 8 hours, had an acceptable r with the total measured MPA AUC₀₋₁₂ (0.817-0.927). In the six, seven, and eight time points, the bias (95% confidence interval) was 3.00% (-4.59 to 10.59), 0.29% (-5.4 to 5.97), and -0.72% (-5.34 to 3.89) and the precision (95% confidence interval) was 10.59% (5.06-16.13), 8.33% (4.55-12.1), and 6.92% (3.94-9.90), respectively. Of the eight simplified approaches, inclusion of seven or eight time points improved the accuracy of the predicted AUC compared with the actual and can be advocated based on the priority of the user.
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Monitoring of Mycophenolic Acid Predose Concentrations in the Maintenance Phase More Than One Year After Renal Transplantation. Ther Drug Monit 2011; 33:295-302. [DOI: 10.1097/ftd.0b013e3182197e38] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Influence of drug transporters and UGT polymorphisms on pharmacokinetics of phenolic glucuronide metabolite of mycophenolic acid in Japanese renal transplant recipients. Ther Drug Monit 2010; 30:559-64. [PMID: 18695635 DOI: 10.1097/ftd.0b013e3181838063] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Mycophenolic acid (MPA) is mainly glucuronized by uridine diphosphate-glucuronosyltransferases (UGTs) into the phenolic MPA glucuronide (MPAG). MPAG is excreted by transporters such as organic anion-transporting polypeptide (gene SLCO), multidrug resistance protein 2 (gene ABCC2), breast cancer resistance protein (BCRP, gene ABCG2) or P-glycoprotein (gene ABCB1). This study investigated the association of UGTs, SLCOs, ABCB1, ABCC2, and ABCG2 polymorphisms with MPAG pharmacokinetics in 80 Japanese renal transplant recipients. Eighty recipients were given repeated doses of combination immunosuppressive therapy consisting of mycophenolate mofetil and tacrolimus every 12 hours at a designated time (0900 and 2100). On day 28, after renal transplantation, plasma concentrations of MPA and MPAG were measured by high-performance liquid chromatography. There were no significant differences in the area under the plasma concentration-time curve (AUC) ratio of MPAG/MPA between UGT1A1, UGT1A6, UGT1A7, UGT1A8, and UGT1A9 I399C/T genotypes. On the other hand, the median dose-adjusted AUC0-12 of MPAG in SLCO1B1 1a/1a+1a/1b+1b+1b (n = 53) and 1a/*15 + 1b/*15+*15/*15 (n = 27) were 1549 and 1134 mg.h L g, respectively (P = 0.03004 in multivariate analysis). The median dose-adjusted AUC0-12 of MPAG in SLCO1B3 334T/T+T/G (699G/G+G/A, n = 46) and 334G/G (699A/A, n = 34) was 1191 and 1580 mg.h L g, respectively (P = 0.02792 in multivariate analysis). There were no significant differences in the dose-adjusted AUC0-12 of MPAG between the ABCB1 C3435T and ABCC2 C-24T genotypes. However, the dose-adjusted AUC0-12 of MPAG was significantly lower in recipients with ABCG2 421C/A+A/A (n = 44) than in those with C/C (n = 36) (P = 0.0295). In conclusion, our findings showed that MPAG pharmacokinetics were significantly influenced by SLCO1B1 and SLCO1B3 polymorphisms and not by UGT polymorphisms. BCRP rather than multidrug resistance protein 2 seems to be the transporter associated with biliary excretion of MPAG.
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A Reliable Limited Sampling Strategy for the Estimation of Mycophenolic Acid Area Under the Concentration Time Curve in Adult Renal Transplant Patients in the Stable Posttransplant Period. Ther Drug Monit 2010; 32:136-40. [DOI: 10.1097/ftd.0b013e3181cd550f] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Early phase limited sampling strategy characterizing tacrolimus and mycophenolic acid pharmacokinetics adapted to the maintenance phase of renal transplant patients. Ther Drug Monit 2010; 31:467-74. [PMID: 19571775 DOI: 10.1097/ftd.0b013e3181ae44b9] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The aim of this study was to examine whether a limited sampling strategy (LSS) to allow the simultaneous estimation of the area under the concentration-time curves (AUCs) of tacrolimus and mycophenolic acid (MPA) calculated in the early stage after renal transplantation could be applied to maintenance phase pharmacokinetics. Seventy Japanese patients were enrolled. One year after transplantation, samples were collected just before and 1, 2, 3, 4, 6, 9, and 12 hours after tacrolimus and mycophenolate mofetil administration at 9:00 am and at 9:00 pm. The prediction formulas on day 28 (tacrolimus AUC 0-12 = 7.04 x C 0h + 1.71 x C 2h + 3.23 x C 4h + 15.19 and 2.25 x C 2h + 1.92 x C 4h + 7.27 x C 9h + 6.61, and MPA AUC 0-12 = 0.26 x C 0h + 2.06 x C 2h + 3.82 x C 4h + 20.38 and 1.77 x C 2h + 2.34 x C 4h + 4.76 x C 9h + 15.94) were applied to pharmacokinetic data obtained at 1 year. Three error indices [percent mean prediction error (ME), % mean absolute error, and percent root mean squared prediction error (RMSE)] were used to evaluate the predictive bias, accuracy, and precision. The predicted AUC 0-12 of tacrolimus and MPA at 3 time points, C 2h-C 4h-C 9h, showed higher correlation with the measured AUC 0-12 of tacrolimus and MPA (r2 = 0.817 and 0.789, respectively) in comparison with those at C 0h-C 2h-C 4h. The values for the prediction formulas for tacrolimus AUC at 1 year using the C 2h-C 4h-C 9h combination yielded less than 5% for %ME and 15% for %RMSE. The %ME and %RMSE values of the prediction formulas for tacrolimus AUC using the C 0h-C 2h-C 4h combination were 6.3% and 15.9%, respectively. The %ME and %RMSE values of the prediction formulas for MPA AUC at 1 year using the C 0h-C 2h-C 4h combination were 5.9% and 25.8%, respectively, and those for the C 2h-C 4h-C 9h combination were 4.9% and 21.2%, respectively. AUC 6-12/AUC 0-12 of MPA 1 year after transplantation was significantly lower than 28 days after transplantation. An LSS using C 2h-C 4h-C 9h seems to be applicable for predicting the AUC of tacrolimus and MPA at either posttransplantation stage. The enterohepatic circulation of MPA was significantly reduced 1 year after transplantation. Therefore, 1 year after transplantation, the estimation of the AUC 0-12 of MPA for the C 0h-C 2h-C 4h equations was imprecise. It is important that the LSS includes C 9h because it contains information on the secondary plasma peak of MPA.
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Genetic polymorphisms influence mycophenolate mofetil-related adverse events in pediatric heart transplant patients. J Heart Lung Transplant 2010; 29:509-16. [PMID: 20061166 DOI: 10.1016/j.healun.2009.11.602] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2009] [Revised: 11/18/2009] [Accepted: 11/20/2009] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Mycophenolate mofetil (MMF) is an effective and commonly used immunosuppressant but has frequent adverse events. Genetic polymorphisms may contribute to variability in MMF efficacy and related complications. In this study we explore the distribution frequencies of common single nucleotide polymorphisms (SNPs) of IMPDH1, IMPDH2 and ABCC2 and investigate whether these SNPs influence MMF adverse events in 59 pediatric heart recipients. METHODS Genotypes were assessed by TaqMan analysis of: ABCC2 rs717620; IMPDH2 rs11706052; and IMPDH1 rs2288553, rs2288549, rs2278293, rs2278294 and rs2228075. Gastrointestinal (GI) intolerance was defined as diarrhea, vomiting, nausea or abdominal pain requiring dose-holding for >48 hours or MMF discontinuation. Bone marrow toxicity was evaluated using Common Terminology Criteria for Adverse Events Version 3 (CTCAE). RESULTS GI intolerance occurred in 21 patients, and 21 had bone marrow toxicity. The ABCC2 rs717620 A variant was significantly associated with GI intolerance leading to drug discontinuation (p < 0.001); the IMPDH1 rs2278294 A variant and rs2228075 A variant were also associated with greater GI intolerance (p = 0.029 and p = 0.002, respectively). The IMPDH2 rs11706052 G variant was associated with more frequent neutropenia requiring dose-holding (p = 0.046). CONCLUSIONS In this small sample of pediatric heart transplant patients receiving MMF, ABCC2, IMPDH1 and IMPDH2 SNPs were associated with MMF GI intolerance and bone marrow toxicity. Thus, genetic polymorphisms may directly influence MMF adverse events.
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Fujiyama N, Miura M, Satoh S, Inoue K, Kagaya H, Saito M, Habuchi T, Suzuki T. Influence of carboxylesterase 2 genetic polymorphisms on mycophenolic acid pharmacokinetics in Japanese renal transplant recipients. Xenobiotica 2009; 39:407-14. [DOI: 10.1080/00498250902807338] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Limited sampling strategy for simultaneous estimation of the area under the concentration-time curve of tacrolimus and mycophenolic acid in adult renal transplant recipients. Ther Drug Monit 2008; 30:52-9. [PMID: 18223463 DOI: 10.1097/ftd.0b013e31815f5416] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The aim of this study was to develop a limited sampling strategy to allow the simultaneous estimation of the area under the concentration-time curves (AUCs) of tacrolimus and mycophenolic acid (MPA), the active metabolite of the prodrug mycophenolate mofetil, using a small number of samples from patients undergoing renal transplantation. Fifty Japanese patients were enrolled. On day 28 after transplantation, samples were collected just before and 1, 2, 3, 4, 6, 9, and 12 hours after tacrolimus and mycophenolate mofetil administration at 9:00 am and 9:00 pm. The full pharmacokinetic profiles obtained from these timed concentration data were used to choose the best sampling times. Three error indices (percent mean error, percent mean absolute error, and percent relative mean square error) were used to evaluate the predictive bias, accuracy, and precision. The predicted AUC0-12 of MPA calculated at the three time points of C2h-C4h-C9h best approximated the actual AUC0-12 of MPA (r = 0.877), and the AUC0-12 of tacrolimus calculated at the same time points predicted a good correlation with the actual AUC (r = 0.928). When the three sampling times of trough level (C0h) and two other points within 4 hours after administration were used, the three points of C0h-C2h-C4h were the best points for estimation of the AUC0-12 tacrolimus and MPA (AUC0-12 = 7.04.C0 + 1.71.C2 + 3.23.C4 + 15.19, r = 0.799, P < 0.001 and AUC0-12 = 0.26.C0 + 2.06.C2 + 3.82.C4 + 20.38, r = 0.693, P < 0.001, respectively). The percent mean error, percent mean absolute error, and percent relative mean square error of the prediction formula using the three time points of C0h-C2h-C4h were -0.3%, 8.8%, and 13.5% for tacrolimus and 2.9%, 17.1%, and 21.5% for MPA, respectively. A limited sampling strategy using C2h-C4h-C9h provides the most reliable and accurate simultaneous estimation of the AUC0-12 of tacrolimus and MPA in patients undergoing renal transplantation. In addition, a limited sampling strategy using C0h-C2h-C4h is recommended for the simultaneous estimation of the AUC0-12 of tacrolimus and MPA when focused on samples collected within 4 hours after administration for clinical expediency.
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Immunosuppression With Generic Tacrolimus and Mycophenolate Mofetil in Renal Transplant Recipients: Preliminary Report in Chile. Transplant Proc 2008; 40:705-7. [DOI: 10.1016/j.transproceed.2008.02.056] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Inoue K, Miura M, Satoh S, Kagaya H, Saito M, Habuchi T, Suzuki T. Influence of UGT1A7 and UGT1A9 Intronic I399 Genetic Polymorphisms on Mycophenolic Acid Pharmacokinetics in Japanese Renal Transplant Recipients. Ther Drug Monit 2007; 29:299-304. [PMID: 17529886 DOI: 10.1097/ftd.0b013e3180686146] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UGT1A7 and UGT1A9 are uridine diphosphate-glucuronosyltransferase isoforms involved in the glucuronidation of mycophenolic acid (MPA). The aim of this study was to elucidate MPA pharmacokinetics in UGT1A7 and UGT1A9 intronic I399 genotypes in Japanese adult renal transplant recipients. Eighty recipients were given repeated doses of combination immunosuppressive therapy consisting of mycophenolate mofetil and tacrolimus every 12 hours at a designated time (9:00 am and 9:00 pm). On day 28 after renal transplantation, plasma MPA concentrations were measured by high-performance liquid chromatography. All patients had UGT1A9 98TT/-275TT/-2152CC and UGT1A10 177GG/605CC genotypes. The UGT1A7*1/*1, *1/*2, *1/*3, *2/*3, and *3/*3 genotypes were detected in 35 (43.8%), five (6.2%), 28 (35.0%), eight (10.0%), and four (5.0%) patients, respectively, and the UGT1A9 I399C/C, C/T, and T/T genotypes were detected in 12 (15.0%), 33 (41.2%), and 35 (43.8%) patients of the 80 Japanese recipients. There were no significant differences in MPA pharmacokinetics among UGT1A7 or UGT1A9 intronic I399 genotype groups. The mean dose-adjusted area under the plasma concentration-time curve from zero to 12 hours (AUC0-12) of MPA in UGT1A7*1/*1, *1/*2, *1/*3, *2/*3, and *3/*3 were 95, 98, 99, 88, and 86 ng.h/mL/mg, respectively (P = 0.9475). The mean dose-adjusted AUC0-12 of MPA in UGT1A9 I399C/C, C/T, and T/T were 87, 99, and 95 ng.h/mL/mg, respectively (P = 0.6937). The dose-adjusted trough levels of MPA in UGT1A9 I399C/C, C/T, and T/T were 5.4, 5.5, and 4.7 ng/mL/mg (P = 0.5845). Although UGT1A7*3 and UGT1A9 I399C/C are known to have low-activity variants when studied in vitro, they do not have reduced in vivo MPA glucuronidation activity. UGT1A7 and UGT1A9 I399 polymorphisms do not contribute to interindividual differences in MPA pharmacokinetics.
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Affiliation(s)
- Kazuyuki Inoue
- Department of Pharmacy, Akita University Hospital, Akita, Japan
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Kagaya H, Inoue K, Miura M, Satoh S, Saito M, Tada H, Habuchi T, Suzuki T. Quantification and 24-hour monitoring of mycophenolic acid by high-performance liquid chromatography in Japanese renal transplant recipients. YAKUGAKU ZASSHI 2007; 126:1357-62. [PMID: 17139160 DOI: 10.1248/yakushi.126.1357] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We developed a rapid, simple, and sensitive high-performance liquid chromatography method with UV detection for the quantitative determination of mycophenolic acid (MPA) in human plasma. MPA and the internal standard (naproxen) were separated using a mobile phase of 0.04 M H(3)PO(4)-acetonitrile-methanol (3:3:4 v/v/v) over a CAPCELL PAK C18 MG column. A flow-rate of 0.5 ml/min was used at ambient temperature and sample detection was carried out at 254 nm. The assay required only 100 microl of plasma and involved liquid-liquid extraction, which gave high recovery (>94%). The lower limit of quantification for MPA was 0.05 microg/ml. Inter- and intra-day coefficients of variation were less than 9.6% and accuracies were within 9.3%. Additionally, we validated this method in 24-hour monitoring of plasma MPA concentrations after mycophenolate mofetil (MMF) morning and evening administration in 40 Japanese renal transplant recipients with 1.5 g/day MMF. The time to reach the maximum (11.7 microg/ml) and second peak (4.5 microg/ml) of MPA after morning 0.75 g MMF administration was 2.6 h and 9.0 h, and time to reach maximum (10.5 microg/ml) after evening 0.75 g administration was 4.0 h.
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Affiliation(s)
- Hideaki Kagaya
- Department of Pharmacy, Akita University Hospital, Japan
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Kagaya H, Inoue K, Miura M, Satoh S, Saito M, Tada H, Habuchi T, Suzuki T. Influence of UGT1A8 and UGT2B7 genetic polymorphisms on mycophenolic acid pharmacokinetics in Japanese renal transplant recipients. Eur J Clin Pharmacol 2007; 63:279-88. [PMID: 17211619 DOI: 10.1007/s00228-006-0248-2] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2006] [Accepted: 11/30/2006] [Indexed: 10/23/2022]
Abstract
OBJECTIVE UGT1A8 and UGT2B7 are important uridine diphosphate-glucuronosyltransferase isoforms for the glucuronidation of mycophenolic acid (MPA). The aim of this investigation was to elucidate MPA pharmacokinetics in UGT1A8 and UGT2B7 genotypes in Japanese renal transplant recipients. METHODS Seventy-two recipients received repeated doses of mycophenolate mofetil and tacrolimus. On day 28 after renal transplantation, plasma MPA concentrations were measured for the next 24 h using high-performance liquid chromatography. UGT1A8*2 (A(173)G) and UGT2B7*2 (Y(268)) were detected using a PCR-RFLP-based procedure. RESULTS There were no significant differences in daytime and nighttime pharmacokinetics of MPA between UGT1A8 or UGT2B7 genotypes. The mean daytime dose-adjusted AUC(0-12) of MPA in UGT1A8*1/*1, *1/*2 and *2/*2 were 2.47, 2.33 and 2.57 ng.h/ml/mg/kg (P = 0.7711), and the mean nighttime AUC(0-12) were 2.15, 2.00 and 2.08 ng.h/ml/mg/kg (P = 0.4656). The mean daytime and nighttime dose-adjusted AUC(0-12) of MPA in UGT2B7*1/*1, *1/*2 and *2/*2 were 2.61, 2.24 and 2.03 ng.h/ml/mg/kg and 2.18, 1.94, and 1.45 ng.h/ml/mg/kg, respectively (P = 0.3475 and 0.2575). The mean nighttime C(max), t(max), and AUC(6-12)/AUC(0-12) ratio (enterohepatic circulation and recirculation ratio) of MPA in all UGT1A8 and UGT2B7 genotypes were lower, longer, and higher, respectively, than the daytime values. CONCLUSIONS Both UGT1A8 and UGT2B7 allelic variants seem not to affect Japanese interindividual variability for plasma MPA concentration. Regardless of UGT1A8 and UGT2B7 genetic polymorphisms, the absorption of MPA through enterohepatic recirculation is higher at night.
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Affiliation(s)
- Hideaki Kagaya
- Department of Pharmacy, Akita University Hospital, 1-1-1 Hondo, Akita, 010-8543, Japan
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Khosroshahi HT, Asghari A, Estakhr R, Baiaz B, Ardalan MR, Shoja MM. Effects of Azathioprine and Mycophenolate Mofetil—Immunosuppressive Regimens on the Erythropoietic System of Renal Transplant Recipients. Transplant Proc 2006; 38:2077-9. [PMID: 16980004 DOI: 10.1016/j.transproceed.2006.06.043] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Azathioprine (AZA) and mycophenolate mofetil (MMF) are major immunosuppressants used to prevent rejection following renal transplantation. Bone marrow suppression is a potential adverse effect of these agents manifesting itself as leukopenia, thrombocytopenia, and anemia. The aim of this study was to compare the effects of AZA versus MMF immunosuppressive regimens on the erythropoietic system of renal transplant recipients within 6 months after transplantation. METHODS Eighty kidney allograft recipients who were on AZA (n = 40) or MMF (n = 40) plus cyclosporine and prednisolone were enrolled in this study. Hematologic parameters included red blood cell counts, hemoglobin (Hb), hematocrit, mean corpuscular volume, mean corpuscular hemoglobin (MCH) and mean corpuscular hemoglobin concentration (MCHC) and were measured before and at 1 week, as well as 1 and 6 months posttransplantation. Plasma erythropoietin level was measured at the end of 6 months. Statistical analysis was performed with Student t test; a P value less than .05 was considered significant. RESULTS There was no significant difference between the two groups regarding red blood cell counts. High Hb level was noted at 1 and 6 months posttransplantation among patients who received MMF. MCH and MCHC were higher among patients on MMF compared with those on AZA at 1 week and 1 month posttransplant. Although the mean plasma erythropoietin levels in AZA-treated patients were higher than those of MMF-treated patients, the trend did not reach statistical significance (P = .066). CONCLUSION MMF administration was apparently associated with a higher level of hemoglobin compared with AZA among renal allograft recipients with good graft function at 6 months posttransplantation.
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Affiliation(s)
- H T Khosroshahi
- Department of Nephrology, Dialysis and Renal Transplantation, Kidney Transplantation Center, Imam Hospital, Tabriz University of Medical Sciences, Daneshgah St. Tabriz, Iran.
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Pallet N, Anglicheau D, Martinez F, Mamzer MF, Legendre C, Thervet E. Comparison of sequential protocol using basiliximab versus antithymocyte globulin with high-dose mycophenolate mofetil in recipients of a kidney graft from an expanded-criteria donor. Transplantation 2006; 81:949-52. [PMID: 16570022 DOI: 10.1097/01.tp.0000198417.91135.1f] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
This retrospective pilot study investigated use of high-dose mycophenolate mofetil with biological induction and sequential introduction of low-dose cyclosporine in recipients of expanded criteria donor (ECD) kidneys. Fifty-four patients received mycophenolate mofetil 3 g/day for 45 days, cyclosporine 4 mg/kg/day, prednisolone, and rabbit antithymocyte globulin (rATG, n=14) or basiliximab (n=40). Acute rejection incidence was 11.3% (7.1% with rATG, 12.6% with basiliximab). Delayed graft function was observed in 31 patients (54%). At one year, measured glomerular filtration rate was 54+/-4 ml/min, with no significant differences between induction therapies. Thirty patients (55%) required > or =1 MMF dose reduction within month 1 due to adverse events (gastrointestinal symptoms, 67%; leucopenia 33%). Leucopenia was more frequent with rATG, while gastrointestinal symptoms were more frequent with basiliximab. Cytomegalovirus replication occurred in three patients (23%) with rATG and 3 (8%) with basiliximab. In conclusion, high-dose MMF, corticosteroids, delayed low-dose cyclosporine and induction therapy offers an excellent risk-to-benefit ratio in patients receiving an ECD allograft.
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Affiliation(s)
- Nicolas Pallet
- Service de Transplantation Rénale, Hôpital Necker, 149 Rue de Sèvres, 75743 Paris Cedex 15, France
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Kocak H, Yakupoglu U, Karatas GU, Yavuz A, Gurkan A, Erdogan O, Ersoy FF, Yakupoglu G, Demirbas A, Tuncer M. Tacrolimus plus low-dose mycophenolate mofetil in renal transplant recipients: better 2-year graft and patient survival than with a higher mycophenolate mofetil dose. Transplant Proc 2006; 37:3009-11. [PMID: 16213288 DOI: 10.1016/j.transproceed.2005.07.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Mycophenolate mofetil (MMF) has become more widely prescribed in recent years, but its adverse effects on the gastrointestinal system and bone marrow restrict its use in certain settings. The aim of this study was to compare the demographic features and clinical data for 173 renal transplant recipients who received tacrolimus (TAC) plus 1 g/d MMF (group I, n = 112) versus TAC plus 2 g/d MMF (group II, n = 61 patients) over a 2-year period. Each patient received similar TAC doses. METHODS We compared demographic data and clinical data for each case: acute rejection (AR) episodes, chronic rejection (CR) episodes, death, graft loss, development of posttransplantation diabetes mellitus (PTDM), and posttransplantation hypertension rates. RESULTS Demographic features were similar. There were also no significant differences between groups I and II with respect to number of AR episodes (17/112 vs 12/61, respectively), number of CR episodes (4/112 vs 1/61, respectively), PTDM, and hypertension rate (P > .05). Kaplan-Meier survival analysis revealed 2-year graft survival rates of 94% in group I versus 83% in group II. The corresponding 2-year patient survival rates were 100% in group I versus 91% in group II. The graft survival and patient survival rates in group I were significantly higher than those in group II (log-rank 0.005 and 0.001, respectively). CONCLUSIONS The 2-year graft and patient survival rates for the renal transplant recipients in this study suggest that the combination of a full TAC dose with 1 g/d MMF is a better choice than 2 g/d MMF.
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Affiliation(s)
- H Kocak
- Department of Nephrology, Akdeniz University School of Medicine, Antalya, Turkey.
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Ayrout C, Lanzetta M, Chunasuwankul R, Gal A, Owen ER. Experimental limb transplantation, part i: identification of an effective tapered triple combination immunosuppressive regime. Transplant Proc 2004; 36:669-74. [PMID: 15110627 DOI: 10.1016/j.transproceed.2004.03.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Limb transplantation was performed across the Brown Norway to Fischer 344 histocompatibility barrier in rats to evaluate the effects of triple combination immunosuppressive therapeutic regimens. Sixty rats were divided into five groups: group I (F344 to F344) isograft controls group II (BN to F344) allograft controls received no immunosuppressive treatment. Groups III and V (BN to F344) received various exposures to tacrolimus (TRL), mycophenolate mofetil (MMF) and prednisolone (Pred) for two weeks: namely, group III: TRL 0.5 mg/kg/d; MMF 10 mg/kg/d; Pred 0.5 mg/kg/d; group IV: TRL 2 mg/kg/d, MMF 15 mg/kg/d, Pred 0.5 mg/kg/d; and group V: TRL 3 mg/kg/d; MMF 20 mg/kg/d; Pred 0.5 mg/kg/d. After 2 weeks, group III and V animals underwent a simultaneous 20% taper of Pred and MMF each further week such that by week 7 the animals were only on TRL. At this time TRL was tapered at the same rate (20% every week) to a maintenance dose of 0.6 mg/kg/d. Evidence of rejection was sought by daily visual observation for swelling, redness, erythema, edema, or skin necrosis. Salvage treatment was used only if rejection occurred after the first 7 weeks, namely, reversing to 100% of the initial TRL dose in that group for 2 weeks with a subsequent taper. Skin and muscle biopsies were obtained from grafted limbs on day 3, 13, 24, 35, and at the endpoint (9 months or uncontrollable rejection). There was no rejection in group I, while all animals showed acute rejection as expected in group II. All group III rats displayed a similar though delayed acute rejection, showing that the regimen was not therapeutic. Rats in group IV displayed the best results, namely, 10 of 12 (83%) with no rejection or side effects at 9 months. Rats in group V displayed numerous, unacceptable side effects due to overtreatment with a 1-month mortality rate of 50%. This study shows that low-dose TRL in combination with MMF and Pred may achieve excellent long-term results of composite tissue transplants. TRL can be used alone as maintenance therapy following an initial loading dose and a tapering period. Rejection is easily reversed by only temporarily increasing the TRL dose.
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MESH Headings
- Animals
- Drug Administration Schedule
- Drug Therapy, Combination
- Extremities/transplantation
- Immunosuppressive Agents/administration & dosage
- Immunosuppressive Agents/therapeutic use
- Male
- Models, Animal
- Necrosis
- Nerve Regeneration
- Postoperative Complications
- Rats
- Rats, Inbred BN
- Rats, Inbred F344
- Skin/pathology
- Transplantation, Autologous/immunology
- Transplantation, Autologous/methods
- Transplantation, Autologous/physiology
- Transplantation, Homologous/immunology
- Transplantation, Homologous/methods
- Transplantation, Homologous/physiology
- Weight Loss
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Affiliation(s)
- C Ayrout
- The Microsearch Foundation of Australia, Sydney, Australia
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Solà R, Díaz JM, Guirado L, Sainz Z, Gich I, Picazo M, García R, Abreu E, Ortiz F, Alcaraz A. Tacrolimus in induction immunosuppressive treatment in renal transplantation: comparison with cyclosporine. Transplant Proc 2003; 35:1699-700. [PMID: 12962763 DOI: 10.1016/s0041-1345(03)00607-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The aim of the study was to compare the efficacy and safety of induction immunosuppression therapies based on tacrolimus or cyclosporine (CsA) in kidney transplantation. The 240 kidney allograft recipients were divided into two groups: group 1 (n=94) received tacrolimus (.01 mg/kg per day), mycophenolate mofetil (MMF, 2 g/d), and steroids (30 mg/d); and group 2 (n=146) CsA (6 mg/kg per day), MMF (2 g/d), and steroids (30 mg/d). Antilymphocyte serum was administered in cases of acute tubular necrosis. The acute rejection rate was higher among group 2 (30.6%) compared with group 1 patients (12.2%) (P=.001). There were no significant differences between the groups in terms of age, gender, body surface area, serologic virus markers (in donor and recipient), baseline creatinine levels, cause of death, HLA incompatibilities, response to acute tubular necrosis, and number of dialysis sessions. We conclude that both immunosuppressive regimens are effective and safe in kidney transplantation. The survival rates of patients and grafts were similar, but the incidence and degree of acute rejection events were reduced in group 1; this finding may forecast a decreased incidence of chronic renal allograft nephropathy.
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Affiliation(s)
- R Solà
- Renal Transplantation Unit, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
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Jensen S, Jackson EC, Riley L, Reddy S, Goebel J. Tacrolimus-based immunosuppression with steroid withdrawal in pediatric kidney transplantation--4-year experience at a moderate-volume center. Pediatr Transplant 2003; 7:119-24. [PMID: 12654052 DOI: 10.1034/j.1399-3046.2003.00027.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Tacrolimus-based immunosuppression with steroid withdrawal in pediatric kidney transplantation was pioneered at the University of Pittsburgh but is not broadly practiced at other centers. We present our 4-year experience with a modified Pittsburgh protocol at our own moderate-volume center. Seventeen pediatric kidney transplant recipients were treated with a tacrolimus-based immunosuppressive regimen involving steroid withdrawal over 6-12 post-transplant months in most cases and followed for up to 49 months. Patient and graft survival as well as graft function were excellent, and beneficial effects on several cardiovascular parameters were noted. Complications included fungal infections, glucose intolerance and post-transplant lymphoproliferative disease and were generally managed successfully. While awaiting longer-term follow-up data, we conclude that tacrolimus-based immunosuppression with steroid withdrawal in pediatric kidney transplantation is potentially beneficial and feasible even at centers managing a rather small number of recipients.
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Affiliation(s)
- Sena Jensen
- Department of Pediatrics, University of Kentucky, Lexington, USA
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Ciancio G, Burke GW, Suzart K, Vaidya A, Roth D, Kupin W, Mattiazzi A, Rosen A, Esquenazi V, Miller J. Efficacy and safety of daclizumab induction for primary kidney transplant recipients in combination with tacrolimus, mycophenolate mofetil, and steroids as maintenance immunosuppression. Transplant Proc 2003; 35:873-4. [PMID: 12644172 DOI: 10.1016/s0041-1345(02)04035-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- G Ciancio
- Department of Surgery, Division of Transplantation, University of Miami School of Medicine, Miami, Florida 33101, USA
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Campistol JM. Sirolimus: a potential option for the prevention of chronic allograft nephropathy. Transplant Rev (Orlando) 2003. [DOI: 10.1053/trre.2003.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Ciancio G, Burke GW, Suzart K, Roth D, Kupin W, Rosen A, Olson L, Esquenazi V, Miller J. Daclizumab induction, tacrolimus, mycophenolate mofetil and steroids as an immunosuppression regimen for primary kidney transplant recipients. Transplantation 2002; 73:1100-6. [PMID: 11965039 DOI: 10.1097/00007890-200204150-00015] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Recent reports have demonstrated the efficacy of interleukin-2-receptor blockers in lowering the incidence of early acute rejection in cyclosporine-treated kidney recipients when compared to patients not induced with an antibody product. The addition of daclizumab to a tacrolimus-mycophenolate mofetil-based immunosuppressive protocol was tested to evaluate whether there might be an additional reduction of the risk of rejection after renal transplantation. METHODS Since March 1998, we studied the effect of daclizumab in a nonrandomized, prospective study of 233 sequential recipients of first renal transplant. They were retrospective compared with a control group of 225 renal transplant recipients receiving a 10-day course of OKT3 induction, and tacrolimus, mycophenolate mofetil, and methylprednisolone maintenance. The study group received the same immunosuppressive regimen with the addition of daclizumab at 1 mg/kg for five doses over 10 weeks in the place of OKT3 therapy. There was at least 1HLA DR antigen compatibility match present between all donors and recipients. Patients were followed for 1 year after renal transplantation for the incidence of biopsy-proven acute rejection, patient and graft survival, and adverse events. RESULTS At 12 months, patient and graft survival for the daclizumab was 98 and 96 vs. 96 and 94% for the OKT3 group, respectively, and were not statistically different. Acute rejection rates (<6 months) were lower in the daclizumab group as compared with the OKT3 group, i.e., 5 (2.1%) vs. 16 (7.1%) (P=0.011) respectively. The incidence of infection requiring hospitalization appeared to be lower with daclizumab (7.3 vs. 16%, P<0.0036) with a similar trend with cyclomegalovirus infection, i.e., 1.6 vs. 4%, respectively (P=0.14). CONCLUSIONS The combination of daclizumab, tacrolimus, mycophenolate mofetil, and steroids is safe and effective for kidney transplant recipients in lowering the incidence of early acute rejection and without any increase in morbidity when compared to our previous protocol, which may have an eventual impact in long-term graft survival.
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Affiliation(s)
- Gaetano Ciancio
- Department of Surgery, Division of Transplantation, University of Miami School of Medicine, Miami, FL 33101, USA
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Montori VM, Basu A, Erwin PJ, Velosa JA, Gabriel SE, Kudva YC. Posttransplantation diabetes: a systematic review of the literature. Diabetes Care 2002; 25:583-92. [PMID: 11874952 DOI: 10.2337/diacare.25.3.583] [Citation(s) in RCA: 426] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To systematically review the incidence of posttransplantation diabetes (PTD), risk factors for its development, prognostic implications, and optimal management. RESEARCH DESIGN AND METHODS We searched databases (MEDLINE, EMBASE, the Cochrane Library, and others) from inception to September 2000, reviewed bibliographies in reports retrieved, contacted transplantation experts, and reviewed specialty journals. Two reviewers independently determined report inclusion (original studies, in all languages, of PTD in adults with no history of diabetes before transplantation), assessed study methods, and extracted data using a standardized form. Meta-regression was used to explain between-study differences in incidence. RESULTS Nineteen studies with 3,611 patients were included. The 12-month cumulative incidence of PTD is lower (<10% in most studies) than it was 3 decades ago. The type of immunosuppression explained 74% of the variability in incidence (P = 0.0004). Risk factors were patient age, nonwhite ethnicity, glucocorticoid treatment for rejection, and immunosuppression with high-dose cyclosporine and tacrolimus. PTD was associated with decreased graft and patient survival in earlier studies; later studies showed improved outcomes. Randomized trials of treatment regimens have not been conducted. CONCLUSIONS Physicians should consider modification of immunosuppressive regimens to decrease the risk of PTD in high-risk transplant recipients. Randomized trials are needed to evaluate the use of oral glucose-lowering agents in transplant recipients, paying particular attention to interactions with immunosuppressive drugs.
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Affiliation(s)
- Victor M Montori
- Division of Endocrinology, Diabetes, Metabolism, Nutrition, and Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA
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Abstract
Mycophenolate mofetil (MMF) is a relatively new immunosuppressive drug. It inhibits inosine monophosphate dehydrogenase, a key enzyme in the de novo pathway of purine synthesis, and thus causes lymphocyte-selective immunosuppression. Large clinical trials have revealed the efficacy of MMF in the prevention of allograft rejection when administered together with cyclosporin or tacrolimus and corticosteroids. Although the adverse effect profile of MMF is comparatively benign, gastrointestinal adverse effects are a major concern. These effects are partially explained by the increased immune suppression, by the mode of action and by interactions, particularly with other immunosuppressants. The aetiology of the rarest gastrointestinal adverse effects is still not completely clear. Therapy depends upon the clinical gravity of the adverse effects and is therefore a case of waiting and ob- serving. An adjustment of dosage of immunosuppressants according to the clinical situation and, particularly in the case of MMF, spreading the total dosage over more than 2 daily doses are often sufficient. Should adverse effects persist for a longer period of time and be of a more serious nature, a comprehensive invasive diagnostic process is necessary, including endoscopy and biopsy and the search for opportunistic infections. In this case, dosage reduction or the complete withdrawal of MMF seems to be unavoidable. Severe gastrointestinal complications with MMF are rare, but when they do occur they may require extensive diagnosis and treatment. In the future, therapeutic drug monitoring and, where necessary, pharmacological modifications of MMF could lead to a further reduction of adverse effects with an equal or even increased efficacy.
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Affiliation(s)
- M Behrend
- Abteilung für Viszeral- und Transplantationschirurgie, Medizinische Hochschule Hannover, Hannover, Germany.
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Affiliation(s)
- R Shapiro
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, Pennsylvania 15213, USA
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Abstract
Mycophenolate mofetil (MMF) is an immunosuppressive drug designed to inhibit inosine monophosphate dehydrogenase (IMPDH). IMPDH is a key enzyme in the de novo purine synthesis of lymphocytes. It is crucially important for proliferative responses of human T and B lymphocytes. The inhibition of IMPDH thus leads to selective lymphocyte suppression. After successful use in various in vitro and animal models, MMF was brought to clinical trial in patients undergoing transplantation. The drug is rapidly and completely absorbed following oral administration. Pilot studies of administration with cyclosporin and corticosteroids suggested a significant reduction in the incidence of organ rejection at dosages of 1 to 3 g/day. As a result of these studies, 3 pivotal randomised double-blind multicentre trials, involving nearly 1500 patients, were designed to investigate the effects of addition of MMF to different standard immunosuppressive protocols on the prevention of acute renal allograft rejection. After 6 months, the rates of biopsy-proven rejection were significantly reduced in patients receiving MMF. In combination with cyclosporin and corticosteroids, the adverse effect profile resembled that of azathioprine. Most adverse effects were associated with the gastrointestinal tract, the blood system and opportunistic infections. MMF offers improved immunosuppressive therapy following renal and probably other solid organ transplantation. MMF has been licensed since 1995 for the prevention of acute renal allograft rejection in most countries. It has been used in different combinations of immunosuppressive drugs and in various dosages and regimens.
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Affiliation(s)
- M Behrend
- Abteilung für Viszeral- und Transplantationschirurgie, Medizinische Hochschule Hannover, Hannover, Germany.
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Shaw LM, Holt DW, Oellerich M, Meiser B, van Gelder T. Current issues in therapeutic drug monitoring of mycophenolic acid: report of a roundtable discussion. Ther Drug Monit 2001; 23:305-15. [PMID: 11477311 DOI: 10.1097/00007691-200108000-00001] [Citation(s) in RCA: 216] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- L M Shaw
- University of Pennsylvania Medical Center, Philadelphia, Pennsylvania, USA.
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Camirand G, Caron NJ, Asselin I, Tremblay JP. Combined immunosuppression of mycophenolate mofetil and FK506 for myoblast transplantation in mdx mice. Transplantation 2001; 72:38-44. [PMID: 11468532 DOI: 10.1097/00007890-200107150-00010] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Overcoming adverse effects of immunosuppressors can be achieved by combining different drugs, thus allowing a dosage reduction. Myoblast transplantation is a potential therapy for Duchenne muscular dystrophy. Our research group previously established that FK506 (tacrolimus) is an effective immunosuppressive drug for myoblast transplantation in mice and monkeys. METHODS In the present study, a reduced dose of FK506 at 1.0 mg/kg/day was used in combination with mycophenolate mofetil (MMF; 80 mg/kg/day) as an immunosuppressive protocol for myoblast transplantation. Graft success was evaluated by quantifying the number of dystrophin-positive fibers per muscle section that were injected with normal cells. RESULTS MMF used alone could not prevent immune rejection of the transplanted myoblasts. MMF given in combination with FK506 immediately after transplantation reduced the success of myoblast transplantation by about 50%. A low dose of FK506 combined with MMF after the establishment of the graft (3 weeks) maintained graft success and controlled immune infiltration compared with a low dose of FK506 alone. However, lymphocyte infiltration was observed at longer term using a low dose of FK506 combined with MMF. CONCLUSIONS The diminution of graft success when combining FK506 and MMF by the time of myoblast transplantation could be attributed to the inhibition of myoblast fusion by MMF. The use of MMF and FK506 after the establishment of the graft did not reduce graft success, however, this combination was not effective at controlling long-term immune rejection in comparison with the optimal dose of FK506 alone.
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Affiliation(s)
- G Camirand
- Unité de Recherche en Génétique humaine, Centre Hospitalier de l'Université Laval, Université Laval, 2705 boul. Laurier, RC-9300, Ste-Foy (Qc) Canada G1V 4G2
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Frühwirth M, Fischer H, Simma B, Ellemunter H. Elevated tacrolimus trough levels in association with mycophenolate mofetil-induced diarrhea: a case report. Pediatr Transplant 2001; 5:132-4. [PMID: 11328552 DOI: 10.1034/j.1399-3046.2001.005002132.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The combination of tacrolimus (TAC) and mycophenolate mofetil (MMF) is frequently used for immunosuppression after organ transplantation (Tx), but the pharmacokinetics and interactions between the two drugs are poorly elucidated. We describe here the increase of TAC trough levels during MMF-induced diarrhea in a 8-yr-old boy after kidney Tx. Early dose reduction of TAC, together with short-term monitoring of TAC trough levels in the presence of diarrhea, is recommended.
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Affiliation(s)
- M Frühwirth
- Department of Pediatrics, University Hospital Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria.
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Abstract
New drugs have recently been added that may eventually replace the two-decade dominance of cyclosporin in solid organ transplantation. This cornerstone of immunosuppression was introduced by Borel [1] and Calne [2] in the mid-70s. In 1989, Starzl et al., after 2 years of preclinical experimentation, introduced tacrolimus (originally designated as FK506 by the Fujisawa Pharmaceutical Company of Japan) as a potent immunosuppressant for liver transplants [3]. Also, in recent years, a variety of novel purine and pyrimidine biosynthesis inhibitors have been tested for transplantation therapy. The leading agent which appears to be replacing the 35-year position occupied by azathioprine is the semi-synthetic morpholinoethyl ester of mycophenolic acid (MPA), mycophenolate mofetil (MMF), introduced by Allison [4] and Sollinger [5], and developed by the Syntex Corporation (now Roche Pharmaceuticals). Others, affecting different intra- or intercellular messages amplifying immunity, are in the pipeline.
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Affiliation(s)
- G Ciancio
- Department of Surgery, Division of Transplantation, University of Miami School of Medicine, PO Box 012440, Miami, Fl. 33101, USA.
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Abstract
Despite limited understanding of therapeutic aetiopathogenesis of ulcerative colitis and Crohn's disease, there is a strong evidence base for the efficacy of pharmacological and biological therapies. It is equally important to recognise toxicity of the medical armamentarium for inflammatory bowel disease (IBD). Sulfasalazine consists of sulfapyridine linked to 5-aminosalicylic acid (5-ASA) via an azo bond. Common adverse effects related to sulfapyridine 'intolerance' include headache, nausea, anorexia, and malaise. Other allergic or toxic adverse effects include fever, rash, haemolytic anaemia, hepatitis, pancreatitis, paradoxical worsening of colitis, and reversible sperm abnormalities. The newer 5-ASA agents were developed to deliver the active ingredient of sulfasalazine while minimising adverse effects. Adverse effects are infrequent but may include nausea, dyspepsia and headache. Olsalazine may cause a secretory diarrhoea. Uncommon hypersensitivity reactions, including worsening of colitis, pancreatitis, pericarditis and nephritis, have also been reported. Corticosteroids are commonly prescribed for treatment of moderate to severe IBD. Despite short term efficacy, corticosteroids have numerous adverse effects that preclude their long term use. Adverse effects include acne, fluid retention, fat redistribution, hypertension, hyperglycaemia, psycho-neurological disturbances, cataracts, adrenal suppression, growth failure in children, and osteonecrosis. Newer corticosteroid preparations offer potential for targeted therapy and less corticosteroid-related adverse effects. Azathioprine and mercaptopurine are associated with pancreatitis in 3 to 15% of patients that resolves upon drug cessation. Bone marrow suppression is dose related and may be delayed. The adverse effects of methotrexate include nausea, leucopenia and, rarely, hypersensitivity pneumonia or hepatic fibrosis. Common adverse effects of cyclosporin include nephrotoxicity, hypertension, headache, gingival hyperplasia, hyperkalaemia, paresthesias, and tremors. These adverse effects usually abate with dose reduction or cessation of therapy. Seizures and opportunistic infections have also been reported. Antibacterials are commonly employed as primary therapy for Crohn's disease. Common adverse effects of metronidazole include nausea and a metallic taste. Peripheral neuropathy can occur with prolonged administration. Ciprofloxacin and other antibacterials may be beneficial in those intolerant to metronidazole. Newer immunosuppressive agents previously reserved for transplant recipients are under investigation for IBD. Tacrolimus has an adverse effect profile similar to cyclosporin, and may cause renal insufficiency. Mycophenolate mofetil, a purine synthesis inhibitor, has primarily gastrointestinal adverse effects. Biological agents targeting specific sites in the immunoinflammatory cascade are now available to treat IBD. Infliximab, a chimeric antibody targeting tumour necrosis factor-or has been well tolerated in clinical trials and early postmarketing experience. Additional trials are needed to assess long term adverse effects.
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Affiliation(s)
- R B Stein
- Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, USA
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40
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Corales R, Chua J, Mawhorter S, Young JB, Starling R, Tomford JW, McCarthy P, Braun WE, Smedira N, Hobbs R, Haas G, Pelegrin D, Majercik M, Hoercher K, Cook D, Avery RK. Significant post-transplant hypogammaglobulinemia in six heart transplant recipients: an emerging clinical phenomenon? Transpl Infect Dis 2000; 2:133-9. [PMID: 11429024 DOI: 10.1034/j.1399-3062.2000.020306.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The recent development of powerful agents such as mycophenolate mofetil and tacrolimus has altered current regimens for the prevention and treatment of allograft rejection. Questions have been raised about these newer regimens in terms of susceptibility to opportunistic infections and effects on host defenses. Severe hypogammaglobulinemia has been infrequently described in solid organ transplant recipients, but has been recently noted in six heart transplant recipients at one center, of whom five were receiving a combination of tacrolimus, mycophenolate mofetil, and prednisone. METHODS Case summaries of six recent heart transplant recipients with total immunoglobulin G (IgG) levels of less than 310 mg/dl, five of whom had cytomegalovirus (CMV) infection and three of whom had multiple infections including Nocardia, invasive Trichophyton, and Acinetobacter bacteremia. Previous literature was reviewed with the aid of a Medline search using the search terms hypogammaglobulinemia; kidney, liver, heart, lung, and organ transplantation; mycophenolate mofetil; tacrolimus; cyclosporine; azathioprine; and nocardiosis. RESULTS We here report six cardiac transplant recipients seen over a period of one year who were found to have immunoglobulin G levels of 310 mg/dl or below (normal: 717-1400 mg/dl). The first five patients were diagnosed because of evaluation for infections; the sixth, who was asymptomatic with an IgG level of 175, was found during screening for hypogammaglobulinemia instituted as a result of these first five patients. All six patients had received steroid pulses for rejection; all received mycophenolate mofetil; and 5/6 had been switched from cyclosporine to tacrolimus because of steroid-resistant rejection. Transient neutropenia (absolute neutrophil count less than 1000) was observed in 2/6; 3/6 had received OKT3 therapy for refractory rejection. These six patients were treated with a combination of antimicrobials, immunoglobulin replacement, and decrease in immunosuppressive therapy. CONCLUSION The finding of unexpected hypogammaglobulinemia and concomitant infectious complications in six heart transplant recipients highlights a possible complication in a subset of patients receiving newer immunosuppressive agents. A larger prospective study is underway to determine risk factors for development of post-transplant hypogammaglobulinemia and to assess pre-transplant immune status of these recipients. Monitoring of immunoglobulin levels in high-risk patients receiving intensified immunosuppressive therapy for rejection may help to prevent infectious complications.
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Affiliation(s)
- R Corales
- Transplant Center, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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Gonin JM. Maintenance immunosuppression: new agents and persistent dilemmas. ADVANCES IN RENAL REPLACEMENT THERAPY 2000; 7:95-116. [PMID: 10782729 DOI: 10.1053/rr.2000.5271] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Since the approval of cyclosporine in 1983, only 3 drugs, mycophenolate mofetil, tacrolimus, and sirolimus, have been approved for maintenance immunosuppression in renal transplant recipients. All 3 agents decrease the incidence of early acute allograft rejection. An increase in intermediate and long-term graft survival has not been shown. However, survival data from these clinical trials should be interpreted with caution because the studies were not designed for this purpose. All 3 drugs have significant, albeit different, safety profiles. It remains to be seen whether, the lower incidence of hypertension and hyperlipidemia seen in tacrolimus-treated patients will reduce the incidence and severity of the cardiovascular disease experienced by renal transplant recipients. Sirolimus causes severe hyperlipidemia, and the long-term consequences both on the pathogenesis of cardiovascular disease and on lipid-associated renal injury have yet to be determined. Tacrolimus and mycophenolate mofetil appear to increase graft survival in pancreas-kidney recipients but their efficacy in another high-risk group, African-American recipients, has not yet been clearly shown. However, the trend toward improved graft survival in African-American recipients treated with tacrolimus is encouraging. Steroid-withdrawal remains a goal in the posttransplant period. The available data from steroid-withdrawal and steroid-avoidance clinical trials are mixed. Steroid withdrawal can be achieved in about 50% of patients on a cyclosporine-based immunosuppression regimen. Steroid-withdrawal under coverage of tacrolimus, mycophenolate mofetil or Neoral (Novartis Pharmaceuticals, East Hanover, NJ) may be more successful than that achieved in patients receiving Sandimmune (Novartis Pharmaceuticals). Further studies are needed in this area.
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Affiliation(s)
- J M Gonin
- Division of Nephrology and Hypertension, Georgetown University Medical Center, Washington, DC 20007, USA.
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Braun F, Canelo R, Lorf T, Schütz E, Grupp C, Müller GA, Ringe B. Living-related versus living-unrelated kidney transplantation using tacrolimus initial immunosuppression. Transplant Proc 2000; 32:115-6. [PMID: 10700989 DOI: 10.1016/s0041-1345(99)00903-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- F Braun
- Klinik für Transplantationschirurgie, Georg-August-Universität, Göttingen, Germany
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Chenhsu RY, Loong CC, Chou MH, Lin MF, Yang WC. Renal allograft dysfunction associated with rifampin-tacrolimus interaction. Ann Pharmacother 2000; 34:27-31. [PMID: 10669182 DOI: 10.1345/aph.19069] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To report an interaction between tacrolimus and rifampin with subsequent adverse effects on renal allograft function. CASE SUMMARY A 61-year-old Chinese man received a cadaveric renal transplant in 1991. Progressive deterioration of allograft function developed during the following six years while the patient was receiving cyclosporine and prednisolone. In January 1998, tacrolimus was substituted for cyclosporine for late biopsy-proven graft rejection, with target trough blood concentrations between 5 and 8 ng/mL. After conversion, serum creatinine fell to 2.0 mg/dL; the nadir was reached within one year. At the same time, rifampin was instituted for controlling tuberculosis and empiric fluconazole was discontinued. Twelve days later, the patient's serum creatinine concentration rose to 2.9 mg/dL and tacrolimus concentration fell to 1.5 ng/mL, along with oliguria. These findings suggested acute rejection, which was successfully reversed by steroid therapy. However, more than a tenfold increase in the tacrolimus dosage was required to maintain the same concentrations during subsequent months, accompanied by an increase in serum creatinine (from 2.0 to 2.6 mg/dL) and decrease in urine excretion. Biopsy at this time demonstrated acute rejection (Banff I), chronic allograft nephropathy (Banff II), and suspected tacrolimus nephrotoxicity. After unsuccessful methylprednisolone recycling, mycophenolate mofetil was introduced to control rejection and facilitate reduction of the tacrolimus dosage to minimize its nephrotoxicity. CONCLUSIONS As a potent CYP3A4 isoenzyme inducer, rifampin coadministration caused the abrupt decrease in tacroiimus blood concentrations, leading to an approximate tenfold increase in its daily dose, which may be important to subsequent allograft dysfunctions.
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Affiliation(s)
- R Y Chenhsu
- Department of Pharmacy, Veterans General Hospital-Taipei, Taiwan, Republic of China.
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Morales JM, Andrés A, Morales E, Herrero JC, Cubas A, Praga M, Hernández E, Ortuño T, Dominguez-Gil B, Carreño A, Delgado M, Manzanares C. Tacrolimus, mycophenolate mofetil and corticosteroids as primary immunosuppression after renal transplantation at the Hospital 12 de Octubre, Madrid. Transplant Proc 1999; 31:75S-77S. [PMID: 10576051 DOI: 10.1016/s0041-1345(99)00801-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- J M Morales
- Nephrology Department, Hospital Universitario 12 de Octubre, Madrid, Spain.
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45
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Hübner GI, Eismann R, Sziegoleit W. Drug interaction between mycophenolate mofetil and tacrolimus detectable within therapeutic mycophenolic acid monitoring in renal transplant patients. Ther Drug Monit 1999; 21:536-9. [PMID: 10519451 DOI: 10.1097/00007691-199910000-00008] [Citation(s) in RCA: 73] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The possible pharmacokinetic interaction between the new immunosuppressive mycophenolate mofetil (MMF) and tacrolimus (TAC), respectively, was assessed by comparing routinely estimated mycophenolic acid (MPA) plasma trough levels of 15 consecutive renal transplant patients receiving MMF in combination with methylprednisolone (MEP) and cyclosporin A (CSA, 10 patients) or in combination with MEP and tacrolimus (TAC, 5 patients). Coadministration of TAC instead of CSA resulted in a significant increase of mean MPA plasma trough levels [3.4 +/- 1.3 microg/mL (n = 22) versus 1.87 +/- 1.1 microg/mL (n = 57); p < 0.001], despite lower MMF doses [1.5 +/- 0.5 g/d versus 1.7 +/- 0.3 g/d (not statistically significant)]. This elevation in MPA levels is possibly caused by an interaction between MMF and TAC and could lead to a recommendation to monitor MPA plasma levels with appropriate dose adjustment.
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Affiliation(s)
- G I Hübner
- Department of Pharmacology and Toxicology, Martin Luther University Halle-Wittenberg, Halle, Germany
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Affiliation(s)
- R Shapiro
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pennsylvania, USA
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Veenstra DL, Best JH, Hornberger J, Sullivan SD, Hricik DE. Incidence and long-term cost of steroid-related side effects after renal transplantation. Am J Kidney Dis 1999; 33:829-39. [PMID: 10213637 DOI: 10.1016/s0272-6386(99)70414-2] [Citation(s) in RCA: 244] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Corticosteroids are an essential component of most immunosuppressive regimens currently used in renal transplantation because of their efficacy in reducing acute rejection and improving graft survival. Steroids, however, are associated with numerous side effects that lead to increased patient morbidity and mortality. The incidence and economic cost of steroid-related side effects have not been quantitatively assessed. Thus, based on a systematic review of the published literature, we estimated the incidence of steroid-related hypertension (15%), posttransplantation diabetes mellitus (10%), peripheral fractures (2% per year), avascular necrosis of the hip (8%), and cataracts (22%). In addition, we estimated that approximately 5% of patients who have cataracts or avascular necrosis of the hip require surgery. We used these literature-based estimates in a model to project the costs of treating side effects over a 10-year posttransplantation time frame for a 50-patient cohort that represented an average-sized renal transplant center. Steroid-induced hypertension and its complications were the most expensive side effect ($93,900), followed closely by posttransplantation diabetes ($89,700) and avascular necrosis of the hip ($61,700). Cataracts and peripheral bone fractures were less costly ($16,300 and $4,300, respectively). The cumulative projected 10-year cost of all side effects for the 50-patient cohort was $265, 900, or $5,300 per transplant patient. Steroid-related side effects add to the long-term cost of medical care of renal transplant recipients. These costs provide a rationale for further investigation of steroid-sparing immunosuppression protocols.
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Affiliation(s)
- D L Veenstra
- Departments of Pharmacy and Health Services, University of Washington, Seattle, WA, USA
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Magee CC, Denton MD, Milford EL. Immunosuppressive agents in organ transplantation. HOSPITAL MEDICINE (LONDON, ENGLAND : 1998) 1999; 60:364-9. [PMID: 10396414 DOI: 10.12968/hosp.1999.60.5.1118] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This article reviews current and future immunosuppressive strategies in organ transplantation. Recently introduced drugs are lowering the rates of acute rejection and allowing more individualized management of transplanted patients.
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Affiliation(s)
- C C Magee
- Laboratory of Immunogenetics and Transplantation (Renal Division), Brigham and Women's Hospital, Boston, MA 02115, USA
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Groth CG, Bäckman L, Morales JM, Calne R, Kreis H, Lang P, Touraine JL, Claesson K, Campistol JM, Durand D, Wramner L, Brattström C, Charpentier B. Sirolimus (rapamycin)-based therapy in human renal transplantation: similar efficacy and different toxicity compared with cyclosporine. Sirolimus European Renal Transplant Study Group. Transplantation 1999; 67:1036-42. [PMID: 10221490 DOI: 10.1097/00007890-199904150-00017] [Citation(s) in RCA: 657] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Sirolimus (rapamycin) is a potent immunosuppressant with a mechanism of action different from cyclosporine (CsA) or tacrolimus. METHODS In 11 European centers, first cadaveric renal allograft recipients were randomized to CsA (n=42) or sirolimus (n=41). Dosing of these agents was concentration-controlled and open-labeled. All patients received corticosteroids and azathioprine. RESULTS At 12 months, graft survival (98% sirolimus vs. 90% CsA), patient survival (100% vs. 98%), and incidence of biopsy-confirmed acute rejection (41% vs. 38%) were similar. Serum creatinine was lower with sirolimus, significantly (P< or =0.05) so at 3 and 4 months, and serum uric acid and magnesium were normal. Laboratory abnormalities reported significantly more often with sirolimus included hypertriglyceridemia (51% vs. 12%), hypercholesterolemia (44% vs. 14%), thrombocytopenia (37% vs. 0%), leukopenia (39% vs. 14%), and, of lesser importance, increased liver enzymes and hypokalemia. These abnormalities improved 2 months after transplantation when the sirolimus target trough level was lowered from 30 to 15 ng/ml. Occurrence of cytomegalovirus was comparable (14% vs. 12%); incidences of herpes simplex (24% vs. 10%, P=0.08) and pneumonia (17% vs. 2%, P=0.03) were higher with sirolimus. No gingival hyperplasia was seen with sirolimus, tremor was rare, and hypertension was less frequent (17% vs. 33%). Two malignancies were observed with CsA and none with sirolimus. CONCLUSIONS Results at 12 months suggest that sirolimus can be used as base therapy in the prophylaxis of acute renal transplant rejection, and has a safety profile that differs from CsA.
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Affiliation(s)
- C G Groth
- Huddinge Hospital, Stockholm, Sweden
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Shapiro R, Jordan ML, Scantlebury VP, Vivas C, Marsh JW, McCauley J, Johnston J, Randhawa P, Irish W, Gritsch HA, Naraghi R, Hakala TR, Fung JJ, Starzl TE. A prospective, randomized trial of tacrolimus/prednisone versus tacrolimus/prednisone/mycophenolate mofetil in renal transplant recipients. Transplantation 1999; 67:411-5. [PMID: 10030287 PMCID: PMC2952470 DOI: 10.1097/00007890-199902150-00012] [Citation(s) in RCA: 95] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Between September 20, 1995 and September 20, 1997, 208 adult patients undergoing renal transplantation were randomized to receive tacrolimus/prednisone (n=106) or tacrolimus/prednisone/mycophenolate mofetil (n=102), with the goal of reducing the incidence of rejection. METHODS The mean recipient age was 50.7+/-13.7 years. Sixty-three (30.3%) patients were 60 years of age or older at the time of transplantation. The mean donor age was 34.5+/-21.7 years. The mean cold ischemia time was 30.5+/-9.2 hr. The mean follow-up is 15+/-7 months. RESULTS The overall 1-year actuarial patient survival was 94%; the overall 1-year actuarial graft survival was 87%. When the patient and graft survival data were stratified to recipients under the age of 60 who did not have delayed graft function, the overall 1-year actuarial patient survival was 97%, and the corresponding 1-year actuarial graft survival was 93%. There were no differences between the two groups. The overall incidence of rejection was 36%; in the double-therapy group, it was 44%, whereas in the triple therapy group, it was 27% (P=0.014). The mean serum creatinine was 1.6+/-0.8 mg/dl. A total of 36% of the successfully transplanted patients were taken off prednisone; 32% of the patients were taken off antihypertensive medications. The incidence of delayed graft function was 21%, the incidence of cytomegalovirus was 12.5%, and the initial and final incidences of posttransplant insulin-dependent diabetes mellitus were 7.0% and 2.9%; again, there was no difference between the two groups. CONCLUSIONS This trial suggests that the combination of tacrolimus, steroids, and mycophenolate mofetil is associated with excellent patient and graft survival and a lower incidence of rejection than the combination of tacrolimus and steroids.
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Affiliation(s)
- R Shapiro
- University of Pittsburgh Medical Center, Thomas E. Starzl Transplantation Institute, Pennsylvania 15213, USA
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