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Yucel OK, Alemdar MS, Akkaya B, Kocak H, Suleymanlar G, Yilmaz VT. Tacrolimus-Associated Pure Red Cell Aplasia in a Patient With Renal Transplant. EXP CLIN TRANSPLANT 2022; 20:1131-1133. [PMID: 33272158 DOI: 10.6002/ect.2020.0290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Pure red cell aplasia is a relatively rare disease characterized by suppression or absence of erythroid precursors while other cell lineages are normal in the bone marrow. The disease could be secondary to other diseases or an adverse side effect of certain drugs. Tacrolimus is widely used as an immunosuppressive agent in solid-organ transplant without significant myelosuppressive effects. However, several tacrolimus-related pure red cell aplasia cases have been reported to date. Here, we report a case of a renal transplant recipient who developed tacrolimus-associated pure red cell aplasia in the posttransplant period and recovered dramatically after switching from tacrolimus to cyclosporine. Early diagnosis of pure red cell aplasia, which generally requires multiple blood transfusions, is very important because an increased number of blood transfusions can cause immunogenic effects and increased risk for allograft survival. Tacrolimus is a prominent drug for immunosuppression and is suspected to cause pure red cell aplasia during the posttransplant period; therefore, clinicians should consider a switch from tacrolimus to another immunosuppressive agent.
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Affiliation(s)
- Orhan Kemal Yucel
- From the Department of Hematology and Stem Cell Transplantation, Akdeniz University School of Medicine, Antalya, Turkey
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2
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Kim HJ, Lee J, Lee JG, Joo DJ, Kim MS. Clinical association between tacrolimus intra-patient variability and liver transplantation outcomes in patients with and without hepatocellular carcinoma. Sci Rep 2022; 12:16169. [PMID: 36171260 PMCID: PMC9519914 DOI: 10.1038/s41598-022-20636-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 09/15/2022] [Indexed: 12/01/2022] Open
Abstract
Tacrolimus is the mainstay of immunosuppression in liver transplantation to prevent rejection. However, the clinical use of tacrolimus is complicated by its narrow therapeutic window and significant intra-patient variability (IPV). High tacrolimus IPV is associated with overexposure and adverse effects, including malignancy. The effects of tacrolimus IPV in liver transplant recipients with and without hepatocellular carcinoma (HCC) are unknown. We investigated the association between tacrolimus IPV and transplant outcomes in 636 liver transplant patients. Tacrolimus IPV was determined by calculating the coefficient of variance (CV) of outpatient tacrolimus trough levels from 3 to 12 months after transplantation. High tacrolimus IPV was defined as CV > 30%. Patients were grouped according to tacrolimus IPV and HCC status. Among 636 liver transplant patients, 349 had HCC and 287 had no HCC. Overall survival in HCC patients was significantly reduced with high tacrolimus IPV (P < 0.001), whereas survival of non-HCC patients was not associated with tacrolimus IPV. Multivariable analysis confirmed the independent association between high tacrolimus IPV and overall mortality in HCC patients (HR, 3.010; 95% CI, 1.084–4.918). HCC recurred in 59 patients (16.9%) post-transplantation. After adjusting for donor/recipient factors, immunosuppression, and tumor characteristics, high tacrolimus IPV was independently associated with an increased risk of HCC recurrence (HR, 2.196; 95% CI, 1.272–3.791). High tacrolimus IPV was associated with significantly increased risks of overall mortality and HCC recurrence in liver transplant recipients with HCC.
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Affiliation(s)
- Hyun Jeong Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Juhan Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Jae Geun Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dong Jin Joo
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Myoung Soo Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
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3
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Broen JCA, van Laar JM. Mycophenolate mofetil, azathioprine and tacrolimus: mechanisms in rheumatology. Nat Rev Rheumatol 2020; 16:167-178. [PMID: 32055040 DOI: 10.1038/s41584-020-0374-8] [Citation(s) in RCA: 115] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2020] [Indexed: 02/08/2023]
Abstract
The introduction of biologic DMARDs into rheumatology has resulted in a substantial reduction of the burden of many rheumatic diseases. In the slipstream of the success achieved with these biologic DMARDs, some conventional immunosuppressive drugs have also found use in new indications. Notably, mycophenolate mofetil, azathioprine and tacrolimus have made their way from solid organ transplantation drugs to become useful assets in rheumatology practice. Mycophenolate mofetil and azathioprine inhibit the purine pathway and subsequently diminish cell proliferation. Both drugs have a pivotal role in the treatment of various rheumatic diseases, including lupus nephritis. Tacrolimus inhibits lymphocyte activation by inhibiting the calcineurin pathway. Mycophenolate mofetil and tacrolimus are, among other indications, increasingly being recognized as useful drugs in the treatment of interstitial lung disease in systemic rheumatic diseases and skin fibrosis in systemic sclerosis. A broad array of trials with mycophenolate mofetil, azathioprine and/or tacrolimus are ongoing within the field of rheumatology that might provide further novel avenues for the use of these drugs. In this Review, we discuss the historical perspective, pharmacodynamics, clinical indications and novel avenues for mycophenolate mofetil, azathioprine and tacrolimus in rheumatology.
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Affiliation(s)
- Jasper C A Broen
- Regional Rheumatology Center, Máxima Medical Center, Eindhoven and Veldhoven, Eindhoven, the Netherlands
| | - Jacob M van Laar
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands.
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4
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Watanabe S, Sakamoto R, Yamamoto H, Imaya M, Yamashita T, Anann T, Nakamura K. Pediatric Pure Red Cell Aplasia Caused by Tacrolimus After Living-Donor Liver Transplant. EXP CLIN TRANSPLANT 2019; 18:838-841. [PMID: 31724928 DOI: 10.6002/ect.2019.0075] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Pure red cell aplasia is a relatively rare disease characterized by selective suppression of erythroid precursors in the bone marrow. This disease can also develop secondary to several other diseases and as a side effect of certain drugs. Tacrolimus, a potent immunosuppressant, is widely used in organ transplant. Several cases of pure red cell aplasia due to tacrolimus administration in organ transplant recipients have been reported.Here, we report a case of reversible pure red cell aplasia that developed during tacrolimus therapy following living-donor liver transplant. The patient, a 1-year-old girl diagnosed with progressive familial intrahepatic cholestasis type II, underwent living-donor liver transplant when she was 10 months old. She was started on 3 immunosuppressants posttransplant: tacrolimus (0.1 mg/kg/day twice daily), mycophenolate mofetil, and prednisolone (0.2 mg/kg/day). One year after transplant, she developed severe progressive anemia. Her hemoglobin concentration was extremely low (5.4 g/dL). A bone marrow biopsy revealed severe hypoplasia of the erythroblasts with no abnormality of other myelocytes. These findings were suggestive of pure red cell aplasia; we suspected that tacrolimus had caused this based on similar previous cases of tacrolimus-associated pure red cell aplasia. Accordingly, tacrolimus was switched to cyclosporine after this diagnosis. One week after this switch, the patient's red blood cell counts, reticulocytes, and hemoglobin concentration increased. Although tacrolimus is considered to have no significant potential for myelosuppression, cases of tacrolimus-related pure red cell aplasia have occurred. In patients who develop pure red cell aplasia during tacrolimus treatment following living-donor liver transplant, clinicians should consider switching from tacrolimus to another immunosuppressant.
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Affiliation(s)
- Suguru Watanabe
- From the Department of Pediatrics, Kumamoto University, Kumamoto, Japan
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5
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Lee HG, Kim LK, Choi JM. NFAT-Specific Inhibition by dNP2-VIVITAmeliorates Autoimmune Encephalomyelitisby Regulation of Th1 and Th17. MOLECULAR THERAPY-METHODS & CLINICAL DEVELOPMENT 2019; 16:32-41. [PMID: 31737742 PMCID: PMC6849366 DOI: 10.1016/j.omtm.2019.10.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 10/16/2019] [Indexed: 11/26/2022]
Abstract
Nuclear factor of activated T cells (NFATs) is an important transcription factor for T cell activation and proliferation. Recent studies have highlighted the role of NFATs in regulating the differentiation of effector CD4 T helper (Th) subsets including Th1 and Th17 cells. Because controlling the effector T cell function is important for the treatment of autoimmune diseases, regulation of NFAT functions in T cells would be an important strategy to control the pathogenesis of autoimmune diseases. Here, we demonstrated that an NFAT inhibitory peptide, VIVIT conjugated to dNP2 (dNP2-VIVIT), a blood-brain barrier-permeable peptide, ameliorated experimental autoimmune encephalomyelitis (EAE) by inhibiting Th1 and Th17 cells, but not regulatory T (Treg) cells. dNP2-VIVIT negatively regulated spinal cord-infiltrating interleukin-17A (IL-17A) and interferon (IFN)-γ-producing CD4+ T cells without affecting the number of Foxp3+ CD4+ Treg cells, whereas dNP2-VEET or 11R-VIVIT could not significantly inhibit EAE. In comparison with cyclosporin A (CsA), dNP2-VIVIT selectively inhibited Th1 and Th17 differentiation, whereas CsA inhibited the differentiation of all T cell subsets including that of Th2 and Treg cells. Collectively, this study demonstrated the role of dNP2-VIVIT as a novel agent for the treatment of autoimmune diseases such as multiple sclerosis by regulating the functions of Th1 and Th17 cells.
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Affiliation(s)
- Hong-Gyun Lee
- Department of Life Science, College of Natural Sciences, Hanyang University, Seoul, Republic of Korea.,Research Institute for Natural Sciences, Hanyang University, Seoul, Republic of Korea
| | - Li-Kyung Kim
- Department of Life Science, College of Natural Sciences, Hanyang University, Seoul, Republic of Korea.,Research Institute for Natural Sciences, Hanyang University, Seoul, Republic of Korea
| | - Je-Min Choi
- Department of Life Science, College of Natural Sciences, Hanyang University, Seoul, Republic of Korea.,Research Institute for Natural Sciences, Hanyang University, Seoul, Republic of Korea.,Research Institute for Convergence of Basic Sciences, Hanyang University, Seoul, Republic of Korea
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6
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The change of immunosuppressive regimen from calcineurin inhibitors to mammalian target of rapamycin (mTOR) inhibitors and its effect on malignancy following heart transplantation. Int Immunopharmacol 2019; 69:150-158. [PMID: 30711744 DOI: 10.1016/j.intimp.2019.01.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 01/24/2019] [Accepted: 01/25/2019] [Indexed: 12/11/2022]
Abstract
Malignancy is a significant cause of mortality after organ transplantation. There is an increased rate of malignancy following heart transplantation (HTx) compared to the general population and other organ transplant recipients. Post-HTx patients with a history of malignancy are also at a higher risk of developing new malignancies or exacerbation of their existing malignancies. Mammalian target of Rapamycin inhibitors (mTORIs) are newly introduced immunosuppressive drugs with a unique mechanism of action. By changing the immunosuppressive regimen from classic drugs, especially calcineurin inhibitors (CNIs) to mTORIs, the rate of developing de novo malignancies and the relapse of former malignancies is significantly reduced. However, issues like allograft function, total surveillance of patients, and post-transplantation complications should be considered during the conversion of drug regimens utilizing CNIs to drug regimens employing mTORIs. We reviewed different post-heart transplant maintenance immunosuppressive regimens and their effect on post-HTx malignancies with a focus on mTORIs, compared safety against effectiveness, and gathered conclusions based on our review of the literature, which may lead clinicians to make a better evidence-based decision regarding post-HTx maintenance immunosuppressive drug regimens. Overall, CNI to mTORI conversion in post-HTx maintenance immunosuppressive drug regimens was associated with a reduced rate of developing malignancy in post-HTx patients. Furthermore, nephrotoxicity decreased significantly while using mTORIs in combination with lower doses of CNIs and the rejection rate was equivalent to CNI-only regimens. In conclusion, mTORI-based maintenance immunosuppressive drug regimens seem to be safe and beneficial when considering efficacy vs. adverse effects, and all-cause mortality rates are significantly lower in patients switched to mTORIs when compared to CNI recipients.
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7
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Lee JU, Kim LK, Choi JM. Revisiting the Concept of Targeting NFAT to Control T Cell Immunity and Autoimmune Diseases. Front Immunol 2018; 9:2747. [PMID: 30538703 PMCID: PMC6277705 DOI: 10.3389/fimmu.2018.02747] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 11/08/2018] [Indexed: 01/15/2023] Open
Abstract
The nuclear factor of activated T cells (NFAT) family of transcription factors, which includes NFAT1, NFAT2, and NFAT4, are well-known to play important roles in T cell activation. Most of NFAT proteins are controlled by calcium influx upon T cell receptor and costimulatory signaling results increase of IL-2 and IL-2 receptor. NFAT3 however is not shown to be expressed in T cells and NFAT5 has not much highlighted in T cell functions yet. Recent studies demonstrate that the NFAT family proteins involve in function of lineage-specific transcription factors during differentiation of T helper 1 (Th1), Th2, Th17, regulatory T (Treg), and follicular helper T cells (Tfh). They have been studied to make physical interaction with the other transcription factors like GATA3 or Foxp3 and they also regulate Th cell signature gene expressions by direct binding on promotor region of target genes. From last decades, NFAT functions in T cells have been targeted to develop immune modulatory drugs for controlling T cell immunity in autoimmune diseases like cyclosporine A, FK506, etc. Due to their undesirable side defects, only limited application is available in human diseases. This review focuses on the recent advances in development of NFAT targeting drug as well as our understanding of each NFAT family protein in T cell biology. We also discuss updated detail molecular mechanism of NFAT functions in T cells, which would lead us to suggest an idea for developing specific NFAT inhibitors as a therapeutic drug for autoimmune diseases.
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Affiliation(s)
- Jae-Ung Lee
- Department of Life Science, College of Natural Sciences, Hanyang University, Seoul, South Korea.,Research Institute for Natural Sciences, Hanyang University, Seoul, South Korea
| | - Li-Kyung Kim
- Department of Life Science, College of Natural Sciences, Hanyang University, Seoul, South Korea.,Research Institute for Natural Sciences, Hanyang University, Seoul, South Korea
| | - Je-Min Choi
- Department of Life Science, College of Natural Sciences, Hanyang University, Seoul, South Korea.,Research Institute for Natural Sciences, Hanyang University, Seoul, South Korea
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8
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Eberhardt W, Nasrullah U, Pfeilschifter J. Activation of renal profibrotic TGFβ controlled signaling cascades by calcineurin and mTOR inhibitors. Cell Signal 2018; 52:1-11. [PMID: 30145216 DOI: 10.1016/j.cellsig.2018.08.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 08/21/2018] [Accepted: 08/22/2018] [Indexed: 12/11/2022]
Abstract
The calcineurin inhibitors (CNI) cyclosporine A (CsA) and tacrolimus represent potent immunosuppressive agents frequently used for solid organ transplantation and treatment of autoimmune disorders. Despite of their immense therapeutic benefits, residual fibrosis mainly in the kidney represents a common side effect of long-term therapy with CNI. Regardless of the immunosuppressive action, an increasing body of evidence implicates that a drug-induced increase in TGFβ and subsequent activation of TGFβ-initiated signaling pathways is closely associated with the development and progression of CNI-induced nephropathy. Mechanistically, an increase in reactive oxygen species (ROS) generation due to drug-induced changes in the intracellular redox homeostasis functions as an important trigger of the profibrotic signaling cascades activated under therapy with CNI. Although, inhibitors of the mechanistic target of rapamycin (mTOR) kinase have firmly been established as alternative compounds with a lower nephrotoxic potential, an activation of fibrogenic signaling cascades has been reported for these drugs as well. This review will comprehensively summarize recent advances in the understanding of profibrotic signaling events modulated by these widely used compounds with a specific focus put on mechanisms occurring independent of their respective immunosuppressive action. Herein, the impact of redox modulation, the activation of canonical TGFβ and non-Smad pathways and modulation of autophagy by both classes of immunosuppressive drugs will be highlighted and discussed in a broader perspective. The comprehensive knowledge of profibrotic signaling events specifically accompanying the immunomodulatory activity of these widely used drugs is needed for a reliable benefit-risk assessment under therapeutic regimens.
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Affiliation(s)
- Wolfgang Eberhardt
- Pharmazentrum frankfurt/ZAFES, Universitätsklinikum und Goethe-Universität, Frankfurt am Main, Germany.
| | - Usman Nasrullah
- Pharmazentrum frankfurt/ZAFES, Universitätsklinikum und Goethe-Universität, Frankfurt am Main, Germany
| | - Josef Pfeilschifter
- Pharmazentrum frankfurt/ZAFES, Universitätsklinikum und Goethe-Universität, Frankfurt am Main, Germany
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9
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Lichtenberg S, Rahamimov R, Green H, Fox BD, Mor E, Gafter U, Chagnac A, Rozen-Zvi B. The incidence of post-transplant cancer among kidney transplant recipients is associated with the level of tacrolimus exposure during the first year after transplantation. Eur J Clin Pharmacol 2017; 73:819-826. [DOI: 10.1007/s00228-017-2234-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Accepted: 03/03/2017] [Indexed: 02/08/2023]
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10
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Kimsa M, Strzalka-Mrozik B, Kimsa-Dudek M, Kruszniewska-Rajs C, Gola J, Adamska J, Mazurek U. Transforming growth factor β-related genes in human retinal pigment epithelial cells after tacrolimus treatment. Pharmacol Rep 2016; 68:969-74. [DOI: 10.1016/j.pharep.2016.04.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 04/28/2016] [Accepted: 04/29/2016] [Indexed: 01/28/2023]
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11
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Yin WY, Lee MC, Huang HB, Lu MC. Increased gene expression of TGF-β in peripheral blood mononuclear cells from renal transplant patients with polyomavirus BK viremia. Clin Transplant 2016; 30:393-8. [PMID: 26783039 DOI: 10.1111/ctr.12698] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/24/2015] [Indexed: 01/25/2023]
Abstract
We aimed to investigate the roles of cytokines during polyomavirus BK (BKV) reactivation in renal transplant patients. Forty-eight renal allograft recipients were enrolled, and their sera BKV viral load and mRNA expression levels of cytokines in peripheral blood mononuclear cells were measured by real-time polymerase chain reaction. Patient's age and gene expression levels of interleukin (IL)-2 (10.04 ± 2.63 vs. 8.70 ± 2.40, p = 0.049) and transforming growth factor (TGF)-β (12.58 ± 2.59 vs. 10.89 ± 1.91, p = 0.015) were significantly higher in BKV viremia (+) renal transplant patients. Multivariate logistic regression analysis revealed that age and mRNA expression levels of TGF-β, but not IL-2, significantly correlated with the presence of BKV viremia. Sera BKV viral loads showed a positive correlation with patient age and the levels of TGF-β and IL-6 mRNA. After adjusting for age and sex in the regression model, both age and TGF-β mRNA levels maintained a significant positive association with sera BKV viral loads. Serum TGF-β concentration tended to be higher in BKV viremia (+) patients (p = 0.079). In conclusion, expression levels of TGF-β were found to correlate with both BKV viremia positivity and sera BKV viral loads in renal transplant patients.
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Affiliation(s)
- Wen-Yao Yin
- Division of General Surgery, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Ming-Che Lee
- School of Medicine, Tzu Chi University, Hualien, Taiwan.,Department of General Surgery, Hualien Tzu Chi Medical Center, Hualien, Taiwan
| | - Hsien-Bin Huang
- Department of Life Science and Institute of Molecular Biology, National Chung Cheng University, Chiayi, Taiwan
| | - Ming-Chi Lu
- School of Medicine, Tzu Chi University, Hualien, Taiwan.,Division of Allergy, Immunology and Rheumatology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
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12
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Colak H, Ersan S, Tanrisev M, Kurtulmus Y, Degirmenci P, Comert S, Tugmen C, Ceylan C. Relationship of Interleukin-10 and Transforming Growth Factor-β Levels With Short-Term Graft Function After Kidney Transplantation. Transplant Proc 2015; 47:1360-3. [PMID: 25964218 DOI: 10.1016/j.transproceed.2015.02.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION We evaluated the relationship of interleukin-10 (IL-10) and transforming growth factor-β (TGF-β) levels with graft function in kidney transplantation patients receiving tacrolimus-based immunosuppression during the early post-transplantation period. MATERIAL AND METHODS There were 112 patients who underwent kidney transplantation from live donors between May 2011 and May 2013. Eight patients had at least 1 of the exclusion criteria, and the remaining 104 patients were included in the study. The recipients underwent evaluation for biochemical markers, complete blood count, and creatinine and cytokine (IL-10, TGF-β) levels during the pretransplantation and post-transplantation 6 months. RESULTS The creatinine level was negatively correlated with IL-10 and positively correlated with TGF-β levels in both the pretransplantation and early post-transplantation period. CONCLUSION Low serum TGF-β and high IL-10 levels at post-transplantation month 6 might have a positive effect on graft survival in living donor kidney recipients on tacrolimus-based immunosuppressive treatment.
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Affiliation(s)
- H Colak
- Department of Nephrology, Tepecik Training and Research Hospital, Izmir, Turkey.
| | - S Ersan
- Department of Nephrology, Tepecik Training and Research Hospital, Izmir, Turkey
| | - M Tanrisev
- Department of Nephrology, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Y Kurtulmus
- Tissue Typing Laboratory, Tepecik Training and Research Hospital, Izmir, Turkey
| | - P Degirmenci
- Department of Allergy and Immunology, Tepecik Training and Research Hospital, Izmir, Turkey
| | - S Comert
- Department of Allergy and Immunology, Tepecik Training and Research Hospital, Izmir, Turkey
| | - C Tugmen
- Department of Surgery, Tepecik Training and Research Hospital, Izmir, Turkey
| | - C Ceylan
- Department of Hematology, Tepecik Training and Research Hospital, Izmir, Turkey
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13
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Nath PR, Isakov N. Insights into peptidyl-prolyl cis–trans isomerase structure and function in immunocytes. Immunol Lett 2015; 163:120-31. [DOI: 10.1016/j.imlet.2014.11.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Revised: 10/27/2014] [Accepted: 11/03/2014] [Indexed: 12/30/2022]
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14
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Muthukumar T, Lee JR, Dadhania DM, Ding R, Sharma VK, Schwartz JE, Suthanthiran M. Allograft rejection and tubulointerstitial fibrosis in human kidney allografts: interrogation by urinary cell mRNA profiling. Transplant Rev (Orlando) 2014; 28:145-54. [PMID: 24929703 DOI: 10.1016/j.trre.2014.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Revised: 04/26/2014] [Accepted: 05/22/2014] [Indexed: 01/07/2023]
Abstract
Because the kidney allograft has the potential to function as an in-vivo flow cytometer and facilitate the access of immune cells and kidney parenchymal cells in to the urinary space, we hypothesized that mRNA profiling of urinary cells offers a noninvasive means of assessing the kidney allograft status. We overcame the inherent challenges of urinary cell mRNA profiling by developing pre-amplification protocols to compensate for low RNA yield from urinary cells and by developing robust protocols for absolute quantification mRNAs using RT-PCR assays. Armed with these tools, we undertook first single-center studies urinary cell mRNA profiling and then embarked on the multicenter Clinical Trials in Organ Transplantation-04 study of kidney transplant recipients. We report here our discovery and validation of diagnostic and prognostic biomarkers of acute cellular rejection and of interstitial fibrosis and tubular atrophy (IF/TA). Our urinary cell mRNA profiling studies, in addition to demonstrating the feasibility of accurate diagnosis of acute cellular rejection and IF/TA in the kidney allograft, advance mechanistic and potentially targetable biomarkers. Interventional trials, guided by urinary cell mRNA profiles, may lead to personalized immunosuppression in recipients of kidney allografts.
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Affiliation(s)
- Thangamani Muthukumar
- Division of Nephrology and Hypertension, Department of Medicine, Weill Cornell Medical College, New York, NY; Department of Transplantation Medicine, New York Presbyterian Hospital - Weill Cornell Medical Center, New York, NY.
| | - John R Lee
- Division of Nephrology and Hypertension, Department of Medicine, Weill Cornell Medical College, New York, NY; Department of Transplantation Medicine, New York Presbyterian Hospital - Weill Cornell Medical Center, New York, NY
| | - Darshana M Dadhania
- Division of Nephrology and Hypertension, Department of Medicine, Weill Cornell Medical College, New York, NY; Department of Transplantation Medicine, New York Presbyterian Hospital - Weill Cornell Medical Center, New York, NY
| | - Ruchuang Ding
- Division of Nephrology and Hypertension, Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Vijay K Sharma
- Division of Nephrology and Hypertension, Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Joseph E Schwartz
- Division of Nephrology and Hypertension, Department of Medicine, Weill Cornell Medical College, New York, NY; Department of Psychiatry and Behavioral Science, Stony Brook School of Medicine, Stony Brook, NY
| | - Manikkam Suthanthiran
- Division of Nephrology and Hypertension, Department of Medicine, Weill Cornell Medical College, New York, NY; Department of Transplantation Medicine, New York Presbyterian Hospital - Weill Cornell Medical Center, New York, NY
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15
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16
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Frascà GM, D'Arezzo M, Ricciatti AM, Balestra E, Taruscia D, Nastasi V, Goteri G. m-TOR inhibitors may be useful in the treatment of encapsulating peritoneal sclerosis (EPS). J Nephrol 2014; 27:587-90. [PMID: 24519842 DOI: 10.1007/s40620-014-0052-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2013] [Accepted: 06/12/2013] [Indexed: 11/26/2022]
Abstract
Encapsulating peritoneal sclerosis (EPS) is a rare but serious complication of long-term peritoneal dialysis, often occurring after patients have been shifted to haemodialysis or undergone renal transplantation. EPS is still associated with high morbidity and mortality but, although various treatment modalities have been tried, the optimal therapy is still debated. The present paper reports a 16-year-old patient who developed EPS 6 months after shifting to haemodialysis and, following adhesiolysis, was successfully treated with a combination of steroids, tamoxifen and everolimus, this last drug chosen for its antiproliferative effect through mammalian target of rapamycin (mTOR) inhibition and its ability to block vascular endothelial growth factor and neoangiogenesis. EPS progressively improved and the patient successfully underwent renal transplantation 5 years later. The case suggests that, in view of their mechanism of action, mTOR inhibitors should be considered as an immunosuppressive agent after renal transplantation in patients at risk and merit investigation in future trials on this condition.
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Affiliation(s)
- Giovanni Maria Frascà
- Nephrology, Dialysis and Renal Transplantation Unit, Ospedali Riuniti, Ancona, Italy,
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17
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Rodríguez-Serrano M, Sánchez-Lázaro I, Almenar-Bonet L, Martínez-Dolz L, Portolés-Sanz M, Rivera-Otero M, Salvador-Sanz A. Does the calcineurin inhibitor have influence on cytomegalovirus infection in heart transplantation? Clin Transplant 2013; 28:88-95. [PMID: 24325305 DOI: 10.1111/ctr.12282] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2013] [Indexed: 12/19/2022]
Abstract
Cytomegalovirus (CMV) infection is a major cause of morbidity and mortality in heart transplant (HTx). Our aim was to analyze the rate of CMV infection in HTx patients receiving treatment with cyclosporine (CsA) or tacrolimus (Tac). Ninety-five patients were randomized to receive either CsA (53.7%) or Tac (46.3%). We performed prophylaxis with valganciclovir in patients with the highest risk of CMV infection. We considered CMV infection as an increased viral load or the presence of CMV in histological samples. We analyzed baseline characteristics, CMV infection, and other complications. Event-free rates were calculated using the Kaplan-Meier method. There were no significant differences in baseline characteristics between both groups. CMV infection was detected in 31.6% of patients (in 66.7% due to asymptomatic replication). The group treated with Tac had a lower rate of CMV infection (15.9% vs. 45.1%, p = 0.002) and longer CMV infection-free survival time (1440 vs. 899 d, p = 0.001). No differences were observed in the complications analyzed in both groups. The independent risk factors for infection identified in the multivariate analysis were treatment with CsA and bacterial infections. This was the first study to demonstrate a lower rate of CMV infection in patients treated with Tac vs. those treated with CsA after HTx.
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Affiliation(s)
- María Rodríguez-Serrano
- Heart Failure and Transplantation Unit, Department of Cardiology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
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Abstract
The first successful kidney transplantation between monozygotic identical twins did not require any immunosuppressive drugs. Clinical application of azathioprine and glucocorticosteroids allowed the transfer of organs between genetically disparate donors and recipients. Transplantation is now the standard of care, a life-saving procedure for patients with failed organs. Progress in our understanding of the immunobiology of rejection has been translated to the development of immunosuppressive agents targeting T cells, B cells, plasma cells, costimulatory signals, complement products, and antidonor antibodies. Modern immunopharmacologic interventions have contributed to the clinical success observed following transplantation but challenges remain in personalizing immunosuppressive therapy.
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Affiliation(s)
- Choli Hartono
- Division of Nephrology and Hypertension, Departments of Medicine and Transplantation Medicine, New York Presbyterian Hospital-Weill Cornell Medical College, New York, New York 10065
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The possible potential therapeutic targets for drug induced gingival overgrowth. Mediators Inflamm 2013; 2013:639468. [PMID: 23690667 PMCID: PMC3652200 DOI: 10.1155/2013/639468] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Accepted: 03/29/2013] [Indexed: 12/14/2022] Open
Abstract
Gingival overgrowth is a side effect of certain medications. The most fibrotic drug-induced lesions develop in response to therapy with phenytoin, the least fibrotic lesions are caused by cyclosporin A, and the intermediate fibrosis occurs in nifedipine-induced gingival overgrowth. Fibrosis is one of the largest groups of diseases for which there is no therapy but is believed to occur because of a persistent tissue repair program. During connective tissue repair, activated gingival fibroblasts synthesize and remodel newly created extracellular matrix. Proteins such as transforming growth factor (TGF), endothelin-1 (ET-1), angiotensin II (Ang II), connective tissue growth factor (CCN2/CTGF), insulin-like growth factor (IGF), and platelet-derived growth factor (PDGF) appear to act in a network that contributes to the development of gingival fibrosis. Since inflammation is the prerequisite for gingival overgrowth, mast cells and its protease enzymes also play a vital role in the pathogenesis of gingival fibrosis. Drugs targeting these proteins are currently under consideration as antifibrotic treatments. This review summarizes recent observations concerning the contribution of TGF-β, CTGF, IGF, PDGF, ET-1, Ang II, and mast cell chymase and tryptase enzymes to fibroblast activation in gingival fibrosis and the potential utility of agents blocking these proteins in affecting the outcome of drug-induced gingival overgrowth.
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Rianthavorn P, Posuwan N, Payungporn S, Theamboonlers A, Poovorawan Y. Polyomavirus reactivation in pediatric patients with systemic lupus erythematosus. TOHOKU J EXP MED 2013; 228:197-204. [PMID: 23076257 DOI: 10.1620/tjem.228.197] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Polyomavirus (PyV) infection usually persists without any symptoms in normal individuals. In immunocompromised patients including patients with systemic lupus erythematosus (SLE), PyV reactivation occurs with a high prevalence and can cause severe clinical complications. In this study, reactivation of six PyV [JC, BK, WU, KI, merkel cell (MC) and trichodysplasia spinulosa (TS)] was investigated in terms of prevalence, clinical implications and correlation with urine transforming growth factor (TGF)-β1 expression in 50 SLE patients aged less than 18 years. Clinical characteristics were obtained from medical record review. PyV viruria was assessed by nested polymerase chain reaction. Urine TGF-β1 was measured with ELISA. The mean age was 13 ± 2.8 years. The prevalence of JC and BK viruria was 16% and 32%, respectively. WU, KI, MC and TS were not isolated from any urine specimens. Co-reactivation of 2 PyV was not detected. Urine TGF-β1 levels in patients with JC viruria, with BK viruria and without PyV viruria were 0.27 ± 0.09, 0.10 ± 0.05 and 0.13 ± 0.09 ng/mg of urine creatinine, respectively. Cumulative doses of cyclophosphamide per body weight and urine TGF-β1 levels were higher in JC viruria than in other groups (p < 0.05). The prevalence of JC and BK reactivation was higher in pediatric patients with SLE than in the normal population. JC reactivation in pediatric patients with SLE was correlated with the administration of high-dose cyclophosphamide and increased urine TGF-β1 levels. Surveillance of JC reactivation is recommended in pediatric patients with chronic and severe SLE receiving high-dose cyclophosphamide.
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Affiliation(s)
- Pornpimol Rianthavorn
- Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Keaney TC, Bhutani T, Sivanesan P, Bandow GD, Weinstein SB, Cheung LC, Malick F, Koo J. Open-label, pilot study examining sequential therapy with oral tacrolimus and topical tacrolimus for severe atopic dermatitis. J Am Acad Dermatol 2012; 67:636-41. [DOI: 10.1016/j.jaad.2011.10.033] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2010] [Revised: 10/11/2011] [Accepted: 10/23/2011] [Indexed: 01/10/2023]
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Treede H, Glanville AR, Klepetko W, Aboyoun C, Vettorazzi E, Lama R, Bravo C, Knoop C, Aubert JD, Reichenspurner H. Tacrolimus and cyclosporine have differential effects on the risk of development of bronchiolitis obliterans syndrome: Results of a prospective, randomized international trial in lung transplantation. J Heart Lung Transplant 2012; 31:797-804. [DOI: 10.1016/j.healun.2012.03.008] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Revised: 03/11/2012] [Accepted: 03/27/2012] [Indexed: 10/28/2022] Open
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Chiasson VL, Jones KA, Kopriva SE, Mahajan A, Young KJ, Mitchell BM. Endothelial cell transforming growth factor-β receptor activation causes tacrolimus-induced renal arteriolar hyalinosis. Kidney Int 2012; 82:857-66. [PMID: 22495293 PMCID: PMC3396764 DOI: 10.1038/ki.2012.104] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Arteriolar hyalinosis is a common histological finding in renal transplant recipients treated with the calcineurin inhibitor tacrolimus; however, the pathophysiologic mechanisms remain unknown. In addition to increasing transforming growth factor (TGF)-β levels, tacrolimus inhibits calcineurin by binding to FK506 binding protein 12 (FKBP12). FKBP12 alone also inhibits TGF-β receptor activation. Here we tested whether tacrolimus binding to FKBP12 removes an inhibition of the TGF-β receptor, allowing ligand binding, ultimately leading to receptor activation and arteriolar hyalinosis. We found that specific deletion of FKBP12 from endothelial cells was sufficient to activate endothelial TGF-β receptors and induce renal arteriolar hyalinosis in these knockout mice, similar to that induced by tacrolimus. Tacrolimus-treated and knockout mice exhibited significantly increased levels of aortic TGF-β receptor activation as evidenced by SMAD2/3 phosphorylation, along with increased collagen and fibronectin expression compared to controls. Treatment of isolated mouse aortas with tacrolimus increased TGF-β receptor activation, collagen and fibronectin expression. These effects were independent of calcineurin, absent in endothelial denuded aortic rings, and could be prevented by the small molecule TGF-β receptor inhibitor SB-505124. Thus endothelial cell TGF-β receptor activation is sufficient to cause vascular remodeling and renal arteriolar hyalinosis.
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Affiliation(s)
- Valorie L Chiasson
- Department of Internal Medicine, Division of Nephrology & Hypertension, Texas A&M Health Science Center College of Medicine, Temple, Texas 76504, USA
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Ward F, Moran AM, Minhas M, Watson A. Successful outcome with early renal transplantation following treatment of encapsulating peritoneal sclerosis. Clin Kidney J 2010; 3:477-9. [PMID: 25984059 PMCID: PMC4421684 DOI: 10.1093/ndtplus/sfq122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2010] [Accepted: 06/22/2010] [Indexed: 11/12/2022] Open
Affiliation(s)
- Frank Ward
- Department of Nephrology , St. Vincent's University Hospital , Dublin , Ireland
| | - Ann-Marie Moran
- Department of Nephrology , St. Vincent's University Hospital , Dublin , Ireland
| | - Malik Minhas
- Department of Nephrology , St. Vincent's University Hospital , Dublin , Ireland
| | - Alan Watson
- Department of Nephrology , St. Vincent's University Hospital , Dublin , Ireland
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Datta D, Contreras AG, Basu A, Dormond O, Flynn E, Briscoe DM, Pal S. Calcineurin inhibitors activate the proto-oncogene Ras and promote protumorigenic signals in renal cancer cells. Cancer Res 2009; 69:8902-9. [PMID: 19903851 DOI: 10.1158/0008-5472.can-09-1404] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The development of cancer is a major problem in immunosuppressed patients, particularly after solid organ transplantation. We have recently shown that calcineurin inhibitors (CNI) used to treat transplant patients may play a critical role in the rapid progression of renal cancer. To examine the intracellular signaling events for CNI-mediated direct tumorigenic pathway(s), we studied the effect of CNI on the activation of proto-oncogenic Ras in human normal renal epithelial cells (REC) and renal cancer cells (786-0 and Caki-1). We found that CNI treatment significantly increased the level of activated GTP-bound form of Ras in these cells. In addition, CNI induced the association of Ras with one of its effector molecules, Raf, but not with Rho and phosphatidylinositol 3-kinase; CNI treatment also promoted the phosphorylation of the Raf kinase inhibitory protein and the downregulation of carabin, all of which may lead to the activation of the Ras-Raf pathway. Blockade of this pathway through either pharmacologic inhibitors or gene-specific small interfering RNA significantly inhibited CNI-mediated augmented proliferation of renal cancer cells. Finally, it was observed that CNI treatment increased the growth of human renal tumors in vivo, and the Ras-Raf pathway is significantly activated in the tumor tissues of CNI-treated mice. Together, targeting the Ras-Raf pathway may prevent the development/progression of renal cancer in CNI-treated patients.
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Affiliation(s)
- Dipak Datta
- Division of Nephrology and Transplantation Research Center, Children's Hospital Boston and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts 02115, USA
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Tacrolimus versus cyclosporine for adult lung transplant recipients: a meta-analysis. Transplant Proc 2009; 41:1821-4. [PMID: 19545736 DOI: 10.1016/j.transproceed.2008.11.016] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2008] [Accepted: 11/14/2008] [Indexed: 11/23/2022]
Abstract
BACKGROUND Tacrolimus and cyclosporine are the 2 major immunosuppressants for lung transplantation. Several studies have compared these 2 drugs, but the outcomes were not consistent. The aim of this meta-analysis of randomized controlled trials (RCTs) was to compare the beneficial and harmful effects of tacrolimus and cyclosporine as the primary immunosuppressant for lung transplant recipients. METHODS We conducted searches of electronic databases and manual bibliographies. We performed a meta-analysis of all RCTs comparing tacrolimus with cyclosporine as primary immunosuppression for lung transplant recipients. Extracted, pooled data for mortality, acute rejection, withdrawals, and adverse events were analyzed using Mantel-Haenszel tests with a random effects model. RESULTS Three RCTs including 297 patients were assessed in this study. Mortality at 1 year or more was comparable between lung recipients treated with tacrolimus and cyclosporine (odds ratio [OR], 0.94; 95% confidence interval [CI], 0.42-2.10; P = .88). Tacrolimus-treated patients experienced fewer incidences of acute rejection (MD = -0.14; 95% CI, -0.28 to -0.01; P = .04). Pooled analysis showed a trend toward a lower risk of bronchiolitis obliterans syndrome (BOS) among tacrolimus-treated patients, although it did not reach significances (OR, 0.53; 95% CI, 0.25-1.12; P = .10). Fewer patients stopped tacrolimus than cyclosporine (OR, 0.12; 95% CI, 0.03-0.48; P = .003). The rate of new-onset diabetes was higher among the tacrolimus group (OR, 3.69; 95% CI, 1.17-11.62; P = .03). The incidence of hypertension and renal dysfunction were comparable in these 2 groups (OR, 0.24; 95% CI, 0.03-1.70; P = .15; and OR, 1.67; 95% CI, 0.70-3.96; P = .25, respectively). There was a trend toward lower risk of malignancy in tacrolimus-treated patients, although it did not reach significance either (OR, 0.19; 95% CI, 0.03-1.13; P = .07). The incidence of infection was comparable in these 2 groups (MD = -0.29, 95% CI, -0.68 to 0.11; P = .16). CONCLUSION Using tacrolimus as primary immunosuppressant for lung transplant recipient resulted in comparable survival and reduction in acute rejection episodes when compared with cyclosporine.
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Ye F, Ying-Bin X, Yu-Guo W, Hetzer R. Tacrolimus versus cyclosporine microemulsion for heart transplant recipients: a meta-analysis. J Heart Lung Transplant 2008; 28:58-66. [PMID: 19134532 DOI: 10.1016/j.healun.2008.10.004] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2008] [Revised: 10/09/2008] [Accepted: 10/14/2008] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Tacrolimus and cyclosporine microemulsion are the 2 major immunosuppressants for heart transplantation. Several studies have compared these 2 drugs, but the outcomes were not consistent. This meta-analysis of randomized controlled trials compared the beneficial and harmful effects of tacrolimus and microemulsion cyclosporine for heart transplant recipients. METHODS Electronic databases and manual bibliography searches were conducted. A meta-analysis was performed of all randomized controlled trials comparing tacrolimus with cyclosporine microemulsion as primary immunosuppression for heart transplant recipients. Data for mortality, acute rejection, withdrawals, and adverse events were extracted. The combined results of the data of the randomized controlled trials were summarized as relative risk with 95% confidence intervals. RESULTS The study assessed 7 randomized controlled trials including 885 patients. There was no difference in mortality at 1 year between recipients treated with tacrolimus and cyclosporine microemulsion. Tacrolimus-treated patients had less acute rejection risk at 6 months and 1 year. Fewer patients stopped tacrolimus than cyclosporine microemulsion. The rate of new-onset diabetes mellitus requiring insulin treatment was higher with tacrolimus. More post-transplantation hypertension occurred with cyclosporine microemulsion. The groups had comparable incidences of malignancy and renal failure needing dialysis. CONCLUSIONS The use of tacrolimus as primary immunosuppressant for heart transplant recipients results in comparable survival and a significant reduction in acute rejection compared with cyclosporine microemulsion.
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Affiliation(s)
- Fan Ye
- Department of Cardiothoracic and Vascular Surgery, Chongqing Xinqiao Hospital, Third Military Medical University, Chongqing, China
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Abend JR, Imperiale MJ. Transforming growth factor-beta-mediated regulation of BK virus gene expression. Virology 2008; 378:6-12. [PMID: 18559281 PMCID: PMC2569840 DOI: 10.1016/j.virol.2008.05.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2007] [Revised: 11/14/2007] [Accepted: 05/14/2008] [Indexed: 12/12/2022]
Abstract
The increasing prevalence of BK virus (BKV)-associated diseases in immunosuppressed patients has prompted an investigation of the immune response to BKV, especially the role of cytokines in regulating viral replication. We examined the effect of TGF-beta, a cytokine that is stimulated by certain immunosuppressive therapies, on BKV gene expression during lytic infection of renal proximal tubule epithelial cells. Viral gene expression, and specifically the activity of the BKV early promoter, is regulated by TGF-beta in a strain-dependent manner. Promoter activity is upregulated in the presence of TGF-beta for the TU strain of BKV, and not for the Dik, Dunlop, or Proto-2 strains. Using site-directed mutagenesis, we have identified a small segment of the TU promoter that is required for stimulation in response to TGF-beta. These results demonstrate that BKV strains can respond differently to cytokine treatment and suggest that TGF-beta may play a role in the reactivation of BKV.
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Affiliation(s)
- Johanna R. Abend
- Department of Microbiology and Immunology, and Comprehensive Cancer Center, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Michael J. Imperiale
- Department of Microbiology and Immunology, and Comprehensive Cancer Center, University of Michigan Medical School, Ann Arbor, MI 48109, USA
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Lloberas N, Torras J, Alperovich G, Cruzado JM, Giménez-Bonafé P, Herrero-Fresneda I, Franquesa ML, Rama I, Grinyó JM. Different renal toxicity profiles in the association of cyclosporine and tacrolimus with sirolimus in rats. Nephrol Dial Transplant 2008; 23:3111-9. [PMID: 18469305 DOI: 10.1093/ndt/gfn223] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The association of calcineurin inhibitors (CNIs) with mTOR inhibitors (mTORi) is still a problem in clinical practice and there is substantial interest in better understanding the impact of these associations on kidney toxicity. We aimed to analyse the functional and histological profiles of damage and to define the contribution of inflammatory and pro-fibrotic mediators in the association of cyclosporine (CsA) and/or tacrolimus (Tac) with sirolimus (SRL). METHODS A well-defined model of nephrotoxicity in salt-depleted male rats was used. Monotherapy groups were distributed as a non-treated control group with saline solution (n = 12), the Tac group (n = 16) (tacrolimus 6 mg/kg/day) and the CsA group (n = 13) (CsA 15 mg/kg/day). The groups with different associations were scattered as the Tac + SRL group (n = 14) (tacrolimus 6 mg/kg/day and rapamycin 3 mg/kg/day) and the CsA + SRL group (n = 7) (CsA 15 mg/kg/day and rapamycin 3 mg/kg/day). Groups were divided into 30 and 70 days of follow-up, but the CsA + SRL group was only studied for 30 days because animals became sick. RESULTS Rats with the CsA + SRL association were the only ones which showed a significant reduction in body weight, impairment of renal function and severe and diffuse tubular vacuolization and tubular atrophy following a striped distribution, and scarce areas of the kidney were still preserved. The Tac + SRL association did not produce renal function impairment, and mild histological damage including enhanced periglomerular tubular atrophy was observed. This local damage affected the distal convoluted tubule involving macula densa and juxtaglomerular apparatus. Pro-inflammatory mediators paralleled functional and structural data. ED-1 and TNF-alpha were noticeably higher in the CsA + SRL than in the Tac + SRL association. Only in the CsA + SRL association an important increase in alpha-SMA+ cells was seen, mainly found in the areas with tubular atrophy. TGF-beta1 was also markedly enhanced in the CsA + SRL association whilst monotherapy or Tac + SRL groups at 30 days TGF-beta1 did not show any changes. However, at 70 days of treatment TGF-beta1 was significantly increased in the Tac + SRL group. Animals receiving SRL showed a decrease in renal vascular endothelial growth factor (VEGF) expression. This growth factor was significantly down-regulated in both CNI associations than in SRL monotherapy. P-glycoprotein (Pgp) was overexpressed in CsA and CsA + SRL therapy whilst Tac and TAC + SRL showed a middle increase Pgp expression but higher than the control and SRL group. CONCLUSION We conclude that the association of SRL with high doses of CsA or Tac produces a different functional, histological, inflammatory and pro-fibrogenic pattern. Thus, the addition of SRL to high doses of CsA leads to severe renal injury. Combination with high doses of Tac is clearly less deleterious in the short term. However, there is a low grade of pro-fibrotic inflammatory expression when this association is prolonged.
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Affiliation(s)
- Núria Lloberas
- Laboratory of Nephrology, Department of Medicine, University of Barcelona, Spain.
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Ciancio G, Burke GW, Gaynor JJ, Sageshima J, Herrada E, Tueros L, Roth D, Kupin W, Rosen A, Esquenazi V, Miller J. Campath-1H induction therapy in African American and Hispanic first renal transplant recipients: 3-year actuarial follow-up. Transplantation 2008; 85:507-16. [PMID: 18347528 DOI: 10.1097/tp.0b013e318163619f] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In a retrospective study of the first 75 primary renal transplant patients given alemtuzumab induction at our center, 20 were African American (27%), 32 were Hispanic (43%), and 23 were non-African American, non-Hispanic (31%). METHODS Alemtuzumab was given intraoperatively and 4 days later (0.3 mg/kg), with planned low-dose maintenance mycophenolate mofetil (500 mg twice daily) and tacrolimus (targeted trough levels of 5 to 7 ng/ml) and no corticosteroid therapy after the first week. Median follow-up among ongoing survivors with a functioning graft was 45 months. RESULTS Three-year actuarial patient and graft survival rates were 95% and 85% in African Americans, 89% and 78% in Hispanics, and 96% and 96% in non-African Americans, non-Hispanics, respectively (not significant). Bioavailability of tacrolimus was significantly lower among African Americans in comparison with the other patient subgroups (P CONCLUSIONS This immunosuppressive protocol appears reasonably safe for 3 years after renal transplantation but suggests higher incidences of biopsy-proven acute rejection, chronic allograft dysfunction, and borderline poorer renal function among African Americans in comparison with the other patient subgroups.
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Affiliation(s)
- Gaetano Ciancio
- Lillian Jean Kaplan Renal Transplant Center, Division of Transplantation, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL 33101, USA.
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Sulemanjee NZ, Merla R, Lick SD, Aunon SM, Taylor M, Manson M, Czer LSC, Schwarz ER. The first year post-heart transplantation: use of immunosuppressive drugs and early complications. J Cardiovasc Pharmacol Ther 2008; 13:13-31. [PMID: 18287587 DOI: 10.1177/1074248407309916] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
A large number of heart transplants are performed annually in different transplant centers in the United States. This is partly because of the improved survival of patients who undergo cardiac transplantation, thus making it a more viable option in the management of end-stage heart failure. The survival benefit after heart transplantation is a result of newer immunosuppressive drug regimens and a better understanding of their effects and interactions. Several studies, mostly involving a small number of patients, describe use and comparison of the many distinct immunosuppressive drugs available to date. Interestingly, many transplant centers perform in-house typical induction treatment regimens because of their own experience and intra-institutional preference. This review summarizes current practices of immunosuppressive drug therapy in the first year post-heart transplant based on the available clinical evidence and discusses future options of heart transplant immunosuppressive drug therapies.
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Affiliation(s)
- Nasir Z Sulemanjee
- Division of Cardiology, Department of Internal Medicine, The University of Texas Medical Branch, Galveston, TX, USA
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Furukawa Y, Yoshikawa H, Iwasa K, Yamada M. Clinical efficacy and cytokine network-modulating effects of tacrolimus in myasthenia gravis. J Neuroimmunol 2008; 195:108-15. [PMID: 18262659 DOI: 10.1016/j.jneuroim.2007.12.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2007] [Revised: 11/09/2007] [Accepted: 12/04/2007] [Indexed: 11/29/2022]
Abstract
To clarify the long-term efficacy, safety and the cytokine network-modulating effects of tacrolimus in myasthenia gravis, medical records of 86 newly diagnosed consecutive patients and nine steroid-dependent patients were retrospectively reviewed, and peripheral blood mononuclear cells (PBMC) were cultured for the cytokine profile. Steroid reduction effects were observed by using tacrolimus, and no serious adverse effects were observed. The culture study showed reduced IL-12, IL-17, IFN-gamma, GM-CSF, TNF-alpha and MIP-1beta, and elevated IL-10 in the PBMC from patients who received tacrolimus, which suggests inhibition of T cells and macrophages, and enhancement of type 1 regulatory T cells.
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Affiliation(s)
- Yutaka Furukawa
- Department of Neurology and Neurobiology of Aging, Kanazawa University, Kanazawa Japan
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Charron T, Nili N, Strauss BH. The cell cycle: a critical therapeutic target to prevent vascular proliferative disease. Can J Cardiol 2007; 22 Suppl B:41B-55B. [PMID: 16498512 PMCID: PMC2780832 DOI: 10.1016/s0828-282x(06)70986-2] [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: 01/07/2023] Open
Abstract
Percutaneous coronary intervention is the preferred revascularization approach for most patients with coronary artery disease. However, this strategy is limited by renarrowing of the vessel by neointimal hyperplasia within the stent lumen (in-stent restenosis). Vascular smooth muscle cell proliferation is a major component in this healing process. This process is mediated by multiple cytokines and growth factors, which share a common pathway in inducing cell proliferation: the cell cycle. The cell cycle is highly regulated by numerous mechanisms ensuring orderly and coordinated cell division. The present review discusses current concepts related to regulation of the cell cycle and new therapeutic options that target aspects of the cell cycle.
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Affiliation(s)
| | | | - Bradley H Strauss
- Correspondence: Dr Bradley H Strauss, St Michael’s Hospital, 30 Bond Street, Toronto, Ontario M5B IW8. Telephone 416-864-5913, fax 416-864-5978, e-mail
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Abstract
Since the introduction of cyclosporin A (CsA) in the early 1980s, the use of immunosuppressants has markedly increased. Already established drugs have proved effective in the treatment of a wide range of diseases outside transplantation medicine and new immunosuppressants have been developed for more specific indications such as psoriasis and atopic dermatitis. Patients in transplantation medicine as well as in dermatology have benefited significantly from systemic and topical application of both new and established drugs. But are these drugs without risks? Cancer-protecting effects have been reported for some of the available immunosuppressants. Conversely, other publications and the issue of a black box warning by the US Food and Drug Administration have increased concerns about cancer-promoting effects. Knowledge of the specific effects as well as adverse effects is paramount to ensure an application that is safe and beneficial for the patient. Here we review the mechanisms of action and therapeutic potential, and critically review recent literature with respect to possible carcinogenic side effects of systemic and topical CsA, tacrolimus, pimecrolimus and rapamycin.
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Affiliation(s)
- Maren Weischer
- Department of Dermatology and Venerology, Eberhard Karls University, Liebermeisterstrasse 25, D-72076 Tuebingen, Germany
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VanBuskirk AM, Lesinski GB, Nye KJ, Carson WE, Yee LD. TGF-beta inhibition of CTL re-stimulation requires accessory cells and induces peroxisome-proliferator-activated receptor-gamma (PPAR-gamma). Am J Transplant 2006; 6:1809-19. [PMID: 16889541 DOI: 10.1111/j.1600-6143.2006.01387.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Effective cellular immunity to Epstein-Barr virus (EBV), necessary to prevent or cure many post-transplant lymphoproliferative disorders (PTLD), can be inhibited by transforming growth factor-beta (TGF-beta). In vitro, TGF-beta inhibits memory CTL re-stimulation from whole PBMC. We show that the effect of TGF-beta on CTL re-stimulation is not directly on the T cell, but requires an accessory cell (AC) population. Further, pre-treatment of AC with TGF-beta significantly reduces memory CTL re-stimulation and suppresses delayed type hypersensitivity (DTH) responses. Addition of exogenous interferon-gamma to the AC overcomes the effects of TGF-beta. TGF-beta pre-treatment also up-regulates expression of peroxisome-proliferator-activated receptor-gamma (PPAR-gamma) in CD14(+) AC. Importantly, pre-treatment of AC with the PPAR-gamma ligand, ciglitazone, results in significantly reduced memory CTL re-stimulation. Thus, the effects of TGF-beta in this system may be mediated in part via PPAR-gamma, and PPAR-gamma activation could have significant inhibitory effects on memory T-cell responses by affecting AC function. These data have important implications in understanding how memory CTL are re-stimulated and function to prevent disease, especially PTLD.
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Affiliation(s)
- A M VanBuskirk
- Division of Surgical Oncology, Department of Surgery, Ohio State University Comprehensive Cancer Center, Columbus, USA.
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Ciancio G, Burke GW, Gaynor JJ, Ruiz P, Roth D, Kupin W, Rosen A, Miller J. A randomized long-term trial of tacrolimus/sirolimus versus tacrolimums/mycophenolate versus cyclosporine/sirolimus in renal transplantation: three-year analysis. Transplantation 2006; 81:845-52. [PMID: 16570006 DOI: 10.1097/01.tp.0000203894.53714.27] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND We report three-year (interim) effects of combining sirolimus (Siro) vs. mycophenolate mofetil (MMF) as adjunctive therapy with calcineurin inhibitors (CI) in renal transplantation in the three different CI-based regimens. METHODS Between May 2000 and December 2001, 150 recipients of deceased donor (DD) and living donor (LD) kidney transplants were randomized into three groups (n=50/group): Group A (Tacro/Siro), Group B (Tacro/MMF) and Group C (CsA/Siro). This report details drug dosing and monitoring, protocol discontinuance, biopsy-proven rejection, graft failure, other adverse events, and death at 36 months postoperatively. RESULTS Actual patient and graft survival respectively in Group A was 90% and 82%, in Group B was 92% and 88%, and in Group C was 96% and 88% (not significant). Biopsy-confirmed acute rejection incidents showed a trend in favor of Group B (10%) vs. Group A (26%) and Group C (20%) combined (P=0.07). The geometric mean */SE serum creatinine concentration and arithmetic mean +/- SE Cockroft-Gault creatinine clearance calculations, respectively, were 1.39*/1.1 and 72.8+/-4.3 for Group A, 1.36*/1.1 and 72.1+/-4.1 for Group B, and 1.60*/1.1 and 61.8+/-3.8 for Group C, a statistically favorable difference for Group B over Group C (P=0.04). There was also less de novo development of posttransplant diabetes mellitus and lipid disorders in Group B vs. A and C (P<0.04). CONCLUSIONS This three-year (interim) analysis has indicated a trend towards better graft function, fewer endocrine disorders, and fewer acute rejection episodes comparing adjunctive MMF and Tacro vs. Siro and Tacro or Siro and CsA, in the dosages used.
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Affiliation(s)
- Gaetano Ciancio
- The Lillian Jean Kaplan Renal Transplant Center, Department of Surgery, Division of Transplantation, University of Miami Miller School of Medicine, PO Box 012440, Miami, FL 33101, USA.
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van Dieren JM, Kuipers EJ, Samsom JN, Nieuwenhuis EE, van der Woude CJ. Revisiting the immunomodulators tacrolimus, methotrexate, and mycophenolate mofetil: their mechanisms of action and role in the treatment of IBD. Inflamm Bowel Dis 2006; 12:311-27. [PMID: 16633053 DOI: 10.1097/01.mib.0000209787.19952.53] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Inflammatory bowel diseases (IBDs) are thought to result from unopposed immune responses to normal gut flora in a genetically susceptible host. A variety of immunomodulating therapies are applied for the treatment of patients with IBDs. The first-line treatment for IBDs consists of 5-aminosalicylate and/or budesonide. However, these first-line therapies are often not suitable for continuous treatment or do not suffice for the treatment of severe IBD. Recently, efforts have been made to generate novel selective drugs that are more effective and have fewer side effects. Despite promising results, most of these novel drugs are still in a developmental stage and unavailable for clinical application. Yet, another class of established immunomodulators exists that is successful in the treatment of inflammatory bowel diseases. While waiting for emerging novel therapies, the use of these more established drugs should be considered. Furthermore, one of the advantages of using established immunomodulators is the well-documented knowledge on the long-term side effects and on the mechanisms of action. In this review, the authors discuss 3 well-known immunomodulators that are being applied with increased frequency for the treatment of IBD: tacrolimus, methotrexate, and mycophenolate mofetil. These agents have been used for many years as treatment modalities for immunosuppression after organ transplantation, for the treatment of cancer, and for immunomodulation in several other immune-mediated diseases. First, this review discusses the potential targets for immunomodulating therapies in IBDs. Second, the immunomodulating mechanisms and effects of the 3 immunomodulators are discussed in relationship to these treatment targets.
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Affiliation(s)
- Jolanda M van Dieren
- Department of Gastroenterology and Hepatology, Division of Gastroenterology and Nutrition, Erasmus MC, University Medical Center, Rotterdam, the Netherlands.
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Lindenfeld J, Miller GG, Shakar SF, Zolty R, Lowes BD, Wolfel EE, Mestroni L, Page RL, Kobashigawa J. Drug therapy in the heart transplant recipient: part II: immunosuppressive drugs. Circulation 2005; 110:3858-65. [PMID: 15611389 DOI: 10.1161/01.cir.0000150332.42276.69] [Citation(s) in RCA: 139] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- JoAnn Lindenfeld
- Division of Cardiology, University of Colorado Health Sciences Center, 4200 E Ninth Ave, B-130, Denver, CO 80262, USA.
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Khanna AK. Reciprocal role of cyclins and cyclin kinase inhibitor p21WAF1/CIP1 on lymphocyte proliferation, allo-immune activation and inflammation. BMC Immunol 2005; 6:22. [PMID: 16176581 PMCID: PMC1242230 DOI: 10.1186/1471-2172-6-22] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2005] [Accepted: 09/21/2005] [Indexed: 11/21/2022] Open
Abstract
Background Immune activation that results due to the aberrant proliferation of lymphocytes leads to inflammation and graft rejection in organ transplant recipients. We hypothesize that the cell cycle control and inflammation are parallel events, inhibition of cellular proliferation by cyclin kinase inhibitor specifically p21 will limit inflammation and prevent allograft rejection. Methods We performed in vitro and in vivo studies using lymphocytes, and rat heart transplant model to understand the role of cyclins and p21 on mitogen and allo-induced lymphocyte activation and inflammation. Lymphocyte proliferation was studied by 3H-thymidine uptake assay and mRNA expression was studied RT-PCR. Results Activation of allo- and mitogen stimulated lymphocytes resulted in increased expression of cyclins, IL-2 and pro-inflammatory cytokines, which was inhibited by cyclosporine. The over-expression of p21 prolonged graft survival in a completely mismatched rat heart transplant model resulted by inhibiting circulating and intra-graft expression of proinflammatory cytokines. Conclusion Cyclins play a significant role in transplant-induced immune activation and p21 over-expression has potential to inhibit T cell activation and inflammation. The results from this study will permit the design of alternate strategies by controlling cell cycle progression to achieve immunosuppression in transplantation.
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Affiliation(s)
- Ashwani K Khanna
- Department of Medicine (Nephrology), Medical College of Wisconsin, Milwaukee, WI 53226, USA.
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Khanna A. Tacrolimus and Cyclosporinein vitro and in vivo Induce Osteopontin mRNA and Protein Expression in Renal Tissues. ACTA ACUST UNITED AC 2005; 101:e119-26. [PMID: 16103732 DOI: 10.1159/000087438] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2004] [Accepted: 04/27/2005] [Indexed: 01/30/2023]
Abstract
The mechanism of immunosuppression-linked nephrotoxicity in organ transplantation remains to be solved. Expression of osteopontin (OPN), a multifunctional secreted glycoprotein, has been associated with various forms of renal injuries. In this study, using in vitro and in vivo models, we examined the effects of cyclosporine (CsA) and tacrolimus (TAC) on OPN mRNA and protein expression. We also examined if CsA- and TAC-induced OPN expression is dependent on transforming growth factor (TGF)-beta expression. For in vivo experiments mice and rats were injected with CsA (25 mg/kg) and TAC (0.2 mg/kg). For in vitro experiments, human proximal tubular epithelial (PTE) cells were treated with CsA and TAC for 4 h. To study the in vivo effect of TGF-beta on OPN mRNA, mice were injected with recombinant TGF-beta protein (3 mg/kg). The expression of OPN was also studied in CsA-treated PTE cells with and without anti-TGF-beta antibody. At the end of in vitro and in vivo treatments, RNA was isolated from kidney tissue and renal cells reverse transcribed to cDNA and amplified for OPN mRNA. Using immunochemistry and Western blot analysis OPN protein expression was also studied in vivo and in vitro, respectively. Both in vitro and in vivo treatment with CsA and TAC resulted in significantly increased OPN mRNA and protein expression. TGF-beta treatment in vivo also resulted in a significantly increased OPN mRNA expression and anti-TGF-beta antibody but not the control antibody in vivo in CsA-treated mice, and in vitro in CsA-treated PTE cells inhibited OPN mRNA expression. OPN may contribute to the CsA- and TAC-induced nephrotoxicity in organ transplant recipients and the increased OPN expression might be mediated by TGF-beta.
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Affiliation(s)
- Ashwani Khanna
- Department of Medicine (Nephrology), Medical College of Wisconsin, Milwaukee, WI 53226, USA.
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Brook NR, Waller JR, Bicknell GR, Nicholson ML. The Experimental Agent Pirfenidone Reduces Pro-Fibrotic Gene Expression in a Model of Tacrolimus-Induced Nephrotoxicity. J Surg Res 2005; 125:137-43. [PMID: 15854665 DOI: 10.1016/j.jss.2004.12.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2004] [Revised: 09/06/2004] [Accepted: 12/09/2004] [Indexed: 10/25/2022]
Abstract
BACKGROUND Tacrolimus nephrotoxicity is thought to contribute to renal allograft dysfunction and subsequent failure, a process that is underpinned by alterations in mRNA expression of genes involved in matrix metabolism. The new anti-fibrotic pirfenidone was tested for its potential to reverse markers of renal dysfunction. MATERIALS AND METHODS Rats were salt-depleted before tacrolimus and pirfenidone treatment. Serum creatinine, urinary protein/creatinine ratio, extracellular matrix deposition (ECM), and mRNA expression of genes involved in matrix turnover were assessed. RESULTS Tacrolimus reduced TGF-beta mRNA expression below control levels and treatment with pirfenidone at all doses did not alter this effect. Likewise, TIMP-1 mRNA expression was depressed by the addition of tacrolimus and pirfenidone caused a further decrease in expression. Collagen III, MMP-2, and MMP-9 expression was unchanged by tacrolimus, but pirfenidone reduced collagen III below control levels. ECM was slight (1-4%) and not significantly different between groups. CONCLUSIONS These findings suggest that pirfenidone can attenuate the limited fibrotic potential of tacrolimus.
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Reichenspurner H. Overview of tacrolimus-based immunosuppression after heart or lung transplantation. J Heart Lung Transplant 2005; 24:119-30. [PMID: 15701425 DOI: 10.1016/j.healun.2004.02.022] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2003] [Revised: 02/23/2004] [Accepted: 02/23/2004] [Indexed: 11/24/2022] Open
Abstract
Transplantation has evolved into an accepted treatment for end-stage heart or lung disease. Acute rejection, complications related to immunosuppressive protocols, and the development of chronic rejection continue to challenge the long-term success of heart and lung transplantations. Wide acceptance of tacrolimus as an important immunosuppressant in renal and hepatic transplantations has led subsequently to its investigation as primary immunosuppression in heart and lung transplant recipients, either combined with azathioprine or with the newer agents mycophenolate mofetil or rapamycin. Studies have shown that tacrolimus is an effective therapeutic alternative to cyclosporine for primary immunosuppression in heart or lung transplantation and demonstrates equivalent if not improved prophylaxis of acute rejection, and more recently demonstrates a potential influence on chronic rejection, particularly in lung transplant recipients. Of importance, the enhanced immunosuppressive activity of tacrolimus is achieved without increased risk of infection or malignancy. Differences in tolerability profiles and side effects between tacrolimus and cyclosporine may be used in selecting the optimal immunotherapy after thoracic transplantation. In particular, the lesser propensity of tacrolimus to cause hypertension and hyperlipidemia potentially offers decreased cardiovascular risk for heart and lung transplant recipients.
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Abstract
Tacrolimus ointment (Protopic) is a topically applied macrolide lactone immunomodulator effective in the treatment of atopic dermatitis. Its mechanism of action primarily involves calcineurin inhibition, which interrupts cytokine gene expression and leads to the downregulation of T-cell activity. Tacrolimus ointment (0.03% and 0.1% for adults and 0.03% for children) is an effective treatment for atopic dermatitis of the trunk and limbs, as well as sensitive skin areas such as the face. Its efficacy is similar to or greater than that of hydrocortisone acetate 1%, hydrocortisone butyrate 0.1% and betamethsone valerate 0.12% ointments and pimecrolimus 1% cream. Systemic absorption of tacrolimus from the ointment is minimal, and adverse events, which are mostly associated with the application site and include skin burning and pruritus, tend to resolve early in treatment. Unlike topical corticosteroids, tacrolimus ointment is not associated with skin atrophy, and it is a well tolerated treatment for adults or children with atopic dermatitis, particularly when long-term treatment is indicated or the face or skin-fold regions are involved.
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Affiliation(s)
- Dene Simpson
- Adis International Limited, Auckland, New Zealand.
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Boots JMM, Christiaans MHL, van Hooff JP. Effect of immunosuppressive agents on long-term survival of renal transplant recipients: focus on the cardiovascular risk. Drugs 2004; 64:2047-73. [PMID: 15341497 DOI: 10.2165/00003495-200464180-00004] [Citation(s) in RCA: 112] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In the control of acute rejection, attention is being focused more and more on the long-term adverse effects of the immunosuppressive agents used. Since cardiovascular disease is the main cause of death in renal transplant recipients, optimal control of cardiovascular risk factors is essential in the long-term management of these patients. Unfortunately, several commonly used immunosuppressive drugs interfere with the cardiovascular system. In this review, the cardiovascular adverse effects of the immunosuppressive agents currently used for maintenance immunosuppression are thoroughly discussed. Optimising immunosuppression means finding a balance between efficacy and safety. Corticosteroids induce endothelial dysfunction, hypertension, hyperlipidaemia and diabetes mellitus, and impair fibrinolysis. The use of corticosteroids in transplant recipients is undesirable, not only because of their cardiovascular effects, but also because they induce such adverse effects as osteoporosis, obesity, and atrophy of the skin and vessel wall. Calcineurin inhibitors are the most powerful agents for maintenance immunosuppression. The calcineurin inhibitor ciclosporin (cyclosporine) not only induces these same adverse effects as corticosteroids but is also nephrotoxic. Tacrolimus has a more favourable cardiovascular risk profile than ciclosporin and is also less nephrotoxic. It has little or no effect on blood pressure and serum lipids; however, its diabetogenic effect is more prominent in the period immediately following transplantation, although at maintenance dosages, the diabetogenic effect appears to be comparable to that of ciclosporin. The diabetogenic effect of tacrolimus can be managed by reducing the dose of tacrolimus and early corticosteroid withdrawal. The effect of tacrolimus on endothelial function has not been completely elucidated. The proliferation inhibitors azathioprine and mycophenolate mofetil (MMF) have little effect on the cardiovascular system. Yet, indirectly, by inducing anaemia, they may lead to left ventricular hypertrophy. MMF is an attractive alternative to azathioprine because of its higher potency and possibly lower risk of malignancies. Sirolimus also induces anaemia, but may be promising because of its antiproliferative features. Whether the hyperlipidaemia induced by sirolimus counteracts its beneficial effects is, as yet, unknown. It may be combined with MMF, however, initial attempts resulted in severe mouth ulcers.
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Affiliation(s)
- Johannes M M Boots
- Department of Nephrology, University Hospital Maastricht, Maastricht, The Netherlands.
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Khanna AK, Plummer MS, Hilton G, Pieper GM, Ledbetter S. Anti-transforming growth factor antibody at low but not high doses limits cyclosporine-mediated nephrotoxicity without altering rat cardiac allograft survival: potential of therapeutic applications. Circulation 2004; 110:3822-9. [PMID: 15583082 DOI: 10.1161/01.cir.0000150400.15354.7d] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Long-term treatment of cardiac transplant recipients with cyclosporine results in a progressive decline in kidney function in a large number of patients. This complication is one of the most important prognostic parameters that determine the outcome of cardiac transplantation. Transforming growth factor-beta (TGF-beta) is one of the most potent mediators of the fibrogenic effects of cyclosporine. METHODS AND RESULTS With the use of an experimental rodent model, heterotopic heart transplantation was performed, creating histocompatibility-disparate allografts. Because TGF-beta in part mediates both the immunosuppressive and nephrotoxic effects of cyclosporine, recipients were treated with cyclosporine with and without anti-TGF-beta antibody to determine whether anti-TGF-beta antibody could reduce the nephrotoxic effects of cyclosporine. Intrarenal expression of TGF-beta, collagen, fibronectin, matrix metalloproteinase-2, and tissue inhibitor of metalloproteinase-2 was studied with the use of reverse transcription-polymerase chain reaction. Intrarenal expression of TGF-beta protein was studied by immunohistochemistry and with the use of ELISA to quantify circulating levels of TGF-beta protein in plasma. Cyclosporine-induced graft survival (immunosuppressive effect) was abrogated with a higher concentration (2.5 mg/kg) of anti-TGF-beta antibody, whereas a lower concentration (1 mg/kg) inhibited both cyclosporine-induced expression of fibrogenic molecules and renal toxicity. CONCLUSIONS These results provide credence to the pivotal role of TGF-beta in immunosuppression-associated renal toxicity in recipients of cardiac transplantation. Furthermore, these findings support a potentially significant therapeutic use of optimal concentration of anti-TGF-beta antibody to ameliorate cyclosporine-associated nephrotoxicity in cardiac transplant recipients.
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MESH Headings
- Animals
- Antibodies, Monoclonal/pharmacology
- Antibodies, Monoclonal/therapeutic use
- Collagen/biosynthesis
- Collagen/genetics
- Cyclosporine/therapeutic use
- Cyclosporine/toxicity
- Drug Evaluation, Preclinical
- Fibronectins/biosynthesis
- Fibronectins/genetics
- Gene Expression Regulation/drug effects
- Heart Transplantation/adverse effects
- Heart Transplantation/immunology
- Immunosuppressive Agents/therapeutic use
- Immunosuppressive Agents/toxicity
- Immunotherapy
- Kidney/drug effects
- Kidney/metabolism
- Kidney Diseases/chemically induced
- Kidney Diseases/genetics
- Kidney Diseases/metabolism
- Kidney Diseases/prevention & control
- Kidney Function Tests
- Matrix Metalloproteinase 1/biosynthesis
- Matrix Metalloproteinase 1/genetics
- RNA, Messenger/biosynthesis
- RNA, Messenger/genetics
- Rats
- Rats, Inbred Lew
- Rats, Inbred WF
- Reverse Transcriptase Polymerase Chain Reaction
- Tissue Inhibitor of Metalloproteinase-2/biosynthesis
- Tissue Inhibitor of Metalloproteinase-2/genetics
- Transforming Growth Factor beta/antagonists & inhibitors
- Transforming Growth Factor beta/biosynthesis
- Transforming Growth Factor beta/genetics
- Transforming Growth Factor beta/immunology
- Transplantation, Heterotopic
- Transplantation, Homologous/adverse effects
- Transplantation, Homologous/immunology
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Affiliation(s)
- Ashwani K Khanna
- Division of Nephrology, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226, USA.
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Ellis JS, Morgan CL, Kirby JA, Taylor JJ, Thomason JM. Plasma TGF-beta1 as a risk factor for gingival overgrowth. J Clin Periodontol 2004; 31:863-8. [PMID: 15367190 DOI: 10.1111/j.1600-051x.2004.00572.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND AND AIMS Induction of the pro-fibrotic growth factor TGF-beta1 has been suggested as a possible mechanism through which immunosuppressant drugs may induce gingival overgrowth. This study aims to investigate plasma levels of TGF-beta1 and relate them to the development and severity of gingival overgrowth in immunosuppressed transplant patients. MATERIALS AND METHODS One hundred and thirty-two ciclosporin-treated and 13 tacrolimus-treated transplant patients and 24 drug-free control subjects underwent a full periodontal examination including a determination of the presence and severity of gingival overgrowth. RESULTS Plasma TGF-beta1 concentrations were determined by ELISA, and were found to be significantly elevated in samples from the transplant patients (mean=29.1 ng/ml) as compared with controls (mean=6.1 ng/ml, p<0.0001). There was no significant difference between the levels of plasma TGF-beta1 in the ciclosporin- and tacrolimus-treated patient groups. CONCLUSIONS Furthermore, concomitant treatment with calcium channel blockers did not influence the levels of plasma TGF-beta1 in the patients group. The relationship between gingival overgrowth, independent periodontal variables and TGF-beta1 plasma concentrations was examined using univariate and multivariate regression analyses; low TGF-beta1 plasma concentrations were found to be a risk factor for gingival overgrowth in immunosuppressed patients concomitantly receiving a calcium channel blocker.
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Affiliation(s)
- J S Ellis
- University of Newcastle upon Tyne, School of Dental Sciences, Framlington Place, Newcastle upon Tyne, UK.
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Ciancio G, Burke GW, Gaynor JJ, Mattiazzi A, Roohipour R, Carreno MR, Roth D, Ruiz P, Kupin W, Rosen A, Esquenazi V, Tzakis AG, Miller J. The Use of Campath-1H as Induction Therapy in Renal Transplantation: Preliminary Results. Transplantation 2004; 78:426-33. [PMID: 15316372 DOI: 10.1097/01.tp.0000128625.29654.eb] [Citation(s) in RCA: 107] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND In an attempt to reduce both initial and long-term (nephrotoxic) calcineurin inhibitor maintenance dosage and totally eliminate maintenance corticosteroids, alemtuzumab (Campath-1H) was used as induction therapy in first cadaver and non-HLA-identical living donor renal transplantation. METHODS Forty-four de novo renal allograft recipients were treated with Campath-1H (0.3 mg/kg) on days 0 and 4 postoperatively, preceded by methylprednisolone boluses. Maintenance target 12-hr tacrolimus trough levels of 5 to 7 ng/mL were operational from the outset as well as (reduced) mycophenolate mofetil dosage of 500 mg twice daily. No corticosteroids were planned to be given after the first week postoperatively. RESULTS With a median follow-up of 9 (range, 1-19) months, patient and graft survival rates are each at 100%. Biopsy-proven acute rejection was diagnosed in four patients. Infections requiring hospitalization developed in four patients. Thirty-eight recipients remain without the need for long-term corticosteroid therapy. CONCLUSIONS In an early assessment, the combination of Campath-1H, low dosing of tacrolimus and mycophenolate mofetil, and avoidance of maintenance corticosteroid use seems to be safe and effective for kidney transplant recipients. Long-term outcomes will be reported in the future.
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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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Kyllönen H, Remitz A, Mandelin JM, Elg P, Reitamo S. Effects of 1-year intermittent treatment with topical tacrolimus monotherapy on skin collagen synthesis in patients with atopic dermatitis. Br J Dermatol 2004; 150:1174-81. [PMID: 15214906 DOI: 10.1111/j.1365-2133.2004.06017.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Topical corticosteroids decrease collagen synthesis during short-term treatment and can induce skin atrophy when applied over the long term. In contrast, short-term tacrolimus ointment therapy does not affect collagen synthesis. OBJECTIVES Our aim was to evaluate the long-term effects of 0.1% tacrolimus ointment on collagen synthesis and on skin thickness in adults with moderate to severe atopic dermatitis (AD) and to compare the findings with the effects of conventional steroid-based therapy. METHODS Fifty-six patients with AD were treated with 0.1% tacrolimus ointment in a 1-year, open-label, prospective clinical trial. Thirty-six patients with AD applied conventional steroid-based therapy and 27 healthy subjects were recruited as controls. The primary endpoint was the change in levels of procollagen propeptides I and III measured by radioimmunoassay between baseline and month 12. Additional endpoints included the change in skin thickness measured by ultrasound between baseline and month 12. RESULTS Procollagen propeptide baseline values were significantly lower in the group to be treated with tacrolimus ointment than in healthy controls. One-year treatment with tacrolimus ointment was associated with an increase in collagen synthesis; the median increase in combined procollagen propeptide levels was 272 micro g L-1 (+ 140.9%, P < 0.001) and was accompanied by a significant increase in skin thickness. In three patients with visible skin atrophy, this condition ameliorated. Corticosteroid-based therapy had no significant effect on collagen synthesis; the median increase in combined procollagen propeptide levels was 11 micro g L-1 (+ 3.9%). A significant reduction in skin thickness was demonstrated. CONCLUSIONS Long-term tacrolimus ointment therapy in patients with AD is nonatrophogenic and reverses corticosteroid-induced skin atrophy.
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Affiliation(s)
- H Kyllönen
- Department of Dermatology, Hospital for Skin and Allergic Diseases, University of Helsinki, 00250, Finland
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Suwelack B, Gerhardt U, Hohage H. Withdrawal of cyclosporine or tacrolimus after addition of mycophenolate mofetil in patients with chronic allograft nephropathy. Am J Transplant 2004; 4:655-62. [PMID: 15023160 DOI: 10.1111/j.1600-6143.2004.00404.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
There has been a need for a prospective, randomized, controlled trial to determine whether the addition of mycophenolate mofetil (MMF) to a calcineurin inhibitor (CNI)-based regimen or MMF addition followed by CNI withdrawal is an effective treatment for chronic allograft nephropathy (CAN). We conducted the first randomized, prospective study to compare the introduction of MMF with or without CNI withdrawal in long-term transplant recipients with histologically proven CAN and deteriorating renal function. The primary endpoint was renal function as indicated by the slope of the inverse serum creatinine vs. time at 32 weeks after randomization. After an interim analysis found a greater-than-expected difference between groups in the slopes of the inverse serum-creatinine, the study was stopped for ethical reasons. There were 20 patients in the MMF/CNI continuation and 19 patients in the MMF/CNI withdrawal groups (mean time post-transplant 7 years). Renal function improved in the dual-therapy compared with the triple-therapy group (p=0.002). Blood pressure decreased in the dual-therapy group with a significant difference between groups at 35 weeks (p=0.04). No acute rejections occurred. Long-term patients with CAN experience a significant improvement in renal function and blood pressure when CNIs are replaced by MMF.
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Affiliation(s)
- Barbara Suwelack
- Department of Internal Medicine D, University of Muenster, Muenster, Germany.
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Khanna A. Concerted effect of transforming growth factor-β, cyclin inhibitor p21, and c-mycon smooth muscle cell proliferation. Am J Physiol Heart Circ Physiol 2004; 286:H1133-40. [PMID: 14766678 DOI: 10.1152/ajpheart.00462.2003] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Increased aortic smooth muscle cell (SMC) proliferation is a key event in the pathogenesis of atherosclerosis. Transforming growth factor-β (TGF-β) is one of the potent inhibitors of SMC proliferation. The purpose of this study was 1) to explore the effect of TGF-β inhibition on proliferation of SMC and expression of growth regulatory molecules like p21 and c- myc and 2) to determine whether restoration of cell cycle regulatory molecules normalizes the altered proliferation. To test the role of TGF-β in SMC proliferation, using antisense plasmid DNA, we inhibited TGF-β gene from aortic SMC, which resulted in a significant increase ( P < 0.03) in proliferation (studied by quantifying new DNA synthesis with [3H]thymidine uptake assay). In TGF-β-altered SMC (TASMC), the mRNA expression (studied by RT-PCR) of c- myc was increased whereas that of the cyclin inhibitor p21 was completely inhibited. Using p21 sense plasmid DNA, we transfected p21 gene in TASMC, which restored p21 mRNA and protein expression and decreased proliferation ( P < 0.002) in TASMC. Similar treatment with c- myc antisense oligonucleotides significantly ( P < 0.001) decreased the proliferation of TASMC. TASMC also exhibited alteration in morphological changes in SMC but returned to normal with treatment of p21 and TGF-β sense plasmid DNA. Two-dimensional gel electrophoresis analysis of SMC and TASMC demonstrated differential expression of proteins relevant to cellular proliferation and atherosclerosis. This study uniquely analyzes the effect of TGF-β at the molecular level on proliferation of SMC and on cell cycle regulatory molecules, implicating their potential role in the pathogenesis of atherosclerosis.
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Affiliation(s)
- Ashwani Khanna
- Dept. of Medicine, Medical College of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI 53226, USA.
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