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Gupta M, Yadav A. Reproductive Health in Kidney Transplant Recipients. ADVANCES IN KIDNEY DISEASE AND HEALTH 2024; 31:466-475. [PMID: 39232617 DOI: 10.1053/j.akdh.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 04/15/2024] [Accepted: 04/24/2024] [Indexed: 09/06/2024]
Abstract
Increasing number of women with kidney transplants are of reproductive age and desire successful pregnancies. Successful outcomes of pregnancy can be achieved with preconception counseling, education about contraception use, the timing of pregnancy (delaying by first year post-transplant), and the choice of immunosuppression medication. Ensuring stable renal function including optimized creatinine, proteinuria, and blood pressure increases successful outcomes. Pregnancy with kidney transplant has an increased risk of preeclampsia, gestational diabetes militeus, cesarean section, and preterm delivery. Multidisciplinary cooperation with high-risk obstetrics and transplant nephrologists is vital.
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Affiliation(s)
- Maitreyee Gupta
- Division of Nephrology and Transplantation, Sidney Kimmel Medical School with Thomas Jefferson University, Philadelphia, PA.
| | - Anju Yadav
- Division of Nephrology and Transplantation, Sidney Kimmel Medical School with Thomas Jefferson University, Philadelphia, PA
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2
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Versluis J, Bourgonje AR, Touw DJ, Meinderts JR, Prins JR, de Jong MFC, Mian P. Pharmacokinetics of Tacrolimus in Pregnant Solid-Organ Transplant Recipients: A Retrospective Study. J Clin Pharmacol 2024; 64:428-436. [PMID: 38084781 DOI: 10.1002/jcph.2393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 12/06/2023] [Indexed: 01/06/2024]
Abstract
Data on the pharmacokinetics of tacrolimus during pregnancy are limited. Therefore, the aim of this retrospective study was to characterize the whole-blood pharmacokinetics of tacrolimus throughout pregnancy. In this single-center retrospective cohort study, whole-blood tacrolimus trough concentrations corrected for the dose (concentration-to-dose [C/D] ratios) were compared before, monthly during, and after pregnancy in kidney, liver, and lung transplant recipients who became pregnant and gave birth between 2000 and 2022. Descriptive statistics and linear mixed models were used to characterize changes in tacrolimus C/D ratios before, during, and after pregnancy. The total study population included 46 pregnancies (31 pregnant women). Nineteen, 21, and 6 pregnancies were following kidney, liver, and lung transplantation, respectively. Immediate-release or extended-release formulations were used in 54.5% and 45.5% of the women, respectively. Tacrolimus C/D ratios significantly (P < .001) decreased (-48%) compared to the prepregnancy state at 7 months of pregnancy. These ratios recovered within 3 months postpartum (P = .002). C/D ratios tended to be lower during treatment with an extended-release formulation than with an immediate-release formulation (P = .071). Transplantation type did not significantly affect C/D ratios during pregnancy (P = .873). In conclusion, we found that tacrolimus whole-blood pharmacokinetics change throughout pregnancy, with the lowest C/D ratios (48% decrease) in the 7th month of pregnancy. In general, the decrease in C/D ratios seems to stabilize from month 4 onward compared to prepregnancy.
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Affiliation(s)
- Jorn Versluis
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen and University of Groningen, Groningen, The Netherlands
| | - Arno R Bourgonje
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Daan J Touw
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen and University of Groningen, Groningen, The Netherlands
- Department of Pharmaceutical Analysis, Groningen Research Institute for Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Jildau R Meinderts
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jelmer R Prins
- Department of Obstetrics and Gynaecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Margriet F C de Jong
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Paola Mian
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen and University of Groningen, Groningen, The Netherlands
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Louchet M, Tisseyre M, Kaguelidou F, Treluyer JM, Préta LH, Chouchana L. Drug-induced fetal and offspring disorders, beyond birth defects. Therapie 2024; 79:205-219. [PMID: 38008599 DOI: 10.1016/j.therap.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 11/09/2023] [Indexed: 11/28/2023]
Abstract
Studies on drug utilization in western countries disclosed that about nine over ten women use at least one or more drugs during pregnancy. Determining whether a drug is safe or not in pregnant women is a challenge of all times. As a developing organism, the fetus is particularly vulnerable to effects of drugs used by the mother. Historically, research has predominantly focused on birth defects, which represent the most studied adverse pregnancy outcomes. However, drugs can also alter the ongoing process of pregnancy and impede the general growth of the fetus. Finally, adverse drug reactions can theoretically damage all developing systems, organs or tissues, such as the central nervous system or the immune system. This extensive review focuses on different aspects of drug-induced damages affecting the fetus or the newborn/infant, beyond birth defects, which are not addressed here.
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Affiliation(s)
- Margaux Louchet
- URP 7323 "Pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte", Université Paris Cité, 75000 Paris, France; Service de gynécologie-obstétrique, Fédération hospitalo-universitaire PREMA, hôpital Louis-Mourier, AP-HP Nord - Université Paris Cité, 75000 Paris, France
| | - Mylène Tisseyre
- URP 7323 "Pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte", Université Paris Cité, 75000 Paris, France; Centre régional de pharmacovigilance, service de pharmacologie périnatale, pédiatrique et adulte, hôpitaux Cochin-Necker, AP-HP Centre - Université Paris Cité, 75000 Paris, France
| | - Florentia Kaguelidou
- URP 7323 "Pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte", Université Paris Cité, 75000 Paris, France; Centre d'investigation clinique pédiatrique, Inserm CIC 1426, hôpital Robert-Debré, AP-HP Nord - Université Paris Cité, 75000 Paris, France
| | - Jean-Marc Treluyer
- URP 7323 "Pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte", Université Paris Cité, 75000 Paris, France; Centre régional de pharmacovigilance, service de pharmacologie périnatale, pédiatrique et adulte, hôpitaux Cochin-Necker, AP-HP Centre - Université Paris Cité, 75000 Paris, France
| | - Laure-Hélène Préta
- URP 7323 "Pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte", Université Paris Cité, 75000 Paris, France
| | - Laurent Chouchana
- URP 7323 "Pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte", Université Paris Cité, 75000 Paris, France; Centre régional de pharmacovigilance, service de pharmacologie périnatale, pédiatrique et adulte, hôpitaux Cochin-Necker, AP-HP Centre - Université Paris Cité, 75000 Paris, France.
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Drljevic-Nielsen A, Heilskov S, Deleuran MS, Vestergaard C. Immunosuppressive and immunomodulating therapy for atopic dermatitis in pregnancy: an appraisal of the literature. Ital J Dermatol Venerol 2024; 159:23-33. [PMID: 38226937 DOI: 10.23736/s2784-8671.23.07692-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2024]
Abstract
Atopic dermatitis (AD) is the most common dermatological diagnosis during pregnancy. Treatment of AD during pregnancy can be challenging, due to the unpredictable course and the fact that the therapy needs to be safe for both the mother and the fetus. Here we present an up-to-date appraisal of the literature on the treatment options available for AD in patients planning pregnancy, during pregnancy, and during breastfeeding. All patients with AD are recommended to supplement any medical treatment with daily applications of emollients. The first step in the medical treatment for AD during pregnancy are topical corticosteroids, and/or topical tacrolimus. If required, UV-light therapy can also be considered. Treatment with systemic therapy during pregnancy should always rely on a careful risk-benefit assessment and be based on shared-decision making between the treating physician and patient. The first-line systemic treatment option is cyclosporine A, whereas azathioprine may be considered in patients already receiving this treatment prior to pregnancy. Systemic glucocorticoids may also be used. Treatment with systemic JAK inhibitors is not recommended, whereas treatment with mycophenolate mofetil and methotrexate is contraindicated. Targeted therapy with dupilumab is not generally recommended, due to lack of experience in human pregnancies, yet some case-reports on their use are emerging. These recommendations are based on the authors appraisal of existing literature and the current recommendation from the European Task Force on Atopic Dermatitis. It is always the responsibility of the treating physician to stay updated on the newest guidelines and literature when treating patients with AD during pregnancy.
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Affiliation(s)
| | - Sofine Heilskov
- Department of Dermatology, Aarhus University Hospital, Aarhus, Denmark
| | - Mette S Deleuran
- Department of Dermatology, Aarhus University Hospital, Aarhus, Denmark
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Schagen MR, Ulu AN, Francke MI, van de Wetering J, van Buren MC, Schoenmakers S, Matic M, van Schaik RHN, Hesselink DA, de Winter BCM. Modelling changes in the pharmacokinetics of tacrolimus during pregnancy after kidney transplantation: A retrospective cohort study. Br J Clin Pharmacol 2024; 90:176-188. [PMID: 37596793 DOI: 10.1111/bcp.15886] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 07/19/2023] [Accepted: 08/05/2023] [Indexed: 08/20/2023] Open
Abstract
AIMS Pregnancy after kidney transplantation is realistic but immunosuppressants should be continued to prevent rejection. Tacrolimus is safe during pregnancy and is routinely dosed based on whole-blood predose concentrations. However, maintaining these concentrations is complicated as physiological changes during pregnancy affect tacrolimus pharmacokinetics. The aim of this study was to describe tacrolimus pharmacokinetics throughout pregnancy and explain the changes by investigating covariates in a population pharmacokinetic model. METHODS Data of pregnant women using a twice-daily tacrolimus formulation following kidney transplantation were retrospectively collected from 6 months before conception, throughout gestation and up to 6 months postpartum. Pharmacokinetic analysis was performed using nonlinear mixed effects modelling. Demographic, clinical and genetic parameters were evaluated as covariates. The final model was evaluated using goodness-of-fit plots, visual predictive checks and a bootstrap analysis. RESULTS A total of 260 whole-blood tacrolimus predose concentrations from 14 pregnant kidney transplant recipients were included. Clearance increased during pregnancy from 34.5 to 41.7 L/h, by 15, 19 and 21% in the first, second and third trimester, respectively, compared to prior to pregnancy. This indicates a required increase in the tacrolimus dose by the same percentage to maintain the prepregnancy concentration. Haematocrit and gestational age were negatively correlated with tacrolimus clearance (P ≤ 0.01), explaining 18% of interindividual and 85% of interoccasion variability in oral clearance. CONCLUSIONS Tacrolimus clearance increases during pregnancy, resulting in decreased exposure to tacrolimus, which is explained by gestational age and haematocrit. To maintain prepregnancy target whole-blood tacrolimus predose concentrations during pregnancy, increasing the dose is required.
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Affiliation(s)
- Maaike R Schagen
- Erasmus MC Transplant Institute, Department of Internal Medicine, Division of Nephrology and Transplantation, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Rotterdam Clinical Pharmacometrics Group, Rotterdam, the Netherlands
| | - Asiye Nur Ulu
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Marith I Francke
- Erasmus MC Transplant Institute, Department of Internal Medicine, Division of Nephrology and Transplantation, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Rotterdam Clinical Pharmacometrics Group, Rotterdam, the Netherlands
| | - Jacqueline van de Wetering
- Erasmus MC Transplant Institute, Department of Internal Medicine, Division of Nephrology and Transplantation, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Marleen C van Buren
- Erasmus MC Transplant Institute, Department of Internal Medicine, Division of Nephrology and Transplantation, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Sam Schoenmakers
- Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Maja Matic
- Department of Clinical Chemistry, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Ron H N van Schaik
- Department of Clinical Chemistry, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Dennis A Hesselink
- Erasmus MC Transplant Institute, Department of Internal Medicine, Division of Nephrology and Transplantation, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Brenda C M de Winter
- Erasmus MC Transplant Institute, Department of Internal Medicine, Division of Nephrology and Transplantation, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Rotterdam Clinical Pharmacometrics Group, Rotterdam, the Netherlands
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
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Coppola P, Butler A, Cole S, Kerwash E. Total and Free Blood and Plasma Concentration Changes in Pregnancy for Medicines Highly Bound to Plasma Proteins: Application of Physiologically Based Pharmacokinetic Modelling to Understand the Impact on Efficacy. Pharmaceutics 2023; 15:2455. [PMID: 37896215 PMCID: PMC10609738 DOI: 10.3390/pharmaceutics15102455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 09/27/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023] Open
Abstract
Free drug concentrations are generally considered the pharmacologically active moiety and are important for cellular diffusion and distribution. Pregnancy-related changes in plasma protein binding and blood partitioning are due to decreases in plasma albumin, alpha-1-acid glycoprotein, and haematocrit; this may lead to increased free concentrations, tissue distribution, and clearance during pregnancy. In this paper we highlight the importance and challenges of considering changes in total and free concentrations during pregnancy. For medicines highly bound to plasma proteins, such as tacrolimus, efavirenz, clindamycin, phenytoin, and carbamazepine, differential changes in concentrations of free drug during pregnancy may be clinically significant and have important implications for dose adjustment. Therapeutic drug monitoring usually relies on the measurement of total concentrations; this can result in dose adjustments that are not necessary when changes in free concentrations are considered. We explore the potential of physiologically based pharmacokinetic (PBPK) models to support the understanding of the changes in plasma proteins binding, using tacrolimus and efavirenz as example drug models. The exposure to either drug was predicted to be reduced during pregnancy; however, the decrease in the exposure to the total tacrolimus and efavirenz were significantly larger than the reduction in the exposure to the free drug. These data show that PBPK modelling can support the impact of the changes in plasma protein binding and may be used for the simulation of free concentrations in pregnancy to support dosing decisions.
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Nastasio S, Mosca A, Alterio T, Sciveres M, Maggiore G. Juvenile Autoimmune Hepatitis: Recent Advances in Diagnosis, Management and Long-Term Outcome. Diagnostics (Basel) 2023; 13:2753. [PMID: 37685291 PMCID: PMC10486972 DOI: 10.3390/diagnostics13172753] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/11/2023] [Accepted: 08/13/2023] [Indexed: 09/10/2023] Open
Abstract
Juvenile autoimmune hepatitis (JAIH) is severe immune-mediated necro-inflammatory disease of the liver with spontaneous progression to cirrhosis and liver failure if left untreated. The diagnosis is based on the combination of clinical, laboratory and histological findings. Prothrombin ratio is a useful prognostic factor to identify patients who will most likely require a liver transplant by adolescence or early adulthood. JAIH treatment consists of immune suppression and should be started promptly at diagnosis to halt inflammatory liver damage and ultimately prevent fibrosis and progression to end-stage liver disease. The risk of relapse is high especially in the setting of poor treatment compliance. Recent evidence however suggests that treatment discontinuation is possible after a prolonged period of normal aminotransferase activity without the need for liver biopsy prior to withdrawal.
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Affiliation(s)
- Silvia Nastasio
- Division of Gastroenterology, Hepatology & Nutrition, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, USA;
| | - Antonella Mosca
- Hepatogastroenterology, Rehabilitative Nutrition, Digestive Endoscopy and Liver Transplant Unit, ERN RARE LIVER, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (A.M.); (T.A.)
| | - Tommaso Alterio
- Hepatogastroenterology, Rehabilitative Nutrition, Digestive Endoscopy and Liver Transplant Unit, ERN RARE LIVER, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (A.M.); (T.A.)
| | - Marco Sciveres
- Pediatric Department and Transplantation, ISMETT, 90133 Palermo, Italy;
| | - Giuseppe Maggiore
- Hepatogastroenterology, Rehabilitative Nutrition, Digestive Endoscopy and Liver Transplant Unit, ERN RARE LIVER, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (A.M.); (T.A.)
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8
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Meyer N, Vu TH, Brodowski L, Schröder-Heurich B, von Kaisenberg C, von Versen-Höynck F. Fetal endothelial colony-forming cell impairment after maternal kidney transplantation. Pediatr Res 2023; 93:810-817. [PMID: 35732823 PMCID: PMC10033415 DOI: 10.1038/s41390-022-02165-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 05/17/2022] [Accepted: 06/04/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Successful pregnancies are nowadays possible after kidney transplantation but are associated with a higher incidence of maternal and fetal complications. Immunosuppressive therapy causes cardiovascular side effects but must be maintained during pregnancy. Little is known about the consequences of maternal kidney transplantation on offspring's endothelial health. Endothelial colony forming cells (ECFCs) represent a highly proliferative subtype of endothelial progenitor cells and are crucial for vascular homeostasis, repair and neovascularization. Therefore, we investigated whether maternal kidney transplantation affects fetal ECFCs' characteristics. METHODS ECFCs were isolated from umbilical cord blood of uncomplicated and post-kidney-transplant pregnancies and analyzed for their functional abilities with proliferation, cell migration, centrosome orientation and angiogenesis assays. Further, ECFCs from uncomplicated pregnancies were exposed to either umbilical cord serum from uncomplicated or post-kidney-transplant pregnancies. RESULTS Post-kidney-transplant ECFCs showed significantly less proliferation, less migration and less angiogenesis compared to control ECFCs. The presence of post-kidney-transplant umbilical cord serum led to similar functional aberrations of ECFCs from uncomplicated pregnancies. CONCLUSIONS These pilot data demonstrate differences in ECFCs' biological characteristics in offspring of women after kidney transplantation. Further studies are needed to monitor offspring's long-term cardiovascular development and to assess possible causal relationships with immunosuppressants, uremia and maternal cardiovascular alterations. IMPACT Pregnancy after kidney transplantation has become more common in the past years but is associated with higher complications for mother and offspring. Little is known of the impact of maternal kidney transplantation and the mandatory immunosuppressive therapy on offspring vascular development. In this study we are the first to address and detect an impairment of endothelial progenitor cell function in offspring of kidney-transplanted mothers. Serum from post-transplant pregnancies also causes negative effects on ECFCs' function. Clinical studies should focus on long-term monitoring of offspring's cardiovascular health.
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Affiliation(s)
- Nadia Meyer
- Gynecology Research Unit, Hannover Medical School, Carl-Neuberg-Strasse 1, D-30625, Hannover, Germany
| | - Thu Huong Vu
- Gynecology Research Unit, Hannover Medical School, Carl-Neuberg-Strasse 1, D-30625, Hannover, Germany
- Department of Obstetrics and Gynecology, Hannover Medical School, Carl-Neuberg-Strasse 1, D-30625, Hannover, Germany
| | - Lars Brodowski
- Gynecology Research Unit, Hannover Medical School, Carl-Neuberg-Strasse 1, D-30625, Hannover, Germany
- Department of Obstetrics and Gynecology, Hannover Medical School, Carl-Neuberg-Strasse 1, D-30625, Hannover, Germany
| | - Bianca Schröder-Heurich
- Gynecology Research Unit, Hannover Medical School, Carl-Neuberg-Strasse 1, D-30625, Hannover, Germany
| | - Constantin von Kaisenberg
- Department of Obstetrics and Gynecology, Hannover Medical School, Carl-Neuberg-Strasse 1, D-30625, Hannover, Germany
| | - Frauke von Versen-Höynck
- Gynecology Research Unit, Hannover Medical School, Carl-Neuberg-Strasse 1, D-30625, Hannover, Germany.
- Department of Obstetrics and Gynecology, Hannover Medical School, Carl-Neuberg-Strasse 1, D-30625, Hannover, Germany.
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Kelly D, Samyn M, Schwarz KB. Biliary Atresia in Adolescence and Adult Life: Medical, Surgical and Psychological Aspects. J Clin Med 2023; 12:1594. [PMID: 36836128 PMCID: PMC9967626 DOI: 10.3390/jcm12041594] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 12/06/2022] [Accepted: 12/23/2022] [Indexed: 02/19/2023] Open
Abstract
Prior to 1955, when Morio Kasai first performed the hepatic portoenterostomy procedure which now bears his name, Biliary atresia (BA) was a uniformly fatal disease. Both the Kasai procedure and liver transplantation have markedly improved the outlook for infants with this condition. Although long-term survival with native liver occurs in the minority, survival rates post liver transplantation are high. Most young people born with BA will now survive into adulthood but their ongoing requirements for health care will necessitate their transition from a family-centred paediatric service to a patient-centred adult service. Despite a rapid growth in transition services over recent years and progress in transitional care, transition from paediatric to adult services is still a risk for poor clinical and psychosocial outcomes and increased health care costs. Adult hepatologists should be aware of the clinical management and complications of biliary atresia and the long-term consequences of liver transplantation in childhood. Survivors of childhood illness require a different approach to that for young adults presenting after 18 years of age with careful consideration of their emotional, social, and sexual health. They need to understand the risks of non-adherence, both for clinic appointments and medication, as well as the implications for graft loss. Developing adequate transitional care for these young people is based on effective collaboration at the paediatric-adult interface and is a major challenge for paediatric and adult providers alike in the 21st century. This entails education for patients and adult physicians in order to familiarise them with the long-term complications, in particular for those surviving with their native liver and the timing of consideration of liver transplantation if required. This article focusses on the outcome for children with biliary atresia who survive into adolescence and adult life with considerations on their current management and prognosis.
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Affiliation(s)
- Deirdre Kelly
- Liver Unit, Birmingham Women’s & Children’s NHS Hospital, University of Birmingham, Birmingham B15 2TT, UK
| | - Marianne Samyn
- Paediatric Liver, Gastroenterology and Nutrition Unit, King’s College Hospital NHS Foundation Trust, London WC2R 2LS, UK
| | - Kathleen B. Schwarz
- Pediatric Liver Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Pediatric Liver Center, UCSD School of Medicine/Rady Children’s Hospital, San Diego, CA 92123, USA
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10
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D'Amico G, Del Prete L, Eghtesad B, Hashimoto K, Miller C, Tzakis A, Quintini C, Falcone T. Immunosuppression in uterus transplantation: from transplant to delivery. Expert Opin Pharmacother 2023; 24:29-35. [PMID: 35723045 DOI: 10.1080/14656566.2022.2090243] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Uterus transplantation introduces unique challenges regarding immunosuppression, including the effects of immunosuppressive drugs on the fetus and graft rejection during pregnancy. Although immunosuppressive regimens are based on protocols used after solid organ transplantation, in recipients of uterus grafts, the physician must consider therapy modifications based on the phase of the transplant, from the intra-operative period through to delivery. AREAS COVERED This review discusses the current immunosuppressive rationale in uterus transplantation, focusing on the therapy in each phase of the transplant. The authors present an overview of the already approved immunosuppressive medications for solid organ transplantation, their application in uterus transplant prior to pregnancy, during pregnancy and as rejection treatment. EXPERT OPINION Most medications used for uterus transplant are adopted from solid organ transplantation experience, especially kidney transplantation, and rejection is treated in standard fashion. Research is needed to clarify the drugs' effects on fetal and neonatal well-being and to develop new medications to achieve better tolerance. Early markers of uterus graft rejection need to be identified, and prior rejection episodes should no longer be a cause to remove the graft during delivery in a recipient who wants a further pregnancy.
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Affiliation(s)
- Giuseppe D'Amico
- Departments of General Surgery, Digestive Disease and Surgery Institute, Liver and Uterus Transplant Unit, Cleveland Clinic, Cleveland, Ohio, USA
| | - Luca Del Prete
- Departments of General Surgery, Digestive Disease and Surgery Institute, Liver and Uterus Transplant Unit, Cleveland Clinic, Cleveland, Ohio, USA.,General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Bijan Eghtesad
- Departments of General Surgery, Digestive Disease and Surgery Institute, Liver and Uterus Transplant Unit, Cleveland Clinic, Cleveland, Ohio, USA
| | - Koji Hashimoto
- Departments of General Surgery, Digestive Disease and Surgery Institute, Liver and Uterus Transplant Unit, Cleveland Clinic, Cleveland, Ohio, USA
| | - Charles Miller
- Departments of General Surgery, Digestive Disease and Surgery Institute, Liver and Uterus Transplant Unit, Cleveland Clinic, Cleveland, Ohio, USA
| | - Andreas Tzakis
- Departments of General Surgery, Digestive Disease and Surgery Institute, Liver and Uterus Transplant Unit, Cleveland Clinic, Cleveland, Ohio, USA
| | - Cristiano Quintini
- Departments of General Surgery, Digestive Disease and Surgery Institute, Liver and Uterus Transplant Unit, Cleveland Clinic, Cleveland, Ohio, USA
| | - Tommaso Falcone
- Cleveland Clinic, Obstetrics and Gynecology and Women's Health Institute, Cleveland, Ohio, USA
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Téllez Arévalo AM, Quaye A, Rojas-Rodríguez LC, Poole BD, Baracaldo-Santamaría D, Tellez Freitas CM. Synthetic Pharmacotherapy for Systemic Lupus Erythematosus: Potential Mechanisms of Action, Efficacy, and Safety. MEDICINA (KAUNAS, LITHUANIA) 2022; 59:56. [PMID: 36676680 PMCID: PMC9866503 DOI: 10.3390/medicina59010056] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 12/14/2022] [Accepted: 12/21/2022] [Indexed: 12/29/2022]
Abstract
The pharmacological treatment of systemic lupus erythematosus (SLE) aims to decrease disease activity, progression, systemic compromise, and mortality. Among the pharmacological alternatives, there are chemically synthesized drugs whose efficacy has been evaluated, but which have the potential to generate adverse events that may compromise adherence and response to treatment. Therapy selection and monitoring will depend on patient characteristics and the safety profile of each drug. The aim of this review is to provide a comprehensive understanding of the most important synthetic drugs used in the treatment of SLE, including the current treatment options (mycophenolate mofetil, azathioprine, and cyclophosphamide), review their mechanism of action, efficacy, safety, and, most importantly, provide monitoring parameters that should be considered while the patient is receiving the pharmacotherapy.
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Affiliation(s)
- Angélica María Téllez Arévalo
- Department of Physiological Sciences, School of Medicine, Pontificia Universidad Javeriana, Carrera 7 No. 40–62, Bogotá 110231, Colombia
| | - Abraham Quaye
- Department of Microbiology and Molecular Biology, Brigham Young University, Provo, UT 84602, USA
| | - Luis Carlos Rojas-Rodríguez
- Pharmacology Unit, Department of Biomedical Sciences, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá 111221, Colombia
| | - Brian D. Poole
- Department of Microbiology and Molecular Biology, Brigham Young University, Provo, UT 84602, USA
| | - Daniela Baracaldo-Santamaría
- Pharmacology Unit, Department of Biomedical Sciences, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá 111221, Colombia
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12
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Evaluation of a Capillary Microsampling Device for Analyzing Plasma Lenvatinib Concentration in Patients With Hepatocellular Carcinoma. Ther Drug Monit 2022; 44:771-776. [PMID: 35863065 DOI: 10.1097/ftd.0000000000001013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 06/19/2022] [Indexed: 01/29/2023]
Abstract
BACKGROUND The anticancer drug, Lenvima (lenvatinib), has severe side effects. Therapeutic drug monitoring helps ensure its efficacy and safety. Regular and optimally timed blood sampling is tough, especially when lenvatinib is self-medicated. Microsampling using the easy to handle Microsampling Wing (MSW) may help circumvent this problem. However, current lenvatinib detection methods are not sensitive enough to detect its concentrations in microsamples (<50-250 μL). Thus, the aim of this study was 2-fold (1) develop an analytic method to estimate plasma lenvatinib concentrations in microsamples and (2) verify whether this method works on micro (5.6 μL) blood plasma samples obtained clinically through MSW from patients with unresectable hepatocellular carcinoma (HCC). METHODS A simple, highly sensitive, and specific liquid chromatography-electrospray ionization tandem mass spectrometry method was developed. Using this novel protocol, the trough blood plasma concentration of lenvatinib was measured for both blood sampled conventionally and that using MSW. Thirty-five venous whole blood samples were obtained from 11 patients with HCC. Furthermore, the stability of lenvatinib in MSW samples during storage was evaluated. RESULTS The mean plasma lenvatinib concentration estimates were not significantly different between the MSW and conventional venous blood samples. CV for interday and intraday assays was low. Up to day 5, the lenvatinib concentration in the MSW samples was 85%-115% of the initial day concentration (when stored at 25°C or 4°C). The interference of endogenous matrix components in the human plasma was low. CONCLUSIONS These results indicate that the novel mass spectrometry protocol accurately measures lenvatinib in human plasma and is reproducible. Thus, MSW could be a useful microsampling device for lenvatinib therapeutic drug monitoring in patients with HCC when used in combination with this novel liquid chromatography-electrospray ionization tandem mass spectrometry detection method.
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13
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Li W, Wang T. Breastfeeding Initiation, Duration, and Associated Factors in Mothers with Systemic Lupus Erythematosus. Breastfeed Med 2022; 17:958-963. [PMID: 36378821 DOI: 10.1089/bfm.2022.0142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: To study breastfeeding initiation, duration, and associated factors in patients with systemic lupus erythematosus (SLE), a cross-sectional study comparing with SLE and non-SLE mothers was conducted. Methods: Thirty patients with SLE who had pregnancy outcomes from September 2018 to December 2020 and 120 non-SLE patients (excluding mothers with other immune system diseases) were included in the study. Data on sociodemographic, obstetric, and SLE clinical information were collected. Breastfeeding initiation, breastfeeding duration, and reasons for not initiating breastfeeding were investigated via telephone. Results: The rate in breastfeeding of SLE group was significantly lower than non-SLE group (36.7% versus 86.7%, respectively, p < 0.001; odds ratio 0.059; 95% confidence interval 0.015-0.241). Non-SLE mothers had a longer duration of breastfeeding than mothers with SLE (log-rank p = 0.001). Fearing of the adverse effects of drugs on babies is the main reason (68.4%) for not initiating breastfeeding in SLE group. Infants with high weight and Apgar scores, primipara women, and having a college degree were significantly associated with breastfeeding among patients with SLE. Conclusion: SLE women showed a lower breastfeeding rate and shorter breastfeeding duration. Postpartum medications are safe for lactation in most patients with SLE. Targeted intervention programs that enhance breastfeeding consultations are required for this group.
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Affiliation(s)
- Wei Li
- Department of Pharmacy, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Tao Wang
- Department of Pharmacy, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
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14
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Moroni G, Calatroni M, Ponticelli C. The Impact of Preeclampsia in Lupus Nephritis. Expert Rev Clin Immunol 2022; 18:1-13. [PMID: 35510378 DOI: 10.1080/1744666x.2022.2074399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 05/03/2022] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Women with systemic lupus erythematosus (SLE), particularly those with lupus nephritis (LN), remain at high risk for adverse pregnancy outcome. Although in the last decades maternal and fetal outcomes have improved dramatically, preeclampsia remains a major cause of maternal and perinatal morbidity and mortality. AREAS COVERED A narrative review of literature was conducted, underlying the importance of pre-conception counseling, and focusing on the correlation between preeclampsia and LN. The clinical characteristics of preeclampsia were described, with emphasis on risk factors in LN and the differential diagnosis between preeclampsia and lupus flares. Additionally, the prevention and treatment of preeclampsia were discussed, as well as the management of short-term and long-term consequences of preeclampsia. We highlight the importance of a pre-pregnancy counseling from a multidisciplinary team to plan pregnancy during inactive SLE and LN. EXPERT OPINION Further studies are needed to evaluate the long-term consequences of pregnancy in LN. Considering that preeclamptic patients can be at high risk for long-term renal failure, we suggest renal checkup for at least 6-12 months after delivery in all patients.
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Affiliation(s)
- Gabriella Moroni
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Marta Calatroni
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Claudio Ponticelli
- Independent Researcher, Past Director Nephrology Policlinico, Milan, Italy
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15
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Rashidi-Alavijeh J, Frey A, Hörster A, Nguyen BP, Iannaccone A, Saner F, Lange CM, Willuweit K. Safe for Mother, Baby, and Graft? Pregnancy After Liver Transplant: A Single-Center Experience. Transplant Proc 2022; 54:744-748. [DOI: 10.1016/j.transproceed.2022.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 01/17/2022] [Indexed: 11/30/2022]
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16
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Martin F, Tullius SG. Immunosuppression after uterus transplantation. Curr Opin Organ Transplant 2021; 26:627-633. [PMID: 34581290 DOI: 10.1097/mot.0000000000000925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Clinical uterus transplantation (UTx) is growing rapidly. The procedure represents the only therapy for women with absolute uterine factor infertility to give birth to a biological baby. Immunosuppression after UTx needs to carefully balance effects with the healthy mother and baby. Unique for UTx is the 'temporary' character of the procedure with a transplant hysterectomy being performed after delivery. Most of the practice on immunosuppression in UTx is currently based on the experience in solid organ transplantation (SOT). RECENT FINDINGS Clinical UTx-trials have been performed in centers worldwide during the recent years and experience on immunosuppression has accumulated. SUMMARY Immunosuppression in UTx has been successfully applied as maintenance treatment in addition to effectively treating acute T- and B-cell mediated rejections. Understanding the biology of UTx in more detail is expected to refine future approaches.
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Affiliation(s)
- Friederike Martin
- Department of General, Visceral and Transplant Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Stefan G Tullius
- Division of Transplant Surgery and Transplant Surgery Research Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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17
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Ponticelli C, Zaina B, Moroni G. Planned Pregnancy in Kidney Transplantation. A Calculated Risk. J Pers Med 2021; 11:jpm11100956. [PMID: 34683097 PMCID: PMC8537874 DOI: 10.3390/jpm11100956] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 09/23/2021] [Accepted: 09/23/2021] [Indexed: 12/13/2022] Open
Abstract
Pregnancy is not contraindicated in kidney transplant women but entails risks of maternal and fetal complications. Three main conditions can influence the outcome of pregnancy in transplant women: preconception counseling, maternal medical management, and correct use of drugs to prevent fetal toxicity. Preconception counseling is needed to prevent the risks of an unplanned untimely pregnancy. Pregnancy should be planned ≥2 years after transplantation. The candidate for pregnancy should have normal blood pressure, stable serum creatinine <1.5 mg/dL, and proteinuria <500 mg/24 h. Maternal medical management is critical for early detection and treatment of complications such as hypertension, preeclampsia, thrombotic microangiopathy, graft dysfunction, gestational diabetes, and infection. These adverse outcomes are strongly related to the degree of kidney dysfunction. A major issue is represented by the potential fetotoxicity of drugs. Moderate doses of glucocorticoids, azathioprine, and mTOR inhibitors are relatively safe. Calcineurin inhibitors (CNIs) are not associated with teratogenicity but may increase the risk of low birth weight. Rituximab and eculizumab should be used in pregnancy only if the benefits outweigh the risk for the fetus. Renin-angiotensin system inhibitors, mycophenolate, bortezomib, and cyclophosphamide can lead to fetal toxicity and should not be prescribed to pregnant women.
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Affiliation(s)
- Claudio Ponticelli
- Nephrology, Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Correspondence:
| | - Barbara Zaina
- Department of Obstetrics and Gynecology, IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Gabriella Moroni
- Department of Biomedical Sciences, IRCCS Humanitas Research Hospital, Humanitas University, 20122 Milan, Italy;
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18
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Malaiyandi D, James E, Peglar L, Karim N, Henkel N, Guilliams K. Neurocritical Care of the Pregnant Patient. Curr Treat Options Neurol 2021; 23:22. [PMID: 34177249 PMCID: PMC8214980 DOI: 10.1007/s11940-021-00676-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2021] [Indexed: 02/07/2023]
Abstract
Purpose of review To summarize recent changes in management and emerging therapies for pregnant neurocritical care patients. Recent findings Diagnostic and treatment options for managing neurologic emergencies in pregnant patients have expanded with both greater understanding of the effects of imaging modalities and medications on pregnancy and application of standard treatments for non-pregnant patients to pregnant populations. Specifically, this includes cerebrovascular diseases (pregnancy-associated ischemic stroke, pregnancy-associated intracerebral hemorrhage, cerebral venous sinus thrombosis), post-maternal cardiac arrest care, seizures and status epilepticus, myasthenia gravis, and fetal somatic support in maternal death by neurologic criteria. Summary With the exception of direct abdominal computed tomography (CT), most imaging studies are reasonably safe in pregnancy. When emergent imaging is needed to prevent maternal morbidity or mortality, any CT sequence with or without contrast is appropriate to pursue. Though new safety data on antiplatelets, antihypertensives, thrombolytics, and antiepileptic drugs have increased options for disease management in pregnancy, unfractionated and low-molecular weight heparin remain the safest options for anticoagulation. Early studies on hypothermia, ketamine, and immunomodulating therapies in pregnancy are promising. In myasthenia gravis, new data on adjunct devices may allow more patients to undergo safe vaginal delivery, avoiding cesarean section and the associated risk of crisis. When difficult decisions regarding preterm delivery arise, recent outcome studies can help inform discussion. Lastly, when the feared complication of maternal death by neurologic criteria occurs, fetal somatic support may help to save at least one life.
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Affiliation(s)
- Deepa Malaiyandi
- Department of Neurology, Division of Neurocritical Care, University of Toledo College of Medicine, Toledo, OH USA.,University of Toledo/ProMedica Neurosciences Center, 2130 W Central Ave, Ste. 201, Toledo, OH USA.,ProMedica Toledo Hospital, Toledo, OH USA
| | - Elysia James
- Department of Neurology, Division of Neurocritical Care, University of Toledo College of Medicine, Toledo, OH USA.,ProMedica Toledo Hospital, Toledo, OH USA
| | - Lindsay Peglar
- Department of Neurology, Washington University, St. Louis, MO USA
| | - Nurose Karim
- Department of Neurology, Division of Neurocritical Care, University of Toledo College of Medicine, Toledo, OH USA
| | - Nicholas Henkel
- Department of Neurology, Division of Neurocritical Care, University of Toledo College of Medicine, Toledo, OH USA
| | - Kristin Guilliams
- Department of Neurology, Washington University, St. Louis, MO USA.,Department of Pediatrics, Washington University, St. Louis, MO USA
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19
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Therapeutic drug monitoring of immunosuppressive drugs in hepatology and gastroenterology. Best Pract Res Clin Gastroenterol 2021; 54-55:101756. [PMID: 34874840 DOI: 10.1016/j.bpg.2021.101756] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 06/11/2021] [Indexed: 01/31/2023]
Abstract
Immunosuppressive drugs have been key to the success of liver transplantation and are essential components of the treatment of inflammatory bowel disease (IBD) and autoimmune hepatitis (AIH). For many but not all immunosuppressants, therapeutic drug monitoring (TDM) is recommended to guide therapy. In this article, the rationale and evidence for TDM of tacrolimus, mycophenolic acid, the mammalian target of rapamycin inhibitors, and azathioprine in liver transplantation, IBD, and AIH is reviewed. New developments, including algorithm-based/computer-assisted immunosuppressant dosing, measurement of immunosuppressants in alternative matrices for whole blood, and pharmacodynamic monitoring of these agents is discussed. It is expected that these novel techniques will be incorporate into the standard TDM in the next few years.
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20
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Accompagnement postgreffe à l’officine. ACTUALITES PHARMACEUTIQUES 2021. [DOI: 10.1016/j.actpha.2021.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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21
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Bergan S, Brunet M, Hesselink DA, Johnson-Davis KL, Kunicki PK, Lemaitre F, Marquet P, Molinaro M, Noceti O, Pattanaik S, Pawinski T, Seger C, Shipkova M, Swen JJ, van Gelder T, Venkataramanan R, Wieland E, Woillard JB, Zwart TC, Barten MJ, Budde K, Dieterlen MT, Elens L, Haufroid V, Masuda S, Millan O, Mizuno T, Moes DJAR, Oellerich M, Picard N, Salzmann L, Tönshoff B, van Schaik RHN, Vethe NT, Vinks AA, Wallemacq P, Åsberg A, Langman LJ. Personalized Therapy for Mycophenolate: Consensus Report by the International Association of Therapeutic Drug Monitoring and Clinical Toxicology. Ther Drug Monit 2021; 43:150-200. [PMID: 33711005 DOI: 10.1097/ftd.0000000000000871] [Citation(s) in RCA: 92] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 01/29/2021] [Indexed: 12/13/2022]
Abstract
ABSTRACT When mycophenolic acid (MPA) was originally marketed for immunosuppressive therapy, fixed doses were recommended by the manufacturer. Awareness of the potential for a more personalized dosing has led to development of methods to estimate MPA area under the curve based on the measurement of drug concentrations in only a few samples. This approach is feasible in the clinical routine and has proven successful in terms of correlation with outcome. However, the search for superior correlates has continued, and numerous studies in search of biomarkers that could better predict the perfect dosage for the individual patient have been published. As it was considered timely for an updated and comprehensive presentation of consensus on the status for personalized treatment with MPA, this report was prepared following an initiative from members of the International Association of Therapeutic Drug Monitoring and Clinical Toxicology (IATDMCT). Topics included are the criteria for analytics, methods to estimate exposure including pharmacometrics, the potential influence of pharmacogenetics, development of biomarkers, and the practical aspects of implementation of target concentration intervention. For selected topics with sufficient evidence, such as the application of limited sampling strategies for MPA area under the curve, graded recommendations on target ranges are presented. To provide a comprehensive review, this report also includes updates on the status of potential biomarkers including those which may be promising but with a low level of evidence. In view of the fact that there are very few new immunosuppressive drugs under development for the transplant field, it is likely that MPA will continue to be prescribed on a large scale in the upcoming years. Discontinuation of therapy due to adverse effects is relatively common, increasing the risk for late rejections, which may contribute to graft loss. Therefore, the continued search for innovative methods to better personalize MPA dosage is warranted.
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Affiliation(s)
- Stein Bergan
- Department of Pharmacology, Oslo University Hospital and Department of Pharmacy, University of Oslo, Oslo, Norway
| | - Mercè Brunet
- Pharmacology and Toxicology Laboratory, Biochemistry and Molecular Genetics Department, Biomedical Diagnostic Center, Hospital Clinic of Barcelona, University of Barcelona, IDIBAPS, CIBERehd, Spain
| | - Dennis A Hesselink
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Kamisha L Johnson-Davis
- Department of Pathology, University of Utah Health Sciences Center and ARUP Laboratories, Salt Lake City, Utah
| | - Paweł K Kunicki
- Department of Drug Chemistry, Faculty of Pharmacy, Medical University of Warsaw, Warszawa, Poland
| | - Florian Lemaitre
- Univ Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail)-UMR_S 1085, Rennes, France
| | - Pierre Marquet
- INSERM, Université de Limoges, Department of Pharmacology and Toxicology, CHU de Limoges, U1248 IPPRITT, Limoges, France
| | - Mariadelfina Molinaro
- Clinical and Experimental Pharmacokinetics Lab, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Ofelia Noceti
- National Center for Liver Tansplantation and Liver Diseases, Army Forces Hospital, Montevideo, Uruguay
| | | | - Tomasz Pawinski
- Department of Drug Chemistry, Faculty of Pharmacy, Medical University of Warsaw, Warszawa, Poland
| | | | - Maria Shipkova
- Synlab TDM Competence Center, Synlab MVZ Leinfelden-Echterdingen GmbH, Leinfelden-Echterdingen, Germany
| | - Jesse J Swen
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Teun van Gelder
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Raman Venkataramanan
- Department of Pharmaceutical Sciences, School of Pharmacy and Department of Pathology, Starzl Transplantation Institute, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Eberhard Wieland
- Synlab TDM Competence Center, Synlab MVZ Leinfelden-Echterdingen GmbH, Leinfelden-Echterdingen, Germany
| | - Jean-Baptiste Woillard
- INSERM, Université de Limoges, Department of Pharmacology and Toxicology, CHU de Limoges, U1248 IPPRITT, Limoges, France
| | - Tom C Zwart
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Markus J Barten
- Department of Cardiac- and Vascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Klemens Budde
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Maja-Theresa Dieterlen
- Department of Cardiac Surgery, Heart Center, HELIOS Clinic, University Hospital Leipzig, Leipzig, Germany
| | - Laure Elens
- Integrated PharmacoMetrics, PharmacoGenomics and PharmacoKinetics (PMGK) Research Group, Louvain Drug Research Institute (LDRI), Université Catholique de Louvain (UCLouvain), Brussels, Belgium
| | - Vincent Haufroid
- Louvain Centre for Toxicology and Applied Pharmacology (LTAP), Institut de Recherche Expérimentale et Clinique, UCLouvain and Department of Clinical Chemistry, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Satohiro Masuda
- Department of Pharmacy, International University of Health and Welfare Narita Hospital, Chiba, Japan
| | - Olga Millan
- Pharmacology and Toxicology Laboratory, Biochemistry and Molecular Genetics Department, Biomedical Diagnostic Center, Hospital Clinic of Barcelona, University of Barcelona, IDIBAPS, CIBERehd, Spain
| | - Tomoyuki Mizuno
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Dirk J A R Moes
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Michael Oellerich
- Department of Clinical Pharmacology, University Medical Center Göttingen, Georg-August-University Göttingen, Göttingen, Germany
| | - Nicolas Picard
- INSERM, Université de Limoges, Department of Pharmacology and Toxicology, CHU de Limoges, U1248 IPPRITT, Limoges, France
| | | | - Burkhard Tönshoff
- Department of Pediatrics I, University Children's Hospital, Heidelberg, Germany
| | - Ron H N van Schaik
- Department of Clinical Chemistry, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Nils Tore Vethe
- Department of Pharmacology, Oslo University Hospital and Department of Pharmacy, University of Oslo, Oslo, Norway
| | - Alexander A Vinks
- Department of Pharmacy, International University of Health and Welfare Narita Hospital, Chiba, Japan
| | - Pierre Wallemacq
- Clinical Chemistry Department, Cliniques Universitaires St Luc, Université Catholique de Louvain, LTAP, Brussels, Belgium
| | - Anders Åsberg
- Department of Transplantation Medicine, Oslo University Hospital-Rikshospitalet and Department of Pharmacy, University of Oslo, Oslo, Norway; and
| | - Loralie J Langman
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
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22
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Taulaigo AV, Moschetti L, Ganhão S, Gerardi MC, Franceschini F, Tincani A, Andreoli L. Safety considerations when using drugs in pregnant patients with systemic lupus erythematosus. Expert Opin Drug Saf 2021; 20:523-536. [PMID: 33599570 DOI: 10.1080/14740338.2021.1893298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Systemic lupus erythematosus (SLE) mainly affects young females during childbearing age; therefore, reproductive issues are of major interest.Areas covered: Pregnancy planning is crucial to adjust the treatment toward drugs that are safe throughout pregnancy and breastfeeding. The evidence about drug safety is limited to post-marketing surveillance, registries, case series, and case reports, as pregnant patients are excluded from randomized clinical trials. The aim of this review is to report the safety considerations when treating pregnant SLE patients. Regarding maternal side effects of drugs, we focused on metabolic, infectious, and hemorrhagic complications. Fetal safety was analyzed looking at drugs teratogenicity, their possible effects on immune system, and on the long-term neuropsychological development of children.Expert opinion: The management of pregnancy in SLE has changed when knowledge about the safety of drugs has become available. Keeping SLE disease activity under control before, during and after pregnancy is of fundamental importance to ensure the best possible outcomes for mother and child. All these issues must be discussed with the patient and her family during preconception counseling. International efforts in terms of pregnancy registries and reproductive health guidelines help physicians improve their communication with SLE patients.
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Affiliation(s)
- Anna Viola Taulaigo
- Unidade De Doenças Auto-imunes/Medicina 7.2, Hospital Curry Cabral, Centro Hospitalar Universitário De Lisboa Central, Lisboa, Portugal
| | - Liala Moschetti
- Unit of Rheumatology and Clinical Immunology, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Sara Ganhão
- Rheumatology Department, Centro Hospitalar E Universitário De São João, Porto, Portugal
| | - Maria-Chiara Gerardi
- Unit of Rheumatology and Clinical Immunology, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Franco Franceschini
- Unit of Rheumatology and Clinical Immunology, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Angela Tincani
- Unit of Rheumatology and Clinical Immunology, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Laura Andreoli
- Unit of Rheumatology and Clinical Immunology, ASST Spedali Civili; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
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23
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Boyer A, Lobbedez T, Ouethrani M, Thuillier Lecouf A, Bouvier N, Châtelet V, Hurault de Ligny B. Paternity in male kidney transplant recipients: a French national survey, the PATeRNAL study. BMC Nephrol 2020; 21:483. [PMID: 33198659 PMCID: PMC7667842 DOI: 10.1186/s12882-020-02115-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 10/20/2020] [Indexed: 12/11/2022] Open
Abstract
Background There is concern about the impact of immunosuppressive agents taken by male kidney transplant (KT) recipients on the risk of foetal malformations. The aim of our survey was to estimate the paternity rate and the outcomes of pregnancies fathered by kidney transplanted males. Methods This survey analysed 1332 male KT recipients older than 18 years, followed in 13 centres in France. A self-reported questionnaire was used to collect data on the patients, treatments at the time of conception and the pregnancy outcomes. Results The study included data on 349 children from 404 pregnancies fathered by 232 male KT recipients. The paternity rate was 17% (95% CI [15–20]). There were 37 (9%, 95% CI [7–12]) spontaneous abortions, 12 (3%, 95% CI [2–5]) therapeutic abortions, 2 (0.5%, 95% CI [0.1–1]) still births, and 13 (4%, 95% CI [2–6]) malformations reported. Compared to the general population, there was no difference in the proportion of congenital malformations nor unwanted outcomes whether the father was exposed or not to immunosuppressive agents. Conclusions This survey does not provide any warning signal that pregnancies fathered by male patients exposed to immunosuppressive agents, notably the debated MMF/MPA, have more complications than pregnancies in the general population. Supplementary Information Supplementary information accompanies this paper at 10.1186/s12882-020-02115-x.
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Affiliation(s)
- Annabel Boyer
- Centre Universitaire des Maladies Rénales, CHU de Caen, Avenue de la côte de Nacre, 14033, Caen, Cedex 9, France. .,U1086 INSERME - ANTICIPE, Centre Régional de Lutte contre le Cancer, François Baclesse, 14076, Caen, Cedex 5, France.
| | - Thierry Lobbedez
- Centre Universitaire des Maladies Rénales, CHU de Caen, Avenue de la côte de Nacre, 14033, Caen, Cedex 9, France.,U1086 INSERME - ANTICIPE, Centre Régional de Lutte contre le Cancer, François Baclesse, 14076, Caen, Cedex 5, France.,Unicaen, UFR de Médecine, Normandie Université, 2 rue des Rochambelles, 14032, Caen, Cedex, France
| | - Mohamed Ouethrani
- Centre Universitaire des Maladies Rénales, CHU de Caen, Avenue de la côte de Nacre, 14033, Caen, Cedex 9, France
| | - Angélique Thuillier Lecouf
- Centre Universitaire des Maladies Rénales, CHU de Caen, Avenue de la côte de Nacre, 14033, Caen, Cedex 9, France
| | - Nicolas Bouvier
- Centre Universitaire des Maladies Rénales, CHU de Caen, Avenue de la côte de Nacre, 14033, Caen, Cedex 9, France.,Unicaen, UFR de Médecine, Normandie Université, 2 rue des Rochambelles, 14032, Caen, Cedex, France
| | - Valérie Châtelet
- Centre Universitaire des Maladies Rénales, CHU de Caen, Avenue de la côte de Nacre, 14033, Caen, Cedex 9, France.,U1086 INSERME - ANTICIPE, Centre Régional de Lutte contre le Cancer, François Baclesse, 14076, Caen, Cedex 5, France.,Unicaen, UFR de Médecine, Normandie Université, 2 rue des Rochambelles, 14032, Caen, Cedex, France
| | - Bruno Hurault de Ligny
- Centre Universitaire des Maladies Rénales, CHU de Caen, Avenue de la côte de Nacre, 14033, Caen, Cedex 9, France.,Unicaen, UFR de Médecine, Normandie Université, 2 rue des Rochambelles, 14032, Caen, Cedex, France
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Kelly D, Wray J. Non-adherence and transition clinics. Best Pract Res Clin Gastroenterol 2020; 46-47:101687. [PMID: 33158474 DOI: 10.1016/j.bpg.2020.101687] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 09/18/2020] [Accepted: 09/18/2020] [Indexed: 02/07/2023]
Abstract
The majority of children who undergo liver transplantation now survive into adulthood and their requirement for life-long follow-up means that they will need to transition from paediatric to adult services. Poor transition is a risk factor for poor clinical and psychosocial outcomes and one of the barriers to effective transition is vulnerability to risk-taking behaviours, and specifically non-adherence. This chapter focuses on practical considerations for transitioning young people from paediatric to adult services, with a particular focus on the risk factors associated with non-adherence and examples of interventions for managing it.
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Affiliation(s)
- Deirdre Kelly
- Liver Unit, Birmingham Women's & Children's Hospital, University of Birmingham, UK.
| | - Jo Wray
- Heart and Lung Directorate, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London WC1N 3JH, UK.
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