1
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Seligson ND, Zhang X, Zemanek MC, Johnson JA, VanGundy Z, Wang D, Phelps MA, Roddy J, Hofmeister CC, Li J, Poi MJ. CYP3A5 influences oral tacrolimus pharmacokinetics and timing of acute kidney injury following allogeneic hematopoietic stem cell transplantation. Front Pharmacol 2024; 14:1334440. [PMID: 38259277 PMCID: PMC10800424 DOI: 10.3389/fphar.2023.1334440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 12/21/2023] [Indexed: 01/24/2024] Open
Abstract
Introduction: Polymorphisms in genes responsible for the metabolism and transport of tacrolimus have been demonstrated to influence clinical outcomes for patients following allogeneic hematologic stem cell transplant (allo-HSCT). However, the clinical impact of germline polymorphisms specifically for oral formulations of tacrolimus is not fully described. Methods: To investigate the clinical impact of genetic polymorphisms in CYP3A4, CYP3A5, and ABCB1 on oral tacrolimus pharmacokinetics and clinical outcomes, we prospectively enrolled 103 adult patients receiving oral tacrolimus for the prevention of graft-versus-host disease (GVHD) following allo-HSCT. Patients were followed in the inpatient and outpatient phase of care for the first 100 days of tacrolimus therapy. Patients were genotyped for CYP3A5 *3 (rs776746), CYP3A4 *1B (rs2740574), ABCB1 exon 12 (rs1128503), ABCB1 exon 21 (rs2032582), ABCB1 exon 26 (rs1045642). Results: Expression of CYP3A5 *1 was highly correlated with tacrolimus pharmacokinetics in the inpatient phase of care (p < 0.001) and throughout the entirety of the study period (p < 0.001). Additionally, Expression of CYP3A5 *1 was associated with decreased risk of developing AKI as an inpatient (p = 0.06). Variants in ABCB1 were not associated with tacrolimus pharmacokinetics in this study. We were unable to discern an independent effect of CYP3A4 *1B or *22 in this population. Conclusion: Expression of CYP3A5 *1 is highly influential on the pharmacokinetics and clinical outcomes for patients receiving oral tacrolimus as GVHD prophylaxis following allo-HSCT.
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Affiliation(s)
- Nathan D. Seligson
- Division of Pharmacy Practice and Science, College of Pharmacy, The Ohio State University, Columbus, OH, United States
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, United States
- Comprehensive Cancer Center, The Ohio State University, Columbus, OH, United States
| | - Xunjie Zhang
- Division of Pharmacy Practice and Science, College of Pharmacy, The Ohio State University, Columbus, OH, United States
| | - Mark C. Zemanek
- Division of Pharmacy Practice and Science, College of Pharmacy, The Ohio State University, Columbus, OH, United States
| | - Jasmine A. Johnson
- Division of Pharmacy Practice and Science, College of Pharmacy, The Ohio State University, Columbus, OH, United States
| | - Zachary VanGundy
- Division of Pharmacy Practice and Science, College of Pharmacy, The Ohio State University, Columbus, OH, United States
| | - Danxin Wang
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Mitch A. Phelps
- Comprehensive Cancer Center, The Ohio State University, Columbus, OH, United States
- Division of Pharmaceutics and Pharmaceutical Chemistry, College of Pharmacy, The Ohio State University, Columbus, OH, United States
| | - Julianna Roddy
- Division of Pharmacy Practice and Science, College of Pharmacy, The Ohio State University, Columbus, OH, United States
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Craig C. Hofmeister
- Department of Hematology and Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, United States
| | - Junan Li
- Comprehensive Cancer Center, The Ohio State University, Columbus, OH, United States
- Division of Outcomes and Translational Sciences, College of Pharmacy, The Ohio State University, Columbus, OH, United States
| | - Ming J. Poi
- Division of Pharmacy Practice and Science, College of Pharmacy, The Ohio State University, Columbus, OH, United States
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, United States
- Comprehensive Cancer Center, The Ohio State University, Columbus, OH, United States
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Truby LK, Maamari D, Saha A, Farr M, Abdulrahim J, Billia F, Peltz M, Khush KK, Wang TJ. Towards Allograft Longevity: Leveraging Omics Technologies to Improve Heart Transplant Outcomes. Curr Heart Fail Rep 2023; 20:493-503. [PMID: 37966542 DOI: 10.1007/s11897-023-00631-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/20/2023] [Indexed: 11/16/2023]
Abstract
PURPOSE OF REVIEW Heart transplantation (HT) remains the optimal therapy for patients living with end-stage heart disease. Despite recent improvements in peri-transplant management, the median survival after HT has remained relatively static, and complications of HT, including infection, rejection, and allograft dysfunction, continue to impact quality of life and long-term survival. RECENT FINDINGS Omics technologies are becoming increasingly accessible and can identify novel biomarkers for, and reveal the underlying biology of, several disease states. While some technologies, such as gene expression profiling (GEP) and donor-derived cell-free DNA (dd-cfDNA), are routinely used in the clinical care of HT recipients, a number of emerging platforms, including pharmacogenomics, proteomics, and metabolomics, hold great potential for identifying biomarkers to aid in the diagnosis and management of post-transplant complications. Omics-based assays can improve patient and allograft longevity by facilitating a personalized and precision approach to post-HT care. The following article is a contemporary review of the current and future opportunities to leverage omics technologies, including genomics, transcriptomics, proteomics, and metabolomics in the field of HT.
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Affiliation(s)
- Lauren K Truby
- University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390, USA.
| | - Dimitri Maamari
- University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390, USA
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Amit Saha
- University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390, USA
| | - Maryjane Farr
- University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390, USA
| | | | | | - Matthias Peltz
- University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390, USA
| | - Kiran K Khush
- Stanford University Medical Center, Palo Alto, CA, USA
| | - Thomas J Wang
- University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390, USA
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Abderahmene A, Ellouz A, Amor D, Ajmi M, Khalij Y, Hamdouni H, Sahtout W, Azzabi A, Omezzine A, Achour A, Bouslama A. The pharmacogenetics of mycophenolate mofetil in Tunisian renal transplant patients. Per Med 2022; 19:383-393. [PMID: 35770851 DOI: 10.2217/pme-2021-0092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Aim: The effects of variants in IMPDH, UGT1A9, UGT1A8, UGT2B7 and SLCO1B1 genes on the efficacy and safety of mycophenolate mofetil (MMF) in the Tunisian population were investigated. Materials & methods: A total of 245 kidney transplant patients being treated with MMF were recruited and cotreated with cyclosporine or tacrolimus. Genotyping was performed using the polymerase chain reaction-restriction fragment length polymorphism method. MMF, cyclosporine and tacrolimus trough levels were measured by immunoassay. The AUC (AUC0-12hMPA) was estimated by a Bayesian method. Results: In the tacrolimus-treated group, anemia and diarrhea were associated with the UGT1A9-98C and UGT1A9-275T alleles, respectively (p < 0.05). In the cyclosporine-treated group, leukopenia was associated with the SLCO1B1-521T allele (p < 0.05). Both groups had an increased risk of rejection (p < 0.05) associated with the variant alleles of IMPDH2-3757T>C, UGT1A9-2152C>T and UGT1A9-275C>A and the common allele of SLCO1B1-388A>G. However, no significant association was found between the studied genotypes and AUC0-12hMPA or cotreatment levels. Conclusion: The results constitute preliminary evidence for the inclusion of the pharmacogenetics of MMF in kidney pretransplantation evaluations.
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Affiliation(s)
- Amani Abderahmene
- Biochemistry Department, LR12SP11, Sahloul University Hospital, Street Route Ceinture Sahloul, 4054, Sousse, Tunisia.,University of Monastir, Faculty of Pharmacy of Monastir, Street Ibn Sina, 5000, Monastir, Tunisia
| | - Amel Ellouz
- Biochemistry Department, LR12SP11, Sahloul University Hospital, Street Route Ceinture Sahloul, 4054, Sousse, Tunisia.,University of Monastir, Faculty of Pharmacy of Monastir, Street Ibn Sina, 5000, Monastir, Tunisia
| | - Dorra Amor
- Biochemistry Department, LR12SP11, Sahloul University Hospital, Street Route Ceinture Sahloul, 4054, Sousse, Tunisia.,University of Monastir, Faculty of Pharmacy of Monastir, Street Ibn Sina, 5000, Monastir, Tunisia
| | - Marwa Ajmi
- Biochemistry Department, LR12SP11, Sahloul University Hospital, Street Route Ceinture Sahloul, 4054, Sousse, Tunisia.,University of Monastir, Higher Institute of Biotechnology of Monastir, Street Taher Hadded, 5000, Monastir, Tunisia
| | - Yassine Khalij
- Biochemistry Department, LR12SP11, Sahloul University Hospital, Street Route Ceinture Sahloul, 4054, Sousse, Tunisia.,University of Monastir, Faculty of Pharmacy of Monastir, Street Ibn Sina, 5000, Monastir, Tunisia
| | - Haithem Hamdouni
- Biochemistry Department, LR12SP11, Sahloul University Hospital, Street Route Ceinture Sahloul, 4054, Sousse, Tunisia.,University of Monastir, Faculty of Pharmacy of Monastir, Street Ibn Sina, 5000, Monastir, Tunisia
| | - Wissal Sahtout
- Nephrology Department, Sahloul University Hospital, Street Route Ceinture Sahloul, 4054, Sousse, Tunisia
| | - Awatef Azzabi
- Nephrology Department, Sahloul University Hospital, Street Route Ceinture Sahloul, 4054, Sousse, Tunisia
| | - Asma Omezzine
- Biochemistry Department, LR12SP11, Sahloul University Hospital, Street Route Ceinture Sahloul, 4054, Sousse, Tunisia.,University of Monastir, Faculty of Pharmacy of Monastir, Street Ibn Sina, 5000, Monastir, Tunisia
| | - Abdellatif Achour
- Nephrology Department, Sahloul University Hospital, Street Route Ceinture Sahloul, 4054, Sousse, Tunisia
| | - Ali Bouslama
- Biochemistry Department, LR12SP11, Sahloul University Hospital, Street Route Ceinture Sahloul, 4054, Sousse, Tunisia.,University of Monastir, Faculty of Pharmacy of Monastir, Street Ibn Sina, 5000, Monastir, Tunisia
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4
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Cremoni M, Cuozzo S, Martinuzzi E, Barbosa S, Ben Hassen N, Massa F, Demonchy E, Durand M, Thaunat O, Esnault V, Le Quintrec M, Caillard S, Glaichenhaus N, Sicard A. Low T Cell Responsiveness in the Early Phase of COVID-19 Associates with Progression to Severe Pneumonia in Kidney Transplant Recipients. Viruses 2022; 14:v14030542. [PMID: 35336949 PMCID: PMC8949290 DOI: 10.3390/v14030542] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 02/27/2022] [Accepted: 03/01/2022] [Indexed: 12/10/2022] Open
Abstract
Kidney transplant (KT) recipients are at increased risk of developing severe forms of COVID-19. Little is known about the immunological mechanisms underlying disease severity in these patients receiving T-cell targeting immunosuppressive drugs. We investigated the relationship between T cell responsiveness at the beginning of the infection and the risk of subsequent progression to respiratory failure. We performed a multicentric prospective study in KT recipients with a positive RT-PCR COVID-19 test and only mild symptoms at inclusion. Blood samples were collected at baseline in a cell culture system containing T cell stimuli. We assessed T cell responsiveness by computing the ratio between the levels of Th1, Th2, Th17 and Treg cytokines produced after polyclonal stimulation and the number of blood lymphocytes. We then used an unsupervised classification approach to stratify patients into low and high T cell responders and a penalized logistic regression to evaluate the association between T cell responsiveness and progression to severe pneumonia. Forty-five patients were included. All patients who progressed to severe pneumonia (24.4%, n = 11) were low T cell responders at baseline (p = 0.01). In multivariate analysis, low T cell responsiveness at baseline was the main risk factor for subsequent progression to severe pneumonia. This study provides novel insights into the mechanisms underlying COVID-19 severity in organ transplant recipients and data of interest to clinicians managing immunosuppressive drugs in these patients.
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Affiliation(s)
- Marion Cremoni
- Department of Nephrology Dialysis and Transplantation, Pasteur 2 Hospital, Nice University Hospital, 06001 Nice, France; (M.C.); (S.C.); (N.B.H.); (V.E.)
- Clinical Research Unit Côte d’Azur (UR2CA), University Côte d’Azur, 06200 Nice, France
| | - Sébastien Cuozzo
- Department of Nephrology Dialysis and Transplantation, Pasteur 2 Hospital, Nice University Hospital, 06001 Nice, France; (M.C.); (S.C.); (N.B.H.); (V.E.)
| | - Emanuela Martinuzzi
- Institute of Molecular and Cellular Pharmacology, University Côte d’Azur, CNRS, 06560 Valbonne, France; (E.M.); (S.B.); (N.G.)
| | - Susana Barbosa
- Clinical Research Unit Côte d’Azur (UR2CA), University Côte d’Azur, 06200 Nice, France
- Institute of Molecular and Cellular Pharmacology, University Côte d’Azur, CNRS, 06560 Valbonne, France; (E.M.); (S.B.); (N.G.)
| | - Nadia Ben Hassen
- Department of Nephrology Dialysis and Transplantation, Pasteur 2 Hospital, Nice University Hospital, 06001 Nice, France; (M.C.); (S.C.); (N.B.H.); (V.E.)
- Clinical Research Unit Côte d’Azur (UR2CA), University Côte d’Azur, 06200 Nice, France
| | - Filippo Massa
- Laboratory of Molecular Physio Medicine, University Côte d’Azur, CNRS, 06107 Nice, France;
| | - Elisa Demonchy
- Infectious Diseases Department, Archet 1 Hospital, Nice University Hospital, 06200 Nice, France;
| | - Matthieu Durand
- Urology Department, Pasteur 2 Hospital, Nice University Hospital, 06001 Nice, France;
| | - Olivier Thaunat
- Department of Transplantation, Nephrology and Clinical Immunology, Edouard Herriot Hospital, Hospices Civils de Lyon, 69003 Lyon, France;
| | - Vincent Esnault
- Department of Nephrology Dialysis and Transplantation, Pasteur 2 Hospital, Nice University Hospital, 06001 Nice, France; (M.C.); (S.C.); (N.B.H.); (V.E.)
| | - Moglie Le Quintrec
- Department of Nephrology, Dialysis and Renal Transplantation, University Hospital of Lapeyronie, 34090 Montpellier, France;
| | - Sophie Caillard
- Department of Nephrology and Transplantation, Strasbourg University Hospital, 67091 Strasbourg, France;
| | - Nicolas Glaichenhaus
- Clinical Research Unit Côte d’Azur (UR2CA), University Côte d’Azur, 06200 Nice, France
- Institute of Molecular and Cellular Pharmacology, University Côte d’Azur, CNRS, 06560 Valbonne, France; (E.M.); (S.B.); (N.G.)
| | - Antoine Sicard
- Department of Nephrology Dialysis and Transplantation, Pasteur 2 Hospital, Nice University Hospital, 06001 Nice, France; (M.C.); (S.C.); (N.B.H.); (V.E.)
- Laboratory of Molecular Physio Medicine, University Côte d’Azur, CNRS, 06107 Nice, France;
- Correspondence: ; Tel.: +33-(0)4-9203-7918
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5
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Job KM, Roberts JK, Enioutina EY, IIIamola SM, Kumar SS, Rashid J, Ward RM, Fukuda T, Sherbotie J, Sherwin CM. Treatment optimization of maintenance immunosuppressive agents in pediatric renal transplant recipients. Expert Opin Drug Metab Toxicol 2021; 17:747-765. [PMID: 34121566 PMCID: PMC10726690 DOI: 10.1080/17425255.2021.1943356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 06/11/2021] [Indexed: 10/21/2022]
Abstract
Introduction: Graft survival in pediatric kidney transplant patients has increased significantly within the last three decades, correlating with the discovery and utilization of new immunosuppressants as well as improvements in patient care. Despite these developments in graft survival for patients, there is still improvement needed, particularly in long-term care in pediatric patients receiving grafts from deceased donor patients. Maintenance immunosuppressive therapies have narrow therapeutic indices and are associated with high inter-individual and intra-individual variability.Areas covered: In this review, we examine the impact of pharmacokinetic variability on renal transplantation and its association with age, genetic polymorphisms, drug-drug interactions, drug-disease interactions, renal insufficiency, route of administration, and branded versus generic drug formulation. Pharmacodynamics are outlined in terms of the mechanism of action for each immunosuppressant, potential adverse effects, and the utility of pharmacodynamic biomarkers.Expert opinion: Acquiring abetter quantitative understanding of immunosuppressant pharmacokinetics and pharmacodynamic components should help clinicians implement treatment regimens to maintain the balance between therapeutic efficacy and drug-related toxicity.
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Affiliation(s)
- Kathleen M Job
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Jessica K Roberts
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Elena Y Enioutina
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Sílvia M IIIamola
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
| | - Shaun S Kumar
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Jahidur Rashid
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Robert M Ward
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
- Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Tsuyoshi Fukuda
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Joseph Sherbotie
- Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Catherine M Sherwin
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
- Department of Pediatrics, Boonshoft School of Medicine, Dayton Children’s Hospital, Wright State University, Dayton, OH, USA
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT, USA
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6
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Abstract
Introduction: Graft-versus-host disease (GVHD) is the most common complication of hematopoietic stem cell transplantation (HSCT); therefore, the prevention of GVHD is important for a successful treatment. Tacrolimus (Tac), a calcineurin inhibitor, has been widely used for the prophylaxis of GVHD in HSCT recipients. Areas covered: This review introduces phase II/III of clinical trials related with Tac's roles in the prevention of GVHD in HSCT. Furthermore, we discuss the normal ranges of Tac concentrations, pharmacogenetics, and drug interactions of Tac, as well as its side effects in adult HSCT recipients. Expert opinion: A series of studies has established the efficacy and safety of Tac alone or in combination with other agents in HSCT. However, successful administration of Tac is complicated by its narrow therapeutic window, inter-patient pharmacokinetic variability, and a spectrum of undesirable side effects. It is necessary to maintain concentrations of Tac within the desired ranges for GVHD prophylaxis. Moreover, various factors contribute to significant variability in Tac pharmacokinetics, including drug interactions and genomic variation.
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Affiliation(s)
- Yuan Gao
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Soochow University , Suzhou , China
| | - Jingjing Ma
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Soochow University , Suzhou , China
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7
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Immunosuppressive drugs and the gastrointestinal tract in renal transplant patients. Transplant Rev (Orlando) 2018; 33:55-63. [PMID: 30473173 DOI: 10.1016/j.trre.2018.11.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 11/07/2018] [Accepted: 11/10/2018] [Indexed: 12/26/2022]
Abstract
Gastrointestinal (GI) discomfort is common after renal transplantation and can be caused by the use of various immunosuppressive drugs. GI symptoms affect the quality of life, lead to an impaired graft survival and an increased mortality. Moreover, diseases and disturbances of the GI tract also affect the pharmacokinetics of immunosuppressive drugs. This review addresses the interaction between immunosuppressive agents and GI disorders. The GI tract is involved in the metabolism of several immunosuppressive drugs. Calcineurin inhibitors, mTor inhibitors, and corticosteroids are subjected to metabolism by the intestinal cytochrome P450 (CYP3A) and by the drug efflux pump ABCB1. Mycophenolate is partly metabolized in the stomach and intestine and undergoes enterohepatic recirculation. Gastrointestinal disturbances can lead to a modified exposure to immunosuppressive drugs. In the first and second part of this review, we focus on the role of the GI tract in the pharmacokinetics of the immunosuppressive drugs and how to adjust immunosuppressive therapy in patients with vomiting, need for tube feeding, delayed gastric emptying, intestinal resection, and diarrhea. In the third part, we review the GI adverse effects of the various immunosuppressive drugs, with special attention for diarrhea and dyspepsia. Finally, we discuss the effects of drugs used for relief of GI complaints on the exposure to immunosuppressive agents.
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8
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Htun YY, Swe HK, Saw TM. CYP3A5*3 Genetic Polymorphism and Tacrolimus Concentration in Myanmar Renal Transplant Patients. Transplant Proc 2018; 50:1034-1040. [PMID: 29731062 DOI: 10.1016/j.transproceed.2018.02.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 02/16/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND Genetic polymorphism is an important factor that influences tacrolimus concentrations and has the potential to predict the optimal dosage of tacrolimus in personalized medicine. Tacrolimus, a drug of narrow therapeutic index, is used in renal transplant recipients as an immunosuppressant agent. It is a substrate of cytochrome P450 3A (CYP3A) and has highly variable pharmacokinetic parameters. OBJECTIVE The aim of this study was to identify the proportion of CYP3A5 gene polymorphism in Myanmar kidney transplant recipients and to determine the impact of CYP3A5 gene polymorphisms on tacrolimus level in CYP3A5 expressors and nonexpressors. METHODS This study included 41 adult Myanmar post-renal transplant patients. Tacrolimus trough blood levels were determined and CYP3A5 genotype analysis was conducted by using polymerase chain reaction amplification of target followed by detection by restriction fragment length polymorphism analysis. RESULTS The CYP3A5 nonexpressors and expressors were detected in 25 (60.97%) and 16 (39.02%) of the 41 renal transplant recipients, respectively. The tacrolimus concentration/dose ratio in the CYP3A5 expressor group was lower than in the CYP3A5 nonexpressor group (1.49 ± 0.69 vs 3.49 ± 3.08 [P = .003] at 1 month; and 1.54 ± 0.9 vs 7.88 ± 8.25 [P = .0001] at 3 months). CONCLUSIONS The findings of the present study revealed that more than one half of the study population were carrying the mutant allele CYP3A5*3(A6986G). CYP3A5 genetic polymorphism is one of the important factors in determining daily requirements for tacrolimus and in adjusting tacrolimus trough concentrations.
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Affiliation(s)
- Y Y Htun
- Department of Pharmacology, University of Medicine, Mandalay, Myanmar.
| | - H K Swe
- Department of Nephrology, University of Medicine, Mandalay, Myanmar
| | - T M Saw
- Department of Pharmacology, University of Medicine, Mandalay, Myanmar
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9
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Sun B, Guo Y, Gao J, Shi W, Fan G, Li X, Qiu J, Qin Y, Liu G. Influence of CYP3A and ABCB1 polymorphisms on cyclosporine concentrations in renal transplant recipients. Pharmacogenomics 2017; 18:1503-1513. [PMID: 28952408 DOI: 10.2217/pgs-2017-0127] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Aim: Cyclosporine is a substrate of CYP3A and ABCB1. This study examined the role of CYP3A and ABCB1 polymorphisms on cyclosporine pharmacokinetics in renal transplant recipients. Patients & methods: CYP3A and ABCB1 SNPs were detected in 521 recipients. The relationships of dose-adjusted concentrations with corresponding genotypes were investigated at the different terms. Results: CYP3A5 rs776746 and CYP3A7 rs10211 genotype affect C0/D at the short-term, medium-term and long-term after transplantation (p < 0.05). CYP3A7 rs2257401 genotype affects C2/D at the medium-term (p < 0.05). CYP3A4 rs4646437, CYP3A5 rs776746 and CYP3A7 rs2257401 genotype affect C2/D at the long-term (p < 0.05). There are no relationships between ABCB1 polymorphism and cyclosporine C/D. Conclusion: CYP3A genetic factors (rs776746, rs4646437, rs2257401 and rs10211) were varied in different stages after transplantation. The role of CYP3A7 in cyclosporine metabolism requires further study.
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Affiliation(s)
- Bo Sun
- Department of Pharmacy, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, P.R. China
| | - Yankun Guo
- Department of Pharmacy, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, P.R. China
| | - Junwei Gao
- Department of Pharmacy, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, P.R. China
| | - Weifeng Shi
- Department of Pharmacy, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, P.R. China
| | - Guorong Fan
- Department of Pharmacy, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, P.R. China
| | - Xiaoyu Li
- Department of Pharmacy, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, P.R. China
| | - Jianxin Qiu
- Department of Renal Transplantation & Urology, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, P.R. China
| | - Yan Qin
- Department of Renal Transplantation & Urology, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, P.R. China
| | - Gaolin Liu
- Department of Pharmacy, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, P.R. China
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10
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Capron A, Haufroid V, Wallemacq P. Intra-cellular immunosuppressive drugs monitoring: A step forward towards better therapeutic efficacy after organ transplantation? Pharmacol Res 2016; 111:610-618. [PMID: 27468645 DOI: 10.1016/j.phrs.2016.07.027] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 07/19/2016] [Accepted: 07/22/2016] [Indexed: 12/15/2022]
Abstract
Immunosuppressive drugs (IS) used in solid organ transplantation are critical dose drugs with high intra- and inter-subject variability. Therefore, IS therapeutic drug monitoring (TDM), mainly as trough levels analysis, is a major support to patient management, mandatory to optimize clinical outcome. Even though transplant patients undoubtedly benefited by this pre-dose (C0) monitoring, the relationship between these C0 concentrations and the incidence of graft rejections remains hardly predictable. Identification and validation of additional biomarkers of efficacy are therefore very much needed. As the main IS effects are mediated through the inhibition of lymphocyte proliferation pathways, direct drug quantification within this target compartment would appear meaningful, providing hopefully more consistent information on drug efficacy. Due to the analytical performances improvement, these intracellular concentrations became accessible for comprehensive studies regarding clinical benefit of intracellular IS TDM after solid organ transplantation. Over the last ten years, number of studies investigated the potential relationship between IS blood and intracellular pharmacokinetics, genetic variability, and clinical efficacy after solid organ transplantation. A recent literature review suggests that calcineurin inhibitors (tacrolimus and cyclosporine) intracellular concentrations appear more closely related to drug efficacy than blood levels. This closer association has however not been described for the m-TOR inhibitors (sirolimus, everolimus) and the antimetabolite (mycophenolic acid). Additional larger and multicenter clinical trials are needed to confirm these observations.
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Affiliation(s)
- A Capron
- Department of Clinical Chemistry, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium; Louvain Center for Toxicology and Applied Pharmacology (LTAP), Institut de Recherche Expérimentale et Clinique (IREC), Université catholique de Louvain, Brussels, Belgium.
| | - V Haufroid
- Department of Clinical Chemistry, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium; Louvain Center for Toxicology and Applied Pharmacology (LTAP), Institut de Recherche Expérimentale et Clinique (IREC), Université catholique de Louvain, Brussels, Belgium
| | - P Wallemacq
- Department of Clinical Chemistry, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium; Louvain Center for Toxicology and Applied Pharmacology (LTAP), Institut de Recherche Expérimentale et Clinique (IREC), Université catholique de Louvain, Brussels, Belgium
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11
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Brooks E, Tett SE, Isbel NM, Staatz CE. Population Pharmacokinetic Modelling and Bayesian Estimation of Tacrolimus Exposure: Is this Clinically Useful for Dosage Prediction Yet? Clin Pharmacokinet 2016; 55:1295-1335. [DOI: 10.1007/s40262-016-0396-1] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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12
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Thervet É. [Applied pharmacogenetic]. Nephrol Ther 2016; 12 Suppl 1:S99-S103. [PMID: 26972091 DOI: 10.1016/j.nephro.2016.02.008] [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: 11/27/2022]
Abstract
Pharmacokinetics is the link between genetic data and the use of treatments. It can be use on several relevant aspects in the clinic, including the treatment selection, efficacy or toxicity prediction and the choice of the dose. Pharmacogenetics has been applied in clinical nephrology since a long time by the genetic prediction of azathiorpine associated myelotoxicity. However, despite an extensive literature describing the links between genetics and metabolism and transport of drugs, genetic tests are little used in clinical practice. One reason for this poor implementation is the current lack of evidence of improved clinical outcomes with pharmacogenetic tests. In addition, with an effective therapeutic drug monitoring, it is possible to correct the effect of genotype on the pharmacokinetic differences, thus reducing the usefulness of the assay based on the genotype. The future of pharmacogenetics will be treatment models in which patient characteristics are combined with data on polymorphisms in multiple genes including pharmacodynamic parameters, drug transporter proteins, and predictors of toxicity.
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Affiliation(s)
- Éric Thervet
- Service de néphrologie, département hypertension artérielle, prévention et prise en charge des maladies rénales et cardiovasculaires, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75015 Paris, France.
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13
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Kravljaca M, Perovic V, Pravica V, Brkovic V, Milinkovic M, Lausevic M, Naumovic R. The importance of MDR1 gene polymorphisms for tacrolimus dosage. Eur J Pharm Sci 2016; 83:109-13. [DOI: 10.1016/j.ejps.2015.12.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Revised: 12/11/2015] [Accepted: 12/14/2015] [Indexed: 10/22/2022]
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14
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van Gelder T, Hesselink DA. Mycophenolate revisited. Transpl Int 2016; 28:508-15. [PMID: 25758949 DOI: 10.1111/tri.12554] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 02/03/2015] [Accepted: 03/06/2015] [Indexed: 12/11/2022]
Abstract
The patent of mycophenolate mofetil (MMF) has expired, and for enteric-coated mycophenolate sodium (EC-MPS), this will happen in 2017. In the twenty years these drugs have been used, they have become extremely popular. In this review, the reasons for the popularity of mycophenolate are discussed, including the benefits compared to azathioprine. MMF and EC-MPS are therapeutically equivalent. Although neither is considered to be a narrow therapeutic index drug, this should not lead to careless switching between the innovator drug and generic formulations, or between one generic formulation and another. The pipeline of new immunosuppressive drugs is dry, and it is very likely that we will be using mycophenolate for many more years to come as a first-line immunosuppressive drug in our transplant population. Whether or not the development of donor-specific anti-HLA antibodies is related to drug exposure (mycophenolic acid concentrations) remains to be investigated.
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Affiliation(s)
- Teun van Gelder
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center, Rotterdam, The Netherlands; Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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15
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Burke MT, Isbel N, Barraclough KA, Jung JW, Wells JW, Staatz CE. Genetics and nonmelanoma skin cancer in kidney transplant recipients. Pharmacogenomics 2016; 16:161-72. [PMID: 25616102 DOI: 10.2217/pgs.14.156] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Kidney transplant recipients (KTRs) have a 65- to 250-fold greater risk than the general population of developing nonmelanoma skin cancer. Immunosuppressive drugs combined with traditional risk factors such as UV radiation exposure are the main modifiable risk factors for skin cancer development in transplant recipients. Genetic variation affecting immunosuppressive drug pharmacokinetics and pharmacodynamics has been associated with other transplant complications and may contribute to differences in skin cancer rates between KTRs. Genetic polymorphisms in genes encoding the prednisolone receptor, GST enzyme, MC1R, MTHFR enzyme and COX-2 enzyme have been shown to increase the risk of nonmelanoma skin cancer in KTRs. Genetic association studies may improve our understanding of how genetic variation affects skin cancer risk and potentially guide immunosuppressive treatment and skin cancer screening in at risk individuals.
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Affiliation(s)
- Michael T Burke
- Department of Nephrology, University of Queensland at the Princess Alexandra Hospital, Brisbane, Australia
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16
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Aouam K, Kolsi A, Kerkeni E, Ben Fredj N, Chaabane A, Monastiri K, Boughattas N. Influence of combined CYP3A4 and CYP3A5 single-nucleotide polymorphisms on tacrolimus exposure in kidney transplant recipients: a study according to the post-transplant phase. Pharmacogenomics 2015; 16:2045-54. [PMID: 26615671 DOI: 10.2217/pgs.15.138] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
AIM The present study investigated in Tunisian renal transplant patients, genetic polymorphisms of CYP3A4 -392A>G and CYP3A5 6986A>G and their influence on tacrolimus (Tac) pharmacokinetics during early and late post-transplant (PT) phases and established customized ranges of Tac doses matching the C0 target levels according to CYP3A4 and CYP3A5 genotype combination and the PT phase. PATIENTS & METHODS We included adult Tunisian patients having received Tac for de novo kidney grafts and undergone a therapeutic drug monitoring of Tac by morning C0 monitoring during early (1 to 90 days) and late (over 90 days) PT phases. The genomic DNA was extracted from peripheral blood mononuclear cells using a salting-out procedure. CYP3A4 promoter (rs2740574; -392A>G) and CYP3A5 (rs776746; 6986A>G) SNP genotyping was analyzed using PCR-RFLP. RESULTS Fifty-two patients were enrolled in the study. During the early PT phase, the CYP3A5 polymorphism but not that of CYP3A4, correlates significantly with Tac dose-normalized C0 (C0/D ratio). During the late PT phase, the effect of CYP3A4 polymorphism becomes significant and that of CYP3A5 becomes nonsignificant on Tac C0/D Tac. The mean daily doses (mg/kg) matching therapeutic C0, regardless of the CYP3A genotypes, were 0.16 ± 0.05 and 0.10 ± 0.05 during early and late PT phase, respectively. Carriers of the CYP3A4*1B allele require higher doses to maintain the C0 in the therapeutic range during the two PT phases. However, patients carrying the CYP3A5*1 require significant higher Tac doses, only during the early phase. CONCLUSION Our data support a critical role of the CYP3A5 6986A>G and CYP3A4 -392A>G polymorphisms on the variation of Tac exposure during the early and the late PT phase, respectively. The establishment of customized Tac doses, according to CYP3A4/CYP3A5 genotype combination and the PT time, may allow preventing graft rejection and improving the safety profile of this drug. Further studies are needed to investigate this issue.
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Affiliation(s)
- Karim Aouam
- Laboratory of Pharmacology, Faculty of Medicine, University of Monastir, Tunisia
| | - Abdessalem Kolsi
- Laboratory of Pharmacology, Faculty of Medicine, University of Monastir, Tunisia
| | - Emna Kerkeni
- Laboratory of Genetics, Faculty of Medicine, University of Monastir, Tunisia
| | - Nadia Ben Fredj
- Laboratory of Pharmacology, Faculty of Medicine, University of Monastir, Tunisia
| | - Amel Chaabane
- Laboratory of Pharmacology, Faculty of Medicine, University of Monastir, Tunisia
| | - Kamel Monastiri
- Laboratory of Genetics, Faculty of Medicine, University of Monastir, Tunisia
| | - Naceur Boughattas
- Laboratory of Pharmacology, Faculty of Medicine, University of Monastir, Tunisia
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Khaled SK, Palmer JM, Herzog J, Stiller T, Tsai NC, Senitzer D, Liu X, Thomas SH, Shayani S, Weitzel J, Forman SJ, Nakamura R. Influence of Absorption, Distribution, Metabolism, and Excretion Genomic Variants on Tacrolimus/Sirolimus Blood Levels and Graft-versus-Host Disease after Allogeneic Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2015; 22:268-276. [PMID: 26325438 DOI: 10.1016/j.bbmt.2015.08.027] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 08/19/2015] [Indexed: 01/23/2023]
Abstract
Allelic variants of genes implicated in drug absorption, distribution, metabolism, and excretion (ADME) determine the pharmacokinetic variability of many medications and are increasingly recognized as important factors determining the success or failure of medical treatments. Both tacrolimus and sirolimus have narrow therapeutic ranges maintained by therapeutic drug monitoring (TDM). Using an ADME panel that covers >99% of the PharmaADME working group core list (188 single nucleotide polymorphism [SNP] and 12 copy number variant [CNV] assays in 36 pharmacogenetically relevant genes), we studied 177 patients who underwent allogeneic hematopoietic cell transplantation (HCT) using tacrolimus/sirolimus-based graft-versus-host disease (GVHD) prophylaxis. We tested for possible associations between ADME variants and tacrolimus/sirolimus drug levels, concentration/dose (C/D) ratio, and clinical endpoints, including acute GVHD. A total of 62 SNP and 6 CNV assays were evaluable after removing the variants, which were homozygous in (nearly) all samples. For sirolimus, rs2032582 (ABCB1) T-carriers versus non-T-carriers were associated with higher blood levels (P = .01), with similar results for C/D ratio. Generalized estimating equation analysis supported these findings. For tacrolimus, rs776746 CYP3A5*3/*3 and CYP3A5*3/*1 were associated with higher blood levels than CYP3A5*1/*1 (P = .002). By multivariable analysis, rs776746 CYP3A5*3/*3 and CYP3A5*3/*1 were independently associated with decreased acute GVHD compared with CYP3A5*1/*1, after adjustment for conditioning, donor type, race/ethnicity, and age. We demonstrated association of specific ADME genetic polymorphisms with blood levels of tacrolimus/sirolimus, and incidence of acute GVHD after HCT, in spite of TDM and dose adjustment. A larger ongoing study will determine whether these associations have clinical utility beyond TDM.
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Affiliation(s)
- Samer K Khaled
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California; Gehr Family Center for Leukemia Research of the Hematologic Malignancies and Stem Cell Transplantation Institute of the City of Hope, Duarte, CA.
| | | | - Josef Herzog
- Division of Clinical Cancer Genetics, City of Hope, Duarte, California
| | - Tracey Stiller
- Division of Biostatistics, City of Hope, Duarte, California
| | - Ni-Chun Tsai
- Division of Biostatistics, City of Hope, Duarte, California
| | - David Senitzer
- Division of Histocompatibility (HLA Laboratory), City of Hope, Duarte, California
| | - Xueli Liu
- Division of Biostatistics, City of Hope, Duarte, California
| | - Sandra H Thomas
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | | | - Jeffrey Weitzel
- Division of Clinical Cancer Genetics, City of Hope, Duarte, California
| | - Stephen J Forman
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Ryotaro Nakamura
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
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18
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CYP3A5*3 and POR*28 genetic variants influence the required dose of tacrolimus in heart transplant recipients. Ther Drug Monit 2015; 36:710-5. [PMID: 24739669 DOI: 10.1097/ftd.0000000000000080] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND After heart transplantation (HTx), the interindividual pharmacokinetic variability of immunosuppressive drugs represents a major therapeutic challenge due to the narrow therapeutic window between over-immunosuppression causing toxicity and under-immunosuppression leading to graft rejection. Although genetic polymorphisms have been shown to influence pharmacokinetics of immunosuppressants, data in the context of HTx are scarce. We thus assessed the role of genetic variation in CYP3A4, CYP3A5, POR, NR1I2, and ABCB1 acting jointly in immunosuppressive drug pathways in tacrolimus (TAC) and ciclosporin (CSA) dose requirement in HTx recipients. METHODS Associations between 7 functional genetic variants and blood dose-adjusted trough (C0) concentrations of TAC and CSA at 1, 3, 6, and 12 months after HTx were evaluated in cohorts of 52 and 45 patients, respectively. RESULTS Compared with CYP3A5 nonexpressors (*3/*3 genotype), CYP3A5 expressors (*1/*3 or *1/*1 genotype) required around 2.2- to 2.6-fold higher daily TAC doses to reach the targeted C0 concentration at all studied time points (P ≤ 0.003). Additionally, the POR*28 variant carriers showed higher dose-adjusted TAC-C0 concentrations at all time points resulting in significant differences at 3 (P = 0.025) and 6 months (P = 0.047) after HTx. No significant associations were observed between the genetic variants and the CSA dose requirement. CONCLUSIONS The CYP3A5*3 variant has a major influence on the required TAC dose in HTx recipients, whereas the POR*28 may additionally contribute to the observed variability. These results support the importance of genetic markers in TAC dose optimization after HTx.
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19
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Cusinato DAC, Lacchini R, Romao EA, Moysés-Neto M, Coelho EB. Relationship of CYP3A5 genotype and ABCB1 diplotype to tacrolimus disposition in Brazilian kidney transplant patients. Br J Clin Pharmacol 2015; 78:364-72. [PMID: 24528196 DOI: 10.1111/bcp.12345] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Accepted: 01/24/2014] [Indexed: 01/19/2023] Open
Abstract
AIMS Tacrolimus (TAC) is one of the most successful immunosuppressive drugs in transplantation. Its pharmacokinetics (PK) and pharmacogenetics (PG) have been extensively studied, with many studies showing the influence of CYP3A5 on TAC metabolism and bioavailability. However, data concerning the functional significance of ABCB1 polymorphisms are uncertain due to inconsistent results. We evaluated the association between ABCB1 diplotypes, CYP3A5 polymorphisms and TAC disposition in a cohort of Brazilian transplant recipients. METHODS Individuals were genotyped for the CYP3A5*3 allele and ABCB1 polymorphisms (2677G>A/T, 1236C>T, 3435C/T) using a TaqMan® PCR technique. Diplotypes were analyzed for correlation with the TAC dose-normalized ratio (Co : dose). RESULTS We genotyped 108 Brazilian kidney recipients for CYP3A5 (11% CYP3A5*1/*1; 31% CYP3A5*1/*3 and 58% CYP3A5*3/*3) and ABCB1 haplotypes (42% CGC/CGC; 41% GCG/TTT and 17% TTT/TTT). Homozygous subjects for the CYP3A5*3 allele or carriers of the ABCB1 TTT/TTT diplotype showed a higher Co : dose ratio compared with wild type subjects [median (interquartile range) 130.2 (97.5-175.4) vs. 71.3 (45.6-109.0), P < 0.0001 and 151.8 (112.1-205.6) vs. 109.6 (58.1-132.9), P = 0.01, respectively]. When stratified for the CYP3A5*3 group, ABCB1 TTT/TTT individuals showed a higher Co : dose ratio compared with non-TTT/TTT individuals [167.8 (130.4-218.0) vs. 119.4 (100.2-166.3), P = 0.04]. Multivariate linear regression analysis showed that the effects of CYP3A5 polymorphisms and ABCB1 diplotypes remained significant after correction for confounding factors. CONCLUSIONS CYP3A5 is the major enzyme responsible for the marked interindividual variability in TAC PK, but it cannot be considered alone when predicting dose adjustment because ABCB1 diplotypes also affect TAC disposition, showing independent and additive effects on the TAC dose-normalized concentration.
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Affiliation(s)
- Diego Alberto C Cusinato
- Department of Pharmacology, Faculty of Medicine of Ribeirão Preto, University of São Paulo, Av. Bandeirantes, 3900, 14049-900, Ribeirão Preto, São Paulo, Brazil
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20
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Ferraresso M, Belingheri M, Turolo S, Ghio L, Tirelli AS, Grillo P, Lepore M, Edefonti A. Long-term effects of ABCB1 and SXR SNPs on the systemic exposure to cyclosporine in pediatric kidney transplant patients. Pharmacogenomics 2013; 14:1605-13. [DOI: 10.2217/pgs.13.148] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Aim: Cyclosporine is characterized by a wide interindividual variability in its pharmacokinetics. The objective of this study was to evaluate the effects of ABCB1 and SXR SNPs on cyclosporine exposure in a group of kidney transplant patients followed up from childhood to adulthood. Patients & methods: Recipients were genotyped for ABCB1 C1236T, G2677T/A and C3435T, and for SXR RS3842689 and A7635G. Dose-adjusted trough levels and weight-adjusted daily doses were compared among patients according to allelic status by a generalized estimation equation approach that allows longitudinal data analyses. Results: A genotype-dependent effect was found in all ABCB1 genotypes and in one of the SXR SNPs. This effect was particularly evident for the TT genotype of the ABCB1 G2677T/A SNP, the TT genotype of the ABCB1 C3435T SNP and for heterozygotes of the deletion of 6 bp in the promoter region of SXR. Conclusion: The presence of specific ABCB1 and SXR SNPs could significantly affect cyclosporine exposure during a kidney transplant patient’s development from childhood to adulthood in a time-dependent fashion. Original submitted 3 May 2013; Revision submitted 25 July 2013
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Affiliation(s)
- Mariano Ferraresso
- Department of Clinical Sciences & Community Health, University of Milan, Milan, Italy
- Division of General & Vascular Surgery, St Joseph Hospital, 20122, Milan, Italy
| | - Mirco Belingheri
- Division of Pediatric Nephology & Kidney Transplantation, Ca’ Granda Foundation, Ospedale Maggiore, IRCCS, Milan, Italy
| | - Stefano Turolo
- Laboratory of Clinical Chemistry & Microbiology, Ca’ Granda Foundation, Ospedale Maggiore, IRCCS, Milan, Italy
| | - Luciana Ghio
- Division of Pediatric Nephology & Kidney Transplantation, Ca’ Granda Foundation, Ospedale Maggiore, IRCCS, Milan, Italy
| | - Amedea Silvia Tirelli
- Laboratory of Clinical Chemistry & Microbiology, Ca’ Granda Foundation, Ospedale Maggiore, IRCCS, Milan, Italy
| | - Paolo Grillo
- Epidemiology Unit, Department of Occupational & Environmental Health, Ca’ Granda Foundation, Ospedale Maggiore, IRCCS, Milan, Italy
| | - Marta Lepore
- Division of Pediatric Nephology & Kidney Transplantation, Ca’ Granda Foundation, Ospedale Maggiore, IRCCS, Milan, Italy
| | - Alberto Edefonti
- Division of Pediatric Nephology & Kidney Transplantation, Ca’ Granda Foundation, Ospedale Maggiore, IRCCS, Milan, Italy
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Polymorphism of genes involved in purine metabolism (XDH, AOX1, MOCOS) in kidney transplant recipients receiving azathioprine. Ther Drug Monit 2013; 34:266-74. [PMID: 22495427 DOI: 10.1097/ftd.0b013e31824aa681] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Xanthine dehydrogenase (XDH), aldehyde oxidase1 (AOX1), and molybdenum cofactor sulfurase (MOCOS) are enzymes involved in purine metabolism. The aim of this study was to investigate single nucleotide polymorphisms (SNPs) in XDH, AOX1, and MOCOS genes in relation to clinical parameters and risk of drug side effects in a cohort of kidney transplant recipients treated with azathioprine (AZA) as a part of standard immunosuppressive regimen. METHODS One hundred fifty-six patients receiving AZA for the first year from the surgery were genotyped for the presence of common SNPs in the coding regions of XDH, AOX1, and MOCOS genes using TaqMan assays. RESULTS AOX1 rs55754655 variant allele carriers received a higher mean AZA dose 3, 6, and 12 months after transplantation (P < 0.05). The patients inheriting rs594445 MOCOS minor allele required significantly lower doses of AZA for efficient treatment compared with wild-type heterozygotes at 3, 6, and 12 months from the transplantation (mean values: 1.39 versus 1.59, 1.38 versus 1.58, and 1.33 versus 1.53 mg·kg·24 h) and displayed lower mean RBC count at the time points evaluated. Multivariate analysis has shown that the effect of MOCOS rs594445 polymorphism is independent of other investigated gene variations and might influence AZA dosage, similarly to TPMT heterozygosity. The authors have not observed an association between any of the studied XDH SNPs and clinical parameters of AZA-treated patients. CONCLUSIONS The results of this study should be regarded as preliminary. However, if the observed association between SNPs: AOX1 rs55754655, MOCOS rs594445, and AZA dose requirements would be positively confirmed in further independent studies, it could be introduced into clinical practice to individualize thiopurine treatment.
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Abstract
Arterial hypertension is prevalent among kidney transplant recipients. The multifactorial pathogenesis involves the interaction of the donor and the recipient's genetic backgrounds with several environmental parameters that may precede or follow the transplant procedure (eg, the nature of the renal disease, the duration of the chronic kidney disease phase and maintenance dialytic therapy, the commonly associated cardiovascular disease with atherosclerosis and arteriosclerosis, the renal mass at implantation, the immunosuppressive regimen used, life of the graft, and de novo medical and surgical complications that may occur after a transplant). Among calcineurin inhibitors, tacrolimus seems to have a better cardiovascular profile. Steroid-free protocols and calcineurin inhibitor-free regimens seem to be associated with better blood pressure control. Posttransplant hypertension is a major amplifier of the chronic kidney disease-cardiovascular disease continuum. Despite the adverse effects of hypertension on graft and patient survival, blood pressure control remains poor because of the high cardiovascular risk profile of the donor-recipient pair. Although the optimal blood pressure level remains unknown, it is recommended to maintain the blood pressure at < 130/80 mm Hg and < 125/75 mm Hg in the absence or presence of proteinuria.
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Affiliation(s)
- Antoine Barbari
- Renal Transplantation Unit, Rafik Hariri University Hospital, Bir Hassan, Beirut-Lebanon.
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23
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NR1I2 Polymorphisms Are Related to Tacrolimus Dose-Adjusted Exposure and BK Viremia in Adult Kidney Transplantation. Transplantation 2012; 94:1025-32. [DOI: 10.1097/tp.0b013e31826c3985] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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The associations of IL-18 serum levels and promoter polymorphism with tacrolimus pharmacokinetics and hepatic allograft dysfunction in Chinese liver transplantation recipients. Gene 2012; 491:251-5. [DOI: 10.1016/j.gene.2011.10.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2011] [Revised: 09/26/2011] [Accepted: 10/01/2011] [Indexed: 01/28/2023]
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Geng F, Jiao Z, Dao YJ, Qiu XY, Ding JJ, Shi XJ, Li ZD, Zhong MK. The association of the UGT1A8, SLCO1B3 and ABCC2/ABCG2 genetic polymorphisms with the pharmacokinetics of mycophenolic acid and its phenolic glucuronide metabolite in Chinese individuals. Clin Chim Acta 2011; 413:683-90. [PMID: 22227166 DOI: 10.1016/j.cca.2011.12.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2011] [Revised: 12/06/2011] [Accepted: 12/06/2011] [Indexed: 01/25/2023]
Abstract
BACKGROUND This study aimed to evaluate the effect of UGT1A8*2, SLCO1B3 T334G, ABCC2 C-24T and ABCG2 C421A polymorphisms on the pharmacokinetics (PKs) of mycophenolic acid (MPA) and its phenolic glucuronide (MPAG) in healthy Chinese volunteers and in stable renal transplant patients. METHODS The data were extracted from comparative bioavailability studies conducted in 42 healthy individuals and 37 renal transplant patients. A complete PK profile was obtained over 48 h for healthy volunteers and over 12h for the transplant patients. The MPA/MPAG plasma concentrations were measured by HPLC. The genotypes were determined using either the Taqman probe technique or direct sequencing. A multivariate analysis was used to assess the effect of the genotypes (UGT1A8*2, SLCO1B3 T334G, ABCC2 C-24T and ABCG2 C421A) and other covariates (age, weight, height, calculated creatinine clearance, serum albumin, haemoglobin and drug comedication) on the AUC(4-12) and AUC(0-12) for MPA and MPAG in the healthy volunteers and patients. RESULTS In the healthy volunteers, the dose-adjusted geometric means (GM) of the MPA AUC(4-12) in individuals with the SLCO1B3 334T allele were 30.4% lower than those values in the 334G homozygote carriers (P<0.05); in the transplant patients, the steroid dose was associated with a negative effect on the AUC of MPAG (P<0.03) and weight was associated with a negative effect on the AUC for MPA in the healthy volunteers and patients (P<0.03). No other significant effect of genotype or of the other studied variables on AUC(4-12) or AUC(0-12) of MPA/MPAG was found in the healthy volunteers or patients. CONCLUSIONS The PKs of MPA is affected by the SLCO1B3 polymorphism in healthy Chinese individuals. The absence of an effect of SLCO1B3 polymorphisms in transplant patients may be due to the co-administration of cyclosporine (CsA). Concomitant steroid dose and weight are two important covariates of the AUC of MPA and MPAG, which should be taken into account in clinical use. Further confirmatory in vivo studies are needed.
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Affiliation(s)
- Fang Geng
- Clinical Pharmacy Laboratory, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
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26
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Elie V, de Beaumais T, Fakhoury M, Jacqz-Aigrain E. Pharmacogenetics and individualized therapy in children: immunosuppressants, antidepressants, anticancer and anti-inflammatory drugs. Pharmacogenomics 2011; 12:827-43. [PMID: 21692614 DOI: 10.2217/pgs.11.19] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Pharmacogenetic polymorphisms that change the amino acid sequences in coding regions only account for part of the interindividual differences in disease susceptibility and drug response. Additional pharmacogenomic and epigenetic factors are also involved. In children, pharmacogenetic studies are limited, although it has been clear for many years that the interactions between developmental patterns of drug-metabolizing enzymes and transporters have a major impact on dose exposure with age-specific dosage requirements. This article will analyze the factors affecting variability in drug response in children and focus on the pharmacogenetic polymorphisms of immunosuppressants, antidepressants, anticancer and anti-inflammatory drugs. Additional pharmacogenetic and epigenetic studies should be performed to allow the individualization of therapy in children.
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Affiliation(s)
- Valery Elie
- Department of Paediatric Pharmacology & Pharmacogenetics, Assistance Publique Hopitaux de Paris, Clinical Investigation Center APHP-Inserm CIC9202, University Paris VII Diderot, Hopital Robert Debré, 48 Boulevard Serurier, 75019 Paris, France
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Yu X, Xie H, Wei B, Zhang M, Wang W, Wu J, Yan S, Zheng S, Zhou L. Association of MDR1 gene SNPs and haplotypes with the tacrolimus dose requirements in Han Chinese liver transplant recipients. PLoS One 2011; 6:e25933. [PMID: 22110582 PMCID: PMC3215699 DOI: 10.1371/journal.pone.0025933] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2011] [Accepted: 09/13/2011] [Indexed: 12/28/2022] Open
Abstract
Background This work seeks to evaluate the association between the C/D ratios (plasma concentration of tacrolimus divided by daily dose of tacrolimus per body weight) of tacrolimus and the haplotypes of MDR1 gene combined by C1236T (rs1128503), G2677A/T (rs2032582) and C3435T (rs1045642), and to further determine the functional significance of haplotypes in the clinical pharmacokinetics of oral tacrolimus in Han Chinese liver transplant recipients. Methodology/Principal Findings The tacrolimus blood concentrations were continuously recorded for one month after initial administration, and the peripheral blood DNA from a total of 62 liver transplant recipients was extracted. Genotyping of C1236T, G2677A/T and C3435T was performed, and SNP frequency, Hardy-Weinberg equilibrium, linkage disequilibrium, haplotypes analysis and multiple testing were achieved by software PLINK. C/D ratios of different SNP groups or haplotype groups were compared, with a p value<0.05 considered statistically significant. Linkage studies revealed that C1236T, G2677A/T and C3435T are genetically associated with each other. Patients carrying T-T haplotype combined by C1236T and G2677A/T, and an additional T/T homozygote at either position would require higher dose of tacrolimus. Tacrolimus C/D ratios of liver transplant recipients varied significantly among different haplotype groups of MDR1 gene. Conclusions Our studies suggest that the genetic polymorphism could be used as a valuable molecular marker for the prediction of tacrolimus C/D ratios of liver transplant recipients.
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Affiliation(s)
- Xiaobo Yu
- Key Lab of Combined Multi-Organ Transplantation, The First Affiliated Hospital, School of Medicine, Zhejiang University, Ministry of Public Health, Hangzhou, Zhejiang, China
| | - Haiyang Xie
- Key Lab of Combined Multi-Organ Transplantation, The First Affiliated Hospital, School of Medicine, Zhejiang University, Ministry of Public Health, Hangzhou, Zhejiang, China
| | - Bajin Wei
- Key Lab of Combined Multi-Organ Transplantation, The First Affiliated Hospital, School of Medicine, Zhejiang University, Ministry of Public Health, Hangzhou, Zhejiang, China
| | - Min Zhang
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Weilin Wang
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Jian Wu
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Sheng Yan
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Shusen Zheng
- Key Lab of Combined Multi-Organ Transplantation, The First Affiliated Hospital, School of Medicine, Zhejiang University, Ministry of Public Health, Hangzhou, Zhejiang, China
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
- * E-mail: (SZ); (LZ)
| | - Lin Zhou
- Key Lab of Combined Multi-Organ Transplantation, The First Affiliated Hospital, School of Medicine, Zhejiang University, Ministry of Public Health, Hangzhou, Zhejiang, China
- * E-mail: (SZ); (LZ)
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Glowacki F, Lionet A, Hammelin JP, Labalette M, Provôt F, Hazzan M, Broly F, Noël C, Cauffiez C. Influence of cytochrome P450 3A5 (CYP3A5) genetic polymorphism on the pharmacokinetics of the prolonged-release, once-daily formulation of tacrolimus in stable renal transplant recipients. Clin Pharmacokinet 2011; 50:451-9. [PMID: 21528942 DOI: 10.2165/11587050-000000000-00000] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND AND OBJECTIVE Tacrolimus is metabolized by cytochrome P450 (CYP) 3A5. The objective of this study was to investigate the influence of the genetic polymorphism of CYP3A5 on the pharmacokinetics of a new modified-release, once-daily formulation of tacrolimus (Advagraf®) after a switch from the immediate-release formulation (Prograf®). PATIENTS AND METHODS This was a prospective, single-centre, open-label study in stable kidney transplant recipients. Seventeen 'expressor' patients (CYP3A5*1/*3 or *1/*1) were matched to 15 'non-expressor' patients (CYP3A5*3/*3). Exposure variables (concentrations and area under the blood concentration-time curve from 0 to 24 hours [AUC(24)]) were obtained before and 15 days after the switch. Delay since grafting was similar for both groups of patients (expressors: 49 ± 24 months; non-expressors: 45 ± 22 months). RESULTS During administration of tacrolimus as Prograf® or Advagraf®, the mean tacrolimus daily dose was significantly higher and the dose-adjusted AUC(24) was significantly lower in the expressor group. Following the switch to Advagraf®, there was a significant decrease in the dose-adjusted AUC(24) for both non-expressor (5910 ± 3019 vs 5334 ± 2668 ng·h/mL per mg/kg/day; p = 0.041) and expressor patients (3701 ± 1409 vs 3273 ± 1372 ng·h/mL per mg/kg/day; p = 0.03). In the non-expressor group, mean blood trough concentration (C(0)) was comparable for both formulations while it decreased significantly in the expressor group after the switch (8.2 ± 2.2 vs 6.3 ± 2.5 ng/mL; p = 0.02). However, a good correlation between AUC(24) and C(0) was observed for both Advagraf® and Prograf® regardless of CYP3A5 genotype. CONCLUSION Tacrolimus exposure significantly decreases after a switch from Prograf® to Advagraf®, on a milligram-for-milligram basis, in CYP3A5 expressor recipients. Consequently, these patients should be carefully monitored.
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Affiliation(s)
- François Glowacki
- Equipe d'Accueil 4483, Faculté de Médecine, Pôle Recherche, Lille, France
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Ferraresso M, Turolo S, Ghio L, Tirelli AS, Belingheri M, Villa R, Groppali E, Edefonti A. Association between CYP3A5 polymorphisms and blood pressure in kidney transplant recipients receiving calcineurin inhibitors. Clin Exp Hypertens 2011; 33:359-65. [PMID: 21851254 DOI: 10.3109/10641963.2011.561896] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Abstract Renal cytochrome P450 3A5 (CYP3A5) has been associated with blood pressure (BP) control in humans. We investigated whether CYP3A5 polymorphisms are associated with post- transplant hypertension in a selected population of kidney recipients receiving calcineurin inhibitors. Ninety-two kidney transplant recipients receiving cyclosporine (CyA) or tacrolimus (Tac) were genotyped for CYP3A5 polymorphisms, and the association between the CYP3A5 alleles (*1,*3) and hypertension on post-operative day (POD) 6 and POD 180 was verified, with multiple regression being used to identify the putative co-variates that may predict the extent and severity of hypertension in transplant recipients at different post-transplant times. The CYP3A5*1 carriers had higher systolic (SBP) and diastolic blood pressure (DBP) in both the immediate and delayed post-transplant period when adjusted for anti-hypertensive medication (POD 6: SBP = 161 ± 23 vs. 140 ± 23 mmHg; DBP = 120 ± 15 vs. 87 ± 14 mmHg, p < 0.05. POD 180: SBP = 136 ± 16 vs. 129 ± 14 mmHg; DBP = 89 ± 15 vs. 80 ± 15 mmHg, p < 0.05). The severity of hypertension between the CYP3A5*1 carriers and noncarriers on POD 6 was documented by the significantly different distribution of hypertension classes, but this was not confirmed on POD 180. The CYP3A5 genotype was the only independent variable affecting mean arterial pressure. The results of this study show that CYP3A5 polymorphisms are associated with the severity and degree of hypertension in kidney transplant recipients receiving calcineurin inhibitors regardless of the time of recording. However, the role of concomitant medications such as steroids with strong CYP3A5 inducing activity, should be taken into account.
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Affiliation(s)
- Mariano Ferraresso
- Department of General Surgery, University of Milan Medical School, Saint Joseph Hospital, Milan, Italy.
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Effects of the CYP3A5*3 variant on cyclosporine exposure and acute rejection rate in renal transplant patients: a meta-analysis. Pharmacogenet Genomics 2011; 20:525-31. [PMID: 20588203 DOI: 10.1097/fpc.0b013e32833ccd56] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Whether the loss-of-function allele CYP3A5*3 variant is associated with significantly impaired metabolism of cyclosporine A (CsA) in transplant patients is still controversial because of the lack of prospective, large-scale clinical studies performed among diversely ethnic populations. OBJECTIVES This meta-analysis was designed to determine whether the CYP3A5*3 variant could affect CsA blood concentrations and the rate of acute rejection in renal transplant recipients. METHODS AND RESULTS All relevant publications were retrieved online from 1966 to March 2010, in which 14 studies were chosen, and 1821 renal transplant patients were enrolled. The results showed that there were significant differences in the CsA dose-adjusted trough concentration (C0) between the CYP3A5*3/*3 and CYP3A5*1/*1 carriers [weighted mean difference (WMD): 10.06 mug/l per mg/kg, 95% confidence interval (CI): 3.12-17.00, P=0.004] and between the non-CYP3A5*1 allele carriers and the CYP3A5*1 allele carriers (WMD: 8.32 mug/l per mg/kg, 95% CI: 3.16-13.49, P=0.002). In addition, a subgroup analysis stratified by ethnicity indicated that a significant difference in CsA dose-adjusted C0 was observed between the non-CYP3A5*1 allele carriers and the CYP3A5*1 allele carriers in Asian patients, but not in Caucasian patients. Moreover, a significant difference in the mean daily dose was observed between the non-CYP3A5*1 allele carriers and the CYP3A5*1 allele carriers (WMD: -0.19 mg/kg, 95% CI: -0.31 to -0.07, P=0.002). However, the meta-analysis suggested that there was little or no association of the CYP3A5*3 variant with the acute rejection rate in renal transplant patients treated with CsA [odds ratio=0.94, 95% CI: 0.57-1.54, P=0.80]. CONCLUSION We concluded that the CYP3A5*3 variant could be associated, to a certain extent, with increased CsA dose-adjusted C0 in blood and reduced mean daily doses, but that this genetic variant allele seemed to have little effect on the acute rejection rate in renal transplant patients taking CsA.
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31
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Developmental pharmacogenetics of immunosuppressants in pediatric organ transplantation. Ther Drug Monit 2011; 32:688-99. [PMID: 21068645 DOI: 10.1097/ftd.0b013e3181f6502d] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Cyclosporine, tacrolimus, sirolimus, and mycophenolate mofetil are the primary immunosuppressants used on pediatric organ transplantation. Therapeutic drug monitoring is used in daily practice, because their clinical use is hampered by a narrow therapeutic index and large variability. Tailoring immunosuppressive therapy to the individual patient to optimize efficacy and minimize toxicity is therefore essential. Because research in pharmacogenetics already identified polymorphisms impacting their pharmacokinetic parameters in adults, developmental pharmacogenetics of immunosuppressants holds promises for optimizing dosage regimens and improving clinical outcome in children. In this review, we focus on the impact of age and pharmacogenetics on these immunosuppressants in children undergoing organ transplantation.
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Niven RW. Toward managing chronic rejection after lung transplant: the fate and effects of inhaled cyclosporine in a complex environment. Adv Drug Deliv Rev 2011; 63:88-109. [PMID: 20950661 DOI: 10.1016/j.addr.2010.10.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2010] [Revised: 09/09/2010] [Accepted: 10/05/2010] [Indexed: 10/19/2022]
Abstract
The fate and effects of inhaled cyclosporine A (CsA) are considered after deposition on the lung surface. Special emphasis is given to a post-lung transplant environment and to the potential effects of the drug on the various cell types it is expected to encounter. The known stability, metabolism, pharmacokinetics and pharmacodynamics of the drug have been reviewed and discussed in the context of the lung microenvironment. Arguments support the contention that the immuno-inhibitory and anti-inflammatory effects of CsA are not restricted to T-cells. It is likely that pharmacologically effective concentrations of CsA can be sustained in the lungs but due to the complexity of uptake and action, the elucidation of effective posology must ultimately rely on clinical evidence.
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Hawwa AF, McElnay JC. Impact of ATP-binding cassette, subfamily B, member 1 pharmacogenetics on tacrolimus-associated nephrotoxicity and dosage requirements in paediatric patients with liver transplant. Expert Opin Drug Saf 2010; 10:9-22. [PMID: 20629603 DOI: 10.1517/14740338.2010.505600] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
IMPORTANCE OF THE FIELD Tacrolimus is the most commonly used immunosuppressive agent following solid-organ transplantation in children. Its clinical use, however, is complicated by side effects (mainly nephrotoxicity), narrow therapeutic index and pharmacokinetic variability which can result in an increased risk of treatment failure or toxicity. Studies examining interindividual differences in the expression of the ABCB1 (ATP-binding cassette, subfamily B, member 1) gene (which encodes the drug transporter, P-gp) and its genetic polymorphisms have attempted to elucidate variations in tacrolimus response and disposition in children. AREAS COVERED IN THIS REVIEW This review explores pharmacogenetic knowledge developed over the last decade regarding the impact of ABCB1 polymorphisms on tacrolimus toxicity and dosage requirements in children. WHAT THE READER WILL GAIN A better understanding of the role of ABCB1 genetic polymorphisms (and corresponding haplotypes) and ABCB1 expression levels in various tissues and organs on tacrolimus outcomes in children with liver transplant. TAKE HOME MESSAGE Pharmacogenetics offers significant potential for optimising tacrolimus use. ABCB1 donor genotypes and ABCB1 expression level in the intestine and leukocytes may be useful in dosage selection. Large prospective studies are, however, required to further explore the potential of genetic testing in identifying children who are at risk of toxicity and to better individualise tacrolimus therapy.
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Affiliation(s)
- Ahmed F Hawwa
- Queen's University Belfast, Medical Biology Centre, School of Pharmacy, Clinical and Practice Research Group, 97 Lisburn Road, Belfast, UK
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Staatz CE, Goodman LK, Tett SE. Effect of CYP3A and ABCB1 single nucleotide polymorphisms on the pharmacokinetics and pharmacodynamics of calcineurin inhibitors: Part II. Clin Pharmacokinet 2010; 49:207-21. [PMID: 20214406 DOI: 10.2165/11317550-000000000-00000] [Citation(s) in RCA: 156] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The calcineurin inhibitors ciclosporin (cyclosporine) and tacrolimus are immunosuppressant drugs used for the prevention of organ rejection following transplantation. Both agents are metabolic substrates for cytochrome P450 (CYP) 3A enzymes - in particular, CYP3A4 and CYP3A5 - and are transported out of cells via P-glycoprotein (ABCB1). Several single nucleotide polymorphisms (SNPs) have been identified in the genes encoding for CYP3A4, CYP3A5 and P-glycoprotein, including CYP3A4 -392A>G (rs2740574), CYP3A5 6986A>G (rs776746), ABCB1 3435C>T (rs1045642), ABCB1 1236C>T (rs1128503) and ABCB1 2677G>T/A (rs2032582). The aim of this review is to provide the clinician with an extensive overview of the recent literature on the known effects of these SNPs on the pharmacodynamics of ciclosporin and tacrolimus in solid-organ transplant recipients. Literature searches were performed and all relevant primary research articles were critiqued and summarized. There is no evidence that the CYP3A4 -392A>G SNP has an effect on the pharmacodynamics of either ciclosporin or tacrolimus; however, studies have been limited. For patients prescribed ciclosporin, the CYP3A5 6986A>G SNP may influence long-term survival, possibly because of a different metabolite pattern over time. This SNP has no clear association with acute rejection during ciclosporin therapy. Despite a strong association between the CYP3A5 6986A>G SNP and tacrolimus pharmacokinetics, there is no consistent evidence of organ rejection as a result of genotype-related under-immunosuppression. This is likely to be explained by the practice of performing tacrolimus dose adjustments in the early phase after transplantation. The effect of the CYP3A5 6986A>G SNP on ciclosporin- and tacrolimus-related nephrotoxicity and development of hypertension is unclear. Similarly, the ABCB1 SNPs exert no clear influence on either ciclosporin or tacrolimus pharmacodynamics, with studies showing conflicting results in regard to the main parameters of acute rejection and nephrotoxicity. In kidney transplant patients, consideration of the donor kidney genotype rather than the recipient genotype may be more important when assessing development of nephrotoxicity. Studies with low patient numbers may account for many inconsistent results to date. The majority of studies have only evaluated the effects of individual SNPs; however, multiple polymorphisms may interact to produce a combined effect. Further haplotype analyses are likely to be useful, particularly ones that consider both donor and recipient genotype. The effects of polymorphisms associated with the pregnane X receptor, organic anion transporting polypeptides, calcineurin inhibitor target sites and immune response pathways need to be further investigated. A large standardized clinical trial is now required to evaluate the relationship between the pharmacokinetics and pharmacodynamics of CYP3A5-mediated tacrolimus metabolism, particularly in regard to the outcomes of acute rejection and nephrotoxicity. It is not yet clear whether pharmacogenetic profiling of calcineurin inhibitors will be a useful clinical tool for personalizing immunosuppressant therapy.
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Staatz CE, Goodman LK, Tett SE. Effect of CYP3A and ABCB1 single nucleotide polymorphisms on the pharmacokinetics and pharmacodynamics of calcineurin inhibitors: Part I. Clin Pharmacokinet 2010; 49:141-75. [PMID: 20170205 DOI: 10.2165/11317350-000000000-00000] [Citation(s) in RCA: 264] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The calcineurin inhibitors ciclosporin (cyclosporine) and tacrolimus are immunosuppressant drugs used for the prevention of organ rejection following transplantation. Both agents are metabolic substrates for cytochrome P450 (CYP) 3A enzymes--in particular, CYP3A4 and CYP3A5--and are transported out of cells via P-glycoprotein (ABCB1). Several single nucleotide polymorphisms (SNPs) have been identified in the genes encoding for CYP3A4, CYP3A5 and P-glycoprotein, including CYP3A4 -392A>G (rs2740574), CYP3A5 6986A>G (rs776746), ABCB1 3435C>T (rs1045642), ABCB1 1236C>T (rs1128503) and ABCB1 2677G>T/A (rs2032582). The aim of this review is to provide the clinician with an extensive overview of the recent literature on the known effects of these SNPs on the pharmacokinetics of ciclosporin and tacrolimus in solid-organ transplant recipients. Literature searches were performed, and all relevant primary research articles were critiqued and summarized. Influence of the CYP3A4 -392A>G SNP on the pharmacokinetics of either ciclosporin or tacrolimus appears limited. Variability in CYP3A4 expression due to environmental factors is likely to be more important than patient genotype. Influence of the CYP3A5 6986A>G SNP on the pharmacokinetics of ciclosporin is also uncertain and likely to be small. CYP3A4 may play a more dominant role than CYP3A5 in the metabolism of ciclosporin. The CYP3A5 6986A>G SNP has a well established influence on the pharmacokinetics of tacrolimus. Several studies in kidney, heart and liver transplant recipients have reported an approximate halving of tacrolimus dose-adjusted trough concentrations and doubling of tacrolimus dose requirements in heterozygous or homozygous carriers of a CYP3A5*1 wild-type allele compared with homozygous carriers of a CYP3A5*3 variant allele. Carriers of a CYP3A5*1 allele take a longer time to reach target blood tacrolimus concentrations. Influence of ABCB1 3435C>T, 1236C>T and 2677G>T/A SNPs on the pharmacokinetics of ciclosporin and tacrolimus remains uncertain, with inconsistent results. Genetic linkage between the three variant genotypes suggests that the pharmacokinetic effects are complex and not related to any one ABCB1 SNP. It is likely that these polymorphisms exert a small but combined effect, which is additive to the effects of the CYP3A5 6986A>G SNP. In liver transplant patients, recipient and donor liver genotypes may act together in determining overall drug disposition, hence the importance of assessing both. Studies with low patient numbers may account for many inconsistent results to date. Meta-analyses of the current data should help resolve some discrepancies. The majority of studies have only evaluated the effects of individual SNPs; however, multiple polymorphisms may interact to produce a combined effect. Further haplotype analyses are likely to be useful. It is not yet clear whether pharmacogenetic profiling of calcineurin inhibitors will be a useful clinical tool for personalizing immunosuppressant therapy.
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Affiliation(s)
- Christine E Staatz
- School of Pharmacy, University of Queensland, Brisbane, Queensland, Australia.
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[Nephrotoxicity of calcineurin inhibitors: presentation, diagnostic problems and risk factors]. Nephrol Ther 2010; 5 Suppl 6:S365-70. [PMID: 20129447 DOI: 10.1016/s1769-7255(09)73427-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Nephrotoxicity of calcineurin inhibitors (CNIs) is an acute, reversible and chronic, irreversible pathology. Histologically, acute nephrotoxicity manifests as hemodynamic modifications caused by vasoconstriction of the essentially afferent arterioles resulting in a drop in the glomerular filtration rate. Chronic nephrotoxicity is characterized by arteriolar hyalinosis resulting in a variety of tubulointerstitial and glomerular lesions with an essentially ischemic mechanism. However, these histological lesions, whether chronic or acute, are not specific of CNI toxicity and can be seen in the course of many pathological circumstances in kidney transplantation. This absence of specificity makes the histological diagnosis of CNI nephrotoxicity difficult. In addition, the individual risk of developing CNI nephrotoxicity, difficult to predict based solely on the pharmacokinetic parameters of systemic CNI exposure, also involves local exposure (CNI concentrations in the graft) modulated by several, notably pharmacogenetic factors. The difficulty of diagnosing CNI nephrotoxicity and the interindividual variability of its risk require development of new diagnostic tools so that the patients at highest risk of developing severe CNI nephrotoxicity lesions, in whom minimization protocols would produce the best risk-benefit ratio, can be identified.
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New insights into the pharmacokinetics and pharmacodynamics of the calcineurin inhibitors and mycophenolic acid: possible consequences for therapeutic drug monitoring in solid organ transplantation. Ther Drug Monit 2010; 31:416-35. [PMID: 19536049 DOI: 10.1097/ftd.0b013e3181aa36cd] [Citation(s) in RCA: 116] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Although therapeutic drug monitoring (TDM) of immunosuppressive drugs has been an integral part of routine clinical practice in solid organ transplantation for many years, ongoing research in the field of immunosuppressive drug metabolism, pharmacokinetics, pharmacogenetics, pharmacodynamics, and clinical TDM keeps yielding new insights that might have future clinical implications. In this review, the authors will highlight some of these new insights for the calcineurin inhibitors (CNIs) cyclosporine and tacrolimus and the antimetabolite mycophenolic acid (MPA) and will discuss the possible consequences. For CNIs, important relevant lessons for TDM can be learned from the results of 2 recently published large CNI minimization trials. Furthermore, because acute rejection and drug-related adverse events do occur despite routine application of CNI TDM, alternative approaches to better predict the dose-concentration-response relationship in the individual patient are being explored. Monitoring of CNI concentrations in lymphocytes and other tissues, determination of CNI metabolites, and CNI pharmacogenetics and pharmacodynamics are in their infancy but have the potential to become useful additions to conventional CNI TDM. Although MPA is usually administered at a fixed dose, there is a rationale for MPA TDM, and this is substantiated by the increasing knowledge of the many nongenetic and genetic factors contributing to the interindividual and intraindividual variability in MPA pharmacokinetics. However, recent, large, randomized clinical trials investigating the clinical utility of MPA TDM have reported conflicting data. Therefore, alternative pharmacokinetic (ie, MPA free fraction and metabolites) and pharmacodynamic approaches to better predict drug efficacy and toxicity are being explored. Finally, for MPA and tacrolimus, novel formulations have become available. For MPA, the differences in pharmacokinetic behavior between the old and the novel formulation will have implications for TDM, whereas for tacrolimus, this probably will not to be the case.
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Análisis farmacogenético de la cinética de absorción de ciclosporina en una población española de pacientes trasplantados cardíacos. FARMACIA HOSPITALARIA 2009. [DOI: 10.1016/s1130-6343(09)72975-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Population pharmacokinetics and pharmacogenetics of tacrolimus in de novo pediatric kidney transplant recipients. Clin Pharmacol Ther 2009; 86:609-18. [PMID: 19865079 DOI: 10.1038/clpt.2009.210] [Citation(s) in RCA: 135] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The aim of this study was to develop a population pharmacokinetic model of tacrolimus in pediatric kidney transplant patients, identify factors that explain variability, and determine dosage regimens. Pharmacokinetic samples were collected from 50 de novo pediatric kidney transplant patients (age 2-18 years) who were on tacrolimus treatment. Population pharmacokinetic analysis of tacrolimus was performed using NONMEM, and the impact of variables (demographic and clinical factors, and CYP3A4-A5, ABCB1, and ABCC2 polymorphisms) was tested. The pharmacokinetic data were described by a two-compartment model that incorporated first-order absorption and lag time. The apparent oral clearance (CL/F) was significantly related to body weight (allometric scaling); in addition, it was higher in patients with low hematocrit levels and lower in patients with CYP3A5*3/*3. The population pharmacokinetic-pharmacogenetic model developed in de novo pediatric kidney transplant patients demonstrated that, in children, tacrolimus dosage should be based on weight, hematocrit levels, and CYP3A5 polymorphism. Individualization of therapy will enable the optimization of tacrolimus exposure, with resultant beneficial effects on kidney function in the initial post-transplantation period.
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Clinical Impact of Polymorphisms of Transport Proteins and Enzymes Involved in the Metabolism of Immunosuppressive Drugs. Transplant Proc 2009; 41:1441-55. [DOI: 10.1016/j.transproceed.2009.03.024] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Girnita DM, Burckart G, Zeevi A. Effect of cytokine and pharmacogenomic genetic polymorphisms in transplantation. Curr Opin Immunol 2008; 20:614-25. [PMID: 18706500 PMCID: PMC2739872 DOI: 10.1016/j.coi.2008.08.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2008] [Revised: 08/01/2008] [Accepted: 08/04/2008] [Indexed: 12/13/2022]
Abstract
Consolidating the information that we have on pharmacogenetics and on cytokine genetics to produce patient-oriented individualized drug regimens is an important challenge in transplantation medicine. Using a multi-variant approach based on genetic profile and other relevant clinical factors a score system may be developed to predict the severity of rejection, infection, or other complications associated with transplantation. The ultimate goal of these studies is to improve patient outcome through individualized drug regimens.
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Affiliation(s)
- Diana M Girnita
- Department of Pathology, Thomas E Starzl Transplant Institute, University of Pittsburgh, Pittsburgh, PA 15213
| | - Gilbert Burckart
- Office of Clinical Pharmacology, Office of Translational Science, U.S. Food and Drug Administration, Silver Spring, MD 20993
| | - Adriana Zeevi
- Department of Pathology, Thomas E Starzl Transplant Institute, University of Pittsburgh, Pittsburgh, PA 15213
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Hesselink DA, van Schaik RHN, Nauta J, van Gelder T. A drug transporter for all ages? ABCB1 and the developmental pharmacogenetics of cyclosporine. Pharmacogenomics 2008; 9:783-9. [PMID: 18518855 DOI: 10.2217/14622416.9.6.783] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Evaluation of: Fanta S, Niemi M, Jönsson S et al.: Pharmacogenetics of cyclosporine in children suggests an age-dependent influence of ABCB1polymorphisms. Pharmacogenet. Genomics 18(2), 77-90 (2008). The clinical use of the immunosuppressive agent cyclosporine is complicated by its toxicity, narrow therapeutic window and highly variable pharmacokinetics between individuals. In adults, genetic polymorphisms in the genes encoding the cyclosporine-metabolizing enzymes CYP3A4 and CYP3A5, as well as the ABCB1 gene, which encodes the efflux-pump P-glycoprotein, seem to have a limited effect, if any, on cyclosporine pharmacokinetics. However, the authors have now reported for the first time an association between cyclosporine oral bioavailability and the ABCB1 c.1236C>T and c.2677G>T polymorphisms, as well as the related haplotype c.1199G-c.1236C-c.2677G-c.3435C, in children with end-stage renal disease older than 8 years of age. Carriers of the variant alleles had a cyclosporine oral bioavailability that was around 1.5-times higher compared with noncarriers. This association was not observed in children younger than 8 years of age. In addition, no relation between cyclosporine disposition and genetic variation in the CYP3A4, CYP3A5, ABCC2, SLCO1B1 and NR1I2 genes was observed. These data suggest that the effect of ABCB1 polymorphisms on cyclosporine pharmacokinetics is related to age, and thus developmental stage. Although further study is necessary to establish the predictive value of ABCB1 genotyping for individualization of cyclosporine therapy in children older than 8 years, an important step towards further personalized immunosuppressive drug therapy has been made.
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Affiliation(s)
- Dennis A Hesselink
- Erasmus MC, Department of Internal Medicine, Division of Nephrology and Renal Transplantation, PO Box 2040, 3000 CA Rotterdam, The Netherlands.
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