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Alonge M, Coller JK, Reuter SE, Jesudason S, Sallustio BC. Determining Plasma Tacrolimus Concentrations Using High-Performance LC-MS/MS in Renal Transplant Recipients. Ther Drug Monit 2024; 46:49-56. [PMID: 38193880 DOI: 10.1097/ftd.0000000000001135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 06/07/2023] [Indexed: 01/10/2024]
Abstract
BACKGROUND Whole-blood therapeutic drug monitoring of tacrolimus is conducted to maintain tacrolimus concentrations within a safe and effective range. Changes in hematocrit cause variability in blood concentrations of tacrolimus because it is highly bound to erythrocytes. Measuring plasma concentrations may eliminate this variability; however, current methods have limitations owing to the use of cross-reactive immunoassays, plasma separation at nonbiological temperatures, and lack of clinical validation. This study aimed to develop and validate a clinically applicable method to measure plasma tacrolimus concentrations in renal transplant recipients and to examine the concentration differences between genotypic CYP3A5 expressors and nonexpressors. METHODS Plasma tacrolimus concentrations were measured in 9 stable renal transplant recipients who were genotypic CYP3A5 expressors or nonexpressors. Tacrolimus was extracted from plasma using solid-phase extraction, and liquid chromatography-tandem mass spectrometry was used for detection and quantitation. RESULTS This assay was sensitive, selective, and linear between 100 and 5000 ng/L, with intraassay and interassay imprecision and inaccuracy <10% and <5% respectively. The extraction recovery of tacrolimus and ascomycin was 74%. Matrix ion suppression effects were 31.5% and 35% with overall recovery of 50.6% and 48.3% for tacrolimus and ascomycin, respectively. Whole-blood concentrations accounted for approximately 46% of the variation in plasma concentrations in CYP3A5 expressors and nonexpressors. No difference in dose-adjusted whole-blood and plasma concentrations was observed between CYP3A5 expressors and nonexpressors. CONCLUSIONS This assay is clinically applicable with excellent performance and demonstrated that tacrolimus plasma concentrations highly correlated with whole-blood concentrations.
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Affiliation(s)
- Mirabel Alonge
- Department of Clinical Pharmacology, The Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Woodville South, Australia
- Discipline of Pharmacology, School of Biomedicine, The University of Adelaide, Adelaide, Australia
| | - Janet K Coller
- Discipline of Pharmacology, School of Biomedicine, The University of Adelaide, Adelaide, Australia
| | - Stephanie E Reuter
- Clinical and Health Sciences, University of South Australia, Adelaide, Australia; and
| | - Shilpanjali Jesudason
- Central and Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, Australia
| | - Benedetta C Sallustio
- Discipline of Pharmacology, School of Biomedicine, The University of Adelaide, Adelaide, Australia
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Wanas H, Kamel MH, William EA, Fayad T, Abdelfattah ME, Elbadawy HM, Mikhael ES. The impact of CYP3A4 and CYP3A5 genetic variations on tacrolimus treatment of living-donor Egyptian kidney transplanted patients. J Clin Lab Anal 2023; 37:e24969. [PMID: 37789683 PMCID: PMC10681408 DOI: 10.1002/jcla.24969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 08/21/2023] [Accepted: 09/20/2023] [Indexed: 10/05/2023] Open
Abstract
BACKGROUND Tacrolimus (TAC) is the mainstay of immunosuppressive regimen for kidney transplantations. Its clinical use is complex due to high inter-individual variations which can be partially attributed to genetic variations at the metabolizing enzymes CYP3A4 and CYP3A5. Two single nucleotide polymorphisms (SNPs), CYP3A4*22 and CYP3A5*3, have been reported as important causes of differences in pharmacokinetics that can affect efficacy and/or toxicity of TAC. OBJECTIVE Investigating the effect of CYP3A4*22 and CYP3A5*3 SNPs individually and in combination on the TAC concentration in Egyptian renal recipients. METHODS Overall, 72 Egyptian kidney transplant recipients were genotyped for CYP3A4*22 G>A and CYP3A5*3 T>C. According to the functional defect associated with CYP3A variants, patients were clustered into: poor (PM) and non-poor metabolizers (Non-PM). The impact on dose adjusted through TAC concentrations (C0) and daily doses at different time points after transplantation was evaluated. RESULTS Cyp3A4*1/*22 and PM groups require significantly lower dose of TAC (mg/kg) at different time points with significantly higher concentration/dose (C0/D) ratio at day 10 in comparison to Cyp3A4*1/*1 and Non-PM groups respectively. However, CyP3A5*3 heterozygous individuals did not show any significant difference in comparison to CyP3A5*1/*3 individuals. By comparing between PM and Non-PM, the PM group had a significantly lower rate of recipients not reaching target C0 at day 14. CONCLUSION This is the first study on Egyptian population to investigate the impact of CYP3A4*22 and CYP3A5*3 SNPs individually and in combination on the TAC concentration. This study and future multicenter studies can contribute to the individualization of TAC dosing in Egyptian patients.
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Affiliation(s)
- Hanaa Wanas
- Medical Pharmacology DepartmentFaculty of Medicine Cairo UniversityCairoEgypt
- Pharmacology and Toxicology Department, Faculty of PharmacyTaibah UniversityMadinahSaudi Arabia
| | - Mai Hamed Kamel
- Clinical and Chemical Pathology DepartmentFaculty of Medicine Cairo UniversityCairoEgypt
| | - Emad Adel William
- National Research Centre, Medical Research and Clinical Studies InstituteCairoEgypt
| | - Tarek Fayad
- Internal Medicine DepartmentFaculty of Medicine Cairo UniversityCairoEgypt
| | | | | | - Emily Samir Mikhael
- Clinical and Chemical Pathology DepartmentFaculty of Medicine Cairo UniversityCairoEgypt
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3
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Manes A, Di Renzo T, Dodani L, Reale A, Gautiero C, Di Lauro M, Nasti G, Manco F, Muscariello E, Guida B, Tarantino G, Cataldi M. Pharmacomicrobiomics of Classical Immunosuppressant Drugs: A Systematic Review. Biomedicines 2023; 11:2562. [PMID: 37761003 PMCID: PMC10526314 DOI: 10.3390/biomedicines11092562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 09/13/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023] Open
Abstract
The clinical response to classical immunosuppressant drugs (cIMDs) is highly variable among individuals. We performed a systematic review of published evidence supporting the hypothesis that gut microorganisms may contribute to this variability by affecting cIMD pharmacokinetics, efficacy or tolerability. The evidence that these drugs affect the composition of intestinal microbiota was also reviewed. The PubMed and Scopus databases were searched using specific keywords without limits of species (human or animal) or time from publication. One thousand and fifty five published papers were retrieved in the initial database search. After screening, 50 papers were selected to be reviewed. Potential effects on cIMD pharmacokinetics, efficacy or tolerability were observed in 17/20 papers evaluating this issue, in particular with tacrolimus, cyclosporine, mycophenolic acid and corticosteroids, whereas evidence was missing for everolimus and sirolimus. Only one of the papers investigating the effect of cIMDs on the gut microbiota reported negative results while all the others showed significant changes in the relative abundance of specific intestinal bacteria. However, no unique pattern of microbiota modification was observed across the different studies. In conclusion, the available evidence supports the hypothesis that intestinal microbiota could contribute to the variability in the response to some cIMDs, whereas data are still missing for others.
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Affiliation(s)
- Annalaura Manes
- Section of Pharmacology, Department of Neuroscience, Reproductive Sciences and Dentistry, Federico II University of Naples, 80131 Naples, Italy; (A.M.); (L.D.); (F.M.)
| | - Tiziana Di Renzo
- Institute of Food Sciences, National Research Council, 83100 Avellino, Italy; (T.D.R.); (A.R.)
| | - Loreta Dodani
- Section of Pharmacology, Department of Neuroscience, Reproductive Sciences and Dentistry, Federico II University of Naples, 80131 Naples, Italy; (A.M.); (L.D.); (F.M.)
| | - Anna Reale
- Institute of Food Sciences, National Research Council, 83100 Avellino, Italy; (T.D.R.); (A.R.)
| | - Claudia Gautiero
- Physiology Nutrition Unit, Department of Clinical Medicine and Surgery, Federico II University of Naples, 80131 Naples, Italy; (C.G.); (M.D.L.); (G.N.); (B.G.)
| | - Mariastella Di Lauro
- Physiology Nutrition Unit, Department of Clinical Medicine and Surgery, Federico II University of Naples, 80131 Naples, Italy; (C.G.); (M.D.L.); (G.N.); (B.G.)
| | - Gilda Nasti
- Physiology Nutrition Unit, Department of Clinical Medicine and Surgery, Federico II University of Naples, 80131 Naples, Italy; (C.G.); (M.D.L.); (G.N.); (B.G.)
| | - Federica Manco
- Section of Pharmacology, Department of Neuroscience, Reproductive Sciences and Dentistry, Federico II University of Naples, 80131 Naples, Italy; (A.M.); (L.D.); (F.M.)
| | - Espedita Muscariello
- Nutrition Unit, Department of Prevention, Local Health Authority Napoli 3 Sud, 80059 Naples, Italy;
| | - Bruna Guida
- Physiology Nutrition Unit, Department of Clinical Medicine and Surgery, Federico II University of Naples, 80131 Naples, Italy; (C.G.); (M.D.L.); (G.N.); (B.G.)
| | - Giovanni Tarantino
- Department of Clinical Medicine and Surgery, Federico II University of Naples, 80131 Naples, Italy;
| | - Mauro Cataldi
- Section of Pharmacology, Department of Neuroscience, Reproductive Sciences and Dentistry, Federico II University of Naples, 80131 Naples, Italy; (A.M.); (L.D.); (F.M.)
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Kim JS, Shim S, Yee J, Choi KH, Gwak HS. Effects of CYP3A4*22 polymorphism on trough concentration of tacrolimus in kidney transplantation: a systematic review and meta-analysis. Front Pharmacol 2023; 14:1201083. [PMID: 37564175 PMCID: PMC10409991 DOI: 10.3389/fphar.2023.1201083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 07/18/2023] [Indexed: 08/12/2023] Open
Abstract
Purpose: Tacrolimus (Tac) is a widely used immunosuppressive agent in kidney transplantation. Cytochrome P450 (CYP), especially CYP3A4 enzymes are responsible for the metabolism of drugs. However, the correlation between plasma Tac concentration and CYP3A4*22 gene variants is controversial. This meta-analysis aims to evaluate the association between CYP3A4*22 polymorphism and the dose-adjusted trough concentration (C0/D) of Tac in adult kidney transplant patients. Methods: We conducted a literature review for qualifying studies using the PubMed, Web of Science, and Embase databases until July 2023. For the continuous variables (C0/D and daily dose), mean difference (MD) and corresponding 95% confidence intervals (CIs) were calculated to evaluate the association between the CYP3A4 * 22 and Tac pharmacokinetics. We performed an additional analysis on the relationship of CYP3A5*3 with Tac PKs and analyzed the effects of CYP3A4*22 in CYP3A5 non-expressers. Results: Overall, eight eligible studies with 2,683 renal transplant recipients were included in this meta-analysis. The CYP3A4*22 allele was significantly associated with a higher C0/D (MD 0.57 ng/mL/mg (95% CI: 0.28 to 0.86; p = 0.0001) and lower mean daily dose requirement (MD -2.02 mg/day, 95% CI: -2.55 to -1.50; p < 0.00001). An additional meta-analysis demonstrated that carrying the CYP3A5*3 polymorphism greatly impacted Tac blood concentration. From the result with CYP3A5 non-expressers, CYP3A4*22 showed significant effects on the Tac C0/D and dose requirement even after adjusting the effect of CYP3A5*3. Conclusion: Patients with CYP3A4*22 allele showed significantly higher plasma C0/D of Tac and required lower daily dose to achieve the therapeutic trough level after kidney transplantation. These findings of our meta-analysis may provide further evidence for the effects of genetic polymorphism in CYP3A4 on the PKs of Tac, which will improve individualized treatment in a clinical setting.
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Affiliation(s)
- Jung Sun Kim
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, Republic of Korea
| | - Sunyoung Shim
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, Republic of Korea
| | - Jeong Yee
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, Republic of Korea
| | - Kyung Hee Choi
- College of Pharmacy, Gachon University, Incheon, Republic of Korea
| | - Hye Sun Gwak
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, Republic of Korea
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Pharmacodynamic Monitoring of Ciclosporin and Tacrolimus: Insights From Nuclear Factor of Activated T-Cell-Regulated Gene Expression in Healthy Volunteers. Ther Drug Monit 2023; 45:87-94. [PMID: 36191295 DOI: 10.1097/ftd.0000000000001046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 07/26/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Although therapeutic drug monitoring of calcineurin inhibitor (CNI) concentrations is performed routinely in clinical practice, an identical concentration may lead to different effects in different patients. Although the quantification of nuclear factor of activated T-cell-regulated gene expression (NFAT-RGE) is a promising method for measuring individual CNI effects, CNI pharmacodynamics are as of yet incompletely understood. METHODS CNI concentrations and NFAT-RGEs were quantified in 24 healthy volunteers receiving either ciclosporin or tacrolimus in 2 clinical trials. NFAT-RGE was measured using quantitative reverse transcription polymerase chain reaction tests of whole-blood samples. Pharmacokinetics and pharmacodynamics were analyzed using compartmental modeling and simulation. In addition, NFAT-RGE data from renal transplant patients were analyzed. RESULTS The average NFAT-RGE during a dose interval was reduced to approximately 50% with ciclosporin, considering circadian changes. The different effect-time course with ciclosporin and tacrolimus could be explained by differences in potency (IC 50 204 ± 41 versus 15.1 ± 3.2 mcg/L, P < 0.001) and pharmacokinetics. Residual NFAT-RGE at the time of maximum concentration (RGE tmax ) of 15% when using ciclosporin and of 30% when using tacrolimus was associated with similar average NFAT-RGEs during a dose interval. Renal transplant patients had similar but slightly stronger effects compared with healthy volunteers. CONCLUSIONS Ciclosporin and tacrolimus led to similar average suppression of NFAT-RGE in a dose interval, despite considerably different RGE tmax . Pharmacodynamic monitoring of average NFAT-RGE should be considered. When using NFAT-RGE at specific time points, the different effect-time courses and circadian changes of NFAT-RGEs should be considered.
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Catić‐Đorđević A, Stefanović N, Pavlović I, Pavlović D, Živanović S, Kundalić A, Veličković‐Radovanović R, Mitić B. Utility of salivary mycophenolic acid concentration monitoring: Modeling and Monte Carlo validation approach. Pharmacol Res Perspect 2022; 10:e01034. [PMID: 36440680 PMCID: PMC9703583 DOI: 10.1002/prp2.1034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 10/20/2022] [Accepted: 11/06/2022] [Indexed: 11/29/2022] Open
Abstract
The results of the previous studies demonstrated an association between mycophenolic acid (MPA) exposure, serum albumin level (ALB), and adverse effects in kidney transplant patients. The aim was the identification of mathematical correlation and association between both, total and unbound MPA concentration in relation to ALB, body mass (BM), age and estimated glomerular filtration rate (eGFR) in stable kidney transplant recipients. Furthermore, investigation was conducted with the aim to clarify the role of salivary concentration (CSAL ) of MPA in adverse effect profile. In order to analyze the association between total and salivary concentration of MPA in relation to ALB, BM, age and eGFR, a least squares method for determining the correlation between these parameters was performed. In addition, derived mathematical model based on experimental data can also be performed and simulated through the Monte Carlo (MC) approach. Adverse effects were grouped according to the nature of symptoms and scored by a previously published validated system. Numerically calculated values of CSAL from the models [CSAL = f(ALB, BM, age, eGFR, CP ) = a00 + a10 *(ALB, BM, age, eGFR) + a01 *CP ] were then compared with those from validation set of patients, where the best fitting model was for ALB [CSAL = 54.96-1.64*ALB +13.4*CP ]. Adverse effects estimation showed the difference in esthetic score, positively correlated with CSAL in the lower ALB group (145.41 ± 219.02 vs. 354.08 ± 262.19; with statistical significance p = .014) and almost significant for gastrointestinal score (167.69 ± 174.79 vs. 347.55 ± 320.95; p = .247). The study showed that CSAL MPA may contribute to management of adverse effects, but these findings require confirmation of clinical utility.
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Affiliation(s)
| | - Nikola Stefanović
- Faculty of Medicine, Department of PharmacyUniversity of NisNisSerbia
| | - Ivan Pavlović
- Faculty of Mechanical EngineeringUniversity of NisNisSerbia
| | - Dragana Pavlović
- Faculty of Medicine, Department of PharmacyUniversity of NisNisSerbia
| | - Slavoljub Živanović
- Faculty of Medicine, Research Center for BiomedicineUniversity of NisNisSerbia
| | - Ana Kundalić
- Faculty of Medicine, Department of PharmacyUniversity of NisNisSerbia
| | | | - Branka Mitić
- Faculty of MedicineUniversity of NisNisSerbia
- Clinic of NephrologyUniversity Clinical Center NisNisSerbia
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Cai XJ, Li RD, Li JH, Tao YF, Zhang QB, Shen CH, Zhang XF, Wang ZX, Jiao Z. Prospective population pharmacokinetic study of tacrolimus in adult recipients early after liver transplantation: A comparison of Michaelis-Menten and theory-based pharmacokinetic models. Front Pharmacol 2022; 13:1031969. [DOI: 10.3389/fphar.2022.1031969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 10/17/2022] [Indexed: 11/11/2022] Open
Abstract
Background and Objective: Tacrolimus, a calcineurin inhibitor widely used as a potent immunosuppressant to prevent graft rejection, exhibits nonlinear kinetics in patients with kidney transplantation and nephrotic syndrome. However, whether nonlinear drug metabolism occurs in adult patients undergoing liver transplantation remains unclear, as do the main underlying mechanisms. Therefore, here we aimed to further confirm the characteristics of nonlinearity through a large sample size, and determine the potential influence of nonlinearity and its possible mechanisms.Methods: In total, 906 trough concentrations from 176 adult patients (150 men/26 women; average age: 50.68 ± 9.71 years, average weight: 64.54 ± 11.85 kg after first liver transplantation) were included in this study. Population pharmacokinetic analysis was performed using NONMEM®. Two modeling strategies, theory-based linear compartmental and nonlinear Michaelis–Menten (MM) models, were evaluated and compared. Potential covariates were screened using a stepwise approach. Bootstrap, prediction-, and simulation-based diagnostics (prediction-corrected visual predictive checks) were performed to determine model stability and predictive performance. Finally, Monte Carlo simulations based on the superior model were conducted to design dosing regimens.Results: Postoperative days (POD), Aspartate aminotransferase (AST), daily tacrolimus dose, triazole antifungal agent (TAF) co-therapy, and recipient CYP3A5*3 genotype constituted the main factors in the theory-based compartmental final model, whereas POD, Total serum bilirubin (TBIL), Haematocrit (HCT), TAF co-therapy, and recipient CYP3A5*3 genotype were important in the nonlinear MM model. The theory-based final model exhibited 234 L h−1 apparent plasma clearance and 11,000 L plasma distribution volume. The maximum dose rate (Vmax) of the nonlinear MM model was 6.62 mg day−1; the average concentration at steady state at half-Vmax (Km) was 6.46 ng ml−1. The nonlinear MM final model was superior to the theory-based final model and used to propose dosing regimens based on simulations.Conclusion: Our findings demonstrate that saturated tacrolimus concentration-dependent binding to erythrocytes and the influence of daily tacrolimus dose on metabolism may partly contribute to nonlinearity. Further investigation is needed is need to explore the causes of nonlinear pharmacokinetic of tacrolimus. The nonlinear MM model can provide reliable support for tacrolimus dosing optimization and adjustment in adult patients undergoing liver transplantation.
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Effect of Sirolimus vs. Everolimus on CMV-Infections after Kidney Transplantation-A Network Meta-Analysis. J Clin Med 2022; 11:jcm11144216. [PMID: 35887977 PMCID: PMC9323040 DOI: 10.3390/jcm11144216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 07/04/2022] [Accepted: 07/06/2022] [Indexed: 11/16/2022] Open
Abstract
(1) Background: Following renal transplantation, infection with cytomegalovirus (CMV) is a common and feared complication. mTOR-inhibitor (mTOR-I) treatment, either alone or in combination with calcineurininhibitors (CNIs), significantly reduces the CMV incidence after organ transplantation. As of now, there is no information on which mTOR-I, sirolimus (SIR) or everolimus (ERL), has a stronger anti-CMV effect. (2) Methods: The current literature was searched for prospective randomized controlled trials in renal transplantation. There were 1164 trials screened, of which 27 could be included (11,655 pts.). We performed a network meta-analysis to analyze the relative risk of different types of mTOR-I treatment on CMV infection 12 months after transplantation compared to CNI treatment. (3) Results: Four different types of mTOR-I treatment were analyzed in network meta-analyses—SIR mono, ERL mono, SIR with CNI, ERL with CNI. The mTOR-I treatment with the strongest anti-CMV effect compared to a regular CNI treatment was ERL in combination with a CNI (relative risk (RR) 0.27, confidence interval (CI) 0.22−0.32, p < 0.0001). The other mTOR-I therapy groups showed a slightly decreased anti-CMV efficacy (SIR monotherapy (mono): RR 0.35, CI 0.22−0.57, p < 0.001; SIR with CNI: RR 0.43, CI 0.29−0.64, p < 0.0001; ERL mono: RR 0.46, CI 0.22−0.93, p = 0.031). (4) Conclusions: The anti-CMV effect of both mTOR-Is (SRL and ERL) is highly effective, irrespective of the combination with other immunosuppressive drugs. Certain differences with respect to the potency against the CMV could be found between SRL and ERL. Data gained from this analysis seem to support that a combination of ERL and CNI has the most potent anti-CMV efficacy.
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Khaleel B, Yousef AM, Al-Zoubi MS, Al-Ulemat M, Masadeh AA, Abuhaliema A, Al-Batayneh KM, Al-Trad B. Impact of Genetic Polymorphisms at the Promoter area of IL-10 Gene on Tacrolimus Level in Jordanian Renal Transplantation Recipients. J Med Biochem 2021; 41:327-334. [PMID: 36042898 PMCID: PMC9375538 DOI: 10.5937/jomb0-33343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 12/12/2021] [Indexed: 11/02/2022] Open
Abstract
Background
Tacrolimus is a widely used immunosuppressant that prevents the solid organ transplant rejection. The pharmacokinetics of Tacrolimus show considerable variability. interleukin-10 (IL-10), in the host’s immune response after transplantation contributes to the variable CYP3A-dependent drug disposition of Tacrolimus. In current study, our aim is to evaluate the impact of single nucleotide polymorphisms (SNP) in the promoter region of of IL-10 on Tacrolimus dose requirements and the Dose Adjusted Concentration (DAC) of Tacrolimus among kidney transplantation recipients.
Methods
Blood levels of Tacrolimus were measured using Micorparticle Enzyme Immunoassay (MEIA) for six months post-transplantation. Genotyping analysis was utilized using specific Polymerase Chain Reaction (PCR) followed by sequencing methods for 98 Jordanian kidney transplant recipients.
Results
Genotyping frequencies of IL-10 (-592) were (CC/CA/AA: 38, 46.7, 15.2%); IL-10 (-819) were (CC/CT/TT: 40.4, 44.1, 15.1%); and IL-10 (-1082) were (AA/AG/GG: 42.6, 44.7, 12.8%). The impact of IL-10 (-1082) on Tacrolimus DAC was gender dependent. Men carrying at least one A allele had significantly lower DAC than men carrying GG genotyping only in the first month post-transplantation [88.2±32.1 vs. 117.5±22.5 ng/ml per mg/kg/day, p=0.04]..
Conclusion
Our current study showed that the interaction between gender and IL-10 -1082 affects Tacrolimus DAC in Jordanian kidney transplantation recipients during the first month post-transplantation.
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Affiliation(s)
- Bara'ah Khaleel
- Yarmouk University, Faculty of Science, Department of Biological Sciences, Irbid, Jordan
| | - Al-Motassem Yousef
- The University of Jordan, School of Pharmacy, Department of Biopharmaceutics and Clinical Pharmacy, Amman, Jordan
| | - Mazhar Salim Al-Zoubi
- Yarmouk University, Faculty of Medicine, Department of Basic Medical Sciences, Irbid, Jordan
| | | | | | - Ali Abuhaliema
- The University of Jordan, School of Pharmacy, Department of Biopharmaceutics and Clinical Pharmacy, Amman, Jordan
| | - Khalid M. Al-Batayneh
- Yarmouk University, Faculty of Science, Department of Biological Sciences, Irbid, Jordan
| | - Bahaa Al-Trad
- Yarmouk University, Faculty of Science, Department of Biological Sciences, Irbid, Jordan
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Zhou H, Xiang H, Cai J, Wang Y, Zhang M, Han Y, Zhang Y. Comparison of a Point-of-Care Testing with Enzyme-Multiplied Immunoassay Technique and Liquid Chromatography Combined With Tandem Mass Spectrometry Methods for Therapeutic Drug Monitoring of Mycophenolic Acid: A Preliminary Study. Ther Drug Monit 2021; 43:630-636. [PMID: 33394991 DOI: 10.1097/ftd.0000000000000861] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 11/29/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND For mycophenolic acid (MPA), therapeutic drug monitoring is an essential tool for dosage optimization in transplant recipients and autoimmune diseases. In China, a new commercial kit using an immunochromatographic assay (FICA) with a point-of-care testing system was approved for therapeutic drug monitoring of MPA. However, corroboration between FICA and clinically used assays remains unknown. The authors evaluated MPA concentrations in heart transplant recipients obtained by FICA, high-performance liquid chromatography combined with tandem mass spectrometry (LC-MS/MS), and enzyme-multiplied immunoassay technique (EMIT). METHODS Nine heart transplant recipients administered a single mycophenolate mofetil (MMF) dose, and 4 administered multiple MMF doses were enrolled. MPA samples were collected before administration, and after 0.5, 1, 1.5, 2, 4, 6, 8, 10, and 12 hours, and assessed by 2 immunoassays (EMIT and FICA) and LC-MS/MS. Consistency between methods was evaluated using Passing-Bablok regression and Bland-Altman analysis. RESULTS For Passing-Bablok regression between FICA and LC-MS/MS, FICA = 0.784 LC-MS/MS + 0.360 (95% CI slope: 0.739 to 0.829, 95% CI intercept: 0.174-0.545). Regardless of a significant observed correlation coefficient (R2 = 0.9126), statistical analyses revealed a significant difference between FICA and the reference LC-MS/MS method. The mean absolute bias was 0.69 mcg/mL between FICA and LC-MS/MS. Bland-Altman plots showed a mean bias of -0.23 mcg/mL (±1.96 SD, -2.19 to 1.72 mcg/mL) and average relative bias of 14.73% (±1.96 SD, -67.91% to 97.37%) between FICA and LC-MS/MS. Unsatisfactory consistency was observed between EMIT and LC-MS/MS, and FICA and EMIT. Differences between pharmacokinetic parameters after a single or 7 days of MMF administration, by LC-MS/MS and FICA, were not statistically significant. CONCLUSIONS The consistency of the new FICA using a point-of-care testing device with LC-MS/MS and EMIT was inadequate, and the accuracy of EMIT and LC-MS/MS was inappropriate. Clinicians should be informed when switching MPA detection methods to avoid misleading results.
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Affiliation(s)
- Hong Zhou
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
- Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan
| | - Hongping Xiang
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
- Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan
| | - Jie Cai
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
| | - Yirong Wang
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
- Department of Pharmacy, the Third People's Hospital of Chengdu, Chengdu; and
| | - Min Zhang
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
- Department of Pharmacy, Chongqing Key Laboratory of Translational Research for Cancer Metastasis and Individualized Treatment, Chongqing University Cancer Hospital and Chongqing Cancer Institute, Chongqing Cancer Hospital, Chongqing, China
| | - Yong Han
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
- Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan
| | - Yu Zhang
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
- Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan
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11
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Al-Kofahi M, Oetting WS, Schladt DP, Remmel RP, Guan W, Wu B, Dorr CR, Mannon RB, Matas AJ, Israni AK, Jacobson PA. Precision Dosing for Tacrolimus Using Genotypes and Clinical Factors in Kidney Transplant Recipients of European Ancestry. J Clin Pharmacol 2021; 61:1035-1044. [PMID: 33512723 DOI: 10.1002/jcph.1823] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 01/26/2021] [Indexed: 12/14/2022]
Abstract
Genetic variation in the CYP3A4 and CYP3A5 (CYP3A4/5) genes, which encode the key enzymes in tacrolimus metabolism, is associated with tacrolimus clearance and dose requirements. Tacrolimus has a narrow therapeutic index with high intra- and intersubject variability, in part because of genetic variation. High tacrolimus clearance and low trough concentration are associated with a greater risk for rejection, whereas high troughs are associated with calcineurin-induced toxicity. The objective of this study was to develop a model of tacrolimus clearance with a dosing equation accounting for genotypes and clinical factors in adult kidney transplant recipients of European ancestry that could preemptively guide dosing. Recipients receiving immediate-release tacrolimus for maintenance immunosuppression from 2 multicenter studies were included. Participants in the GEN03 study were used for tacrolimus model development (n = 608 recipients) and was validated by prediction performance in the DeKAF Genomics study (n = 1361 recipients). Nonlinear mixed-effects modeling was used to develop the apparent oral tacrolimus clearance (CL/F) model. CYP3A4/5 genotypes and clinical covariates were tested for their influence on CL/F. The predictive performance of the model was determined by assessing the bias (median prediction error [ME] and median percentage error [MPE]) and the precision (root median squared error [RMSE]) of the model. CYP3A5*3, CYP3A4*22, corticosteroids, calcium channel blocker and antiviral drug use, age, and diabetes significantly contributed to the interindividual variability of oral tacrolimus apparent clearance. The bias (ME, MPE) and precision (RMSE) of the final model was good, 0.49 ng/mL, 6.5%, and 3.09 ng/mL, respectively. Prospective testing of this equation is warranted.
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Affiliation(s)
- Mahmoud Al-Kofahi
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
| | - William S Oetting
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
| | - David P Schladt
- Hennepin Health Research Institute, Minneapolis, Minnesota, USA
| | - Rory P Remmel
- Department of Medicinal Chemistry, University of Minnesota, Minneapolis, Minnesota, USA
| | - Weihua Guan
- Department of Biostatistics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Baolin Wu
- Department of Biostatistics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Casey R Dorr
- Hennepin Health Research Institute, Minneapolis, Minnesota, USA
- Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA
| | - Roslyn B Mannon
- Division of Nephrology, University of Nebraska, Omaha, Nebraska, USA
| | - Arthur J Matas
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ajay K Israni
- Hennepin Health Research Institute, Minneapolis, Minnesota, USA
- Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA
- Department of Epidemiology & Community Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Pamala A Jacobson
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
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12
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Therapeutic drug monitoring of immunosuppressive drugs in hepatology and gastroenterology. Best Pract Res Clin Gastroenterol 2021; 54-55:101756. [PMID: 34874840 DOI: 10.1016/j.bpg.2021.101756] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 06/11/2021] [Indexed: 01/31/2023]
Abstract
Immunosuppressive drugs have been key to the success of liver transplantation and are essential components of the treatment of inflammatory bowel disease (IBD) and autoimmune hepatitis (AIH). For many but not all immunosuppressants, therapeutic drug monitoring (TDM) is recommended to guide therapy. In this article, the rationale and evidence for TDM of tacrolimus, mycophenolic acid, the mammalian target of rapamycin inhibitors, and azathioprine in liver transplantation, IBD, and AIH is reviewed. New developments, including algorithm-based/computer-assisted immunosuppressant dosing, measurement of immunosuppressants in alternative matrices for whole blood, and pharmacodynamic monitoring of these agents is discussed. It is expected that these novel techniques will be incorporate into the standard TDM in the next few years.
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13
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Kindem IA, Bjerre A, Åsberg A, Midtvedt K, Bergan S, Vethe NT. Tacrolimus Measured in Capillary Volumetric Microsamples in Pediatric Patients-A Cross-Validation Study. Ther Drug Monit 2021; 43:371-375. [PMID: 33596033 PMCID: PMC8115734 DOI: 10.1097/ftd.0000000000000873] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 01/16/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Therapeutic drug monitoring of tacrolimus (Tac) is mandatory in solid organ transplant (SOT) recipients. Finger-prick microsampling is more flexible and tolerable during the therapeutic drug monitoring of tacrolimus and has been shown to be applicable in adult SOT recipients. In this study, a previously validated method applying volumetric absorptive microsampling (VAMS) to measure Tac in adults was cross-validated in a pediatric population. METHODS Patients with SOT scheduled for standard posttransplant follow-up visits were recruited. Blood samples were obtained by trained phlebotomists using standard venipuncture and capillary microsampling, before the morning dose of Tac as well as 2 and 5 hours after dosing. Tac concentrations were quantified using liquid chromatography-tandem mass spectrometry. Concordance between Tac concentrations obtained with venipuncture and VAMS was evaluated using Passing-Bablok regression, calculation of absolute and relative differences, and percentage of samples within ±20% and ±30% difference. RESULTS A total of 39 SOT patients aged 4-18 years (22 male) were included. The median (range) predose venous blood concentration was 4.8 (2.6-13.6) mcg/L, with a difference between VAMS and venous blood samples of -0.2 ± 0.7 mcg/L. The relative mean difference was -1.3% [95% confidence interval (CI), -5.9% to 3.4%]. Ninety-two percent and 97% of the sample pairs demonstrated differences within ±20% and ±30%, respectively. Postdose (2 hours and/or 5 hours, n = 17) median concentration in venous blood was 7.9 (4.8-19.2) mcg/L. The difference between VAMS and venous blood samples was 0.1 ± 1.0 mcg/L, with a relative mean difference of -2.5% (95% confidence interval, -8.8% to 3.8%). Eighty-eight percent of the postdose sample pairs were within ±20% difference, and all were within ±30% difference. CONCLUSIONS Tac concentrations can be accurately measured using VAMS technology in pediatric SOT recipients. This makes home-based Tac monitoring feasible in the pediatric population.
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Affiliation(s)
- Ingvild Andrea Kindem
- Departments of Transplantation Medicine and
- Pediatric and Adolescent Medicine, Oslo University Hospital
- Institute of Clinical Medicine, University of Oslo
| | - Anna Bjerre
- Pediatric and Adolescent Medicine, Oslo University Hospital
- Institute of Clinical Medicine, University of Oslo
| | - Anders Åsberg
- Departments of Transplantation Medicine and
- Department of Pharmacy, University of Oslo, Oslo, Norway
| | | | - Stein Bergan
- Department of Pharmacology, Oslo University Hospital; and
- Department of Pharmacy, University of Oslo, Oslo, Norway
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14
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Wilmes D, Coche E, Rodriguez-Villalobos H, Kanaan N. Fungal pneumonia in kidney transplant recipients. Respir Med 2021; 185:106492. [PMID: 34139578 DOI: 10.1016/j.rmed.2021.106492] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 05/26/2021] [Accepted: 05/28/2021] [Indexed: 10/21/2022]
Abstract
Fungal pneumonia is a dreaded complication encountered after kidney transplantation, complicated by increased mortality and often associated with graft failure. Diagnosis can be challenging because the clinical presentation is non-specific and diagnostic tools have limited sensitivity and specificity in kidney transplant recipients and must be interpreted in the context of the clinical setting. Management is difficult due to the increased risk of dissemination and severity, multiple comorbidities, drug interactions and reduced immunosuppression which should be applied as an important adjunct to therapy. This review will focus on the main causes of fungal pneumonia in kidney transplant recipients including Pneumocystis, Aspergillus, Cryptococcus, mucormycetes and Histoplasma. Epidemiology, clinical presentation, laboratory and radiographic features, specific characteristics will be discussed with an update on diagnostic procedures and treatment.
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Affiliation(s)
- D Wilmes
- Division of Internal Medicine, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - E Coche
- Division of Radiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - H Rodriguez-Villalobos
- Division of Microbiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - N Kanaan
- Division of Nephrology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium.
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15
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Tanaka R, Suzuki Y, Watanabe H, Fujioka T, Hirata K, Shin T, Ando T, Ono H, Tatsuta R, Mimata H, Maruyama T, Itoh H. Association of CYP3A5 polymorphisms and parathyroid hormone with blood level of tacrolimus in patients with end-stage renal disease. Clin Transl Sci 2021; 14:2034-2042. [PMID: 34058078 PMCID: PMC8504850 DOI: 10.1111/cts.13065] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/24/2021] [Accepted: 04/02/2021] [Indexed: 12/02/2022] Open
Abstract
Because tacrolimus is predominantly metabolized by CYP3A, the blood concentration/dose (C/D) ratio is affected by CYP3A5 polymorphism. Parathyroid hormone (PTH) expression increases in secondary hyperparathyroidism, which is frequently associated with end‐stage renal disease. Recently, PTH has been shown to downregulate CYP3A expression at mRNA level. In this study, we examined the influence of CYP3A5 polymorphism on and association of serum intact‐PTH (iPTH) level with blood tacrolimus concentration in patients with end‐stage renal disease just before kidney transplantation. Forty‐eight patients who satisfied the selection criteria were analyzed. Subjects were classified into two phenotype subgroups: CYP3A5 expressor (CYP3A5*1/*1 and *1/*3; n = 15) and CYP3A5 nonexpressor (CYP3A5*3/*3; n = 33). The blood tacrolimus C/D (per body weight) ratio was significantly lower in CYP3A5 expressors than that in CYP3A5 nonexpressors. A significant positive correlation was found between tacrolimus C/D and iPTH concentrations (r = 0.305, p = 0.035), and the correlation coefficient was higher after excluding 20 patients co‐administered CYP3A inhibitor or inducer (r = 0.428, p = 0.023). A multiple logistic regression analysis by stepwise selection identified CYP3A5 polymorphism and serum iPTH level as significant factors associated with tacrolimus C/D. These results may suggest the importance of dose design considering not only the CYP3A5 phenotype but also serum iPTH level when using tacrolimus in patients who undergo renal transplantation.
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Affiliation(s)
- Ryota Tanaka
- Department of Clinical Pharmacy, Oita University Hospital, Oita, Japan
| | - Yosuke Suzuki
- Department of Medication Use Analysis and Clinical Research, Meiji Pharmaceutical University, Tokyo, Japan
| | - Hiroshi Watanabe
- Department of Biopharmaceutics, Graduate School of Pharmaceutical Sciences, Kumamoto University, Kumamoto, Japan
| | - Takashi Fujioka
- Laboratory of Medical Pharmaceutics, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan
| | - Kenshiro Hirata
- Department of Clinical Pharmaceutics, Faculty of Pharmaceutical Sciences, Sojo University, Kumamoto, Japan
| | - Toshitaka Shin
- Department of Urology, Faculty of Medicine, Oita University, Oita, Japan
| | - Tadasuke Ando
- Department of Urology, Faculty of Medicine, Oita University, Oita, Japan
| | - Hiroyuki Ono
- Department of Clinical Pharmacy, Oita University Hospital, Oita, Japan
| | - Ryosuke Tatsuta
- Department of Clinical Pharmacy, Oita University Hospital, Oita, Japan
| | - Hiromitsu Mimata
- Department of Urology, Faculty of Medicine, Oita University, Oita, Japan
| | - Toru Maruyama
- Department of Biopharmaceutics, Graduate School of Pharmaceutical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hiroki Itoh
- Department of Clinical Pharmacy, Oita University Hospital, Oita, Japan
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16
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Tacrolimus Area Under the Concentration Versus Time Curve Monitoring, Using Home-Based Volumetric Absorptive Capillary Microsampling. Ther Drug Monit 2021; 42:407-414. [PMID: 31479042 DOI: 10.1097/ftd.0000000000000697] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Therapeutic drug monitoring (TDM) of tacrolimus (Tac) is mandatory in renal transplant recipients (RTxR). Area under the concentration versus time curve (AUC) is the preferred measure for Tac exposure; however, for practical purposes, most centers use trough concentrations as a clinical surrogate. Limited sampling strategies in combination with population pharmacokinetic model-derived Bayesian estimators (popPK-BE) may accurately predict individual AUC. The use of self-collected capillary microsamples could simplify this strategy. This study aimed to investigate the potential of AUC-targeted Tac TDM using capillary microsamples in combination with popPK-BE. METHODS A single-center prospective pharmacokinetic study was conducted in standard-risk RTxR (n = 27) receiving Tac twice daily. Both venous and capillary microsamples (Mitra; Neoteryx, Torrance, CA) were obtained across 2 separate 12-hour Tac dosing intervals (n = 13 samples/AUC). Using popPK-BE, reference AUC (AUCref) was determined for each patient using all venous samples. Different limited sampling strategies were tested for AUC predictions: (1) the empiric sampling scheme; 0, 1, and 3 hours after dose and (2) 3 sampling times determined by the multiple model optimal sampling time function in Pmetrics. Agreement between the predicted AUCs and AUCref were evaluated using C-statistics. Accepted agreement was defined as a total deviation index ≤±15%. RESULTS The AUC from capillary microsamples revealed high accuracy and precision compared with venous AUCref, and 85% of the AUCs had an error within ±11.9%. Applying microsamples at 0, 1, and 3 hours after dose predicted venous AUCref with acceptable agreement. Patients performed self-sampling with acceptable accuracy. CONCLUSIONS Capillary microsampling is patient-centered, making AUC-targeted TDM of Tac feasible without extended hospital stays. Samples obtained 0, 1, and 3 hours after dose, combined with popPK-BE, accurately predict venous Tac AUC.
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17
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Bergan S, Brunet M, Hesselink DA, Johnson-Davis KL, Kunicki PK, Lemaitre F, Marquet P, Molinaro M, Noceti O, Pattanaik S, Pawinski T, Seger C, Shipkova M, Swen JJ, van Gelder T, Venkataramanan R, Wieland E, Woillard JB, Zwart TC, Barten MJ, Budde K, Dieterlen MT, Elens L, Haufroid V, Masuda S, Millan O, Mizuno T, Moes DJAR, Oellerich M, Picard N, Salzmann L, Tönshoff B, van Schaik RHN, Vethe NT, Vinks AA, Wallemacq P, Åsberg A, Langman LJ. Personalized Therapy for Mycophenolate: Consensus Report by the International Association of Therapeutic Drug Monitoring and Clinical Toxicology. Ther Drug Monit 2021; 43:150-200. [PMID: 33711005 DOI: 10.1097/ftd.0000000000000871] [Citation(s) in RCA: 76] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 01/29/2021] [Indexed: 12/13/2022]
Abstract
ABSTRACT When mycophenolic acid (MPA) was originally marketed for immunosuppressive therapy, fixed doses were recommended by the manufacturer. Awareness of the potential for a more personalized dosing has led to development of methods to estimate MPA area under the curve based on the measurement of drug concentrations in only a few samples. This approach is feasible in the clinical routine and has proven successful in terms of correlation with outcome. However, the search for superior correlates has continued, and numerous studies in search of biomarkers that could better predict the perfect dosage for the individual patient have been published. As it was considered timely for an updated and comprehensive presentation of consensus on the status for personalized treatment with MPA, this report was prepared following an initiative from members of the International Association of Therapeutic Drug Monitoring and Clinical Toxicology (IATDMCT). Topics included are the criteria for analytics, methods to estimate exposure including pharmacometrics, the potential influence of pharmacogenetics, development of biomarkers, and the practical aspects of implementation of target concentration intervention. For selected topics with sufficient evidence, such as the application of limited sampling strategies for MPA area under the curve, graded recommendations on target ranges are presented. To provide a comprehensive review, this report also includes updates on the status of potential biomarkers including those which may be promising but with a low level of evidence. In view of the fact that there are very few new immunosuppressive drugs under development for the transplant field, it is likely that MPA will continue to be prescribed on a large scale in the upcoming years. Discontinuation of therapy due to adverse effects is relatively common, increasing the risk for late rejections, which may contribute to graft loss. Therefore, the continued search for innovative methods to better personalize MPA dosage is warranted.
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Affiliation(s)
- Stein Bergan
- Department of Pharmacology, Oslo University Hospital and Department of Pharmacy, University of Oslo, Oslo, Norway
| | - Mercè Brunet
- Pharmacology and Toxicology Laboratory, Biochemistry and Molecular Genetics Department, Biomedical Diagnostic Center, Hospital Clinic of Barcelona, University of Barcelona, IDIBAPS, CIBERehd, Spain
| | - Dennis A Hesselink
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Kamisha L Johnson-Davis
- Department of Pathology, University of Utah Health Sciences Center and ARUP Laboratories, Salt Lake City, Utah
| | - Paweł K Kunicki
- Department of Drug Chemistry, Faculty of Pharmacy, Medical University of Warsaw, Warszawa, Poland
| | - Florian Lemaitre
- Univ Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail)-UMR_S 1085, Rennes, France
| | - Pierre Marquet
- INSERM, Université de Limoges, Department of Pharmacology and Toxicology, CHU de Limoges, U1248 IPPRITT, Limoges, France
| | - Mariadelfina Molinaro
- Clinical and Experimental Pharmacokinetics Lab, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Ofelia Noceti
- National Center for Liver Tansplantation and Liver Diseases, Army Forces Hospital, Montevideo, Uruguay
| | | | - Tomasz Pawinski
- Department of Drug Chemistry, Faculty of Pharmacy, Medical University of Warsaw, Warszawa, Poland
| | | | - Maria Shipkova
- Synlab TDM Competence Center, Synlab MVZ Leinfelden-Echterdingen GmbH, Leinfelden-Echterdingen, Germany
| | - Jesse J Swen
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Teun van Gelder
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Raman Venkataramanan
- Department of Pharmaceutical Sciences, School of Pharmacy and Department of Pathology, Starzl Transplantation Institute, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Eberhard Wieland
- Synlab TDM Competence Center, Synlab MVZ Leinfelden-Echterdingen GmbH, Leinfelden-Echterdingen, Germany
| | - Jean-Baptiste Woillard
- INSERM, Université de Limoges, Department of Pharmacology and Toxicology, CHU de Limoges, U1248 IPPRITT, Limoges, France
| | - Tom C Zwart
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Markus J Barten
- Department of Cardiac- and Vascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Klemens Budde
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Maja-Theresa Dieterlen
- Department of Cardiac Surgery, Heart Center, HELIOS Clinic, University Hospital Leipzig, Leipzig, Germany
| | - Laure Elens
- Integrated PharmacoMetrics, PharmacoGenomics and PharmacoKinetics (PMGK) Research Group, Louvain Drug Research Institute (LDRI), Université Catholique de Louvain (UCLouvain), Brussels, Belgium
| | - Vincent Haufroid
- Louvain Centre for Toxicology and Applied Pharmacology (LTAP), Institut de Recherche Expérimentale et Clinique, UCLouvain and Department of Clinical Chemistry, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Satohiro Masuda
- Department of Pharmacy, International University of Health and Welfare Narita Hospital, Chiba, Japan
| | - Olga Millan
- Pharmacology and Toxicology Laboratory, Biochemistry and Molecular Genetics Department, Biomedical Diagnostic Center, Hospital Clinic of Barcelona, University of Barcelona, IDIBAPS, CIBERehd, Spain
| | - Tomoyuki Mizuno
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Dirk J A R Moes
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Michael Oellerich
- Department of Clinical Pharmacology, University Medical Center Göttingen, Georg-August-University Göttingen, Göttingen, Germany
| | - Nicolas Picard
- INSERM, Université de Limoges, Department of Pharmacology and Toxicology, CHU de Limoges, U1248 IPPRITT, Limoges, France
| | | | - Burkhard Tönshoff
- Department of Pediatrics I, University Children's Hospital, Heidelberg, Germany
| | - Ron H N van Schaik
- Department of Clinical Chemistry, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Nils Tore Vethe
- Department of Pharmacology, Oslo University Hospital and Department of Pharmacy, University of Oslo, Oslo, Norway
| | - Alexander A Vinks
- Department of Pharmacy, International University of Health and Welfare Narita Hospital, Chiba, Japan
| | - Pierre Wallemacq
- Clinical Chemistry Department, Cliniques Universitaires St Luc, Université Catholique de Louvain, LTAP, Brussels, Belgium
| | - Anders Åsberg
- Department of Transplantation Medicine, Oslo University Hospital-Rikshospitalet and Department of Pharmacy, University of Oslo, Oslo, Norway; and
| | - Loralie J Langman
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
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18
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Uhl P, Heilos A, Bond G, Meyer E, Böhm M, Puchhammer-Stöckl E, Arbeiter K, Müller-Sacherer T, Csaicsich D, Aufricht C, Rusai K. Torque teno viral load reflects immunosuppression in paediatric kidney-transplanted patients-a pilot study. Pediatr Nephrol 2021; 36:153-162. [PMID: 32524259 PMCID: PMC7701084 DOI: 10.1007/s00467-020-04606-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 05/01/2020] [Accepted: 05/08/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Chronic deterioration of kidney graft function is related to inadequate immunosuppression (IS). A novel tool to assess the individual net state of IS in transplanted patients might be the monitoring of Torque teno virus (TTV) viral load. TTV is a non-pathogen virus detectable in almost all individuals. TTV level in the peripheral blood has been linked to the immune-competence of its host and should thus reflect IS after solid organ transplantation. METHODS TTV plasma load was quantified monthly by RT-PCR for a period of 1 year in 45 kidney-transplanted children. Post-transplant time was at least 3 months. The relation of the virus DNA levels to IS and transplant-specific clinical and laboratory parameters was analysed longitudinally. RESULTS TTV DNA was detectable in 94.5% of the plasma samples. There was a significant association with the post-transplant follow-up time as well as with the type of IS regimen, with lower virus loads in patients after longer post-transplant time and mTOR inhibitor-based IS. Furthermore, a significant positive correlation with the dose of prednisolone and mycophenolate mofetil was found. CONCLUSIONS TTV levels show an association/correlation with the strength of IS. Further studies are needed in order to evaluate TTV measurement as a tool for IS monitoring for hard clinical outcomes such as presence of donor-specific antibodies, rejections or infections-common consequences of insufficient or too intense IS.
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Affiliation(s)
- Phoebe Uhl
- Department of Paediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Division of Paediatric Nephrology and Gastroenterology, Medical University of Vienna, Vienna, Austria
| | - Andreas Heilos
- Department of Paediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Division of Paediatric Nephrology and Gastroenterology, Medical University of Vienna, Vienna, Austria
| | - Gregor Bond
- Department of Medicine III, Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Elias Meyer
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Michael Böhm
- Department of Paediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Division of Paediatric Nephrology and Gastroenterology, Medical University of Vienna, Vienna, Austria
| | | | - Klaus Arbeiter
- Department of Paediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Division of Paediatric Nephrology and Gastroenterology, Medical University of Vienna, Vienna, Austria
| | - Thomas Müller-Sacherer
- Department of Paediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Division of Paediatric Nephrology and Gastroenterology, Medical University of Vienna, Vienna, Austria
| | - Dagmar Csaicsich
- Department of Paediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Division of Paediatric Nephrology and Gastroenterology, Medical University of Vienna, Vienna, Austria
| | - Christoph Aufricht
- Department of Paediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Division of Paediatric Nephrology and Gastroenterology, Medical University of Vienna, Vienna, Austria
| | - Krisztina Rusai
- Department of Paediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Division of Paediatric Nephrology and Gastroenterology, Medical University of Vienna, Vienna, Austria.
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19
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Muhedier M, Li J, Liu H, Ma G, Amahong K, Lin R, Lü G. Tacrolimus, a rapamycin target protein inhibitor, exerts anti-cystic echinococcosis effects both in vitro and in vivo. Acta Trop 2020; 212:105708. [PMID: 32956634 DOI: 10.1016/j.actatropica.2020.105708] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 08/27/2020] [Accepted: 09/11/2020] [Indexed: 12/12/2022]
Abstract
In view of a growing need for new treatment options for human cystic echinococcosis (CE), we aimed to investigate the efficacy of mTOR pathway inhibitors against CE in vitro and in vivo. Among the seven mTOR inhibitors evaluated, tacrolimus (TAC) showed significant dose- and time-dependent killing of cultured protoscoleces and cysts in vitro. Notably, the oral administration of TAC (4 mg/kg/day) to CE mice model highly effectively reduced both the weight and number of parasitic cysts. Transmission electron microscopy revealed that TAC destroys the ultrastructure of cysts, both in vitro and in vivo. Furthermore, TAC had no significant effect on blood glucose, body weight, liver, or kidney functions in mice. We further observed that the ATP levels and glucose content of cysts reduced upon TAC treatment, indicating that inhibiting mTORC1 activity possibly affects glucose metabolism in the cysts of mice. Based on our experimental data, TAC emerged as a promising anti-cyst drug that efficiently inhibits the growth of cysts.
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Affiliation(s)
- Muzhabaier Muhedier
- State Key Laboratory of Pathogenesis, Prevention, and Treatment of Central Asian High Incidence Diseases, Clinical Medical Research Institute, First Affiliated Hospital of Xinjiang Medical University, China; Xinjiang Key Laboratory of Echinococcosis, Clinical Medicine Institute, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China; Kashi maternal and child health care hospital, Kashi, Xinjiang, China
| | - Jintian Li
- State Key Laboratory of Pathogenesis, Prevention, and Treatment of Central Asian High Incidence Diseases, Clinical Medical Research Institute, First Affiliated Hospital of Xinjiang Medical University, China; Xinjiang Key Laboratory of Echinococcosis, Clinical Medicine Institute, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China; College of pharmacy, Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Hui Liu
- State Key Laboratory of Pathogenesis, Prevention, and Treatment of Central Asian High Incidence Diseases, Clinical Medical Research Institute, First Affiliated Hospital of Xinjiang Medical University, China; Xinjiang Key Laboratory of Echinococcosis, Clinical Medicine Institute, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Guizhi Ma
- College of pharmacy, Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Kuerbannisha Amahong
- State Key Laboratory of Pathogenesis, Prevention, and Treatment of Central Asian High Incidence Diseases, Clinical Medical Research Institute, First Affiliated Hospital of Xinjiang Medical University, China; Xinjiang Key Laboratory of Echinococcosis, Clinical Medicine Institute, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Renyong Lin
- State Key Laboratory of Pathogenesis, Prevention, and Treatment of Central Asian High Incidence Diseases, Clinical Medical Research Institute, First Affiliated Hospital of Xinjiang Medical University, China; Xinjiang Key Laboratory of Echinococcosis, Clinical Medicine Institute, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China.
| | - Guodong Lü
- State Key Laboratory of Pathogenesis, Prevention, and Treatment of Central Asian High Incidence Diseases, Clinical Medical Research Institute, First Affiliated Hospital of Xinjiang Medical University, China; Xinjiang Key Laboratory of Echinococcosis, Clinical Medicine Institute, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China; College of pharmacy, Xinjiang Medical University, Urumqi, Xinjiang, China.
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20
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Brazeau DA, Attwood K, Meaney CJ, Wilding GE, Consiglio JD, Chang SS, Gundroo A, Venuto RC, Cooper L, Tornatore KM. Beyond Single Nucleotide Polymorphisms: CYP3A5∗3∗6∗7 Composite and ABCB1 Haplotype Associations to Tacrolimus Pharmacokinetics in Black and White Renal Transplant Recipients. Front Genet 2020; 11:889. [PMID: 32849848 PMCID: PMC7433713 DOI: 10.3389/fgene.2020.00889] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 07/20/2020] [Indexed: 12/12/2022] Open
Abstract
Interpatient variability in tacrolimus pharmacokinetics is attributed to metabolism by cytochrome P-450 3A5 (CYP3A5) isoenzymes and membrane transport by P-glycoprotein. Interpatient pharmacokinetic variability has been associated with genotypic variants for both CYP3A5 or ABCB1. Tacrolimus pharmacokinetics was investigated in 65 stable Black and Caucasian post-renal transplant patients by assessing the effects of multiple alleles in both CYP3A5 and ABCB1. A metabolic composite based upon the CYP3A5 polymorphisms: ∗3(rs776746), ∗6(10264272), and ∗7(41303343), each independently responsible for loss of protein expression was used to classify patients as extensive, intermediate and poor metabolizers. In addition, the role of ABCB1 on tacrolimus pharmacokinetics was assessed using haplotype analysis encompassing the single nucleotide polymorphisms: 1236C > T (rs1128503), 2677G > T/A(rs2032582), and 3435C > T(rs1045642). Finally, a combined analysis using both CYP3A5 and ABCB1 polymorphisms was developed to assess their inter-related influence on tacrolimus pharmacokinetics. Extensive metabolizers identified as homozygous wild type at all three CYP3A5 loci were found in 7 Blacks and required twice the tacrolimus dose (5.6 ± 1.6 mg) compared to Poor metabolizers [2.5 ± 1.1 mg (P < 0.001)]; who were primarily Whites. These extensive metabolizers had 2-fold faster clearance (P < 0.001) with 50% lower AUC∗ (P < 0.001) than Poor metabolizers. No differences in C12 h were found due to therapeutic drug monitoring. The majority of blacks (81%) were classified as either Extensive or Intermediate Metabolizers requiring higher tacrolimus doses to accommodate the more rapid clearance. Blacks who were homozygous for one or more loss of function SNPS were associated with lower tacrolimus doses and slower clearance. These values are comparable to Whites, 82% of who were in the Poor metabolic composite group. The ABCB1 haplotype analysis detected significant associations of the wildtype 1236T-2677T-3435T haplotype to tacrolimus dose (P = 0.03), CL (P = 0.023), CL/LBW (P = 0.022), and AUC∗ (P = 0.078). Finally, analysis combining CYP3A5 and ABCB1 genotypes indicated that the presence of the ABCB1 3435 T allele significantly reduced tacrolimus clearance for all three CPY3A5 metabolic composite groups. Genotypic associations of tacrolimus pharmacokinetics can be improved by using the novel composite CYP3A5∗3∗4∗5 and ABCB1 haplotypes. Consideration of multiple alleles using CYP3A5 metabolic composites and drug transporter ABCB1 haplotypes provides a more comprehensive appraisal of genetic factors contributing to interpatient variability in tacrolimus pharmacokinetics among Whites and Blacks.
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Affiliation(s)
- Daniel A Brazeau
- Department of Pharmacy Practice, Administration and Research, School of Pharmacy, Marshall University, Huntington, WV, United States
| | - Kristopher Attwood
- Department of Biostatistics, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, United States
| | - Calvin J Meaney
- Immunosuppressive Pharmacology Research Program, Translational Pharmacology Research Core, NYS Center of Excellence in Bioinformatics and Life Sciences, Buffalo, NY, United States.,School of Pharmacy and Pharmaceutical Sciences, Buffalo, NY, United States
| | - Gregory E Wilding
- Department of Biostatistics, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, United States
| | - Joseph D Consiglio
- Department of Biostatistics, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, United States
| | - Shirley S Chang
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, United States.,Erie County Medical Center, Buffalo, NY, United States
| | - Aijaz Gundroo
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, United States.,Erie County Medical Center, Buffalo, NY, United States
| | - Rocco C Venuto
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, United States.,Erie County Medical Center, Buffalo, NY, United States
| | - Louise Cooper
- Immunosuppressive Pharmacology Research Program, Translational Pharmacology Research Core, NYS Center of Excellence in Bioinformatics and Life Sciences, Buffalo, NY, United States.,School of Pharmacy and Pharmaceutical Sciences, Buffalo, NY, United States
| | - Kathleen M Tornatore
- Immunosuppressive Pharmacology Research Program, Translational Pharmacology Research Core, NYS Center of Excellence in Bioinformatics and Life Sciences, Buffalo, NY, United States.,School of Pharmacy and Pharmaceutical Sciences, Buffalo, NY, United States.,Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, United States
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21
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Marx S, Adam C, Mihm J, Weyrich M, Sester U, Sester M. A Polyclonal Immune Function Assay Allows Dose-Dependent Characterization of Immunosuppressive Drug Effects but Has Limited Clinical Utility for Predicting Infection on an Individual Basis. Front Immunol 2020; 11:916. [PMID: 32499781 PMCID: PMC7243819 DOI: 10.3389/fimmu.2020.00916] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 04/20/2020] [Indexed: 12/19/2022] Open
Abstract
Dosage of immunosuppressive drugs after transplantation critically determines rejection and infection episodes. In this study, a global immune function assay was characterized among controls, dialysis-patients, and transplant-recipients to evaluate its utility for pharmacodynamic monitoring of immunosuppressive drugs and for predicting infections. Whole-blood samples were stimulated with anti-CD3/toll-like-receptor (TLR7/8)-agonist in the presence or absence of drugs and IFN-γ secretion was measured by ELISA. Additional stimulation-induced cytokines were characterized among T-, B-, and NK-cells using flow-cytometry. Cytokine-secretion was dominated by IFN-γ, and mainly observed in CD4, CD8, and NK-cells. Intra-assay variability was low (CV = 10.4 ± 6.2%), whereas variability over time was high, even in the absence of clinical events (CV = 65.0 ± 35.7%). Cyclosporine A, tacrolimus and steroids dose-dependently inhibited IFN-γ secretion, and reactivity was further reduced when calcineurin inhibitors were combined with steroids. Moreover, IFN-γ levels significantly differed between controls, dialysis-patients, and transplant-recipients, with lowest IFN-γ levels early after transplantation (p < 0.001). However, a single test had limited ability to predict infectious episodes. In conclusion, the assay may have potential for basic pharmacodynamic characterization of immunosuppressive drugs and their combinations, and for assessing loss of global immunocompetence after transplantation, but its application to guide drug-dosing and to predict infectious on an individual basis is limited.
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Affiliation(s)
- Stefanie Marx
- Department of Transplant and Infection Immunology, Saarland University, Homburg, Germany
| | - Claudia Adam
- Department of Internal Medicine IV, Saarland University, Homburg, Germany
| | - Janine Mihm
- Department of Internal Medicine IV, Saarland University, Homburg, Germany
| | - Michael Weyrich
- Department of Internal Medicine IV, Saarland University, Homburg, Germany
| | - Urban Sester
- Department of Internal Medicine IV, Saarland University, Homburg, Germany
| | - Martina Sester
- Department of Transplant and Infection Immunology, Saarland University, Homburg, Germany
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22
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Zhang M, Tajima S, Shigematsu T, Fu R, Noguchi H, Kaku K, Tsuchimoto A, Okabe Y, Egashira N, Masuda S. Donor CYP3A5 Gene Polymorphism Alone Cannot Predict Tacrolimus Intrarenal Concentration in Renal Transplant Recipients. Int J Mol Sci 2020; 21:ijms21082976. [PMID: 32340188 PMCID: PMC7215698 DOI: 10.3390/ijms21082976] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 04/20/2020] [Accepted: 04/22/2020] [Indexed: 12/12/2022] Open
Abstract
CYP3A5 gene polymorphism in recipients plays an important role in tacrolimus blood pharmacokinetics after renal transplantation. Even though CYP3A5 protein is expressed in renal tubular cells, little is known about the influence on the tacrolimus intrarenal exposure and hence graft outcome. The aim of our study was to investigate how the tacrolimus intrarenal concentration (Ctissue) could be predicted based on donor CYP3A5 gene polymorphism in renal transplant recipients. A total of 52 Japanese renal transplant patients receiving tacrolimus were enrolled in this study. Seventy-four renal biopsy specimens were obtained at 3 months and 1 year after transplantation to determine the donor CYP3A5 polymorphism and measure the Ctissue by liquid chromatography-tandem mass spectrometry (LC-MS-MS). The tacrolimus Ctissue ranged from 52 to 399 pg/mg tissue (n = 74) and was weak but significantly correlated with tacrolimus trough concentration (C0) at 3 months after transplantation (Spearman, r = 0.3560, p = 0.0096). No significant relationship was observed between the donor CYP3A5 gene polymorphism and Ctissue or Ctissue/C0. These data showed that the tacrolimus systemic level has an impact on tacrolimus renal accumulation after renal transplantation. However, donor CYP3A5 gene polymorphism alone cannot be used to predict tacrolimus intrarenal exposure. This study may be valuable for exploring tacrolimus renal metabolism and toxicology mechanism in renal transplant recipients.
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Affiliation(s)
- Mengyu Zhang
- Department of Clinical Pharmacology and Biopharmaceutics, Graduate School of Pharmaceutical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan; (M.Z.); (T.S.); (R.F.); (N.E.)
| | - Soichiro Tajima
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan;
| | - Tomohiro Shigematsu
- Department of Clinical Pharmacology and Biopharmaceutics, Graduate School of Pharmaceutical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan; (M.Z.); (T.S.); (R.F.); (N.E.)
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan;
| | - Rao Fu
- Department of Clinical Pharmacology and Biopharmaceutics, Graduate School of Pharmaceutical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan; (M.Z.); (T.S.); (R.F.); (N.E.)
| | - Hiroshi Noguchi
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan; (H.N.); (K.K.); (Y.O.)
| | - Keizo Kaku
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan; (H.N.); (K.K.); (Y.O.)
| | - Akihiro Tsuchimoto
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan;
| | - Yasuhiro Okabe
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan; (H.N.); (K.K.); (Y.O.)
| | - Nobuaki Egashira
- Department of Clinical Pharmacology and Biopharmaceutics, Graduate School of Pharmaceutical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan; (M.Z.); (T.S.); (R.F.); (N.E.)
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan;
| | - Satohiro Masuda
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan;
- Department of Pharmacy, International University of Health and Welfare Narita Hospital, 852 Hatakeda, Narita 286-0124, Japan
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, International University of Health and Welfare, 2600-1 Kita-kanemaru, Otawara 324-8501, Japan
- Correspondence: ; Tel.: +81-476-35-5600
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23
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Kelava T, Turcic P, Markotic A, Ostojic A, Sisl D, Mrzljak A. Importance of genetic polymorphisms in liver transplantation outcomes. World J Gastroenterol 2020; 26:1273-1285. [PMID: 32256016 PMCID: PMC7109269 DOI: 10.3748/wjg.v26.i12.1273] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 03/01/2020] [Accepted: 03/05/2020] [Indexed: 02/06/2023] Open
Abstract
Although, liver transplantation serves as the only curative treatment for patients with end-stage liver diseases, it is burdened with complications, which affect survival rates. In addition to clinical risk factors, contribution of recipient and donor genetic prognostic markers has been extensively studied in order to reduce the burden and improve the outcomes. Determination of single nucleotide polymorphisms (SNPs) is one of the most important tools in development of personalized transplant approach. To provide a better insight in recent developments, we review the studies published in the last three years that investigated an association of recipient or donor SNPs with most common issues in liver transplantation: Acute cellular rejection, development of new-onset diabetes mellitus and non-alcoholic fatty liver disease, hepatocellular carcinoma recurrence, and tacrolimus concentration variability. Reviewed studies confirmed previously established SNP prognostic factors, such as PNPLA3 rs738409 for non-alcoholic fatty liver disease development, or the role of CYP3A5 rs776746 in tacrolimus concentration variability. They also identified several novel SNPs, with a reasonably strong association, which have the potential to become useful predictors of post-transplant complications. However, as the studies were typically conducted in one center on relatively low-to-moderate number of patients, verification of the results in other centers is warranted to resolve these limitations. Furthermore, of 29 reviewed studies, 28 used gene candidate approach and only one implemented a genome wide association approach. Genome wide association multicentric studies are needed to facilitate the development of personalized transplant medicine.
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Affiliation(s)
- Tomislav Kelava
- Laboratory for Molecular Immunology, Croatian Institute for Brain Research, University of Zagreb, School of Medicine, Zagreb 10000, Croatia
| | - Petra Turcic
- Department of Pharmacology, Faculty of Pharmacy and Biochemistry of University of Zagreb, Zagreb 10000, Croatia
| | - Antonio Markotic
- Center for Clinical Pharmacology, University Clinical Hospital Mostar, Mostar 88000, Bosnia and Herzegovina
| | - Ana Ostojic
- Department of Medicine, Merkur University Hospital, Zagreb 10000, Croatia
| | - Dino Sisl
- Laboratory for Molecular Immunology, Croatian Institute for Brain Research, University of Zagreb, School of Medicine, Zagreb 10000, Croatia
| | - Anna Mrzljak
- Department of Medicine, Merkur University Hospital; School of Medicine, University of Zagreb, Zagreb 10000, Croatia
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24
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Wolf S, Lauseker M, Schiergens T, Wirth U, Drefs M, Renz B, Ryll M, Bucher J, Werner J, Guba M, Andrassy J. Infections after kidney transplantation: A comparison of mTOR‐Is and CNIs as basic immunosuppressants. A systematic review and meta‐analysis. Transpl Infect Dis 2020; 22:e13267. [DOI: 10.1111/tid.13267] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 01/24/2020] [Accepted: 02/16/2020] [Indexed: 01/18/2023]
Affiliation(s)
- Sebastian Wolf
- Department of General‐, Visceral‐ and Transplantation‐Surgery University Hospital Augsburg Augsburg Germany
| | | | - Tobias Schiergens
- Department of General‐, Visceral‐ and Transplantation‐Surgery Ludwig‐Maximilian's University Munich Germany
| | - Ulrich Wirth
- Department of General‐, Visceral‐ and Transplantation‐Surgery Ludwig‐Maximilian's University Munich Germany
| | - Moritz Drefs
- Department of General‐, Visceral‐ and Transplantation‐Surgery Ludwig‐Maximilian's University Munich Germany
| | - Bernhard Renz
- Department of General‐, Visceral‐ and Transplantation‐Surgery Ludwig‐Maximilian's University Munich Germany
| | - Martin Ryll
- Department of General‐, Visceral‐ and Transplantation‐Surgery Ludwig‐Maximilian's University Munich Germany
| | - Julian Bucher
- Department of General‐, Visceral‐ and Transplantation‐Surgery Ludwig‐Maximilian's University Munich Germany
| | - Jens Werner
- Department of General‐, Visceral‐ and Transplantation‐Surgery Ludwig‐Maximilian's University Munich Germany
| | - Markus Guba
- Department of General‐, Visceral‐ and Transplantation‐Surgery Ludwig‐Maximilian's University Munich Germany
| | - Joachim Andrassy
- Department of General‐, Visceral‐ and Transplantation‐Surgery Ludwig‐Maximilian's University Munich Germany
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25
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Wang Z, Zheng M, Yang H, Han Z, Tao J, Chen H, Sun L, Guo M, Wang L, Tan R, Wei JF, Gu M. Association of Genetic Variants in CYP3A4, CYP3A5, CYP2C8, and CYP2C19 with Tacrolimus Pharmacokinetics in Renal Transplant Recipients. Curr Drug Metab 2020; 20:609-618. [PMID: 31244435 DOI: 10.2174/1389200220666190627101927] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 05/05/2019] [Accepted: 05/31/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Our study aimed to investigate the pharmacogenetics of cytochrome P3A4 (CYP3A4), CYP3A5, CYP2C8, and CYP2C19 and their influence on TAC Pharmacokinetics (PKs) in short-term renal transplant recipients. METHODS A total of 105 renal transplant recipients were enrolled. Target Sequencing (TS) based on next-generation sequencing technology was used to detect all exons, exon/intron boundaries, and flanking regions of CYP3A4, CYP3A5, CYP2C8, and CYP2C19. After adjustment of Minor Allele Frequencies (MAF) and Hardy-Weinberg Equilibrium (HWE) analysis, tagger Single-nucleotide Polymorphisms (SNPs) and haplotypes were identified. Influence of tagger SNPs on TAC concentrations was analyzed. RESULTS A total of 94 SNPs were identified in TS analysis. Nine tagger SNPs were selected, and two SNPs (rs15524 and rs4646453) were noted to be significantly associated with TAC PKs in short-term post-transplant follow-up. Measurement time points of TAC, body mass index (BMI), usage of sirolimus, and incidence of Delayed Graft Function (DGF) were observed to be significantly associated with TAC PKs. Three haplotypes were identified, and rs15524-rs4646453 was found to remarkably contribute to TAC PKs. Recipients carrying H2/H2 (GG-AA) haplotype also showed significantly high weight- and dose-adjusted TAC concentrations in posttransplant periods of 7, 14, and 30 days and 3 and 6 months. CONCLUSIONS Two tagger SNPs, namely, rs15524 and rs4646453, are significantly related to the variability of TAC disposition, and TAC measurement time points, BMI, usage of sirolimus, and incidence of DGF contribute to this influence. Recipients carrying H2/H2 (GG-AA) haplotype in rs15524-rs4646453 may require a low dosage of TAC during 1-year follow-up posttransplant.
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Affiliation(s)
- Zijie Wang
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Ming Zheng
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Haiwei Yang
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Zhijian Han
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Jun Tao
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Hao Chen
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Li Sun
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Miao Guo
- Research Division of Clinical Pharmacology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Libin Wang
- Research Division of Clinical Pharmacology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Ruoyun Tan
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Ji-Fu Wei
- Research Division of Clinical Pharmacology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Min Gu
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
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26
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Oberbauer R, Bestard O, Furian L, Maggiore U, Pascual J, Rostaing L, Budde K. Optimization of tacrolimus in kidney transplantation: New pharmacokinetic perspectives. Transplant Rev (Orlando) 2020; 34:100531. [PMID: 31955920 DOI: 10.1016/j.trre.2020.100531] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 11/05/2019] [Accepted: 12/08/2019] [Indexed: 02/07/2023]
Abstract
Tacrolimus is the cornerstone of immunosuppressive therapy after kidney transplantation (KT), but its use is complicated by a narrow therapeutic index and high inter- and intra-patient pharmacokinetic variability. There are three available oral formulations of tacrolimus: immediate-release tacrolimus (IR-Tac), extended-release tacrolimus (ER-Tac) and a MeltDose® (LCPT) formulation, the latter favoring a prolonged drug release and increased bioavailability. The time-concentration curves of these formulations are different. Compared with IR-Tac and ER-Tac, LCPT has a relatively flat pharmacokinetic profile with less fluctuation between trough and peak exposures, and a delayed peak concentration. This translates to a more stable delivery of tacrolimus and may alleviate the risk of underexposure and allograft rejection or overexposure and toxicity. The once-daily formulation of both ER-TAC and LCPT may also offer a potential advantage on patient adherence. Fast metabolizers of tacrolimus, the elderly, and human leukocyte antigen-sensitized patients are at risk of poorer outcomes after KT, possibly associated with a different exhibited pharmacokinetics of tacrolimus or different requirements in terms of exposure. Simple, practical strategies are needed to identify patients at risk of suboptimal KT outcomes and those who would benefit from a more proactively personalized approach to tacrolimus treatment. This review aims to increase awareness of the link between the pharmacokinetics of oral tacrolimus formulations and the clinical needs of patients after KT, particularly among those who have clinically significant pharmacokinetic variation of tacrolimus.
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Affiliation(s)
- Rainer Oberbauer
- Department of Nephrology, Medical University of Vienna, Vienna, Austria
| | - Oriol Bestard
- Kidney Transplant Unit, Nephrology department, Bellvitge University Hospital, Barcelona, Spain
| | - Lucrezia Furian
- Kidney and Pancreas Transplantation Unit, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Italy
| | - Umberto Maggiore
- Kidney and Kidney-Pancreas Transplant Unit (Department of Nephrology), Parma University Hospital, Parma, Italy
| | - Julio Pascual
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
| | - Lionel Rostaing
- Nephrology and Transplantation Department, CHU Grenoble, Grenoble, France
| | - Klemens Budde
- Department of Nephrology, Internal Intensive Care Medicine, Campus Charité Mitte, Berlin, Germany.
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27
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van Merendonk LN, Fontova P, Rigo-Bonnin R, Colom H, Vidal-Alabró A, Bestard O, Torras J, Cruzado JM, Grinyó JM, Lloberas N. Validation and evaluation of four sample preparation methods for the quantification of intracellular tacrolimus in peripheral blood mononuclear cells by UHPLC-MS/MS. Clin Chim Acta 2019; 503:210-217. [PMID: 31794770 DOI: 10.1016/j.cca.2019.11.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 11/22/2019] [Accepted: 11/25/2019] [Indexed: 10/25/2022]
Abstract
Rejection and toxicity occur despite monitoring of tacrolimus blood levels during clinical routine. The intracellular concentration in lymphocytes could be a better reflection of the tacrolimus exposure. Four extraction methods for tacrolimus in peripheral blood mononuclear cells were validated and evaluated with UHPLC-MS/MS. Methods based on protein precipitation (method 1), solid phase extraction (method 2), phospholipids and proteins removal (method 3) and liquid-liquid extraction (method 4) were evaluated on linearity, lower limit of quantification (LLOQ), imprecision and bias. Validation was completed for the methods within these requirements, adding matrix effect and recovery. Linearity was 0.126 (LLOQ)-15 µg/L, 0.504 (LLOQ)-15 µg/L and 0.298 (LLOQ)-15 µg/L with method 1, 2 and 3, respectively. With method 4 non-linearity and a LLOQ higher than 0.504 µg/L were observed. Inter-day imprecision and bias were ≤4.6%, ≤10.9%; ≤6.8%, ≤-11.2%; ≤9.4%, ≤10.3% and ≤44.6%, ≤23.1%, respectively, with methods 1, 2, 3 and 4. Validation was completed for method 1 and 3 adding matrix effect (7.6%; 15.0%) and recovery (8.9%; 10.8%), respectively. The most suitable UHPLC-MS/MS method for quantification of intracellular tacrolimus was protein precipitation due to the best performance characteristics and the least time-consuming rate and complexity.
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Affiliation(s)
- Lisanne N van Merendonk
- Nephrology Department, IDIBELL, Hospital Universitari de Bellvitge, University of Barcelona, Barcelona, Spain
| | - Pere Fontova
- Nephrology Department, IDIBELL, Hospital Universitari de Bellvitge, University of Barcelona, Barcelona, Spain
| | - Raül Rigo-Bonnin
- Biochemistry Department, IDIBELL, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Helena Colom
- Biopharmaceutics and Pharmacokinetics Unit, Department of Pharmacy and Pharmaceutical Technology Department, School of Pharmacy, University of Barcelona, Barcelona, Spain
| | - Anna Vidal-Alabró
- Nephrology Department, IDIBELL, Hospital Universitari de Bellvitge, University of Barcelona, Barcelona, Spain
| | - Oriol Bestard
- Nephrology Department, IDIBELL, Hospital Universitari de Bellvitge, University of Barcelona, Barcelona, Spain
| | - Juan Torras
- Nephrology Department, IDIBELL, Hospital Universitari de Bellvitge, University of Barcelona, Barcelona, Spain
| | - Josep M Cruzado
- Nephrology Department, IDIBELL, Hospital Universitari de Bellvitge, University of Barcelona, Barcelona, Spain
| | - Josep M Grinyó
- Nephrology Department, IDIBELL, Hospital Universitari de Bellvitge, University of Barcelona, Barcelona, Spain
| | - Núria Lloberas
- Nephrology Department, IDIBELL, Hospital Universitari de Bellvitge, University of Barcelona, Barcelona, Spain.
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Tacrolimus Can Be Reliably Measured With Volumetric Absorptive Capillary Microsampling Throughout the Dose Interval in Renal Transplant Recipients. Ther Drug Monit 2019; 41:607-614. [DOI: 10.1097/ftd.0000000000000655] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Fernandez HE, Amaral S, Shaw PA, Doyle AM, Bloom RD, Palmer JA, Baluarte HJ, Furth SL. The effect of transfer to adult transplant care on kidney function and immunosuppressant drug level variability in pediatric kidney transplant recipients. Pediatr Transplant 2019; 23:e13527. [PMID: 31209988 DOI: 10.1111/petr.13527] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 03/30/2019] [Accepted: 05/12/2019] [Indexed: 11/29/2022]
Abstract
Adolescent age at time of transplant has been recognized as a risk factor for renal allograft loss. Increased risk for graft failure may persist from adolescence to young adulthood. Transfer of care is hypothesized as a risk factor for non-adherence and graft loss. We explored whether kidney allograft function declined at an accelerated rate after transfer of care to adult transplant centers and whether coefficient of variation of tacrolimus (CV TAC) trough levels predicted allograft loss. Single-center, retrospective chart review was performed for pediatric kidney transplant recipients who received transplants between 1999 and 2011. Change in eGFR pre- and post-transfer was performed via a linear mixed-effects model. CV TAC was calculated in transplant recipients with TAC data pre- and post-transfer. t test was performed to determine the difference between means of CV TAC in subjects with and without allograft loss following transfer of care. Of the 138 subjects who transferred to adult care, 47 subjects with data pre- and post-transfer demonstrated a decrease in the rate of eGFR decline post-transfer from 8.0 mL/min/1.73 m2 per year to 2.1 mL/min/1.73 m2 per year, an ~80% decrease in eGFR decline post-transfer (P = 0.01). Twenty-four subjects had CV TAC data pre- and post-transfer of care. Pretransfer CV TAC for subjects with allograft loss post-transfer was significantly higher than in subjects without allograft loss (49% vs 26%, P < 0.05). Transfer of care was not independently associated with acceleration in eGFR decline. CV TAC may aid in identifying patients at risk for allograft loss post-transfer.
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Affiliation(s)
- Hilda E Fernandez
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Sandra Amaral
- Division of Nephrology, Department of Pediatrics, Children's Hospital of Philadelphia, and University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pamela A Shaw
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alden M Doyle
- Division of Nephrology, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Roy D Bloom
- Renal Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jo Ann Palmer
- Division of Nephrology, Department of Pediatrics, Children's Hospital of Philadelphia, and University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hobart J Baluarte
- Division of Nephrology, Department of Pediatrics, Children's Hospital of Philadelphia, and University of Pennsylvania, Philadelphia, Pennsylvania
| | - Susan L Furth
- Division of Nephrology, Department of Pediatrics, Children's Hospital of Philadelphia, and University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Brooks E, Tett SE, Isbel NM, McWhinney B, Staatz CE. Investigation of the Association Between Total and Free Plasma and Saliva Mycophenolic Acid Concentrations Following Administration of Enteric-Coated Mycophenolate Sodium in Adult Kidney Transplant Recipients. Clin Drug Investig 2019; 39:1175-1184. [DOI: 10.1007/s40261-019-00844-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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31
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Okimoto A, Yamamoto R, Hirose J, Shimatani K, Koshika T, Maeda M, Hattori K, Morokata T. ASP1126, a Novel Sphingosine-1-Phosphate-Selective Agonist With a Favorable Safety Profile, Prolongs Allograft Survival in Rats and Nonhuman Primates in Combination With Tacrolimus With a Broad Safety Margin for Bradycardia. Transplant Proc 2019; 51:2081-2098. [PMID: 31399186 DOI: 10.1016/j.transproceed.2019.05.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 05/07/2019] [Indexed: 11/28/2022]
Abstract
Sphingosine-1-phosphate (S1P) is a biologically active sphingolipid that acts through the members of a family of 5 G protein-coupled receptors (S1P1 to S1P5). Among these, S1P1 is a major regulator of lymphocyte trafficking. Fingolimod, whose active metabolite, fingolimod phosphate, acts as a nonselective S1P-receptor agonist, exerts its immunomodulatory effect, at least in part, by regulating lymphocyte trafficking via downregulation of S1P1 expression on lymphocytes. Here, we describe the pharmacologic profile of a novel S1P1 agonist, ASP1126. ASP1126 preferentially activated S1P1 compared to S1P3 in rat and human guanosine-5'-(γ-thio)-triphosphate (GTPγS) assays. Oral single administration of ASP1126 decreased the number of peripheral lymphocytes and repeated dosing showed a cumulative effect on lymphopenia in both rats and monkeys. ASP1126 prolonged allograft survival in a rat heterotopic heart transplantation model in combination with a subtherapeutic dose of tacrolimus that was independent of drug-drug interactions. In addition, in nonhuman primate (NHP) renal transplantation, pretreatment with ASP1126 reduced not only the number of naive T cells and central memory T cells but also effector memory T cells in the peripheral blood, all of which could contribute to acute graft rejection and prolonged allograft survival in combination with tacrolimus. Further, we confirmed that ASP1126 has a broad ranging safety margin with respect to its effect on lung weight in rats and bradycardia in NHPs, which were the adverse events found in clinical studies of fingolimod. ASP1126 with improved safety profile has the potential to be an adjunct therapy in combination with tacrolimus in clinical transplantation.
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Affiliation(s)
- Akira Okimoto
- Drug Discovery Research, Astellas Pharma Inc, Ibaraki, Japan.
| | - Rie Yamamoto
- Drug Discovery Research, Astellas Pharma Inc, Ibaraki, Japan
| | - Jun Hirose
- Drug Discovery Research, Astellas Pharma Inc, Ibaraki, Japan
| | | | | | - Masashi Maeda
- Drug Discovery Research, Astellas Pharma Inc, Ibaraki, Japan
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Effects of cyclosporine and dexamethasone on canine T cell expression of interleukin-2 and interferon-gamma. Vet Immunol Immunopathol 2019; 216:109892. [PMID: 31446206 DOI: 10.1016/j.vetimm.2019.109892] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 10/07/2018] [Accepted: 07/08/2019] [Indexed: 12/12/2022]
Abstract
Cyclosporine and glucocorticoids are powerful immunosuppressive agents used to treat many inflammatory diseases in dogs. Cyclosporine inhibits calcineurin-dependent pathways of T cell activation and resultant T cell cytokine production, and glucocorticoids directly inhibit genes coding for cytokines. Little work has been done comparing the effects of these agents on T cell cytokine production in dogs. Our study measured T cell interleukin-2 (IL-2) and interferon-gamma (IFN-γ) production using flow cytometry and T cell IL-2 and IFN-γ gene expression using quantitative reverse transcription polymerase chain reaction (qRT-PCR) in activated canine T cells incubated with cyclosporine and dexamethasone in vitro. For flow cytometric assays, diluted whole blood was cultured for 7 h in the presence of cyclosporine (10, 100, 500, and 1000 ng/mL) or dexamethasone (10 ng/mL, 100 ng/mL, 1 μg/mL, and 10 μg/mL). For qRT-PCR, whole blood was cultured for 5 h with the same drugs at the same concentrations, and RNA was then extracted from leukocytes. Flow cytometry and qRT-PCR both demonstrated inhibition of IL-2 and IFN-γ that was concentration-dependent in response to cyclosporine, and was more variable for dexamethasone. Quantitative RT-PCR but not flow cytometry documented significant reduction of IL-2 expression after dexamethasone treatment, while both methods showed concentration-dependent suppression of IFN-γ. Quantitative RT-PCR also revealed additional cytokine suppression at higher cyclosporine concentrations, an effect not found using flow cytometry, and may therefore be the preferred method for cytokine determination in dogs. Suppression of IL-2 and IFN-γ in activated T cells may have potential as an indicator of the efficacy of cyclosporine and glucocorticoids in suppressing canine T cell function in vivo, and may therefore be of value for characterizing the immunosuppression induced by these drugs in clinical patients.
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Berger FA, Mulder MB, Ten Bosch-Dijksman W, van Schaik RHN, Coenen S, de Winter BCM. Differences in CYP3A genotypes of a liver transplant recipient and the donor liver graft and adjustment of tacrolimus dose. Br J Clin Pharmacol 2019; 85:1852-1854. [PMID: 31190414 PMCID: PMC6624396 DOI: 10.1111/bcp.13958] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 03/18/2019] [Accepted: 03/22/2019] [Indexed: 12/18/2022] Open
Abstract
Tacrolimus (Tac) is well established as main immunosuppressant in most immunosuppressive regimens in solid organ transplantation. Due to the narrow therapeutic window, pre dose Tac levels (C0) are monitored in all patients receiving Tac to reach optimal therapeutic levels. Tac is metabolized in the liver and intestine by the cytochrome P450 3A (CYP3A) isoforms CYP3A4 and CYP3A5. We present a case of an African American woman who underwent a liver transplantation in which adequate Tac levels were difficult to accomplish due to differences in cytochrome P450 3A4/5 (CYP3A4/5) polymorphisms of the transplant recipient and the donor liver graft. This case report highlights that genotyping the liver transplant recipient and the donor liver graft might provide data which could be used to predict the tacrolimus metabolism post transplantation.
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Affiliation(s)
- Florine A Berger
- Department of Hospital Pharmacy, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Midas B Mulder
- Department of Hospital Pharmacy, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | - Ron H N van Schaik
- Department of Clinical Chemistry, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Sandra Coenen
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Brenda C M de Winter
- Department of Hospital Pharmacy, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
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Campagne O, Mager DE, Brazeau D, Venuto RC, Tornatore KM. The impact of tacrolimus exposure on extrarenal adverse effects in adult renal transplant recipients. Br J Clin Pharmacol 2019; 85:516-529. [PMID: 30414331 DOI: 10.1111/bcp.13811] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Revised: 10/12/2018] [Accepted: 10/24/2018] [Indexed: 12/28/2022] Open
Abstract
AIMS Tacrolimus has been associated with notable extrarenal adverse effects (AEs), which are unpredictable and impact patient morbidity. The association between model-predicted tacrolimus exposure metrics and standardized extrarenal AEs in stable renal transplant recipients was investigated and a limited sampling strategy (LSS) was developed to predict steady-state tacrolimus area under the curve over a 12-h dosing period (AUCss,0-12h ). METHODS All recipients receiving tacrolimus and mycophenolic acid ≥6 months completed a 12-h cross-sectional observational pharmacokinetic-pharmacodynamic study. Patients were evaluated for the presence of individual and composite gastrointestinal, neurological, and aesthetic AEs during the study visit. The associations between AEs and tacrolimus exposure metrics generated from a published population pharmacokinetic model were investigated using a logistic regression analysis in NONMEM 7.3. An LSS was determined using a Bayesian estimation method with the same patients. RESULTS Dose-normalized tacrolimus AUCss,0-12h and apparent clearance were independently associated with diarrhoea, dyspepsia, insomnia and neurological AE ratio. Dose-normalized tacrolimus maximum concentration was significantly correlated with skin changes and acne. No AE associations were found with trough concentrations. Using limited sampling at 0, 2h; 0, 1, 4h; and 0, 1, 2, 4h provided a precise and unbiased prediction of tacrolimus AUC (root mean squared prediction error < 10%), which was not well characterized using trough concentrations only (root mean squared prediction error >15%). CONCLUSIONS Several AEs (i.e. diarrhoea, dyspepsia, insomnia and neurological AE ratio) were associated with tacrolimus dose normalized AUCss,0-12h and clearance. Skin changes and acne were associated with dose-normalized maximum concentrations. To facilitate clinical implementation, a LSS was developed to predict AUCss,0-12h values using sparse patient data to efficiently assess projected immunosuppressive exposure and potentially minimize AE manifestations.
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Affiliation(s)
- Olivia Campagne
- Department of Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA.,Faculty of Pharmacy, Universités Paris Descartes-Paris Diderot, Paris, France
| | - Donald E Mager
- Department of Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA
| | - Daniel Brazeau
- Department of Pharmaceutical Sciences, College of Pharmacy, University of New England, Portland, ME, USA
| | - Rocco C Venuto
- Erie County Medical Center, Division of Nephrology; Department of Medicine: Nephrology Division; School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Kathleen M Tornatore
- Erie County Medical Center, Division of Nephrology; Department of Medicine: Nephrology Division; School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA.,Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, Immunosuppressive Pharmacology Research Program, University at Buffalo, Buffalo, NY, USA
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35
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Soliman KM, Posadas Salas AC, Taber DJ. Change in Mycophenolate and Tacrolimus Exposure by Transplant Vintage and Race. EXP CLIN TRANSPLANT 2018; 17:707-713. [PMID: 30570456 DOI: 10.6002/ect.2018.0055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Although both tacrolimus and mycophenolate have improved outcomes after kidney transplant, studies regarding effects of exposure on outcomes, specifically related to racial disparities, are sparse. MATERIALS AND METHODS In this 8-year longitudinal cohort study of adult kidney transplant recipients, mycophenolate and tacrolimus levels were compared across transplant vintage stratified by non-African Americans versus African Americans. Data were analyzed with standard univariate tests and multivariable regression models. RESULTS Our study included 1217 patients (transplanted from 2005-2013) who had tacrolimus and myco-phenolate exposure data, with follow-up through 2015 (53.7% were African Americans). Mean mycophenolate dose was 1672 ± 463 mg/day during the first 3 years posttransplant. Although transplant vintage did not appreciably impact mycophenolate dosing in non-African Americans (0.7 mg/day/y; P = .903), doses significantly decreased in African Americans across transplant vintage (-20.5 mg/day/y; P < .001). Rate of mycophenolate being held or discontinued based on transplant vintage significantly increased in African Americans but did not change in non-African Americans. At the beginning of the study, mean tacrolimus levels were lower in African Americans; however, levels then slightly decreased in non-African Americans (-0.03 ng/mL/y; P = .279) and slightly increased in African Americans (+0.03 ng/mL/y; P = .247), with similar levels by 2013. Higher tacrolimus levels were protective against rejection in African Americans only but were protective against death-censored graft loss in both race/ethnicity groups. Mycophenolate dosing had no appreciable impact on outcomes in African Americans, but higher mycophenolate dosing was a significant risk factor for death-censored graft loss in non-African Americans. CONCLUSIONS Tacrolimus and mycophenolate exposure levels have significantly changed over time and differed by race/ethnicity. In non-African Americans, those transplanted more recently tended to have lower tacrolimus but similar mycophenolate exposure. Although mycophenolate exposure in African Americans has recently decreased, tacrolimus has increased. Differences in outcomes likely reflect improved understanding of immunosuppressant tolerability by recipient race/ethnicity.
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Affiliation(s)
- Karim M Soliman
- From the Division of Nephrology and Hypertension, Department of Medicine Medical University of South Carolina, Charleston, South Carolina, USA and the Cairo University, Division of Nephrology, Department of Medicine, Cairo, Egypt
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36
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Evaluation of Multiple Linear Regression-Based Limited Sampling Strategies for Enteric-Coated Mycophenolate Sodium in Adult Kidney Transplant Recipients. Ther Drug Monit 2018; 40:195-201. [PMID: 29461443 DOI: 10.1097/ftd.0000000000000486] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Although multiple linear regression-based limited sampling strategies (LSSs) have been published for enteric-coated mycophenolate sodium, none have been evaluated for the prediction of subsequent mycophenolic acid (MPA) exposure. This study aimed to examine the predictive performance of the published LSS for the estimation of future MPA area under the concentration-time curve from 0 to 12 hours (AUC0-12) in renal transplant recipients. METHODS Total MPA plasma concentrations were measured in 20 adult renal transplant patients on 2 occasions a week apart. All subjects received concomitant tacrolimus and were approximately 1 month after transplant. Samples were taken at 0, 0.33, 0.5, 1, 1.5, 2, 2.5, 3, 3.5, 4, 6, and 8 hours and 0, 0.25, 0.5, 0.75, 1, 1.25, 1.5, 2, 3, 4, 6, 9, and 12 hours after dose on the first and second sampling occasion, respectively. Predicted MPA AUC0-12 was calculated using 19 published LSSs and data from the first or second sampling occasion for each patient and compared with the second occasion full MPA AUC0-12 calculated using the linear trapezoidal rule. Bias (median percentage prediction error) and imprecision (median absolute prediction error) were determined. RESULTS Median percentage prediction error and median absolute prediction error for the prediction of full MPA AUC0-12 were <15% for 4 LSSs, using the data from the same (second) occasion. One equation (1.583C1 + 0.765C2 + 0.369C2.5 + 0.748C3 + 1.518C4 + 2.158C6 + 3.292C8 + 3.6690) showed bias and imprecision <15% for the prediction of future MPA AUC0-12, where the predicted AUC0-12 from the first occasion was compared with the full AUC0-12 from the second. All LSSs with an acceptable predictive performance included concentrations taken at least 6 hours after the dose. CONCLUSIONS Only one LSS had an acceptable bias and precision for future estimation. Accurate dosage prediction using a multiple linear regression-based LSS was not possible without concentrations up to at least 8 hours after the dose.
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Improved Pulse Wave Velocity and Renal Function in Individualized Calcineurin Inhibitor Treatment by Immunomonitoring: The Randomized Controlled Calcineurin Inhibitor-Sparing Trial. Transplantation 2018; 102:510-520. [PMID: 29077654 DOI: 10.1097/tp.0000000000001973] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND A new immune monitoring tool which assesses the expression of nuclear factor of activated T cells (NFAT)-regulated genes measures the functional effects of cyclosporine A. This is the first prospective randomized controlled study to compare standard pharmacokinetic monitoring by cyclosporine trough levels to NFAT-regulated gene expression (NFAT-RE). METHODS Expression of the NFAT-regulated genes was determined by qRT-PCR at cyclosporine trough and peak level. Cardiovascular risk was assessed by change of pulse wave velocity from baseline to month 6. Clinical follow-up was 12 months. RESULTS In total, 55 stable kidney allograft recipients were enrolled. Mean baseline residual NFAT-RE was 13.1 ± 9.1%. Patients in the NFAT-RE group showed a significant decline in pulse wave velocity from baseline to month 6 versus the standard group (-1.7 ± 2.0 m/s vs 0.4 ± 1.4 m/s, P < 0.001). Infections occurred more often in the standard group compared with the immune monitoring group. No opportunistic infections occurred with NFAT-RE monitoring. At 12 months of follow-up, renal function was significantly better with NFAT-RE versus standard monitoring (Nankivell glomerular filtration rate: 68.5 ± 17.4 mL/min vs 57.2 ± 19.0 mL/min; P = 0.009). CONCLUSIONS NFAT-RE as translational immune monitoring tool proved efficacious and safe in individualizing cyclosporine therapy, with the opportunity to reduce the cardiovascular risk and improve long-term renal allograft function.
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Iovino L, Taddei R, Bindi ML, Morganti R, Ghinolfi D, Petrini M, Biancofiore G. Clinical use of an immune monitoring panel in liver transplant recipients: A prospective, observational study. Transpl Immunol 2018; 52:45-52. [PMID: 30414446 DOI: 10.1016/j.trim.2018.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 11/05/2018] [Accepted: 11/05/2018] [Indexed: 02/07/2023]
Abstract
Immunosuppressive therapy greatly contributed to making liver transplantation the standard treatment for end-stage liver diseases. However, it remains difficult to predict and measure the efficacy of pharmacological immunosuppression. Therefore, we used a panel of standardized, commonly available, biomarkers with the aim to describe their changes in the first 3 weeks after the transplant procedure and assess if they may help therapeutic drug monitoring in better tailoring the dose of the immunosuppressive drugs. We prospectively studied 72 consecutive patients from the day of liver transplant (post-operative day #0) until the post-operative day #21. Leukocytes, neutrophils, lymphocytes (CD4+, CD8+), natural killer cells, monocytes, immunoglobulins and tacrolimus serum levels were measured on peripheral blood (at day 0, 3, 7, 14, 21 after surgery). Patients who developed infections showed significantly higher CD64+ monocytes on post operative day #7. IgG levels were lower on post operative day #3 among patients who later developed infections. We also found that a sharp decrease in IgA from post operative day #0 to 3 (-226 mg/dL in the ROC curve analysis) strongly correlates with the onset of infections among HCV- patients. No specific markers of rejection emerged from the tested panel of markers. Our results show that some early changes in peripheral blood white cells and immunoglobulins may predict the onset of infections and may be useful in modulating the immunosuppressive therapy. However, a panel of commonly available, standardized biomarkers do not support in improving therapeutic drug monitoring ability to individualize immunosuppressive drugs dosing.
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Affiliation(s)
- Lorenzo Iovino
- Hematology Division, University School of Medicine, Via Roma, 56100 Pisa, Italy; Program in Immunology, Clinical Research Division and Immunotherapy Integrated Research Center, Fred Hutchinson Cancer Research Center, Seattle (WA), USA
| | - Riccardo Taddei
- Transplant Anesthesia and Critical Care, Azienda Ospedaliera Universitaria Pisana, University School of Medicine, Via Paradisa, 2, 56100 Pisa, Italy
| | - Maria Lucia Bindi
- Transplant Anesthesia and Critical Care, Azienda Ospedaliera Universitaria Pisana, University School of Medicine, Via Paradisa, 2, 56100 Pisa, Italy
| | - Riccardo Morganti
- Department of Clinical and Experimental Medicine, University School of Medicine, Via Roma, 56100 Pisa, Italy
| | - Davide Ghinolfi
- Liver Transplant Surgery, Azienda Ospedaliera Universitaria Pisana, University School of Medicine, Via Paradisa, 2, 56100 Pisa, Italy
| | - Mario Petrini
- Hematology Division, University School of Medicine, Via Roma, 56100 Pisa, Italy
| | - Gianni Biancofiore
- Transplant Anesthesia and Critical Care, Azienda Ospedaliera Universitaria Pisana, University School of Medicine, Via Paradisa, 2, 56100 Pisa, Italy.
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Campagne O, Mager DE, Tornatore KM. Population Pharmacokinetics of Tacrolimus in Transplant Recipients: What Did We Learn About Sources of Interindividual Variabilities? J Clin Pharmacol 2018; 59:309-325. [PMID: 30371942 DOI: 10.1002/jcph.1325] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 09/18/2018] [Indexed: 12/24/2022]
Abstract
Tacrolimus, a calcineurin inhibitor, is a common immunosuppressant prescribed after organ transplantation and has notable inter- and intrapatient pharmacokinetic variability. The sources of variability have been investigated using population pharmacokinetic modeling over the last 2 decades. This article provides an updated synopsis on published nonlinear mixed-effects analyses developed for tacrolimus in transplant recipients. The objectives were to establish a detailed overview of the current data and to investigate covariate relationships determined by the models. Sixty-three published analyses were reviewed, and data regarding the study design, modeling approach, and resulting findings were extracted and summarized. Most of the studies investigated tacrolimus pharmacokinetics in adult and pediatric renal and liver transplants after administration of the immediate-release formulation. Model structures largely depended on the study sampling strategy, with ∼50% of studies developing a 1-compartment model using trough concentrations and a 2-compartment model with delayed absorption from intensive sampling. The CYP3A5 genotype, as a covariate, consistently impacted tacrolimus clearance, and dosing adjustments were required to achieve similar drug exposure among patients. Numerous covariates were identified as sources of interindividual variability on tacrolimus pharmacokinetics with limited consistency across these studies, which may be the result of the study designs. Additional analyses are required to further evaluate the potential impact of these covariates and the clinical implementation of these models to guide tacrolimus dosing recommendations. This article may be useful for guiding the design of future population pharmacokinetic studies and provides recommendations for the selection of an existing optimal model to individualize tacrolimus therapy.
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Affiliation(s)
- Olivia Campagne
- Department of Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA.,Faculty of Pharmacy, Universités Paris Descartes-Paris Diderot, Paris, France
| | - Donald E Mager
- Department of Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA
| | - Kathleen M Tornatore
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, Immunosuppressive Pharmacology Research Program, Translational Pharmacology Research Core, NYS Center of Excellence in Bioinformatics and Life Sciences, University at Buffalo, Buffalo, NY, USA
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40
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Large-Scale Variability of Inpatient Tacrolimus Therapeutic Drug Monitoring at an Academic Transplant Center: A Retrospective Study. Ther Drug Monit 2018; 40:394-400. [DOI: 10.1097/ftd.0000000000000526] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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41
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Campagne O, Mager DE, Brazeau D, Venuto RC, Tornatore KM. Tacrolimus Population Pharmacokinetics and Multiple CYP3A5 Genotypes in Black and White Renal Transplant Recipients. J Clin Pharmacol 2018; 58:1184-1195. [PMID: 29775201 DOI: 10.1002/jcph.1118] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 02/13/2018] [Indexed: 01/08/2023]
Abstract
Tacrolimus exhibits inter-patient pharmacokinetic variability attributed to CYP3A5 isoenzymes and the efflux transporter, P-glycoprotein. Most black renal transplant recipients require higher tacrolimus doses compared to whites to achieve similar troughs when race-adjusted recommendations are used. An established guideline provides tacrolimus genotype dosing recommendations based on CYP3A5*1(W/T) and loss of protein function variants: CYP3A5*3 (rs776746), CYP3A5*6 (rs10264272), CYP3A5*7 (rs41303343) and may provide more comprehensive race-adjusted dosing recommendations. Our objective was to develop a tacrolimus population pharmacokinetic model evaluating demographic, clinical, and genomic factors in stable black and white renal transplant recipients. A secondary objective investigated race-based tacrolimus regimens and genotype-specific dosing. Sixty-seven recipients receiving oral tacrolimus and mycophenolic acid ≥6 months completed a 12-hour pharmacokinetic study. CYP3A5*3,*6,*7 and ABCB1 1236C>T, 2677G>T/A, 3435C>T polymorphisms were characterized. Patients were classified as extensive, intermediate, and poor metabolizers using a novel CYP3A5*3*6*7 metabolic composite. Modeling and simulation was performed with computer software (NONMEM 7.3, ICON Development Solutions; Ellicott City, Maryland). A 2-compartment model with first-order elimination and absorption with lag time best described the data. The CYP3A5*3*6*7 metabolic composite was significantly associated with tacrolimus clearance (P value < .05), which was faster in extensive (mean: 45.0 L/hr) and intermediate (29.5 L/hr) metabolizers than poor metabolizers (19.8 L/hr). Simulations support CYP3A5*3*6*7 genotype-based tacrolimus dosing to enhance general race-adjusted regimens, with dose increases of 1.5-fold and 2-fold, respectively, in intermediate and extensive metabolizers for comparable exposures to poor metabolizers. This model offers a novel approach to determine tacrolimus dosing adjustments that maintain comparable therapeutic exposure between black and white recipients with different CYP3A5 genotypes.
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Affiliation(s)
- Olivia Campagne
- Department of Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA.,Faculty of Pharmacy, Universités Paris Descartes-Paris Diderot, Paris, France
| | - Donald E Mager
- Department of Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA
| | - Daniel Brazeau
- Department of Pharmaceutical Sciences, College of Pharmacy, University of New England, Portland, ME, USA
| | - Rocco C Venuto
- Erie County Medical Center, Division of Nephrology, Department of Medicine, School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Kathleen M Tornatore
- Erie County Medical Center, Division of Nephrology, Department of Medicine, School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA.,Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, Immunosuppressive Pharmacology Research Program, Translational Pharmacology Research Core, NYS Center of Excellence in Bioinformatics and Life Sciences, University at Buffalo, Buffalo, NY, USA
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42
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Woodworth MH, Kraft CS, Meredith EJ, Mehta AK, Wang T, Mamo YT, Dhere T, Sitchenko KL, Patzer RE, Friedman-Moraco RJ. Tacrolimus concentration to dose ratio in solid organ transplant patients treated with fecal microbiota transplantation for recurrent Clostridium difficile infection. Transpl Infect Dis 2018; 20:e12857. [PMID: 29446866 PMCID: PMC5891373 DOI: 10.1111/tid.12857] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Revised: 10/16/2017] [Accepted: 11/26/2017] [Indexed: 12/29/2022]
Abstract
Fecal microbiota transplantation (FMT) is increasingly being performed for Clostridium difficile infection in solid organ transplant (SOT) patients; however, little is known about the potential pharmacokinetic or pharmacomicrobial effects this may have on tacrolimus levels. We reviewed the medical records of 10 SOT patients from September 2012-December 2016 who were taking tacrolimus at time of FMT for recurrent C. difficile infection. We compared the differences in tacrolimus concentration/dose ratio (C/D ratio) 3 months prior to FMT vs 3 months after FMT. The mean of the differences in C/D ratio calculated as (ng/mL)/(mg/kg/d) was -17.65 (95% CI -1.25 to 0.58) (ng/mL)/(mg/kg/d), P-value .43 by Wilcoxon signed-rank test. The mean of the differences in C/D ratio calculated as (ng/mL)/(mg/d) was -0.33 (95% CI -1.25 to 0.58) (ng/mL)/(mg/d), P-value .28 by Wilcoxon signed-rank test. Of these patients, 2/10 underwent allograft biopsy for allograft dysfunction in the year after FMT, with no evidence of allograft rejection on pathology. These preliminary data suggest that FMT may not predictably alter tacrolimus levels and support its safety for SOT patients however further study in randomized trials is needed.
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Affiliation(s)
- Michael H. Woodworth
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine
| | - Colleen S. Kraft
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine
- Department of Pathology, Emory University Hospital
| | | | - Aneesh K. Mehta
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine
- Department of Surgery, Division of Transplantation, Emory University School of Medicine
| | | | | | - Tanvi Dhere
- Department of Medicine, Division of Digestive Diseases Medicine, Emory University School of Medicine
| | - Kaitlin L. Sitchenko
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine
| | - Rachel E. Patzer
- Department of Surgery, Division of Transplantation, Emory University School of Medicine
- Department of Medicine, Division of Renal Medicine, Emory University School of Medicine
- Department of Epidemiology, Rollins School of Public Health
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43
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Andrews LM, Li Y, De Winter BCM, Shi YY, Baan CC, Van Gelder T, Hesselink DA. Pharmacokinetic considerations related to therapeutic drug monitoring of tacrolimus in kidney transplant patients. Expert Opin Drug Metab Toxicol 2017; 13:1225-1236. [PMID: 29084469 DOI: 10.1080/17425255.2017.1395413] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Tacrolimus (Tac) is the cornerstone of immunosuppressive therapy after solid organ transplantation and will probably remain so. Excluding belatacept, no new immunosuppressive drugs were registered for the prevention of acute rejection during the last decade. For several immunosuppressive drugs, clinical development halted because they weren't sufficiently effective or more toxic. Areas covered: Current methods of monitoring Tac treatment, focusing on traditional therapeutic drug monitoring (TDM), controversies surrounding TDM, novel matrices, pharmacogenetic and pharmacodynamic monitoring are discussed. Expert opinion: Due to a narrow therapeutic index and large interpatient pharmacokinetic variability, TDM has been implemented for individualization of Tac dose to maintain drug efficacy and minimize the consequences of overexposure. The relationship between predose concentrations and the occurrence of rejection or toxicity is controversial. Acute cellular rejection also occurs when the Tac concentration is within the target range, suggesting that Tac whole blood concentrations don't necessarily correlate with pharmacological effect. Intracellular Tac, the unbound fraction of Tac or pharmacodynamic monitoring could be better biomarkers/tools for adequate Tac exposure - research into this has been promising. Traditional TDM, perhaps following pre-emptive genotyping for Tac-metabolizing enzymes, must suffice for a few years before these strategies can be implemented in clinical practice.
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Affiliation(s)
- Louise M Andrews
- a Department of Hospital Pharmacy , Erasmus MC, University Medical Center Rotterdam , Rotterdam , The Netherlands
| | - Yi Li
- a Department of Hospital Pharmacy , Erasmus MC, University Medical Center Rotterdam , Rotterdam , The Netherlands.,b Department of Laboratory Medicine , West China Hospital of Sichuan University , Chengdu , China
| | - Brenda C M De Winter
- a Department of Hospital Pharmacy , Erasmus MC, University Medical Center Rotterdam , Rotterdam , The Netherlands
| | - Yun-Ying Shi
- c Department of Nephrology , West China Hospital of Sichuan University , Chengdu , China
| | - Carla C Baan
- d Department of Internal Medicine , Erasmus MC, University Medical Center Rotterdam , Rotterdam , The Netherlands
| | - Teun Van Gelder
- a Department of Hospital Pharmacy , Erasmus MC, University Medical Center Rotterdam , Rotterdam , The Netherlands.,d Department of Internal Medicine , Erasmus MC, University Medical Center Rotterdam , Rotterdam , The Netherlands
| | - Dennis A Hesselink
- d Department of Internal Medicine , Erasmus MC, University Medical Center Rotterdam , Rotterdam , The Netherlands
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Goldsmith PM, Bottomley MJ, Okechukwu O, Ross VC, Ghita R, Wandless D, Falconer SJ, Papachristos S, Nash P, Androshchuk V, Clancy M. Impact of intrapatient variability (IPV) in tacrolimus trough levels on long-term renal transplant function: multicentre collaborative retrospective cohort study protocol. BMJ Open 2017; 7:e016144. [PMID: 28756385 PMCID: PMC5642769 DOI: 10.1136/bmjopen-2017-016144] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION High intrapatient variability (IPV) in tacrolimus trough levels has been shown to be associated with higher rates of renal transplant failure. There is no consensus on what level of IPV constitutes a risk of graft loss. The establishment of such a threshold could help to guide clinicians in identifying at-risk patients to receive targeted interventions to improve IPV and thus outcomes. METHODS AND ANALYSIS A multicentre Transplant Audit Collaborative has been established to conduct a retrospective study examining tacrolimus IPV and renal transplant outcomes. Patients in receipt of a renal transplant at participating centres between 2009 and 2014 and fulfilling the inclusion criteria will be included in the study. The aim is to recruit a minimum of 1600 patients with follow-up spanning at least 2 years in order to determine a threshold IPV above which a renal transplant recipient would be considered at increased risk of graft loss. The study also aims to determine any national or regional trends in IPV and any demographic associations. ETHICS AND DISSEMINATION Consent will not be sought from patients whose data are used in this study as no additional procedures or information will be required from participants beyond that which would normally take place as part of clinical care. The study will be registered locally in each participating centre in line with local research and development protocols. It is anticipated that the results of this audit will be disseminated locally, in participating NHS Trusts, through national and international meetings and publications in peer-reviewed journals.
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Affiliation(s)
- Petra M Goldsmith
- Renal Transplant Unit, Royal Liverpool University Hospitals NHS Trust, Liverpool, UK
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Matthew J Bottomley
- Department of Nephrology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Okidi Okechukwu
- Department of Transplantation, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Victoria C Ross
- Department of Transplantation, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Ryan Ghita
- Department of Transplantation, NHS Greater Glasgow and Clyde, Glasgow, UK
| | | | | | - Stavros Papachristos
- Department of Transplantation, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Philip Nash
- Department of Nephrology, King's College Hospital NHS Foundation Trust, London, UK
| | - Vitaliy Androshchuk
- Department of Nephrology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Marc Clancy
- Department of Transplantation, NHS Lothian, Edinburgh, UK
- School of Medicine, Dentistry and Surgery, University of Glasgow, Glasgow, UK
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Tang J, Liu R, Zhang YL, Liu MZ, Hu YF, Shao MJ, Zhu LJ, Xin HW, Feng GW, Shang WJ, Meng XG, Zhang LR, Ming YZ, Zhang W. Application of Machine-Learning Models to Predict Tacrolimus Stable Dose in Renal Transplant Recipients. Sci Rep 2017; 7:42192. [PMID: 28176850 PMCID: PMC5296901 DOI: 10.1038/srep42192] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 01/06/2017] [Indexed: 01/08/2023] Open
Abstract
Tacrolimus has a narrow therapeutic window and considerable variability in clinical use. Our goal was to compare the performance of multiple linear regression (MLR) and eight machine learning techniques in pharmacogenetic algorithm-based prediction of tacrolimus stable dose (TSD) in a large Chinese cohort. A total of 1,045 renal transplant patients were recruited, 80% of which were randomly selected as the “derivation cohort” to develop dose-prediction algorithm, while the remaining 20% constituted the “validation cohort” to test the final selected algorithm. MLR, artificial neural network (ANN), regression tree (RT), multivariate adaptive regression splines (MARS), boosted regression tree (BRT), support vector regression (SVR), random forest regression (RFR), lasso regression (LAR) and Bayesian additive regression trees (BART) were applied and their performances were compared in this work. Among all the machine learning models, RT performed best in both derivation [0.71 (0.67–0.76)] and validation cohorts [0.73 (0.63–0.82)]. In addition, the ideal rate of RT was 4% higher than that of MLR. To our knowledge, this is the first study to use machine learning models to predict TSD, which will further facilitate personalized medicine in tacrolimus administration in the future.
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Affiliation(s)
- Jie Tang
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, P. R. China.,Institute of Clinical Pharmacology, Central South University; Hunan Key Laboratory of Pharmacogenetics, Changsha, 410078, Hunan, P. R. China
| | - Rong Liu
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, P. R. China.,Institute of Clinical Pharmacology, Central South University; Hunan Key Laboratory of Pharmacogenetics, Changsha, 410078, Hunan, P. R. China
| | - Yue-Li Zhang
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, P. R. China.,Institute of Clinical Pharmacology, Central South University; Hunan Key Laboratory of Pharmacogenetics, Changsha, 410078, Hunan, P. R. China
| | - Mou-Ze Liu
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, P. R. China.,Institute of Clinical Pharmacology, Central South University; Hunan Key Laboratory of Pharmacogenetics, Changsha, 410078, Hunan, P. R. China
| | - Yong-Fang Hu
- Peking University Third Hospital, Beijing, 100191, P. R. China
| | - Ming-Jie Shao
- Research Center of Chinese Health Ministry of Transplantation Medicine Engineering and Technology, Third Affiliated Hospital, Central South University, Changsha, 410013, Hunan, P. R. China
| | - Li-Jun Zhu
- Research Center of Chinese Health Ministry of Transplantation Medicine Engineering and Technology, Third Affiliated Hospital, Central South University, Changsha, 410013, Hunan, P. R. China
| | - Hua-Wen Xin
- Department of Clinical Pharmacology, Wuhan General Hospital of Guangzhou Command, Wuhan, 430070, Hubei, P. R. China
| | - Gui-Wen Feng
- Department of Renal Transplantation, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, P. R. China
| | - Wen-Jun Shang
- Department of Renal Transplantation, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, P. R. China
| | - Xiang-Guang Meng
- School of Basic Medical Sciences, Zhengzhou University, Zhengzhou, 450001, Henan, P. R. China
| | - Li-Rong Zhang
- School of Basic Medical Sciences, Zhengzhou University, Zhengzhou, 450001, Henan, P. R. China
| | - Ying-Zi Ming
- Research Center of Chinese Health Ministry of Transplantation Medicine Engineering and Technology, Third Affiliated Hospital, Central South University, Changsha, 410013, Hunan, P. R. China
| | - Wei Zhang
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, P. R. China.,Institute of Clinical Pharmacology, Central South University; Hunan Key Laboratory of Pharmacogenetics, Changsha, 410078, Hunan, P. R. China
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Thijs JL, de Bruin-Weller MS, Hijnen D. Current and Future Biomarkers in Atopic Dermatitis. Immunol Allergy Clin North Am 2017; 37:51-61. [DOI: 10.1016/j.iac.2016.08.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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47
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Pharmacokinetics, Pharmacodynamics and Pharmacogenomics of Immunosuppressants in Allogeneic Haematopoietic Cell Transplantation: Part I. Clin Pharmacokinet 2016; 55:525-50. [PMID: 26563168 DOI: 10.1007/s40262-015-0339-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Although immunosuppressive treatments and target concentration intervention (TCI) have significantly contributed to the success of allogeneic haematopoietic cell transplantation (alloHCT), there is currently no consensus on the best immunosuppressive strategies. Compared with solid organ transplantation, alloHCT is unique because of the potential for bidirectional reactions (i.e. host-versus-graft and graft-versus-host). Postgraft immunosuppression typically includes a calcineurin inhibitor (cyclosporine or tacrolimus) and a short course of methotrexate after high-dose myeloablative conditioning, or a calcineurin inhibitor and mycophenolate mofetil after reduced-intensity conditioning. There are evolving roles for the antithymyocyte globulins (ATGs) and sirolimus as postgraft immunosuppression. A review of the pharmacokinetics and TCI of the main postgraft immunosuppressants is presented in this two-part review. All immunosuppressants are characterized by large intra- and interindividual pharmacokinetic variability and by narrow therapeutic indices. It is essential to understand immunosuppressants' pharmacokinetic properties and how to use them for individualized treatment incorporating TCI to improve outcomes. TCI, which is mandatory for the calcineurin inhibitors and sirolimus, has become an integral part of postgraft immunosuppression. TCI is usually based on trough concentration monitoring, but other approaches include measurement of the area under the concentration-time curve (AUC) over the dosing interval or limited sampling schedules with maximum a posteriori Bayesian personalization approaches. Interpretation of pharmacodynamic results is hindered by the prevalence of studies enrolling only a small number of patients, variability in the allogeneic graft source and variability in postgraft immunosuppression. Given the curative potential of alloHCT, the pharmacodynamics of these immunosuppressants deserves to be explored in depth. Development of sophisticated systems pharmacology models and improved TCI tools are needed to accurately evaluate patients' exposure to drugs in general and to immunosuppressants in particular. Sequential studies, first without and then with TCI, should be conducted to validate the clinical benefit of TCI in homogenous populations; randomized trials are not feasible, because there are higher-priority research questions in alloHCT. In Part I of this article, we review the alloHCT process to facilitate optimal design of pharmacokinetic and pharmacodynamics studies. We also review the pharmacokinetics and TCI of calcineurin inhibitors and methotrexate.
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Bamoulid J, Staeck O, Halleck F, Khadzhynov D, Paliege A, Brakemeier S, Dürr M, Budde K. Immunosuppression and Results in Renal Transplantation. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.eursup.2016.04.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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49
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Andrews LM, De Winter BC, Van Gelder T, Hesselink DA. Consideration of the ethnic prevalence of genotypes in the clinical use of tacrolimus. Pharmacogenomics 2016; 17:1737-1740. [PMID: 27790923 DOI: 10.2217/pgs-2016-0136] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Louise M Andrews
- Department of Hospital Pharmacy, Erasmus Medical Center, Room Na-206, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Brenda Cm De Winter
- Department of Hospital Pharmacy, Erasmus Medical Center, Room Na-206, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Teun Van Gelder
- Department of Hospital Pharmacy, Erasmus Medical Center, Room Na-206, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.,Department of Internal Medicine, Nephrology & Transplantation, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Dennis A Hesselink
- Department of Internal Medicine, Nephrology & Transplantation, Erasmus Medical Center, Rotterdam, The Netherlands
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50
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Rausch L, Koenecke C, Koch HF, Kaltenborn A, Emmanouilidis N, Pape L, Lehner F, Arelin V, Baumann U, Schrem H. Matched-pair analysis: identification of factors with independent influence on the development of PTLD after kidney or liver transplantation. Transplant Res 2016; 5:6. [PMID: 27486513 PMCID: PMC4970231 DOI: 10.1186/s13737-016-0036-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 07/24/2016] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Post-transplant lymphoproliferative disorder (PTLD) adversely affects patients' long-term outcome. METHODS The paired t test and McNemar's test were applied in a retrospective 1:1 matched-pair analysis including 36 patients with PTLD and 36 patients without PTLD after kidney or liver transplantation. Matching criteria were age, gender, indication, type of transplantation, and duration of follow-up. All investigated PTLD specimen were histologically positive for EBV. Risk-adjusted multivariable regression analysis was used to identify independence of risk factors for PTLD detected in matched-pair analysis. The resultant prognostic model was assessed with ROC-curve analysis. RESULTS Patients suffering with PTLD had shorter mean survival (p = 0.004), more episodes of CMV infections or reactivations (p = 0.042), and fewer recipient HLA A2 haplotypes (p = 0.007), a tacrolimus-based immunosuppressive regimen (p = 0.052) and higher dosages of tacrolimus at hospital discharge (Tac dosage) (p = 0.052). Significant independent risk factors for PTLD were recipient HLA A2 (OR = 0.07, 95 % CI = 0.01-0.55, p = 0.011), higher Tac dosages (OR = 1.29, 95 % CI = 1.01-1.64, p = 0.040), and higher numbers of graft rejection episodes (OR = 0.38, 95 % CI = 0.17-0.87, p = 0.023). The following prognostic model for the prediction of PTLD demonstrated good model fit and a large area under the ROC curve (0.823): PTLD probability in % = Exp(y)/(1 + Exp(y)) with y = 0.671 - 1.096 × HLA A2-positive recipient + 0.151 × Tac dosage - 0.805 × number of graft rejection episodes. CONCLUSIONS This study suggests prognostic relevance for recipient HLA A2, CMV, and EBV infections or reactivations and strong initial tacrolimus-based immunosuppression. Patients with risk factors may benefit from intensified screening for PTLD.
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Affiliation(s)
- Lisa Rausch
- Core Facility Quality Management & Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Christian Koenecke
- Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Hans-Friedrich Koch
- Core Facility Quality Management & Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Alexander Kaltenborn
- Core Facility Quality Management & Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
- Trauma and Orthopedic Surgery, Federal Armed Forces Hospital Westerstede, Westerstede, Germany
| | - Nikos Emmanouilidis
- Core Facility Quality Management & Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
- General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Lars Pape
- Pediatric Nephrology, Hepatology and Metabolic Disorders, Hannover Medical School, Hannover, Germany
| | - Frank Lehner
- General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Viktor Arelin
- Core Facility Quality Management & Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
- Nephrology, Hannover Medical School, Hannover, Germany
| | - Ulrich Baumann
- Pediatric Nephrology, Hepatology and Metabolic Disorders, Hannover Medical School, Hannover, Germany
| | - Harald Schrem
- Core Facility Quality Management & Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
- General, Visceral and Transplant Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
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