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Parant F, Delignette MC, Charpiat B, Lacaille L, Lebosse F, Monneret G, Mohkam K, Mabrut JY, Aubrun F, Heyer L, Antonini T. Tacrolimus Monitoring in Liver Transplant Recipients, Posttransplant Cholestasis: A Comparative Between 2 Commercial Immunoassays and a Liquid Chromatography-Tandem Mass Spectrometry Method. Ther Drug Monit 2024:00007691-990000000-00213. [PMID: 38648663 DOI: 10.1097/ftd.0000000000001201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 12/23/2023] [Indexed: 04/25/2024]
Abstract
BACKGROUND Cholestasis commonly occurs after orthotopic liver transplantation. It can be extrahepatic because of mechanical obstruction or intrahepatic because of various causes. During cholestasis episodes, blood concentrations of tacrolimus (TAC) metabolites may increase, potentially affecting TAC concentrations measured by immunoassays. This study aimed to simultaneously evaluate the analytical performance of 2 TAC immunoassays, a quantitative microsphere system (QMS) immunoassay, and chemiluminescence microparticle immunoassay, using liquid chromatography-tandem mass spectrometry (LC-MS/MS) as a reference method in liver transplant recipients. METHODS This single-center study included 265 patients who underwent orthotopic liver transplantation. In total, 942 blood samples were collected. TAC trough concentrations were measured using LC-MS/MS and 2 immunoassays in parallel. The plasma concentrations of conjugated bilirubin were measured in all samples. The results were analyzed using Bland-Altman plots and Passing-Bablok regressions. RESULTS The Bland-Altman plot analysis showed that the TAC QMS immunoassay has a significant bias (+37%) compared with LC-MS/MS, and this bias was higher in patients with cholestasis with hyperbilirubinemia (≤+70% in patients with conjugated bilirubin >150 µmol/L). In comparison, the chemiluminescence microparticle immunoassay showed acceptable analytical performance in patients with hyperbilirubinemia (bias <10%). CONCLUSIONS In agreement with previous findings, the TAC QMS immunoassay showed a positive bias compared with LC-MS/MS. This bias is remarkably high in patients with cholestasis and hyperbilirubinemia, suggesting the cross-reactivity of TAC metabolites with the monoclonal antibody used in the QMS immunoassay.
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Affiliation(s)
- François Parant
- Service de Biochimie et Biologie Moléculaire, Laboratoire de Biologie Médicale Multi-Sites (LBMMS), Hôpital Lyon-Sud-Hospices Civils de Lyon, Pierre-Bénite, France
| | | | - Bruno Charpiat
- Service pharmaceutique, Hôpital de la Croix Rousse-Hospices Civils de Lyon, Lyon, France
| | - Louis Lacaille
- Service de Biochimie et Biologie Moléculaire, Laboratoire de Biologie Médicale Multi-Sites (LBMMS), Hôpital de la Croix Rousse-Hospices Civils de Lyon, Lyon, France
| | - Fanny Lebosse
- Service d'Hépatologie, Hôpital de la Croix Rousse-Hospices Civils de Lyon, Lyon, France
| | - Guillaume Monneret
- Laboratoire d'Immunologie, Hôpital Édouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Kayvan Mohkam
- Service de chirurgie générale, digestive et transplantations hépatiques et intestinales, Hôpital de la Croix Rousse-Hospices Civils de Lyon, France; and
| | - Jean-Yves Mabrut
- Service de chirurgie générale, digestive et transplantations hépatiques et intestinales, Hôpital de la Croix Rousse-Hospices Civils de Lyon, France; and
- Centre de Recherche en Cancérologie de Lyon, INSERM U1052, Lyon, France
| | - Frederic Aubrun
- Service d'Anesthésie Réanimation, Hôpital de la Croix Rousse-Hospices Civils de Lyon, Lyon, France
| | - Laurent Heyer
- Service d'Anesthésie Réanimation, Hôpital de la Croix Rousse-Hospices Civils de Lyon, Lyon, France
| | - Teresa Antonini
- Service d'Hépatologie, Hôpital de la Croix Rousse-Hospices Civils de Lyon, Lyon, France
- Centre de Recherche en Cancérologie de Lyon, INSERM U1052, Lyon, France
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Neuberger M, Sommerer C, Böhnisch S, Metzendorf N, Mehrabi A, Stremmel W, Gotthardt D, Zeier M, Weiss KH, Rupp C. Effect of mycophenolic acid on inosine monophosphate dehydrogenase (IMPDH) activity in liver transplant patients. Clin Res Hepatol Gastroenterol 2020; 44:543-550. [PMID: 31924555 DOI: 10.1016/j.clinre.2019.12.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 12/02/2019] [Accepted: 12/03/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Due to the development of immunosuppressants, the focus in transplanted patients has shifted from short-term to long-term survival as well as a better adjustment of these drugs in order to prevent over- and under-immunosuppression. Mycophenolic acid (MPA) is a noncompetitive inhibitor of inosine monophosphate dehydrogenase (IMPDH) and approved for prophylaxis of acute rejection after kidney, heart, and liver transplantation, where it has become a part of the standard therapy. Targeting inosine monophosphate IMPDH activity as a surrogate pharmacodynamic marker of MPA-induced immunosuppression may allow a more accurate assessment of efficacy and aid in limiting toxicity in liver transplanted patients. AIM Assess IMPDH-inhibition in liver transplant recipients and its impact on biliary/infectious complications, acute cellular rejection (ACR) and liver dependent survival. METHODS This observational cohort study comprises 117 liver transplanted patients that were treated with mycophenolate mofetil (MMF) for at least 3 months. Blood samples (BS) were collected and MPA serum level and IMPDH activity were measured before (t(0)), 30minutes (t(30)) and 2h after (t(120)) MMF morning dose administration. Regarding MPA, we assessed the area under the curve (AUC). Patients were prospectively followed up for one year and assessed for infectious and biliary complications, episodes of ACR and liver dependent survival. RESULTS The MPA levels showed a broad interindividual variability at t(0) (2.0±1.8ng/ml), t(30) (12.7±9.0ng/ml) and t(120) (7.5±4.3ng/ml). Corresponding IMPDH activity was at t(o) (23.2±9.5 nmol/h/mg), at t(30) (16.3±8.8 nmol/h/mg) and t(120) (18.2±8.7 nmol/h/mg). With regard to MPA level we found no correlation with infectious or biliary complications within the follow-up period. Patients with baseline IMPDH(a) below the median had significant more viral infections (6 (10.2%) vs. 17 (29.3%); P=0.009) with especially more cytomegalovirus (CMV) infections (1 (3.4%) vs. 6 (21.4%); P=0.03)). Furthermore, patients with baseline IMPDH(a) above the median developed more often non-anastomotic biliary strictures (8 (13.6%) vs. 1 (1.7%), P=0.03). We found the group reaching the combined clinical endpoint of death and re-transplantation showing significantly lower MPA baseline values (t(0) 0.9±0.7 vs. 2.1±1.8μg/ml Mann-Whitney-U: P=0.02). We calculated a simplified MPA(AUC) with the MPA level at baseline, 30 and 120minutes after MPA administration. Whereas we found no differences with regard to baseline characteristics at entry into the study patients with MPA (AUC) below the median experienced significantly more often the combined clinical endpoint (12.1% (7/58) vs. 0.0% (0/57); P=0.002) and had a reduced actuarial re-transplantation-free survival (1.0 year vs. 0.58 years; Log-rank: P=0.007) during the prospective one-year follow-up period. In univariate and multivariate analysis including gender, age, BMI, ACR, MPA (AUC) and IMPDH(a) only BMI, MPA (AUC) and IMPDH(a) were independently associated with reduced actuarial re-transplantation-free survival. CONCLUSION MPA-levels and IMPDH-activity in liver transplanted patients allows individual risk assessment. Patients with higher IMPDH inhibition acquire more often viral infections. Insufficient IMPDH inhibition is associated with development of non-anastomotic bile duct strictures and reduced re-transplantation-free survival.
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Affiliation(s)
- M Neuberger
- University Hospital Heidelberg, Internal Medicine IV, 69120 Heidelberg, Germany
| | - C Sommerer
- University Hospital Heidelberg, Division of Nephrology, 69120 Heidelberg, Germany
| | - S Böhnisch
- University Hospital Heidelberg, Division of Nephrology, 69120 Heidelberg, Germany
| | - N Metzendorf
- University Hospital Heidelberg, Division of Nephrology, 69120 Heidelberg, Germany
| | - A Mehrabi
- University of Heidelberg, Department of General, Visceral, and Transplantation Surgery, 69120 Heidelberg, Germany
| | - W Stremmel
- University Hospital Heidelberg, Internal Medicine IV, 69120 Heidelberg, Germany
| | - D Gotthardt
- University Hospital Heidelberg, Internal Medicine IV, 69120 Heidelberg, Germany
| | - M Zeier
- University Hospital Heidelberg, Division of Nephrology, 69120 Heidelberg, Germany
| | - K H Weiss
- University Hospital Heidelberg, Internal Medicine IV, 69120 Heidelberg, Germany
| | - C Rupp
- University Hospital Heidelberg, Internal Medicine IV, 69120 Heidelberg, Germany.
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Lao MY, Ma T, Bai XL, Zhang XZ, Tang TY, Liang TB. Probable sirolimus-induced rupture of arterial anastomosis after liver transplantation in a patient intolerant of tacrolimus. Hepatobiliary Pancreat Dis Int 2019; 18:398-400. [PMID: 31053410 DOI: 10.1016/j.hbpd.2019.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 04/15/2019] [Indexed: 02/05/2023]
Affiliation(s)
- Meng-Yi Lao
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou 310003, China; Key Laboratory of Pancreatic Disease of Zhejiang Province, Hangzhou 310009, China
| | - Tao Ma
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou 310003, China; Key Laboratory of Pancreatic Disease of Zhejiang Province, Hangzhou 310009, China
| | - Xue-Li Bai
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou 310003, China; Key Laboratory of Pancreatic Disease of Zhejiang Province, Hangzhou 310009, China
| | - Xiao-Zhen Zhang
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou 310003, China; Key Laboratory of Pancreatic Disease of Zhejiang Province, Hangzhou 310009, China
| | - Tian-Yu Tang
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou 310003, China; Key Laboratory of Pancreatic Disease of Zhejiang Province, Hangzhou 310009, China
| | - Ting-Bo Liang
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou 310003, China; Key Laboratory of Pancreatic Disease of Zhejiang Province, Hangzhou 310009, China.
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Brussee JM, Krekels EHJ, Calvier EAM, Palić S, Rostami-Hodjegan A, Danhof M, Barrett JS, de Wildt SN, Knibbe CAJ. A Pediatric Covariate Function for CYP3A-Mediated Midazolam Clearance Can Scale Clearance of Selected CYP3A Substrates in Children. AAPS JOURNAL 2019; 21:81. [PMID: 31250333 PMCID: PMC6597607 DOI: 10.1208/s12248-019-0351-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 06/07/2019] [Indexed: 12/12/2022]
Abstract
Recently a framework was presented to assess whether pediatric covariate models for clearance can be extrapolated between drugs sharing elimination pathways, based on extraction ratio, protein binding, and other drug properties. Here we evaluate when a pediatric covariate function for midazolam clearance can be used to scale clearance of other CYP3A substrates. A population PK model including a covariate function for clearance was developed for midazolam in children aged 1–17 years. Commonly used CYP3A substrates were selected and using the framework, it was assessed whether the midazolam covariate function accurately scales their clearance. For eight substrates, reported pediatric clearance values were compared numerically and graphically with clearance values scaled using the midazolam covariate function. For sildenafil, clearance values obtained with population PK modeling based on pediatric concentration-time data were compared with those scaled with the midazolam covariate function. According to the framework, a midazolam covariate function will lead to systemically accurate clearance scaling (absolute prediction error (PE) < 30%) for CYP3A substrates binding to albumin with an extraction ratio between 0.35 and 0.65 when binding < 10% in adults, between 0.05 and 0.55 when binding > 90%, and with an extraction ratio ranging between these values when binding between 10 and 90%. Scaled clearance values for eight commonly used CYP3A substrates were reasonably accurate (PE < 50%). Scaling of sildenafil clearance was accurate (PE < 30%). We defined for which CYP3A substrates a pediatric covariate function for midazolam clearance can accurately scale plasma clearance in children. This scaling approach may be useful for CYP3A substrates with scarce or no available pediatric PK information.
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Affiliation(s)
- Janneke M Brussee
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research (LACDR), Leiden University, Leiden, The Netherlands
| | - Elke H J Krekels
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research (LACDR), Leiden University, Leiden, The Netherlands
| | - Elisa A M Calvier
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research (LACDR), Leiden University, Leiden, The Netherlands
| | - Semra Palić
- Dutch Cancer Institute (NKI), Amsterdam, The Netherlands
| | - Amin Rostami-Hodjegan
- Centre for Applied Pharmacokinetic Research, University of Manchester, Manchester, UK.,Simcyp Limited (A Certara Company), Sheffield, UK
| | - Meindert Danhof
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research (LACDR), Leiden University, Leiden, The Netherlands
| | - Jeffrey S Barrett
- Bill & Melinda Gates Medical Research Institute, Cambridge, Massachusetts, USA.,Department of Pediatrics, Division of Clinical Pharmacology & Therapeutics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Saskia N de Wildt
- Department of Pharmacology and Toxicology, Radboud University Medical Centre, Nijmegen, The Netherlands.,Intensive Care and Department of Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Catherijne A J Knibbe
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research (LACDR), Leiden University, Leiden, The Netherlands. .,Department of Clinical Pharmacy, St. Antonius Hospital, PO Box 2500, 3430, EM, Nieuwegein, The Netherlands.
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Longitudinal Study of Tacrolimus in Lymphocytes During the First Year After Kidney Transplantation. Ther Drug Monit 2018; 40:558-566. [DOI: 10.1097/ftd.0000000000000539] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Pereira MS, Wagner VP, Munerato MC, Clausell NO, Goldraich LA, Martins MAT, Martins MD, Carrard VC. Chronic painful oral ulcers in a heart transplant recipient. Oral Surg Oral Med Oral Pathol Oral Radiol 2018; 127:468-476. [PMID: 29555363 DOI: 10.1016/j.oooo.2018.01.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 12/20/2017] [Accepted: 01/02/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Manoela S Pereira
- Department of Oral Medicine, Porto Alegre Clinics Hospital (HCPA/UFRGS), Porto Alegre, RS, Brazil
| | - Vivian P Wagner
- Department of Oral Pathology, Dental School, Federal University of Rio do Sul, Porto Alegre, RS, Brazil
| | - Maria Cristina Munerato
- Department of Oral Medicine, Porto Alegre Clinics Hospital (HCPA/UFRGS), Porto Alegre, RS, Brazil
| | - Nadine O Clausell
- Post-Graduate Program in Cardiovascular Sciences, Faculty of Medicine, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Livia A Goldraich
- Heart Failure and Transplant Program, Porto Alegre Clinics Hospital (HCPA/UFRGS), Porto Alegre, RS, Brazil
| | - Marco Antonio T Martins
- Department of Oral Medicine, Porto Alegre Clinics Hospital (HCPA/UFRGS), Porto Alegre, RS, Brazil
| | - Manoela D Martins
- Department of Oral Medicine, Porto Alegre Clinics Hospital (HCPA/UFRGS), Porto Alegre, RS, Brazil; Department of Oral Pathology, Dental School, Federal University of Rio do Sul, Porto Alegre, RS, Brazil
| | - Vinicius C Carrard
- Department of Oral Medicine, Porto Alegre Clinics Hospital (HCPA/UFRGS), Porto Alegre, RS, Brazil; Department of Oral Pathology, Dental School, Federal University of Rio do Sul, Porto Alegre, RS, Brazil.
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Shi YY, Hesselink DA, van Gelder T. Pharmacokinetics and pharmacodynamics of immunosuppressive drugs in elderly kidney transplant recipients. Transplant Rev (Orlando) 2015; 29:224-30. [PMID: 26048322 DOI: 10.1016/j.trre.2015.04.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 04/29/2015] [Accepted: 04/30/2015] [Indexed: 02/05/2023]
Abstract
Elderly patients are a fast growing population among transplant recipients over the past decades. Both the innate and adaptive immune reactivity decrease with age, which is believed to contribute to the decreased incidence of acute rejection and increased infectious death rate in elderly transplant recipients. In contrast to recipient age, donor age is associated with a higher incidence of acute rejection. Pharmacokinetic studies in renal transplant recipients show that CNI troughs are >5% higher in elderly compared to younger patients given the same dose normalized by body weight. This may impact the starting dose of tacrolimus and cyclosporine. Possibly in elderly patients the intracellular (in lymphocyte) concentrations are relatively high in relation to the whole blood concentration, resulting in a stronger pharmacodynamic effect at the same whole blood trough concentration. For cyclosporine this has been shown, but it is not clear if the same is true for other immunosuppressive drugs. Pharmacodynamic studies have compared the inhibition of target enzymes, or more downstream effects of immunosuppressive drugs, in younger and older patients. Measurement of nuclear factor of activated T-cell (NFAT)-regulated gene expression (RGE), a pharmacodynamic read-out of CNI, is a promising biomarker of immunosuppression. Low levels of NFAT RGE are associated with increased risk of infection and non-melanoma skin cancer in elderly patients. Clinical trials to evaluate the safety and efficacy of immunosuppression regimens in this specific patient population, which is underrepresented in published trials, are lacking. More studies in elderly patients are needed to investigate the impact of age on the pharmacokinetics or pharmacodynamics of immunosuppressive drugs, and to decide on the optimal regimen and target levels for elderly transplant recipients.
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Affiliation(s)
- Yun-Ying Shi
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Department of Nephrology, West China Hospital of Sichuan University, Chengdu, China
| | - Dennis A Hesselink
- Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Teun van Gelder
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.
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