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Paul S, Nirmal G, Chadha V, Sharma R, Kochar I, Jerath N, Vohra R, Kharya G. Sirolimus-induced Hypertriglyceridemia Leads to Acute Pancreatitis and Diabetic Ketoacidosis Post Stem Cell Transplant for Sickle Cell Disease. J Pediatr Hematol Oncol 2024; 46:e91-e93. [PMID: 38019672 DOI: 10.1097/mph.0000000000002793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 10/18/2023] [Indexed: 12/01/2023]
Abstract
Sirolimus (mammalian target of rapamycin inhibitor) is a potent immunosuppressive agent, used in patients receiving hematopoietic stem cell transplant (HSCT) for Graft vs Host disease prophylaxis. Compared to calcineurin inhibitors, sirolimus has no neurotoxicity or nephrotoxicity, but sirolimus causes dose-dependent thrombocytopenia, leukopenia, delayed wound healing, hyperlipidemia, and hypertriglyceridemia. Here we report a case of acute pancreatitis and diabetic ketoacidosis in a patient with sickle cell disease post haploidentical family donor HSCT which was managed conservatively without plasmapheresis. Based on our review of the literature, this is the first reported case of developing acute pancreatitis as an adverse effect of sirolimus-induced hypertriglyceridemia leading to diabetic ketoacidosis in a recipient of HSCT.
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Affiliation(s)
- Subhasish Paul
- Department of Pediatrics, Centre for Bone Marrow Transplant & Cellular Therapy
| | - Garima Nirmal
- Department of Pediatrics, Centre for Bone Marrow Transplant & Cellular Therapy
| | - Vaibhav Chadha
- Department of Pediatrics, Centre for Bone Marrow Transplant & Cellular Therapy
| | - Rahul Sharma
- Department of Pediatrics, Centre for Bone Marrow Transplant & Cellular Therapy
| | | | - Namith Jerath
- Pediatrics, Indraprastha Apollo Hospital, Delhi, India
| | - Rohit Vohra
- Pediatrics, Indraprastha Apollo Hospital, Delhi, India
| | - Gaurav Kharya
- Department of Pediatrics, Centre for Bone Marrow Transplant & Cellular Therapy
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2
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Aziz F, Jorgenson M, Garg N, Parajuli S, Mohamed M, Raza F, Mandelbrot D, Djamali A, Dhingra R. New Approaches to Cardiovascular Disease and Its Management in Kidney Transplant Recipients. Transplantation 2022; 106:1143-1158. [PMID: 34856598 DOI: 10.1097/tp.0000000000003990] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Cardiovascular events, including ischemic heart disease, heart failure, and arrhythmia, are common complications after kidney transplantation and continue to be leading causes of graft loss. Kidney transplant recipients have both traditional and transplant-specific risk factors for cardiovascular disease. In the general population, modification of cardiovascular risk factors is the best strategy to reduce cardiovascular events; however, studies evaluating the impact of risk modification strategies on cardiovascular outcomes among kidney transplant recipients are limited. Furthermore, there is only minimal guidance on appropriate cardiovascular screening and monitoring in this unique patient population. This review focuses on the limited scientific evidence that addresses cardiovascular events in kidney transplant recipients. Additionally, we focus on clinical management of specific cardiovascular entities that are more prevalent among kidney transplant recipients (ie, pulmonary hypertension, valvular diseases, diastolic dysfunction) and the use of newer evolving drug classes for treatment of heart failure within this cohort of patients. We note that there are no consensus documents describing optimal diagnostic, monitoring, or management strategies to reduce cardiovascular events after kidney transplantation; however, we outline quality initiatives and research recommendations for the assessment and management of cardiovascular-specific risk factors that could improve outcomes.
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Affiliation(s)
- Fahad Aziz
- Division of Nephrology, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Margaret Jorgenson
- Department of Pharmacology, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Neetika Garg
- Division of Nephrology, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Sandesh Parajuli
- Division of Nephrology, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Maha Mohamed
- Division of Nephrology, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Farhan Raza
- Cardiovascular Division, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Didier Mandelbrot
- Division of Nephrology, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Arjang Djamali
- Division of Nephrology, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
- Division of Transplantation, Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Ravi Dhingra
- Cardiovascular Division, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
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3
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Fida N, Tantrachoti P, Guha A, Bhimaraj A. Post-transplant Management in Heart Transplant Recipients: New Drugs and Prophylactic Strategies. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021. [DOI: 10.1007/s11936-021-00933-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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4
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Pang C, Evans N, Jethwa P, Papadopoulou A, Khalifa M, Tsui J, Hamilton G, Lim CS, Brookes J. Single Center Experience of Sirolimus Therapy in Head and Neck Low-flow Vascular Malformations. Vasc Endovascular Surg 2021; 55:482-490. [PMID: 33878964 DOI: 10.1177/15385744211010378] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Recently, studies have shown that sirolimus is clinically efficacious in the treatment of some low-flow vascular malformations (LFVM). This study aimed to assess the efficacy and safety of sirolimus in treating complex head and neck (H&N) LFVM that were challenging and/or refractory to standard treatment. METHODS Each patient had baseline and 6-months assessments consisting of clinical history and examination, quality of life (QoL) questionnaires, laboratory investigations, MRI and medical photography. Patients were followed up 1-week and then 1-monthly for 6-months. Wilcoxon signed-rank test was used to compare pre-and 6-months treatment in all 8 domains of RAND 36-Item Short Form Health Survey (SF-36), hospital anxiety and depression scale (HADS), and visual analog score for pain (VAS-P). P < 0.05 was considered significant. RESULTS Seven patients (median age 43 years, range 23-65 years) were recruited. Six patients completed the six-months course of therapy with 1 patient withdrawing due to intolerable side effects. All six patients reported reduction of swelling with and without other symptom improvement related to the vascular malformations while on treatment. However, at 1-month review after discontinuation of sirolimus, 5 patients reported return of initial symptoms. Overall, patients demonstrated an improvement in QoL six-months treatment but there was no statistical significance (P > 0.05) in all 8 domains of SF-36, HADS and VAS-P. Five patients demonstrated a minimum 10% decrease in lesion size six-months treatment (median 21%, range 13-40%). A Wilcoxon signed-rank test showed that sirolimus treatment did elicit a statistically significant change in lesion size in either direction (Z = -1.992, P = 0.046). The most common side effects found were dyslipidaemia (n-4) and mouth ulcers (n = 2). CONCLUSION In our preliminary experience, sirolimus is effective and safe in treating patients with complex H&N LFVM. This provides an alternative treatment where standard treatment is challenging and/or refractory.
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Affiliation(s)
- Calver Pang
- Department of Vascular Surgery, 4965Royal Free London NHS Foundation Trust, London, United Kingdom.,Department of Surgical Biotechnology, Division of Surgery & Interventional Science, Faculty of Medical Sciences, University College London, United Kingdom
| | - Nicholas Evans
- Department of Vascular Surgery, 4965Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Poonam Jethwa
- Department of Pharmacy, 4965Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Anthie Papadopoulou
- Department of Interventional Radiology, 4965Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Mohamed Khalifa
- Department of Interventional Radiology, 4965Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Janice Tsui
- Department of Vascular Surgery, 4965Royal Free London NHS Foundation Trust, London, United Kingdom.,Department of Surgical Biotechnology, Division of Surgery & Interventional Science, Faculty of Medical Sciences, University College London, United Kingdom
| | - George Hamilton
- Department of Vascular Surgery, 4965Royal Free London NHS Foundation Trust, London, United Kingdom.,Department of Surgical Biotechnology, Division of Surgery & Interventional Science, Faculty of Medical Sciences, University College London, United Kingdom
| | - Chung Sim Lim
- Department of Vascular Surgery, 4965Royal Free London NHS Foundation Trust, London, United Kingdom.,Department of Surgical Biotechnology, Division of Surgery & Interventional Science, Faculty of Medical Sciences, University College London, United Kingdom
| | - Jocelyn Brookes
- Department of Vascular Surgery, 4965Royal Free London NHS Foundation Trust, London, United Kingdom.,Department of Interventional Radiology, 4965Royal Free London NHS Foundation Trust, London, United Kingdom
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Skulas-Ray AC, Wilson PWF, Harris WS, Brinton EA, Kris-Etherton PM, Richter CK, Jacobson TA, Engler MB, Miller M, Robinson JG, Blum CB, Rodriguez-Leyva D, de Ferranti SD, Welty FK. Omega-3 Fatty Acids for the Management of Hypertriglyceridemia: A Science Advisory From the American Heart Association. Circulation 2019; 140:e673-e691. [PMID: 31422671 DOI: 10.1161/cir.0000000000000709] [Citation(s) in RCA: 224] [Impact Index Per Article: 44.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Hypertriglyceridemia (triglycerides 200-499 mg/dL) is relatively common in the United States, whereas more severe triglyceride elevations (very high triglycerides, ≥500 mg/dL) are far less frequently observed. Both are becoming increasingly prevalent in the United States and elsewhere, likely driven in large part by growing rates of obesity and diabetes mellitus. In a 2002 American Heart Association scientific statement, the omega-3 fatty acids (n-3 FAs) eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) were recommended (at a dose of 2-4 g/d) for reducing triglycerides in patients with elevated triglycerides. Since 2002, prescription agents containing EPA+DHA or EPA alone have been approved by the US Food and Drug Administration for treating very high triglycerides; these agents are also widely used for hypertriglyceridemia. The purpose of this advisory is to summarize the lipid and lipoprotein effects resulting from pharmacological doses of n-3 FAs (>3 g/d total EPA+DHA) on the basis of new scientific data and availability of n-3 FA agents. In treatment of very high triglycerides with 4 g/d, EPA+DHA agents reduce triglycerides by ≥30% with concurrent increases in low-density lipoprotein cholesterol, whereas EPA-only did not raise low-density lipoprotein cholesterol in very high triglycerides. When used to treat hypertriglyceridemia, n-3 FAs with EPA+DHA or with EPA-only appear roughly comparable for triglyceride lowering and do not increase low-density lipoprotein cholesterol when used as monotherapy or in combination with a statin. In the largest trials of 4 g/d prescription n-3 FA, non-high-density lipoprotein cholesterol and apolipoprotein B were modestly decreased, indicating reductions in total atherogenic lipoproteins. The use of n-3 FA (4 g/d) for improving atherosclerotic cardiovascular disease risk in patients with hypertriglyceridemia is supported by a 25% reduction in major adverse cardiovascular events in REDUCE-IT (Reduction of Cardiovascular Events With EPA Intervention Trial), a randomized placebo-controlled trial of EPA-only in high-risk patients treated with a statin. The results of a trial of 4 g/d prescription EPA+DHA in hypertriglyceridemia are anticipated in 2020. We conclude that prescription n-3 FAs (EPA+DHA or EPA-only) at a dose of 4 g/d (>3 g/d total EPA+DHA) are an effective and safe option for reducing triglycerides as monotherapy or as an adjunct to other lipid-lowering agents.
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Ziegelasch N, Vogel M, Müller E, Tremel N, Jurkutat A, Löffler M, Terliesner N, Thiery J, Willenberg A, Kiess W, Dittrich K. Cystatin C serum levels in healthy children are related to age, gender, and pubertal stage. Pediatr Nephrol 2019; 34:449-457. [PMID: 30460495 PMCID: PMC6349798 DOI: 10.1007/s00467-018-4087-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 08/05/2018] [Accepted: 09/12/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND This study aims to establish age- and gender-specific cystatin C (CysC) reference values for healthy infants, children, and adolescents and to relate them to pubertal stage, height, weight, and body mass index (BMI). METHODS Serum CysC and creatinine levels of 6217 fasting, morning venous blood samples from 2803 healthy participants of the LIFE Child study (age 3 months to 18 years) were analyzed by an immunoassay. Recruitment started in 2011; 1636 participants provided at least one follow-up measurement. Percentiles for CysC were calculated. Age- and gender-related effects of height, weight, BMI, and puberty status were assessed through linear regression models. RESULTS Over the first 2 years of life, median CysC levels decrease depending on height (ß = - 0.010 mg/l/cm, p < 0.001) and weight (ß = - 0.033 mg/l/kg, p < 0.001) from 1.06 to 0.88 mg/l for males and from 1.04 to 0.87 mg/l for females. Following the second year of age, the levels remain stable for eight years. From 11 to 14 years of age, there is an increase of median CysC levels in males to 0.98 mg/l and a decrease in females to 0.86 mg/l. The change is associated with puberty (ß = 0.105 mg/l/Tanner stage, p < 0.001 in males and ß = - 0.093 mg/l/Tanner stage, p < 0.01 in females) and in males with height (ß = 0.003 mg/l/cm, p < 0.001). CONCLUSIONS CysC levels depend on age, gender, and height, especially during infancy and puberty. We recommend the use of age- and gender-specific reference values for CysC serum levels for estimating kidney function in clinical practice.
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Affiliation(s)
- Niels Ziegelasch
- LIFE Leipzig Research Center for Civilization Diseases, University of Leipzig, Philipp-Rosenthal-Strasse 27, 04103, Leipzig, Germany
| | - Mandy Vogel
- LIFE Leipzig Research Center for Civilization Diseases, University of Leipzig, Philipp-Rosenthal-Strasse 27, 04103, Leipzig, Germany.,Center of Paediatric Research (CPL), University of Leipzig, 04103, Leipzig, Germany
| | - Eva Müller
- LIFE Leipzig Research Center for Civilization Diseases, University of Leipzig, Philipp-Rosenthal-Strasse 27, 04103, Leipzig, Germany
| | - Nadin Tremel
- LIFE Leipzig Research Center for Civilization Diseases, University of Leipzig, Philipp-Rosenthal-Strasse 27, 04103, Leipzig, Germany
| | - Anne Jurkutat
- LIFE Leipzig Research Center for Civilization Diseases, University of Leipzig, Philipp-Rosenthal-Strasse 27, 04103, Leipzig, Germany
| | - Markus Löffler
- Institute for Medical Informatics, Statistics and Epidemiology (IMISE), University of Leipzig, 04107, Leipzig, Germany
| | - Nicolas Terliesner
- Hospital for Children and Adolescents, University of Leipzig, Liebigstraße 20a, 04103, Leipzig, Germany
| | - Joachim Thiery
- Institute for Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics (ILM), University Hospital Leipzig, 04103, Leipzig, Germany
| | - Anja Willenberg
- Institute for Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics (ILM), University Hospital Leipzig, 04103, Leipzig, Germany
| | - Wieland Kiess
- LIFE Leipzig Research Center for Civilization Diseases, University of Leipzig, Philipp-Rosenthal-Strasse 27, 04103, Leipzig, Germany.,Center of Paediatric Research (CPL), University of Leipzig, 04103, Leipzig, Germany.,Hospital for Children and Adolescents, University of Leipzig, Liebigstraße 20a, 04103, Leipzig, Germany
| | - Katalin Dittrich
- Center of Paediatric Research (CPL), University of Leipzig, 04103, Leipzig, Germany. .,Hospital for Children and Adolescents, University of Leipzig, Liebigstraße 20a, 04103, Leipzig, Germany.
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Warden BA, Duell PB. Management of dyslipidemia in adult solid organ transplant recipients. J Clin Lipidol 2019; 13:231-245. [PMID: 30928441 DOI: 10.1016/j.jacl.2019.01.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 01/21/2019] [Accepted: 01/22/2019] [Indexed: 02/07/2023]
Abstract
Solid organ transplantation (SOT) has revolutionized treatment of end-stage disease. Improvements in the SOT continuum of care have unmasked a significant burden of cardiovascular disease, manifesting as a leading cause of morbidity and mortality. Although several risk factors for development of post-transplant cardiovascular disease exist, dyslipidemia remains one of the most frequent and modifiable risks. An important contributor to dyslipidemia in SOT recipients is the off-target metabolic effects of immunosuppressive medications, which may alter lipoproteins and their metabolism. Dyslipidemia management is paramount as lipid-lowering therapy with statins has demonstrated reductions in graft vasculopathy, decreased rejection rates, and improved survival. Several nonstatin medication options are available, but data supporting their benefit in the SOT population are minimal, typically extrapolated from studies in the general population. Further compounding dyslipidemia management is the complex interplay of drug interactions between lipid-lowering and immunosuppressant medications, which can result in serious toxicity and/or therapeutic failure.
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Affiliation(s)
- Bruce A Warden
- Center for Preventive Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - P Barton Duell
- Center for Preventive Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA.
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8
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Kelsh SE, Girgis R, Dickinson M, McDermott JK. Everolimus Use for Intolerance or Failure of Baseline Immunosuppression in Adult Heart and Lung Transplantation. Ann Transplant 2018; 23:744-750. [PMID: 30348935 PMCID: PMC6248067 DOI: 10.12659/aot.910952] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background Everolimus can be utilized after heart or lung transplantation to reduce calcineurin inhibitor associated nephrotoxicity, due to cell cycle inhibitor adverse effects, and as adjunct therapy for rejection, cardiac allograft vasculopathy, and bronchiolitis obliterans syndrome. Material/Methods A single-center, retrospective cohort study was conducted including 51 adult heart transplant patients (n=32) and lung transplant patients (n=19) started on everolimus due to immunosuppressive therapy intolerance or failure, between 2010 and 2017. Everolimus indication, response, efficacy, and tolerability were assessed. Results Everolimus was most commonly initiated due to leukopenia/neutropenia (n=17, 33%) or renal dysfunction (n=13, 25%). Leukopenia/neutropenia resolved in 76% of patients (13 out of 17 patients). Renal function (GFR) increased 7.4 mL/min from baseline to 3 months after everolimus initiation (P=0.011). The most common adverse effects were edema (n=23, 45%) and hyperlipidemia (n=25, 49%). A high discontinuation rate was observed (n=21, 41%), mostly from edema. Conclusions Everolimus might be beneficial in heart and lung transplant patients with leukopenia or neutropenia and lead to modest, short-term renal function improvement. Patient selection is crucial because adverse effects frequently lead to everolimus discontinuation.
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Affiliation(s)
- Shelby E Kelsh
- Richard DeVos Heart and Lung Transplant Program, Spectrum Health, Grand Rapids, MI, USA
| | - Reda Girgis
- Richard DeVos Heart and Lung Transplant Program, Spectrum Health, Grand Rapids, MI, USA.,Department of Medicine, Michigan State University, College of Human Medicine, Grand Rapids, MI, USA
| | - Michael Dickinson
- Richard DeVos Heart and Lung Transplant Program, Spectrum Health, Grand Rapids, MI, USA.,Department of Medicine, Michigan State University, College of Human Medicine, Grand Rapids, MI, USA
| | - Jennifer K McDermott
- Richard DeVos Heart and Lung Transplant Program, Spectrum Health, Grand Rapids, MI, USA.,Department of Medicine, Michigan State University, College of Human Medicine, Grand Rapids, MI, USA
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De Gennaro Colonna V, Pavanello C, Rusconi F, Sartore-Bianchi A, Siena S, Castelnuovo S, Sirtori CR, Mombelli G. Lipid-lowering therapy of everolimus-related severe hypertriglyceridaemia in a pancreatic neuroendocrine tumour (pNET). J Clin Pharm Ther 2018; 43:114-116. [DOI: 10.1111/jcpt.12588] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 06/06/2017] [Indexed: 01/18/2023]
Affiliation(s)
- V. De Gennaro Colonna
- Department of Clinical Sciences and Community Health; University of Milano; Milano Italy
- Dyslipidemia Center; ASST Grande Ospedale Metropolitano Niguarda; Milano Italy
| | - C. Pavanello
- Department of Pharmacological and Biomolecular Sciences and; University of Milano; Milano Italy
| | - F. Rusconi
- Department of Hematology and Oncology; Niguarda Cancer Center; ASST Grande Ospedale Metropolitano Niguarda; Milano Italy
| | - A. Sartore-Bianchi
- Department of Hematology and Oncology; Niguarda Cancer Center; ASST Grande Ospedale Metropolitano Niguarda; Milano Italy
| | - S. Siena
- Department of Hematology and Oncology; Niguarda Cancer Center; ASST Grande Ospedale Metropolitano Niguarda; Milano Italy
- Department of Oncology and Hematology; University of Milano; Milano Italy
| | - S. Castelnuovo
- Dyslipidemia Center; ASST Grande Ospedale Metropolitano Niguarda; Milano Italy
| | - C. R. Sirtori
- Dyslipidemia Center; ASST Grande Ospedale Metropolitano Niguarda; Milano Italy
| | - G. Mombelli
- Dyslipidemia Center; ASST Grande Ospedale Metropolitano Niguarda; Milano Italy
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10
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Singla A, Gupta N, Apewokin S, McCormack FX. Sirolimus for the treatment of lymphangioleiomyomatosis. Expert Opin Orphan Drugs 2017. [DOI: 10.1080/21678707.2017.1391089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- Abhishek Singla
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Nishant Gupta
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Senu Apewokin
- Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Francis X. McCormack
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, USA
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11
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Kido K, Evans RA, Gopinath A, Flynn JD. Severe Hypertriglyceridemia Induced by Sirolimus Treated With Medical Management Without Plasmapheresis: A Case Report. J Pharm Pract 2017; 31:104-106. [PMID: 28205445 DOI: 10.1177/0897190017692920] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Hypertriglyceridemia and hyperlipidemia are the most remarkable metabolic complications seen with long-term sirolimus therapy. We report the case of a 36-year-old woman status post bilateral lung transplantation on a maintenance immunosuppression regimen of sirolimus, tacrolimus, and prednisone who presented with status migrainosus, chest pain, abdominal discomfort, and triglyceride levels greater than 4425 mg/dL. In previously reported cases of severe hypertriglyceridemia that developed on maintenance sirolimus therapy, plasmapheresis has been utilized as an early strategy to rapidly lower triglycerides in order to minimize the risk of acute complications such as pancreatitis, but our case was managed medically without plasmapheresis. The most recent triglyceride was down to 520 mg/dL 2 months after discontinuation of sirolimus. We estimate the probability of this reaction to sirolimus as probable based on a score of 5 points on the Naranjo scale. This is the first case report to our knowledge that highlights the sole use of oral lipid-lowering drug agents to treat severe hypertriglyceridemia secondary to sirolimus without the use of plasmapheresis. CONCLUSION Sirolimus-induced severe hypertriglyceridemia can be managed with oral lipid-lowering agents without plasmapheresis. Clinician needs to be aware of the importance of baseline and regular triglyceride monitoring in patients on sirolimus.
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Affiliation(s)
- Kazuhiko Kido
- 1 Department of Pharmacy Practice, South Dakota State University, Sioux Falls, SD, USA.,2 Department of Pharmacy Service, Avera McKennan Hospital, Sioux Falls, SD, USA
| | - Rickey A Evans
- 3 Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY, USA
| | - Anil Gopinath
- 4 Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kentucky HealthCare, Lexington, KY, USA
| | - Jeremy D Flynn
- 3 Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY, USA
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12
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Adegunsoye A, Strek ME, Garrity E, Guzy R, Bag R. Comprehensive Care of the Lung Transplant Patient. Chest 2016; 152:150-164. [PMID: 27729262 DOI: 10.1016/j.chest.2016.10.001] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 09/27/2016] [Accepted: 10/01/2016] [Indexed: 12/20/2022] Open
Abstract
Lung transplantation has evolved into a life-saving treatment with improved quality of life for patients with end-stage respiratory failure unresponsive to other medical or surgical interventions. With improving survival rates, the number of lung transplant recipients with preexisting and posttransplant comorbidities that require attention continues to increase. A partnership between transplant and nontransplant care providers is necessary to deliver comprehensive and optimal care for transplant candidates and recipients. The goals of this partnership include timely referral and assistance with transplant evaluation, optimization of comorbidities and preparation for transplantation, management of common posttransplant medical comorbidities, immunization, screening for malignancy, and counseling for a healthy lifestyle to maximize the likelihood of a good outcome. We aim to provide an outline of the main aspects of the care of candidates for and recipients of lung transplants for nontransplant physicians and other care providers.
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Affiliation(s)
- Ayodeji Adegunsoye
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, IL
| | - Mary E Strek
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, IL
| | - Edward Garrity
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, IL; Lung Transplant Program, University of Chicago, Chicago, IL
| | - Robert Guzy
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, IL; Lung Transplant Program, University of Chicago, Chicago, IL
| | - Remzi Bag
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, IL; Lung Transplant Program, University of Chicago, Chicago, IL.
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13
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14
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Mateu-de Antonio J, Echeverría-Esnal D. Intravenous lipid emulsions in kidney transplant patients requiring parenteral nutrition. Nutrition 2016; 32:397-8. [PMID: 26732836 DOI: 10.1016/j.nut.2015.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 10/22/2015] [Accepted: 10/23/2015] [Indexed: 11/25/2022]
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15
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Hollis IB, Reed BN, Moranville MP. Medication management of cardiac allograft vasculopathy after heart transplantation. Pharmacotherapy 2015; 35:489-501. [PMID: 26011142 DOI: 10.1002/phar.1580] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Cardiac allograft vasculopathy (CAV) is a common complication following heart transplantation (HT), resulting in diminished graft survival. The preferred strategy for preventing CAV is optimal medical management; however, for patients who develop CAV, delaying disease progression through effective medication management is equally important. A review of the literature regarding medication management of CAV was conducted via a search of the MEDLINE database. Studies were included if they were published in English, conducted in humans ≥ 18 years of age or older, and used noninvestigational medications. Immunosuppressive medications such as the antiproliferative mycophenolate, the calcineurin inhibitor tacrolimus, and the proliferation signal inhibitors sirolimus and everolimus have been shown to prevent the development of CAV. Certain cardiovascular medications, such as HMG-CoA reductase inhibitors (statins), gemfibrozil, calcium channel blockers, and angiotensin-converting enzyme inhibitors, have also demonstrated efficacy in preventing this disease process. Prevention of CAV has also been observed with prophylaxis against cytomegalovirus infection and antioxidant medications. Despite being commonly used in HT patients, neither antiplatelet agents nor glycemic control have proved effective at preventing CAV. Only sirolimus has been shown to arrest the progress of existing CAV.
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Affiliation(s)
- Ian B Hollis
- Department of Pharmacy, University of North Carolina Hospitals, Chapel Hill, North Carolina
| | - Brent N Reed
- School of Pharmacy, University of Maryland, Baltimore, Maryland
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Effect of immunosuppressive therapy on the serum fatty acids of phospholipids fraction in patients after heart transplantation. Transplant Proc 2014; 46:2825-9. [PMID: 25380928 DOI: 10.1016/j.transproceed.2014.09.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND The effects of tacrolimus (Tac) and cyclosporine (CsA) on lipid profile is well known; however, little is known about the changes in fatty acids (FA) of phosholipids fraction (PL) in heart transplant patients after treatment with these immunosuppressants. This study aimed to investigate the effect of Tac and CsA on serum FA of PL in heart transplant patients. METHODS The study included 23 patients after heart transplantation on Tac (n = 14; group II) or CsA (n = 9; group I). Eleven healthy persons served as a control group. Serum FA of PL were extracted, separated on Sep-Pak NH2, methylated, and measured with the use of gas chromatography. Chemstation software was used to analyze the data. RESULTS No differences between the studied groups and control were noted for saturated FA, monounsaturated FA, polyunsaturated FA (PUFA), total FA, and PUFA n-6. The mean value of PUFA n-3 was significantly higher in the CsA group compared with the Tac group (P < .015) and control (P < .002) as well as in the Tac group compared with control (P < .001). For individual FA, higher mean concentration, compared with control, was found for C24, C20:2, C20:4, and C22:6 (P < .001 in all cases) and lower for C18:2cis (P < .001 in both groups) and for C18:3 in the Tac group. The mean values of PUFA n-6 to PUFA n-3 ratios were lower than in control (both P < .001). CONCLUSIONS Different pattern of FA of PL may indicate the different FA metabolism in heart transplant patients treated by different immunosuppressants. This should be taken into account when FA supplementation in these patients is considered.
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Shivaswamy V, Bennett RG, Clure CC, Ottemann B, Davis JS, Larsen JL, Hamel FG. Tacrolimus and sirolimus have distinct effects on insulin signaling in male and female rats. Transl Res 2014; 163:221-31. [PMID: 24361102 DOI: 10.1016/j.trsl.2013.12.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Revised: 11/14/2013] [Accepted: 12/01/2013] [Indexed: 10/25/2022]
Abstract
Although the contribution of the immunosuppressants tacrolimus (TAC) and sirolimus (SIR) to the development of posttransplant diabetes mellitus (PTDM) are being increasingly recognized, the mechanisms of immunosuppressant-induced hyperglycemia are unclear. SIR induces insulin resistance predominantly, but is associated with β-cell dysfunction in rodents. TAC affects islet function but is associated with worsening insulin sensitivity in a few, and improvement in some, clinical studies. We sought to clarify the contributions of TAC and SIR to insulin resistance and islet function. Four groups of male and female Sprague-Dawley rats received TAC, SIR, TAC and SIR, or control for 2 weeks. All rats were administered an oral glucose challenge at the end of treatment. Half the groups were sacrificed 10 minutes after administration of regular insulin whereas the other half did not receive insulin before sacrifice. Liver, pancreas, fat, and muscle were harvested subsequently. Quantification of Western blots revealed that SIR and TAC plus SIR suppressed the phospho-Akt (pAkt)-to-Akt ratios in liver, muscle, and fat compared with control, regardless of sex. TAC alone did not impair the pAkt-to-Akt ratios in any of the tissues in male and female rats. β-Cell mass was reduced significantly after TAC treatment in male rats. SIR did not affect β-cell mass, regardless of sex. Our study demonstrated very clearly that SIR impairs insulin signaling, without any effect on β-cell mass, and TAC does not impair insulin signaling but reduces β-cell mass. Our efforts are key to understanding the mechanisms of immunosuppressant-induced hyperglycemia and to tailoring treatments for PTDM.
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Affiliation(s)
- Vijay Shivaswamy
- VA Nebraska-Western Iowa Health Care System, University of Nebraska Medical Center, Omaha, Neb; Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Neb.
| | - Robert G Bennett
- VA Nebraska-Western Iowa Health Care System, University of Nebraska Medical Center, Omaha, Neb; Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Neb; Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, Neb
| | - Cara C Clure
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Neb
| | - Brendan Ottemann
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Neb
| | - John S Davis
- VA Nebraska-Western Iowa Health Care System, University of Nebraska Medical Center, Omaha, Neb; Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, Neb; Obstetrics and Gynecology, University of Nebraska Medical Center, Omaha, Neb
| | - Jennifer L Larsen
- VA Nebraska-Western Iowa Health Care System, University of Nebraska Medical Center, Omaha, Neb; Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Neb
| | - Frederick G Hamel
- VA Nebraska-Western Iowa Health Care System, University of Nebraska Medical Center, Omaha, Neb; Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Neb
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Filler G, Yasin A, Medeiros M. Methods of assessing renal function. Pediatr Nephrol 2014; 29:183-92. [PMID: 23417278 DOI: 10.1007/s00467-013-2426-7] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Revised: 01/14/2013] [Accepted: 01/17/2013] [Indexed: 12/15/2022]
Abstract
Accurate assessment of renal function is critical for appropriate drug dosing of renally excreted compounds. Glomerular filtration rate (GFR) is considered the best marker of kidney function. Inulin clearance forms the gold standard for measuring GFR, both in adults and in children. The method is invasive, cumbersome, and smaller children require urinary catheterization for accurate timed urine collections. Nuclear medicine methods replaced inulin clearance in the 1970s after (51)Cr EDTA clearance was introduced. Inulin has no plasma protein binding, whereas all commonly used radioisotopes have a small amount of plasma protein binding that leads to lower values. Only iohexol does not have significant plasma protein binding. The underestimation due to plasma protein binding is partially offset by overestimation due to the use of non-compartmental pharmacokinetic modeling of the plasma disappearance of the radioisotope. The problem could be overcome with a urinary nuclear medicine clearance method, but these have not been validated in children. Endogenous markers of GFR include serum creatinine and low molecular weight proteins such as cystatin C and beta-trace protein. Of these, estimation of GFR using cystatin C appears to be the most promising, although its accuracy in pregnancy and in the neonatal period may be limited.
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Affiliation(s)
- Guido Filler
- Department of Pediatrics, Children's Hospital, London Health Science Centre, University of Western Ontario, 800 Commissioners Road East, London, Ontario, Canada, N6A 5W9,
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Shah M, Critchley W, Yonan N, Williams S, Shaw S. Second Line Options for Hyperlipidemia Management after Cardiac Transplantation. Cardiovasc Ther 2013; 31:138-46. [DOI: 10.1111/j.1755-5922.2012.00315.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
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Klintmalm G, O'Farrelly C. Taking the rap: multiple effects of blocking mammalian target of rapamycin. Hepatology 2013; 57:1-3. [PMID: 22767219 DOI: 10.1002/hep.25934] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Accepted: 06/15/2012] [Indexed: 02/06/2023]
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Filler G, Weiglein G, Gharib MT, Casier S. Ω3 fatty acids may reduce hyperlipidemia in pediatric renal transplant recipients. Pediatr Transplant 2012; 16:835-9. [PMID: 22835217 DOI: 10.1111/j.1399-3046.2012.01772.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Life expectancy after pediatric renal transplantation remains lower than that of the normal population largely due to cardiovascular morbidity and mortality. Hyperlipidemia is a potentially modifiable risk factor for cardiovascular morbidity. Retrospective chart review of all available pediatric renal transplant patients (26) in a single center with assessment of anthropometry, renal function, steroid, calcineurin or mTOR inhibitor exposure and Ω3 FA supplementation. Eighteen transplant recipients without Ω3 FA supplementation served as control. Nutrition and supplement surveys were conducted with standardized questionnaires. Fasting cholesterol values were compared using the latest value prior to start of Ω3 FA and at last follow-up. Eight patients (five receiving mTOR inhibitor) started Ω3 FA supplementation at a mean dose of 29.2 ± 12 mg of EPA/kg and 16.1 ± 7.4 mg DHA/kg body weight. Median duration of treatment was 2.5 yr (range 0.8-5.9 yr) and their total fasting cholesterol at last follow-up dropped significantly from 5.08 ± 0.97 (control group 3.77 ± 0.81, p = 0.0084) to 4.17 ± 0.54 mm (p = 0.0158). High-density lipoprotein cholesterol increased not significantly from 1.74 ± 0.49 to 2.02 ± 0.93 mm. No patient had increased bleeding. Supplementation of omega-3 FAs may reduce hyperlipidaemia after pediatric renal transplantation.
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Affiliation(s)
- Guido Filler
- Department of Pediatrics, Children's Hospital at London Health Sciences Center, University of Western Ontario, London, ON, Canada.
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22
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Neuringer IP, Noone P, Cicale RK, Davis K, Aris RM. Managing complications following lung transplantation. Expert Rev Respir Med 2012; 3:403-23. [PMID: 20477331 DOI: 10.1586/ers.09.27] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Lung transplantation has become a proven therapeutic option for patients with end-stage lung disease, extending life and providing improved quality of life to those who otherwise would continue to be breathless and oxygen-dependent. Over the past 20 years, considerable experience has been gained in understanding the multitude of medical and surgical issues that impact upon patient survival. Today, clinicians have an armamentarium of tools to manage diverse problems such as primary graft dysfunction, acute and chronic allograft rejection, airway anastomotic issues, infectious complications, renal dysfunction, diabetes and osteoporosis, hematological and gastrointestinal problems, malignancy, and other unique issues that confront immunosuppressed solid organ transplant recipients.
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Affiliation(s)
- Isabel P Neuringer
- Division of Pulmonary and Critical Care Medicine and the Cystic Fibrosis/Pulmonary Research and Treatment Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7524, USA.
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23
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Drug Interaction Between Cyclosporine and mTOR Inhibitors in Experimental Model of Chronic Cyclosporine Nephrotoxicity and Pancreatic Islet Dysfunction. Transplantation 2012; 93:383-9. [DOI: 10.1097/tp.0b013e3182421604] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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McKenna GJ, Trotter JF. Sirolimus--it doesn't deserve its bad Rap(a). J Hepatol 2012; 56:285-7. [PMID: 21781945 DOI: 10.1016/j.jhep.2011.06.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2010] [Revised: 06/09/2011] [Accepted: 06/09/2011] [Indexed: 12/04/2022]
Affiliation(s)
- Greg J McKenna
- Annette C and Harold C Simmons Transplant Institute, Baylor University Medical Center, 3410 Worth St, Suite 950, Dallas, TX 75246, USA.
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Mendelsohn AR, Larrick JW. Rapamycin as an antiaging therapeutic?: targeting mammalian target of rapamycin to treat Hutchinson-Gilford progeria and neurodegenerative diseases. Rejuvenation Res 2011; 14:437-41. [PMID: 21851176 DOI: 10.1089/rej.2011.1238] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Mammalian target of rapamycin (mTOR), a serine/threonine kinase and component of the mTORC1 signaling complex, acts as an energy, nutrient, growth factor, stress, and redox sensor to increase protein synthesis and decrease macroautophagy. mTORC1 plays a central role in the maintenance of homeostasis and its deterioration, seen in aging. The Food and Drug Administration (FDA)-approved immunosuppressive macrolide rapamycin binds immunophilin FKBP12 (FK506-binding protein) to inhibit mTORC1. Unlike most other interventions tested to date, inhibition of mTORC1 by rapamycin extends life span in old mice, likely by a combination of increased autophagy and decreased mRNA translation. Hutchinson-Gilford progeria syndrome (HGPS) is a lethal genetic disorder affecting children that is characterized by symptoms of premature aging, such as atherosclerosis. Increased autophagy induced by rapamycin reduces accumulation of progerin, an alternate spliced form of lamin A/C, that forms insoluble toxic aggregates, resulting in reduced HGPS-associated nuclear blebbing, growth inhibition, epigenetic dysregulation, and genomic instability. Rapamycin-induced autophagy also suppresses symptoms in mouse models of Alzheimer, Parkinson, and Huntington diseases, where toxic insoluble protein aggregates accumulate. On the basis of these results, modulation of mTORC1 function is a promising target for the development of therapeutics for neurodegenerative diseases and HGPS. Rapamycin is the obvious candidate for near-term evaluation in the treatment of these diseases. However, the substantial set of rapamycin-associated adverse effects, as well as the lack of aging-specific human data, should caution the routine use of rapamycin as an antiaging agent. The use of safer, but perhaps weaker, indirect mTORC1 inhibitors, such as metformin and resveratrol, may prove useful. Further study will ascertain whether such compounds extend human health or life span.
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Affiliation(s)
- Andrew R Mendelsohn
- Panorama Research Institute and Regenerative Sciences Institute, 1230 Bordeaux Drive, Sunnyvale, CA 94089, USA.
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26
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Filler G. Challenges in pediatric transplantation: the impact of chronic kidney disease and cardiovascular risk factors on long-term outcomes and recommended management strategies. Pediatr Transplant 2011; 15:25-31. [PMID: 21155958 DOI: 10.1111/j.1399-3046.2010.01439.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Barriers to successful outcomes following pediatric transplantation have shifted from ischemic reperfusion injury and rejection to more long-term complications. Of particular concern is the high prevalence of CKD owing to preexisting damage and nephrotoxicity, as well as other CV complications such as hypertension and cardiomyopathy. All of these contribute to graft loss and shortened life expectancy, thereby limiting the success story of solid-organ transplantation. Managing CKD and related CV morbidity should be integral to the care of pediatric transplant patients, and timely detection of any irregularities would increase the chances of restoring lost kidney function. GFR is still the widely accepted indicator of renal function, and nuclear medicine techniques are the gold standard measurement methods. These methods are limited by costs, radiation exposure and substrate injection, and current practice still uses the Schwartz estimate, despite its well-documented limitations. Newer endogenous markers of GFR, such as cystatin C clearance, give a more accurate measure of true GFR but have not been embraced in the management of pediatric transplant recipients. Furthermore, indirect markers (e.g., microalbuminuria and hypertension) could also aid early detection of renal damage. The effects of mainstay immunosuppressants on kidney and heart function are varied, with available data indicating favorable outcomes with tacrolimus compared with ciclosporin. There is a need for appropriately designed and powered randomized controlled trials to validate innovative concepts for tailored immunosuppression in the pediatric population. To date, very few studies have generated long-term data in pediatric renal transplant patients - results of 1-4-yr study favored tacrolimus over ciclosporin, but other immunosuppressive agents also need to be evaluated.
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Affiliation(s)
- Guido Filler
- Department of Paediatrics, London Health Science Centre, Children's Hospital, University of Western Ontario, London, ON, Canada.
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Common Occurrence of Everolimus-Associated Aphthous Stomatitis in Japanese Heart Transplant Recipients. Transplant Proc 2010; 42:3700-3. [DOI: 10.1016/j.transproceed.2010.06.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2010] [Revised: 04/07/2010] [Accepted: 06/10/2010] [Indexed: 11/23/2022]
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Gupta G, Unruh ML, Nolin TD, Hasley PB. Primary care of the renal transplant patient. J Gen Intern Med 2010; 25:731-40. [PMID: 20422302 PMCID: PMC2881977 DOI: 10.1007/s11606-010-1354-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2009] [Revised: 11/30/2009] [Accepted: 03/26/2010] [Indexed: 12/25/2022]
Abstract
There has been a remarkable rise in the number of kidney transplant recipients (KTR) in the US over the last decade. Increasing use of potent immunosuppressants, which are also potentially diabetogenic and atherogenic, can result in worsening of pre-existing medical conditions as well as development of post-transplant disease. This, coupled with improving long-term survival, is putting tremendous pressure on transplant centers that were not designed to deliver primary care to KTR. Thus, increasing numbers of KTR will present to their primary care physicians (PCP) post-transplant for routine medical care. Similar to native chronic kidney disease patients, KTRs are vulnerable to cardiovascular disease as well as a host of other problems including bone disease, infections and malignancies. Deaths related to complications of cardiovascular disease and malignancies account for 60-65% of long-term mortality among KTRs. Guidelines from the National Kidney Foundation and the European Best Practice Guidelines Expert Group on the management of hypertension, dyslipidemia, smoking, diabetes and bone disease should be incorporated into the long-term care plan of the KTR to improve outcomes. A number of transplant centers do not supply PCPs with protocols and guidelines, making the task of the PCP more difficult. Despite this, PCPs are expected to continue to provide general preventive medicine, vaccinations and management of chronic medical problems. In this narrative review, we examine the common medical problems seen in KTR from the PCP's perspective. Medical management issues related to immunosuppressive medications are also briefly discussed.
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Affiliation(s)
- Gaurav Gupta
- Nephrology Division, Department of Medicine, Johns Hopkins University, Baltimore, MD 21205, USA.
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Dyslipidemia after allogeneic hematopoietic stem cell transplantation: evaluation and management. Blood 2010; 116:1197-204. [PMID: 20439623 DOI: 10.1182/blood-2010-03-276576] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Currently, approximately 15,000 to 20,000 patients undergo allogeneic hematopoietic stem cell transplantation (HSCT) annually throughout the world, with the number of long-term survivors increasing rapidly. In long-term follow-up after transplantation, the focus of care moves beyond cure of the original disease to the identification and treatment of late effects after HSCT. One of the more serious complications is therapy-related cardiovascular disease. Long-term survivors after HSCT probably have an increased risk of premature cardiovascular events. Cardiovascular complications related to dyslipidemia and other risk factors account for a significant proportion of late nonrelapse morbidity and mortality. This review addresses the risk and causes of dyslipidemia and impact on cardiovascular complications after HSCT. Immunosuppressive therapy, chronic graft-versus-host disease, and other long-term complications influence the management of dyslipidemia. There are currently no established guidelines for evaluation and management of dyslipidemia in HSCT patients; in this review, we have summarized our suggested approach in the HSCT population.
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Johnston PB, Inwards DJ, Colgan JP, Laplant BR, Kabat BF, Habermann TM, Micallef IN, Porrata LF, Ansell SM, Reeder CB, Roy V, Witzig TE. A Phase II trial of the oral mTOR inhibitor everolimus in relapsed Hodgkin lymphoma. Am J Hematol 2010; 85:320-4. [PMID: 20229590 DOI: 10.1002/ajh.21664] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Everolimus is an oral antineoplastic agent that targets the raptor mammalian target of rapamycin (mTORC1). The phosphatidylinositol 3-kinase/mTOR signal transduction pathway has been demonstrated to be activated in tumor samples from patients with Hodgkin lymphoma (HL). The goal of this trial was to learn the antitumor activity and toxicity of everolimus in patients with relapsed/refractory HL. Patients were eligible if they had measurable disease, a platelet count >75,000, and an absolute neutrophil count >1,000. Patients received everolimus 10 mg PO daily. Dose reductions were allowed. Response was assessed after two and six cycles and then every three cycles until progression. Patients could remain on drug until progression or toxicity. Nineteen patients were enrolled. Median age was 37 years (range, 27-68). Patients had received a median of six prior therapies (range, 3-14) and 84% had undergone prior autologous stem cell transplant. The ORR was 47% (95% CI: 24-71%) with eight patients achieving a PR and one patient achieving a CR. The median TTP was 7.2 months. Four responders remained progression free at 12 months. Patients received a median of seven cycles of therapy. Of the 19 patients, one remains on therapy at 36 months; the others went off study because of progressive disease (16), toxicity (1), and death from infection (1). Four patients experienced a Grade 3 or higher pulmonary toxicity. Everolimus has single-agent activity in relapsed/refractory HL and provides proof-of-concept that targeting the mTOR pathway in HL is clinically relevant.
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Affiliation(s)
- Patrick B Johnston
- Division of Hematology, Department of Medicine, Mayo Clinic College of Medicine and Mayo Foundation, Rochester, Minnesota 55905, USA
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Epailly E, Lorho R. Effets secondaires des inhibiteurs du signal de prolifération et leur gestion. ACTA ACUST UNITED AC 2009; 33 Suppl 4:S268-74. [DOI: 10.1016/s0399-8320(09)73165-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Chen WQ, Zhong L, Zhang L, Ji XP, Zhang M, Zhao YX, Zhang C, Zhang Y. Oral rapamycin attenuates inflammation and enhances stability of atherosclerotic plaques in rabbits independent of serum lipid levels. Br J Pharmacol 2009; 156:941-51. [PMID: 19239473 DOI: 10.1111/j.1476-5381.2008.00102.x] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND AND PURPOSE Atherosclerotic plaque rupture and thrombosis are the main cause of acute coronary syndrome. The study was aimed to test the hypothesis that oral administration of rapamycin may attenuate inflammation, inhibit progression and enhance stability of atherosclerotic plaques. EXPERIMENTAL APPROACH Thirty New Zealand rabbits were subjected to balloon-induced endothelial injury of the abdominal aorta and were fed a diet of 1% cholesterol for 20 weeks. From week 9 to week 20, the animals were treated with oral rapamycin (0.5 mg x kg(-1) x day(-1); group A), oral simvastatin (5 mg x kg(-1) x day(-1); group B) and no drugs (group C). At the end of week 20, all rabbits were challenged with injection of Chinese Russell's viper venom and histamine. Serological, ultrasonographic, pathological, immunohistochemical and gene expression studies were performed. KEY RESULTS Rapamycin significantly increased the thickness of the fibrous caps and decreased plaque vulnerability index in group A rabbits. Serum lipid levels were higher whereas plaque burden was lower in group A than in group B (P < 0.05). The incidence of plaque rupture in group A (0%) and group B (0%) was significantly lower than that in group C (56.0%, P < 0.05). CONCLUSIONS AND IMPLICATIONS Oral administration of rapamycin effectively attenuated inflammation, inhibited progression and enhanced stability of atherosclerotic plaques in rabbits, without altering serum lipid levels. Our findings suggest a novel approach to the treatment of atherosclerosis.
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Affiliation(s)
- Wen Qiang Chen
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, Shandong University Qilu Hospital, Jinan, Shandong, China
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Safety and Efficacy of Statin Therapy in Patients Switched From Cyclosporine A to Sirolimus After Cardiac Transplantation. Transplantation 2008; 86:1771-6. [DOI: 10.1097/tp.0b013e3181910eb2] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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