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Villeneuve C, Humeau A, Monchaud C, Labriffe M, Rerolle JP, Couzi L, Westeel PF, Etienne I, Kamar N, Büchler M, Thierry A, Marquet P. Better Rejection-Free Survival at Three Years in Kidney Transplant Recipients With Model-Informed Precision Dosing of Mycophenolate Mofetil. Clin Pharmacol Ther 2024; 116:351-362. [PMID: 38372185 DOI: 10.1002/cpt.3206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 01/25/2024] [Indexed: 02/20/2024]
Abstract
The clinical impact of individual dose adjustment of mycophenolate mofetil is still debated, due to conflicting results from randomized clinical trials. This retrospective study aimed to compare 3-year rejection-free survival and adverse effects between adult kidney transplant recipients (KTRs) with or without mycophenolate mofetil model-informed precision dosing (MIPD). MIPD is defined here as mycophenolic acid area under the curve (AUC0-12h) estimation using a limited sampling strategy, pharmacokinetic models and Bayesian estimators; dose recommendation to reach AUC0-12h = 45 mg.h/L; using a widely used online expert system. The study, nested in two multicenter prospective cohort studies, focused on patients who received a mycophenolate drug and were followed up for 1-3 years. Mycophenolate mofetil MIPD was prescribed as per local practice, on a regular basis, when deemed necessary, or not at all. The MIPD group included 341 KTRs and the control group 392. At 3 years, rejection-free survival was respectively 91.2% and 80.6% (P < 0.001) and the cumulative incidence of rejection 5.08% vs. 12.7% per patient × year (hazard ratio = 0.49 (0.34, 0.71), P < 0.001), corresponding to a 2.5-fold reduction. Significant association with rejection-free survival was confirmed in patients at low or high risk of rejection (P = 0.017 and 0.013) and in patients on tacrolimus, but not on cyclosporine (P < 0.001 and 0.205). The mycophenolate mofetil MIPD group had significantly more adverse effects, but most occurred before the first AUC0-12h, suggesting some may be the reason why MIPD was ordered.
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Affiliation(s)
- Claire Villeneuve
- Department of Pharmacology, Toxicology and Pharmacovigilance, Centre Hospitalier Universitaire de Limoges, Limoges, France
- Pharmacology & Transplantation, Institut National de la Santé et de la Recherche Médicale U1248, Université de Limoges, Limoges, France
- Fédération Hospitalo-Universitaire SUrvival oPtimization in ORgan Transplantation (FHU SUPORT), Limoges, France
| | - Antoine Humeau
- Pharmacology & Transplantation, Institut National de la Santé et de la Recherche Médicale U1248, Université de Limoges, Limoges, France
- Fédération Hospitalo-Universitaire SUrvival oPtimization in ORgan Transplantation (FHU SUPORT), Limoges, France
| | - Caroline Monchaud
- Department of Pharmacology, Toxicology and Pharmacovigilance, Centre Hospitalier Universitaire de Limoges, Limoges, France
- Pharmacology & Transplantation, Institut National de la Santé et de la Recherche Médicale U1248, Université de Limoges, Limoges, France
- Fédération Hospitalo-Universitaire SUrvival oPtimization in ORgan Transplantation (FHU SUPORT), Limoges, France
| | - Marc Labriffe
- Department of Pharmacology, Toxicology and Pharmacovigilance, Centre Hospitalier Universitaire de Limoges, Limoges, France
- Pharmacology & Transplantation, Institut National de la Santé et de la Recherche Médicale U1248, Université de Limoges, Limoges, France
- Fédération Hospitalo-Universitaire SUrvival oPtimization in ORgan Transplantation (FHU SUPORT), Limoges, France
| | - Jean-Phillipe Rerolle
- Pharmacology & Transplantation, Institut National de la Santé et de la Recherche Médicale U1248, Université de Limoges, Limoges, France
- Fédération Hospitalo-Universitaire SUrvival oPtimization in ORgan Transplantation (FHU SUPORT), Limoges, France
- Department of Nephrology, Dialysis and Transplantation, Centre Hospitalier Universitaire de Limoges, Limoges, France
- Department of Nephrology, Transplantation, Dialysis, Centre Hospitalier Universitaire Pellegrin, Bordeaux, France
| | - Lionel Couzi
- Centre National de la Recherche Scientifique, UMR 5164 Immuno ConcEpT, Bordeaux University, Bordeaux, France
| | - Pierre-François Westeel
- Department of Nephrology and Kidney Transplantation, University Hospital of Amiens, Amiens, France
| | - Isabelle Etienne
- Service de Néphrologie, Rouen University Hospital, Rouen, France
| | - Nassim Kamar
- Department of Nephrology and Organ Transplantation, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
- Université Paul Sabatier, Toulouse, France
- Institut National de la Santé et de la Recherche Médicale, U1043, IFR-BMT, Centre Hospitalier Universitaire Purpan, Toulouse, France
| | - Mathias Büchler
- Fédération Hospitalo-Universitaire SUrvival oPtimization in ORgan Transplantation (FHU SUPORT), Limoges, France
- Department of Nephrology and Kidney Transplantation, University Hospital of Tours, Tours, France
- François Rabelais University, Tours, France
| | - Antoine Thierry
- Fédération Hospitalo-Universitaire SUrvival oPtimization in ORgan Transplantation (FHU SUPORT), Limoges, France
- Department of Nephrology, Dialysis and Transplantation, Centre Hospitalier Universitaire de Poitiers, Tours, France
| | - Pierre Marquet
- Department of Pharmacology, Toxicology and Pharmacovigilance, Centre Hospitalier Universitaire de Limoges, Limoges, France
- Pharmacology & Transplantation, Institut National de la Santé et de la Recherche Médicale U1248, Université de Limoges, Limoges, France
- Fédération Hospitalo-Universitaire SUrvival oPtimization in ORgan Transplantation (FHU SUPORT), Limoges, France
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Wuttiputhanun T, Naiyarakseree N, Udomkarnjananun S, Kittanamongkolchai W, Asada L, Chariyavilaskul P, Townamchai N, Avihingsanon Y. Therapeutic drug monitoring of mycophenolic acid and clinical outcomes of lupus nephritis: a systematic review and meta-analysis. Lupus Sci Med 2024; 11:e001093. [PMID: 38233072 PMCID: PMC10806523 DOI: 10.1136/lupus-2023-001093] [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: 10/30/2023] [Accepted: 12/16/2023] [Indexed: 01/19/2024]
Abstract
INTRODUCTION Mycophenolic acid (MPA) is a primary immunosuppressive agent used in the treatment of lupus nephritis (LN). While therapeutic drug monitoring (TDM) of MPA is well established in organ transplantation, its role in LN treatment remains uncertain. Our objective was to review and summarise current knowledge on TDM of MPA in the LN treatment. METHODS A systematic search was conducted in the online databases, specifically targeted patients diagnosed with LN receiving MPA treatment. The included studies had to report both MPA pharmacokinetic parameters and renal outcomes. A random-effects model meta-analysis was conducted to assess the relationship between clinical responses and MPA pharmacokinetics. RESULTS A total of 1507 studies were initially screened, resulting in the inclusion of 16 studies for meta-analysis, encompassing 433 patients. The response group exhibited significantly higher MPA area under the concentration-time curve (AUC) compared with the non-response group (51.44±21.73 mg·h/L vs 30.30±16.24 mg·h/L). The weighted mean difference (WMD) of MPA-AUC between responders and non-responders was 16.83 mg·h/L (95% CI 10.59 to 23.06; p<0.001). Similarly, trough concentration (C0) of MPA showed a strong association with renal response, evidenced by C0 values of 2.50±1.73 mg/L in the response group vs 1.51±1.33 mg/L in the non-response group (WMD 1.37 mg/L; 95% CI 0.77 to 1.97; p<0.001). There was no significant relationship identified between MPA-AUC and adverse events. CONCLUSION This meta-analysis emphasised the meaningful correlation between MPA AUC and C0 with renal response in LN treatment. Randomised controlled trials are necessary to validate this approach and determine its superiority over fixed dosing in the context of LN treatment.
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Affiliation(s)
- Thunyatorn Wuttiputhanun
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Nuanjanthip Naiyarakseree
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Suwasin Udomkarnjananun
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- Excellence Center for Solid Organ Transplantation, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- Renal Immunology and Transplantation Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Center of Excellence on Translational Research in Inflammation and Immunology (CETRII), Department of Microbiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Wonngarm Kittanamongkolchai
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- Renal Immunology and Transplantation Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Mahachakri Sirindhorn Clinical Research Center, Research Affairs, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Leelahavanichkul Asada
- Center of Excellence on Translational Research in Inflammation and Immunology (CETRII), Department of Microbiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Immunology Unit, Department of Microbiology, Chulalongkorn University, Bangkok, Thailand
| | - Pajaree Chariyavilaskul
- Center of Excellence in Clinical Pharmacokinetics and Pharmacogenomics, Chulalongkorn University, Bangkok, Thailand
- Department of Pharmacology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Natavudh Townamchai
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- Excellence Center for Solid Organ Transplantation, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- Renal Immunology and Transplantation Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Yingyos Avihingsanon
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- Excellence Center for Solid Organ Transplantation, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- Renal Immunology and Transplantation Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Immunosuppression in the Age of Precision Medicine. Semin Nephrol 2022; 42:86-98. [DOI: 10.1016/j.semnephrol.2022.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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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: 87] [Impact Index Per Article: 29.0] [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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Ehren R, Schijvens AM, Hackl A, Schreuder MF, Weber LT. Therapeutic drug monitoring of mycophenolate mofetil in pediatric patients: novel techniques and current opinion. Expert Opin Drug Metab Toxicol 2020; 17:201-213. [PMID: 33107768 DOI: 10.1080/17425255.2021.1843633] [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] [Indexed: 01/13/2023]
Abstract
Introduction: Mycophenolate mofetil (MMF) is an ester prodrug of the immunosuppressant mycophenolic acid (MPA) and is recommended and widely used for maintenance immunosuppressive therapy in solid organ and stem-cell transplantation as well as in immunological kidney diseases. MPA is a potent, reversible, noncompetitive inhibitor of the inosine monophosphate dehydrogenase (IMPDH), a crucial enzyme in the de novo purine synthesis in T- and B-lymphocytes, thereby inhibiting cell-mediated immunity and antibody formation. The use of therapeutic drug monitoring (TDM) of MMF is still controversial as outcome data of clinical trials are equivocal. Areas covered: This review covers in great depth the existing literature on TDM of MMF in the field of pediatric (kidney) transplantation. In addition, the relevance of TDM in immunological kidney diseases, in particular childhood nephrotic syndrome is highlighted. Expert opinion: TDM of MMF has the potential to optimize therapy in pediatric transplantation as well as in nephrotic syndrome. Limited sampling strategies to estimate MPA exposure increase its feasibility. Future perspectives rather encompass approaches reflecting total immunosuppressive load than single drug TDM.
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Affiliation(s)
- Rasmus Ehren
- Faculty of Medicine and University Hospital Cologne, Department of Pediatrics, University of Cologne , Cologne, Germany
| | - Anne M Schijvens
- Department of Pediatric Nephrology, Amalia Children's Hospital, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center , Nijmegen, The Netherlands
| | - Agnes Hackl
- Faculty of Medicine and University Hospital Cologne, Department of Pediatrics, University of Cologne , Cologne, Germany
| | - Michiel F Schreuder
- Department of Pediatric Nephrology, Amalia Children's Hospital, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center , Nijmegen, The Netherlands
| | - Lutz T Weber
- Faculty of Medicine and University Hospital Cologne, Department of Pediatrics, University of Cologne , Cologne, Germany
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Holford N, Ma G, Metz D. TDM is dead. Long live TCI! Br J Clin Pharmacol 2020; 88:1406-1413. [PMID: 32543717 PMCID: PMC9290673 DOI: 10.1111/bcp.14434] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 04/28/2020] [Accepted: 05/19/2020] [Indexed: 12/21/2022] Open
Abstract
Twenty years ago, target concentration intervention (TCI) was distinguished from therapeutic drug monitoring (TDM). It was proposed that TCI would bring more clinical benefit because of the precision of the approach and the ability to link TCI to principles of pharmacokinetics and pharmacodynamics to predict the dose required by an individual (1). We examine the theory and clinical trial evidence supporting the benefits of TCI over TDM and conclude that in the digital age TDM should be abandoned and replaced by TCI.
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Affiliation(s)
- Nick Holford
- Department of Pharmacology & Clinical Pharmacology, University of Auckland, Auckland, New Zealand
| | - Guangda Ma
- Department of Pharmacology & Clinical Pharmacology, University of Auckland, Auckland, New Zealand
| | - David Metz
- Department of Pediatrics, University of Melbourne, Melbourne, Victoria, Australia
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Bentata Y. Mycophenolates: The latest modern and potent immunosuppressive drugs in adult kidney transplantation: What we should know about them? Artif Organs 2020; 44:561-576. [DOI: 10.1111/aor.13623] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 11/25/2019] [Accepted: 12/20/2019] [Indexed: 12/18/2022]
Affiliation(s)
- Yassamine Bentata
- Nephrology and Kidney Transplantation Unit University Hospital Mohammed VI University Mohammed First Oujda Morocco
- Laboratory of Epidemiology Clinical Research and Public Health Medical School University Mohammed First Oujda Morocco
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Metz DK, Holford N, Kausman JY, Walker A, Cranswick N, Staatz CE, Barraclough KA, Ierino F. Optimizing Mycophenolic Acid Exposure in Kidney Transplant Recipients: Time for Target Concentration Intervention. Transplantation 2019; 103:2012-2030. [PMID: 31584924 PMCID: PMC6756255 DOI: 10.1097/tp.0000000000002762] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 03/29/2019] [Accepted: 04/03/2019] [Indexed: 12/24/2022]
Abstract
The immunosuppressive agent mycophenolate is used extensively in kidney transplantation, yet dosing strategy applied varies markedly from fixed dosing ("one-dose-fits-all"), to mycophenolic acid (MPA) trough concentration monitoring, to dose optimization to an MPA exposure target (as area under the concentration-time curve [MPA AUC0-12]). This relates in part to inconsistent results in prospective trials of concentration-controlled dosing (CCD). In this review, the totality of evidence supporting mycophenolate CCD is examined: pharmacological characteristics, observational data linking exposure to efficacy and toxicities, and randomized controlled trials of CCD, with attention to dose optimization method and exposure achieved. Fixed dosing of mycophenolate consistently leads to underexposure associated with rejection, as well as overexposure associated with toxicities. When CCD is driven by pharmacokinetic calculation to a target concentration (target concentration intervention), MPA exposure is successfully controlled and clinical benefits are seen. There remains a need for consensus on practical aspects of mycophenolate target concentration intervention in contemporary tacrolimus-containing regimens and future research to define maintenance phase exposure targets. However, given ongoing consequences of both overimmunosuppression and underimmunosuppression in kidney transplantation, impacting short- and long-term outcomes, these should be a priority. The imprecise "one-dose-fits-all" approach should be replaced by the clinically proven MPA target concentration strategy.
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Affiliation(s)
- David K. Metz
- Department of Nephrology, Royal Children’s Hospital, Melbourne, VIC, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
- Murdoch Children’s Research Institute, Melbourne, VIC, Australia
- Clinical Pharmacology Unit, Royal Children’s Hospital, Melbourne, VIC, Australia
| | - Nick Holford
- Department of Pharmacology and Clinical Pharmacology, University of Auckland, Auckland, New Zealand
| | - Joshua Y. Kausman
- Department of Nephrology, Royal Children’s Hospital, Melbourne, VIC, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
- Murdoch Children’s Research Institute, Melbourne, VIC, Australia
| | - Amanda Walker
- Department of Nephrology, Royal Children’s Hospital, Melbourne, VIC, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
- Murdoch Children’s Research Institute, Melbourne, VIC, Australia
| | - Noel Cranswick
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
- Murdoch Children’s Research Institute, Melbourne, VIC, Australia
- Clinical Pharmacology Unit, Royal Children’s Hospital, Melbourne, VIC, Australia
| | | | - Katherine A. Barraclough
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
- Department of Nephrology, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Francesco Ierino
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
- Department of Nephrology, St Vincent’s Health, Melbourne, VIC, Australia
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Kiang TKL, Ensom MHH. Exposure-Toxicity Relationships of Mycophenolic Acid in Adult Kidney Transplant Patients. Clin Pharmacokinet 2019; 58:1533-1552. [DOI: 10.1007/s40262-019-00802-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Alsheikh R, Gabardi S. Post-Renal Transplantation Outcomes in Elderly Patients Compared to Younger Patients in the Setting of Early Steroid Withdrawal. Prog Transplant 2018; 28:322-329. [PMID: 30213228 DOI: 10.1177/1526924818800039] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Previous studies reported improved outcomes for renal recipients undergoing early steroid withdrawal (ESW), with significantly lower rates of new-onset diabetes, cytomegalovirus (CMV), and malignancy. As renal transplants in older adults has increased, studies have shown similar outcomes between elderly and younger patients. We aim to evaluate post-renal transplantation outcomes in elderly patients compared to younger patients who have undergone ESW. METHODS A retrospective analysis of adults who received transplants between January 2004 and December 2014 and received either basiliximab or antithymocyte globulin for induction, underwent ESW, and received tacrolimus and mycophenolate for maintenance. Patients were stratified based on age (≥60 vs <60). The 1-year primary end point was a composite of patient survival, graft survival, biopsy-proven acute rejection, and serum creatinine. The secondary outcomes included renal function, the incidence of opportunistic infections, malignancies, diabetes, and cardiovascular complications. Cox regression was used to evaluate variables that may affect rejection. RESULTS The sample included 292 patients; 72 were elderly individuals and 220 were younger adults. No significant differences were found in the primary end point or incidence of CMV, BK virus, or malignancy ( P = 1.0, .82, and .06, respectively). The use of blood pressure medications and the need for lipid-lowering agents were significantly higher in elderly patients at last follow-up. Diabetes was more common in elderly patients (15.2% vs 8.41%, P = .11). The induction agent used did not show any significant effect on rejection risk. CONCLUSION We report similar outcomes in elderly patients compared to younger patients in the setting of ESW.
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Affiliation(s)
- Razan Alsheikh
- 1 Clinical Pharmacy Department, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia.,2 Department of Pharmacy Practice and Science, University of Arizona, Tucson, AZ, USA
| | - Steven Gabardi
- 3 Departments of Transplant Surgery and Pharmacy Services, and the Renal Division, Brigham and Women's Hospital, Boston, MA, USA.,4 Harvard Medical School, Boston, MA, USA
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11
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Wehmeier C, Hirt-Minkowski P, Amico P, Georgalis A, Hopfer H, Steiger J, Dickenmann M, Schaub S. Successful steroid withdrawal guided by surveillance biopsies-A single-center experience. Clin Transplant 2018; 32:e13181. [DOI: 10.1111/ctr.13181] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Caroline Wehmeier
- Clinic for Transplantation Immunology and Nephrology; University Hospital Basel; Basel Switzerland
| | - Patricia Hirt-Minkowski
- Clinic for Transplantation Immunology and Nephrology; University Hospital Basel; Basel Switzerland
| | - Patrizia Amico
- Clinic for Transplantation Immunology and Nephrology; University Hospital Basel; Basel Switzerland
- HLA-Diagnostics and Immunogenetics; Department of Laboratory Medicine; University Hospital Basel; Basel Switzerland
| | - Argyrios Georgalis
- Clinic for Transplantation Immunology and Nephrology; University Hospital Basel; Basel Switzerland
| | - Helmut Hopfer
- Institute for Pathology; University Hospital Basel; Basel Switzerland
| | - Jürg Steiger
- Clinic for Transplantation Immunology and Nephrology; University Hospital Basel; Basel Switzerland
| | - Michael Dickenmann
- Clinic for Transplantation Immunology and Nephrology; University Hospital Basel; Basel Switzerland
| | - Stefan Schaub
- Clinic for Transplantation Immunology and Nephrology; University Hospital Basel; Basel Switzerland
- HLA-Diagnostics and Immunogenetics; Department of Laboratory Medicine; University Hospital Basel; Basel Switzerland
- Department of Biomedicine; Transplantation Immunology and Nephrology; University Basel; Basel Switzerland
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12
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Early Steroid Withdrawal in Recipients of a Kidney Transplant From a Living Donor: Experience of a Single Mexican Center. Transplant Proc 2016; 48:42-9. [PMID: 26915841 DOI: 10.1016/j.transproceed.2015.12.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 11/25/2015] [Accepted: 12/10/2015] [Indexed: 01/18/2023]
Abstract
BACKGROUND Early steroid withdrawal (ESW) can improve lipid and hemodynamic profiles without severe acute rejection (AR) events in renal transplant patients. Our objective was to evaluate the effects of ESW on the frequency and severity of AR. METHODS A randomized, open-label, controlled clinical trial was performed on renal transplant recipients with a follow-up of 12 months. In the ESW group, patients were selected for corticosteroid treatment withdrawal on the fifth day post transplantation. In the Control group, patients continued with steroid treatment. All patients were over 18 years of age with panel reactive antibody (PRA) class I and II HLA <20%. RESULTS In total, 71 patients, 37 in the ESW group (52.1%) and 34 in the Control group (47.9%), had comparable AR incidences at the end of the follow-up (16% vs 15%) (NS) (RR = 1.20, 95% CI = 0.32-3.33). Although renal graft survival was similar between the ESW and Control groups (87% vs 94%), renal function was superior in the ESW group (85 vs 75 mL/min). Additionally, hypertension was less frequent in the ESW group (3% vs 35%), requiring the use of fewer antihypertensives (8% vs 50%). CONCLUSIONS ESW was also associated with better blood pressure control and similar AR risk. The ESW group exhibited stable renal function.
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13
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Corticosteroid-Sparing and Optimization of Mycophenolic Acid Exposure in Liver Transplant Recipients Receiving Mycophenolate Mofetil and Tacrolimus. Transplantation 2016; 100:1705-13. [DOI: 10.1097/tp.0000000000001228] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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14
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Martial LC, Jacobs BAW, Cornelissen EAM, de Haan AFJ, Koch BCP, Burger DM, Aarnoutse RE, Schreuder MF, Brüggemann RJM. Pharmacokinetics and target attainment of mycophenolate in pediatric renal transplant patients. Pediatr Transplant 2016; 20:492-9. [PMID: 26923724 DOI: 10.1111/petr.12695] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/29/2016] [Indexed: 01/23/2023]
Abstract
MPA is an immunosuppressive agent used to prevent graft rejection after renal transplantation. MPA shows considerable inter- and intraindividual variability in exposure in children and has a defined therapeutic window, and TDM is applied to individualize therapy. We aimed to study the exposure to MPA measured as the AUC in pediatric renal transplant patients, to identify factors influencing exposure and to assess target attainment. Children transplanted between 1998 and 2014 in a single center were included. Two groups were identified: Group 1 (AUC <3 wk post-transplantation) and Group 2 (AUC >18 months post-transplantation). Therapeutic targets were set at: AUC0-12h of 30-60 mg h/L. A total of 39 children were included in Group 1 (median age 13.3 yr) vs. 14 in Group 2 (median age 13.4 yr). AUC0-12h was 29.7 mg h/L in Group 1 and 56.6 mg h/L in Group 2, despite a lower dosage in Group 2 (584 and 426 mg/m(2) , respectively). About 46% of patients reached the target AUC0-12h in Group 1. Time since transplantation and serum creatinine were significantly associated with MPA exposure (p < 0.001), explaining 36% of the variability. Individualization of the mycophenolate dose by more intense and more early TDM could improve target attainment.
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Affiliation(s)
- Lisa C Martial
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Institute for Health Sciences, Radboud University, Nijmegen, The Netherlands
| | - Bart A W Jacobs
- Department of Clinical Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Anton F J de Haan
- Radboud Institute for Health Sciences, Radboud University, Nijmegen, The Netherlands
| | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - David M Burger
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Institute for Health Sciences, Radboud University, Nijmegen, The Netherlands
| | - Rob E Aarnoutse
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Institute for Health Sciences, Radboud University, Nijmegen, The Netherlands
| | - Michiel F Schreuder
- Department of Pediatric Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Roger J M Brüggemann
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Institute for Health Sciences, Radboud University, Nijmegen, The Netherlands
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15
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Bamgbola O. Metabolic consequences of modern immunosuppressive agents in solid organ transplantation. Ther Adv Endocrinol Metab 2016; 7:110-27. [PMID: 27293540 PMCID: PMC4892400 DOI: 10.1177/2042018816641580] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Among other factors, sophistication of immunosuppressive (IS) regimen accounts for the remarkable success attained in the short- and medium-term solid organ transplant (SOT) survival. The use of steroids, mycophenolate mofetil and calcineurin inhibitors (CNI) have led to annual renal graft survival rates exceeding 90% in the last six decades. On the other hand, attrition rates of the allograft beyond the first year have remained unchanged. In addition, there is a persistent high cardiovascular (CV) mortality rate among transplant recipients with functioning grafts. These shortcomings are in part due to the metabolic effects of steroids, CNI and sirolimus (SRL), all of which are implicated in hypertension, new onset diabetes after transplant (NODAT), and dyslipidemia. In a bid to reduce the required amount of harmful maintenance agents, T-cell-depleting antibodies are increasingly used for induction therapy. The downsides to their use are greater incidence of opportunistic viral infections and malignancy. On the other hand, inadequate immunosuppression causes recurrent rejection episodes and therefore early-onset chronic allograft dysfunction. In addition to the adverse metabolic effects of the steroid rescue needed in these settings, the generated proinflammatory milieu may promote accelerated atherosclerotic disorders, thus setting up a vicious cycle. The recent availability of newer agent, belatacept holds a promise in reducing the incidence of metabolic disorders and hopefully its long-term CV consequences. Although therapeutic drug monitoring as applied to CNI may be helpful, pharmacodynamic tools are needed to promote a customized selection of IS agents that offer the most benefit to an individual without jeopardizing the allograft survival.
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Affiliation(s)
- Oluwatoyin Bamgbola
- State University of New York Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, NY 11203-2098, USA
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16
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Kiang TKL, Ensom MHH. Therapeutic drug monitoring of mycophenolate in adult solid organ transplant patients: an update. Expert Opin Drug Metab Toxicol 2016; 12:545-53. [DOI: 10.1517/17425255.2016.1170806] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Tony K. L. Kiang
- Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia, Canada
- Department of Pharmacy, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Mary H. H. Ensom
- Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia, Canada
- Department of Pharmacy, Children’s and Women’s Health Centre of British Columbia, Vancouver, British Columbia, Canada
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17
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Pouché L, Koitka M, Stojanova J, Woillard JB, Monchaud C, Villeneuve C, Essig M, Abraham J, Le Meur Y, Rerolle JP, Kamar N, Rostaing L, Merville P, Gandia P, Bouchet S, Petersen BS, Marquet P, Picard N. A candidate gene approach of the calcineurin pathway to identify variants associated with clinical outcomes in renal transplantation. Pharmacogenomics 2016; 17:375-91. [PMID: 26894651 DOI: 10.2217/pgs.15.181] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
AIM To investigate the potential influence of variants in genes involved in the calcineurin pathway on the efficacy and toxicity of calcineurin inhibitors in renal transplantation. MATERIALS & METHODS Twenty-three polymorphisms in thirteen genes were tested in 381 renal transplant recipients receiving ciclosporin (n = 221) or tacrolimus (n = 160) and mycophenolate mofetil. Data were collected prospectively over the first year post-transplantation. RESULTS Multivariate survival analyses revealed no genetic associations with biopsy proven acute graft rejection and serious infections. Donor-recipient Cytomegalovirus mismatch was the only variable associated with serious infection. CONCLUSION This large exploratory study casts doubts on the potential interest of genetic biomarkers related to CNI pharmacodynamics but associations with other phenotypes in transplantation deserve further studies.
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Affiliation(s)
- Lucie Pouché
- Inserm, UMR 850, 2 Avenue Martin-Luther King, F-87042 Limoges, France.,Univ. Limoges, Faculty of Medicine & Pharmacy, 2 rue du Dr Marcland, F-87025 Limoges, France.,CHU Limoges, Department of Pharmacology, Toxicology & Pharmacovigilance, 2 Avenue Martin-Luther King, F-87042 Limoges, France
| | - Matthias Koitka
- Inserm, UMR 850, 2 Avenue Martin-Luther King, F-87042 Limoges, France.,Univ. Limoges, Faculty of Medicine & Pharmacy, 2 rue du Dr Marcland, F-87025 Limoges, France
| | - Jana Stojanova
- Inserm, UMR 850, 2 Avenue Martin-Luther King, F-87042 Limoges, France.,Univ. Limoges, Faculty of Medicine & Pharmacy, 2 rue du Dr Marcland, F-87025 Limoges, France.,Laboratory of Chemical Carcinogenesis & Pharmacogenetics, University of Chile, Santiago, Chile
| | - Jean-Baptiste Woillard
- Inserm, UMR 850, 2 Avenue Martin-Luther King, F-87042 Limoges, France.,Univ. Limoges, Faculty of Medicine & Pharmacy, 2 rue du Dr Marcland, F-87025 Limoges, France.,CHU Limoges, Department of Pharmacology, Toxicology & Pharmacovigilance, 2 Avenue Martin-Luther King, F-87042 Limoges, France
| | - Caroline Monchaud
- Inserm, UMR 850, 2 Avenue Martin-Luther King, F-87042 Limoges, France.,CHU Limoges, Department of Pharmacology, Toxicology & Pharmacovigilance, 2 Avenue Martin-Luther King, F-87042 Limoges, France
| | - Claire Villeneuve
- Inserm, UMR 850, 2 Avenue Martin-Luther King, F-87042 Limoges, France.,Univ. Limoges, Faculty of Medicine & Pharmacy, 2 rue du Dr Marcland, F-87025 Limoges, France.,CHU Limoges, Department of Pharmacology, Toxicology & Pharmacovigilance, 2 Avenue Martin-Luther King, F-87042 Limoges, France
| | - Marie Essig
- Inserm, UMR 850, 2 Avenue Martin-Luther King, F-87042 Limoges, France.,Univ. Limoges, Faculty of Medicine & Pharmacy, 2 rue du Dr Marcland, F-87025 Limoges, France.,CHU Limoges, Department of Nephrology, Dialysis & Transplantation, 2 Avenue Martin-Luther King, F-87042 Limoges, France
| | - Julie Abraham
- CHU Limoges, Department of Clinical Hematology, 2 Avenue Martin-Luther King, F-87042 Limoges, France
| | - Yannick Le Meur
- CHU Brest, Hôpital Cavale Blanche, Department of Nephrology, F-29609 Brest, France
| | - Jean-Phillippe Rerolle
- CHU Limoges, Department of Nephrology, Dialysis & Transplantation, 2 Avenue Martin-Luther King, F-87042 Limoges, France
| | - Nassim Kamar
- CHU Toulouse Rangueil, Department of Nephrology & Organ Transplantation, F-31000 Toulouse, France.,INSERM, U1043, Structure Fédérative de Recherche Bio-Médicale de Toulouse (SFR-BMT), Centre Hospitalier Universitaire (CHU) Purpan, Toulouse, France.,Université Paul Sabatier, 118 route de Narbonne, F-31062 Toulouse, France
| | - Lionel Rostaing
- CHU Toulouse Rangueil, Department of Nephrology & Organ Transplantation, F-31000 Toulouse, France.,INSERM, U1043, Structure Fédérative de Recherche Bio-Médicale de Toulouse (SFR-BMT), Centre Hospitalier Universitaire (CHU) Purpan, Toulouse, France.,Université Paul Sabatier, 118 route de Narbonne, F-31062 Toulouse, France
| | - Pierre Merville
- CHU Bordeaux, Department of Nephrology, Transplantation, Dialysis, F-33000 Bordeaux, France
| | - Peggy Gandia
- CHU Toulouse, Laboratory of Pharmacokinetics & Clinical Toxicology, F-31000 Toulouse, France
| | - Stephane Bouchet
- CHU Bordeaux, Department of Clinical Pharmacology & Toxicology, F-33000 Bordeaux, France
| | - Britt-Sabina Petersen
- Institute of Clinical Molecular Biology, Christian-Albrechts-University Kiel, Germany
| | - Pierre Marquet
- Inserm, UMR 850, 2 Avenue Martin-Luther King, F-87042 Limoges, France.,Univ. Limoges, Faculty of Medicine & Pharmacy, 2 rue du Dr Marcland, F-87025 Limoges, France.,CHU Limoges, Department of Pharmacology, Toxicology & Pharmacovigilance, 2 Avenue Martin-Luther King, F-87042 Limoges, France
| | - Nicolas Picard
- Inserm, UMR 850, 2 Avenue Martin-Luther King, F-87042 Limoges, France.,Univ. Limoges, Faculty of Medicine & Pharmacy, 2 rue du Dr Marcland, F-87025 Limoges, France.,CHU Limoges, Department of Pharmacology, Toxicology & Pharmacovigilance, 2 Avenue Martin-Luther King, F-87042 Limoges, France
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18
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Fu L, Huang Z, Song T, He S, Zeng D, Rao Z, Xie L, Song Y, Wang L, Lin T. Short-term therapeutic drug monitoring of mycophenolic acid reduces infection: a prospective, single-center cohort study in Chinese living-related kidney transplantation. Transpl Infect Dis 2014; 16:760-6. [PMID: 25092411 DOI: 10.1111/tid.12275] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Revised: 03/16/2014] [Accepted: 05/16/2014] [Indexed: 02/05/2023]
Abstract
BACKGROUND The role of therapeutic drug monitoring (TDM) of mycophenolic acid (MPA) in kidney transplant recipients (KTRs) is not clear. We performed a prospective cohort study to evaluate the efficiency of MPA TDM in the Chinese population. METHODS A total of 183 living-related KTRs were studied; 101 KTRs received controlled-dose mycophenolate mofetil (MMF) (the CD group), and 82 patients received fixed-dose MMF (the FD group). MPA exposure was measured at days 3, 7, 14, and 30 in the CD group, and at day 30 in the FD group. The primary endpoint was treatment failure (a composite of acute rejection, graft loss, death, or MMF discontinuation) at 12 months post transplantation. RESULTS In the CD group, with a starting MMF dose of 2 g/day, approximately 35% of patients had high MPA levels, which were >60 mg × h/L, and mean MPA levels were 59.17 mg × h/L and 61.38 mg × h/L for the CD and FD groups, respectively (P = 0.588). After adjusting MMF dose, MPA exposures in the CD group at day 30 were lower than those in the FD group at day 30 (54.06 vs. 61.38, P = 0.004). At month 12, the CD group had fewer infections (16.8% vs. 31.7%, P = 0.018) with no difference in treatment failure, acute rejection, diarrhea, or anemia. CONCLUSIONS KTRs can benefit from short-term TDM of MPA in reducing infection, without increasing acute rejection.
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Affiliation(s)
- L Fu
- Department of Urology, West China Hospital, Sichuan University, Sichuan, People's Republic of China
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19
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Exposure to Mycophenolic Acid Better Predicts Immunosuppressive Efficacy Than Exposure to Calcineurin Inhibitors in Renal Transplant Patients. Clin Pharmacol Ther 2014; 96:508-15. [DOI: 10.1038/clpt.2014.140] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 06/10/2014] [Indexed: 11/08/2022]
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20
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Pharmacology and toxicology of mycophenolate in organ transplant recipients: an update. Arch Toxicol 2014; 88:1351-89. [PMID: 24792322 DOI: 10.1007/s00204-014-1247-1] [Citation(s) in RCA: 138] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 04/15/2014] [Indexed: 12/22/2022]
Abstract
This review aims to provide an update of the literature on the pharmacology and toxicology of mycophenolate in solid organ transplant recipients. Mycophenolate is now the antimetabolite of choice in immunosuppressant regimens in transplant recipients. The active drug moiety mycophenolic acid (MPA) is available as an ester pro-drug and an enteric-coated sodium salt. MPA is a competitive, selective and reversible inhibitor of inosine-5'-monophosphate dehydrogenase (IMPDH), an important rate-limiting enzyme in purine synthesis. MPA suppresses T and B lymphocyte proliferation; it also decreases expression of glycoproteins and adhesion molecules responsible for recruiting monocytes and lymphocytes to sites of inflammation and graft rejection; and may destroy activated lymphocytes by induction of a necrotic signal. Improved long-term allograft survival has been demonstrated for MPA and may be due to inhibition of monocyte chemoattractant protein 1 or fibroblast proliferation. Recent research also suggested a differential effect of mycophenolate on the regulatory T cell/helper T cell balance which could potentially encourage immune tolerance. Lower exposure to calcineurin inhibitors (renal sparing) appears to be possible with concomitant use of MPA in renal transplant recipients without undue risk of rejection. MPA displays large between- and within-subject pharmacokinetic variability. At least three studies have now reported that MPA exhibits nonlinear pharmacokinetics, with bioavailability decreasing significantly with increasing doses, perhaps due to saturable absorption processes or saturable enterohepatic recirculation. The role of therapeutic drug monitoring (TDM) is still controversial and the ability of routine MPA TDM to improve long-term graft survival and patient outcomes is largely unknown. MPA monitoring may be more important in high-immunological recipients, those on calcineurin-inhibitor-sparing regimens and in whom unexpected rejection or infections have occurred. The majority of pharmacodynamic data on MPA has been obtained in patients receiving MMF therapy in the first year after kidney transplantation. Low MPA area under the concentration time from 0 to 12 h post-dose (AUC0-12) is associated with increased incidence of biopsy-proven acute rejection although AUC0-12 optimal cut-off values vary across study populations. IMPDH monitoring to identify individuals at increased risk of rejection shows some promise but is still in the experimental stage. A relationship between MPA exposure and adverse events was identified in some but not all studies. Genetic variants within genes involved in MPA metabolism (UGT1A9, UGT1A8, UGT2B7), cellular transportation (SLCOB1, SLCO1B3, ABCC2) and targets (IMPDH) have been reported to effect MPA pharmacokinetics and/or response in some studies; however, larger studies across different ethnic groups that take into account genetic linkage and drug interactions that can alter a patient's phenotype are needed before any clinical recommendations based on patient genotype can be formulated. There is little data on the pharmacology and toxicology of MPA in older and paediatric transplant recipients.
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21
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Controlled-dose versus fixed-dose mycophenolate mofetil for kidney transplant recipients: a systematic review and meta-analysis of randomized controlled trials. Transplantation 2013; 96:361-7. [PMID: 23558507 DOI: 10.1097/tp.0b013e31828c6dc7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Although mycophenolate mofetil (MMF) is recommended at a fixed dose, there is increasing interest in controlled-dose (CD) MMF based on therapeutic drug monitoring. We systematically evaluated published randomized controlled trials (RCTs) on the efficacy and safety of CD versus fixed-dose MMF for kidney transplant recipients. METHODS The electronic databases Medline, Embase, and Cochrane Library (up to June 2012) were searched to identify relevant RCTs. Two reviewers independently applied the study selection criteria, examined the study quality, and extracted the data. Dichotomous measures were expressed as relative risk (RR) and continuous outcomes were expressed as weighted mean difference, both with 95% confidence intervals (CIs). All statistical analyses were performed using Review Manager 5.1.6. RESULTS Four RCTs met our selection criteria and included 1755 de novo recipients. The differences between CD and fixed-dose MMF in treatment failure (RR, 0.95; 95% CI, 0.82-1.10; P=0.52), serum creatinine clearance (weighted mean difference, 2.46; 95% CI, -1.15 to 6.07; P=0.18), total gastrointestinal adverse events (RR, 1.23; 95% CI, 0.65-2.35; P=0.53), diarrhea (RR, 1.08; 95% CI, 0.92-1.25; P=0.35), anemia (RR, 1.24; 95% CI, 0.95-1.64; P=0.12), leukopenia (RR, 1.12; 95% CI, 0.93-1.35; P=0.25), thrombocytopenia (RR, 0.80; 95% CI, 0.47-1.36; P=0.41), and malignancy (RR, 0.61; 95% CI, 0.27-1.38; P=0.23) were not statistically significant. Furthermore, total infections were more frequent in the CD group (36.0% vs. 30.9%; RR, 1.16; 95% CI, 1.03-1.30; P=0.01). CONCLUSIONS Based on current evidence, CD MMF administration cannot be recommended as routine practice for kidney transplant recipients. Therapeutic drug monitoring for MMF may be targeted toward high-risk recipients, who should be identified in future studies.
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22
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Impact of longitudinal exposure to mycophenolic acid on acute rejection in renal-transplant recipients using a joint modeling approach. Pharmacol Res 2013; 72:52-60. [DOI: 10.1016/j.phrs.2013.03.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Revised: 03/22/2013] [Accepted: 03/22/2013] [Indexed: 11/22/2022]
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