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Kwakyi E, Nartey ET, Otabil MK, Asiedu-Gyekye I, Ahorhorlu SY, Bioma V, Kudzi W. A descriptive study of the single-nucleotide polymorphisms known to affect the Tacrolimus trough concentration per dose, among a population of kidney failure patients in a tertiary hospital in Ghana. BMC Res Notes 2024; 17:210. [PMID: 39080672 PMCID: PMC11288130 DOI: 10.1186/s13104-024-06868-8] [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: 11/11/2023] [Accepted: 07/16/2024] [Indexed: 08/03/2024] Open
Abstract
BACKGROUND The burden of chronic kidney disease (CKD) and kidney failure in Ghana is on the ascendency, with the prevalence of CKD estimated at 13.3%. Patients with CKD who progress to kidney failure require life sustaining kidney replacement therapy (KRT) which is almost exclusively available in Ghana as haemodialysis. Kidney transplantation is considered the best KRT option for patients with irreversible kidney failure due to its relative cost efficiency as well as its superiority in terms of survival and quality of life. However, because transplants may trigger an immune response with potential organ rejection, immunosuppressants such as tacrolimus dosing are required. OBJECTIVE This study sought to determine single nucleotide polymorphisms in CYP3A5, CYP3A4 and MDR1 genes that affect the pharmacokinetics of Tacrolimus in a population of Ghanaian patients with kidney failure. METHOD This cross-sectional study comprised of 82 kidney failure patients undergoing maintenance haemodialysis at the Renal and Dialysis unit of Korle-Bu Teaching Hospital (KBTH). Clinical and demographic data were collected and genomic DNA isolated. Samples were genotyped for specific SNPs using Polymerase Chain Reaction-Restriction Fragment Length Polymorphism (PCR-RFLP). RESULTS Participants, 58/82 (70.73%) harbored the wildtype CYP3A5*1/*1 AA genotype, 20/82 (24.39%) carried the heterozygous CYP3A5*1/*3 AG genotype, and 4/82 (4.88%) had the homozygous mutant CYP3A5*3/*3 GG genotype. Also, 6/82 (7.32%) carried the wildtype AA genotype, 11/82 (13.41%) had the heterozygous AG genotype, and 65/82 (79.27%) harbored the homozygous mutant GG genotype of CYP3A4*1B (-290 A>G). For MDR1_Ex21 (2677 G>T), 81/82 (98.78%) carried the wildtype GG genotype, while 1/82 (1.22%) had the heterozygous GT genotype. For MDR1_Ex26 (3435 C>T), 63/82 (76.83%) had the wildtype CC genotype, while 18/82 (21.95%) carried the heterozygous CT genotype, and 1/82 (1.22%) harbored the mutant TT genotype. CONCLUSION SNPs in CYP3A4, CYP3A5, and MDR1 genes in a population of Ghanaian kidney failure patients were described. The varying SNPs of the featured genes suggest the need to consider the genetic status of Ghanaians kidney failure patients prior to transplantation and tacrolimus therapy.
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Affiliation(s)
- Edward Kwakyi
- Department of Medicine, University of Ghana Medical School, Legon, Ghana
| | - Edmund Tetteh Nartey
- Center for Tropical Clinical Pharmacology and Therapeutics, University of Ghana Medical School, University of Ghana, P.O. Box GP 4236, Legon, Accra, Ghana.
| | - Michael Kobina Otabil
- Department of Pharmacology and Toxicology, School of Pharmacy, University of Ghana, Legon, Ghana
| | - Isaac Asiedu-Gyekye
- Department of Pharmacology and Toxicology, School of Pharmacy, University of Ghana, Legon, Ghana
| | - Samuel Yao Ahorhorlu
- Center for Tropical Clinical Pharmacology and Therapeutics, University of Ghana Medical School, University of Ghana, P.O. Box GP 4236, Legon, Accra, Ghana
| | - Vincent Bioma
- Department of Medicine, University of Ghana Medical School, Legon, Ghana
| | - William Kudzi
- Center for Tropical Clinical Pharmacology and Therapeutics, University of Ghana Medical School, University of Ghana, P.O. Box GP 4236, Legon, Accra, Ghana
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Du W, Wang X, Zhang D, Zuo X. Genotype-Guided Model for Prediction of Tacrolimus Initial Dosing After Lung Transplantation. J Clin Pharmacol 2024; 64:719-727. [PMID: 38327217 DOI: 10.1002/jcph.2411] [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: 12/16/2023] [Accepted: 01/10/2024] [Indexed: 02/09/2024]
Abstract
The determination of the appropriate initial dose for tacrolimus is crucial in achieving the target concentration promptly and avoiding adverse effects and poor prognosis. However, the trial-and-error approach is still common practice. This study aimed to establish a prediction model for an initial dosing algorithm of tacrolimus in patients receiving a lung transplant. A total of 210 lung transplant recipients were enrolled, and 26 single nucleotide polymorphisms (SNP) from 18 genes that could potentially affect tacrolimus pharmacokinetics were genotyped. Associations between SNPs and tacrolimus concentration/dose ratio were analyzed. SNPs that remained significant in pharmacogenomic analysis were further combined with clinical factors to construct a prediction model for tacrolimus initial dose. The dose needed to reach steady state tacrolimus concentrations and achieve the target range was used to validate model prediction efficiency. Our final model consisted of 7 predictors-CYP3A5 rs776746, SLCO1B3 rs4149117, SLC2A2 rs1499821, NFATc4 rs1955915, alanine aminotransferase, direct bilirubin, and hematocrit-and explained 41.4% variance in the tacrolimus concentration/dose ratio. It achieved an area under the receiver operating characteristic curve of 0.804 (95% confidence interval, 0.746-0.861). The Hosmer-Lemeshow test yielded a nonsignificant P value of .790, suggesting good fit of the model. The predicted dose exhibited good correlation with the observed dose in the early postoperative period (r = 0.748, P less than .001). Our study provided a genotype-guided prediction model for tacrolimus initial dose, which may help to guide individualized dosing of tacrolimus in the lung transplant population in clinical practice.
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Affiliation(s)
- Wenwen Du
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, China
| | - Xiaoxing Wang
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, China
| | - Dan Zhang
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, China
| | - Xianbo Zuo
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, China
- Department of Dermatology, Department of Pharmacy, China-Japan Friendship Hospital, Beijing, China
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3
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Deininger KM, Anderson HD, Patrinos GP, Mitropoulou C, Aquilante CL. Cost-effectiveness analysis of CYP3A5 genotype-guided tacrolimus dosing in solid organ transplantation using real-world data. THE PHARMACOGENOMICS JOURNAL 2024; 24:14. [PMID: 38750044 DOI: 10.1038/s41397-024-00334-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 04/05/2024] [Accepted: 04/23/2024] [Indexed: 06/15/2024]
Abstract
The objective of this study was to estimate the cost-effectiveness of CYP3A5 genotype-guided tacrolimus dosing in kidney, liver, heart, and lung transplant recipients relative to standard of care (SOC) tacrolimus dosing, from a US healthcare payer perspective. We developed decision-tree models to compare economic and clinical outcomes between CYP3A5 genotype-guided and SOC tacrolimus therapy in the first six months post-transplant. We derived inputs for CYP3A5 phenotype frequencies and physician use of genotype test results to inform clinical care from literature; tacrolimus exposure [high vs low tacrolimus time in therapeutic range using the Rosendaal algorithm (TAC TTR-Rosendaal)] and outcomes (incidences of acute tacrolimus nephrotoxicity, acute cellular rejection, and death) from real-world data; and costs from the Medicare Fee Schedule and literature. We calculated cost per avoided event and performed sensitivity analyses to evaluate the robustness of the results to changes in inputs. Incremental costs per avoided event for CYP3A5 genotype-guided vs SOC tacrolimus dosing were $176,667 for kidney recipients, $364,000 for liver recipients, $12,982 for heart recipients, and $93,333 for lung recipients. The likelihood of CYP3A5 genotype-guided tacrolimus dosing leading to cost-savings was 19.8% in kidney, 32.3% in liver, 51.8% in heart, and 54.1% in lung transplant recipients. Physician use of genotype results to guide clinical care and the proportion of patients with a high TAC TTR-Rosendaal were key parameters driving the cost-effectiveness of CYP3A5 genotype-guided tacrolimus therapy. Relative to SOC, CYP3A5 genotype-guided tacrolimus dosing resulted in a slightly greater benefit at a higher cost. Further economic evaluations examining intermediary outcomes (e.g., dose modifications) are needed, particularly in populations with higher frequencies of CYP3A5 expressers.
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Affiliation(s)
- Kimberly M Deininger
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Heather D Anderson
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - George P Patrinos
- Department of Pharmacy, University of Patras School of Health Sciences, Patras, Greece
- Department of Genetics and Genomics, United Arab Emirates University, College of Medicine and Health Sciences, Al-Ain, Abu Dhabi, UAE
- Zayed Center for Health Sciences, United Arab Emirates University, Al-Ain, Abu Dhabi, UAE
| | - Christina Mitropoulou
- Department of Genetics and Genomics, United Arab Emirates University, College of Medicine and Health Sciences, Al-Ain, Abu Dhabi, UAE
- The Golden Helix Foundation, London, UK
| | - Christina L Aquilante
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA.
- Colorado Center for Personalized Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
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4
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Choong CL, Islahudin F, Wong HS, Yahya R, Mohd Tahir NA, Makmor-Bakry M. The Impact of ABCC2 -24C>T Gene Polymorphism on Graft Survival in Kidney Transplant Recipients. J Pers Med 2024; 14:440. [PMID: 38673067 PMCID: PMC11050844 DOI: 10.3390/jpm14040440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 03/15/2024] [Accepted: 03/19/2024] [Indexed: 04/28/2024] Open
Abstract
Personalized medicine in kidney transplantation has the potential to improve outcomes and reduce complications. The aim of this study was to investigate the influence of single nucleotide polymorphisms in genes encoding metabolizing enzymes (CYP3A5) and transporters (ABCC2) on clinical outcomes (acute graft failure and/or acute tubular necrosis (ATN)) in kidney transplant recipients (KTR). This was a multicenter, retrospective cohort study where adult KTR who had undergone kidney transplantation between 2020 and 2021 and received tacrolimus-mycophenolate treatment were enrolled in the study. DNA was extracted from collected blood samples using a commercially available kit. CYP3A5*3, ABCC2 -24C>T and ABCC2 3972C>T SNP were determined by polymerase chain reaction. Of the total 39 patients included, nine (23.1%) KTR had an incidence of acute graft failure and/or ATN. A multiple logistic regression showed wildtype ABCC2 -24C>T C allele had a higher risk of developing acute graft rejection and/or ATN compared to the variant allele carriers (adjusted Odd Ratios [aOR]: 27.675, p = 0.038). Recipients who had delayed graft function (aOR: 49.214, p = 0.012) and a history of CMV infection (aOR: 18.097, p = 0.009) were at 49.2 and 18.1-times increased risk for acute graft failure and/or ATN, respectively. The large aOR was inevitable due to the small sample size and required cautious interpretation. This is the first study to determine the effect of the ABCC2 -24C>T genetic polymorphism on clinical outcomes in Malaysian KTR and forms the basis for further work on ABCC2 -24C>T effects in long-term KTR.
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Affiliation(s)
- Chiau Ling Choong
- Center of Quality Medicine Management, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, Kuala Lumpur 50300, Malaysia; (C.L.C.); (N.A.M.T.); (M.M.-B.)
| | - Farida Islahudin
- Center of Quality Medicine Management, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, Kuala Lumpur 50300, Malaysia; (C.L.C.); (N.A.M.T.); (M.M.-B.)
| | - Hin-Seng Wong
- Department of Nephrology, Selayang Hospital, Ministry of Health Malaysia, Batu Caves 68100, Malaysia;
- Sunway Medical Centre, Jalan Lagoon Selatan, Bandar Sunway, Subang Jaya 46150, Malaysia
| | - Rosnawati Yahya
- Department of Nephrology, Kuala Lumpur Hospital, Ministry of Health Malaysia, Kuala Lumpur 50586, Malaysia;
| | - Nor Asyikin Mohd Tahir
- Center of Quality Medicine Management, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, Kuala Lumpur 50300, Malaysia; (C.L.C.); (N.A.M.T.); (M.M.-B.)
| | - Mohd Makmor-Bakry
- Center of Quality Medicine Management, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, Kuala Lumpur 50300, Malaysia; (C.L.C.); (N.A.M.T.); (M.M.-B.)
- Faculty of Pharmacy, Universitas Airlangga, Surabaya 60115, Indonesia
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5
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Abderahmene A, Francke MI, Andrews LM, Hesselink DA, Amor D, Sahtout W, Ajmi M, Mastouri H, Bouslama A, Zellama D, Omezzine A, De Winter BCM. A Population Pharmacokinetic Model to Predict the Individual Starting Dose of Tacrolimus for Tunisian Adults after Renal Transplantation. Ther Drug Monit 2024; 46:57-66. [PMID: 38018879 DOI: 10.1097/ftd.0000000000001147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 07/23/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Tacrolimus is the most frequently used immunosuppressive drug for preventing renal rejection. However, its use is hampered by its narrow therapeutic index and large intra and interpatient variability in pharmacokinetics. The objective of this study was to externally validate a tacrolimus population pharmacokinetic model developed for the Dutch population and adjust the model for the Tunisian population for use in predicting the starting dose requirement after kidney transplantation. METHODS Data on tacrolimus exposure were obtained from kidney transplant recipients (KTRs) during the first 3 months post-transplantation. External validation of the Dutch model and its adjustment for the Tunisian population was performed using nonlinear mixed-effects modeling. RESULTS In total, 1901 whole-blood predose tacrolimus concentrations from 196 adult KTRs were analyzed. According to a visual predictive check, the Dutch model underestimated the starting dose for the Tunisian adult population. The effects of age, together with the CYP3A5*3 and CYP3A4*22 genotypes on tacrolimus clearance were significantly different in the Tunisian population than in the Dutch population. Based on a bodyweight-based dosing, only 21.9% of tacrolimus concentrations were within the target range, whereas this was estimated to be 54.0% with the newly developed model-based dosing. After adjustment, the model was successfully validated internally in a Tunisian population. CONCLUSIONS A starting-dose population pharmacokinetic model of tacrolimus for Tunisian KTRs was developed based on a previously published Dutch model. Using this starting dose could potentially increase the percentage of patients achieving target tacrolimus concentrations after the initial starting dose.
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Affiliation(s)
- Amani Abderahmene
- Department of Biochemistry , LR12SP11, Sahloul University Hospital, Sousse, University of Monastir Faculty of Pharmacy of Monastir, Monastir, Tunisia
- Rotterdam Clinical Pharmacometrics Group, Rotterdam, the Netherlands
| | - Marith I Francke
- Rotterdam Clinical Pharmacometrics Group, Rotterdam, the Netherlands
- Division of Nephrology and Transplantation, Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
- Erasmus MC Transplant Institute, Rotterdam, the Netherlands
| | - Louise M Andrews
- Department of Hospital Pharmacy, Meander MC, Amersfoort, the Netherlands
| | - Dennis A Hesselink
- Division of Nephrology and Transplantation, Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
- Erasmus MC Transplant Institute, Rotterdam, the Netherlands
| | - Dorra Amor
- Department of Biochemistry , LR12SP11, Sahloul University Hospital, Sousse, University of Monastir Faculty of Pharmacy of Monastir, Monastir, Tunisia
| | - Wissal Sahtout
- Department of Nephrology, Sahloul University Hospital, Sousse, Tunisia; and
| | - Marwa Ajmi
- Department of Biochemistry , LR12SP11, Sahloul University Hospital, Sousse, University of Monastir Faculty of Pharmacy of Monastir, Monastir, Tunisia
| | - Hayfa Mastouri
- Department of Biochemistry , LR12SP11, Sahloul University Hospital, Sousse, University of Monastir Faculty of Pharmacy of Monastir, Monastir, Tunisia
| | - Ali Bouslama
- Department of Biochemistry , LR12SP11, Sahloul University Hospital, Sousse, University of Monastir Faculty of Pharmacy of Monastir, Monastir, Tunisia
| | - Dorsaf Zellama
- Department of Nephrology, Sahloul University Hospital, Sousse, Tunisia; and
| | - Asma Omezzine
- Department of Biochemistry , LR12SP11, Sahloul University Hospital, Sousse, University of Monastir Faculty of Pharmacy of Monastir, Monastir, Tunisia
| | - Brenda C M De Winter
- Rotterdam Clinical Pharmacometrics Group, Rotterdam, the Netherlands
- Erasmus MC Transplant Institute, Rotterdam, the Netherlands
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, the Netherlands
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6
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Abderahmene A, Khalij Y, Moussa A, Ammar M, Ellouz A, Amor D, Abbes H, Ganouni MR, Sahtout W, Chouchene S, Omezzine A, Zellama D, Bouslama A. The pharmacogenetics of tacrolimus in renal transplant patients: association with tremors, new-onset diabetes and other clinical events. THE PHARMACOGENOMICS JOURNAL 2024; 24:3. [PMID: 38253626 DOI: 10.1038/s41397-024-00323-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 01/04/2024] [Indexed: 01/24/2024]
Abstract
Our study is the first study to investigate the effect of SNPs in CYP3A5, CYP3A4, ABCB1 and POR genes on the incidence of tremors, nephrotoxicity, and diabetes mellitus. A total of 223 renal transplant patients receiving tacrolimus and mycophenolate mofetil (MMF) were recruited. Both adults and children patients participated in the study. Genotyping was performed using PROFLEX-PCR followed by RFLP. MPA and tacrolimus plasma concentrations were measured by immunoassay. The AUC0-12h of MMF was estimated by a Bayesian method. We found a statistically significant association between the CYP3A5*3 and CYP3A4*1B genotypes and the tacrolimus exposure. We found a lower occurrence of nephrotoxicity (p = 0.03), tremor (p = 0.01), and new-onset diabetes (p = 0.002) associated with CYP3A5*1 allele. The CYP3A4*1B allele was significantly associated with a lower occurrence of new-onset diabetes (p = 0.026). The CYP3A5*1 allele was significantly associated with an increased risk of acute and chronic rejection (p = 0.03 and p < 0.001, respectively). Our results support the usefulness of tacrolimus pharmacokinetics in pre-kidney transplant assessments.
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Affiliation(s)
- Amani Abderahmene
- Biochemistry Department, LR12SP11, Sahloul University Hospital, Street Route Ceinture Sahloul, 4054, Sousse, Tunisia.
- University of Monastir, Faculty of Pharmacy of Monastir, Street Ibn Sina, 5000, Monastir, Tunisia.
| | - Yassine Khalij
- Biochemistry Department, LR12SP11, Sahloul University Hospital, Street Route Ceinture Sahloul, 4054, Sousse, Tunisia
- University of Monastir, Faculty of Pharmacy of Monastir, Street Ibn Sina, 5000, Monastir, Tunisia
| | - Amira Moussa
- Biochemistry Department, LR12SP11, Sahloul University Hospital, Street Route Ceinture Sahloul, 4054, Sousse, Tunisia
- University of Monastir, Faculty of Pharmacy of Monastir, Street Ibn Sina, 5000, Monastir, Tunisia
| | - Meriam Ammar
- Biochemistry Department, LR12SP11, Sahloul University Hospital, Street Route Ceinture Sahloul, 4054, Sousse, Tunisia
- University of Monastir, Faculty of Pharmacy of Monastir, Street Ibn Sina, 5000, Monastir, Tunisia
| | - Amel Ellouz
- Biochemistry Department, LR12SP11, Sahloul University Hospital, Street Route Ceinture Sahloul, 4054, Sousse, Tunisia
- University of Monastir, Faculty of Pharmacy of Monastir, Street Ibn Sina, 5000, Monastir, Tunisia
| | - Dorra Amor
- Biochemistry Department, LR12SP11, Sahloul University Hospital, Street Route Ceinture Sahloul, 4054, Sousse, Tunisia
- University of Monastir, Faculty of Pharmacy of Monastir, Street Ibn Sina, 5000, Monastir, Tunisia
| | - Houwaida Abbes
- Biochemistry Department, LR12SP11, Sahloul University Hospital, Street Route Ceinture Sahloul, 4054, Sousse, Tunisia
- University of Monastir, Faculty of Pharmacy of Monastir, Street Ibn Sina, 5000, Monastir, Tunisia
| | - Mohamed Rayen Ganouni
- Biochemistry Department, LR12SP11, Sahloul University Hospital, Street Route Ceinture Sahloul, 4054, Sousse, Tunisia
- University of Monastir, Faculty of Pharmacy of Monastir, Street Ibn Sina, 5000, Monastir, Tunisia
| | - Wissal Sahtout
- Nephrology Department, Sahloul University Hospital, Street Route Ceinture Sahloul, 4054, Sousse, Tunisia
| | - Saoussen Chouchene
- Hematology Department, Fattouma Bourguiba University Hospital, 5000, Monastir, Tunisia
| | - Asma Omezzine
- Biochemistry Department, LR12SP11, Sahloul University Hospital, Street Route Ceinture Sahloul, 4054, Sousse, Tunisia
- University of Monastir, Faculty of Pharmacy of Monastir, Street Ibn Sina, 5000, Monastir, Tunisia
| | - Dorsaf Zellama
- Nephrology Department, Sahloul University Hospital, Street Route Ceinture Sahloul, 4054, Sousse, Tunisia
| | - Ali Bouslama
- Biochemistry Department, LR12SP11, Sahloul University Hospital, Street Route Ceinture Sahloul, 4054, Sousse, Tunisia
- University of Monastir, Faculty of Pharmacy of Monastir, Street Ibn Sina, 5000, Monastir, Tunisia
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Budde K, Rostaing L. A first small step toward personalized immunosuppression. Kidney Int 2023; 104:652-654. [PMID: 37739615 DOI: 10.1016/j.kint.2023.06.036] [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: 06/24/2023] [Accepted: 06/27/2023] [Indexed: 09/24/2023]
Abstract
Lloberas et al. provide further evidence for the benefits of an individualized tacrolimus dosing algorithm based on population pharmacokinetics and pharmacogenetics. Better tacrolimus dosing could prevent underexposure and overexposure and potentially save costs. Most important, this could be the start of precision medicine in kidney transplantation, incorporating improved immunologic and donor quality assessments, advanced biopsy readouts, innovative pharmacogenomics for drug safety, and novel diagnostic and outcome algorithms to guide a truly personalized therapy.
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Affiliation(s)
- Klemens Budde
- Department of Nephrology and Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany.
| | - Lionel Rostaing
- Department of Nephrology, Hemodialysis, Apheresis, and Transplantation, CHU Grenoble-Alpes, Grenoble, France
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Lloberas N, Grinyó JM, Colom H, Vidal-Alabró A, Fontova P, Rigo-Bonnin R, Padró A, Bestard O, Melilli E, Montero N, Coloma A, Manonelles A, Meneghini M, Favà A, Torras J, Cruzado JM. A prospective controlled, randomized clinical trial of kidney transplant recipients developed personalized tacrolimus dosing using model-based Bayesian Prediction. Kidney Int 2023; 104:840-850. [PMID: 37391040 DOI: 10.1016/j.kint.2023.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 05/25/2023] [Accepted: 06/02/2023] [Indexed: 07/02/2023]
Abstract
For three decades, tacrolimus (Tac) dose adjustment in clinical practice has been calculated empirically according to the manufacturer's labeling based on a patient's body weight. Here, we developed and validated a Population pharmacokinetic (PPK) model including pharmacogenetics (cluster CYP3A4/CYP3A5), age, and hematocrit. Our study aimed to assess the clinical applicability of this PPK model in the achievement of Tac Co (therapeutic trough Tac concentration) compared to the manufacturer's labelling dosage. A prospective two-arm, randomized, clinical trial was conducted to determine Tac starting and subsequent dose adjustments in 90 kidney transplant recipients. Patients were randomized to a control group with Tac adjustment according to the manufacturer's labeling or the PPK group adjusted to reach target Co (6-10 ng/ml) after the first steady state (primary endpoint) using a Bayesian prediction model (NONMEM). A significantly higher percentage of patients from the PPK group (54.8%) compared with the control group (20.8%) achieved the therapeutic target fulfilling 30% of the established superiority margin defined. Patients receiving PPK showed significantly less intra-patient variability compared to the control group, reached the Tac Co target sooner (5 days vs 10 days), and required significantly fewer Tac dose modifications compared to the control group within 90 days following kidney transplant. No statistically significant differences occurred in clinical outcomes. Thus, PPK-based Tac dosing offers significant superiority for starting Tac prescription over classical labeling-based dosing according to the body weight, which may optimize Tac-based therapy in the first days following transplantation.
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Affiliation(s)
- Nuria Lloberas
- Nephrology Department, Hospital Universitari de Bellvitge-Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona, Spain.
| | - Josep M Grinyó
- Department of Clinical Sciences, Medicine Unit, University of Barcelona, Barcelona, Spain
| | - Helena Colom
- Biopharmaceutics and Pharmacokinetics Unit, Department of Pharmacy and Pharmaceutical Technology and Physical Chemistry, School of Pharmacy, University of Barcelona, Barcelona, Spain.
| | - Anna Vidal-Alabró
- Nephrology Department, Hospital Universitari de Bellvitge-Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona, Spain
| | - Pere Fontova
- Nephrology Department, Hospital Universitari de Bellvitge-Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona, Spain
| | - Raul Rigo-Bonnin
- Biochemistry Department, Hospital Universitari de Bellvitge-Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona, Spain
| | - Ariadna Padró
- Biochemistry Department, Hospital Universitari de Bellvitge-Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona, Spain
| | - Oriol Bestard
- Nephrology Department, Hospital Universitari de Bellvitge-Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona, Spain
| | - Edoardo Melilli
- Nephrology Department, Hospital Universitari de Bellvitge-Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona, Spain
| | - Nuria Montero
- Nephrology Department, Hospital Universitari de Bellvitge-Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona, Spain
| | - Ana Coloma
- Nephrology Department, Hospital Universitari de Bellvitge-Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona, Spain
| | - Anna Manonelles
- Nephrology Department, Hospital Universitari de Bellvitge-Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona, Spain
| | - Maria Meneghini
- Nephrology Department, Hospital Universitari de Bellvitge-Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona, Spain
| | - Alex Favà
- Nephrology Department, Hospital Universitari de Bellvitge-Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona, Spain
| | - Joan Torras
- Nephrology Department, Hospital Universitari de Bellvitge-Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona, Spain
| | - Josep M Cruzado
- Nephrology Department, Hospital Universitari de Bellvitge-Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona, Spain
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Sanghvi S, Ferner RE, Scourfield A, Urquhart R, Amin S, Hingorani AD, Sofat R. How to assess pharmacogenomic tests for implementation in the NHS in England. Br J Clin Pharmacol 2023; 89:2649-2657. [PMID: 37313748 DOI: 10.1111/bcp.15820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 05/28/2023] [Accepted: 05/28/2023] [Indexed: 06/15/2023] Open
Abstract
AIMS Pharmacogenomic testing has the potential to target medicines more effectively towards those who will benefit and avoid use in individuals at risk of harm. Health economies are actively considering how pharmacogenomic tests can be integrated into health care systems to improve use of medicines. However, one of the barriers to effective implementation is evaluation of the evidence including clinical usefulness, cost-effectiveness, and operational requirements. We sought to develop a framework that could aid the implementation of pharmacogenomic testing. We take the view from the National Health Service (NHS) in England. METHODS We used a literature review using EMBASE and Medline databases to identify prospective studies of pharmacogenomic testing, focusing on clinical outcomes and implementation of pharmacogenomics. Using this search, we identified key themes relating to the implementation of pharmacogenomic tests. We used a clinical advisory group with expertise in pharmacology, pharmacogenomics, formulary evaluation, and policy implementation to review data from our literature review and the interpretation of these data. With the clinical advisory group, we prioritized themes and developed a framework to evaluate proposals to implement pharmacogenomics tests. RESULTS Themes that emerged from review of the literature and subsequent discussion were distilled into a 10-point checklist that is proposed as a tool to aid evidence-based implementation of pharmacogenomic testing into routine clinical care within the NHS. CONCLUSION Our 10-point checklist outlines a standardized approach that could be used to evaluate proposals to implement pharmacogenomic tests. We propose a national approach, taking the view of the NHS in England. Using this approach could centralize commissioning of appropriate pharmacogenomic tests, reduce inequity and duplication using regional approaches, and provide a robust and evidence-based framework for adoption. Such an approach could also be applied to other health systems.
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Affiliation(s)
- Sonali Sanghvi
- North Central London NHS Integrating Pharmacy & Medicines Optimisation Team, London, UK
- Clinical Support Services Division, University College London Hospitals NHS Foundation Trust, London, UK
| | - Robin E Ferner
- School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK
- Department of Clinical Pharmacology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Andrew Scourfield
- Department of Clinical Pharmacology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Robert Urquhart
- Clinical Support Services Division, University College London Hospitals NHS Foundation Trust, London, UK
| | - Sejal Amin
- North Central London NHS Integrating Pharmacy & Medicines Optimisation Team, London, UK
- Clinical Support Services Division, University College London Hospitals NHS Foundation Trust, London, UK
| | - Aroon D Hingorani
- Institute of Cardiovascular Science, Centre for Clinical Department of Clinical Pharmacology and Therapeutics and the UCL BHF Research Accelerator, University College London, London, UK
| | - Reecha Sofat
- Health Data Research, London, UK
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
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10
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Henkel L, Jehn U, Thölking G, Reuter S. Tacrolimus-why pharmacokinetics matter in the clinic. FRONTIERS IN TRANSPLANTATION 2023; 2:1160752. [PMID: 38993881 PMCID: PMC11235362 DOI: 10.3389/frtra.2023.1160752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 08/07/2023] [Indexed: 07/13/2024]
Abstract
The calcineurin inhibitor (CNI) Tacrolimus (Tac) is the most prescribed immunosuppressant drug after solid organ transplantation. After renal transplantation (RTx) approximately 95% of recipients are discharged with a Tac-based immunosuppressive regime. Despite the high immunosuppressive efficacy, its adverse effects, narrow therapeutic window and high intra- and interpatient variability (IPV) in pharmacokinetics require therapeutic drug monitoring (TDM), which makes treatment with Tac a major challenge for physicians. The C/D ratio (full blood trough level normalized by daily dose) is able to classify patients receiving Tac into two major metabolism groups, which were significantly associated with the clinical outcomes of patients after renal or liver transplantation. Therefore, the C/D ratio is a simple but effective tool to identify patients at risk of an unfavorable outcome. This review highlights the challenges of Tac-based immunosuppressive therapy faced by transplant physicians in their daily routine, the underlying causes and pharmacokinetics (including genetics, interactions, and differences between available Tac formulations), and the latest data on potential solutions to optimize treatment of high-risk patients.
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Affiliation(s)
- Lino Henkel
- Department of Medicine D, University of Münster, Münster, Germany
| | - Ulrich Jehn
- Department of Medicine D, University of Münster, Münster, Germany
| | - Gerold Thölking
- Department of Medicine D, University of Münster, Münster, Germany
- Department of Internal Medicine and Nephrology, University Hospital of Münster Marienhospital Steinfurt, Steinfurt, Germany
| | - Stefan Reuter
- Department of Medicine D, University of Münster, Münster, Germany
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11
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Schagen MR, Volarevic H, Francke MI, Sassen SDT, Reinders MEJ, Hesselink DA, de Winter BCM. Individualized dosing algorithms for tacrolimus in kidney transplant recipients: current status and unmet needs. Expert Opin Drug Metab Toxicol 2023; 19:429-445. [PMID: 37642358 DOI: 10.1080/17425255.2023.2250251] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 08/17/2023] [Indexed: 08/31/2023]
Abstract
INTRODUCTION Tacrolimus is a potent immunosuppressive drug with many side effects including nephrotoxicity and post-transplant diabetes mellitus. To limit its toxicity, therapeutic drug monitoring (TDM) is performed. However, tacrolimus' pharmacokinetics are highly variable within and between individuals, which complicates their clinical management. Despite TDM, many kidney transplant recipients will experience under- or overexposure to tacrolimus. Therefore, dosing algorithms have been developed to limit the time a patient is exposed to off-target concentrations. AREAS COVERED Tacrolimus starting dose algorithms and models for follow-up doses developed and/or tested since 2015, encompassing both adult and pediatric populations. Literature was searched in different databases, i.e. Embase, PubMed, Web of Science, Cochrane Register, and Google Scholar, from inception to February 2023. EXPERT OPINION Many algorithms have been developed, but few have been prospectively evaluated. These performed better than bodyweight-based starting doses, regarding the time a patient is exposed to off-target tacrolimus concentrations. No benefit in reduced tacrolimus toxicity has yet been observed. Most algorithms were developed from small datasets, contained only a few tacrolimus concentrations per person, and were not externally validated. Moreover, other matrices should be considered which might better correlate with tacrolimus toxicity than the whole-blood concentration, e.g. unbound plasma or intra-lymphocytic tacrolimus concentrations.
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Affiliation(s)
- Maaike R Schagen
- Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Erasmus MC, Rotterdam Clinical Pharmacometrics Group, Rotterdam, the Netherlands
| | - Helena Volarevic
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Marith I Francke
- Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Sebastiaan D T Sassen
- Erasmus MC, Rotterdam Clinical Pharmacometrics Group, Rotterdam, the Netherlands
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Marlies E J Reinders
- Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Dennis A Hesselink
- Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Brenda C M de Winter
- Erasmus MC, Rotterdam Clinical Pharmacometrics Group, Rotterdam, the Netherlands
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
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12
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Abdel-Kahaar E, Keller F. Clinical Pharmacokinetics and Pharmacodynamics of Voclosporin. Clin Pharmacokinet 2023; 62:693-703. [PMID: 37133755 PMCID: PMC10182160 DOI: 10.1007/s40262-023-01246-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2023] [Indexed: 05/04/2023]
Abstract
Voclosporin is an approved option for the long-term treatment of lupus nephritis. We aimed to provide a narrative review of the pharmacokinetics and pharmacodynamics of voclosporin. In addition, we derived values for pharmacokinetic and pharmacodynamic parameters by graphical analysis of published diagrams. Compared with cyclosporin, low-dose voclosporin is associated with a lower nephrotoxicity risk and, compared to tacrolimus, with a lower diabetes risk. After repetitive dosing of 23.7 mg twice daily and at target trough concentrations of 10-20 ng/mL, the dominant or effect-indicative half-life is estimated at 7 hours. Compared with the pharmacodynamics of cyclosporin, the potency of voclosporin is stronger, with a lower concentration CE50 of 50 ng/mL already producing the half-maximum immunosuppressive effect. The Hill coefficient can be predicted to be low at H = 1.3, indicating a concentration-dependent effect on the immune system. The corresponding effect bisection time of 10 hours allows for dosing every 12 hours. Accordingly, the trough concentration will be above the threshold concentration that produces 5% of the maximum effect of 5.2 ng/mL for immunosuppression but below both the predicted threshold of 30 ng/mL for nephrotoxicity and the predicted threshold of 40 ng/mL for new-onset diabetes. The pharmacokinetic and pharmacodynamic properties suggest the use of low-dose voclosporin combined with mycophenolate and low-dose glucocorticoids for immunosuppressive maintenance therapy.
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Affiliation(s)
- Emaad Abdel-Kahaar
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, University Hospital Ulm, Helmholtzstrasse 20, 89081, Ulm, Germany
- Department of Pharmacology, Qena Faculty of Medicine, South Valley University, Qena, Egypt
- , Ulm, Germany
| | - Frieder Keller
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, University Hospital Ulm, Helmholtzstrasse 20, 89081, Ulm, Germany.
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Reininger KA, Onyeaghala G, Anderson-Haag T, Schladt DS, Wu B, Guan W, Dorr CR, Remmel RP, Mannon R, Matas AJ, Oetting WS, Stahler P, Israni AK, Jacobson PA. Higher number of tacrolimus dose adjustments in kidney transplant recipients who are extensive and intermediate CYP3A5 metabolizers. Clin Transplant 2023; 37:e14893. [PMID: 36571802 PMCID: PMC10089949 DOI: 10.1111/ctr.14893] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 12/20/2022] [Indexed: 12/27/2022]
Abstract
Kidney transplant recipients carrying the CYP3A5*1 allele have lower tacrolimus troughs, and higher dose requirements compared to those with the CYP3A5*3/*3 genotype. However, data on the effect of CYP3A5 alleles on post-transplant tacrolimus management are lacking. The effect of CYP3A5 metabolism phenotypes on the number of tacrolimus dose adjustments and troughs in the first 6 months post-transplant was evaluated in 78 recipients (64% Caucasians). Time to first therapeutic concentration, percentage of time in therapeutic range (TTR), and estimated glomerular filtration rate (eGFR) were also evaluated. Fifty-five kidney transplant recipients were CYP3A5 poor metabolizers (PM), 17 were intermediate metabolizers (IM), and 6 were extensive metabolizers (EM). Compared to PMs, EMs/IMs had significantly more dose adjustments (6.1 vs. 8.1, p = .015). Overall, 33.82% of trough measurements resulted in a dose change. There was no difference in the number of tacrolimus trough measurements between PMs and EM/IMs. The total daily tacrolimus dose requirements were higher in EMs and IMs compared to PMs (<.001). TTR was ∼50% in the PMs and EMs/IMs groups. CYP3A5 EM/IM metabolizers have more tacrolimus dose changes and higher dose requirements which increases clinical management complexity. Larger studies are needed to assess the cost and benefits of including genotyping data to improve clinical management.
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Affiliation(s)
- Kevin A Reininger
- Department of Pharmacy, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Guillaume Onyeaghala
- Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
- Division of Nephrology, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA
| | - Teresa Anderson-Haag
- Department of Pharmacy, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - David S Schladt
- Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | - Baolin Wu
- Department of Biostatistics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Weihua Guan
- Department of Biostatistics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Casey R Dorr
- Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
- Division of Nephrology, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA
| | - Rory P Remmel
- Department of Medicinal Chemistry, University of Minnesota, Minneapolis, Minnesota, USA
| | - Roslyn Mannon
- Division of Nephrology, University of Nebraska, Omaha, Nebraska, USA
| | - Arthur J Matas
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - William S Oetting
- Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Paul Stahler
- Division of Surgery, Hennepin Healthcare, Minneapolis, Minnesota, USA
| | - Ajay K Israni
- Division of Nephrology, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA
- Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Pamala A Jacobson
- Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis, Minnesota, USA
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14
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Gong F, Hu H, Ouyang Y, Liao ZZ, Kong Y, Hu JF, He H, Zhou Y. Physiologically-based pharmacokinetic modeling-guided rational combination of tacrolimus and voriconazole in patients with different CYP3A5 and CYP2C19 alleles. Toxicol Appl Pharmacol 2023; 466:116475. [PMID: 36931438 DOI: 10.1016/j.taap.2023.116475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 03/11/2023] [Accepted: 03/14/2023] [Indexed: 03/17/2023]
Abstract
The drug-drug interactions (DDIs) between tacrolimus and voriconazole are highly variable among individuals. We aimed to develop a physiologically based pharmacokinetic (PBPK) model to predict the DDIs in people with different CYP3A5 and CYP2C19 alleles. First, pharmacokinetic data of humans receiving tacrolimus with or without voriconazole from the literature were used to construct and validate the PBPK model. Thereafter, we developed a model incorporating the metabolism of voriconazole mediated by CYP2C19 and the inhibitory effect of voriconazole on CYP3A4/5. Finally, the model was used to evaluate the dose adjustment of tacrolimus in people with different CYP3A5 and CYP2C19 alleles. When tacrolimus was administered alone (3 mg PO, single dose), the predicted AUC0-∞ of tacrolimus in CYP3A5 nonexpressers (19.22) was 3.5-fold higher than that in expressers (5.48). Following voriconazole (200 mg PO, bid) administration in human with different CYP2C19 genotypes, the AUC0-∞ of tacrolimus increased by 5.1- to 8.3-fold in CYP3A5 expressers and by 5.3- to 10.2-fold in CYP3A5 nonexpressers. The lower the gene expression level of CYP2C19 in the population, the higher the exposure to tacrolimus. When tacrolimus was combined with voriconazole (200 mg, bid; 400 mg, bid, on Day 1), the final model simulations suggested that the dose regimen of tacrolimus should be regulated to 0.15 mg/kg/day (qd) in CYP3A5 expressers with different CYP2C19 genotypes. For CYP3A5 nonexpressers, the dosing schedule of tacrolimus should be modified to 0.05 mg/kg/24 h for patients with 2C19 EM, 0.05 mg/kg/48 h for 2C19 IM and 0.05 mg/kg/72 h for 2C19 PM. In conclusion, a PBPK model with CYP3A5 and CYP2C19 polymorphisms was successfully established, providing more insights regarding the DDIs between tacrolimus and voriconazole to guide the clinical use of tacrolimus.
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Affiliation(s)
- Fei Gong
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang 330006, China; Center for Molecular Diagnosis and Precision Medicine, Department of Clinical Laboratory, The First Affiliated Hospital of Nanchang University, Nanchang 330006, China; School of Pharmacy, Nanchang University, Nanchang 330006, China
| | - Huihui Hu
- Center of Drug Metabolism and Pharmacokinetics, China Pharmaceutical University, Nanjing 210009, China
| | - Ying Ouyang
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang 330006, China; School of Pharmacy, Nanchang University, Nanchang 330006, China
| | - Zheng-Zheng Liao
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang 330006, China
| | - Ying Kong
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang 330006, China
| | - Jin-Fang Hu
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang 330006, China
| | - Hua He
- Center of Drug Metabolism and Pharmacokinetics, China Pharmaceutical University, Nanjing 210009, China.
| | - Ying Zhou
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang 330006, China.
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15
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Shi B, Liu Y, Liu D, Yuan L, Guo W, Wen P, Su Z, Wang J, Xu S, Xia J, An W, Wang R, Wen P, Xing T, Zhang J, Gu H, Wang Z, Zhong L, Fan J, Li H, Zhang W, Peng Z. Genotype-guided model significantly improves accuracy of tacrolimus initial dosing after liver transplantation. EClinicalMedicine 2023; 55:101752. [PMID: 36444212 PMCID: PMC9700266 DOI: 10.1016/j.eclinm.2022.101752] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 10/31/2022] [Accepted: 11/01/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The initial dose of tacrolimus after liver transplantation (LT) is critical for rapidly achieving the steady state of the drug concentration, minimizing the potential adverse reactions and warranting long-term patient prognosis. We aimed to develop and validate a genotype-guided model for determining personalized initial dose of tacrolimus. METHODS By combining pharmacokinetic modeling, pharmacogenomic analysis and multiple statistical methods, we developed a genotype-guided model to predict individualized tacrolimus initial dose after LT in the discovery (n = 150) and validation cohorts (n = 97) respectively. This model was further validated in a prospective, randomized and single-blind clinical trial from August, 2021 to February, 2022 (n = 40, ChiCTR2100050288). FINDINGS Our model included donor's and recipient's genotypes, recipient's weight and total bilirubin, which achieved an area under the curve of receiver operating characteristic curve (AUC of ROC) of 0.88 and 0.79 in the discovery and validation cohorts, respectively. We found that patients who were given tacrolimus within the recommended concentration range (RCR) (4-10 ng/mL), the new-onset metabolic syndromes are lower, especially for new-onset diabetes (p = 0.043). In the clinical trial, compared to those in experience-based (EB) group, patients in the model-based (MB) group were more likely to achieving the RCR (75% vs 40%, p = 0.025) with a more variable individualized dose (0.023-0.096 mg/kg/day vs 0.045-0.057 mg/kg/day). Moreover, significantly fewer medication adjustments were required for the MB group than the EB group (2.75 ± 2.01 vs 6.05 ± 3.35, p = 0.001). INTERPRETATION Our genotype-based model significantly improved the initial dosing accuracy of tacrolimus and reduced the number of medication adjustments, which are critical for improving the prognosis of LT patients. FUNDING National Natural Science Foundation of China, Shanghai three-year action plan, National Science and Technology Major Project of China.
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Affiliation(s)
- Baojie Shi
- Organ Transplantation Clinical Medical Center of Xiamen University, Department of Organ Transplantation, Xiang'an Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, 361005, Fujian, China
- Organ Transplantation Institute of Xiamen University, Fujian Provincial Key Laboratory of Organ and Tissue Regeneration, School of Medicine, Xiamen University, Xiamen, 361005, Fujian, China
| | - Yuan Liu
- Department of General Surgery, Shanghai General Hospital, Shanghai Jiao Tong University, 200080, Shanghai, China
| | - Dehua Liu
- Organ Transplantation Clinical Medical Center of Xiamen University, Department of Organ Transplantation, Xiang'an Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, 361005, Fujian, China
- Organ Transplantation Institute of Xiamen University, Fujian Provincial Key Laboratory of Organ and Tissue Regeneration, School of Medicine, Xiamen University, Xiamen, 361005, Fujian, China
| | - Liyun Yuan
- Bio-Med Big Data Center, Key Laboratory of Computational Biology, CAS-MPG Partner Institute for Computational Biology, Shanghai Institute of Nutrition and Health, Shanghai Institutes for Biological Sciences, University of Chinese Academy of Sciences, Chinese Academy of Sciences, 200031, Shanghai, China
| | - Wenzhi Guo
- Department of General Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450000, Henan, China
| | - Peihao Wen
- Department of General Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450000, Henan, China
| | - Zhaojie Su
- Organ Transplantation Clinical Medical Center of Xiamen University, Department of Organ Transplantation, Xiang'an Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, 361005, Fujian, China
- Organ Transplantation Institute of Xiamen University, Fujian Provincial Key Laboratory of Organ and Tissue Regeneration, School of Medicine, Xiamen University, Xiamen, 361005, Fujian, China
| | - Jie Wang
- Organ Transplantation Clinical Medical Center of Xiamen University, Department of Organ Transplantation, Xiang'an Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, 361005, Fujian, China
- Organ Transplantation Institute of Xiamen University, Fujian Provincial Key Laboratory of Organ and Tissue Regeneration, School of Medicine, Xiamen University, Xiamen, 361005, Fujian, China
| | - Shiquan Xu
- Organ Transplantation Clinical Medical Center of Xiamen University, Department of Organ Transplantation, Xiang'an Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, 361005, Fujian, China
- Organ Transplantation Institute of Xiamen University, Fujian Provincial Key Laboratory of Organ and Tissue Regeneration, School of Medicine, Xiamen University, Xiamen, 361005, Fujian, China
| | - Junjie Xia
- Organ Transplantation Institute of Xiamen University, Fujian Provincial Key Laboratory of Organ and Tissue Regeneration, School of Medicine, Xiamen University, Xiamen, 361005, Fujian, China
| | - Wenbin An
- Organ Transplantation Clinical Medical Center of Xiamen University, Department of Organ Transplantation, Xiang'an Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, 361005, Fujian, China
- Organ Transplantation Institute of Xiamen University, Fujian Provincial Key Laboratory of Organ and Tissue Regeneration, School of Medicine, Xiamen University, Xiamen, 361005, Fujian, China
| | - Rui Wang
- Organ Transplantation Clinical Medical Center of Xiamen University, Department of Organ Transplantation, Xiang'an Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, 361005, Fujian, China
- Organ Transplantation Institute of Xiamen University, Fujian Provincial Key Laboratory of Organ and Tissue Regeneration, School of Medicine, Xiamen University, Xiamen, 361005, Fujian, China
| | - Peizhen Wen
- Organ Transplantation Clinical Medical Center of Xiamen University, Department of Organ Transplantation, Xiang'an Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, 361005, Fujian, China
- Organ Transplantation Institute of Xiamen University, Fujian Provincial Key Laboratory of Organ and Tissue Regeneration, School of Medicine, Xiamen University, Xiamen, 361005, Fujian, China
| | - Tonghai Xing
- Department of General Surgery, Shanghai General Hospital, Shanghai Jiao Tong University, 200080, Shanghai, China
| | - Jinyan Zhang
- Department of General Surgery, Shanghai General Hospital, Shanghai Jiao Tong University, 200080, Shanghai, China
| | - Haitao Gu
- Department of General Surgery, Shanghai General Hospital, Shanghai Jiao Tong University, 200080, Shanghai, China
| | - Zhaowen Wang
- Department of General Surgery, Shanghai General Hospital, Shanghai Jiao Tong University, 200080, Shanghai, China
| | - Lin Zhong
- Department of General Surgery, Shanghai General Hospital, Shanghai Jiao Tong University, 200080, Shanghai, China
| | - Junwei Fan
- Department of General Surgery, Shanghai General Hospital, Shanghai Jiao Tong University, 200080, Shanghai, China
- Corresponding author.
| | - Hao Li
- Organ Transplantation Clinical Medical Center of Xiamen University, Department of Organ Transplantation, Xiang'an Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, 361005, Fujian, China
- Organ Transplantation Institute of Xiamen University, Fujian Provincial Key Laboratory of Organ and Tissue Regeneration, School of Medicine, Xiamen University, Xiamen, 361005, Fujian, China
- Corresponding author.
| | - Weituo Zhang
- Hongqiao International Institute of Medicine, Shanghai Tong Ren Hospital and Clinical Research Institute, Shanghai Jiao Tong University School of Medicine, 200050, Shanghai, China
- Corresponding author.
| | - Zhihai Peng
- Organ Transplantation Clinical Medical Center of Xiamen University, Department of Organ Transplantation, Xiang'an Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, 361005, Fujian, China
- Organ Transplantation Institute of Xiamen University, Fujian Provincial Key Laboratory of Organ and Tissue Regeneration, School of Medicine, Xiamen University, Xiamen, 361005, Fujian, China
- Corresponding author.
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16
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Guimbellot JS, Nichols DP, Brewington JJ. Novel Applications of Biomarkers and Personalized Medicine in Cystic Fibrosis. Clin Chest Med 2022; 43:617-630. [PMID: 36344070 DOI: 10.1016/j.ccm.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
As routine care in cystic fibrosis (CF) becomes increasingly personalized, new opportunities to further focus care on the individual have emerged. These opportunities are increasingly filled through research in tools aiding drug selection, drug monitoring and titration, disease-relevant biomarkers, and evaluation of therapeutic benefits. Herein, we will discuss such research tools presently being translated into the clinic to improve the personalization of care in CF.
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Affiliation(s)
- Jennifer S Guimbellot
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham; 1600 7th Avenue South, ACC 620, Birmingham, AL 35233, USA
| | - David P Nichols
- Department of Pediatrics, Division of Pulmonary Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Building Cure, 1920 Terry Avenue, Office 4-209, Seattle, WA 98109, USA
| | - John J Brewington
- Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH 45267, USA; Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2021, Cincinnati, OH 45229, USA.
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17
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Xie D, Guo J, Dang R, Li Y, Si Q, Han W, Wang S, Wei N, Meng J, Wu L. The effect of tacrolimus-induced toxicity on metabolic profiling in target tissues of mice. BMC Pharmacol Toxicol 2022; 23:87. [PMID: 36443830 PMCID: PMC9703746 DOI: 10.1186/s40360-022-00626-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 11/14/2022] [Indexed: 11/29/2022] Open
Abstract
Tacrolimus (Tac) is a common immunosuppressant that used in organ transplantation. However, its therapeutic index is narrow, and it is prone to adverse side effects, along with an increased risk of toxicity, namely, cardio-, nephro-, hepato-, and neurotoxicity. Prior metabolomic investigations involving Tac-driven toxicity primarily focused on changes in individual organs. However, extensive research on multiple matrices is uncommon. Hence, in this research, the authors systemically evaluated Tac-mediated toxicity in major organs, namely, serum, brain, heart, liver, lung, kidney, and intestines, using gas chromatography-mass spectrometry (GC-MS). The authors also employed multivariate analyses, including orthogonal projections to the latent structure (OPLS) and t-test, to screen 8 serum metabolites, namely, D-proline, glycerol, D-fructose, D-glucitol, sulfurous acid, 1-monopalmitin (MG (16:0/0:0/0:0)), glycerol monostearate (MG (0:0/18:0/0:0)), and cholesterol. Metabolic changes within the brain involved alterations in the levels of butanamide, tartronic acid, aminomalonic acid, scyllo-inositol, dihydromorphine, myo-inositol, and 11-octadecenoic acid. Within the heart, the acetone and D-fructose metabolites were altered. In the liver, D-glucitol, L-sorbose, palmitic acid, myo-inositol, and uridine were altered. In the lung, L-lactic acid, L-5-oxoproline, L-threonine, phosphoric acid, phosphorylethanolamine, D-allose, and cholesterol were altered. Lastly, in the kidney, L-valine and D-glucose were altered. Our findings will provide a systematic evaluation of the metabolic alterations in target organs within a Tac-driven toxicity mouse model.
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Affiliation(s)
- Dadi Xie
- grid.508306.8Tengzhou Central People’s Hospital, Tengzhou, 277500 China
| | - Jinxiu Guo
- grid.459518.40000 0004 1758 3257Translational Pharmaceutical Laboratory, Jining First People’s Hospital, Jining, 272000 China
| | - Ruili Dang
- grid.459518.40000 0004 1758 3257Translational Pharmaceutical Laboratory, Jining First People’s Hospital, Jining, 272000 China
| | - Yanan Li
- grid.459518.40000 0004 1758 3257Translational Pharmaceutical Laboratory, Jining First People’s Hospital, Jining, 272000 China
| | - Qingying Si
- grid.508306.8Tengzhou Central People’s Hospital, Tengzhou, 277500 China
| | - Wenxiu Han
- grid.459518.40000 0004 1758 3257Translational Pharmaceutical Laboratory, Jining First People’s Hospital, Jining, 272000 China
| | - Shan Wang
- grid.459518.40000 0004 1758 3257Translational Pharmaceutical Laboratory, Jining First People’s Hospital, Jining, 272000 China
| | - Ning Wei
- Department of Gastroenterology, Shanting District People’s Hospital, Zaozhuang, 277200 China
| | - Junjun Meng
- grid.459518.40000 0004 1758 3257Translational Pharmaceutical Laboratory, Jining First People’s Hospital, Jining, 272000 China
| | - Linlin Wu
- grid.508306.8Tengzhou Central People’s Hospital, Tengzhou, 277500 China
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18
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Francke MI, Hesselink DA, Andrews LM, van Gelder T, Keizer RJ, de Winter BCM. Model-Based Tacrolimus Follow-up Dosing in Adult Renal Transplant Recipients: A Simulation Trial. Ther Drug Monit 2022; 44:606-614. [PMID: 35344525 DOI: 10.1097/ftd.0000000000000979] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 02/24/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Initial algorithm-based dosing appears to be effective in predicting tacrolimus dose requirement. However, achieving and maintaining the target concentrations is challenging. Model-based follow-up dosing, which considers patient characteristics and pharmacological data, may further personalize treatment. This study investigated whether model-based follow-up dosing could lead to more accurate tacrolimus exposure than standard therapeutic drug monitoring (TDM) in kidney transplant recipients after an initial algorithm-based dose. METHODS This simulation trial included patients from a prospective trial that received an algorithm-based tacrolimus starting dose followed by TDM. For every measured tacrolimus predose concentration (C 0,obs ), model-based dosing advice was simulated using the InsightRX software. Based on previous tacrolimus doses and C 0 , age, body surface area, CYP3A4 and CYP3A5 genotypes, hematocrit, albumin, and creatinine, the optimal next dose, and corresponding tacrolimus concentration (C 0,pred ) were predicted. RESULTS Of 190 tacrolimus C 0 values measured in 59 patients, 121 (63.7%; 95% CI 56.8-70.5) C 0,obs were within the therapeutic range (7.5-12.5 ng/mL) versus 126 (66.3%, 95% CI 59.6-73.0) for C 0,pred ( P = 0.89). The median absolute difference between the tacrolimus C 0 and the target tacrolimus concentration (10.0 ng/mL) was 1.9 ng/mL for C 0,obs versus 1.6 ng/mL for C 0,pred . In a historical cohort of 114 kidney transplant recipients who received a body weight-based starting dose followed by TDM, 172 of 335 tacrolimus C 0 (51.3%) were within the therapeutic range (10.0-15.0 ng/mL). CONCLUSIONS The combination of an algorithm-based tacrolimus starting dose with model-based follow-up dosing has the potential to minimize under- and overexposure to tacrolimus in the early posttransplant phase, although the additional effect of model-based follow-up dosing on initial algorithm-based dosing seems small.
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Affiliation(s)
- Marith I Francke
- Division of Nephrology and Transplantation, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Erasmus MC Transplant Institute , Rotterdam, the Netherlands
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Rotterdam Clinical Pharmacometrics Group, Rotterdam, the Netherlands
| | - Dennis A Hesselink
- Division of Nephrology and Transplantation, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Erasmus MC Transplant Institute , Rotterdam, the Netherlands
| | - Louise M Andrews
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Hospital Pharmacy, Meander Medical Center, Amersfoort, the Netherlands
| | - Teun van Gelder
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, the Netherlands; and
| | | | - Brenda C M de Winter
- Erasmus MC Transplant Institute , Rotterdam, the Netherlands
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Rotterdam Clinical Pharmacometrics Group, Rotterdam, the Netherlands
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19
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Tacrolimus Concentration Is Effectively Predicted Using Combined Clinical and Genetic Factors in the Perioperative Period of Kidney Transplantation and Associated with Acute Rejection. J Immunol Res 2022; 2022:3129389. [PMID: 36118414 PMCID: PMC9481373 DOI: 10.1155/2022/3129389] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 07/22/2022] [Accepted: 08/20/2022] [Indexed: 12/02/2022] Open
Abstract
Background Tacrolimus has unpredictable pharmacokinetic (PK) characteristics, which are partially attributed to CYP3A5 polymorphism. The potential effects of clinical factors in the postoperative period of transplantation on tacrolimus PK and those of early tacrolimus PK variability on clinical outcomes are yet to be clarified. Methods We examined the genetic and clinical factors affecting early tacrolimus PK variability in 256 kidney transplant recipients. The relationships among tacrolimus exposure, graft function delay (DGF), and acute rejection (AR) were further explored. Findings. The CYP3A5 genotype were strongly associated with tacrolimus concentration/dose ratio (C0/D). Additionally, ABCB1 (rs1045642 and rs2032582) and ABCC2 (rs3740066) were found to have potential independent effects on early tacrolimus C0/D in multivariate analysis. Red blood counts and albumin level were the most significant clinical factors associated with tacrolimus C0/D. Wuzhi capsule also exerted an effect on tacrolimus PK. A model combined with pharmacogenetic and clinical factors explained 43.4% tacrolimus PK variability compared with 16.3% on the basis of CYP3A5 genotype only. Notably, increasing tacrolimus concentrations in the early postoperative stage were associated with AR, but not DGF. Conclusions Combined analysis of genotype and specific clinical factors is important for the formulation of precise tacrolimus dose regimens in the early stage after kidney transplantation.
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20
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Koppe L, Soulage CO. Protein-bound uremic toxins: putative modulators of calcineurin inhibitors exposure. Nephrol Dial Transplant 2022; 37:2044-2047. [PMID: 35916444 DOI: 10.1093/ndt/gfac229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Indexed: 11/14/2022] Open
Affiliation(s)
- Laetitia Koppe
- Department of Nephrology, Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Pierre-Bénite, France.,Univ. Lyon, CarMeN lab, INSA-Lyon, INSERM U1060, INRA, Université Claude Bernard Lyon 1, Villeurbanne, France
| | - Christophe O Soulage
- Univ. Lyon, CarMeN lab, INSA-Lyon, INSERM U1060, INRA, Université Claude Bernard Lyon 1, Villeurbanne, France
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21
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Use of Pharmacogenetics to Optimize Immunosuppressant Therapy in Kidney-Transplanted Patients. Biomedicines 2022; 10:biomedicines10081798. [PMID: 35892699 PMCID: PMC9332547 DOI: 10.3390/biomedicines10081798] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 07/18/2022] [Accepted: 07/22/2022] [Indexed: 12/17/2022] Open
Abstract
Immunosuppressant drugs (ISDs) are routinely used in clinical practice to maintain organ transplant survival. However, these drugs are characterized by a restricted therapeutic index, a high inter- and intra-individual pharmacokinetic variability, and a series of severe adverse effects. In particular, genetic factors have been estimated to play a role in this variability because of polymorphisms regarding genes encoding for enzymes and transporters involved in the ISDs pharmacokinetic. Several studies showed important correlations between genetic polymorphisms and ISDs blood levels in transplanted patients; therefore, this review aims to summarize the pharmacogenetics of approved ISDs. We used PubMed database to search papers on pharmacogenetics of ISDs in adults or pediatric patients of any gender and ethnicity receiving immunosuppressive therapy after kidney transplantation. We utilized as search term: “cyclosporine or tacrolimus or mycophenolic acid or sirolimus or everolimus and polymorphism and transplant”. Our data showed that polymorphisms in CYP3A5, CYP3A4, ABCB1, and UGT1A9 genes could modify the pharmacokinetics of immunosuppressants, suggesting that patient genotyping could be a helpful strategy to select the ideal ISDs dose for each patient.
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22
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Liu M, Shaver CM, Birdwell KA, Heeney SA, Shaffer CM, Van Driest SL. Composite CYP3A phenotypes influence tacrolimus dose-adjusted concentration in lung transplant recipients. Pharmacogenet Genomics 2022; 32:209-217. [PMID: 35389944 PMCID: PMC9177686 DOI: 10.1097/fpc.0000000000000472] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Interpatient variability in tacrolimus pharmacokinetics is attributed to metabolism by cytochrome P-450 3A4/5 isoenzymes (encoded by CYP3A4 and CYP3A5). Guidelines for adjusting tacrolimus based on CYP3A5 test results are published; however, CYP3A4 variants also contribute to the variability in tacrolimus pharmacokinetics. The effects of composite phenotypes incorporating CYP3A5 and CYP3A4 increased (*1G, *1B) and decreased (*22) function variants have not been evaluated. The objective of this study is to investigate the impact of both increased and decreased function CYP3A variants on weight and dose-adjusted tacrolimus concentration (C0/D). METHODS We performed a single-center retrospective cohort study of lung transplant recipients to evaluate the median tacrolimus C0/D by composite CYP3A phenotype groups during the index transplant hospitalization. CYP3A4 and CYP3A5 alleles were used to classify patients into four CYP3A groups from least to most CYP3A activity. Exploratory analyses of ABCB1 and additional candidate genes were also assessed. RESULTS Of the 92 included individuals, most (58) were CYP3A Group 2. The median tacrolimus C0/D differed significantly between CYP3A groups (P = 0.0001). CYP3A Group 2 median tacrolimus C0/D was 190.5 (interquartile range: 147.6-267.5) (ng/ml)/(mg/kg/d) and significantly higher than Group 4 [107.9 (90.4-116.1), P = 0.0001)]. Group 2 median tacrolimus C0/D did not significantly differ from Group 1 and Group 3 [373.5 (149.2-490.3) and 81.4 (62.6-184.1), respectively]. No significant differences in tacrolimus C0/D were found for the ABCB1 diplotypes. CONCLUSION These data indicate that a composite CYP3A phenotype incorporating both increase and decrease variant information from CYP3A4 in addition to CYP3A5 may significantly influence tacrolimus C0/D during the early postoperative period.
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Affiliation(s)
- Michelle Liu
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ciara M. Shaver
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kelly A. Birdwell
- Division of Nephrology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Stephanie A. Heeney
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christian M. Shaffer
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sara L. Van Driest
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of General Pediatrics, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
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23
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Sridharan K, Shah S, Jassim A, Hammad M, Ebrahim Al Gadhban J, Al Segai O. Evaluation of Pharmacogenetics of Drug-Metabolizing Enzymes and Drug Efflux Transporter in Renal Transplants Receiving Immunosuppressants. J Pers Med 2022; 12:jpm12050823. [PMID: 35629245 PMCID: PMC9147030 DOI: 10.3390/jpm12050823] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 05/12/2022] [Accepted: 05/14/2022] [Indexed: 02/06/2023] Open
Abstract
Cytochrome P450 (CYP) enzymes, such as CYP3A4, and CYP3A5, P450 oxidoreductase (POR), peroxisome proliferator activated receptor alpha (PPAR-alpha), and drug transporter (ABCB1) were observed to influence concentrations of immunosuppressants (cyclosporine, everolimus, sirolimus, and tacrolimus) and outcomes in renal transplants. We carried out the present study to evaluate the prevalence and impact of these single nucleotide polymorphisms (SNPs) in adult renal transplants. SNPs were evaluated using commercial TaqMan® assays. Serum drug concentrations were estimated using immunoassays. One hundred and forty-six patients were recruited. SNPs in CYP3A5*3 were significantly associated with greater dose-adjusted cyclosporine and tacrolimus concentrations. SNPs in POR*28 were observed with significantly lower dose-adjusted concentrations, particularly with cyclosporine and tacrolimus. ABCB1 homozygous polymorphisms were observed with significantly lower time spent in the therapeutic range with cyclosporine and everolimus/sirolimus. Cyclosporine was observed in a significantly greater proportion of patients with elevated GGT, and SNPs in PPAR-alpha were significantly associated with an increased risk of this adverse event. Hypertriglyceridemia with everolimus was significantly associated with POR*28 polymorphisms. There is a need to validate the influence of these SNPs in a prospective study and develop an algorithm predicting the achievement of target concentrations.
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Affiliation(s)
- Kannan Sridharan
- Department of Pharmacology & Therapeutics, College of Medicine & Medical Sciences, Arabian Gulf University, Manama 328, Bahrain
- Correspondence: ; Tel.: +973-33453123
| | - Shamik Shah
- Department of Nephrology, Salmaniya Medical Complex, Manama 328, Bahrain; (S.S.); (J.E.A.G.)
- Department of Internal Medicine, College of Medicine & Medical Sciences, Arabian Gulf University, Manama 328, Bahrain
| | - Anfal Jassim
- Department of Molecular Medicine, College of Medicine and Medical Sciences, Arabian Gulf University, Manama 328, Bahrain;
| | - Mona Hammad
- Salmaniya Medical Complex, Manama 328, Bahrain;
| | | | - Ola Al Segai
- Department of Biochemistry, Salmaniya Medical Complex, Manama 328, Bahrain;
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24
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Body composition is associated with tacrolimus pharmacokinetics in kidney transplant recipients. Eur J Clin Pharmacol 2022; 78:1273-1287. [PMID: 35567629 PMCID: PMC9283366 DOI: 10.1007/s00228-022-03323-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 04/15/2022] [Indexed: 12/03/2022]
Abstract
Purpose A population pharmacokinetic (popPK) model may be used to improve tacrolimus dosing and minimize under- and overexposure in kidney transplant recipients. It is unknown how body composition parameters relate to tacrolimus pharmacokinetics and which parameter correlates best with tacrolimus exposure. The aims of this study were to investigate which body composition parameter has the best association with the pharmacokinetics of tacrolimus and to describe this relationship in a popPK model. Methods Body composition was assessed using bio-impedance spectroscopy (BIS). Pharmacokinetic analysis was performed using nonlinear mixed effects modeling (NONMEM). Lean tissue mass, adipose tissue mass, over-hydration, and phase angle were measured with BIS and then evaluated as covariates. The final popPK model was evaluated using goodness-of-fit plots, visual predictive checks, and a bootstrap analysis. Results In 46 kidney transplant recipients, 284 tacrolimus concentrations were measured. The base model without body composition parameters included age, plasma albumin, plasma creatinine, CYP3A4 and CYP3A5 genotypes, and hematocrit as covariates. After full forward inclusion and backward elimination, only the effect of the phase angle on clearance (dOFV = − 13.406; p < 0.01) was included in the final model. Phase angle was positively correlated with tacrolimus clearance. The inter-individual variability decreased from 41.7% in the base model to 34.2% in the final model. The model was successfully validated. Conclusion The phase angle is the bio-impedance spectroscopic parameter that correlates best with tacrolimus pharmacokinetics. Incorporation of the phase angle in a popPK model can improve the prediction of an individual’s tacrolimus dose requirement after transplantation. Supplementary information The online version contains supplementary material available at 10.1007/s00228-022-03323-0.
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25
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Warzyszyńska K, Zawistowski M, Karpeta E, Jałbrzykowska A, Kosieradzki M. Renal Cyp3a5-Expressing Genotype Decreases Tacrolimus-to-Dose Ratio in Small Cohort of Renal Transplant Recipients—Preliminary Report. Transplant Proc 2022; 54:960-967. [DOI: 10.1016/j.transproceed.2022.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 02/10/2022] [Accepted: 02/18/2022] [Indexed: 11/29/2022]
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26
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Franken LG, Francke MI, Andrews LM, van Schaik RHN, Li Y, de Wit LEA, Baan CC, Hesselink DA, de Winter BCM. A Population Pharmacokinetic Model of Whole-Blood and Intracellular Tacrolimus in Kidney Transplant Recipients. Eur J Drug Metab Pharmacokinet 2022; 47:523-535. [PMID: 35442010 PMCID: PMC9232416 DOI: 10.1007/s13318-022-00767-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND OBJECTIVE The tacrolimus concentration within peripheral blood mononuclear cells may correlate better with clinical outcomes after transplantation compared to concentrations measured in whole blood. However, intracellular tacrolimus measurements are not easily implemented in clinical practice. The prediction of intracellular concentrations based on whole-blood concentrations would be a solution for this. Therefore, the aim of this study was to describe the relationship between intracellular and whole-blood tacrolimus concentrations in a population pharmacokinetic (popPK) model. METHODS Pharmacokinetic analysis was performed using non-linear mixed effects modelling software (NONMEM). The final model was evaluated using goodness-of-fit plots, visual predictive checks, and a bootstrap analysis. RESULTS A total of 590 tacrolimus concentrations from 184 kidney transplant recipients were included in the study. All tacrolimus concentrations were measured in the first three months after transplantation. The intracellular tacrolimus concentrations (n = 184) were best described with an effect compartment. The distribution into the effect compartment was described by the steady-state whole-blood to intracellular ratio (RWB:IC) and the intracellular distribution rate constant between the whole-blood and intracellular compartments. Lean body weight was negatively correlated [delta objective function value (ΔOFV) -8.395] and haematocrit was positively correlated (ΔOFV = - 6.752) with RWB:IC, and both lean body weight and haematocrit were included in the final model. CONCLUSION We were able to accurately describe intracellular tacrolimus concentrations using whole-blood concentrations, lean body weight, and haematocrit values in a popPK model. This model may be used in the future to more accurately predict clinical outcomes after transplantation and to identify patients at risk for under- and overexposure. Dutch National Trial Registry number NTR2226.
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Affiliation(s)
- Linda G Franken
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Marith I Francke
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands. .,Erasmus MC Transplant Institute, University Medical Center, Rotterdam, The Netherlands. .,Rotterdam Clinical Pharmacometrics Group, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.
| | - Louise M Andrews
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Ron H N van Schaik
- Department of Clinical Chemistry, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Yi Li
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.,Department of Laboratory Medicine, Research Center of Clinical Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Lucia E A de Wit
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Carla C Baan
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Erasmus MC Transplant Institute, University Medical Center, Rotterdam, The Netherlands
| | - Dennis A Hesselink
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Erasmus MC Transplant Institute, University Medical Center, Rotterdam, The Netherlands
| | - Brenda C M de Winter
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.,Rotterdam Clinical Pharmacometrics Group, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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An Integrated Clinical and Genetic Prediction Model for Tacrolimus Levels in Pediatric Solid Organ Transplant Recipients. Transplantation 2022; 106:597-606. [PMID: 33755393 PMCID: PMC8862776 DOI: 10.1097/tp.0000000000003700] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND There are challenges in achieving and maintaining therapeutic tacrolimus levels after solid organ transplantation (SOT). The purpose of this genome-wide association study was to generate an integrated clinical and genetic prediction model for tacrolimus levels in pediatric SOT. METHODS In a multicenter prospective observational cohort study (2015-2018), children <18 years old at their first SOT receiving tacrolimus as maintenance immunosuppression were included (455 as discovery cohort; 322 as validation cohort). Genotyping was performed using a genome-wide single nucleotide polymorphism (SNP) array and analyzed for association with tacrolimus trough levels during 1-y follow-up. RESULTS Genome-wide association study adjusted for clinical factors identified 25 SNPs associated with tacrolimus levels; 8 were significant at a genome-wide level (P < 1.025 × 10-7). Nineteen SNPs were replicated in the validation cohort. After removing SNPs in strong linkage disequilibrium, 14 SNPs remained independently associated with tacrolimus levels. Both traditional and machine learning approaches selected organ type, age at transplant, rs776746, rs12333983, and rs12957142 SNPs as the top predictor variables for dose-adjusted 36- to 48-h posttacrolimus initiation (T1) levels. There was a significant interaction between age and organ type with rs776476*1 SNP (P < 0.05). The combined clinical and genetic model had lower prediction error and explained 30% of the variation in dose-adjusted T1 levels compared with 18% by the clinical and 12% by the genetic only model. CONCLUSIONS Our study highlights the importance of incorporating age, organ type, and genotype in predicting tacrolimus levels and lays the groundwork for developing an individualized age and organ-specific genotype-guided tacrolimus dosing algorithm.
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Tornatore KM, Meaney CJ, Attwood K, Brazeau DA, Wilding GE, Consiglio JD, Gundroo A, Chang SS, Gray V, Cooper LM, Venuto RC. Race and sex associations with tacrolimus pharmacokinetics in stable kidney transplant recipients. Pharmacotherapy 2022; 42:94-105. [PMID: 35103348 PMCID: PMC9020367 DOI: 10.1002/phar.2656] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 10/27/2021] [Accepted: 10/28/2021] [Indexed: 11/22/2022]
Abstract
Study Objective This study investigated race and sex differences in tacrolimus pharmacokinetics and pharmacodynamics in stable kidney transplant recipients. Design and Setting A cross‐sectional, open‐label, single center, 12‐h pharmacokinetic‐pharmacodynamic study was conducted. Tacrolimus pharmacokinetic parameters included area under the concentration‐time curve (AUC0–12), AUC0–4, 12‐h troughs (C12 h), maximum concentrations (Cmax), oral clearance (Cl), with dose‐normalized AUC0–12, troughs, and Cmax with standardized adverse effect scores. Statistical models were used to analyze end points with individual covariate‐adjustment including clinical factors, genotypic variants CYP3A5*3, CYP3A5*6, CYP3A5*7(CYP3A5*3*6*7) metabolic composite, and ATP binding cassette gene subfamily B member 1 (ABCB1) polymorphisms. Patients 65 stable, female and male, Black and White kidney transplant recipients receiving tacrolimus and mycophenolic acid ≥6 months post‐transplant were evaluated. Measurements and Main Results Black recipients exhibited higher tacrolimus AUC0–12 (Race: p = 0.005), lower AUC* (Race: p < 0.001; Race × Sex: p = 0.068), and higher Cl (Race: p < 0.001; Sex: p = 0.066). Greater cumulative (Sex: p < 0.001; Race × Sex: p = 0.014), neurologic (Sex: p = 0.021; Race × Sex: p = 0.005), and aesthetic (Sex: p = 0.002) adverse effects were found in females, with highest scores in Black women. In 84.8% of Black and 68.8% of White patients, the target AUC0–12 was achieved (p = 0.027). In 31.3% of White and 9.1% of Black recipients, AUC0–12 was <100 ng‧h/ml despite tacrolimus troughs in the target range (p = 0.027). The novel CYP3A5*3*6*7 metabolic composite was the significant covariate accounting for 15%–19% of tacrolimus variability in dose (p = 0.002); AUC0–12 h* (p < 0.001), and Cl (p < 0.001). Conclusions Tacrolimus pharmacokinetics and adverse effects were different among stable kidney transplant recipient groups based upon race and sex with interpatient variability associated with the CYP3A5*3*6*7 metabolic composite. More cumulative, neurologic, and aesthetic adverse effects were noted among females. Tacrolimus regimens that consider race and sex may reduce adverse effects and enhance allograft outcomes by facilitating more patients to achieve the targeted AUC0–12 h.
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Affiliation(s)
- Kathleen M. Tornatore
- Immunosuppressive Pharmacology Research Program Translational Pharmacology Research Core NYS Center of Excellence in Bioinformatics & Life Sciences Buffalo New York USA
- Pharmacy School of Pharmacy and Pharmaceutical Sciences Buffalo New York USA
- Nephrology Division Medicine School of Medicine and Biomedical Sciences Buffalo New York USA
| | - Calvin J. Meaney
- Immunosuppressive Pharmacology Research Program Translational Pharmacology Research Core NYS Center of Excellence in Bioinformatics & Life Sciences Buffalo New York USA
- Pharmacy School of Pharmacy and Pharmaceutical Sciences Buffalo New York USA
| | - Kristopher Attwood
- Biostatistics School of Public Health and Health Professions Buffalo New York USA
| | - Daniel A. Brazeau
- Department of Biomedical Sciences Joan C Edwards School of Medicine Marshall University Huntington West Virginia USA
| | - Gregory E. Wilding
- Biostatistics School of Public Health and Health Professions Buffalo New York USA
| | - Joseph D. Consiglio
- Biostatistics School of Public Health and Health Professions Buffalo New York USA
| | - Aijaz Gundroo
- Nephrology Division Medicine School of Medicine and Biomedical Sciences Buffalo New York USA
- Erie County Medical Center Buffalo New York USA
| | - Shirley S. Chang
- Nephrology Division Medicine School of Medicine and Biomedical Sciences Buffalo New York USA
- Erie County Medical Center Buffalo New York USA
| | - Vanessa Gray
- Nephrology Division Medicine School of Medicine and Biomedical Sciences Buffalo New York USA
| | - Louise M. Cooper
- Immunosuppressive Pharmacology Research Program Translational Pharmacology Research Core NYS Center of Excellence in Bioinformatics & Life Sciences Buffalo New York USA
- Pharmacy School of Pharmacy and Pharmaceutical Sciences Buffalo New York USA
| | - Rocco C. Venuto
- Nephrology Division Medicine School of Medicine and Biomedical Sciences Buffalo New York USA
- Erie County Medical Center Buffalo New York USA
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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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30
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Fernando ME, Raj TY, Srinivasa prasad ND, Sujit S, Valavan KT, Harshavardhan TS, Ramanathan A. Efficacy and outcomes of CYP3A5 genotype-based tacrolimus dosing compared to conventional body weight-based dosing in living donor kidney transplant recipients. Indian J Nephrol 2022; 32:240-246. [PMID: 35814319 PMCID: PMC9267083 DOI: 10.4103/ijn.ijn_278_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 08/07/2020] [Accepted: 05/31/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction: Clinical use of tacrolimus has been challenging due to its narrow therapeutic index and highly variable pharmacokinetics. In this study, we compared patients who received body weight-based tacrolimus dosing pre-transplant (transplanted from 2016 to 2018) with those who received CYP3A5 genotype-based dosing (2018 to 2020). Methods: Eighty-two renal transplant recipients were non-randomly assigned to genotype-adapted or bodyweight-based tacrolimus dosing groups. The primary end point was to study the proportion of subjects who achieved the target tacrolimus C0 on post-op day 4. Secondary end points included clinical outcomes and safety. Results: The proportion of subjects who achieved the target tacrolimus C0 on postoperative days 4 and 10 were significantly higher in the adapted group, 53.6% and 47.5%, compared to 24.3% and 17% in controls, respectively (P = 0.01). Adapted group subjects achieved their first target tacrolimus C0 significantly earlier (4 days) compared to 25 days in controls (P = 0.01). The total number of tacrolimus dose modifications required in the first postop month were lower in the adapted group; 47 compared to 68 in the controls (P = 0.05). The proportion of subjects with sub-therapeutic tacrolimus exposure on postoperative day 4 was significantly higher in the controls, 56% versus 10% in the adapted group (P < 0.001). There were no significant differences between the groups in the rate of biopsy proven acute rejections, adverse events, and graft function at the end of 3 months follow up. Conclusion: Genotype-based tacrolimus dosing leads to more subjects achieving the target tacrolimus C0 earlier. However, there may be a higher risk of tacrolimus nephrotoxicity.
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31
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Du W, Wang X, Zhang D, Chen W, Zhang X, Li P. The impact of cytochrome P450 3A5 genotype on early tacrolimus metabolism and clinical outcomes in lung transplant recipients. Int J Clin Pharm 2021; 44:418-427. [PMID: 34859357 DOI: 10.1007/s11096-021-01359-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 11/17/2021] [Indexed: 12/29/2022]
Abstract
Background Tacrolimus (Tac) is the cornerstone of immunosuppressant therapy after lung transplantation (LTx). It shows great inter-individual variability in pharmacokinetics, which could partly be explained by pharmacogenetic factors. Aim We aim to investigate the influence of cytochrome P450 3A5 (CYP3A5) genotypes on early post-LTx Tac metabolism and whether it is affected by concomitant use of azole antifungals. Also, we explored the association between CYP3A5 genotype and clinical outcomes. Method 90 recipients who underwent LTx from 2017 to 2019 were enrolled in the study. The effect of CYP3A5 genotype on Tac metabolism and interaction with azole antifungals were assessed during week 1-4 after transplantation. Associations between CYP3A5 genotype and the incidence of acute kidney injury (AKI), length of hospital stay and mortality were analyzed. ResultsCYP3A5*1 carriers had lower dose adjusted concentration (C/D) than CYP3A5*3/*3 group at all time points (p < 0.05). The dose ratio of CYP3A5*1 carriers to CYP3A5*3/*3 was between 1.3 and 2.4 when comparable concentrations were reached. Use of azole antifungals did not blunt the effect of CYP3A5 genotypes on Tac metabolism. Logistic regression showed Tac concentration ≥ 7.5 ng/mL at week 1 was associated with higher incidence of AKI. No statistically significant difference was found between CYP3A5 genotypes and the length of hospital stay. Kaplan-Meier analysis showed no statistically significant difference between 30-day or 1-year mortality and CYP3A5 genotype. Conclusion CYP3A5 genotype could affect Tac metabolism early after LTx. However, it had no influence on the incidence of AKI, length of hospital stay and mortality.
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Affiliation(s)
- Wenwen Du
- Department of Pharmacy, China-Japan Friendship Hospital, Chaoyang District, Beijing, China
| | - Xiaoxing Wang
- Department of Pharmacy, China-Japan Friendship Hospital, Chaoyang District, Beijing, China
| | - Dan Zhang
- Department of Pharmacy, China-Japan Friendship Hospital, Chaoyang District, Beijing, China
| | - Wenqian Chen
- Department of Pharmacy, China-Japan Friendship Hospital, Chaoyang District, Beijing, China
| | - Xianglin Zhang
- Department of Pharmacy, China-Japan Friendship Hospital, Chaoyang District, Beijing, China
| | - Pengmei Li
- Department of Pharmacy, China-Japan Friendship Hospital, Chaoyang District, Beijing, China.
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32
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Cheng F, Li Q, Wang J, Hu M, Zeng F, Wang Z, Zhang Y. Genetic Polymorphisms Affecting Tacrolimus Metabolism and the Relationship to Post-Transplant Outcomes in Kidney Transplant Recipients. Pharmgenomics Pers Med 2021; 14:1463-1474. [PMID: 34824543 PMCID: PMC8610755 DOI: 10.2147/pgpm.s337947] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 11/10/2021] [Indexed: 12/28/2022] Open
Abstract
Background Tacrolimus is a key drug in kidney transplantation with a narrow therapeutic index. However, whether tacrolimus exposure variability affects clinical outcomes and adverse reactions remains unknown. Objective Our study investigated the factors that influence tacrolimus exposure in kidney transplantation recipients and the relationship between tacrolimus concentration and clinical outcomes and adverse reactions. Settings and Methods We examined the effect of tacrolimus concentration on clinical outcomes and adverse reactions in 201 kidney transplantation recipients, and identified clinical and pharmacogenetic factors that explain tacrolimus exposure. Results The CYP3A5 genotype was clearly associated with dose-adjusted trough blood tacrolimus concentrations (C0/D), whereas no significant difference was observed in patients with the CYP3A4*1B, CYP3A4*22, ABCB1, ABCC2, POR*28 or PXR alleles. Clinical factors such as red blood cell count, hemoglobin, and albumin were the most useful influence factors affecting tacrolimus C0/D. Besides, Wuzhi capsule increased tacrolimus C0/D in kidney transplantation recipients. Furthermore, higher tacrolimus concentrations were associated with higher diarrhea and post-transplant diabetes mellitus (PTDM) risk but not with acute rejection and chronic allograft kidney dysfunction. Conclusion Clinical factors, medication, and CYP-enzyme polymorphisms accounted for tacrolimus concentration variability in kidney transplantation recipients. Furthermore, higher tacrolimus concentrations were associated with higher diarrhea and PTDM risk.
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Affiliation(s)
- Fang Cheng
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People's Republic of China.,Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, 430022, People's Republic of China
| | - Qiang Li
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People's Republic of China.,Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, 430022, People's Republic of China
| | - Jinglin Wang
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People's Republic of China.,Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, 430022, People's Republic of China
| | - Min Hu
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People's Republic of China.,Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, 430022, People's Republic of China
| | - Fang Zeng
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People's Republic of China.,Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, 430022, People's Republic of China
| | - Zhendi Wang
- Department of Urology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People's Republic of China
| | - Yu Zhang
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, People's Republic of China.,Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, 430022, People's Republic of China
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Fu Q, Jing Y, Liu Mr G, Jiang Mr X, Liu H, Kong Y, Hou X, Cao L, Deng P, Xiao P, Xiao J, Peng H, Wei X. Machine learning-based method for tacrolimus dose predictions in Chinese kidney transplant perioperative patients. J Clin Pharm Ther 2021; 47:600-608. [PMID: 34802160 DOI: 10.1111/jcpt.13579] [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] [Received: 08/23/2021] [Revised: 10/28/2021] [Accepted: 11/11/2021] [Indexed: 11/26/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVES Tacrolimus (TAC), a first-line immunosuppressant in solid-organ transplant, has a narrow therapeutic window and large inter-individual variability, which affects its use in clinical practice. Successful predictions using machine learning algorithms have been reported in several fields. However, a comparison of 10 machine learning model-based TAC pharmacogenetic and pharmacokinetic dosing algorithms for kidney transplant perioperative patients of Chinese descent has not been reported. The objective of this study was to screen and establish an appropriate machine learning method to predict the individualized dosages of TAC for perioperative kidney transplant patients. METHODS The records of 2551 patients were collected from three transplant centres, 80% of which were randomly selected as a 'derivation cohort' to develop the dose prediction algorithm, while the remaining 20% constituted a 'validation cohort' to validate the final algorithm selected. Important features were screened according to our previously established population pharmacokinetic model of tacrolimus. The performances of the algorithms were evaluated and compared using R-squared and the mean percentage in the remaining 20% of patients. RESULTS AND DISCUSSION This study identified several factors influencing TAC dosage, including CYP3A5 rs776746, CYP3A4 rs4646437, haematocrit, Wuzhi capsules, TAC daily dose, age, height, weight, post-operative time, nifedipine and the medication history of the patient. According to our results, among the 10 machine learning models, the extra trees regressor (ETR) algorithm showed the best performance in the training set (R-squared: 1, mean percentage within 20%: 100%) and test set (R-squared: 0.85, mean percentage within 20%: 92.77%) of the derivation cohort. The ETR model successfully predicted the ideal TAC dosage in 97.73% of patients, especially in the intermediate dosage range (>5 mg/day to <8 mg/day), whereby the ideal TAC dosage could be successfully predicted in 99% of the patients. WHAT IS NEW AND CONCLUSION The results indicated that the ETR algorithm, which was chosen to establish the dose prediction model, performed better than the other nine machine learning models. This study is the first to establish ETR algorithms to predict TAC dosage. This study will further promote the individualized medication of TAC in kidney transplant patients in the future, which has great significance in ensuring the safety and effectiveness of drug use.
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Affiliation(s)
- Qun Fu
- School of Pharmacy, Nanchang University, Nanchang, China.,Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yan Jing
- School of Pharmacy, Nanchang University, Nanchang, China.,Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | | | - Xuehui Jiang Mr
- School of Pharmacy, Nanchang University, Nanchang, China.,Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Hong Liu
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Ying Kong
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xiongjun Hou
- Department of Clinical Pharmacology, Jiangxi Provincial People's Hospital, Nanchang, China
| | - Lei Cao
- Department of Information, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Pei Deng
- Department of Information, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Pin Xiao
- Department of Pharmacy, Hospital of Jiangxi Provincial Armed Police Corps, Nanchang, China
| | - Jiansheng Xiao
- Department of Transplantation, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Hongwei Peng
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xiaohua Wei
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, China.,Institute of Clinical Pharmacology, Jiangxi Institute of Clinical Medical Sciences, Nanchang, China
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Maciel NB, Schwambach KH, Blatt CR. LIVER TRANSPLANTATION: TACROLIMUS BLOOD LEVELS VARIATION AND SURVIVAL, REJECTION AND DEATH OUTCOMES. ARQUIVOS DE GASTROENTEROLOGIA 2021; 58:370-376. [PMID: 34705973 DOI: 10.1590/s0004-2803.202100000-62] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 04/12/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Immunosuppressive drugs have important role in transplant of solid grafts, it aim avoid episodes of acute and chronic rejection and improving graft survival and patient survival. In Brazil, in 2016, liver transplantation was the third most frequent, with 1,880 transplants performed, of which 150 in Rio Grande do Sul. Several studies evaluated the association between variability in blood levels of immunosuppressive tacrolimus and late acute cellular graft rejection. OBJECTIVE To investigate the association of tacrolimus blood levels with clinical outcomes late acute cellular rejection, death, patient survival and graft survival in patients undergoing liver transplantation. METHODS This is a retrospective longitudinal study including patients submitted to adult liver transplantation by the Liver Transplantation Group in the Santa Casa de Misericórdia Hospital of Porto Alegre, from January 2006 to January 2013, and who used tacrolimus as immunosuppressive therapy. RESULTS Of the 127 patients included in the study, the majority were male (70.1%), 52-60 years old (33.9%) at the transplant. The most frequent causes of liver transplantation in this series were hepatitis C virus and hepatocellular carcinoma (24.4%) and alcohol (15.7%). Thirteen patients had late acute cellular rejection (10.2%); of these, three had two episodes. Regarding severity classification, seven patients had mild late acute cellular rejection. The mean time of rejection after liver transplantation was 14 months (ranging from 8 to 33 months). Overall survival was 8.98 years. Regarding tacrolimus blood levels, 52 patients with a variation ≥2 standard deviations were identified. Of these patients, eight had rejection; however, the association was not significant (P=0.146). A significant association was found between variation ≥2 standard deviations in tacrolimus blood levels and death (P=0.023) and survival (P=0.019). Regarding 5-year follow-up of graft survival, being two standard deviations above increases by 2.26 times the risk of transplanted graft loss, and for each unit of increase of standard deviation of tacrolimus blood levels there is a two-fold increase in the risk of graft loss in 5 years. CONCLUSION Increased risk of graft loss associated with increased standard deviations of tacrolimus blood levels may indicate the need for more rigorous and prospective monitoring of tacrolimus blood levels.
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Affiliation(s)
- Nicole Bianchin Maciel
- Universidade Federal de Ciências da Saúde de Porto Alegre, Programa de Pós-Graduação em Hepatologia, Porto Alegre, RS, Brasil
| | - Karin Hepp Schwambach
- Universidade Federal de Ciências da Saúde de Porto Alegre, Programa de Pós-Graduação em Hepatologia, Porto Alegre, RS, Brasil
| | - Carine Raquel Blatt
- Universidade Federal de Ciências da Saúde de Porto Alegre, Programa de Pós-Graduação em Hepatologia, Porto Alegre, RS, Brasil
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35
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Gabardi S. Unraveling the Genomic Architecture of the CYP3A Locus and ADME Genes for Personalized Tacrolimus Dosing. Transplantation 2021; 105:2135-2136. [PMID: 33534527 DOI: 10.1097/tp.0000000000003661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Steven Gabardi
- Department of Transplant Surgery and Pharmacy Services, Brigham and Women's Hospital, Boston, MA
- Department of Renal Division, Brigham and Women's Hospital, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
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36
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Henin E, Govoni M, Cella M, Laveille C, Piotti G. Therapeutic Drug Monitoring Strategies for Envarsus in De Novo Kidney Transplant Patients Using Population Modelling and Simulations. Adv Ther 2021; 38:5317-5332. [PMID: 34515977 DOI: 10.1007/s12325-021-01905-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 08/26/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Tacrolimus, the cornerstone of transplantation immunosuppression, is a narrow therapeutic index drug with a low and highly variable bioavailability. Therapeutic drug monitoring based on trough level assessment is mandatory in order to target a personalised exposure and avoid both rejection and toxicity. Population pharmacokinetic (POPPK) models might be a useful tool for improving early attainment of target range by guiding initial doses until steady state is reached and trough levels can be reliably used as surrogate marker of exposure. Here we present the first POPPK for predicting the initial doses of the once-daily prolonged release tacrolimus Envarsus (LCPT) in adult kidney recipients. METHODS The model was developed exploiting the data from a recent pharmacokinetic randomised clinical study, in which 69 de novo kidney recipients, 33 of whom treated with LCPT, underwent an intensive blood sampling strategy for tacrolimus including four complete pharmacokinetic profiles. RESULTS The complex and prolonged absorption of LCPT is well described by the three-phase model that incorporates body weight and CYP3A5 genotype as significant covariates accounting for a great proportion of the inter-patient variability: in particular, CYP3A5*1/*3 expressors had a 66% higher LCPT clearance. We have then generated by simulation a personalised dosing strategy based on the model that could improve the early attainment of therapeutic trough levels by almost doubling the proportion of patients within target range (69.3% compared to 36.1% with the standard body weight-based approach) on post-transplantation day 4 and significantly reduce the proportion of overexposed patients at risk of toxicity. CONCLUSIONS A POPPK model was successfully developed for LCPT in de novo kidney recipients. The model could guide a personalised dosing strategy early after transplantation. For the model to be translated into clinical practice, its beneficial impact of earlier attainment of therapeutic trough levels should be demonstrated on hard clinical outcomes in further studies.
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Affiliation(s)
| | - Mirco Govoni
- Global Clinical Development, Chiesi Farmaceutici S.p.A., Parma, Italy
| | - Massimo Cella
- Global Clinical Development, Chiesi Farmaceutici S.p.A., Parma, Italy
| | | | - Giovanni Piotti
- Global Clinical Development, Chiesi Farmaceutici S.p.A., Parma, Italy.
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Andrews LM, de Winter BCM, Cornelissen EAM, de Jong H, Hesselink DA, Schreuder MF, Brüggemann RJM, van Gelder T, Cransberg K. A Population Pharmacokinetic Model Does Not Predict the Optimal Starting Dose of Tacrolimus in Pediatric Renal Transplant Recipients in a Prospective Study: Lessons Learned and Model Improvement. Clin Pharmacokinet 2021; 59:591-603. [PMID: 31654367 PMCID: PMC7217818 DOI: 10.1007/s40262-019-00831-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background and Objective Bodyweight-based dosing of tacrolimus is considered standard care. Currently, at first steady state, a third of pediatric kidney transplant recipients has a tacrolimus pre-dose concentration within the target range. We investigated whether adaptation of the starting dose according to a validated dosing algorithm could increase this proportion. Methods This was a multi-center, single-arm, prospective trial with a planned interim analysis after 16 patients, in which the tacrolimus starting dose was based on bodyweight, cytochrome P450 3A5 genotype, and donor status (living vs. deceased donor). Results At the interim analysis, 31% of children had a tacrolimus pre-dose concentration within the target range. As the original dosing algorithm was poorly predictive of tacrolimus exposure, the clinical trial was terminated prematurely. Next, the original model was improved by including the data of the children included in this trial, thereby doubling the number of children in the model building cohort. Data were best described with a two-compartment model with inter-individual variability, allometric scaling, and inter-occasion variability on clearance. Cytochrome P450 3A5 genotype, hematocrit, and creatinine influenced the tacrolimus clearance. A new starting dose model was developed in which the cytochrome P450 3A5 genotype was incorporated. Both models were successfully internally and externally validated. Conclusions The weight-normalized starting dose of tacrolimus should be higher in patients with a lower bodyweight and in those who are cytochrome P450 3A5 expressers. Electronic supplementary material The online version of this article (10.1007/s40262-019-00831-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Louise M Andrews
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
| | - Brenda C M de Winter
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Elisabeth A M Cornelissen
- Department of Pediatric Nephrology, Radboudumc Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Huib de Jong
- Department of Pediatric Nephrology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Dennis A Hesselink
- Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Michiel F Schreuder
- Department of Pediatric Nephrology, Radboudumc Amalia Children's Hospital, Nijmegen, The Netherlands
| | | | - Teun van Gelder
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
- Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Karlien Cransberg
- Department of Pediatric Nephrology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
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38
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Cheng F, Li Q, Wang J, Zeng F, Zhang Y. Effects and safety evaluation of Wuzhi Capsules combined with tacrolimus for the treatment of kidney transplantation recipients. J Clin Pharm Ther 2021; 46:1636-1649. [PMID: 34342024 DOI: 10.1111/jcpt.13493] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 07/07/2021] [Accepted: 07/12/2021] [Indexed: 01/06/2023]
Abstract
WHAT IS KNOWN AND OBJECTIVE Tacrolimus (FK506), an effective and potent calcineurin inhibitor, is the cornerstone of immunosuppression after kidney transplantation. Wuzhi capsule (WZC), a prescribed ethanol extract of Nan-Wuweizi (Schisandra sphenanthera), is widely prescribed for kidney transplant recipients for the maintenance of tacrolimus concentration in clinical settings. Previous studies have demonstrated that WZC can increase the blood concentration of tacrolimus. However, it remains controversial whether to use WZC can be used to increase tacrolimus concentration in clinical practice. Our study aimed to evaluate the efficacy and safety of WZC combined with tacrolimus in the treatment of kidney transplant recipients. METHODS One hundred and ninety four Chinese kidney transplant recipients were included in this retrospective study. The recipients were divided into two groups (non-WZC group and WZC group). We investigated the effects of WZC on tacrolimus in terms of tacrolimus metabolism, laboratory tests, pharmacogenomics, renal function and adverse reactions. RESULTS AND DISCUSSION The concentration/dose (C0 /D) of tacrolimus was significantly higher in the WZC group than the non-WZC group. The laboratory findings of blood routine tests, liver and kidney function were not significantly different between the two groups. The CYP3A5 genotype showed clearly associated with tacrolimus C0 /D, whereas no significant difference was observed in patients with CYP3A4*1B, CYP3A4*22, ABCB1, ABCC2, POR*28 or PXR alleles. The improvement of C0 /D by administration of WZC was significant in CYP3A5 expressers compared to non-expressers. Furthermore, the WZC group had a remarkably higher proportion of subjects who reached the target tacrolimus concentration than the non-WZC group. No significant differences in renal function and adverse reactions were observed between the groups. WHAT IS NEW AND CONCLUSION Wuzhi capsule can increase tacrolimus concentration without negative effects on renal function and adverse reactions, especially in CYP3A5 expressers. Efficient and economical synergistic effects can be achieved by the combined administration of WZC in kidney transplant recipients.
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Affiliation(s)
- Fang Cheng
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, China
| | - Qiang Li
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, China
| | - Jinglin Wang
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, China
| | - Fang Zeng
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, China
| | - Yu Zhang
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, China
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39
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Mulder TAM, van Eerden RAG, de With M, Elens L, Hesselink DA, Matic M, Bins S, Mathijssen RHJ, van Schaik RHN. CYP3A4∗22 Genotyping in Clinical Practice: Ready for Implementation? Front Genet 2021; 12:711943. [PMID: 34306041 PMCID: PMC8296839 DOI: 10.3389/fgene.2021.711943] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 06/17/2021] [Indexed: 12/26/2022] Open
Abstract
Cytochrome P450 3A4 (CYP3A4) is the most important drug metabolizing enzyme in the liver, responsible for the oxidative metabolism of ∼50% of clinically prescribed drugs. Therefore, genetic variation in CYP3A4 could potentially affect the pharmacokinetics, toxicity and clinical outcome of drug treatment. Thus far, pharmacogenetics for CYP3A4 has not received much attention. However, the recent discovery of the intron 6 single-nucleotide polymorphism (SNP) rs35599367C > T, encoding the CYP3A4∗22 allele, led to several studies into the pharmacogenetic effect of CYP3A4∗22 on different drugs. This allele has a relatively minor allele frequency of 3-5% and an effect on CYP3A4 enzymatic activity. Thus far, no review summarizing the data published on several drugs is available yet. This article therefore addresses the current knowledge on CYP3A4∗22. This information may help in deciding if, and for which drugs, CYP3A4∗22 genotype-based dosing could be helpful in improving drug therapy. CYP3A4∗22 was shown to significantly influence the pharmacokinetics of several drugs, with currently being most thoroughly investigated tacrolimus, cyclosporine, and statins. Additional studies, focusing on toxicity and clinical outcome, are warranted to demonstrate clinical utility of CYP3A4∗22 genotype-based dosing.
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Affiliation(s)
- Tessa A M Mulder
- Department of Clinical Chemistry, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Ruben A G van Eerden
- Department of Medical Oncology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Mirjam de With
- Department of Clinical Chemistry, Erasmus MC University Medical Center, Rotterdam, Netherlands.,Department of Medical Oncology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Laure Elens
- Department of Clinical Chemistry, Erasmus MC University Medical Center, Rotterdam, Netherlands.,Integrated PharmacoMetrics, PharmacoGenomics and PharmacoKinetics, Louvain Drug Research Institute, Université Catholique de Louvain, Brussels, Belgium.,Louvain Centre for Toxicology and Applied Pharmacology, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Dennis A Hesselink
- Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, Netherlands.,Erasmus MC Transplant Institute, Rotterdam, Netherlands
| | - Maja Matic
- Department of Clinical Chemistry, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Sander Bins
- Department of Medical Oncology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Ron H J Mathijssen
- Department of Medical Oncology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Ron H N van Schaik
- Department of Clinical Chemistry, Erasmus MC University Medical Center, Rotterdam, Netherlands
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40
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Leino AD, Park JM, Pasternak AL. Impact of CYP3A5 phenotype on tacrolimus time in therapeutic range and clinical outcomes in pediatric renal and heart transplant recipients. Pharmacotherapy 2021; 41:649-657. [PMID: 34129685 DOI: 10.1002/phar.2601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 06/01/2021] [Accepted: 06/02/2021] [Indexed: 11/11/2022]
Abstract
STUDY OBJECTIVE This study investigated the effect of CYP3A5 phenotype on time in therapeutic range (TTR) of tacrolimus post-transplant in pediatric patients. DESIGN AND DATA SOURCE This retrospective study assessed medical records of pediatric kidney and heart recipients with available CYP3A5 genotype for tacrolimus dosing, troughs, and the clinical events (biopsy-proven acute rejection [BPAR] and de novo donor-specific antibodies [dnDSA]). MEASUREMENTS AND MAIN RESULTS The primary outcome, mean TTR in the first 90 days post-transplant, was 9.0% (95% CI: -16.1, -1.9) lower in CYP3A5 expressers (p = 0.014) when adjusting for time to therapeutic concentration and organ type. There was no difference between CYP3A5 phenotypes in time to the first clinical event using TTR during the first 90 days. When applying TTR over the first year, there was a significant difference in event-free survival (EFS) which was 50.0% for CYP3A5 expressers/TTR < 35%, 45.5% for expressers/TTR ≥ 35%, 38.1% for nonexpressers/TTR < 35%, and 72.9% for nonexpressers/TTR ≥ 35% (log-rank p = 0.03). A post hoc analysis of EFS identified CYP3A5 expressers had lower EFS compared to nonexpressers in patients with TTR ≥ 35% (p = 0.04) but no difference among patients with TTR < 35% (p = 0.6). CONCLUSIONS The relationship between TTR and CYP3A5 phenotype suggests that achieving a TTR ≥ 35% during the first year may be a modifiable factor to attenuate the risk of BPAR and dnDSA.
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Affiliation(s)
- Abbie D Leino
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Jeong M Park
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Amy L Pasternak
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
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41
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Therapeutic drug monitoring of immunosuppressive drugs in hepatology and gastroenterology. Best Pract Res Clin Gastroenterol 2021; 54-55:101756. [PMID: 34874840 DOI: 10.1016/j.bpg.2021.101756] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 06/11/2021] [Indexed: 01/31/2023]
Abstract
Immunosuppressive drugs have been key to the success of liver transplantation and are essential components of the treatment of inflammatory bowel disease (IBD) and autoimmune hepatitis (AIH). For many but not all immunosuppressants, therapeutic drug monitoring (TDM) is recommended to guide therapy. In this article, the rationale and evidence for TDM of tacrolimus, mycophenolic acid, the mammalian target of rapamycin inhibitors, and azathioprine in liver transplantation, IBD, and AIH is reviewed. New developments, including algorithm-based/computer-assisted immunosuppressant dosing, measurement of immunosuppressants in alternative matrices for whole blood, and pharmacodynamic monitoring of these agents is discussed. It is expected that these novel techniques will be incorporate into the standard TDM in the next few years.
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42
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Significance of Ethnic Factors in Immunosuppressive Therapy Management After Organ Transplantation. Ther Drug Monit 2021; 42:369-380. [PMID: 32091469 DOI: 10.1097/ftd.0000000000000748] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Clinical outcomes after organ transplantation have greatly improved in the past 2 decades with the discovery and development of immunosuppressive drugs such as calcineurin inhibitors, antiproliferative agents, and mammalian target of rapamycin inhibitors. However, individualized dosage regimens have not yet been fully established for these drugs except for therapeutic drug monitoring-based dosage modification because of extensive interindividual variations in immunosuppressive drug pharmacokinetics. The variations in immunosuppressive drug pharmacokinetics are attributed to interindividual variations in the functional activity of cytochrome P450 enzymes, UDP-glucuronosyltransferases, and ATP-binding cassette subfamily B member 1 (known as P-glycoprotein or multidrug resistance 1) in the liver and small intestine. Some genetic variations have been found to be involved to at least some degree in pharmacokinetic variations in post-transplant immunosuppressive therapy. It is well known that the frequencies and effect size of minor alleles vary greatly between different races. Thus, ethnic considerations might provide useful information for optimizing individualized immunosuppressive therapy after organ transplantation. Here, we review ethnic factors affecting the pharmacokinetics of immunosuppressive drugs requiring therapeutic drug monitoring, including tacrolimus, cyclosporine, mycophenolate mofetil, sirolimus, and everolimus.
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Pasternak AL, Marshall VD, Gersch CL, Rae JM, Englesbe M, Park JM. Evaluating the Impact of CYP3A5 Genotype on Post-Transplant Healthcare Resource Utilization in Pediatric Renal and Heart Transplant Recipients Receiving Tacrolimus. PHARMACOGENOMICS & PERSONALIZED MEDICINE 2021; 14:319-326. [PMID: 33746516 PMCID: PMC7967030 DOI: 10.2147/pgpm.s285444] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 01/11/2021] [Indexed: 01/10/2023]
Abstract
Purpose CYP3A5 genotype is a significant contributor to inter-individual tacrolimus exposure and may impact the time required to achieve therapeutic concentrations and number of tacrolimus dose adjustments in transplant patients. Increased modifications to tacrolimus therapy may indicate a higher burden on healthcare resources. The purpose of this study was to evaluate whether CYP3A5 genotype was predictive of healthcare resource utilization in pediatric renal and heart transplant recipients. Patients and Methods Patients <18 years of age with a renal or heart transplant between 6/1/2014–12/31/2018 and tacrolimus-based immunosuppression were included. Secondary use samples were obtained for CYP3A5 genotyping. Clinical data was retrospectively collected from the electronic medical record. Healthcare resource utilization measures included the number of dose changes, number of tacrolimus concentrations, length of stay, number of clinical encounters, and total charges within the first year post-transplant. Rejection and donor-specific antibody (DSA) formation within the first year were also collected. The impact of CYP3A5 genotype was evaluated via univariate analysis for the first year and multivariable analysis at 30, 90, 180, 270, and 365 days post-transplant. Results Eighty-five subjects were included, 48 renal transplant recipients and 37 heart transplant recipients. CYP3A5 genotype was not associated with any outcomes in renal transplant, however, a CYP3A5 expresser phenotype was a predictor of more dose changes, more tacrolimus concentrations, longer length of stay, and higher total charges in heart transplant recipients. CYP3A5 genotype was not associated with rejection or DSA formation. Age and induction therapy were associated with higher total charges. Conclusion CYP3A5 genotype may predict healthcare resource utilization in the first year post-transplant, although this may be mitigated by differences in tacrolimus management. Future studies should evaluate the impact of genotype-guided dosing strategies for tacrolimus on healthcare utilization resources.
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Affiliation(s)
- Amy L Pasternak
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI, 48109, USA
| | - Vincent D Marshall
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI, 48109, USA
| | - Christina L Gersch
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, 48109, USA
| | - James M Rae
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, 48109, USA
| | - Michael Englesbe
- Department of Surgery, Michigan Medicine, Ann Arbor, MI, 48109, USA
| | - Jeong M Park
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI, 48109, USA
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Yang H, Sun Y, Yu X, Hu X, Wang W, Zhang X, Liu L. Clinical Impact of the Adaptation of Initial Tacrolimus Dosing to the CYP3A5 Genotype After Kidney Transplantation: Systematic Review and Meta-Analysis of Randomized Controlled Trials. Clin Pharmacokinet 2021; 60:877-885. [PMID: 33751414 DOI: 10.1007/s40262-020-00955-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2020] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The aim of this systematic review and meta-analysis was to compare the clinical outcomes between genotype-guided and conventional tacrolimus doses in kidney transplantation patients. MATERIALS AND METHODS We performed a comprehensive literature search of the PubMed, EMBASE, and Cochrane databases from the date of inception to 26 February 2020. References of the retrieved articles were also reviewed and any further relevant studies were included. The search terms included 'tacrolimus', 'cytochrome P-450 CYP3A', 'polymorphism, genetic', 'genomics', 'genome', 'genotype', 'genes', 'alleles', and 'pharmacogenetics'. RESULTS Our study showed that the genotype-guided group included an increased proportion of patients with tacrolimus concentrations in the therapeutic range at steady state (risk ratio [RR] 1.40, 95% confidence interval [CI] 1.14-1.72, p = 0.001; high quality), with a trend for achieving therapeutic concentrations earlier compared with those in the conventional group. However, there was no statistical difference in the incidence of delayed graft function (RR 1.98, 95% CI 0.92-1.76, p = 0.12; moderate quality), incidence of acute rejection (RR 1.00, 95% CI 0.64-1.55, p = 1.00; moderate quality), incidence of graft survival censored for death (RR 1.02, 95% CI 0.98-1.06, p = 0.37; moderate quality), and incidence of adverse effects (AEs). CONCLUSIONS Although the genotype-guided group had a higher proportion of patients within the targeted concentration and less median time to achieve the therapeutic range, the clinical endpoints, including delayed graft function, acute rejection, graft survival censored for death, and AEs were similar in both groups. All in all, evidence suggested there was no utility in pharmacogenetics for tacrolimus based on the cytochrome P450 (CYP) 3A5 genotype. Studies with Chinese and African American populations are needed due to the frequency of genetic polymorphisms of CYP3A5. Furthermore, a dosing algorithm that includes demographic and clinical factors plus multiple genetic variants should be added for consideration, and may optimize early tacrolimus exposure.
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Affiliation(s)
- Hui Yang
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, China
| | - Yiqi Sun
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, China
| | - Xiaojia Yu
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, China
| | - Xiaopeng Hu
- Department of Urology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Wei Wang
- Department of Urology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Xiaodong Zhang
- Department of Urology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Lihong Liu
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, China.
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Francke MI, Andrews LM, Le HL, van de Wetering J, Clahsen-van Groningen MC, van Gelder T, van Schaik RHN, van der Holt B, de Winter BCM, Hesselink DA. Avoiding Tacrolimus Underexposure and Overexposure with a Dosing Algorithm for Renal Transplant Recipients: A Single Arm Prospective Intervention Trial. Clin Pharmacol Ther 2021; 110:169-178. [PMID: 33452682 PMCID: PMC8359222 DOI: 10.1002/cpt.2163] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 12/21/2020] [Indexed: 12/20/2022]
Abstract
Bodyweight‐based tacrolimus dosing followed by therapeutic drug monitoring is standard clinical care after renal transplantation. However, after transplantation, a meager 38% of patients are on target at first steady‐state and it can take up to 3 weeks to reach the target tacrolimus predose concentration (C0). Tacrolimus underexposure and overexposure is associated with an increased risk of rejection and drug‐related toxicity, respectively. To minimize subtherapeutic and supratherapeutic tacrolimus exposure in the immediate post‐transplant phase, a previously developed dosing algorithm to predict an individual’s tacrolimus starting dose was tested prospectively. In this single‐arm, prospective, therapeutic intervention trial, 60 de novo kidney transplant recipients received a tacrolimus starting dose based on a dosing algorithm instead of a standard, bodyweight‐based dose. The algorithm included cytochrome P450 (CYP)3A4 and CYP3A5 genotype, body surface area, and age as covariates. The target tacrolimus C0, measured for the first time at day 3, was 7.5–12.5 ng/mL. Between February 23, 2019, and July 7, 2020, 60 patients were included. One patient was excluded because of a protocol violation. On day 3 post‐transplantation, 34 of 59 patients (58%, 90% CI 47–68%) had a tacrolimus C0 within the therapeutic range. Markedly subtherapeutic (< 5.0 ng/mL) and supratherapeutic (> 20 ng/mL) tacrolimus concentrations were observed in 7% and 3% of the patients, respectively. Biopsy‐proven acute rejection occurred in three patients (5%). In conclusion, algorithm‐based tacrolimus dosing leads to the achievement of the tacrolimus target C0 in as many as 58% of the patients on day 3 after kidney transplantation.
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Affiliation(s)
- Marith I Francke
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Rotterdam Transplant Group, Rotterdam, The Netherlands.,Netherlands Institute for Health Sciences, Rotterdam, The Netherlands
| | - Louise M Andrews
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Hospital Pharmacy, Meander Medical Center, Amersfoort, The Netherlands
| | - Hoang Lan Le
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jacqueline van de Wetering
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Rotterdam Transplant Group, Rotterdam, The Netherlands
| | - Marian C Clahsen-van Groningen
- Rotterdam Transplant Group, Rotterdam, The Netherlands.,Department of Pathology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Teun van Gelder
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ron H N van Schaik
- Department of Clinical Chemistry, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Bronno van der Holt
- Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Brenda C M de Winter
- Rotterdam Transplant Group, Rotterdam, The Netherlands.,Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Dennis A Hesselink
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Rotterdam Transplant Group, Rotterdam, The Netherlands
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Nobakht E, Jagadeesan M, Paul R, Bromberg J, Dadgar S. Precision Medicine in Kidney Transplantation: Just Hype or a Realistic Hope? Transplant Direct 2021; 7:e650. [PMID: 33437865 PMCID: PMC7793397 DOI: 10.1097/txd.0000000000001102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/27/2020] [Accepted: 10/29/2020] [Indexed: 12/17/2022] Open
Abstract
Desirable outcomes including rejection- and infection-free kidney transplantation are not guaranteed despite current strategies for immunosuppression and using prophylactic antimicrobial medications. Graft survival depends on factors beyond human leukocyte antigen matching such as the level of immunosuppression, infections, and management of other comorbidities. Risk stratification of transplant patients based on predisposing genetic modifiers and applying precision pharmacotherapy may help improving the transplant outcomes. Unlike certain fields such as oncology in which consistent attempts are being carried out to move away from the "error and trial approach," transplant medicine is lagging behind in implementing personalized immunosuppressive therapy. The need for maintaining a precarious balance between underimmunosuppression and overimmunosuppression coupled with adverse effects of medications calls for a gene-based guidance for precision pharmacotherapy in transplantation. Technologic advances in molecular genetics have led to increased accessibility of genetic tests at a reduced cost and have set the stage for widespread use of gene-based therapies in clinical care. Evidence-based guidelines available for precision pharmacotherapy have been proposed, including guidelines from Clinical Pharmacogenetics Implementation Consortium, the Pharmacogenomics Knowledge Base National Institute of General Medical Sciences of the National Institutes of Health, and the US Food and Drug Administration. In this review, we discuss the implications of pharmacogenetics and potential role for genetic variants-based risk stratification in kidney transplantation. A single score that provides overall genetic risk, a polygenic risk score, can be achieved by combining of allograft rejection/loss-associated variants carried by an individual and integrated into practice after clinical validation.
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Affiliation(s)
- Ehsan Nobakht
- Division of Renal Diseases and Hypertension, Department of Medicine, George Washington University School of Medicine, Washington, DC
| | - Muralidharan Jagadeesan
- Division of Renal Diseases and Hypertension, Department of Medicine, George Washington University School of Medicine, Washington, DC
| | - Rohan Paul
- Division of Renal Diseases and Hypertension, Department of Medicine, George Washington University School of Medicine, Washington, DC
| | - Jonathan Bromberg
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Sherry Dadgar
- Division of Renal Diseases and Hypertension, Department of Medicine, George Washington University School of Medicine, Washington, DC
- Personalized Medicine Care Diagnostics Laboratory (PMCDx), Inc., Germantown, MD
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Abdullah-Koolmees H, van Keulen AM, Nijenhuis M, Deneer VHM. Pharmacogenetics Guidelines: Overview and Comparison of the DPWG, CPIC, CPNDS, and RNPGx Guidelines. Front Pharmacol 2021; 11:595219. [PMID: 33568995 PMCID: PMC7868558 DOI: 10.3389/fphar.2020.595219] [Citation(s) in RCA: 76] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 10/30/2020] [Indexed: 12/12/2022] Open
Abstract
Many studies have shown that the efficacy and risk of side effects of drug treatment is influenced by genetic variants. Evidence based guidelines are essential for implementing pharmacogenetic knowledge in daily clinical practice to optimize pharmacotherapy of individual patients. A literature search was performed to select committees developing guidelines with recommendations being published in English. The Dutch Pharmacogenetics Working Group (DPWG), the Clinical Pharmacogenetics Implementation Consortium (CPIC), the Canadian Pharmacogenomics Network for Drug Safety (CPNDS), and the French National Network (Réseau) of Pharmacogenetics (RNPGx) were selected. Their guidelines were compared with regard to the methodology of development, translation of genotypes to predicted phenotypes, pharmacotherapeutic recommendations and recommendations on genotyping. A detailed overview of all recommendations for gene-drug combinations is given. The committees have similar methodologies of guideline development. However, the objectives differed at the start of their projects, which have led to unique profiles and strengths of their guidelines. DPWG and CPIC have a main focus on pharmacotherapeutic recommendations for a large number of drugs in combination with a patient’s genotype or predicted phenotype. DPWG, CPNDS and RNPGx also recommend on performing genetic testing in daily clinical practice, with RNPGx even describing specific clinical settings or medical conditions for which genotyping is recommended. Discordances exist, however committees also initiated harmonizing projects. The outcome of a consensus project was to rename “extensive metabolizer (EM)” to “normal metabolizer (NM)”. It was decided to translate a CYP2D6 genotype with one nonfunctional allele (activity score 1.0) into the predicted phenotype of intermediate metabolizer (IM). Differences in recommendations are the result of the methodologies used, such as assessment of dose adjustments of tricyclic antidepressants. In some cases, indication or dose specific recommendations are given for example for clopidogrel, codeine, irinotecan. The following drugs have recommendations on genetic testing with the highest level: abacavir (HLA), clopidogrel (CYP2C19), fluoropyrimidines (DPYD), thiopurines (TPMT), irinotecan (UGT1A1), codeine (CYP2D6), and cisplatin (TPMT). The guidelines cover many drugs and genes, genotypes, or predicted phenotypes. Because of this and their unique features, considering the totality of guidelines are of added value. In conclusion, many evidence based pharmacogenetics guidelines with clear recommendations are available for clinical decision making by healthcare professionals, patients and other stakeholders.
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Affiliation(s)
- Heshu Abdullah-Koolmees
- Division of Laboratories, Pharmacy, and Biomedical Genetics, Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, Netherlands
| | - Antonius M van Keulen
- Division of Pharmacoepidemiology and Clinical Pharmacology, Department of Pharmaceutical Sciences, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, Netherlands
| | - Marga Nijenhuis
- Royal Dutch Pharmacists Association (KNMP), Hague, Netherlands
| | - Vera H M Deneer
- Division of Laboratories, Pharmacy, and Biomedical Genetics, Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, Netherlands.,Division of Pharmacoepidemiology and Clinical Pharmacology, Department of Pharmaceutical Sciences, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, Netherlands
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Nguyen TT, Pearson RA, Mohamed ME, Schladt DP, Berglund D, Rivers Z, Skaar DJ, Wu B, Guan W, van Setten J, Keating BJ, Dorr C, Remmel RP, Matas AJ, Mannon RB, Israni AK, Oetting WS, Jacobson PA. Pharmacogenomics in kidney transplant recipients and potential for integration into practice. J Clin Pharm Ther 2020; 45:1457-1465. [PMID: 32662547 PMCID: PMC7719579 DOI: 10.1111/jcpt.13223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 05/14/2020] [Accepted: 06/11/2020] [Indexed: 11/29/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Pharmacogenomic biomarkers are now used in many clinical care settings and represent one of the successes of precision medicine. Genetic variants are associated with pharmacokinetic and pharmacodynamic changes leading to medication adverse effects and changes in clinical response. Actionable pharmacogenomic variants are common in transplant recipients and have implications for medications used in transplant, but yet are not broadly incorporated into practice. METHODS From the Clinical Pharmacogenetics Implementation Consortium and Dutch Pharmacogenetics Working Group guidelines, and PharmGKB databases, 12 pharmacogenomic genes with 30 variants were selected and used to create diplotypes and actionable pharmacogenomic phenotypes. A total of 853 kidney allograft recipients who had genomic information available from a genome-wide association study were included. RESULTS Each recipient had at least one actionable pharmacogenomic diplotype/phenotype, whereas the majority (58%) had three or four actionable diplotypes/phenotypes and 17.4% had five or more among the 12 genes. The participants carried actionable diplotypes/phenotypes for multiple medications, including tacrolimus, azathioprine, clopidogrel, warfarin, simvastatin, voriconazole, antidepressants and proton-pump inhibitors. WHAT IS NEW AND CONCLUSION Pharmacogenomic variants are common in transplant recipients, and transplant recipients receive medications that have actionable variants. CLINICAL TRIAL Genomics of Transplantation, clinicaltrials.gov (NCT01714440).
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Affiliation(s)
- Tam T Nguyen
- College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
| | | | - Moataz E Mohamed
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
- Department of Pharmacy Practice, Faculty of Pharmacy, Helwan University, Cairo, Egypt
| | - David P Schladt
- Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, MN, USA
| | - Danielle Berglund
- Complex Care Core Analytics, Fairview University of Minnesota, Minneapolis, MN, USA
| | - Zachary Rivers
- Social and Administrative Pharmacy, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
| | - Debra J Skaar
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
| | - Baolin Wu
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Weihua Guan
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Jessica van Setten
- Department of Cardiology, University Medical Center Utrecht, University of Utrecht, Utrecht, Netherlands
| | - Brendan J Keating
- Penn Transplant Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Casey Dorr
- Minneapolis Medical Research Foundation and Division of Nephrology, Hennepin Healthcare, Minneapolis, MN, USA
| | - Rory P Remmel
- Department of Medicinal Chemistry, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
| | - Arthur J Matas
- Department of Surgery, School of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Roslyn B Mannon
- Department of Nephrology, School of Medicine, University of Nebraska, Omaha, NE, USA
| | - Ajay K Israni
- Division of Nephrology, Hennepin Healthcare, Minneapolis, MN, USA
- Epidemiology & Community Health, University of Minnesota, Minneapolis, MN, USA
| | - William S Oetting
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
| | - Pamala A Jacobson
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
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Francke MI, Hesselink DA, Li Y, Koch BCP, de Wit LEA, van Schaik RHN, Yang L, Baan CC, van Gelder T, de Winter BCM. Monitoring the tacrolimus concentration in peripheral blood mononuclear cells of kidney transplant recipients. Br J Clin Pharmacol 2020; 87:1918-1929. [PMID: 33025649 PMCID: PMC8056738 DOI: 10.1111/bcp.14585] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 09/10/2020] [Accepted: 09/23/2020] [Indexed: 02/05/2023] Open
Abstract
Aims Tacrolimus is a critical dose drug and to avoid under‐ and overexposure, therapeutic drug monitoring is standard practice. However, rejection and drug‐related toxicity occur despite whole‐blood tacrolimus pre‐dose concentrations ([Tac]blood) being on target. Monitoring tacrolimus concentrations at the target site (within peripheral blood mononuclear cells; [Tac]cells) may better correlate with drug‐efficacy. The aim of this study was to (1) investigate the relationship between [Tac]blood and [Tac]cells, (2) identify factors affecting the tacrolimus distribution in cells and whole‐blood, and (3) study the relationship between [Tac]cells and clinical outcomes after kidney transplantation. Methods A total of 175 renal transplant recipients were prospectively followed. [Tac]blood and [Tac]cells were determined at Months 3, 6 and 12 post‐transplantation. Patients were genotyped for ABCB1 1199G>A and 3435C>T, CYP3A4 15389C>T, and CYP3A5 6986G>A. Data on rejection and tacrolimus‐related nephrotoxicity and post‐transplant diabetes mellitus were collected. Results Correlations between [Tac]blood and [Tac]cells were moderate to poor (Spearman's r = 0.31; r = 0.41; r = 0.61 at Months 3, 6 and 12, respectively). The [Tac]cells/[Tac]blood ratio was stable over time in most patients (median intra‐patient variability 39.0%; range 3.5%–173.2%). Age, albumin and haematocrit correlated with the [Tac]cells/[Tac]blood ratio. CYP3A5 and CYP3A4 genotype combined affected both dose‐corrected [Tac]blood and [Tac]cells. ABCB1 was not significantly related to tacrolimus distribution. Neither [Tac]blood nor [Tac]cells correlated with clinical outcomes. Conclusions The correlation between [Tac]blood and [Tac]cells is poor. Age, albumin and haematocrit correlate with the [Tac]cells/[Tac]blood ratio, whereas genetic variation in ABCB1, CYP3A4 and CYP3A5 do not. Neither [Tac]blood nor [Tac]cells correlated with clinical outcomes.
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Affiliation(s)
- Marith I Francke
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands.,Rotterdam Transplant Group, Rotterdam, Netherlands
| | - Dennis A Hesselink
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands.,Rotterdam Transplant Group, Rotterdam, Netherlands
| | - Yi Li
- Department of Laboratory Medicine, Research Center of Clinical Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China.,Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Lucia E A de Wit
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Ron H N van Schaik
- Department of Clinical Chemistry, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Lin Yang
- Department of Pharmacy, Fujian Cancer Hospital & Fujian Medical University Cancer Hospital, Fuzhou, China
| | - Carla C Baan
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands.,Rotterdam Transplant Group, Rotterdam, Netherlands
| | - Teun van Gelder
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands.,Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Brenda C M de Winter
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
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Ro H, Jeong JC, Kong JM, Min JW, Park SK, Lee J, Koo TY, Yang J, Kim MS, Hwang S, Ahn C. The tacrolimus metabolism affect post‐transplant outcome mediating acute rejection and delayed graft function: analysis from Korean Organ Transplantation Registry data. Transpl Int 2020; 34:163-174. [DOI: 10.1111/tri.13777] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 05/14/2020] [Accepted: 10/21/2020] [Indexed: 01/07/2023]
Affiliation(s)
- Han Ro
- Department of Internal Medicine Gil Hospital Gachon University Incheon Korea
| | - Jong Cheol Jeong
- Department of Internal Medicine Seoul National University Bundang Hospital Seongnam Korea
| | - Jin Min Kong
- Department of Internal Medicine BHS Hanseo Hospital Busan Korea
| | - Ji Won Min
- Department of Internal Medicine Bucheon St. Mary’s Hospital The Catholic University of Korea Bucheon Korea
| | - Sung Kwang Park
- Department of Internal Medicine Chonbuk National University Medical School Jeonju Korea
| | - Joongyub Lee
- Department of Prevention and Management School of Medicine Inha University Hospital Inha University Incheon Korea
| | - Tai Yeon Koo
- Transplantation Research Institute Seoul National University Hospital Seoul Korea
| | - Jaeseok Yang
- Department of Surgery Transplantation Center Seoul National University Hospital Seoul Korea
| | - Myoung Soo Kim
- Department of Surgery Yonsei University College of Medicine Seoul Korea
| | - Seungsik Hwang
- Department of Public Health Sciences Graduate School of Public Health Seoul National University Seoul Korea
| | - Curie Ahn
- Department of Internal Medicine Seoul National University Hospital Seoul National University College of Medicine Seoul Korea
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