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Deml L, Hüber CM, Barabas S, Spindler T, Cozzi E, Grossi P. Stimulatory Effect of CMV Immunoglobulin on Innate Immunity and on the Immunogenicity of CMV Antigens. Transplant Direct 2021; 7:e781. [PMID: 34712781 PMCID: PMC8547921 DOI: 10.1097/txd.0000000000001236] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 08/29/2021] [Indexed: 12/25/2022] Open
Abstract
Background. Cytomegalovirus (CMV) immunoglobulin (CMVIG) is used for the prophylaxis of CMV infection after transplantation. Beyond providing passive CMV-specific immunity, CMVIG exerts enhancing and suppressive immunomodulatory functions. Although the anti-inflammatory activities of CMVIG have been extensively documented, its immunostimulatory activities remain poorly characterized. Methods. This exploratory study analyzed the capacity of CMVIG to modulate cell-mediated innate and adaptive immunities in vitro on freshly isolated peripheral blood mononuclear cells (PBMCs) of CMV-seropositive and -seronegative healthy individuals, using interferon-γ (IFN-γ) enzyme-linked immunospot and intracellular cytokine staining assays. Results. We showed that CMVIG treatment increases the number of IFN-γ–secreting PBMCs of both CMV-seronegative and -seropositive individuals, indicating a global stimulatory effect on innate immune cells. Indeed, CMVIG significantly increased the frequency of natural killer cells producing the T helper cell 1–type cytokines tumor necrosis factor and IFN-γ. This was associated with the induction of interleukin-12–expressing monocytes and the activation of cluster of differentiation (CD) 4+ and CD8+ T cells, as measured by the expression of tumor necrosis factor and IFN-γ. Interestingly, stimulation of PBMCs from CMV-seropositive subjects with CMVIG-opsonized CMV antigens (phosphoprotein 65, CMV lysate) enhanced CD4+ and CD8+ T-cell activation, suggesting that CMVIG promotes the immunogenicity of CMV antigens. Conclusions. Our data demonstrate that CMVIG can stimulate effector cells of both innate and adaptive immunities and promote the immunogenicity of CMV antigens. These immunostimulatory properties might contribute to the protective effect against CMV infection mediated by CMVIG.
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Affiliation(s)
- Ludwig Deml
- Lophius Biosciences GmbH, Regensburg, Germany
| | | | | | | | - Emanuele Cozzi
- Transplant Immunology Unit, University of Padua, Padova, Italy
| | - Paolo Grossi
- Infectious and Tropical Diseases Unit, Department of Medicine and Surgery, University of Insubria-ASST-Sette Laghi, Varese, Italy
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Eichelbaum M, Dahl ML, Sjöqvist F. Clinical pharmacology in Stockholm 50 years-report from the jubilee symposium. Eur J Clin Pharmacol 2018; 74:843-851. [PMID: 29487959 PMCID: PMC5942344 DOI: 10.1007/s00228-018-2432-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 12/27/2017] [Indexed: 01/09/2023]
Affiliation(s)
- Michel Eichelbaum
- Dr. Margarete Fischer-Bosch Institute, Stuttgart and Division of Clinical Pharmacology, University of Tübingen, Tübingen, Germany
| | - Marja-Liisa Dahl
- Division of Clinical Pharmacology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
| | - Folke Sjöqvist
- Division of Clinical Pharmacology, Karolinska Institutet, Stockholm, Sweden.
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Nowacki M, Nazarewski Ł, Kloskowski T, Tyloch D, Pokrywczyńska M, Pietkun K, Jundziłł A, Tyloch J, Habib SL, Drewa T. Novel surgical techniques, regenerative medicine, tissue engineering and innovative immunosuppression in kidney transplantation. Arch Med Sci 2016; 12:1158-1173. [PMID: 27695507 PMCID: PMC5016594 DOI: 10.5114/aoms.2016.61919] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2014] [Accepted: 02/08/2015] [Indexed: 01/09/2023] Open
Abstract
On the 60th anniversary of the first successfully performed renal transplantation, we summarize the historical, current and potential future status of kidney transplantation. We discuss three different aspects with a potential significant influence on kidney transplantation progress: the development of surgical techniques, the influence of regenerative medicine and tissue engineering, and changes in immunosuppression. We evaluate the standard open surgical procedures with modern techniques and compare them to less invasive videoscopic as well as robotic techniques. The role of tissue engineering and regenerative medicine as a potential method for future kidney regeneration or replacement and the interesting search for novel solutions in the field of immunosuppression will be discussed. After 60 years since the first successfully performed kidney transplantation, we can conclude that the greatest achievements are associated with the development of surgical techniques and with planned systemic immunosuppression.
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Affiliation(s)
- Maciej Nowacki
- Chair of Urology, Department of Regenerative Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
- Chair of Surgical Oncology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
| | - Łukasz Nazarewski
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Tomasz Kloskowski
- Chair of Urology, Department of Regenerative Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
| | - Dominik Tyloch
- Chair of Urology, Department of Regenerative Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
| | - Marta Pokrywczyńska
- Chair of Urology, Department of Regenerative Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
| | - Katarzyna Pietkun
- Chair of Urology, Department of Regenerative Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
| | - Arkadiusz Jundziłł
- Chair of Urology, Department of Regenerative Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
| | - Janusz Tyloch
- Chair of Urology, Department of Regenerative Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
| | - Samy L. Habib
- Department of Geriatrics, Geriatric Research, Education, and Clinical Center, South Texas Veterans Healthcare System, San Antonio, TX, USA
- Department of Cellular and Structural Biology, University of Texas Health Science Center, San Antonio, TX, USA
| | - Tomasz Drewa
- Chair of Urology, Department of Regenerative Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
- Department of General and Oncological Urology, Nicolaus Copernicus Hospital, Torun, Poland
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Jacobson PA, Schladt D, Israni A, Oetting WS, Lin YC, Leduc R, Guan W, Lamba V, Matas AJ. Genetic and clinical determinants of early, acute calcineurin inhibitor-related nephrotoxicity: results from a kidney transplant consortium. Transplantation 2012; 93:624-31. [PMID: 22334041 DOI: 10.1097/tp.0b013e3182461288] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Calcineurin inhibitor (CNI)-related acute nephrotoxicity is a common complication of transplantation. Clinical factors and elevated CNI levels are associated with nephrotoxicity; however, they do not fully explain the risk. Genetic factors may also predispose individuals to nephrotoxicity. METHODS We enrolled 945 kidney recipients into a multicenter, prospective study. DNA was genotyped for 2724 single-nucleotide polymorphisms (SNPs) using a customized chip. Cox models, unadjusted and adjusted for clinical factors, examined the association between SNPs and time to early CNI-related acute nephrotoxicity in the first 6 months posttransplant. RESULTS Cyclosporine was associated with a 1.49 hazard (95% confidence interval, 1.04-2.14) of acute nephrotoxicity relative to tacrolimus. Acute nephrotoxicity occurred in 22.6% of cyclosporine and 19.8% of tacrolimus recipients. The median (interquartile range) daily dose and trough concentration at time of nephrotoxicity were 400 mg (400-500 mg) and 228 ng/mL (190-272 ng/mL) in the cyclosporine group, and 6 mg (4-8 mg) and 12.6 ng/mL (10.2-15.9 ng/mL) in the tacrolimus group, respectively. In single-SNP adjusted analysis, nine SNPs in the XPC, CYP2C9, PAX4, MTRR, and GAN genes were associated with cyclosporine nephrotoxicity. In a multi-SNP analysis, SNPs from the same genes remained significant after adjusting for the clinical factors, showing that the SNPs are jointly and independently predictive of cyclosporine nephrotoxicity. No SNPs were associated with tacrolimus nephrotoxicity. CONCLUSION We identified SNPs that were potentially associated with early, acute cyclosporine-related nephrotoxicity. Identifying risk SNPs before transplantation provides an opportunity for personalization of immunosuppression by identifying those who may benefit from CNI-avoidance or minimization, or assist in selecting CNI type. These SNPs require independent validation.
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Affiliation(s)
- Pamala A Jacobson
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN 55455, USA.
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Mohammadpour N, Elyasi S, Vahdati N, Mohammadpour AH, Shamsara J. A review on therapeutic drug monitoring of immunosuppressant drugs. IRANIAN JOURNAL OF BASIC MEDICAL SCIENCES 2011; 14:485-98. [PMID: 23493821 PMCID: PMC3586862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/11/2010] [Accepted: 03/27/2011] [Indexed: 12/03/2022]
Abstract
: Immunosuppressants require therapeutic drug monitoring because of their narrow therapeutic index and significant inter-individual variability in blood concentrations. This variability can be because of factors like drug-nutrient interactions, drug-disease interactions, renal-insufficiency, inflammation and infection, gender, age, polymorphism and liver mass. Drug monitoring is widely practiced especially for cyclosporine, tacrolimus, sirolimus and mycophenolic acid. CYCLOSPORINE: Therapeutic monitoring of immunosuppressive therapy with cyclosporine is a critical requirement because of intra- and inter-patient variability of drug absorption, narrow therapeutic window and drug induced nephrotoxicity. MYCOPHENOLIC ACID MPA: Some reasons for therapeutic drug monitoring of MPA during post-transplant period include: relationship between MPA pharmacokinetic parameters and clinical outcomes, Inter-patient pharmacokinetic variability for MPA despite fixed MMF doses, alternations of MPA pharmacokinetics during the first months after transplantation, drug- drug interaction and influence of kidney function on MPA pharmacokinetic. SIROLIMUS: A recent review of the pharmacokinetics of sirolimus suggested a therapeutic range of 5 to 10 μg l(-1) in whole blood. However, the only consensus guidelines published on the therapeutic monitoring of sirolimus concluded that there was not enough information available about the clinical use of the drug to make recommendations. TACROLIMUS: Sudies have shown, in kidney and liver transplant patients, significant associations of low tacrolimus concentrations with rejection and of high concentrations with nephrotoxicity. Although the feasibility of a limited sampling scheme to predict AUC has been demonstrated, as yet, trough, or pre-dose, whole blood concentration monitoring is still the method of choice.
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Affiliation(s)
- Niloufar Mohammadpour
- Department of Microbiology, School of Medicine, Islamic Azad University, Mashhad Branch, Mashhad, Iran
- Zakariya Research Centre, Islamic Azad University, Mashhad Branch, Mashhad, Iran
| | - Sepideh Elyasi
- Department of Pharmacodinamy and Toxicology, School of Pharmacy, Mashhad University of Medical Sciences,Mashhad, Iran
| | - Naser Vahdati
- Department of Pharmacodinamy and Toxicology, School of Pharmacy, Mashhad University of Medical Sciences,Mashhad, Iran
| | - Amir Hooshang Mohammadpour
- Department of Pharmacodinamy and Toxicology, School of Pharmacy, Mashhad University of Medical Sciences,Mashhad, Iran
- Pharmaceutical Research Centre, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Jamal Shamsara
- Department of Biotechnology, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
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Al Wakeel J, Shaheen F, Mathew M, Abou Zeinab H, Al Alfi A, Tarif N, Al Mousawi M, Mahmoud T, Alorrayed A, Fagir E, Dham R, Shaker D. Six-Month Clinical Outcome of Cyclosporine Microemulsion Formulation (Sigmasporin Microral) in Stable Renal Transplant Patients Previously Maintained on Sandimmun Neoral. Transplant Proc 2008; 40:2245-51. [DOI: 10.1016/j.transproceed.2008.06.044] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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7
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Tang W, Zhou R, Yang Y, Li YC, Yang YF, Zuo JP. Suppression of (5R)-5-hydroxytriptolide (LLDT-8) on Allograft Rejection in Full MHC-Mismatched Mouse Cardiac Transplantation. Transplantation 2006; 81:927-33. [PMID: 16570019 DOI: 10.1097/01.tp.0000203299.39843.d2] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND (5R)-5-hydroxytriptolide (LLDT-8) is a new compound derived from triptolide, which is the major immunosuppressive fraction of Tripterygium wilfordii Hook. F (TWHF). Studies in vitro and in vivo have demonstrated that LLDT-8 had potent immunosuppressive activities. Here we tested LLDT-8 in major histocompatibility complex (MHC)-mismatched cardiac transplantation and investigated the mechanisms underlying the prevention of transplant rejection. METHODS LLDT-8 was administered orally to recipients in Balb/c to C57BL/6 murine cardiac transplantation model. Allograft survival after transplantation was recorded in recipients. The T cell immunity and cytokine production were observed. Histological analysis was performed. The chemokine and its receptor were analyzed by reverse transcriptase-polymerase chain reaction on cardiac graft RNA. RESULTS LLDT-8 administered orally significantly induced the survival prolongation of allogeneic cardiac graft. Histological results showed that LLDT-8 well preserved myocardium and significantly reduced infiltration of the graft with inflammatory cells. LLDT-8 decreased IL-2 production in recipient splenocytes stimulated by concanavalin A (ConA) ex vivo. LLDT-8 significantly inhibited the immunoreactivity of recipient to specific donor alloantigens, but preserved immunity to third-party alloantigens and mitogen. However, the flow cytometry analysis of the proportion of CD4+, CD8+ T cell subgroup in recipient spleens showed LLDT-8 had a normalizing effect on the splenic lymphocytes population. LLDT-8 decreased CC chemokine receptor 5 (CCR5) and their ligands macrophage inflammatory protein 1 alpha (MIP-1alpha) and beta (MIP-1beta) mRNA expressions in allografts. CONCLUSION The results outline the great potential of LLDT-8 as a therapeutic tool in transplant rejection.
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Affiliation(s)
- Wei Tang
- Laboratory of Immunopharmacology, State Key Laboratory of Drug Research, Shanghai Institutes of Materia Medica and Biological Sciences, Graduate School of the Chinese Academy of Sciences, 555 Zuchongzhi Road, Shanghai 201203, P.R. China
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8
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Tokui K, Kimata T, Uchida K, Yuasa H, Hayashi Y, Itatsu T, Nabeshima T. Dose adjustment strategy for oral microemulsion formulation of cyclosporine: population pharmacokinetics-based analysis in kidney transplant patients. Ther Drug Monit 2004; 26:287-94. [PMID: 15167630 DOI: 10.1097/00007691-200406000-00012] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The present study aims to determine the population pharmacokinetic parameters of cyclosporine (CsA) after multiple oral administration of the microemulsion formulation, Neoral, in kidney transplant patients and to propose a limited sampling strategy to predict AUC(0-4h) using them and the Bayesian method. The AUC(0-4h) is a parameter that has recently been recommended as an index for the dose adjustment in therapeutic drug monitoring of CsA. Blood samples were obtained at the trough level and at hourly intervals up to 5 hours from 125 patients (78 male and 47 female) who were receiving Neoral twice daily, and whole-blood concentrations of CsA were measured. The population pharmacokinetic parameters were estimated using the NONMEM computer program and a linear two-compartment model with first-order absorption. The observed AUC0-4h and concentrations at different sampling times were compared with those computer-predicted by the Bayesian method, using the population pharmacokinetic parameters and 2 or 3 concentrations from those at 0 h (C(0)), 1 h (C(1)), and 2 h (C(2)) after administration. Typical values for the absorption rate constant (k(a)), elimination rate constant (k(el)), apparent volume of distribution for the central compartment (Vd/F), and oral clearance (CL/F) calculated by population pharmacokinetic analysis were 2.16 hours(-1), 0.547 hours(-1), 43.3 L, and 23.7 L/h, respectively. The CsA concentrations predicted using either the 2-point or 3-point sampling strategy exhibited an excellent correlation with the observed values (R(2) > 0.81), and accordingly, the predicted AUC(0-4h) values were in excellent agreement with those observed. The best predictability of AUC(0-4h) was found for the 3-point sampling strategy using C(0), C(1), and C(2), closely followed by a 2-point sampling strategy using C(1) and C(2). The present findings suggest that a simplified strategy based on population pharmacokinetics can accurately predict AUC(0-4h) from concentrations at 2 or 3 sampling time points, providing an excellent method for the daily dose adjustment of Neoral in routine clinical use for kidney transplant patients.
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Affiliation(s)
- Kenji Tokui
- Department of Pharmacy, Nagoya Daini Red Cross Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya 466-8650, Japan.
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Seikku P, Hoppu K, Jalanko H, Holmberg C. Predictive value of pretransplantation cyclosporine pharmacokinetic studies on initial post-transplantation dosing in pediatric kidney allograft recipients. Pediatr Transplant 2003; 7:102-10. [PMID: 12654050 DOI: 10.1034/j.1399-3046.2003.00025.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Despite the introduction of a variety of new immunosuppressive agents, cyclosporine A (CsA) has maintained a strong position in pediatric transplantation (Tx). Post-Tx dosing with CsA is a challenging task because of the narrow therapeutic window of the drug, the great individual variability of metabolism and the lack of consensus about the optimal dosage and targeted blood concentration. Sufficient administration of CsA may be protective against acute rejections and other early complications after Tx, which is crucial for the long-term survival of the graft. Individual doses based on pre-Tx pharmacokinetic studies might be helpful in achieving optimal early concentrations of CsA. To asses the usefulness of pharmacokinetic studies, we retrospectively compared the post-Tx doses administered with the individually predicted doses between 1988 and 1998. Multiple regression of data on 65 de novo renal transplant recipients, 1.1-15.5 yr old, was used to analyze the significance of the predicted dose, trough blood concentration of CsA (B-CsA), serum creatinine and age at the time of Tx in explaining the doses used during the first three post-Tx weeks. Patients were grouped according to age (<2, 2-8 and >8 yr), according to the predicted dose (within or outside +/-25% of age-group average), and according to the oral formulation of CsA. Standard dosing scheme was simulated by using age-specific average doses in the place of the individual predicted doses. Administered doses of CsA were high [averaging 22.6 (504), 20.7 (484), and 12.4 mg/kg/d (329 mg/m2/d) for patients <2, 2-8, and >8 yr old] but the average B-CsA remained in the target range of 250-450 microg/L. The predicted dose and age were significant parameters in explaining the administered doses during the first 3 wk after Tx. B-CsA and S-creatinine were non-significant. The predicted doses were used to initiate the dosing of CsA after Tx (R2 = 0.70) and adjustments to dosing were made during the next weeks (R2 = 0.59, 0.52). Multiple regression model showed better fit for 60% of our patients, who had atypical predicted doses (R2 = 0.74, 0.60, 0.64 for first, second and third post-Tx weeks, respectively), most remarkably in patients <2 yr of age, than for the study population as a whole. A simulated standard dose was not able to explain the administered doses of CsA. In conclusion, pre-Tx pharmacokinetic studies are valuable for determining individual post-Tx starting doses, especially for those patients who need high or low doses of CsA. Individual dosing led to relatively high initial CsA doses, which could be significant for the long-term survival of the graft.
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Affiliation(s)
- Paula Seikku
- Hospital for Children and Adolescents, University of Helsinki, Pediatric Nephrology and Transplantation, Helsinki, Finland.
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Leger F, Debord J, Le Meur Y, Rousseau A, Büchler M, Lachâtre G, Paintaud G, Marquet P. Maximum a posteriori Bayesian estimation of oral cyclosporin pharmacokinetics in patients with stable renal transplants. Clin Pharmacokinet 2002; 41:71-80. [PMID: 11825098 DOI: 10.2165/00003088-200241010-00006] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
OBJECTIVE To develop a maximum a posteriori probability (MAP) Bayesian estimator for the pharmacokinetics of oral cyclosporin, based on only three timepoints, and evaluate its performance with respect to a full-profile nonlinear regression approach. PATIENTS 20 adult patients with stable renal transplants given orally administered microemulsified cyclosporin and mycophenolate. METHODS Cyclosporin was assayed by liquid chromatography-mass spectrometry. Nonlinear regression and MAP Bayesian estimation were performed using a home-made program and a previously designed pharmacokinetic model including an S-shaped absorption profile described by a gamma distribution. OUTCOME MEASURES AND RESULTS MAP Bayesian estimation using the best limited sampling strategy (before administration, and 1 and 3 hours after administration) was compared with nonlinear regression (taken as the reference method) for the prediction of the different pharmacokinetic parameters and exposure indices. Median relative prediction error was -0.49 and -3.42% for area under the concentration-time curve over the administration interval of 12 hours (AUC12) and estimated peak drug concentration (Cmax), respectively (nonsignificant). Relative precision was 2.00 and 4.32%, and correlation coefficient (r) was 0.985 and 0.955, for AUC12 and Cmax, respectively. CONCLUSION This paper reports preliminary results in a stable renal transplant patient population, showing that MAP Bayesian estimation can allow accurate prediction of AUC12 and Cmax with only three samples (0, 1 and 3 hours). Although these results require confirmation by further studies in other clinical settings, using other drug combinations, other analytical methods and commercially available pharmacokinetic software, the method seems promising as a tool for the therapeutic drug monitoring of cyclosporin in clinical practice or for exposure-controlled studies.
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Affiliation(s)
- Frédéric Leger
- Service de Pharmacologie et Toxicologie, CHU Dupuytren, Limoges, France.
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de Mattos AM, Olyaei AJ, Bennett WM. Nephrotoxicity of immunosuppressive drugs: long-term consequences and challenges for the future. Am J Kidney Dis 2000; 35:333-46. [PMID: 10676738 DOI: 10.1016/s0272-6386(00)70348-9] [Citation(s) in RCA: 305] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The calcineurin inhibitors cyclosporin A (CsA) and tacrolimus (FK506) are associated with dose- and efficacy-limiting adverse events, including nephrotoxicity, which may diminish their overall benefits for long-term graft survival. Nephrotoxicity is difficult to distinguish from chronic allograft rejection and is a particular problem in the setting of renal transplantation. Minimizing immunosuppressant-induced nephrotoxicity could improve long-term renal allograft survival. However, to obtain significant long-term improvement in renal allograft outcomes, it may be necessary to adopt new immunosuppressive regimens that rely less on calcineurin inhibitors. Recipients of other transplanted organs, as well as patients with autoimmune diseases who require immunosuppressant therapy, could also benefit from this change in immunosuppressive drug strategy because their healthy, native kidneys are particularly susceptible to the nephrotoxic effects of CsA and FK506. CsA- and FK506-sparing regimens, which use reduced doses of CsA and FK506 in combination with other nonnephrotoxic immunosuppressants, may be the best current option for reducing nephrotoxicity. The chemical immunosuppressant mycophenolate mofetil (MMF) has been used as part of CsA- and FK506-sparing regimens that provide improved renal function while maintaining adequate immunosuppression. Such regimens should reduce patient morbidity and mortality. Also, because immunosuppressant-induced nephrotoxicity has been associated with significant financial costs, CsA- and FK506-sparing regimens should result in substantial savings in health care costs.
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Affiliation(s)
- A M de Mattos
- Division of Nephrology, Hypertension, and Clinical Pharmacology, Oregon Health Sciences University, Portland 97201, USA
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12
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Porta B, Pérez-Ruixo JJ, Górriz JL, Crespo JF, Sancho A, Pallardó LM, Jiménez NV. Population pharmacokinetics of cyclosporine in kidney transplant patients. Transplant Proc 1999; 31:2246-7. [PMID: 10500561 DOI: 10.1016/s0041-1345(99)00322-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- B Porta
- Servicio de Farmacia, Hospital Universitario Dr Peset, Valencia, Spain
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13
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Mahalati K, Belitsky P, Sketris I, West K, Panek R. Neoral monitoring by simplified sparse sampling area under the concentration-time curve: its relationship to acute rejection and cyclosporine nephrotoxicity early after kidney transplantation. Transplantation 1999; 68:55-62. [PMID: 10428267 DOI: 10.1097/00007890-199907150-00011] [Citation(s) in RCA: 336] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cyclosporine (CsA) dosing is traditionally based on trough blood levels (C0) rather than area under the concentration-time curve (AUC), although AUC correlates better with posttransplantation clinical events. For Neoral, AUC based on limited sampling correlates closely with full 12-hr AUC. The purpose of our study was to correlate C0 with AUC based on CsA levels at 0, 1, 2, 3, and 4 hr after dose (PK0-4) and to compare this AUC with C0 in predicting acute rejection (AR) and acute cyclosporine nephrotoxicity (CsANT) in de novo first kidney transplant patients. METHODS PK0-4 was done 2-4 days after starting Neoral for 156 patients. All received CsA-based triple-drug immunosuppression without antibody induction. AUC was calculated as projected 12-hr (AUC0-12) and actual 4-hr (AUC0-4) from the PK0-4 using the parallel trapezoid rule. Neoral dosing was based on C0 not AUC. AUC was retrospectively compared with C0 as a predictor of AR and CsANT during the first 90 days. RESULTS C0 correlated poorly with AUC0-12 and AUC0-4 (r=0.61 and r=0.42). C0 (mean+/-SEM) levels were not significantly different in 34 patients with and 109 without AR (293+/-21 vs. 294+/-11 microg/L, P=0.95). AUC0-12 and AUC0-4 were significantly lower in patients with than without AR (AUC0-12 9090+/-598 vs. 10608+/-336 microg x h/L, P=0.01; AUC0-4 3934+/-306 vs. 4802+/-166 microg.h/L, P=0.006). In stepwise regression analysis only AUC0-12 or AUC0-4 (P=0.03/P=0.02) and delayed graft function (P=0.007) predicted AR. AUC0-12, AUC0-4, and C0 were all significantly higher in patients with CsANT than without CsANT (AUC0-12 11746+/-650 vs. 10023+/-301 microg x h/L, P=0.01; AUC0-4 5270+/-358 vs. 4474+/-150 microg x h/L, P=0.01; C0 343+/-18 vs. 287+/-10 microg/L, P=0.01), but in stepwise regression analysis C0 was not an independent predictor of CsANT. Patients with AUC0-12 in the range of 9500 to 11500 microg x h/L or AUC0-4 between 4400 and 5500 microg x h/L had the lowest incidence of AR (13% and 7%, respectively) without significantly higher risk for CsANT. CONCLUSION C0 correlates poorly with AUC based on PK0-4. Early AUC based on PK0-4 is more closely associated with AR and CsANT than is C0. Our data suggest that a target AUC0-12 of 9500-11500 or AUC0-4 of 4400-5500 microg x h/L may provide optimal Neoral immunosuppression.
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Affiliation(s)
- K Mahalati
- Department of Urology, Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
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Johnston A, Holt DW. Therapeutic drug monitoring of immunosuppressant drugs. Br J Clin Pharmacol 1999; 47:339-50. [PMID: 10233195 PMCID: PMC2014241 DOI: 10.1046/j.1365-2125.1999.00911.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/1998] [Accepted: 11/16/1998] [Indexed: 11/20/2022] Open
Affiliation(s)
- A Johnston
- The Analytical Unit, Cardiological Sciences, St George's Hospital Medical School, London SW17 ORE, UK
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15
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Wallemacq PE, Alexandre K. Evaluation of the New AxSYM Cyclosporine Assay: Comparison with TDx Monoclonal Whole Blood and Emit Cyclosporine Assays. Clin Chem 1999. [DOI: 10.1093/clinchem/45.3.432] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Pierre E Wallemacq
- Laboratory of Therapeutic Drug Monitoring, Department of Clinical Chemistry, University Hospital St Luc, University of Louvain, 10 Hippocrate Avenue, B-1200 Brussels, Belgium, and
| | - Kathy Alexandre
- Abbott Diagnostics Division, Rue du Bosquet 2, B-1348 Ottignies/Louvain-la-Neuve, Belgium
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16
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Steimer W. Performance and Specificity of Monoclonal Immunoassays for Cyclosporine Monitoring: How Specific Is Specific? Clin Chem 1999. [DOI: 10.1093/clinchem/45.3.371] [Citation(s) in RCA: 112] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
Background: Immunoassays designed for the selective measurement of cyclosporin A (CsA) inadvertently show cross-reactivity for CsA metabolites. The extent and clinical significance of the resulting overestimation is controversial. A comprehensive assessment of old and new methods in clinical specimens is needed.
Methods: In a comprehensive evaluation, CsA was analyzed in 145 samples with the new CEDIA® assay and compared with the Emit® assay with the old and new pretreatments, the TDx® monoclonal and polyclonal assays, the AxSYM®, and HPLC. All samples were from patients with liver and/or kidney transplants.
Results: The CEDIA offered the easiest handling, followed by the AxSYM, which showed the longest calibration stability. The TDx monoclonal assay provided the lowest detection limit and the lowest CVs. The mean differences compared with HPLC were as follows: Emit, 9–12%; CEDIA, 18%; AxSYM, 29%; and TDx monoclonal, 57%. The CycloTrac® RIA paralleled the Emit results. In contrast to the mean differences, substantial (>200%) and variable overestimations of the CsA concentration were observed in individual patient samples. Metabolic ratios, estimates of the overall concentrations of several cross-reacting metabolites (nonspecific TDx polyclonal/specific reference method), correlated with the apparent biases of the various monoclonal assays. Metabolic ratios varied up to 10-fold, which translated into biases for individual samples between −7% and +174%. The higher the cross-reactivity of an assay was, the higher was the range of biases observed. The interindividual differences markedly exceeded other factors of influence (organ transplanted, hepatic function).
Conclusion: Because assay bias cannot be predicted in individual samples, substantially erratic CsA dosing can result. The specificity of CsA assays for parent CsA remains a major concern.
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17
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Parke J, Charles BG. NONMEM population pharmacokinetic modeling of orally administered cyclosporine from routine drug monitoring data after heart transplantation. Ther Drug Monit 1998; 20:284-93. [PMID: 9631925 DOI: 10.1097/00007691-199806000-00008] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The population pharmacokinetics of cyclosporine (CsA) in adult recipients of cardiac transplants were determined from sparse, retrospective drug monitoring data accumulated for at least 3 months after surgery. All were receiving oral CsA twice daily, and morning trough levels in whole-blood were measured by high-performance liquid chromatography. Additional data included height, weight, gender, age, ethnicity, hematocrit, total bilirubin, and concurrent drug use. Population modeling was performed using NONMEM on 36 randomly selected patients, assuming a one-compartment model with first-order absorption and elimination. Improved fits were obtained by incorporating the following expression in the model to adjust oral bioavailability as a function of postoperative day (POD): F = 0.2 + 10 x ABS (POD - 7)/([POD + 10] x 60). Interpatient variability (CV%) in clearance (CL) was 20.2%. There was a mean bias of 8.5% at the average CsA concentration of 250 ng/ml when the predictive performance was assessed statistically in a reserved subset of 33 patients who received cardiac transplants. For the entire population (n = 69 patients), the average CsA CL and terminal half-life (T1/2) were, respectively: CL (l/h) = 0.256 x weight (kg); T1/2 = 11.0 hours, or CL (l/h) = 0.184 x weight (kg); T1/2 = 14.7 hours, if there was concomitant diltiazem administration. These results compared favorably with those reported elsewhere for studies of postcardiac transplant kinetics using the traditional multiple blood sampling approach.
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Affiliation(s)
- J Parke
- Pharmacy Department, The Prince Charles Hospital, Brisbane, Queensland, Australia
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18
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Primmett DR, Levine M, Kovarik JM, Mueller EA, Keown PA. Cyclosporine monitoring in patients with renal transplants: two- or three-point methods that estimate area under the curve are superior to trough levels in predicting drug exposure. Ther Drug Monit 1998; 20:276-83. [PMID: 9631924 DOI: 10.1097/00007691-199806000-00007] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The recent introduction of a cyclosporine microemulsion demonstrating less pharmacokinetic variability than the conventional formulation offers the potential for accurately and precisely predicting area under the curve (AUC) with a limited-sampling monitoring strategy. This was studied based on the pharmacokinetic profiles from 55 stable patients with renal transplants who were observed on two occasions at steady state on both formulations. Multiple linear regression analyses were performed on a training dataset from 27 patients, in which combinations of cyclosporine concentrations drawn from 0 to 4 hours postdose were regressed against the full AUC over the dosing interval. Predictor regression equations used concentration combinations ranging from one-point (concentrations at 0, 1, 2, 3, or 4 hours) through five-points (all five concentrations 0 to 4 hours). The predictive performance of these equations was then assessed in the training group with data from a subsequent profiling occasion and in the remaining 28 patients who constituted an independent test group. Prediction bias (mean prediction error) and prediction precision (absolute prediction error) were quantified and compared between formulations. Correlations between predicted and actual AUC were consistently stronger for the microemulsion, suggesting the possibility of more accurate and precise predictions of exposure than from the conventional formulation. For both formulations, the one-point predictors rendered the lowest prediction precision, and predictive performance improved considerably when multiple-point predictors were used. Significantly higher precision and lower variability were observed with the microemulsion for most predictors in the both training and test groups. For the microemulsion, two-point (C0 + C1 or C0 + C2) and three-point (C0 + C1 + C2) predictors yielded relatively unbiased and precise exposure predictions, inasmuch as mean absolute prediction error was less than 10% and 5%, respectively. Hence, a two- or three-point method may provide a clinically important improvement over the use of trough levels in monitoring cyclosporine therapy in patients with renal transplants.
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Affiliation(s)
- D R Primmett
- Faculty of Pharmaceutical Sciences, University of British Columbia, British Columbia Children's & Women's Hospitals, Vancouver, Canada
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19
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Barbari A, Stephan A, Kamel G, Kilany H, Masri MA. Experience with new cyclosporine formulations: Consupren and Neoral in renal transplant patients. Transplant Proc 1997; 29:2941-4. [PMID: 9365622 DOI: 10.1016/s0041-1345(97)00738-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- A Barbari
- Transplant Unit, Rizk Hospital, Beirut, Lebanon
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20
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Krmar RT, Wühl E, Ding R, Aulmann M, Schärer K. Pharmacokinetics of a new microemulsion formulation of cyclosporin A (Neoral) in young patients after renal transplantation. Transpl Int 1996; 9:476-80. [PMID: 8875790 DOI: 10.1007/bf00336825] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Pharmacokinetics of the new galenic formulation of cyclosporin A, Neoral, (Sandoz) was examined in 12 stable young patients after renal transplantation. Six of these patients were tested before and 4 weeks after switching from the standard formulation Sandimmun to Neoral. No significant changes were observed in trough levels, Lmax, Cmax, and AUC0-12 h, but the absorption rate constant (Ka) increased (P = 0.03). Glomerular filtration rate, as assessed by inulin clearance, increased by more than 10% in three patients and decreased in two, and was usually associated with a respective drop and rise in Cmax and AUC0-12 h of cyclosporin A. The large interindividual variability in the response to the conversion to the new formulation points to a need for close monitoring of cyclosporin A trough levels and renal function after switching from Sandimmun to Neoral in this age group in order to avoid nephrotoxicity.
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Affiliation(s)
- R T Krmar
- Division of Pediatric Nephrology, University of Heidelberg, Germany
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21
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Krmar RT, Wiihl E, Ding R, Aulmann M, Scharer K. Pharmacokinetics of a new microemulsion formulation of cyclosporin A (Neoral) in young patients after renal transplantation. Transpl Int 1996. [DOI: 10.1111/j.1432-2277.1996.tb00991.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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22
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Tsunoda SM, Aweeka FT. The use of therapeutic drug monitoring to optimise immunosuppressive therapy. Clin Pharmacokinet 1996; 30:107-40. [PMID: 8906895 DOI: 10.2165/00003088-199630020-00003] [Citation(s) in RCA: 51] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Most experience of the therapeutic drug monitoring of immunosuppressive agents has been acquired in the field of solid organ transplantation; however, agents such as cyclosporin (cyclosporin A) are being increasingly utilised for the management of autoimmune diseases. Cyclosporin is the most widely studied immunosuppressant, but in spite of this many controversies still exist as to the optimum strategy for monitoring this drug. Owing to its widely variable pharmacokinetics and metabolism, and the absence of a simple method to measure therapeutic effectiveness, many factors should be considered. In most circumstances, measuring whole blood through concentrations of cyclosporin with a specific assay methodology is warranted. In addition, knowledge of other factors that may alter the pharmacokinetics (such as liver function, concomitant food or medications, gastrointestinal status, and time since transplantation) should be taken into account so that therapy can be appropriately adjusted. Other methods of monitoring have been investigated, such as AUC (area under the concentration-time curve) monitoring and immunological monitoring. However, further refinement of these techniques and greater experience with their efficacy must be accumulated before their role in the monitoring of cyclosporin can be defined. Tacrolimus, like cyclosporin, shares many of the difficulties in monitoring for efficacy and toxicity due largely to the variable pharmacokinetics; similarly to cyclosporin, whole blood through concentration monitoring should be utilised in combination with knowledge of the factors that may affect the pharmacokinetics. Muromonab CD3 (OKT3) is a monoclonal antibody used for the treatment and prophylaxis of acute allograft rejection. Several immunological monitoring techniques have been investigated for this agent. Monitoring CD3+ levels can assist clinicians in determining therapeutic efficacy, while measuring antimuromonab CD3 antibody titres can help determine if xenosensitisation has occurred, causing therapeutic ineffectiveness. The clinical monitoring of azathioprine, one of the first immunosuppressive agents used in transplantation, has historically been limited to monitoring complete blood counts for bone marrow suppression. However, newer techniques measuring intracellular DNA nucleotides appear to be promising. The new immunosuppressants on the horizon include mycophenolate mofetil and rapamycin. The clinical experience with therapeutic drug monitoring of these 2 compounds is scant in the literature; however, both agents have demonstrated efficacy in preventing or treating allograft rejection while maintaining a relatively well tolerated toxicity profile in recent clinical trials. Routine monitoring does not appear to be warranted for immunosuppressive therapy in autoimmune diseases.
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Affiliation(s)
- S M Tsunoda
- Bouve College of Pharmacy and Health Sciences, Northeastern University, Boston, Massachusetts, USA
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23
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Hamashima T, Stepkowski SM, Chou TC, Kahan BD. Synergistic interaction of 3 M KCl-extracted donor antigens (e-HAg) with cyclosporine or cyclosporine/sirolimus for prolongation of rat heart allograft survival. Transpl Immunol 1995; 3:335-41. [PMID: 8665153 DOI: 10.1016/0966-3274(95)80020-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Extracted donor histocompatibility antigens (e-HAg) may potentiate the effects of drugs to protect organ allografts from rejection. We examined the capacity of e-HAg when combined with cyclosporine (CsA) alone, sirolimus (rapamycin, RAPA) alone, or CsA/RAPA combinations to prolong heart allograft survival in rats. Wistar-Furth (WF; RT1u) rats that received CsA (10 mg/kg/day) by oral gavage for 3 (days 0, 1 and 2) or 7 (days 0, 1, 2, 3, 4, 5 and 6) consecutive days displayed modest prolongation of Brown Norway (BN; RT1n) heart allograft survival from a mean survival time of 7.2 +/- 0.8 days in untreated controls to 12.2 +/- 1.1 days and 18.6 +/- 2.7 days, respectively (p < 0.01). Although administration on the day of transplantation (day 0) of a single intravenous (i.v.) dose of BN e-HAg (5 mg/kg) failed to affect allograft survival, both three (days 0, 1 and 2) and five (days 0, 1, 2, 3 and 4) injections significantly potentiated the effect of a 3-day course of oral CsA (18.6 +/- 1.3 days (p < 0.01) and 20.0 +/- 1.4 days (p < 0.01), respectively) and of a 7-day course of oral CsA (25.3 +/- 4.4 days (p < 0.05) and 33.5 +/- 9.3 days (p < 0.01), respectively). Median-effect analysis confirmed a synergistic interaction between CsA (0.5 mg/kg x 7 days, i.v.) and e-HAg with combination index (CI) values less than 0.7 (CI = 1 shows additive interactions, CI < 1 synergistic, and CI > 1 antagonistic, interactions). In contrast, e-HAg failed to affect the immunosuppressive effect of RAPA. However, e-HAg (5.0 mg/kg x 3 days) significantly potentiated the effects of a 7-day or 14-day course of RAPA (0.01 mg/kg)/CsA (0.5 mg/kg) combination therapy, namely from 26.0 +/- 4.8 days with a 7-day treatment of CsA/RAPA alone to 32.6 +/- 3.6 days (p < 0.01) and from 28.2 +/- 2.7 days with a 14-day course of CsA/RAPA alone to 42.0 +/- 4.9 days (p < 0.05), respectively (CI = 0.2-0.5). Thus, e-HAg potentiates the immunosuppressive effects of CsA alone and of the CsA/RAPA combination, but not of sirolimus alone.
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Affiliation(s)
- T Hamashima
- Department of Surgery, University of Texas Medical School at Houston 77030, USA
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24
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Jusko WJ, Piekoszewski W, Klintmalm GB, Shaefer MS, Hebert MF, Piergies AA, Lee CC, Schechter P, Mekki QA. Pharmacokinetics of tacrolimus in liver transplant patients. Clin Pharmacol Ther 1995; 57:281-90. [PMID: 7535213 DOI: 10.1016/0009-9236(95)90153-1] [Citation(s) in RCA: 176] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To characterize the pharmacokinetics of the immunosuppressive agent tacrolimus (FK 506) in liver transplant patients. METHODS Patients (n = 16) were assessed during and after 1- to 3-day intravenous infusions followed by a 2-week course of oral dose therapy. Plasma and whole blood data were fitted simultaneously with equations accounting for nonlinear drug binding by red blood cells to generate clearance (CL) and volume of distribution (V). RESULTS The maximum blood/plasma ratio of tacrolimus was 55.5 +/- 26.8 (SD) and half-life averaged 12.1 +/- 4.7 hours. The CL and V were relatively high based on plasma concentrations (CL, 1.7 L/hr/kg; V, 30 L/kg) and low based on whole blood (CL, 54 ml/hr/kg; V, 0.9 L/kg), with moderate variability (coefficient of variation, 34% to 49%) among the patients. Correlations of plasma CL and V with maximum blood/plasma ratios (ranging from 13 to 114) were strong (r = 0.65 and r = 0.73). Blood binding affects the disposition of tacrolimus, and plasma concentrations are indirectly and inversely related to red cell binding. The oral dose data for tacrolimus yielded a brief absorption lag time (tlag, 0.39 hour), a variable first-order absorption rate constant (ka, 4.5 +/- 3.0 hr-1), and consistent bioavailability (F, 25% +/- 10%). The area under the concentration-time curve versus 12-hour minimum concentration relationships for both whole blood and plasma were nearly linear, confirming the utility of trough values for monitoring drug exposure. CONCLUSION This study provides pharmacokinetic guidelines for the use of tacrolimus in patients undergoing hepatic transplantation. Nonlinear blood binding is a major source of interpatient variation in the disposition of tacrolimus.
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Affiliation(s)
- W J Jusko
- Department of Pharmaceutics, School of Pharmacy, State University of New York at Buffalo 14260, USA
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25
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Holt DW, Johnston A, Roberts NB, Tredger JM, Trull AK. Methodological and clinical aspects of cyclosporin monitoring: report of the Association of Clinical Biochemists task force. Ann Clin Biochem 1994; 31 ( Pt 5):420-46. [PMID: 7832569 DOI: 10.1177/000456329403100503] [Citation(s) in RCA: 52] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- D W Holt
- Analytical Unit, St George's Hospital Medical School, London, UK
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Fujimura A, Shiga T, Ohashi K, Ebihara A. Chronopharmacokinetic study of a new immunosuppressive agent, FK 506, in mice. JAPANESE JOURNAL OF PHARMACOLOGY 1993; 61:137-9. [PMID: 7681489 DOI: 10.1254/jjp.61.137] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Chronopharmacokinetic profiles of a new immunosuppressive agent, FK 506, were examined in mice. FK 506 (1 mg/kg) was given orally at 10 AM (day trial) or 10 PM (night trial) once a day for 7 days. Blood samples for measurement of FK 506 concentration in whole blood were obtained just before and at 1, 2, 3, 4, 6, 8 and 12 hr after the final dosage. The time to maximum concentration was shorter and the maximum concentration was greater in the night trial than in the day trial. These findings suggest that absorption of FK 506 is faster and its blood concentrations is higher in the night trial.
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Affiliation(s)
- A Fujimura
- Department of Clinical Pharmacology, Jichi Medical School, Tochigi, Japan
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Abstract
Cyclosporin is a unique immunosuppressive agent with a narrow therapeutic range. The pharmacokinetics of the drug present substantial within- and between-patient variability and drug interactions can significantly alter blood cyclosporin concentrations. Monitoring of cyclosporin concentrations in blood is an invaluable and essential aid in adjusting dosage to ensure adequate immunosuppression while minimising toxicity. The principal rationale behind therapeutic monitoring of cyclosporin is the fact that the incidence of rejection is higher at low cyclosporin concentrations and toxicity occurs more often at high concentrations. In renal transplant recipients, cyclosporin concentrations help to discriminate between insufficient immunosuppression and cyclosporin-induced nephrotoxicity. There are several methods available, both specific and nonspecific, for the routine measurement of cyclosporin. Radioimmunoassay and fluorescence polarisation immunoassay are most widely employed, while high performance liquid chromatography remains the reference procedure. The allegedly specific immunoassays tend to slightly overestimate the actual blood cyclosporin concentrations. There is a need for assay systems capable of measuring the biological activity of cyclosporin. Cyclosporin concentrations should be determined by a specific method, using whole blood as the sample matrix. The routine monitoring of individual cyclosporin metabolites is not warranted, but characterising the metabolite pattern of cyclosporin by concomitant use of a nonspecific and a specific assay can be clinically useful in patients with cyclosporin-associated toxicity or impaired liver function. In organ transplantation, measurement of blood cyclosporin concentration should be continued periodically as long as the therapy continues, whereas monitoring is only indicated in special circumstances in patients with autoimmune and other nontransplant diseases. The assessment of a 'therapeutic window' for cyclosporin is complicated for several reasons and definite target ranges cannot be given. Cyclosporin concentrations should always be interpreted in conjunction with the recent blood concentration history and other relevant clinical and laboratory data.
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Affiliation(s)
- K T Kivistö
- Department of Pharmacology, University of Turku, Finland
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Abstract
The success of organ transplantation is closely related to clinical use of the immunosuppressive drug cyclosporin (CsA). The dosage of CsA is complicated by the large intra- and interindividual variability in its pharmacokinetics, as well as by the narrow concentration range between insufficient immunosuppression and toxicity. Potential sources of error in the sampling procedure and the advantages and disadvantages of the available analytical methods are discussed. Traditionally, 12 or 24 hour trough concentrations of CsA are monitored. Recently, peak concentrations or estimation of AUCs by a limited sampling strategy have been tried to improve the relatively weak concentration-effect and concentration-toxicity relationships found with trough CsA concentration monitoring. Studies of the CsA concentration-effect relationships for various treatment indications are reviewed.
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Affiliation(s)
- A Lindholm
- Department of Clinical Pharmacology, Karolinska Institute, Huddinge University Hospital, Sweden
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29
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Abstract
This paper reviews the current data which provide a rationale for the measurement of cyclosporin as a guide to therapy. Methodological problems related to sample matrix and analytical technique are considered, and the most commonly used methods considered. Factors which could influence the clinical interpretation of cyclosporin measurements are examined, including other drug therapy, compliance with therapy, cyclosporin metabolites, pharmacokinetic variables and sample timing. It is concluded that, whilst isolated measurements do not offer a definitive diagnostic tool, taken in context they can be of considerable value in optimising therapy.
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Affiliation(s)
- D W Holt
- Analytical Unit, St. George's Hospital Medical School, London, U.K
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30
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Lindholm A. Monitoring of the free concentration of cyclosporine in plasma in man. Eur J Clin Pharmacol 1991; 40:571-5. [PMID: 1884737 DOI: 10.1007/bf00279972] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The free fraction of cyclosporine A (CsA) and its total plasma concentration as determined by HPLC(CsAT) were prospectively monitored in 66 recipients of renal transplants. The free CsA levels (CsAu) were calculated. The variability in free CsA levels was no less than for total CsAT levels. The correlation between CsAu and CsAT was high (r = 0.90). Both CsAT and CsAu covaried with serum triglycerides and apolipoprotein A1. Fourty-four of the 66 patients suffered acute rejection episodes on 69 occasions. CsAT and CSAu both decreased and to a similar extent at the occurrence of acute rejection (42% and 59% decrease, respectively; significant vs baseline. Not significant difference in decrease in CsAT vs CsAu). Acute nephrotoxicity occurred on 11 occasions in 10 patients. Both CsAT and CSAu were approximately twice as high at the time of acute nephrotoxicity as compared to one week previously. Both CsAT and CsAu were higher during the first month after transplantation in patients with than in patients without systemic infection. Thus, plasma CsAu gave no additional clinical information or guidance compared to CsAT in renal transplant recipients. Due to the complexity of its assay, which requires two consecutive analyses, there does not appear to be any need for routine monitoring of CsAu in renal transplant recipients.
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Affiliation(s)
- A Lindholm
- Department of Clinical Pharmacology, Huddinge Hospital, Sweden
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