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Schmucki K, Hofmann P, Fehr T, Inci I, Kohler M, Schuurmans MM. Mammalian Target of Rapamycin Inhibitors and Kidney Function After Thoracic Transplantation: A Systematic Review and Recommendations for Management of Lung Transplant Recipients. Transplantation 2023; 107:53-73. [PMID: 36508646 PMCID: PMC9746343 DOI: 10.1097/tp.0000000000004336] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/18/2022] [Accepted: 07/19/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Chronic kidney disease (CKD) after lung transplantation is common and limits the survival of transplant recipients. The calcineurin inhibitors (CNI), cyclosporine A, and tacrolimus being the cornerstone of immunosuppression are key mediators of nephrotoxicity. The mammalian target of rapamycin (mTOR) inhibitors, sirolimus and everolimus, are increasingly used in combination with reduced CNI dosage after lung transplantation. METHODS This systematic review examined the efficacy and safety of mTOR inhibitors after lung transplantation and explored their effect on kidney function. RESULTS mTOR inhibitors are often introduced to preserve kidney function. Several clinical trials have demonstrated improved kidney function and efficacy of mTOR inhibitors. The potential for kidney function improvement and preservation increases with early initiation of mTOR inhibitors and low target levels for both mTOR inhibitors and CNI. No defined stage of CKD for mTOR inhibitor initiation exists, nor does severe CKD preclude the improvement of kidney function under mTOR inhibitors. Baseline proteinuria may negatively predict the preservation and improvement of kidney function. Discontinuation rates of mTOR inhibitors due to adverse effects increase with higher target levels. CONCLUSIONS More evidence is needed to define the optimal immunosuppressive regimen incorporating mTOR inhibitors after lung transplantation. Not only the indication criteria for the introduction of mTOR inhibitors are needed, but also the best timing, target levels, and possibly discontinuation criteria must be defined more clearly. Current evidence supports the notion of nephroprotective potential under certain conditions.
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Affiliation(s)
- Katja Schmucki
- Division of Pulmonology, University Hospital Zurich, Zurich, Switzerland
- Department of Internal Medicine, Cantonal Hospital Graubünden, Chur, Switzerland
| | - Patrick Hofmann
- Division of Pulmonology, University Hospital Zurich, Zurich, Switzerland
- Department of Internal Medicine, Cantonal Hospital Graubünden, Chur, Switzerland
| | - Thomas Fehr
- Department of Internal Medicine, Cantonal Hospital Graubünden, Chur, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Ilhan Inci
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
- Department of Thoracic Surgery, Zurich University Hospital, Zurich, Switzerland
| | - Malcolm Kohler
- Division of Pulmonology, University Hospital Zurich, Zurich, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Macé M. Schuurmans
- Division of Pulmonology, University Hospital Zurich, Zurich, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
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Abstract
Renal complications are common following heart and/or lung transplantation and lead to increased morbidity and mortality. Renal dysfunction is also associated with increased mortality for patients on the transplant wait list. Dialysis dependence is a relative contraindication for heart or lung transplantation at most centers, and such patients are often listed for a simultaneous kidney transplant. Several factors contribute to the impaired renal function in patients undergoing heart and/or lung transplantation, including the interplay between cardiopulmonary and renal hemodynamics, complex perioperative issues, and exposure to nephrotoxic medications, mainly calcineurin inhibitors.
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Qiu Y, Wang X, Fan J, Rao Z, Lu Y, Lin T. Conversion From Calcineurin Inhibitors to Mammalian Target-of-Rapamycin Inhibitors in Heart Transplant Recipients: A Meta-Analysis of Randomized Controlled Trials. Transplant Proc 2016; 47:2952-6. [PMID: 26707320 DOI: 10.1016/j.transproceed.2015.09.059] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 09/17/2015] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Conversion from calcineurin inhibitors (CNIs) to mammalian target-of-rapamycin inhibitors (mTORi) was systematically evaluated in heart transplant recipients (HTRs) for the first time. METHODS MEDLINE (PUBMED), EMBASE, Cochrane Library, and clinical trial registries were searched comprehensively. After screening for eligibility, the randomized controlled trials (RCTs) comparing continuation of CNI with conversion to mTORi therapy underwent review, quality assessment, and data extraction. Outcomes analyzed including creatinine clearance, serum creatinine level, rejection, adverse effects, and triglyceride levels were expressed as mean differences (MDs) or as risk ratios (RRs) with 95% confidence intervals (CIs). RESULTS This is the first systematic review evaluating converting from CNI to mTORi therapy in HTRs. A total of 4 RCTs (231 HTRs, 117 vs 114) were included in our analysis. Patients converted to mTORi had a higher creatinine clearance (MD, 19.31; 95% CI [11.16, 27.46]; P < .00001) and lower serum creatinine levels (MD, -0.15; 95% CI [-0.25, -0.05]; P = .002). Patients converted to mTORi had a significantly higher occurrence of adverse effects, which included skin diseases, gastrointestinal side effects, bone marrow suppression, and infections. There was no significant difference between the 2 groups regarding graft rejection and triglyceride levels (RR, 2.61; 95% CI [0.08, 81.25]; P = .58; MD, 22.89; 95% CI [-21.86, 67.63]; P = .32). CONCLUSIONS Conversion from CNI to mTORi therapy may improve the renal function in HTRs, but the patients may suffer from a high incidence of mTORi-associated adverse events. Therefore, conversion to mTORi must be carefully assessed for the benefits and risks.
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Affiliation(s)
- Y Qiu
- Department of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - X Wang
- Department of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - J Fan
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Z Rao
- Department of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Y Lu
- Department of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - T Lin
- Department of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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Solé A, Zurbano F, Borro JM, Monforte V, Ussetti P, Santos F. Prevalence and Diagnosis of Chronic Kidney Disease in Maintenance Lung Transplant Patients: ICEBERG Study. Transplant Proc 2016; 47:1966-71. [PMID: 26293082 DOI: 10.1016/j.transproceed.2015.04.097] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Revised: 03/26/2015] [Accepted: 04/15/2015] [Indexed: 01/14/2023]
Abstract
BACKGROUND Chronic renal dysfunction (CRD) after lung transplantation (LT) is a common and noteworthy complication associated with increased morbidity and mortality rates. The study objectives were to determine the prevalence of CRD according to different diagnostic criteria and describe its therapeutic management. METHODS This observational, multicenter, retrospective study included LT patients with ≥ 2 years of evolution. CRD was defined according to 2 different methods: (1) by the physician's subjective clinical criteria and (2) by analytical criteria (estimated glomerular filtration rate [eGFR] by Modification of Diet in Renal Disease of ≤ 59 mL/min). RESULTS We included 113 patients; 65.5% were men and the mean age at transplant was 49.1 (12.6) years. At 6 months after transplant, approximately half of patients had CRD according to analytical criteria, and, at 2 years after transplantation, the prevalence rose to 80%. Although clinical prevalence and analytical prevalence were similar (68.8% and 78.6%), a weak concordance was observed (Kappa index: 0.6). Among patients who were not classified as having CRD according to clinical criteria, 40.0% (14/35) were diagnosed with CRD according to analytical criteria. None of the patients underwent renal biopsy, and 5.1% of patients required dialysis. In 77.0% of patients with clinical CRD diagnosis, the immunosuppressive regimen was modified: reduction of isolated calcineurin inhibitors (CNIs) (35.0%), CNIs decreased with mycophenolic acid change (23.3%), and CNIs lowering with mammalian target of rapamycin introduction (6.7%). In a multivariate logistic regression model, the independent factors associated with CRD were an older recipient age, low body mass index (BMI) at transplant, treatment with cyclosporine/azathioprine, and low eGFR at the first month after transplant. CONCLUSIONS We found a high incidence of CRD at the first year after transplantation, which increased subsequently. Moreover, CRD was considerably underestimated by physicians' subjective clinical criteria. End points related to CRD development were older age, low BMI, azathioprine use, and low eGFR during the first month after transplant. The latter finding provides an opportunity to implement prevention strategies.
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Affiliation(s)
- A Solé
- Unidad de Trasplante Pulmonar, Hospital La Fe, Valencia, Spain.
| | - F Zurbano
- Servicio de Neumología, Unidad de Trasplante Pulmonar, Hospital Marqués de Valdecilla, Santander, Spain
| | - J M Borro
- Servicio de Neumología, Hospital Juan Canalejo, A Coruña, Spain
| | - V Monforte
- Servicio de Neumología, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - P Ussetti
- Servicio de Neumología, Hospital Puerta de Hierro, Madrid, Spain
| | - F Santos
- Servicio de Neumología, Hospital Reina Sofia, Cordoba, Spain
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Söderlund C, Rådegran G. Immunosuppressive therapies after heart transplantation — The balance between under- and over-immunosuppression. Transplant Rev (Orlando) 2015; 29:181-9. [DOI: 10.1016/j.trre.2015.02.005] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Revised: 01/16/2015] [Accepted: 02/22/2015] [Indexed: 01/06/2023]
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Chronic renal insufficiency in heart transplant recipients: risk factors and management options. Drugs 2015; 74:1481-94. [PMID: 25134671 DOI: 10.1007/s40265-014-0274-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Renal dysfunction after heart transplantation is a frequently observed complication, in some cases resulting in significant limitation of quality of life and reduced survival. Since the pathophysiology of renal failure (RF) is multifactorial, the current etiologic paradigm for chronic kidney disease after heart transplantation relies on the concept of calcineurin inhibitor (CNI)-related nephrotoxicity acting on a predisposed recipient. Until recently, the management of RF has been restricted to the minimization of CNI dosage and general avoidance of classic nephrotoxic risk factors, with somewhat limited success. The recent introduction of proliferation signal inhibitors (PSIs) (sirolimus and everolimus), a new class of immunosuppressive drugs lacking intrinsic nephrotoxicity, has provided a completely new alternative in this clinical setting. As clinical experience with these new drugs increases, new renal-sparing strategies are becoming available. PSIs can be used in combination with reduced doses of CNIs and even in complete CNI-free protocols. Different strategies have been devised, including de novo use to avoid acute renal toxicity in high-risk patients immediately after transplantation, or more delayed introduction in those patients developing chronic RF after prolonged CNI exposure. In this review, the main information on the clinical relevance and pathophysiology of RF after heart transplantation, as well as the currently available experience with renal-sparing immunosuppressive regimens, particularly focused on the use of PSIs, is reviewed and summarized, including the key practical points for their appropriate clinical usage.
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Gonzalez-Vilchez F, Vazquez de Prada JA, Paniagua MJ, Gomez-Bueno M, Arizon JM, Almenar L, Roig E, Delgado J, Lambert JL, Perez-Villa F, Sanz-Julve ML, Crespo-Leiro M, Segovia J, Lopez-Granados A, Martinez-Dolz L, Mirabet S, Escribano P, Diaz-Molina B, Farrero M, Blasco T. Use of mTOR inhibitors in chronic heart transplant recipients with renal failure: calcineurin-inhibitors conversion or minimization? Int J Cardiol 2013; 171:15-23. [PMID: 24309084 DOI: 10.1016/j.ijcard.2013.11.036] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Revised: 11/08/2013] [Accepted: 11/17/2013] [Indexed: 01/13/2023]
Abstract
BACKGROUND In the last decade, mTOR inhibitors (mTOR-is) have become the cornerstone of the calcineurin inhibitor (CNI)-reduced/free regimens aimed to the preservation of post-transplant renal function. We compared utility and safety of the total replacement of calcineurin inhibitors with a mTOR-i with a strategy based on calcineurin inhibitor minimization and concomitant use of m-TOR-i. METHODS In a retrospective multi-center cohort of 394 maintenance cardiac recipients with renal failure (GFR<60 mL/min/1.73 m(2)), we compared 235 patients in whom CNI was replaced with a mTOR-i (sirolimus or everolimus) with 159 patients in whom mTOR-is were used to minimize CNIs. A propensity score analysis was carried out to balance between group differences. RESULTS Overall, after a median time of 2 years from mTOR-i initiation, between group differences for the evolution of renal function were not observed. In a multivariate adjusted model, improvement of renal function was limited to patients with mTOR-i usage within 5years after transplantation, particularly with the conversion strategy, and in those patients who could maintain mTOR-i therapy. Significant differences between strategies were not found for mortality, infection and mTOR-i withdrawal due to drug-related adverse events. However, conversion group tended to have a higher acute rejection incidence than the minimization group (p=0.07). CONCLUSION In terms of renal benefits, our results support an earlier use of mTOR-is, irrespective of the strategy. The selection of either a conversion or a CNI minimization protocol should be based on the clinical characteristics of the patients, particularly their rejection risk.
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Affiliation(s)
- F Gonzalez-Vilchez
- Heart Failure and Cardiac Transplantation Unit, Cardiology Service, University Hospital Marques de Valdecilla, Instituto de Formación e Investigación Marqués de Valdecilla (IFIMAV), Santander, Spain.
| | - J A Vazquez de Prada
- Heart Failure and Cardiac Transplantation Unit, Cardiology Service, University Hospital Marques de Valdecilla, Instituto de Formación e Investigación Marqués de Valdecilla (IFIMAV), Santander, Spain
| | - M J Paniagua
- Heart Failure and Cardiac Transplantation Unit, Cardiology Service, University Hospital de La Coruña, La Coruña, Spain
| | - M Gomez-Bueno
- Heart Failure and Cardiac Transplantation Unit, Cardiology Service, University Hospital Puerta de Hierro, Majadahonda, Madrid, Spain
| | - J M Arizon
- Heart Failure and Cardiac Transplantation Unit, Cardiology Service, University Hospital Reina Sofia, Cordoba, Spain
| | - L Almenar
- Heart Failure and Cardiac Transplantation Unit, Cardiology Service, University Hospital La Fe, Valencia, Spain
| | - E Roig
- Heart Failure and Cardiac Transplantation Unit, Cardiology Service, University Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - J Delgado
- Heart Failure and Cardiac Transplantation Unit, Cardiology Service, University Hospital 12 de Octubre, Madrid, Spain
| | - J L Lambert
- Heart Failure and Cardiac Transplantation Unit, Cardiology Service, University Hospital Central de Asturias, Oviedo, Spain
| | - F Perez-Villa
- Heart Failure and Cardiac Transplantation Unit, Cardiology Service, University Hospital Clinic de Barcelona, Barcelona, Spain
| | - M L Sanz-Julve
- Heart Failure and Cardiac Transplantation Unit, Cardiology Service, University Hospital Miguel Servet, Zaragoza, Spain
| | - M Crespo-Leiro
- Heart Failure and Cardiac Transplantation Unit, Cardiology Service, University Hospital de La Coruña, La Coruña, Spain
| | - J Segovia
- Heart Failure and Cardiac Transplantation Unit, Cardiology Service, University Hospital Puerta de Hierro, Majadahonda, Madrid, Spain
| | - A Lopez-Granados
- Heart Failure and Cardiac Transplantation Unit, Cardiology Service, University Hospital Reina Sofia, Cordoba, Spain
| | - L Martinez-Dolz
- Heart Failure and Cardiac Transplantation Unit, Cardiology Service, University Hospital La Fe, Valencia, Spain
| | - S Mirabet
- Heart Failure and Cardiac Transplantation Unit, Cardiology Service, University Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - P Escribano
- Heart Failure and Cardiac Transplantation Unit, Cardiology Service, University Hospital 12 de Octubre, Madrid, Spain
| | - B Diaz-Molina
- Heart Failure and Cardiac Transplantation Unit, Cardiology Service, University Hospital Central de Asturias, Oviedo, Spain
| | - M Farrero
- Heart Failure and Cardiac Transplantation Unit, Cardiology Service, University Hospital Clinic de Barcelona, Barcelona, Spain
| | - T Blasco
- Heart Failure and Cardiac Transplantation Unit, Cardiology Service, University Hospital Miguel Servet, Zaragoza, Spain
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Thibodeau JT, Mishkin JD, Patel PC, Kaiser PA, Ayers CR, Mammen PPA, Markham DW, Ring WS, Peltz M, Drazner MH. Tolerability of sirolimus: a decade of experience at a single cardiac transplant center. Clin Transplant 2013; 27:945-52. [DOI: 10.1111/ctr.12269] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2013] [Indexed: 01/09/2023]
Affiliation(s)
| | - Joseph D. Mishkin
- Department of Internal Medicine; Division of Cardiology; Dallas TX USA
| | - Parag C. Patel
- Department of Internal Medicine; Division of Cardiology; Dallas TX USA
| | | | - Colby R. Ayers
- Department of Internal Medicine; Division of Cardiology; Dallas TX USA
| | | | - David W. Markham
- Department of Internal Medicine; Division of Cardiology; Dallas TX USA
| | - William Steves Ring
- Department of Cardiovascular and Thoracic Surgery; University of Texas Southwestern Medical Center; Dallas TX USA
| | - Matthias Peltz
- Department of Cardiovascular and Thoracic Surgery; University of Texas Southwestern Medical Center; Dallas TX USA
| | - Mark H. Drazner
- Department of Internal Medicine; Division of Cardiology; Dallas TX USA
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Penninga L, Penninga EI, Møller CH, Iversen M, Steinbrüchel DA, Gluud C. Tacrolimus versus cyclosporin as primary immunosuppression for lung transplant recipients. Cochrane Database Syst Rev 2013:CD008817. [PMID: 23728681 DOI: 10.1002/14651858.cd008817.pub2] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Lung transplantation is a well-accepted treatment for people with most end-stage lung diseases. Although both tacrolimus and cyclosporin are used as primary immunosuppressive agents in lung transplant recipients, it is unclear which of these drugs is better in reducing rejection and death without causing adverse effects. OBJECTIVES To assess the benefits and harms of tacrolimus versus cyclosporin for primary immunosuppression in lung transplant recipients. SEARCH METHODS We searched the Cochrane Renal Group's Specialised Register to 10 April 2013 through contact with the Trials Search Co-ordinator using search terms relevant to this review. We also searched Science Citation Index Expanded and the Transplant Library to 20 April 2013. SELECTION CRITERIA We included all randomised controlled trials (RCT) that compared any dose and duration of administration of tacrolimus versus cyclosporin as primary immunosuppressive treatment in lung transplant recipients. Our selection criteria required that all included patients received the same additional immunosuppressive therapy within each study. DATA COLLECTION AND ANALYSIS Three authors extracted data. For dichotomous data we used risk ratio (RR) and used mean difference (MD) for continuous data, each with 95% confidence intervals (CI). Methodological components of the included studies were used to assess risk of systematic errors (bias). Trial sequential analysis was used to assess risk of random errors (play of chance). MAIN RESULTS We included three studies that enrolled a total of 413 adult patients that compared tacrolimus with microemulsion or oral solution cyclosporin. All studies were found to be at high risk of bias. Tacrolimus seemed to be significantly superior to cyclosporin regarding the incidence of bronchiolitis obliterans syndrome (RR 0.46, 95% CI 0.29 to 0.74), lymphocytic bronchitis score (MD -0.60, 95% CI -1.04 to -0.16), treatment withdrawal (RR 0.27, 95% CI 0.16 to 0.46), and arterial hypertension (RR 0.67, 95% CI 0.50 to 0.89). However, the finding for arterial hypertension was not confirmed when analysed using a random-effects model (RR 0.54, 95% CI 0.17 to 1.73). Furthermore, trial sequential analysis found that none of the meta-analyses reached the required information sizes and cumulative Z-curves did not cross trial sequential monitoring boundaries. Diabetes mellitus occurred more frequently among people in the tacrolimus group compared with the cyclosporin group when the fixed-effect model was applied (RR 4.24, 95% CI 1.58 to 11.40), but no difference was found when the random-effects model was used for analysis (RR 4.43, 95% CI 0.75 to 26.05). Again, trial sequential analysis found that the required information threshold was not reached and cumulative Z-curve did not cross the trial sequential monitoring boundary. No significant difference between treatment groups was observed regarding mortality (RR 1.06, 95% CI 0.75 to 1.49), incidence of acute rejection (RR 0.89, 95% CI 0.77 to 1.03), numbers of infections/100 patient-days (MD -0.15, 95% CI -0.30 to 0.00), cancer (RR 0.21, 95% CI 0.04 to 1.16), kidney dysfunction (RR 1.41, 95% CI 0.93 to 2.14), kidney failure (RR 1.57, 95% CI 0.28 to 8.94), neurotoxicity (RR 7.06, 95% CI 0.37 to 135.19), and hyperlipidaemia (RR 0.60, 95% CI 0.30 to 1.20). Trial sequential analysis showed the required information thresholds were not reached for any of these outcome measures. AUTHORS' CONCLUSIONS Tacrolimus may be superior to cyclosporin regarding bronchiolitis obliterans syndrome, lymphocytic bronchitis, treatment withdrawal, and arterial hypertension, but may be inferior regarding development of diabetes. No difference in mortality and acute rejection was observed between patients treated with tacrolimus and cyclosporin. There were few studies comparing tacrolimus and cyclosporin after lung transplantation, and the numbers of patients and events in the included studies were limited. Furthermore, the included studies were deemed to be at high risk of bias. Hence, more RCTs are needed to assess the results of the present review. Such studies ought to be conducted with low risks of systematic errors (bias) and of random errors (play of chance).
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Affiliation(s)
- Luit Penninga
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital,Copenhagen, Denmark. .
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Neuringer IP, Noone P, Cicale RK, Davis K, Aris RM. Managing complications following lung transplantation. Expert Rev Respir Med 2012; 3:403-23. [PMID: 20477331 DOI: 10.1586/ers.09.27] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Lung transplantation has become a proven therapeutic option for patients with end-stage lung disease, extending life and providing improved quality of life to those who otherwise would continue to be breathless and oxygen-dependent. Over the past 20 years, considerable experience has been gained in understanding the multitude of medical and surgical issues that impact upon patient survival. Today, clinicians have an armamentarium of tools to manage diverse problems such as primary graft dysfunction, acute and chronic allograft rejection, airway anastomotic issues, infectious complications, renal dysfunction, diabetes and osteoporosis, hematological and gastrointestinal problems, malignancy, and other unique issues that confront immunosuppressed solid organ transplant recipients.
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Affiliation(s)
- Isabel P Neuringer
- Division of Pulmonary and Critical Care Medicine and the Cystic Fibrosis/Pulmonary Research and Treatment Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7524, USA.
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Thibodeau JT, Mishkin JD, Patel PC, Kaiser PA, Ayers CR, Mammen PPA, Markham DW, Ring WS, Peltz M, Drazner MH. Sirolimus use and incidence of venous thromboembolism in cardiac transplant recipients. Clin Transplant 2012; 26:953-9. [DOI: 10.1111/j.1399-0012.2012.01677.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2012] [Indexed: 01/01/2023]
Affiliation(s)
- Jennifer T. Thibodeau
- Division of Cardiology; Department of Internal Medicine; University of Texas Southwestern Medical Center; Dallas; TX; USA
| | - Joseph D. Mishkin
- Division of Cardiology; Department of Internal Medicine; University of Texas Southwestern Medical Center; Dallas; TX; USA
| | - Parag C. Patel
- Division of Cardiology; Department of Internal Medicine; University of Texas Southwestern Medical Center; Dallas; TX; USA
| | - Patricia A. Kaiser
- Division of Cardiology; Department of Internal Medicine; University of Texas Southwestern Medical Center; Dallas; TX; USA
| | - Colby R. Ayers
- Department of Clinical Sciences; University of Texas Southwestern Medical Center; Dallas; TX; USA
| | - Pradeep P. A. Mammen
- Division of Cardiology; Department of Internal Medicine; University of Texas Southwestern Medical Center; Dallas; TX; USA
| | - David W. Markham
- Division of Cardiology; Department of Internal Medicine; University of Texas Southwestern Medical Center; Dallas; TX; USA
| | - W. Steves Ring
- Department of Cardiovascular and Thoracic Surgery; University of Texas Southwestern Medical Center; Dallas; TX; USA
| | - Matthias Peltz
- Department of Cardiovascular and Thoracic Surgery; University of Texas Southwestern Medical Center; Dallas; TX; USA
| | - Mark H. Drazner
- Division of Cardiology; Department of Internal Medicine; University of Texas Southwestern Medical Center; Dallas; TX; USA
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12
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Incidence of impaired renal function after lung transplantation. J Heart Lung Transplant 2012; 31:238-43. [DOI: 10.1016/j.healun.2011.08.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2011] [Revised: 07/29/2011] [Accepted: 08/27/2011] [Indexed: 12/22/2022] Open
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Potena L, Prestinenzi P, Bianchi IG, Masetti M, Romani P, Magnani G, Fallani F, Coccolo F, Russo A, Ponticelli C, Rapezzi C, Grigioni F, Branzi A. Cyclosporine lowering with everolimus versus mycophenolate mofetil in heart transplant recipients: long-term follow-up of the SHIRAKISS randomized, prospective study. J Heart Lung Transplant 2012; 31:565-70. [PMID: 22341702 DOI: 10.1016/j.healun.2012.01.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2011] [Revised: 11/22/2011] [Accepted: 01/04/2012] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Cyclosporine nephrotoxicity negatively impacts long-term outcome after heart transplantation (HT). We previously reported 1-year results from a randomized study showing that cyclosporine-lowering strategies based on everolimus or mycophenolate mofetil (MMF) are equally effective for reducing progression of renal dysfunction. It is unknown whether this efficacy could be maintained over the long term. METHODS Thirty-four recipients 1 to 4 years after HT and with 25 to 60 ml/min of creatinine clearance (CrCl) were randomized to everolimus with a very low dose (C(0): 50 to 90 ng/ml, n = 17) or MMF with low dose of cyclosporine (C(0): 100 to 150 ng/ml, n = 17). Follow-up was prolonged up to 3 years, and calculated CrCl was the main efficacy measure. RESULTS Cyclosporine was maintained at 70% and 30% lower than baseline in the everolimus and MMF arms, respectively, throughout the 3-year study period. CrCl remained stable in the everolimus patients (+7% from baseline; p = 0.7), but improved in the MMF patients (+20% from baseline; p < 0.01), with a trend toward improved values compared with everolimus patients (46 ± 12 vs 56 ± 15 ml/min; p = 0.06). Subgroup analysis revealed that baseline proteinuria markedly influenced the renal function response to everolimus: whereas in patients with baseline proteinuria CrCl significantly worsened (-20%; p = 0.04), it improved in those without (+15%; p = 0.03). Safety was comparable between the two study arms. CONCLUSIONS Cyclosporine nephrotoxicity improved after a prolonged dose reduction in patients receiving MMF. The everolimus-based strategy provided a similar benefit only to patients without baseline proteinuria. While raising caution against the universal use of everolimus for kidney protection, our long-term results support the need for customized approaches in the management of drug toxicities in maintenance HT recipients.
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Affiliation(s)
- Luciano Potena
- Cardiovascular Department, University of Bologna, Academic Hospital S. Orsola-Malpighi, via Massarenti 9, Bologna, Italy.
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Sofroniadou S, Goldsmith D. Mammalian target of rapamycin (mTOR) inhibitors: potential uses and a review of haematological adverse effects. Drug Saf 2011; 34:97-115. [PMID: 21247219 DOI: 10.2165/11585040-000000000-00000] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Mammalian target of rapamycin (mTOR) inhibitors (mTORis) constitute a relatively new category of immunosuppressive and antineoplastic drugs. These share a unique mechanism of action that is focused on the inhibition of the mTOR. Their clinical applications have recently expanded significantly to cover a wide spectrum of immune and non-immune-mediated disorders, including, apart from solid organ transplantation, various solid organ and haematological malignancies, rheumatological and auto-immune diseases such as rheumatoid arthritis, systemic lupus erythematosus, fibrotic conditions, e.g. pulmonary and hepatic fibrosis, and even metabolic problems such as diabetes mellitus and obesity. The most challenging and frequent adverse effects of the mTORis are the haematological ones, especially anaemia, leukopenia and thrombocytopenia. A unique characteristic of mTORi-induced anaemia is concurrent marked microcytosis. Recently, mechanisms have been proposed to explain the microcytic appearance of this anaemia; these include globin production defect, erythropoietin resistance, chronic inflammation, dysregulation of cellular iron metabolism and hepcidin-mediated iron homeostasis interference. As the differential diagnosis of microcytic anaemia includes pure iron deficiency, functional iron deficiency and haemoglobinopathies, characterization of the anaemia requires significant investigation, time and costs. Therefore, understanding of the likely interaction between mTORis and patients is valuable in clinical practice. Moreover, this could expand the drugs' therapeutic applications to other disorders, and suggest novel targets for further research.
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Affiliation(s)
- Sofia Sofroniadou
- Department of Renal Medicine and Transplantation, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre (AHSC), London, UK
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15
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Sofroniadou S, Goldsmith D. Mammalian target of rapamycin (mTOR) inhibitors: potential uses and a review of haematological adverse effects. Drug Saf 2011. [PMID: 21247219 DOI: 10.2165/11585040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Mammalian target of rapamycin (mTOR) inhibitors (mTORis) constitute a relatively new category of immunosuppressive and antineoplastic drugs. These share a unique mechanism of action that is focused on the inhibition of the mTOR. Their clinical applications have recently expanded significantly to cover a wide spectrum of immune and non-immune-mediated disorders, including, apart from solid organ transplantation, various solid organ and haematological malignancies, rheumatological and auto-immune diseases such as rheumatoid arthritis, systemic lupus erythematosus, fibrotic conditions, e.g. pulmonary and hepatic fibrosis, and even metabolic problems such as diabetes mellitus and obesity. The most challenging and frequent adverse effects of the mTORis are the haematological ones, especially anaemia, leukopenia and thrombocytopenia. A unique characteristic of mTORi-induced anaemia is concurrent marked microcytosis. Recently, mechanisms have been proposed to explain the microcytic appearance of this anaemia; these include globin production defect, erythropoietin resistance, chronic inflammation, dysregulation of cellular iron metabolism and hepcidin-mediated iron homeostasis interference. As the differential diagnosis of microcytic anaemia includes pure iron deficiency, functional iron deficiency and haemoglobinopathies, characterization of the anaemia requires significant investigation, time and costs. Therefore, understanding of the likely interaction between mTORis and patients is valuable in clinical practice. Moreover, this could expand the drugs' therapeutic applications to other disorders, and suggest novel targets for further research.
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Affiliation(s)
- Sofia Sofroniadou
- Department of Renal Medicine and Transplantation, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre (AHSC), London, UK
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16
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Predictors of long-term renal function after conversion to proliferation signal inhibitors in long-term heart transplant recipients. J Heart Lung Transplant 2011; 30:552-7. [DOI: 10.1016/j.healun.2010.11.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2010] [Revised: 10/04/2010] [Accepted: 11/10/2010] [Indexed: 01/09/2023] Open
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17
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Penninga L, Penninga EI, Møller CH, Steinbrüchel DA, Gluud C. Tacrolimus versus cyclosporin as primary immunosuppression for lung transplant recipients. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2010. [DOI: 10.1002/14651858.cd008817] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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18
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Siemionow M, Klimczak A. Advances in the development of experimental composite tissue transplantation models. Transpl Int 2010; 23:2-13. [DOI: 10.1111/j.1432-2277.2009.00948.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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