Contribution of cyclosporin metabolites to immunosuppression in liver-transplanted patients with severe graft dysfunction

Cyclosporin A elicits dose-dependent biphasic effects on osteoblast differentiation and bone formation

Cyclosporin A (CsA) is thought to prevent immune reactions after organ transplantation by inhibiting calcineurin (Cn) and its substrate, the Nuclear Factor of Activated T Cells (NFAT). A dichotomy exists in describing the effects of CsA on bone formation. The concept that the suppression of Cn/NFAT signaling by CsA inhibits bone formation is not entirely supported by many clinical reports and laboratory animal studies. Gender, dosage and basal inflammatory activity have all been suggested as explanations for these seemingly contradictory reports. Here we examine the effects of varying concentrations of CsA on bone formation and osteoblast differentiation and elucidate the role of NFATc1 in this response. We show that low concentrations of CsA (<1 microM in vitro and 35.5 nM in vivo) are anabolic as they increase bone formation, osteoblast differentiation, and bone mass, while high concentrations (>1 microM in vitro and in vivo) elicit an opposite and catabolic response. The overexpression of constitutively active NFATc1 inhibits osteoblast differentiation, and treatment with low concentrations of CsA does not ameliorate this inhibition. Treating osteoblasts with low concentrations of CsA (<1 microM) increases fra-2 gene expression and protein levels in a dose-dependent manner as well as AP-1 DNA-binding activity. Finally, NFATc1 silencing with siRNA increases Fra-2 expression, whereas NFATc1 overexpression inhibits Fra-2 expression. Therefore, NFATc1 negatively regulates osteoblast differentiation, and its specific inhibition may represent a viable anabolic therapy for osteoporosis.

The synergistic immunosuppressive potential of cyclosporin metabolite combinations

Out of the 29 cyclosporin (CS) metabolites defined so far seven representatives were isolated from the bile of liver grafted patients, purified by HPLC and characterized by FAB-MS and/or 1H-NMR. These were used to determine the growth inhibitory effects on concanavalin A stimulated rat lymphocytes (LN). Metabolites diluted in culture medium at concentrations re-checked by HPLC at the respective assay time were added and proliferation determined by [3H]-thymidine incorporation after 48 h. A 50% growth inhibition of LN by single metabolites (AM) was achieved at the following concentrations (mg/l): CS: 0.023; primary metabolites AM1: 0.11; AM1c: 0.65; AM9: 1.05; secondary metabolites AM19: 1.02; AM4N9: 1.02; H355: 1.85; AM1A: 4.5. Although all metabolites were immunosuppressive at higher concentrations in vitro on a single metabolite level, only AM1 with 20% of the activity of native CS seemed to play a role in vivo. However, when we tested the antiproliferative effects of double or triple metabolite combinations, we found a strong synergism not only of primary metabolites, but even with combinations including secondary metabolites. The concentration of the participating metabolites necessary to decrease LN growth by 50% was far below the trough levels observed in vivo. Finally, to mimic to some extent the in vivo situation we determined the interaction of native CS with single metabolites or double combinations. In contrast to the clear synergism in the absence of CS the combinations of metabolites with native CS resulted in an additive growth inhibition. These results indicate an immunosuppressive potential of all metabolites tested and a clear synergism of metabolites in the absence of CS. Although up to double metabolite combinations did only additively enhance CS induced immunosuppression, the combination of 29 metabolites occurring in vivo might have significant immunosuppressive effects in situations where CS levels drop below active concentrations.

Practical aspects in the use of cyclosporin in paediatric nephrology

Many factors must be considered for the effective and safe use of cyclosporin A (CsA) in paediatric nephrology. Detailed knowledge of the variable bioavailability, tissue distribution, and metabolism, as well as causes which lead to their alteration are necessary. Factors which affect the activity of the mixed function oxidase system cytochrome P-450 must be considered, i.e. liver dysfunction and many drugs. Precise knowledge of the CsA determination method and the spectrum of metabolites is essential. In children with renal transplants, a body surface area-related dose will better meet the dose requirements than a body weight related-dose. For drug level monitoring whole blood rather than plasma should be used, and the parent drug level should be the main determinant; elevated metabolite levels may be important in suspected nephrotoxicity or liver dysfunction. Pharmacokinetic profiles are necessary to discover absorption problems or increased CsA clearance rates which necessitate shorter dosing intervals. In children with steroid-dependent minimal change nephrotic syndrome, remission without steroids is maintained as long as CsA is given. The appropriate starting dosage is 150 mg/m2 per day; trough level monitoring is mandatory to prevent nephrotoxicity and to confirm adequate immunosuppressive drug levels which should be 80-160 ng/ml (parent drug level). Although the benefit of CsA has been reported in some cases of lupus erythematosus, its use should be restricted to severe cases only until its efficacy and safety has been confirmed in controlled trials.