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Wysoczańska B, Dratwa M, Nieszporek A, Niepiekło-Miniewska W, Kamińska D, Ramuś T, Rasała J, Krajewska M, Bogunia-Kubik K. Analysis of IL-17A, IL-17F, and miR-146a-5p Prior to Transplantation and Their Role in Kidney Transplant Recipients. J Clin Med 2024; 13:2920. [PMID: 38792460 PMCID: PMC11122464 DOI: 10.3390/jcm13102920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 04/29/2024] [Accepted: 05/14/2024] [Indexed: 05/26/2024] Open
Abstract
Background/Objectives: The balance between regulatory and Th17 cells plays an important role in maintaining the immune tolerance after kidney transplantation (KTx) which is essential for transplantation success, defined as a long graft survival and an absence of organ rejection. The present study aimed to assess whether the pretransplant characteristics of IL-17A and IL-17F, their receptors, as well as miR-146a-5p, an miRNA associated with IL-17A/F regulation, can predict KTx outcomes. Methods: A group of 108 pre-KTx dialysis patients and 125 healthy controls were investigated for single nucleotide substitutions within genes coding for IL-17A, IL-17F, their IL-17RA/RC receptors, and miR-146a-5p. Genotyping was performed using LightSNiP assays. In addition, IL17-A/F serum concentrations were determined using ELISA while miR-146a-5p expression was analyzed by RT-PCR. Results: The IL-17F (rs763780) G allele prevailed in KTx recipients as compared to healthy individuals (OR = 23.59, p < 0.0001) and was associated with a higher IL-17F serum level (p = 0.0381) prior to transplantation. Higher miR-146a-5p expression before KTx was more frequently detected in recipients with an increased IL-17A serum concentration (p = 0.0177). Moreover, IL-17A (rs2275913) GG homozygosity was found to be associated with an increased incidence of deaths before KTx (OR = 4.17, p = 0.0307). T-cell or acute rejection episodes were more frequently observed among patients with the C allele of miR-146a-5p (rs2910164) (OR = 5.38, p = 0.0531). IL17-RA/-RC genetic variants (p < 0.05) seem to be associated with eGFR values. Conclusions: These results imply that IL-17F (rs763780) polymorphism is associated with the serum level of this cytokine and may be related to the risk of renal disease and transplant rejection together with miR-146a-5p (rs2910164), while the IL-17A (rs2275913) genotype may affect patients' survival before KTx.
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Affiliation(s)
- Barbara Wysoczańska
- Laboratory of Clinical Immunogenetics and Pharmacogenetics, Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, 53-114 Wroclaw, Poland; (M.D.); (K.B.-K.)
| | - Marta Dratwa
- Laboratory of Clinical Immunogenetics and Pharmacogenetics, Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, 53-114 Wroclaw, Poland; (M.D.); (K.B.-K.)
| | - Artur Nieszporek
- Laboratory of Clinical Immunogenetics and Pharmacogenetics, Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, 53-114 Wroclaw, Poland; (M.D.); (K.B.-K.)
- Biobank Research Group, Lukasiewicz Research Network—PORT Polish Center for Technology Development, 54-066 Wroclaw, Poland
| | - Wanda Niepiekło-Miniewska
- Laboratory of Tissue Immunology, Medical Center, Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, 53-114 Wroclaw, Poland;
| | - Dorota Kamińska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, 50-367 Wroclaw, Poland; (D.K.); (M.K.)
| | - Tomasz Ramuś
- Faculty of Medicine, Wroclaw Medical University, 50-367 Wroclaw, Poland;
| | | | - Magdalena Krajewska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, 50-367 Wroclaw, Poland; (D.K.); (M.K.)
| | - Katarzyna Bogunia-Kubik
- Laboratory of Clinical Immunogenetics and Pharmacogenetics, Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, 53-114 Wroclaw, Poland; (M.D.); (K.B.-K.)
- Laboratory of Tissue Immunology, Medical Center, Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, 53-114 Wroclaw, Poland;
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Hernandez-Suarez L, Diez-Martin E, Egiguren-Ortiz J, Fernandez R, Etxebarria A, Astigarraga E, Miguelez C, Ramirez-Garcia A, Barreda-Gómez G. Serological Antibodies against Kidney, Liver, and Spleen Membrane Antigens as Potential Biomarkers in Patients with Immune Disorders. Int J Mol Sci 2024; 25:2025. [PMID: 38396703 PMCID: PMC10888476 DOI: 10.3390/ijms25042025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 01/30/2024] [Accepted: 02/05/2024] [Indexed: 02/25/2024] Open
Abstract
Immune disorders arise from complex genetic and environmental factors, which lead to dysregulation at the cellular and inflammatory levels and cause tissue damage. Recent research highlights the crucial role of reactive antibodies in autoimmune diseases and graft rejection, but their complex determination poses challenges for clinical use. Therefore, our study aimed to ascertain whether the presence of reactive antibodies against membrane antigens in tissues from both animal models and humans could serve as biomarkers in patients with autoimmune disorders. To address this issue, we examined the binding profile of serological antibodies against a diverse panel of cell membranes from the spleen, liver, and kidney tissues of monkeys, rats, and humans. After developing the cell membrane microarrays, human sera were immunologically assayed. The study was first conducted on sera from two groups, healthy subjects and patients with inflammatory and autoimmune disorders, and then optimized for kidney transplant patient sera. A significant increase in antibody reactivity against specific monkey kidney and spleen membranes was observed in the serum of patients with lupus nephritis, while kidney transplant patients showed a significant enhancement against human tissues and human embryonic kidney 293 cells. These results show the potential importance for clinical and basic research purposes of studying the presence of specific IgG against membrane antigens in patients' serum as potential biomarkers of immune disorders. However, it is important to note that these results need to be verified in further studies with a larger sample size to confirm their relevance.
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Affiliation(s)
- Leidi Hernandez-Suarez
- Department of Research and Development, IMG Pharma Biotech S.L., 48170 Zamudio, Spain; (L.H.-S.); (E.D.-M.); (J.E.-O.); (R.F.); (A.E.); (E.A.)
- Department of Immunology, Microbiology and Parasitology, Faculty of Science and Technology, University of the Basque Country (UPV/EHU), 48940 Leioa, Spain;
| | - Eguzkiñe Diez-Martin
- Department of Research and Development, IMG Pharma Biotech S.L., 48170 Zamudio, Spain; (L.H.-S.); (E.D.-M.); (J.E.-O.); (R.F.); (A.E.); (E.A.)
- Department of Immunology, Microbiology and Parasitology, Faculty of Science and Technology, University of the Basque Country (UPV/EHU), 48940 Leioa, Spain;
| | - June Egiguren-Ortiz
- Department of Research and Development, IMG Pharma Biotech S.L., 48170 Zamudio, Spain; (L.H.-S.); (E.D.-M.); (J.E.-O.); (R.F.); (A.E.); (E.A.)
- Department of Pharmacology, Faculty of Medicine and Nursing, University of the Basque Country (UPV/EHU), 48940 Leioa, Spain;
| | - Roberto Fernandez
- Department of Research and Development, IMG Pharma Biotech S.L., 48170 Zamudio, Spain; (L.H.-S.); (E.D.-M.); (J.E.-O.); (R.F.); (A.E.); (E.A.)
| | - Aitor Etxebarria
- Department of Research and Development, IMG Pharma Biotech S.L., 48170 Zamudio, Spain; (L.H.-S.); (E.D.-M.); (J.E.-O.); (R.F.); (A.E.); (E.A.)
| | - Egoitz Astigarraga
- Department of Research and Development, IMG Pharma Biotech S.L., 48170 Zamudio, Spain; (L.H.-S.); (E.D.-M.); (J.E.-O.); (R.F.); (A.E.); (E.A.)
| | - Cristina Miguelez
- Department of Pharmacology, Faculty of Medicine and Nursing, University of the Basque Country (UPV/EHU), 48940 Leioa, Spain;
- Neurodegenerative Diseases Group, BioBizkaia Health Research Institute, 48940 Barakaldo, Spain
| | - Andoni Ramirez-Garcia
- Department of Immunology, Microbiology and Parasitology, Faculty of Science and Technology, University of the Basque Country (UPV/EHU), 48940 Leioa, Spain;
| | - Gabriel Barreda-Gómez
- Department of Research and Development, IMG Pharma Biotech S.L., 48170 Zamudio, Spain; (L.H.-S.); (E.D.-M.); (J.E.-O.); (R.F.); (A.E.); (E.A.)
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Huang DL, He YR, Liu YJ, He HY, Gu ZY, Liu YM, Liu WJ, Luo Z, Ju MJ. The immunomodulation role of Th17 and Treg in renal transplantation. Front Immunol 2023; 14:1113560. [PMID: 36817486 PMCID: PMC9928745 DOI: 10.3389/fimmu.2023.1113560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 01/09/2023] [Indexed: 02/04/2023] Open
Abstract
Kidney transplantation (KT) is an ultimate treatment of end-stage chronic kidney disease, which can meet a lot of complications induced by immune system. With under-controlled immunosuppression, the patient will obtain a good prognosis. Otherwise, allograft disfunction will cause severe organ failure and even immune collapse. Acute or chronic allograft dysfunction after KT is related to Th17, Treg, and Th17/Treg to a certain extent. Elevated Th17 levels may lead to acute rejection or chronic allograft dysfunction. Treg mainly plays a protective role on allografts by regulating immune response. The imbalance of the two may further aggravate the balance of immune response and damage the allograft. Controlling Th17 level, improving Treg function and level, and adjusting Th17/Treg ratio may have positive effects on longer allograft survival and better prognosis of receptors.
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Affiliation(s)
- Dan-Lei Huang
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yi-Ran He
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yu-Jing Liu
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Hong-Yu He
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhun-Yong Gu
- Department of Urinary Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yi-Mei Liu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wen-Jun Liu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhe Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China,*Correspondence: Min-Jie Ju, ; Zhe Luo,
| | - Min-Jie Ju
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China,*Correspondence: Min-Jie Ju, ; Zhe Luo,
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Role of the Immune System in Renal Transplantation, Types of Response, Technical Approaches and Current Challenges. IMMUNO 2022. [DOI: 10.3390/immuno2040035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Advances over the last decades have made renal transplantation an important therapy for patients with end-stage renal disease, as the incidences of acute rejection and short-term transplant loss have been significantly reduced. However, long-term transplant survival remains a challenge in the renal transplantation community. The main causes of long-term graft loss are acute and chronic rejection, as well as the complications related to immunosuppression therapy. In spite of the breakthroughs achieved in recent years, histology is the gold standard technique to confirm the activation of the immune system against the graft with all the ensuing problems that taking biopsies brings to immunosuppressed patients. For this reason, several assays have been developed to try to monitor the immune function, but they show serious constraints owing to the fact that they require substantial laboratory work, they are not clinically available and they provide controversial results, so the combination of multiple assays is often needed to obtain a reliable diagnosis. Thus, the aim of this review is to perform a retrospective study of the immune system in renal transplantation, with special emphasis on the cutting-edge technological developments for monitoring, classification and early detection of rejection episodes in order to contribute to a better adjustment of immunosuppressive therapies and, hence, to a more personalized medicine that improves the quality of life of patients.
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Meszaros M, Dubois V, Congy-Jolivet N, Hamada S, Thevenin C, Faure S, Boillot O, Kamar N, Pageaux GP, Del Bello A, Dumortier J. Impact of calcineurin inhibitor-free immunosuppression on de novo donor-specific antibody formation in liver transplant recipients. Liver Int 2022; 42:1132-1143. [PMID: 35184373 DOI: 10.1111/liv.15201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 12/14/2021] [Accepted: 01/12/2022] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Low calcineurin inhibitor (CNI) levels expose liver transplant recipients to rejection episodes and potentially to antibody-mediated rejection. There are little data on the impact of CNI-free immunosuppression on de novo donor-specific HLA antibody (dnDSA) development. Here we evaluated the prevalence of dnDSA in liver transplant recipients on CNI-free maintenance regimens and their associations with histopathological abnormalities of allografts. METHODS Seven hundred and twenty-seven liver transplant recipients underwent a first liver transplant between 2000 and 2018 in three French transplant centres and had protocolized follow-up with dnDSA screening and allograft biopsy 1, 5 and 10 years after transplantation. RESULTS CNIs were withdrawn in 166 (22.8%) patients with or without conversion to mammalian target of rapamycin inhibitors and/or maintenance with mycophenolic acid. DSA were present after withdrawal in 30.1% (50/166) patients on CNI-free immunosuppression compared with 16% (90/561) on CNI maintenance therapy (p < 0.001). The cumulative incidence of dnDSA 10 years after transplant was 20% in the CNI group versus 28% in the CNI-free group (p < 0.01). dnDSAs were associated with histological graft abnormalities (significant allograft fibrosis or rejection) (HR 2.24, 95% CI 1.2-4.1; p = 0.01). In univariate Cox regression analysis, being on a CNI-free regimen did not impact graft histology. CONCLUSIONS Patients on a CNI-free IS regimen have a higher prevalence of dnDSA than patients on a standard IS regimen. dnDSAs but not CNI-free immunosuppression were associated with abnormal allograft histology.
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Affiliation(s)
- Magdalena Meszaros
- Département d'hépatologie et transplantation hépatique, CHU Saint Eloi, Montpellier, France
| | - Valérie Dubois
- Etablissement Français du Sang, Laboratoire d'Histocompatibilité, Lyon, France
| | | | - Sarah Hamada
- Etablissement Français du Sang, Laboratoire d'Histocompatibilité, Lyon, France
| | - Céline Thevenin
- Département d'Immunologie, CHU Montpellier, Montpellier, France
| | - Stephanie Faure
- Département d'hépatologie et transplantation hépatique, CHU Saint Eloi, Montpellier, France
| | - Olivier Boillot
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Unité de Transplantation hépatique, Lyon, France
| | - Nassim Kamar
- Département de Néphrologie et Transplantation d'Organes, CHU, Toulouse, France
| | | | - Arnaud Del Bello
- Département de Néphrologie et Transplantation d'Organes, CHU, Toulouse, France
| | - Jérôme Dumortier
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Unité de Transplantation hépatique, Lyon, France
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High Dimensional Renal Profiling: Towards a Better Understanding or Renal Transplant Immune Suppression. CURRENT TRANSPLANTATION REPORTS 2019; 6:60-68. [PMID: 31595214 DOI: 10.1007/s40472-019-0225-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE OF REVIEW The goal of this review is to discuss new approaches to avoid CNI/CCS toxicities with a focus on new biologics and new methods to understand transplant rejection at the single-cell level. RECENT FINDINGS Recently developed biologics hold significant promise as the next wave of therapeutics designed to promote CNI/CCS-free long-term allograft acceptance. Indeed, belatacept, soluble CTLA4-Ig, is largely devoid of CNI-like toxicities, although it is accompanied by an increased frequency of acute rejection. Besides belatacept, other biologics hold promise as CNI-free immune suppressive approaches. Finally, powerful new single cell approaches can enable characterization of cellular populations that drive rejection within the rejecting allograft. SUMMARY We propose that the incorporated single cell profiling into studies investigating new biologics in transplantation, could be tailored to each patient, correlated with potential biomarkers in the blood and urine, and provide a platform where therapeutic targets can be rationally defined, mechanistically-based, and exploited.
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Chung BH, Yang CW, Cho ML. Clinical significance of Th17 cells in kidney transplantation. Korean J Intern Med 2018; 33:860-866. [PMID: 29843491 PMCID: PMC6129639 DOI: 10.3904/kjim.2018.095] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 03/13/2018] [Indexed: 12/12/2022] Open
Abstract
Transplantation research has focused on cytotoxic T-cell and plasma cell/B-cell-targeted strategies, but little attention has been paid to the role of T helper 17 (Th17) cells in allograft dysfunction. However, accumulating evidence suggests that Th17 cells contribute to the development of acute and chronic allograft injury after transplantation of various organs, including the kidney. This review summarizes recent reports on the role of Th17 cells in kidney transplantation. Means of improving allograft outcomes by targeting the Th17 pathway are also suggested.
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Affiliation(s)
- Byung Ha Chung
- Convergent Research Consortium for Immunologic Disease, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
- Transplant Research Center, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
- Division of Nephrology, Department of Internal Medicine, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Chul Woo Yang
- Convergent Research Consortium for Immunologic Disease, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
- Transplant Research Center, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
- Division of Nephrology, Department of Internal Medicine, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Mi-La Cho
- Convergent Research Consortium for Immunologic Disease, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
- Correspondence to Mi-La Cho, Ph.D. Department of Internal Medicine, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Korea Tel: +82-2-2258-7467 Fax: +82-2-599-4287 E-mail:
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Tsai MK, Wu FELINLIN, Lai LRUE, Lee CY, Hu RH, Lee POHUANG. Decreased Acute Rejection and Improved Renal Allograft Survival Using Sirolimus and Low-Dose Calcineurin Inhibitors without Induction Therapy. Int J Artif Organs 2018; 32:371-80. [DOI: 10.1177/039139880903200608] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Background Chronic nephrotoxicity of calcineurin inhibitors (CNIs) causes irreversible renal dysfunction and shortens renal transplant survival. We conducted a retrospective cohort study to test a hypothesis that de novo CNI minimization combined with sirolimus (SRL) improves graft survival in renal transplant patients without antibody induction therapy. Methods Between October 2000 and August 2007, we performed 100 cases of renal transplantation with de novo CNI (either cyclosporine or tacrolimus) minimization combined with sirolimus (SRL group). The initial target trough levels were 100–200 ng/ml for cyclosporine (CsA) and 4–8 ng/mL for tacrolimus (TAC). SRL was given at a loading dose of 6 mg plus 2 mg/day for maintenance. The results for the SRL group were compared to those of 104 transplant recipients given standard CNI- (CsA- or TAC-) based immunosuppressive regimens including mycophenolate mofetil (MMF group) during the same period. Results The 1-year rejection-free survival (94.8%) and 5-year graft survival (87.7%) rates of the SRL group were significantly better than those of the MMF group (85.5% and 75.2%, respectively). On univariate analyses, 6-month estimated glomerular filtration rate (eGFR), acute rejection and SRL therapy had a significant impact on graft survival, and SRL therapy and tacrolimus therapy had a significant impact on rejection-free survival. Multivariate analyses identified 6-month eGFR as the only prognostic factor for graft survival. Acute rejection and SRL therapy were significant for post-transplant renal function. Conclusions De novo CNI minimization combined with SRL could decrease acute rejection and improve renal function and graft survival after renal transplantation without the use of antibody induction therapy.
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Affiliation(s)
- Meng-Kun Tsai
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei - Taiwan
| | - FE-LIN LIN Wu
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei - Taiwan
- Department of Pharmacy, National Taiwan University Hospital, Taipei - Taiwan
| | - l-RUE Lai
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei - Taiwan
| | - Chih-Yuan Lee
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei - Taiwan
| | - Rey-Heng Hu
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei - Taiwan
| | - PO-HUANG Lee
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei - Taiwan
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Wen X, Casey MJ, Santos AH, Hartzema A, Womer KL. Comparison of Utilization and Clinical Outcomes for Belatacept- and Tacrolimus-Based Immunosuppression in Renal Transplant Recipients. Am J Transplant 2016; 16:3202-3211. [PMID: 27137884 DOI: 10.1111/ajt.13853] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Revised: 03/27/2016] [Accepted: 04/21/2016] [Indexed: 01/25/2023]
Abstract
The performance of belatacept in a real clinical setting has not been reported. A retrospective cohort study was conducted using registry data comparing 1-year clinical outcomes between belatacept- and tacrolimus-treated adult kidney transplant recipients (KTRs) from January 6, 2011, through January 12, 2014. Of 50 244 total patients, 417 received belatacept plus tacrolimus, 458 received belatacept alone, and 49 369 received tacrolimus alone at discharge. In the overall study cohort, belatacept alone was associated with a higher risk of 1-year acute rejection, with the highest rates associated with non-lymphocyte-depleting induction (adjusted hazard ratio 2.65, 95% confidence interval 1.90-3.70, p < 0.0001). There was no significant difference in rejection rates between belatacept plus tacrolimus and tacrolimus alone. In KTRs who met inclusion criteria for the Belatacept Evaluation of Nephroprotection and Efficacy as First-line Immunosuppression Trial-Extended Criteria Donors (BENEFIT-EXT), 1-year kidney function was higher with belatacept plus tacrolimus and belatacept alone versus tacrolimus alone (mean estimated GFR 65.6, 60.4 and 54.3 mL/min per 1.73 m2 , respectively; p < 0.001). The incidence of new-onset diabetes after transplantation was significantly lower with belatacept plus tacrolimus and belatacept alone versus tacrolimus alone (1.7%, 2.2%, and 3.8%, respectively; p = 0.01). Despite improved graft function and metabolic complications with belatacept alone, it may be advisable to add short-term tacrolimus in the first year after transplant and to consider lymphocyte-depleting induction in patients with high rejection risk, as the risk-benefit ratio allows.
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Affiliation(s)
- X Wen
- Department of Medicine, University of Florida, Gainesville, FL.
| | - M J Casey
- Department of Medicine, University of Florida, Gainesville, FL
| | - A H Santos
- Department of Medicine, University of Florida, Gainesville, FL
| | - A Hartzema
- Department of Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, FL
| | - K L Womer
- Department of Medicine, University of Florida, Gainesville, FL
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Cicora F, Roberti J. Recurrent Psoriasis After Introduction of Belatacept in 2 Kidney Transplant Recipients. Prog Transplant 2016; 26:109-11. [PMID: 27207397 DOI: 10.1177/1526924816640674] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Organ transplant recipients may have skin diseases as a result of immunosuppression, but psoriasis is reported infrequently. This skin condition may be induced by immunosuppression imbalance. We present 2 cases of recurrent psoriasis in 2 kidney transplant patients with belatacept-based immunosuppressive regimens. Two years after transplant, upon suspicion of calcineurin inhibitor neurotoxicity in the first patient, tacrolimus was replaced with belatacept. The patient's neurological signs resolved but the patient presented with skin lesions compatible with psoriatic plaques, successfully treated with betamethasone dipropionate and hydrocortisone. The second patient had a history of obesity and dyslipidemia, left foot amputation, and psoriasis. He received a kidney transplant, and maintenance immunosuppression included prednisone, mycophenolate mofetil, and belatacept. At posttransplant month 15, the patient presented with cutaneous erythematosus, maculopapular, and desquamative lesions compatible with psoriasis, treated with betamethasone dipropionate. The belatacept-based immunosuppressive regimens were maintained and psoriasis resolved. Psoriasis is a potential complication in kidney recipients that may recur when belatacept is used and/or tacrolimus is withdrawn as it could have happened in the first patient. The characteristics of the second case may suggest that belatacept might not have been the inciting agent. Good results were obtained with topical treatment.
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Affiliation(s)
- Federico Cicora
- Foundation for Research and Assistance in Kidney Disease (FINAER), Buenos Aires, Argentina
| | - Javier Roberti
- Foundation for Research and Assistance in Kidney Disease (FINAER), Buenos Aires, Argentina
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Abudou M, Wu T, Evans JR, Chen X. Immunosuppressants for the prophylaxis of corneal graft rejection after penetrating keratoplasty. Cochrane Database Syst Rev 2015; 2015:CD007603. [PMID: 26313245 PMCID: PMC9233756 DOI: 10.1002/14651858.cd007603.pub2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Penetrating keratoplasty is a corneal transplantation procedure in which a full-thickness cornea from the host is replaced by a graft from a donor. The use of various immunosuppressants to prevent graft rejection, the most common cause of graft failure in the late postoperative period, is increasing. OBJECTIVES To assess the effectiveness of immunosuppressants in the prophylaxis of corneal allograft rejection after high- and normal-risk keratoplasty. SEARCH METHODS We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2015, Issue 4), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to May 2015), EMBASE (January 1980 to May 2015), China National Knowledge Infrastructure (CNKI) (January 1913 to February 2015), VIP database (January 1989 to February 2015), Wanfang Data (www.wanfangdata.com) (January 1990 to February 2015), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov), and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the English language databases on 18 May 2015 and the Chinese language databases on 20 February 2015. SELECTION CRITERIA We included all randomised controlled trials (RCTs) assessing the use of immunosuppressants in the prevention of graft rejection, irrespective of publication language. DATA COLLECTION AND ANALYSIS We used standard procedures expected by Cochrane. The primary outcome was clear graft survival at 12 months after penetrating keratoplasty. Secondary outcomes included graft rejection, best-corrected visual acuity, and quality of life. We defined 'high-risk keratoplasty' as repeat keratoplasty and other indications of reduced graft survival. MAIN RESULTS We included six studies conducted in Germany (three studies), Iran, India, and China. Three studies were conducted in people undergoing high-risk keratoplasty and investigated three different comparisons: systemic mycophenolate mofetil (MMF) versus no MMF; systemic MMF versus systemic cyclosporine A (CsA); and topical CsA versus placebo. One study compared topical tacrolimus to topical steroid in people with normal-risk keratoplasty, and two studies compared topical CsA to placebo in people experiencing graft rejection after normal-risk keratoplasty. Overall, we considered the trials to be at unclear or high risk of bias.MMF may not improve clear graft survival (risk ratio (RR) 1.06, 95% confidence interval (CI) 0.84 to 1.33, 1 RCT, 87 participants, low-quality evidence) but may reduce the risk of graft rejection (RR 0.49, 95% CI 0.22 to 1.08, 1 RCT, 87 participants, low-quality evidence) compared to no MMF. Visual acuity was not reported.In 1 study of 52 people comparing systemic MMF and systemic CsA, there were no graft failures in the first year of follow-up. Data from the longest follow-up (three years) suggest that there may be little difference in the effect of these two treatments on clear graft survival (RR 1.10, 95% CI 0.90 to 1.35, low-quality evidence). There was low-quality evidence of an increased risk of graft rejection with systemic MMF compared to systemic CsA, but with wide CIs compatible with increased risk with systemic CsA (RR 1.48, 95% CI 0.56 to 3.93, low-quality evidence). Visual acuity was not reported.One study of 84 people comparing topical CsA to placebo did not report clear graft survival at 1 year, which suggests that all grafts survived to 1 year. This study suggests that the use of topical CsA probably leads to little or no difference in graft rejection (RR 1.00, 95% CI 0.39 to 2.58, moderate-quality evidence). At one year, the mean difference (MD) between the two groups in visual acuity was 0.07 (95% CI -0.01 to 0.15, moderate-quality evidence).Topical CsA probably does not have an effect on clear graft survival in people experiencing graft rejection after normal-risk keratoplasty compared to placebo (RR 1.03, 95% CI 0.96 to 1.10, 2 RCTs, 283 participants, moderate-quality evidence). There were inconsistent findings on graft rejection, with one study reporting a reduced incidence of graft rejection in the CsA group (RR 0.35, 95% CI 0.14 to 0.87, 230 participants) but the other study reporting a higher average number of episodes of graft rejection in people treated with CsA (MD 1.30, 95% CI 0.39 to 2.21, 43 participants). Overall, we judged this to be low-quality evidence due to risk of bias and inconsistency. There was no evidence for a difference in visual acuity between the 2 groups at final follow-up (approximately 18 months, range 2 to 33 months) (MD 0.04, 95% CI -0.10 to 0.18, 1 RCT, 43 participants, low-quality evidence).In 1 study comparing topical tacrolimus to topical steroid, the graft survived in all of the 12 treated participants and 20 control participants at 6 months. Graft rejection was rare (0 out of 12 versus 2 out of 20) (RR 0.32, 95% CI 0.02 to 6.21, low-quality evidence). Visual acuity was not reported.None of the studies reported on quality of life. We identified an unpublished trial of basiliximab (Simulect) (NCT00409656), probably completed in 2005. AUTHORS' CONCLUSIONS Current evidence on the effect of immunosuppressants in the prevention of graft failure and rejection after high- and normal-risk keratoplasty is largely low quality because the number of trials was limited, and, in general, the trials were small and at risk of bias. Future trials should be large enough to detect important clinical effects, conducted with a view to minimising the risk of bias, and they should measure outcomes important to patients.
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Affiliation(s)
- Minawaer Abudou
- Xinjiang Medical UniversityThe Eye Department of the First Affiliated HospitalXinjiangChina
| | - Taixiang Wu
- West China Hospital, Sichuan UniversityChinese Clinical Trial Registry, Chinese Ethics Committee of Registering Clinical TrialsNo. 37, Guo Xue XiangChengduSichuanChina610041
| | - Jennifer R Evans
- London School of Hygiene & Tropical MedicineCochrane Eyes and Vision Group, ICEHKeppel StreetLondonUKWC1E 7HT
| | - Xueyi Chen
- First Affiliated Hospital of Xinjiang Medical UniversityEye DepartmentXinjiangChina
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De Simone P, Precisi A, Petruccelli S, Balzano E, Carrai P, Catalano G, Campani D, Filipponi F. The impact of everolimus on renal function in maintenance liver transplantation. Transplant Proc 2014; 41:1300-2. [PMID: 19460545 DOI: 10.1016/j.transproceed.2009.03.051] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
We retrospectively investigated the impact on renal function (RF) of conversion from calcineurin inhibitors (CNI) to everolimus (EVL) monotherapy in orthotopic liver transplant (OLT) recipients. Between January 2006 and July 2007, 70 deceased donor OLT recipients including 51 men and 19 women of overall mean age of 55.9 +/- 11 years were enrolled into a program of conversion to EVL monotherapy at a mean interval of 45 +/- 35.9 months from transplantation (range, 7-192 months). The indication for conversion was deteriorating RF in 64 (91.4%). Efficacy failure was defined as the persistence of CNI, EVL discontinuation, death, graft loss, loss to follow-up, or need for dialysis at 12 months. Twelve months after switching, 53 patients (75.7%) were on EVL monotherapy. Their mean change in creatinine clearance (CrCl) from baseline (day 1 before EVL introduction) to endpoint (12 months) was 5.8 +/- 13.1 mL/min. On univariate and multivariate analyses, the clinical variable correlated with the greatest probability of improvement was the baseline CrCl (P < .0001). Conversion from CNI to EVL monotherapy was successful in 75.7% of cases with improvement in RF correlated with baseline CrCl. These data supported preemptive minimization of CNI in the posttransplant course, seeking to delay the decline in RF.
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Affiliation(s)
- P De Simone
- Unità Operativa Chirurgia Generale e Trapianti di Fegato, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
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13
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Paz M, Roberti J, Mos F, Cicora F. Conversion to Belatacept-Based Immunosuppression Therapy in Renal Transplant Patients. Transplant Proc 2014; 46:2987-90. [DOI: 10.1016/j.transproceed.2014.07.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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14
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Cicora F, Massari P, Acosta F, Petrone H, Cambariere R, González I, Imperiali N, López F, Otero A, Roberti J. Use of Everolimus in Renal Transplant Recipients: Data From a National Registry. Transplant Proc 2014; 46:2991-5. [DOI: 10.1016/j.transproceed.2014.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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15
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Mathis AS, Egloff G, Ghin HL. Calcineurin inhibitor sparing strategies in renal transplantation, part one: Late sparing strategies. World J Transplant 2014; 4:57-80. [PMID: 25032096 PMCID: PMC4094953 DOI: 10.5500/wjt.v4.i2.57] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2014] [Revised: 03/25/2014] [Accepted: 05/14/2014] [Indexed: 02/05/2023] Open
Abstract
Kidney transplantation improves quality of life and reduces the risk of mortality. A majority of the success of kidney transplantation is attributable to the calcineurin inhibitors (CNIs), cyclosporine and tacrolimus, and their ability to reduce acute rejection rates. However, long-term graft survival rates have not improved over time, and although controversial, evidence does suggest a role of chronic CNI toxicity in this failure to improve outcomes. Consequently, there is interest in reducing or removing CNIs from immunosuppressive regimens in an attempt to improve outcomes. Several strategies exist to spare calcineurin inhibitors, including use of agents such as mycophenolate mofetil (MMF), mycophenolate sodium (MPS), sirolimus, everolimus or belatacept to facilitate late calcineurin inhibitor withdrawal, beyond 6 mo post-transplant; or using these agents to plan early withdrawal within 6 mo; or to avoid the CNIs all together using CNI-free regimens. Although numerous reviews have been written on this topic, practice varies significantly between centers. This review organizes the data based on patient characteristics (i.e., the baseline immunosuppressive regimen) as a means to aid the practicing clinician in caring for their patients, by matching up their situation with the relevant literature. The current review, the first in a series of two, examines the potential of immunosuppressive agents to facilitate late CNI withdrawal beyond 6 mo post-transplant, and has demonstrated that the strongest evidence resides with MMF/MPS. MMF or MPS can be successfully introduced/maintained to facilitate late CNI withdrawal and improve renal function in the setting of graft deterioration, albeit with an increased risk of acute rejection and infection. Additional benefits may include improved blood pressure, lipid profile and serum glucose. Sirolimus has less data directly comparing CNI withdrawal to an active CNI-containing regimen, but modest improvement in short-term renal function is possible, with an increased risk of proteinuria, especially in the setting of baseline renal dysfunction and/or proteinuria. Renal outcomes may be improved when sirolimus is used in combination with MMF. Although data with everolimus is less robust, results appear similar to those observed with sirolimus.
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Croze LE, Tetaz R, Roustit M, Malvezzi P, Janbon B, Jouve T, Pinel N, Masson D, Quesada JL, Bayle F, Zaoui P. Conversion to mammalian target of rapamycin inhibitors increases risk ofde novodonor-specific antibodies. Transpl Int 2014; 27:775-83. [DOI: 10.1111/tri.12330] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 11/24/2013] [Accepted: 03/26/2014] [Indexed: 12/01/2022]
Affiliation(s)
| | - Rachel Tetaz
- Clinique Universitaire de Néphrologie; CHU Grenoble; Grenoble France
| | - Matthieu Roustit
- Centre d'Investigation Clinique; INSERM CIC03; CHU Grenoble; Grenoble France
- INSERM U1042 - HP2; Université Joseph Fourier; Grenoble France
| | - Paolo Malvezzi
- Clinique Universitaire de Néphrologie; CHU Grenoble; Grenoble France
| | - Bénédicte Janbon
- Clinique Universitaire de Néphrologie; CHU Grenoble; Grenoble France
| | - Thomas Jouve
- Clinique Universitaire de Néphrologie; CHU Grenoble; Grenoble France
| | - Nicole Pinel
- Départment d'Anatomo-Pathologie; CHU Grenoble; Grenoble France
| | - Dominique Masson
- Laboratoire d'Immunologie et Histocompatibilité; Etablissement Français du Sang; Grenoble France
| | - Jean-Louis Quesada
- Centre d'Investigation Clinique; INSERM CIC03; CHU Grenoble; Grenoble France
| | - François Bayle
- Clinique Universitaire de Néphrologie; CHU Grenoble; Grenoble France
| | - Philippe Zaoui
- Clinique Universitaire de Néphrologie; CHU Grenoble; Grenoble France
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Gatault P, Lebranchu Y. Conversion to mTOR-inhibitor-based immunosuppression: which patients and when? Transplant Res 2013; 2:S3. [PMID: 24565231 PMCID: PMC3834549 DOI: 10.1186/2047-1440-2-s1-s3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Mammalian target of rapamycin (mTOR) inhibitors are currently considered an alternative immunosuppressive treatment that can prevent the nephrotoxicity, viral infections and malignancies that are associated with calcineurin inhibitor-based immunosuppressive regimens. However, the side effects of mTOR-inhibitor-based regimens lead to frequent treatment discontinuations, and not all patients seem to have the same benefits from conversion to mTOR inhibitors. This review focuses on long-term results of trials that have assessed early and late conversion to sirolimus or everolimus. The renal benefit of late conversion (≥1 year post transplantation) is limited, except in patients with good renal function and without proteinuria. Early conversion to mTOR inhibitors in the first 6 months, in combination with mycophenolate mofetil, could be an appropriate strategy for maintenance therapy in renal transplant recipients with a low immunological risk after careful screening at the time of conversion. Good renal function (glomerular filtration rate >40 ml/ minute), weak proteinuria (<1 g/day), an absence of previous acute rejection and subclinical rejection, and appearance of donor-specific anti-human leukocyte antigen antibodies appear to be the most important criteria in identifying patients for whom conversion to an mTOR inhibitor may improve renal function at 5 years.
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18
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Huh KH, Cho Y, Kim BS, Do JH, Park YJ, Joo DJ, Kim MS, Kim YS. The role of thioredoxin 1 in the mycophenolic acid-induced apoptosis of insulin-producing cells. Cell Death Dis 2013; 4:e721. [PMID: 23846223 PMCID: PMC3730420 DOI: 10.1038/cddis.2013.247] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Revised: 06/07/2013] [Accepted: 06/07/2013] [Indexed: 01/12/2023]
Abstract
Mycophenolic acid (MPA) is one of many effective immunosuppressive drugs. However, MPA can induce cellular toxicity and impair cellular function in β-cells. To explore the effects of MPA and the relation between MPA and Trx-1, we used various methods, including an Illumina microarray, to identify the genes regulated during pancreatic β-cell death following MPA treatment. INS-1E cells (a pancreatic β-cell line) and isolated rat islets were treated with MPA for 12, 24, or 36 h, and subsequent microarray analysis showed that (Trx1) gene expression was significantly reduced by MPA. Further, Trx1 overexpression increased the cell viability, decreased the activations of c-jun N-terminal kinase (JNK) and caspase-3 by MPA, and attenuated ROS upregulation by MPA. Furthermore, siRNA knockdown of Trx1 increased MPA-induced cell death and the activations of p-JNK and caspase-3, and MPA significantly provoked the apoptosis of insulin-secreting cells via Trx1 downregulation. Our findings suggest that the prevention of Trx1 downregulation in response to MPA is critical for successful islet transplantation.
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Affiliation(s)
- K H Huh
- Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Republic of Korea
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19
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Chen GD, Liu XC, Shi L, Qiu J, Wang CX, Fei JG, Li J, Huang G, Chen LZ. Calcineurin Inhibitor Conversion to Rapamycin Can Improve Graft Function in Living Donor Kidney Transplantation With Older Donors. Transplant Proc 2013; 45:1648-50. [DOI: 10.1016/j.transproceed.2013.01.099] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Revised: 01/16/2013] [Accepted: 01/31/2013] [Indexed: 11/28/2022]
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Wang XF, van Velkinburgh JC, Zhang Y, Ni B, Yang ZY. Effects of immunosuppressive agents on Th17 cells involved in transplantation. Clin Transplant 2013; 27:E12-20. [PMID: 23215778 DOI: 10.1111/ctr.12043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2012] [Indexed: 12/13/2022]
Abstract
The lymphocyte-derived helper T (Th) cells are critical regulators of the adaptive immune response and are associated with inflammatory disease. The most recently recognized Th-cell lineage, Th17, plays an important role in host defense against extracellular pathogens by secreting the proinflammatory cytokine, interleukin 17, and recruiting reactive oxygen species (ROS)-producing monocytes to the site of infection. However, accumulating evidence has implicated Th17-cell dysregulation as an underlying cause for some immune-related pathogenic conditions, including allograft rejection. Recent studies of human transplant patients have indicated that Th17 cells exhibit resistance to current immunosuppressive therapies that would otherwise prevent allograft rejection. In this review, we will discuss the most current research findings related to Th17-cell function in various kinds of allografts.
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Affiliation(s)
- Xiao-Fei Wang
- Hepatobiliary Surgery Department, Southwest Hospital, PLA, Third Military Medical University, Chongqing, China
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Halleck F, Duerr M, Waiser J, Huber L, Matz M, Brakemeier S, Liefeldt L, Neumayer HH, Budde K. An evaluation of sirolimus in renal transplantation. Expert Opin Drug Metab Toxicol 2012; 8:1337-56. [PMID: 22928953 DOI: 10.1517/17425255.2012.719874] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Sirolimus is a powerful antiproliferative immunosuppressive drug approved for the prevention of kidney allograft rejection. By its unique mechanism of action, sirolimus provides a multitude of clinical potential and has been used effectively in different drug combinations. Extensive experience has been gained regarding the best timing of its application, side effect profile and potential benefits and limitations compared with other immunosuppressive drugs. AREAS COVERED The authors evaluate the recent experience with sirolimus in kidney transplantation. Pivotal randomized controlled trials were used to provide an overview with special attention to pharmacokinetic and dynamic aspects of sirolimus, its current clinical use as well as perspectives for its future role. EXPERT OPINION Sirolimus enriches the possibilities of immunosuppressive therapies after renal transplantation. Beneficial effects toward kidney function by allowing CNI sparing, lower incidence of malignancies and less viral infections have been suggested. Sirolimus should be used cautiously in de novo patients for reasons of wound healing. An early conversion to a sirolimus-based CNI-free regimen has shown promising results, whereas late conversion is more challenging. Finally, sirolimus-associated side effects are causing tolerability concerns and frequent discontinuations. Future research should aim to better define the therapeutic window and those patients most likely to benefit.
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Affiliation(s)
- Fabian Halleck
- Department of Nephrology, Charité Universitätsmedizin, Berlin, Germany.
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Abstract
PURPOSE OF REVIEW The utilization of calcineurin inhibitors (CNI) in kidney transplantation has dramatically improved short-term outcomes but significant gains in long-term outcomes have proved elusive. Nephrotoxicity is the major problem associated with CNIs and is responsible for the disappointing progress seen in long-term graft survival. In this review, we assess CNI efficacy as well as the latest strategies employed to limit long-term CNI nephrotoxicity. RECENT FINDINGS Three CNI sparing strategies - CNI withdrawal, CNI avoidance, and CNI minimization - are evaluated with discussion of key studies such as the Efficacy Limiting Toxicity Elimination-Symphony and Spare-the-Nephron studies. Recent breakthroughs in transplant immunosuppression are discussed such as the BENEFIT and BENEFIT-EXT studies, which have led to the recent US Food and Drug Administratrion approval of belatacept, a novel T-cell costimulation blocker. SUMMARY For now, CNIs remain the proven standard of care in modern immunosuppression. However, some novel agents may challenge the role CNIs play in kidney transplantation in the very near future.
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Behnke-Hall K, Bauer J, Thul J, Akintuerk H, Reitz K, Bauer A, Schranz D. Renal function in children with heart transplantation after switching to CNI-free immunosuppression with everolimus. Pediatr Transplant 2011; 15:784-9. [PMID: 21883744 DOI: 10.1111/j.1399-3046.2011.01550.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Renal impairment because of CNI contributes to long-term morbidity. Therefore, CNI avoiding or sparing treatment strategies are important. In this article, we describe the results of a CNI-free treatment protocol with regard to recovery of renal function. Twenty-eight patients with heart transplantation were switched from CNI regimen to everolimus and mycophenolate, when cGFR was <75 mL/min/1.73 m(2). In all patients, CNI was stopped, when everolimus trough levels of 5-8 ng/L were achieved. Serum creatinine and cGFR were determined before and after 6 and 12 months. Median serum creatinine decreased from 1.2 mg/dL (range 0.7-3.7) before everolimus to 1.0 (range 0.6-1.8) and 1.0 (range 0.5-1.9) mg/dL after 6 and 12 months. Median cGFR was 47.81 (range 18.3-72.6) mL/min/1.73 m(2) before everolimus and 63.1 (range 37.8-108.7) mL/min/1.73 m(2) at six months and 64.8 (range 37.7-106.6) mL/min/1.73 m(2) after 12 months. All changes from baseline to six and 12 months were statistically significant (p < 0.05). Adverse events were infections (n = 3) and rejections (n = 3). Therapy was discontinued in four patients. Conversion to CNI-free immunosuppression resulted in significant improvements of renal function within six months of CNI withdrawal. Side effects are common. However, more studies are required to demonstrate the effectiveness in children.
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Wei X, Chen XM, Wang L, Song JP, Deng YP. Effects of immunosuppressants after penetrating keratoplasty: meta-analysis of randomized controlled trials. Int J Ophthalmol 2011; 4:529-36. [PMID: 22553716 DOI: 10.3980/j.issn.2222-3959.2011.05.14] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Accepted: 09/25/2011] [Indexed: 02/05/2023] Open
Abstract
AIM To assess the effectiveness of immunosuppressants in the prophylaxis of corneal allograft rejection after high-risk keratoplasty and normal-risk keratoplasty. METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CNKI, VIP and reference lists of articles. Date of most recent search: 18 June, 2011. All randomised controlled trials (RCTs) assessing the use of immunosupressants in the prevention of graft rejection, irrespective of publication language. Two authors assessed trial quality and extracted data independently. Only dichotomous outcomes (clear graft survival, ratio of immune reactions and side effects) were available and were expressed as relative risk (RR) and 95% confidence intervals (CI). RESULTS Seven studies were included in this review. In the comparing of mycophenolate mofetil (MMF) with placebo, the results showed MMF could significantly reduce immune reactions compared with placebo (RR 1.08 95% Cl 0.95 to 1.21), but no effect on clear graft survival (RR 1.11 95% Cl 0.90 to 1.35). In clear graft survival and immune reactions, MMF and cyclosporine A (CsA) showed similar effect (RR 1.11 95% Cl 0.90 to 1.35, and RR 1.48, 95% Cl 0.56 to 3.93, respectively). Tacrolimus (FK506) and steroid showed similar effects on clear graft survival and immune reactions (RR 0.32, 95% CI 0.02 to 6.21, and RR 1.00, 95%CI 0.88 to 1.14, respectively). No drug relative side effect has been found. CONCLUSION MMF may reduce immune reactions in both normal-risk and high-risk rejection of penetrating keratoplasty. CsA and FK506 showed similar effects as MMF. However, due to the lack of large clinical trials, the evidence remain weak, the quality of evidences were rated as very low to moderate. Large, properly randomised, placebo-controlled, double masked trials are needed to evaluate the effect of immunosuppressants.
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Affiliation(s)
- Xin Wei
- Department of Ophthalmology & Ophthalmic Laboratories, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
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Sahin S, Gürkan A, Uyar M, Dheir H, Turunç V, Varilsuha C, Kaçar S. Conversion to Proliferation Signal Inhibitors–Based Immunosuppressive Regimen in Kidney Transplantation: To Whom and When? Transplant Proc 2011; 43:837-40. [DOI: 10.1016/j.transproceed.2011.01.097] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Budde K, Becker T, Arns W, Sommerer C, Reinke P, Eisenberger U, Kramer S, Fischer W, Gschaidmeier H, Pietruck F. Everolimus-based, calcineurin-inhibitor-free regimen in recipients of de-novo kidney transplants: an open-label, randomised, controlled trial. Lancet 2011; 377:837-47. [PMID: 21334736 DOI: 10.1016/s0140-6736(10)62318-5] [Citation(s) in RCA: 274] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Non-nephrotoxic immunosuppressive strategies that allow reduction of calcineurin-inhibitor exposure without compromising safety or efficacy remain a goal in kidney transplantation. Immunosuppression based on the mammalian-target-of-rapamycin inhibitor everolimus was assessed as a strategy for elimination of calcineurin-inhibitor exposure and optimisation of renal-graft function while maintaining efficacy. METHODS In the ZEUS multicentre, open-label study, 503 patients (aged 18-65 years) who had received de-novo kidney transplants were enrolled. After initial treatment with ciclosporin, based on trough concentrations, and enteric-coated mycophenolate sodium (1440 mg/day, orally), corticosteroids (≥5 mg/day prednisolone or equivalent, orally), and basiliximab induction (20 mg, intravenously, on day 0 [2 h before transplantation], and on day 4), 300 (60%) patients were randomly assigned at 4·5 months in a 1:1 ratio to undergo calcineurin-inhibitor elimination (everolimus-based regimen that was based on trough concentrations [6-10 ng/mL] and enteric-coated mycophenolate sodium [1440 mg/day] with corticosteroids), or continue standard ciclosporin-based treatment. Randomisation was done by use of a central, validated system that automated the random assignment of treatment groups to randomisation numbers. The primary objective was to show better renal function (glomerular filtration rate [GFR]; Nankivell formula) with the calcineurin-inhibitor-free everolimus regimen at 12 months after transplantation. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00154310. FINDINGS 118 (76%) of 155 everolimus-treated patients and 117 (81%) of 145 ciclosporin-treated patients completed treatment with study drug up to 12 months after transplantation. At this timepoint, the everolimus regimen was associated with a significant improvement in GFR versus the ciclosporin regimen (71·8 mL/min per 1·73 m(2) vs 61·9 mL/min per 1·73 m(2), respectively; mean difference 9·8 mL/min per 1·73 m(2), 95% CI -12·2 to -7·5). Rates of biopsy-proven acute rejection were higher in the everolimus group than in the ciclosporin group after randomisation (15 [10%] of 154 vs five [3%] of 146; p = 0·036), but similar for the full study period (23 [15%] vs 22 [15%]). Compared with the ciclosporin regimen, higher mean lipid concentrations, slightly increased urinary protein excretion, and lower haemoglobin concentrations were noted with the everolimus regimen; thrombocytopenia, aphthous stomatitis, and diarrhoea also occurred more often in the everolimus group. A higher incidence of hyperuricaemia was noted with ciclosporin. INTERPRETATION Early elimination of calcineurin inhibitor by use of everolimus-based immunosuppression improved renal function at 12 months while maintaining efficacy and safety, indicating that this strategy may facilitate improved long-term outcomes in selected patients. FUNDING Novartis Pharma.
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Affiliation(s)
- Klemens Budde
- Department of Nephrology, Charité University, Berlin, Germany.
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Ladrière M. [Proliferation signal inhibitors: what therapeutic protocols are followed in 2009?]. Nephrol Ther 2010; 5 Suppl 6:S385-9. [PMID: 20129450 DOI: 10.1016/s1769-7255(09)73430-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Proliferation signal inhibitors (PSI) have been used in France for kidney transplants for some ten years. They provide a certain number of long-term benefits for kidney function in transplant patients due to their anti-proliferation and anti-tumour properties and absence of nephrotoxicity. Their use has been evaluated in therapeutic regimens aimed at reducing the nephrotoxicity associated with calcineurin inhibitors (CNI). Strategies based on minimizing the use of CNIs and therapy switches between 3 and 6 months have shown promising results, especially in terms of prevention of deterioration of kidney function. The best time to make the switch has not yet been defined with certainty, but predictors of success, preservation of good kidney function and absence of proteinuria have been established. Aside from cases of demonstrated CNI toxicity, a history or onset of de novo cancer is a situation in which this type of regimen can be considered.
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Affiliation(s)
- M Ladrière
- CHU Nancy, Hôpital d'adultes de Brabois, Service de néphrologie, Avenue de Bourgogne, Vandoeuvre Les Nancy, France.
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Hushmendy S, Jayakumar L, Hahn AB, Bhoiwala D, Bhoiwala DL, Crawford DR. Select phytochemicals suppress human T-lymphocytes and mouse splenocytes suggesting their use in autoimmunity and transplantation. Nutr Res 2009; 29:568-78. [PMID: 19761891 PMCID: PMC2746920 DOI: 10.1016/j.nutres.2009.08.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2009] [Revised: 08/14/2009] [Accepted: 08/18/2009] [Indexed: 12/26/2022]
Abstract
We have considered a novel "rational" gene targeting approach for treating pathologies whose genetic bases are defined using select phytochemicals. We reason that one such potential application of this approach would be conditions requiring immunosuppression such as autoimmune disease and transplantation, where the genetic target is clearly defined; i.e., interleukin-2 and associated T-cell activation. Therefore, we hypothesized that select phytochemicals can suppress T-lymphocyte proliferation both in vitro and in vivo. The immunosuppressive effects of berry extract, curcumin, quercetin, sulforaphane, epigallocatechin gallate (EGCG), resveratrol, alpha-tocopherol, vitamin C and sucrose were tested on anti-CD3 plus anti-CD28-activated primary human T-lymphocytes in culture. Curcumin, sulforaphane, quercetin, berry extract and EGCG all significantly inhibited T-cell proliferation, and this effect was not due to toxicity. IL-2 production was also reduced by these agents, implicating this important T-cell cytokine in proliferation suppression. Except for berry extract, these same agents also inhibited mouse splenic T-cell proliferation and IL-2 production. Subsequent in vivo studies revealed that quercetin (but not sulforaphane) modestly suppressed mouse splenocyte proliferation following supplementation of BALB/c mice diets. This effect was especially prominent if corrected for the loss of supplement "recall" as observed in cultured T-cells. These results suggest the potential use of these select phytochemicals for treating autoimmune and transplant patients, and support our strategy of using select phytochemicals to treat genetically-defined pathologies, an approach that we believe is simple, healthy, and cost-effective.
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Affiliation(s)
- Shazaan Hushmendy
- Center for Immunology and Microbial Disease MC-151, The Albany Medical College, Albany, NY 12208, USA
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Campistol JM, Cockwell P, Diekmann F, Donati D, Guirado L, Herlenius G, Mousa D, Pratschke J, Millán JCRS. Practical recommendations for the early use of m-TOR inhibitors (sirolimus) in renal transplantation. Transpl Int 2009; 22:681-7. [DOI: 10.1111/j.1432-2277.2009.00858.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Laschke MW, Häufel JM, Roller J, Schorr H, Menger MD. Rapamycin, but not cyclosporine A, inhibits vascularization and incorporation of implanted surgical meshes. Transpl Int 2009; 22:654-62. [DOI: 10.1111/j.1432-2277.2009.00841.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Abstract
Calcineurin inhibitors (CNIs) and steroids, the cornerstones of most immunosuppressive regimens over the past 20 years, have undesirable chronic side effects, leading to the application of new strategies with sirolimus (SRL) and mycophenolate mofetil (MMF). We evaluated de novo CNI avoidance and early steroid withdrawal among 145 renal recipients randomized to receive either SRL (n = 71) or cyclosporine (CsA; n = 74). All patients received polyclonal antithymocyte globulin (ATG) for 5 days, MMF, and steroid withdrawal at 6 months (SPIESSER study). At 12 months, patient and graft survivals, incidence of biopsy-proven acute rejection (BPAR), and rates of steroid withdrawal were not statistically different namely, 97% versus 97%; 90% versus 93%, 14.3% versus 8.6%, and 82.8% versus 84.1%, respectively. Among patients who remained on treatment according to the protocol, the estimated glomerular filtration rate (eGFR) was significantly higher with SRL (69 +/- 19 versus 60 +/- 14 mL/min; P < .01). In another study of delayed introduction of SRL, 192 renal recipients were prospectively randomized at week 12 to switch from CsA to SRL (n = 95) or to continue CsA (n = 97; CONCEPT study). At 12 months, patient and graft survivals of the randomized patients, incidence of BPAR, and rates of steroid withdrawal were not significantly different: 100% versus 100%, 100% versus 98%, 17% versus 8%, and 72% versus 78%, respectively. Upon ITT eGFR was significantly higher with SRL (68.9 vs 64.4 mL/min; P = .017). In both studies, a significant improvement in renal function was observed at 12 months among patients receiving a maintenance regimen with SRL plus MMF. Furthermore, steroids could be withdrawn in three quarters of the patients.
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Affiliation(s)
- Y Lebranchu
- University Hospital of Tours, Tours, France.
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Denhaerynck K, Burkhalter F, Schäfer-Keller P, Steiger J, Bock A, De Geest S. Clinical consequences of non adherence to immunosuppressive medication in kidney transplant patients. Transpl Int 2009; 22:441-6. [DOI: 10.1111/j.1432-2277.2008.00820.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Immunosuppressants for the prophylaxis of corneal graft rejection after penetrating keratoplasty. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2009. [DOI: 10.1002/14651858.cd007603] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Klawitter J, Bendrick-Peart J, Rudolph B, Beckey V, Klawitter J, Haschke M, Rivard C, Chan L, Leibfritz D, Christians U, Schmitz V. Urine metabolites reflect time-dependent effects of cyclosporine and sirolimus on rat kidney function. Chem Res Toxicol 2009; 22:118-28. [PMID: 19099400 PMCID: PMC2646011 DOI: 10.1021/tx800253x] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
The clinical use of the immunosuppressant calcineurin inhibitor cyclosporine is limited by its nephrotoxicity. This is enhanced when combined with the immunosuppressive mTOR inhibitor sirolimus. Nephrotoxicity of both drugs is not yet fully understood. The goal was to gain more detailed mechanistic insights into the time-dependent effects of cyclosporine and sirolimus on the rat kidney by using a comprehensive approach including metabolic profiling in urine ((1)H NMR spectroscopy), kidney histology, kidney function parameters in plasma, measurement of glomerular filtration rates, the oxidative stress marker 15-F(2t)-isoprostane in urine, and immunosuppressant concentrations in blood and kidney. Male Wistar rats were treated with vehicle (controls), cyclosporine (10/25 mg/kg/day), and/or sirolimus (1 mg/kg/day) by oral gavage once daily for 6 and 28 days. Twenty-eight day treatment led to a decrease of glomerular filtration rates (cyclosporine, -59%; sirolimus, -25%). These were further decreased when both drugs were combined (-86%). Histology revealed tubular damage after treatment with cyclosporine, which was enhanced when sirolimus was added. No other part of the kidney was affected. (1)H NMR spectroscopy analysis of urine (day 6) revealed time-dependent changes of 2-oxoglutarate, citrate, and succinate concentrations. In combination with increased urine isoprostane concentrations, these changes indicated oxidative stress. After 28 days of cyclosporine treatment, urine metabonomics shifted to patterns typical for proximal tubular damage with reduction of Krebs cycle intermediates and trimethylamine-N-oxide concentrations, whereas acetate, lactate, trimethylamine, and glucose concentrations increased. Again, sirolimus enhanced these negative effects. Our results indicate that cyclosporine and/or sirolimus induce damage of the renal tubular system. This is reflected by urine metabolite patterns, which seem to be more sensitive than currently used clinical kidney function markers such as creatinine concentrations in serum. Metabolic profiling in urine may provide the basis for the development of toxicodynamic monitoring strategies for immunosuppressant nephrotoxicity.
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Affiliation(s)
- Jost Klawitter
- Departments of Anesthesiology and Nephrology, University of Colorado, Denver, Colorado, USA
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Sankatsing SUC, Prins JM, Yong SLL, Roelofsen J, van Kuilenburg ABP, Kewn S, Back DJ, Bemelman FJ, ten Berge IJM. Mycophenolate mofetil inhibits T-cell proliferation in kidney transplant recipients without lowering intracellular dGTP and GTP. Transpl Int 2008; 21:1066-71. [PMID: 18699845 DOI: 10.1111/j.1432-2277.2008.00739.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
To study if mycophenolic acid (MPA), the active metabolite of mycophenolate mofetil (MMF), indeed inhibits T-cell proliferation in kidney transplant recipients by lowering intracellular deoxyguanosine triphosphate (dGTP) and guanosine triphosphate (GTP) levels. Blood was drawn from 11 kidney transplant recipients. Ex vivo T-cell proliferation was measured by stimulation with phytohemagglutin (PHA) and anti-CD3 monoclonal antibody (mAb). Plasma MPA levels and intracellular dGTP and GTP in peripheral blood mononuclear cells were measured. MMF induces a significant decrease in T-lymphocyte proliferation at all time points (i.e. 24 h, 10 days and 8 weeks) after stimulation with both PHA (P = 0.001, 0.002 and 0.013 respectively) and anti-CD3 mAb (P = 0.004, 0.004 and 0.005 respectively). There was no significant change in intracellular dGTP (P = 0.31, 0.16 and 0.35) or GTP levels (P = 0.99, 0.32 and 0.49) between baseline and day 1, day 10 or week 8. All MPA levels were above the minimal required concentration for the inhibition of lymphocyte proliferation. MMF inhibits T-lymphocyte proliferation in kidney transplant recipients without lowering intracellular dGTP or GTP levels. This suggests another mechanism underlying its immunosuppressive capacity.
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Affiliation(s)
- Sanjay U C Sankatsing
- Division of Infectious Diseases, Tropical Medicine and AIDS, Department of Internal Medicine, and Center for Infection and Immunity Amsterdam (CINIMA), University of Amsterdam, Amsterdam, The Netherlands.
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De Simone P, Carrai P, Precisi A, Petruccelli S, Baldoni L, Balzano E, Ducci J, Caneschi F, Coletti L, Campani D, Filipponi F. Conversion to everolimus monotherapy in maintenance liver transplantation: feasibility, safety, and impact on renal function. Transpl Int 2008; 22:279-86. [PMID: 19054383 DOI: 10.1111/j.1432-2277.2008.00768.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
We present the 12-month results of a prospective trial of conversion from calcineurin inhibitors (CNI) to everolimus (EVL) in maintenance liver transplant (LT) recipients. Forty (M:F = 28:12; 54.9 +/- 11 years) patients were enrolled at a mean interval of 45.5 +/- 31.2 months from transplantation. Conversion was with EVL at a dosage of 0.75 mg b.i.d., withdrawal of antimetabolites, and a 50%-per-week reduction of CNI to a complete stop within 4 weeks. The treatment success was conversion to EVL monotherapy at 12 months while failure was presence of CNI, death, and graft loss. Indication to conversion was deteriorating renal function in 36 (90%). At 12 months, patient- and graft survival were 100% and the success rate was 75% (30/40). Ten patients (25%) were failures: four (10%) for acute rejection; three hepatitis C virus-RNA positive patients (7.5%) for hypertransaminasemia; one (2.5%) for acute cholangitis; and two (5%) due to persistent pruritus and oral ulcers. In patients on EVL monotherapy, at 12 months the mean change of calculated creatinine clearance (cCrCl) was 4.03 +/- 12.6 mL/min and the only variable correlated with the probability of improvement was baseline cCrCl (P < 0.0001). Conversion from CNI to EVL is feasible in 75% of the cases and associated with improvement in renal function for patients with higher baseline cCrCl.
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Affiliation(s)
- Paolo De Simone
- Unità Operativa Chirurgia Generale e Trapianti di Fegato, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
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Effect on kidney graft survival of reducing or discontinuing maintenance immunosuppression after the first year posttransplant. Transplantation 2008; 86:371-6. [PMID: 18698238 DOI: 10.1097/tp.0b013e31817fdddb] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Data are scarce concerning the impact of maintenance immunosuppression dose reductions posttransplant. METHODS Graft survival according to dose reduction or discontinuation of calcineurin inhibitors or mycophenolate mofetil (MMF) after the first year posttransplant was evaluated in 25,045 patients undergoing kidney transplantation during 1996 to 2005. No patient in this analysis had experienced a rejection and all had good graft function before dose reduction. RESULTS Reduction of cyclosporine (CsA) dose to less than or equal to 150 mg/day, tacrolimus to less than or equal to 2 mg/day, or MMF to less than or equal to 1.0 g/day in patients on CsA or less than or equal to 0.5 g/day in patients on tacrolimus during the second year posttransplant was associated with a statistically significant reduction in graft survival (hazard ratios between 1.37 and 1.65). Withdrawal of CsA, tacrolimus, or MMF during year 2 was also associated with an increase in the risk of graft loss compared with continuing treatment (hazard ratio 1.52-1.73). CONCLUSIONS This observational analysis indicates that in kidney transplant patients with good graft function, withdrawing maintenance CsA, tacrolimus or MMF, or reducing the dose of these agents below certain thresholds after the first year posttransplant is associated with a significant risk of graft loss.
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Rovira J, Marcelo Arellano E, Burke JT, Brault Y, Moya-Rull D, Bañón-Maneus E, Ramírez-Bajo MJ, Gutiérrez-Dalmau A, Revuelta I, Quintana LF, Campistol JM, Diekmann F. Effect of mTOR inhibitor on body weight: from an experimental rat model to human transplant patients. Transpl Int 2008; 21:992-8. [PMID: 18657090 DOI: 10.1111/j.1432-2277.2008.00710.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
UNLABELLED The aim was to study the influence of sirolimus (SRL) on body weight in a rat model and in kidney transplant patients. Wistar rats (15 weeks old) were either treated with vehicle (VEH; n = 8) or SRL (n = 7) 1.0 mg/kg three times per week for 12 weeks. Body mass and food intake were measured weekly. Adipocyte diameter was determined in hematoxylin-eosin stains. The body mass index (BMI) obtained from clinical kidney transplant trials comparing SRL-based with cyclosporine-based therapy was analyzed. ANIMALS SRL produced a decrease of the weight gain curve. At the end of the study, mean body weight in the SRL group was lower than in the VEH group (356 vs. 507 g, P < 0.01) in spite of comparable food intake normalized for body weight was not different. Mean adipocyte diameter was 36 mum in VEH and 25 mum in SRL rats (P = 0.009). Mean SRL blood trough concentration was 38 ng/ml. Kidney transplant patients: Two years after transplantation, BMI was significantly lower in the SRL-based treatment arm compared to cyclosporine (24.17 +/- 2.99 vs. 25.97 +/- 5.01 kg/m(2), P = 0.031). SRL treatment leads to less body mass. Adipocyte cell diameter was reduced in SRL-treated animals. A possible explanation may be the effects of SRL on metabolic regulation and cell growth.
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Affiliation(s)
- Jordi Rovira
- Department of Nephrology and Renal Transplantation, Laboratori Experimental de Nefrologia i Trasplantament (LENIT), Hospital Clínic i Provincial de Barcelona, Barcelona, Spain.
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Can We Maintain Immunosuppression Avoiding Nephrotoxic Agents in Pancreas Transplantation? Transplant Proc 2008; 40:516-7. [DOI: 10.1016/j.transproceed.2008.01.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Cruzado JM. Nonimmunosuppressive effects of mammalian target of rapamycin inhibitors. Transplant Rev (Orlando) 2008; 22:73-81. [DOI: 10.1016/j.trre.2007.09.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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