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Wang YY, Zou LP, Xu KF, Xu WS, Zhang MN, Lu Q, Tian XL, Pang LY, He W, Wang QH, Gao Y, Liu LY, Chen XQ, Ma SF, Chen HM, Dun S, Yang XY, Luo XM, Huang LL, Li YF. Long-term safety and influence on growth in patients receiving sirolimus: a pooled analysis. Orphanet J Rare Dis 2024; 19:299. [PMID: 39148107 PMCID: PMC11325711 DOI: 10.1186/s13023-024-03243-5] [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: 12/11/2022] [Accepted: 06/05/2024] [Indexed: 08/17/2024] Open
Abstract
BACKGROUND Sirolimus is increasingly utilized in treating diseases associated with mTOR pathway overactivation. Despite its potential, the lack of evidence regarding its long-term safety across all age groups, particularly in pediatric patients, has limited its further application. This study aims to assess the long-term safety of sirolimus, with a specific focus on its impact on growth patterns in pediatric patients. METHODS This pooled analysis inlcudes two prospective cohort studies spanning 10 years, including 1,738 participants (aged 5 days to 69 years) diagnosed with tuberous sclerosis and/or lymphangioleiomyomatosis. All participants were mTOR inhibitor-naive and received 1 mg/m²/day of sirolimus, with dose adjustments during a two-week titration period to maintain trough blood concentrations between 5 and 10 ng/ml (maximum dose 2 mg). Indicators of physical growth, hematopoietic, liver, renal function, and blood lipid levels were all primary outcomes and were analyzed. The adverse events and related management were also recorded. RESULTS Sirolimus administration did not lead to deviations from normal growth ranges, but higher doses exhibited a positive association with Z-scores exceeding 2 SD in height, weight, and BMI. Transient elevations in red blood cell and white blood cell counts, along with hyperlipidemia, were primarily observed within the first year of treatment. Other measured parameters remained largely unchanged, displaying only weak correlations with drug use. Stomatitis is the most common adverse event (920/1738, 52.9%). In adult females, menstrual disorders were observed in 48.5% (112/217). CONCLUSIONS Sirolimus's long-term administration is not associated with adverse effects on children's physical growth pattern, nor significant alterations in hematopoietic, liver, renal function, or lipid levels. A potential dose-dependent influence on growth merits further exploration. TRIAL REGISTRATION Pediatric patients: Chinese clinical trial registry, No. ChiCTR-OOB-15,006,535. Adult patients: ClinicalTrials, No. NCT03193892.
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Affiliation(s)
- Yang-Yang Wang
- Department of Pediatrics, The First Medical Center of PLA General Hospital, Chinese PLA General Hospital, Beijing, 100853, China
| | - Li-Ping Zou
- Department of Pediatrics, The First Medical Center of PLA General Hospital, Chinese PLA General Hospital, Beijing, 100853, China.
- Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing, 100069, China.
| | - Kai-Feng Xu
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, 100730, China.
| | - Wen-Shuai Xu
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, 100730, China
| | - Meng-Na Zhang
- Department of Pediatrics, The First Medical Center of PLA General Hospital, Chinese PLA General Hospital, Beijing, 100853, China
| | - Qian Lu
- Department of Pediatrics, The First Medical Center of PLA General Hospital, Chinese PLA General Hospital, Beijing, 100853, China
| | - Xin-Lun Tian
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, 100730, China
| | - Ling-Yu Pang
- Department of Neurology, Hebei Children's Hospital, Hebei, China
| | - Wen He
- Department of Pediatrics, The First Medical Center of PLA General Hospital, Chinese PLA General Hospital, Beijing, 100853, China
| | - Qiu-Hong Wang
- Department of Pediatrics, The First Medical Center of PLA General Hospital, Chinese PLA General Hospital, Beijing, 100853, China
| | - Yang Gao
- Deyang People's Hospital, Sichuan, China
| | - Li-Ying Liu
- Department of Pediatrics, The First Medical Center of PLA General Hospital, Chinese PLA General Hospital, Beijing, 100853, China
| | - Xiao-Qiao Chen
- Department of Pediatrics, The 904th Hospital of Joint Logistic Support Force, Jiangsu, China
| | - Shu-Fang Ma
- Department of Pediatrics, Binzhou Medical University Hospital, Shandong, China
| | - Hui-Min Chen
- Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing, 100069, China
| | - Shuo Dun
- Department of Pediatrics, The First Medical Center of PLA General Hospital, Chinese PLA General Hospital, Beijing, 100853, China
| | - Xiao-Yan Yang
- Department of Pediatrics, The First Medical Center of PLA General Hospital, Chinese PLA General Hospital, Beijing, 100853, China
| | - Xiao-Mei Luo
- Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing, 100069, China
| | - Lu-Lu Huang
- Department of Pediatrics, Zhujiang Hospital of Southern Medical University, Guangdong, China
| | - Yu-Fen Li
- Department of Pediatrics, Shandong Linyi People's Hospital, Shandong, China
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Poudel S, Gupta S, Saigal S. Basics and Art of Immunosuppression in Liver Transplantation. J Clin Exp Hepatol 2024; 14:101345. [PMID: 38450290 PMCID: PMC10912712 DOI: 10.1016/j.jceh.2024.101345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 01/09/2024] [Indexed: 03/08/2024] Open
Abstract
Liver transplantation is one of the most challenging areas in the medical field. Despite that, it has already been established as a standard treatment option, especially in decompensated cirrhosis and selected cases of hepatocellular carcinoma and acute liver failure. Complications due to graft rejection, including mortality and morbidity, have greatly improved over time due to better immunosuppressive agents and management protocols. Currently, immunosuppression in liver transplant patients makes use of the best possible combinations of effective agents to achieve optimal immunosuppression for long-term graft survival. Induction agents are no longer used routinely, and the aim is to provide minimal immunosuppression in the maintenance phase. Currently available immunosuppressive agents are mainly classified as biological and pharmacological agents. Though the protocols may vary among the centers and over time, the basics of effective use usually remain similar. Most protocols use the combination of multiple agents with different mechanisms of action to reduce the dose and minimize the side effects. Along with the improvement in operative and perioperative techniques, this art of immunosuppression has contributed to the recent progress made in the outcomes of liver transplants. In this review, we will discuss the various types of immunosuppressive agents currently in use, the different protocols of immunosuppression used, and the art of optimal use for achieving maximum immunosuppression without increasing toxicity. We will also discuss the practical aspects of various immunosuppression regimens, including drug monitoring, and briefly discuss the concepts of immunosuppression minimization and withdrawal.
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Affiliation(s)
- Shekhar Poudel
- Fellow Transplant Hepatology, Centre for Liver and Biliary Sciences, Max Super Specialty Hospital, Saket, New Delhi, India
| | - Subhash Gupta
- Liver Transplant and Gastrointestinal Surgery, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Sanjiv Saigal
- Principal Director and Head, Transplant Hepatology, Centre for Liver and Biliary Sciences, Max Super Specialty Hospital, Saket, New Delhi, India
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Is there a procoagulant state long-term after lung transplantation? A prospective study. Respir Med 2021; 188:106584. [PMID: 34560353 DOI: 10.1016/j.rmed.2021.106584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 08/18/2021] [Accepted: 08/22/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a major complication after lung transplantation (LT). However, its pathophysiology remains unknown, and coagulation profiles have yet to be described. OBJECTIVE The aim of this study was to longitudinally assess coagulation status after LT. METHODS We performed a prospective study and described the coagulation profiles of 48 patients at 5 different time-points: before LT and at 24-72 h, 2 weeks, 4 months, and 1 year after LT. RESULTS At baseline, almost all analyzed coagulation factors were within the normal range, except for FVIII, which was above the normal range. Von Willebrand factor (vWF) and FVIII were increased after LT and remained high at 1 year after transplantation. The cumulative incidence of VTE was 22.9%. Patients who developed VTE had higher FVIII activity 2 weeks after LT. CONCLUSIONS This is the first study to describe coagulation profiles up to 1 year after LT. We show that most markers of a procoagulant state normalize at 2 weeks after LT, but that values of FVIII and vWF remain abnormal at 1 year. This problem has received little attention in the literature. Larger studies are necessary to confirm the results and to design appropriate prophylactic strategies.
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Lacquaniti A, Campo S, Casuscelli Di Tocco T, Rovito S, Bucca M, Ragusa A, Monardo P. Acute and chronic kidney disease after pediatric liver transplantation: An underestimated problem. Clin Transplant 2020; 34:e14082. [PMID: 32949054 DOI: 10.1111/ctr.14082] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 08/02/2020] [Accepted: 08/15/2020] [Indexed: 12/13/2022]
Abstract
Acute and chronic kidney injuries represent critical issues after liver transplantation (LTx), but whereas renal dysfunction in adult transplant patients is well documented, little is known about its prevalence in childhood. It is a challenge to accurately evaluate renal function in patients with liver disease, due to several confounding factors. Creatinine-based equations estimating glomerular filtration rate, validated in nephropathic patients without hepatic issues, are frequently inaccurate in end-stage liver disease, underestimating the real impact of renal disease. Moreover, whereas renal issues observed within 1 year from LTx were often related to acute injuries, kidney damage observed after 5-7 years from LTx, is due to chronic, irreversible mechanisms. Most immunosuppression protocols are based on calcineurin inhibitors (CNIs) and corticosteroids, but mycophenolate mofetil or sirolimus could play significant roles, also in children. Early diagnosis and personalized treatment represent the bases of kidney disease management, in order to minimize its close relation with increased mortality. This review analyzed acute and chronic kidney damage after pediatric LTx, also discussing the impact of pre-existent renal disease. The main immunosuppressant strategies have been reviewed, highlighting their impact on kidney function. Different methods assessing renal function were reported, with the potential application of new renal biomarkers.
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Affiliation(s)
- Antonio Lacquaniti
- Department of Internal Medicine, Nephrology and Dialysis Unit, Papardo Hospital of Messina, Messina, Italy
| | - Susanna Campo
- Department of Internal Medicine, Nephrology and Dialysis Unit, Papardo Hospital of Messina, Messina, Italy
| | - Teresa Casuscelli Di Tocco
- Department of Internal Medicine, Nephrology and Dialysis Unit, Papardo Hospital of Messina, Messina, Italy
| | - Stefania Rovito
- Department of Internal Medicine, Nephrology and Dialysis Unit, Papardo Hospital of Messina, Messina, Italy
| | - Maurizio Bucca
- Department of Internal Medicine, Nephrology and Dialysis Unit, Papardo Hospital of Messina, Messina, Italy
| | - Antonino Ragusa
- Department of Internal Medicine, Nephrology and Dialysis Unit, Papardo Hospital of Messina, Messina, Italy
| | - Paolo Monardo
- Department of Internal Medicine, Nephrology and Dialysis Unit, Papardo Hospital of Messina, Messina, Italy
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Saparbay J, Tanaka Y, Tanimine N, Ohira M, Ohdan H. Everolimus enhances TRAIL‐mediated anti‐tumor activity of liver resident natural killer cells in mice. Transpl Int 2019; 33:229-243. [DOI: 10.1111/tri.13536] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 06/04/2019] [Accepted: 09/21/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Jamilya Saparbay
- Department of Gastroenterological and Transplant Surgery Applied Life Sciences Institute of Biomedical & Health Sciences Hiroshima University Hiroshima Japan
| | - Yuka Tanaka
- Department of Gastroenterological and Transplant Surgery Applied Life Sciences Institute of Biomedical & Health Sciences Hiroshima University Hiroshima Japan
| | - Naoki Tanimine
- Department of Gastroenterological and Transplant Surgery Applied Life Sciences Institute of Biomedical & Health Sciences Hiroshima University Hiroshima Japan
- Department of Surgery Center for Transplantation Sciences Massachusetts General Hospital Boston MA USA
| | - Masahiro Ohira
- Department of Gastroenterological and Transplant Surgery Applied Life Sciences Institute of Biomedical & Health Sciences Hiroshima University Hiroshima Japan
- Division of Regeneration and Medicine Medical Center for Translational and Clinical Research Hiroshima University Hospital Hiroshima Japan
| | - Hideki Ohdan
- Department of Gastroenterological and Transplant Surgery Applied Life Sciences Institute of Biomedical & Health Sciences Hiroshima University Hiroshima Japan
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Treatment with mTOR inhibitors after liver transplantation enables a sustained increase in regulatory T-cells while preserving their suppressive capacity. Clin Res Hepatol Gastroenterol 2018; 42:237-244. [PMID: 29175009 DOI: 10.1016/j.clinre.2017.10.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 09/26/2017] [Accepted: 10/02/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND The mammalian targets of rapamycin (mTOR) inhibitors (sirolimus [SRL] and everolimus [EVR]) are used after transplantation for their immunosuppressive activity. Regulatory T-cells (Tregs) play a crucial role in immune tolerance. mTOR inhibitors appear to preserve Tregs, unlike Tacrolimus (Tac). AIM The aim of this study was to evaluate the number and function of Tregs in liver transplant recipients before and after conversion from Tac to mTOR inhibitors. METHODS Fifteen patients with stable graft function where converted to SRL (n=5) or EVR (n=10). Tregs (CD4+ CD25+ FoxP3+ CD127low) number and activity were analysed prospectively in blood cells using flow cytometry, and functional assay. RESULTS Patients of both groups displayed a sustained rise in Treg levels after introduction of mTOR inhibitors (Treg levels at 3 months: 6.45±0.38% of CD4 T-cells, vs. baseline level of 3.61±0.37%, P<0.001; mean fold increase 2.04±0.73). In SRL group, 3-month Treg levels were 6.01±0.53 vs. 3.79±0.39; P=0.037, while in EVR group they were 6.63±0.67 vs. 3.54±0.51; P=0.001. By contrast, no statistical change was observed in an unconverted Tac control group. Tregs also preserved their functional ability to suppress activated T-cells. CONCLUSION These results suggest that mTOR inhibitors induce a significant increase in Tregs while maintaining suppressive activity after LT.
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Sáez-Giménez B, Berastegui C, Sintes H, Perez-Miranda J, Figueredo A, López Meseguer M, Monforte V, Bravo C, Santamaría A, Ramon MA, Gómez-Ollés S, Roman A. Prophylaxis with enoxaparin for prevention of venous thromboembolism after lung transplantation: a retrospective study. Transpl Int 2017; 30:1266-1274. [DOI: 10.1111/tri.13021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 04/24/2017] [Accepted: 07/31/2017] [Indexed: 01/25/2023]
Affiliation(s)
- Berta Sáez-Giménez
- Pulmonology Service, Lung Transplant Program; Hospital Universitari Vall d'Hebrón; Universitat Autònoma de Barcelona; Barcelona Spain
| | - Cristina Berastegui
- Pulmonology Service, Lung Transplant Program; Hospital Universitari Vall d'Hebrón; Universitat Autònoma de Barcelona; Barcelona Spain
| | - Helena Sintes
- Pulmonology Service, Lung Transplant Program; Hospital Universitari Vall d'Hebrón; Universitat Autònoma de Barcelona; Barcelona Spain
| | - Javier Perez-Miranda
- Pulmonology Service, Lung Transplant Program; Hospital Universitari Vall d'Hebrón; Universitat Autònoma de Barcelona; Barcelona Spain
| | - Ana Figueredo
- Pulmonology Service, Lung Transplant Program; Hospital Universitari Vall d'Hebrón; Universitat Autònoma de Barcelona; Barcelona Spain
| | - Manuel López Meseguer
- Pulmonology Service, Lung Transplant Program; Hospital Universitari Vall d'Hebrón; Universitat Autònoma de Barcelona; Barcelona Spain
| | - Víctor Monforte
- Pulmonology Service, Lung Transplant Program; Hospital Universitari Vall d'Hebrón; Universitat Autònoma de Barcelona; Barcelona Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES); Instituto de Salud Carlos III; Madrid Spain
| | - Carlos Bravo
- Pulmonology Service, Lung Transplant Program; Hospital Universitari Vall d'Hebrón; Universitat Autònoma de Barcelona; Barcelona Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES); Instituto de Salud Carlos III; Madrid Spain
| | - Amparo Santamaría
- Hemostasis and Thrombosis Unit; Department of Hematology; Hospital Universitari Vall d'Hebrón; Barcelona Spain
| | - Maria Antonia Ramon
- Pulmonology Service, Lung Transplant Program; Hospital Universitari Vall d'Hebrón; Universitat Autònoma de Barcelona; Barcelona Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES); Instituto de Salud Carlos III; Madrid Spain
| | - Susana Gómez-Ollés
- Pulmonology Service, Lung Transplant Program; Hospital Universitari Vall d'Hebrón; Universitat Autònoma de Barcelona; Barcelona Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES); Instituto de Salud Carlos III; Madrid Spain
| | - Antonio Roman
- Pulmonology Service, Lung Transplant Program; Hospital Universitari Vall d'Hebrón; Universitat Autònoma de Barcelona; Barcelona Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES); Instituto de Salud Carlos III; Madrid Spain
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Moini M, Schilsky ML, Tichy EM. Review on immunosuppression in liver transplantation. World J Hepatol 2015; 7:1355-1368. [PMID: 26052381 PMCID: PMC4450199 DOI: 10.4254/wjh.v7.i10.1355] [Citation(s) in RCA: 144] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 12/23/2014] [Accepted: 02/12/2015] [Indexed: 02/06/2023] Open
Abstract
The optimal level of immunosuppression in solid organ transplantation, in particular for the liver, is a delicate balance between the benefit of preventing rejection and the adverse side effects of immunosuppression. There is uncertainty about when this level is achieved in any individual recipient. Immunosuppression regimens vary between individual centers and changes with time as new agents and data are available. Presently concerns about the adverse side effects of calcineurin inhibitor, the main class of immunosuppressive agents used in liver transplantation (LT), has led to consideration of the use of antibody induction therapies for patients at higher risk of developing adverse side effects. The longevity of the transplanted organ is potentially improved by better management of rejection episodes and special consideration for tailoring of immunosuppression to the individual with viral hepatitis C, hepatocellular carcinoma or pregnancy. This review provides an overview of the current strategies for post LT immunosuppression and discusses modifications to consider for special patient populations.
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The benefit of sirolimus maintenance immunosuppression and rabbit antithymocyte globulin induction in liver transplant recipients that develop acute kidney injury in the early postoperative period. J Transplant 2015; 2015:926168. [PMID: 25861462 PMCID: PMC4377545 DOI: 10.1155/2015/926168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 01/22/2015] [Accepted: 02/22/2015] [Indexed: 11/18/2022] Open
Abstract
Published data are limited describing renal outcomes in orthotopic liver transplant (OLT) recipients prescribed sirolimus (SRL) maintenance immunosuppression (MIS) and rabbit antithymocyte globulin (rATG) induction. We investigated whether SRL MIS and rATG induction facilitated recovery of acute kidney injury in the early postoperative period. This retrospective descriptive study screened 308 consecutive OLTs performed between 2006 and 2009. All patients received rATG induction with steroid avoidance. MIS consisted of SRL or TAC with mycophenolate mofetil. A total of 197 patients were included: 168 (85%) received TAC and 29 (15%) received SRL for a median of 365 days. Demographics were similar between groups except for a higher incidence of pretransplant renal dysfunction in the SRL recipients (SRL 59% versus TAC 21%; P < 0.05). The eGFR was significantly (P < 0.05) higher for all time points in the TAC group with the exception of month 2. However, improvement in eGFR was significantly (P < 0.05) greater in the SRL group postoperatively. Our study suggests that rATG induction and SRL maintenance immunosuppression facilitate renal recovery for liver transplant recipients that develop acute kidney injury in the early postoperative period.
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Deep vein thrombosis and pulmonary embolism after solid organ transplantation: an unresolved problem. Transplant Rev (Orlando) 2015; 29:85-92. [DOI: 10.1016/j.trre.2014.12.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Revised: 12/11/2014] [Accepted: 12/12/2014] [Indexed: 01/15/2023]
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Fernández-Yunquera A, Ripoll C, Bañares R, Puerto M, Rincón D, Yepes I, Catalina V, Salcedo M. Everolimus immunosuppression reduces the serum expression of fibrosis markers in liver transplant recipients. World J Transplant 2014; 4:133-140. [PMID: 25032102 PMCID: PMC4094948 DOI: 10.5500/wjt.v4.i2.133] [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: 10/30/2013] [Revised: 01/29/2014] [Accepted: 02/19/2014] [Indexed: 02/05/2023] Open
Abstract
AIM: To evaluate the expression of serum fibrosis markers in liver transplantation (LT) recipients on everolimus monotherapy compared to patients on an anti-calcineurin regimen.
METHODS: This cross-sectional case-control study included LT patients on everolimus monotherapy (cases) (E) (n = 30) and matched controls on an anti-calcineurin regimen (calcineurin inhibitors, CNI), paired by etiology of liver disease and time since LT (n = 30). Clinical characteristics, blood tests and elastography were collected. Serum levels of transforming growth factor-β (TGF-β), angiopoietin-1, tumor necrosis factor (TNF), platelet derived growth factor, amino-terminal propeptide of type III procollagen (PIIINP), hyaluronic acid (HA), VCM-1 (ng/mL), interleukin (IL)-10, interferon-inducible protein 10 (IP-10), vascular endothelial growth factor and hepatocyte growth factor (HGF) (pg/mL) were determined by enzyme-linked immunosorbent assay. Expression of these markers between E and CNI was compared. Stratified analysis was done according to factors that may influence liver fibrosis. Variables are described with medians (interquartillic range) or percentages.
RESULTS: A total of 60 patients [age: 59 (49-64), hepatitis C virus (HCV): n = 21 (35%), time from LT: 73 mo (16-105)] were included. Patients had been on everolimus for a median of 15 mo. No differences in inflammatory activity, APRI test or liver elastography were found between the groups. No significant differences were observed between the groups in serum levels of PIIINP, metalloproteinase type = 1, angiopoietin, HGF, IP-10, TNF-α, IL-10 and vascular cell adhesion molecule. Patients on E had a lower expression of TGF-β [E: 12.7 (3.7-133.6), CNI: 152.5 (14.4-333.2), P = 0.009] and HA [E: 702.89 (329.4-838.2), CNI: 1513.6 (691.9-1951.4), P = 0.001] than those on CNI. This difference was maintained in the stratified analysis when recipient age is more than 50 years (TFG-β1: P = 0.06; HA: P = 0.005), in patients without active neoplasia (TFG-β1, P = 0.009; HA: P = 0.01), according to time since LT (> than 5 years, TFG-β1: P = 0.001; HA: P = 0.002), related to previous history of biliary complications (HA: P = 0.01) and HCV recurrence (HA: P = 0.004). Liver transplant recipients with everolimus monotherapy had less serum expression of TGF-β y HA than matched patients with anti-calcineurins. This difference remains when classifying patients according to donor age and time since LT. Due to the small sample size, when examining patients with a prior history of biliary complications or recurrent HCV, the difference was non-significant but trends towards the lower expression of TFG-β1 in the everolimus group. Mammalian target of rapamycin (mTOR) plays a role in the transformation of quiescent hepatocellular stellate cell to their active profibrotic state, and experimental models have demonstrated the potential activity of mTOR inhibition in attenuating fibrogenesis.
CONCLUSION: This study supports a possible role of everolimus in liver fibrosis modulation after LT in a clinical setting and suggests that tailoring immunosuppression could avoid fibrosis progression in the allograft.
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Klintmalm GB, Nashan B. The Role of mTOR Inhibitors in Liver Transplantation: Reviewing the Evidence. J Transplant 2014; 2014:845438. [PMID: 24719752 PMCID: PMC3955586 DOI: 10.1155/2014/845438] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Revised: 09/20/2013] [Accepted: 09/21/2013] [Indexed: 12/14/2022] Open
Abstract
Despite the success of liver transplantation, long-term complications remain, including de novo malignancies, metabolic syndrome, and the recurrence of hepatitis C virus (HCV) and hepatocellular carcinoma (HCC). The current mainstay of treatment, calcineurin inhibitors (CNIs), can also worsen posttransplant renal dysfunction, neurotoxicity, and diabetes. Clearly there is a need for better immunosuppressive agents that maintain similar rates of efficacy and renal function whilst minimizing adverse effects. The mammalian target of rapamycin (mTOR) inhibitors with a mechanism of action that is different from other immunosuppressive agents has the potential to address some of these issues. In this review we surveyed the literature for reports of the use of mTOR inhibitors in adult liver transplantation with respect to renal function, efficacy, safety, neurological symptoms, de novo tumors, and the recurrence of HCC and HCV. The results of our review indicate that mTOR inhibitors are associated with efficacy comparable to CNIs while having benefits on renal function in liver transplantation. We also consider newer dosing schedules that may limit side effects. Finally, we discuss evidence that mTOR inhibitors may have benefits in the oncology setting and in relation to HCV-related allograft fibrosis, metabolic syndrome, and neurotoxicity.
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Affiliation(s)
- Goran B. Klintmalm
- Baylor Simmons Transplant Institute, Baylor University Medical Center, 3410 Worth Street, Suite 950, Dallas, TX 75246, USA
| | - Björn Nashan
- Department of Hepatobiliary Surgery and Visceral Transplantation, University Medical Center Eppendorf, Martinistraβe 52, 20246 Hamburg, Germany
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Asrani SK, Wiesner RH, Trotter JF, Klintmalm G, Katz E, Maller E, Roberts J, Kneteman N, Teperman L, Fung JJ, Millis JM. De novo sirolimus and reduced-dose tacrolimus versus standard-dose tacrolimus after liver transplantation: the 2000-2003 phase II prospective randomized trial. Am J Transplant 2014; 14:356-66. [PMID: 24456026 DOI: 10.1111/ajt.12543] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Revised: 09/20/2013] [Accepted: 09/20/2013] [Indexed: 01/25/2023]
Abstract
We studied whether the use of sirolimus with reduced-dose tacrolimus, as compared to standard-dose tacrolimus, after liver transplantation is safe, tolerated and efficacious. In an international multicenter, open-label, active-controlled randomized trial (2000-2003), adult primary liver transplant recipients (n=222) were randomly assigned immediately after transplantation to conventional-dose tacrolimus (trough: 7-15 ng/mL) or sirolimus (loading dose: 15 mg, initial dose: 5 mg titrated to a trough of 4-11 ng/mL) and reduced-dose tacrolimus (trough: 3-7 ng/mL). The study was terminated after 21 months due to imbalance in adverse events. The 24-month cumulative incidence of graft loss (26.4% vs. 12.5%, p=0.009) and patient death (20% vs. 8%, p=0.010) was higher in subjects receiving sirolimus. A numerically higher rate of hepatic artery thrombosis/portal vein thrombosis was observed in the sirolimus arm (8% vs. 3%, p=0.065). The incidence of sepsis was higher in the sirolimus arm (20.4% vs. 7.2%, p=0.006). Rates of acute cellular rejection were similar between the two groups. Early use of sirolimus using a loading dose followed by maintenance doses and reduced-dose tacrolimus in de novo liver transplant recipients is associated with higher rates of graft loss, death and sepsis when compared to the use of conventional-dose tacrolimus alone.
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Affiliation(s)
- S K Asrani
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN; William J. von Liebig Transplant Center, Mayo Clinic, Rochester, MN; Annette C and Harold-Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
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14
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Congly SE, Doucette KE, Coffin CS. Outcomes and management of viral hepatitis and human immunodeficiency virus co-infection in liver transplantation. World J Gastroenterol 2014; 20:414-424. [PMID: 24574710 PMCID: PMC3923016 DOI: 10.3748/wjg.v20.i2.414] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Revised: 10/22/2013] [Accepted: 11/05/2013] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation for human immunodeficiency virus (HIV) positive patients with viral hepatitis co-infection is increasingly offered in many North American and European liver transplant centers. Prior studies have demonstrated acceptable post-transplant outcomes and no increased risk of HIV complications in patients co-infected with hepatitis B virus (HBV). However, liver transplantation in HIV positive patients with hepatitis C virus (HCV) has poorer outcomes overall, requiring careful selection of candidates. This review aims to summarize the published literature on outcomes after transplant in HIV patients with HBV or HCV related end-stage liver disease and recommendations for management. In particular the pre-transplant factors impacting outcomes in HCV/HIV co-infected candidates and importance of multidisciplinary management will be discussed.
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15
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Teperman L, Moonka D, Sebastian A, Sher L, Marotta P, Marsh C, Koneru B, Goss J, Preston D, Roberts JP. Calcineurin inhibitor-free mycophenolate mofetil/sirolimus maintenance in liver transplantation: the randomized spare-the-nephron trial. Liver Transpl 2013; 19:675-89. [PMID: 23775875 DOI: 10.1002/lt.23658] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2012] [Accepted: 04/08/2013] [Indexed: 12/12/2022]
Abstract
Mycophenolate mofetil (MMF) and sirolimus (SRL) have been used for calcineurin inhibitor (CNI) minimization to reduce nephrotoxicity following liver transplantation. In this prospective, open-label, multicenter study, patients undergoing transplantation from July 2005 to June 2007 who were maintained on MMF/CNI were randomized 4 to 12 weeks after transplantation to receive MMF/SRL (n = 148) or continue MMF/CNI (n = 145) and included in the intent-to-treat population. The primary efficacy endpoints were the mean percentage change in the calculated glomerular filtration rate (GFR) and a composite of biopsy-proven acute rejection (BPAR), graft lost, death, and lost to follow-up 12 months after transplantation. Patients were followed for a median of 519 days after randomization. MMF/SRL was associated with a significantly greater renal function improvement from baseline with a mean percentage change in GFR of 19.7 ± 40.6 (versus 1.2 ± 39.9 for MMF/CNI, P = 0.0012). The composite endpoint demonstrated the noninferiority of MMF/SRL versus MMF/CNI (16.4% versus 15.4%, 90% confidence interval = -7.1% to 9.0%). The incidence of BPAR was significantly greater with MMF/SRL (12.2%) versus MMF/CNI (4.1%, P = 0.02). Graft loss (including death) occurred in 3.4% of the MMF/SRL-treated patients and in 8.3% of the MMF/CNI-treated patients (P = 0.04). Malignancy-related deaths were less frequent with MMF/SRL. Adverse events caused withdrawal for 34.2% of the MMF/SRL-treated patients and for 24.1% of the MMF/CNI-treated patients (P = 0.06). The use of MMF/SRL is an option for liver transplant recipients who can benefit from improved renal function but is associated with an increased risk of rejection (but not graft loss).
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Affiliation(s)
- Lewis Teperman
- Mary Lea Johnson Richards Organ Transplant Center, New York University School of Medicine, New York, NY 10016, USA.
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16
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Klintmalm G, O'Farrelly C. Taking the rap: multiple effects of blocking mammalian target of rapamycin. Hepatology 2013; 57:1-3. [PMID: 22767219 DOI: 10.1002/hep.25934] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Accepted: 06/15/2012] [Indexed: 02/06/2023]
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17
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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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18
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McKenna GJ, Trotter JF. Sirolimus conversion for renal dysfunction in liver transplant recipients: the devil really is in the details…. Am J Transplant 2012; 12:521-2. [PMID: 22300457 DOI: 10.1111/j.1600-6143.2011.03922.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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19
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Potter DA, Yee D, Guo Z, Rodriguez M. Should diabetic women with breast cancer have their own intervention studies? Endocr Relat Cancer 2012; 19:C13-7. [PMID: 22180498 PMCID: PMC3680369 DOI: 10.1530/erc-11-0309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This commentary on 'Calorie restriction and rapamycin inhibit MMTV-Wnt-1 mammary tumor growth in a mouse model of postmenopausal obesity' by Nogueira et al., published in this issue of Endocrine-Related Cancer, addresses the challenges of translating diet, exercise, and pharmacologic trials in diabetic mouse mammary tumor models to human studies. We propose that trials specifically designed to test such interventions in diabetic women with breast cancer would be valuable and informative.
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Affiliation(s)
- David A Potter
- Division of Hematology, Oncology and Transplantation, Masonic Cancer Center, University of Minnesota, 420 Delaware Street SouthEast, MMC 480, Minneapolis, Minnesota 55455-0392, USA.
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20
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Massoud O, Wiesner RH. The use of sirolimus should be restricted in liver transplantation. J Hepatol 2012; 56:288-90. [PMID: 21741926 DOI: 10.1016/j.jhep.2011.06.012] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Revised: 06/09/2011] [Accepted: 06/09/2011] [Indexed: 01/26/2023]
Abstract
Sirolimus and mTOR inhibitors are important additions to the therapeutic armamentarium to prevent allograft rejection, but their role in liver transplantation is evolving. De novo use of Sirolimus in the early post-transplant period has undoubtedly been influenced by the high incidence of hepatic artery thrombosis and decreased patient and graft survival leading to a black box warning. The jury remains undecided on the role of conversion from CNIs to mTOR inhibitors in those developing renal insufficiency and it must be noted that a second warning was issued by the FDA because of decreased survival in those conversion studies. Finally, the anti-atherogenic, antiviral, and anti-neoplastic effects associated with Sirolimus, which might favor their use in certain liver transplant patients, need further evaluation before firm recommendations can be made.
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21
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McKenna GJ, Trotter JF. Sirolimus--it doesn't deserve its bad Rap(a). J Hepatol 2012; 56:285-7. [PMID: 21781945 DOI: 10.1016/j.jhep.2011.06.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2010] [Revised: 06/09/2011] [Accepted: 06/09/2011] [Indexed: 12/04/2022]
Affiliation(s)
- Greg J McKenna
- Annette C and Harold C Simmons Transplant Institute, Baylor University Medical Center, 3410 Worth St, Suite 950, Dallas, TX 75246, USA.
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22
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Basso MS, Subramaniam P, Tredger M, Verma A, Heaton N, Rela M, Mieli-Vergani G, Dhawan A. Sirolimus as renal and immunological rescue agent in pediatric liver transplant recipients. Pediatr Transplant 2011; 15:722-7. [PMID: 22004546 DOI: 10.1111/j.1399-3046.2011.01560.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
CNI have improved the outcome of LT. However, their inherent potential to nephrotoxic and sometimes-inadequate immunosuppressive effect has lead to the usage of newer drugs like SRL. Aim of this study was to review children who received SRL. Thirty-seven (20 women) children post-LT, median age 10.4 yr (0.8-17.4) with a minimum follow-up of six months comprised the study group. Indications for SRL were biopsy-proven resistant acute allograft rejection (n = 12), early CR (n = 12), and CNI-induced nephropathy with MMF intolerance (n = 11). In two patients, the indication was the recurrence of BSEP disease in the allograft. In patients with acute rejection, AST normalized in 10/12 patients. In patients with CR, AST normalized in 6/12 patients. Those with renal impairment showed improvement in their creatinine levels from a mean baseline of 99-56.7 μm (p = 0.03) and their mean cystatin C was 1.02 after SRL. Side effects leading to discontinuation of SRL were seen in three patients. SRL was effective in rescuing patients with acute and chronic allograft rejection and improving renal function in CNI-induced nephropathy group.
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Affiliation(s)
- Maria-Sole Basso
- Paediatric Liver, GI and Nutrition Centre, Institute of Liver Studies, King's College Hospital, London, UK
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23
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Abstract
The introduction of calcineurin inhibitor (CNI) based immunosuppression has revolutionized the field of liver transplantation by dramatically reducing the incidence of acute cellular rejection and prolonging patient and allograft survival. However, the introduction of CNIs has also come at the price of increased patient morbidity, particularly with regard to the well-known nephrotoxic effects of the medications. In an effort to minimize the adverse effects, immunosuppression regimen have evolved to include the use of various induction agents and purine synthesis inhibitors to limit the dose of CNI necessary to achieve low acute cellular rejection rates. Careful assessments of risks and benefits are needed as these newer agents have their own side effect profiles. In addition, the impact of newer immunosuppression regimen on hepatitis C (HCV) recurrence has not been completely elucidated. This review will provide an overview of the most common immunosuppression regimen used in liver transplantation and discuss their impact on acute cellular rejection, patient and allograft survival, and HCV recurrence.
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Affiliation(s)
- Jayme E Locke
- Johns Hopkins Medical institutions, Department of Surgery, Division of Transplantation, Baltimore, MD, USA
| | - Andrew L Singer
- Johns Hopkins Medical institutions, Department of Surgery, Division of Transplantation, Baltimore, MD, USA
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A Decade of Experience Using mTor Inhibitors in Liver Transplantation. J Transplant 2011; 2011:913094. [PMID: 21461386 PMCID: PMC3064995 DOI: 10.1155/2011/913094] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2010] [Revised: 12/20/2010] [Accepted: 01/04/2011] [Indexed: 02/07/2023] Open
Abstract
Some studies suggest that Sirolimus (SRL) is associated with an increased risk of death in liver transplant recipients compared to treatment with calcineurin inhibitors (CNIs). We compared patients who received SRL or CNI in the first year after liver transplant. Our database included 688 patients who received a liver transplant. The patients were divided into groups. (1) CNI + MPS (mycophenolate sodium) at time of discharge. (2) CNI + MPS at time of discharge; SRL was added within the first 6 months and continued through the first year. (3) CNI + MPS at time of discharge; SRL was added within the first 6 months and discontinued before the first year. (4) SRL as primary immunosuppression. (5) SRL as primary immunosuppression and discontinued before the first year. We used mortality and graft loss as the primary measures of outcome. We also quantified renal function using the change in glomerular filtration rate (GFR), the presence of biopsy proven acute cellular reject (ACR), and steroid-resistant rejection (SRR). There were no significant differences in mortality or graft loss. There was no difference in patient or graft survival. Patients that received SRL as primary immunosuppression had 50% less rejection compared to controls.
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25
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Penninga L, Wettergren A, Chan AW, Steinbrüchel DA, Gluud C. Conversion of calcineurin inhibitor treatment to target of rapamycin inhibitor treatment versus continuation of calcineurin inhibitor treatment for liver transplant recipients. Cochrane Database Syst Rev 2010. [DOI: 10.1002/14651858.cd008853] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Luit Penninga
- Rigshospitalet, Copenhagen University Hospital; Copenhagen Trial Unit, Centre for Clinical Intervention Research, Dept 3344 & Surgery and Transplantation, Dept C2122; Blegdamsvej 9 Copenhagen Denmark DK-2100
| | - Andre Wettergren
- Copenhagen University Hospital Rigshospitalet; Department of Surgery and Transplantation C2122; Blegdamsvej 9 Copenhagen Denmark DK-2100-Ø
| | - An-Wen Chan
- 140 Simcoe St Suite 718, Toronto ON Canada M5H 4E9
| | - Daniel A Steinbrüchel
- Rigshospitalet, Copenhagen University Hospital, Dept 2152; Cardiothoracic Surgery; Blegdamsvej 9 Copenhagen Denmark DK-2100
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 3344, Rigshospitalet, Copenhagen University Hospital; Cochrane Hepato-Biliary Group; Blegdamsvej 9 Copenhagen Denmark DK-2100
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