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Andréasson K, Hamberg V, Wigén J, Westergren-Thorsson G. Is classifying SSc-ILD drugs as either immunosuppressive or anti-fibrotic misleading? Nat Rev Rheumatol 2023; 19:675. [PMID: 37605003 DOI: 10.1038/s41584-023-01013-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2023]
Affiliation(s)
- Kristofer Andréasson
- Section of Rheumatology, Department of Clinical Sciences, Lund University, Lund, Sweden.
| | - Viggo Hamberg
- Section of Rheumatology, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Jenny Wigén
- Lung Biology Unit, Department of Experimental Medical Science, Lund University, Lund, Sweden
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2
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Yang Z, Zhang L, Zhu H, Zhou K, Wang H, Wang Y, Su R, Guo D, Zhou L, Xu X, Song P, Zheng S, Xie H. Nanoparticle formulation of mycophenolate mofetil achieves enhanced efficacy against hepatocellular carcinoma by targeting tumour-associated fibroblast. J Cell Mol Med 2021; 25:3511-3523. [PMID: 33713546 PMCID: PMC8034467 DOI: 10.1111/jcmm.16434] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 02/15/2021] [Accepted: 02/20/2021] [Indexed: 12/15/2022] Open
Abstract
Hepatocellular carcinoma (HCC) is one of the most aggressive tumours with marked fibrosis. Mycophenolate mofetil (MMF) was well‐established to have antitumour and anti‐fibrotic properties. To overcome the poor bioavailability of MMF, this study constructed two MMF nanosystems, MMF‐LA@DSPE‐PEG and MMF‐LA@PEG‐PLA, by covalently conjugating linoleic acid (LA) to MMF and then loading the conjugate into polymer materials, PEG5k‐PLA8k and DSPE‐ PEG2k, respectively. Hepatocellular carcinoma cell lines and C57BL/6 xenograft model were used to examine the anti‐HCC efficacy of nanoparticles (NPs), whereas NIH‐3T3 fibroblasts and highly‐fibrotic HCC models were used to explore the anti‐fibrotic efficacy. Administration of NPs dramatically inhibited the proliferation of HCC cells and fibroblasts in vitro. Animal experiments revealed that MMF‐LA@DSPE‐PEG achieved significantly higher anti‐HCC efficacy than free MMF and MMF‐LA@PEG‐PLA both in C57BL/6 HCC model and highly‐fibrotic HCC models. Immunohistochemistry further confirmed that MMF‐LA@DSPE‐PEG dramatically reduced cancer‐associated fibroblast (CAF) density in tumours, as the expression levels of alpha‐smooth muscle actin (α‐SMA), fibroblast activation protein (FAP) and collagen IV were significantly downregulated. In addition, we found the presence of CAF strongly correlated with increased HCC recurrence risk after liver transplantation. MMF‐LA@DSPE‐PEG might act as a rational therapeutic strategy in treating HCC and preventing post‐transplant HCC recurrence.
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Affiliation(s)
- Zhentao Yang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Afliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou, China.,Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, Research Unit of Collaborative Diagnosis and Treatment for Hepatobiliary and Pancreatic Cancer, Chinese Academy of Medical Sciences (2019RU019), Hangzhou, China.,Key Laboratory of Organ Transplantation, Hangzhou, China
| | - Liang Zhang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Afliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou, China.,Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, Research Unit of Collaborative Diagnosis and Treatment for Hepatobiliary and Pancreatic Cancer, Chinese Academy of Medical Sciences (2019RU019), Hangzhou, China.,Key Laboratory of Organ Transplantation, Hangzhou, China
| | - Hai Zhu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Afliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou, China.,Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, Research Unit of Collaborative Diagnosis and Treatment for Hepatobiliary and Pancreatic Cancer, Chinese Academy of Medical Sciences (2019RU019), Hangzhou, China.,Key Laboratory of Organ Transplantation, Hangzhou, China
| | - Ke Zhou
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Afliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou, China.,Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, Research Unit of Collaborative Diagnosis and Treatment for Hepatobiliary and Pancreatic Cancer, Chinese Academy of Medical Sciences (2019RU019), Hangzhou, China.,Key Laboratory of Organ Transplantation, Hangzhou, China
| | - Hangxiang Wang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Afliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou, China.,Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, Research Unit of Collaborative Diagnosis and Treatment for Hepatobiliary and Pancreatic Cancer, Chinese Academy of Medical Sciences (2019RU019), Hangzhou, China.,Key Laboratory of Organ Transplantation, Hangzhou, China
| | - Yuchen Wang
- NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou, China.,Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, Research Unit of Collaborative Diagnosis and Treatment for Hepatobiliary and Pancreatic Cancer, Chinese Academy of Medical Sciences (2019RU019), Hangzhou, China.,Key Laboratory of Organ Transplantation, Hangzhou, China
| | - Rong Su
- NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou, China.,Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, Research Unit of Collaborative Diagnosis and Treatment for Hepatobiliary and Pancreatic Cancer, Chinese Academy of Medical Sciences (2019RU019), Hangzhou, China.,Key Laboratory of Organ Transplantation, Hangzhou, China
| | - Danjing Guo
- NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou, China.,Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, Research Unit of Collaborative Diagnosis and Treatment for Hepatobiliary and Pancreatic Cancer, Chinese Academy of Medical Sciences (2019RU019), Hangzhou, China.,Key Laboratory of Organ Transplantation, Hangzhou, China
| | - Lin Zhou
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Afliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou, China.,Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, Research Unit of Collaborative Diagnosis and Treatment for Hepatobiliary and Pancreatic Cancer, Chinese Academy of Medical Sciences (2019RU019), Hangzhou, China.,Key Laboratory of Organ Transplantation, Hangzhou, China
| | - Xiao Xu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Afliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou, China.,Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, Research Unit of Collaborative Diagnosis and Treatment for Hepatobiliary and Pancreatic Cancer, Chinese Academy of Medical Sciences (2019RU019), Hangzhou, China.,Key Laboratory of Organ Transplantation, Hangzhou, China
| | - Penghong Song
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Afliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou, China.,Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, Research Unit of Collaborative Diagnosis and Treatment for Hepatobiliary and Pancreatic Cancer, Chinese Academy of Medical Sciences (2019RU019), Hangzhou, China.,Key Laboratory of Organ Transplantation, Hangzhou, China
| | - Shusen Zheng
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Afliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou, China.,Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, Research Unit of Collaborative Diagnosis and Treatment for Hepatobiliary and Pancreatic Cancer, Chinese Academy of Medical Sciences (2019RU019), Hangzhou, China.,Key Laboratory of Organ Transplantation, Hangzhou, China
| | - Haiyang Xie
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Afliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou, China.,Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, Research Unit of Collaborative Diagnosis and Treatment for Hepatobiliary and Pancreatic Cancer, Chinese Academy of Medical Sciences (2019RU019), Hangzhou, China.,Key Laboratory of Organ Transplantation, Hangzhou, China
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3
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Ciancio G, Gaynor JJ, Guerra G, Roth D, Chen L, Kupin W, Mattiazzi A, Ortigosa-Goggins M, Moni L, Burke GW. Randomized trial of 3 maintenance regimens (TAC/SRL vs. TAC/MMF vs. CSA/SRL) with low-dose corticosteroids in primary kidney transplantation: 18-year results. Clin Transplant 2020; 34:e14123. [PMID: 33070366 DOI: 10.1111/ctr.14123] [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: 08/27/2020] [Revised: 10/05/2020] [Accepted: 10/10/2020] [Indexed: 12/21/2022]
Abstract
A randomized trial of 150 primary kidney transplant recipients, initiated in May 2000, compared tacrolimus (TAC)/sirolimus (SRL) vs. TAC/mycophenolate mofetil (MMF) vs. cyclosporine microemulsion (CSA)/SRL (N = 50/group). All patients received daclizumab induction and maintenance corticosteroids. With current median follow-up of 18 years post-transplant, biopsy-proven acute rejection (BPAR) occurred less often in TAC/MMF (26% (13/50)), vs. the TAC/SRL (36% (18/50)) and CSA/SRL (34% (17/50)) arms combined (p = .23), with statistical significance favoring TAC/MMF (p = .05) after controlling for the multivariable (Cox model) effects of recipient age, recipient race/ethnicity, and donor age. First BPAR rate was clearly more favorable for TAC/MMF after stratifying patients by having 0-1 (N = 72) vs. 2-3 (N = 78) unfavorable baseline characteristics (recipient age <50 years, African American or Hispanic recipient, and donor age ≥50 years) (p = .02). Mean estimated glomerular filtration rate (eGFR), using the CKD-EPI formula, was consistently higher for TAC/MMF, particularly after controlling for the multivariable effect of donor age, throughout the first 96 months post-transplant (p ≤ .008). These differences were translated into an observed more favorable graft failure due to immunologic cause (CAI/TG) rate for TAC/MMF (p = .06), although no significant differences in overall death-uncensored graft loss were observed. Previously reported significantly higher study drug discontinuation and requirement for antilipid therapy rates in the SRL-assigned arms were maintained over time. Overall, these results at 18 years post-transplant more definitively show that TAC/MMF should be the gold standard for achieving optimal, long-term maintenance immunosuppression in kidney transplantation.
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Affiliation(s)
- Gaetano Ciancio
- Miami Transplant Institute, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA.,The Lillian Jean Kaplan Renal Transplant Center of the Division of Transplantation, The DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Jeffrey J Gaynor
- Miami Transplant Institute, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA.,The Lillian Jean Kaplan Renal Transplant Center of the Division of Transplantation, The DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Giselle Guerra
- Miami Transplant Institute, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA.,Division of Nephrology, Department of Medicine, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
| | - David Roth
- Miami Transplant Institute, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA.,Division of Nephrology, Department of Medicine, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Linda Chen
- Miami Transplant Institute, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA.,The Lillian Jean Kaplan Renal Transplant Center of the Division of Transplantation, The DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Warren Kupin
- Miami Transplant Institute, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA.,Division of Nephrology, Department of Medicine, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Adela Mattiazzi
- Miami Transplant Institute, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA.,Division of Nephrology, Department of Medicine, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Mariella Ortigosa-Goggins
- Miami Transplant Institute, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA.,Division of Nephrology, Department of Medicine, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Lissett Moni
- Miami Transplant Institute, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA.,The Lillian Jean Kaplan Renal Transplant Center of the Division of Transplantation, The DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
| | - George W Burke
- Miami Transplant Institute, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA.,The Lillian Jean Kaplan Renal Transplant Center of the Division of Transplantation, The DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
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4
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Ji SM, Xie KN, Chen JS, Wen JQ, Cheng DR, Cheng DP, Li X, Ni XF, Liu ZH. Retrospective evaluation of the effect of mycophenolate mofetil dosage on survival of kidney grafts based on biopsy results. Transplant Proc 2015; 46:3383-9. [PMID: 25498056 DOI: 10.1016/j.transproceed.2014.09.107] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Revised: 08/21/2014] [Accepted: 09/17/2014] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Plasma concentration monitoring is commonly used to adjust immunosuppressant dosage in transplant recipients, but adjustment is often based on clinical experience rather than rigorous quantitative indicators. METHODS We examined the effect of mycophenolate mofetil (MMF) dosage on graft survival by pathologic and immunologic analysis of 88 kidney recipients who were given a postoperative immunosuppressive regimen of tacrolimus (FK506), MMF, and corticosteroids. Patients were given a conventional dosage (≥1.5 g/d; n = 40) or a reduced dosage (n = 48) of MMF owing to postoperative adverse side effects. RESULTS The reduced-dose group included patients given low doses (≤1.0 g/d; n = 27), ultra-low doses (≤0.5 g/d; n = 15), and those who discontinued MMF (n = 6). The dose reduction group had increased acute rejection, chronic rejection, and graft dysfunction, poorer pathologic scores, and increased cell infiltration of graft tissue (CD4, CD8, CD68, and CD138 positivity) and expression of interleukin-2R and HLA-DR. Finally, hazard analysis indicated that patients given low doses and ultra-low doses of MMF had poorer long-term kidney grafts survival (hazard ratios of 1.52 and 1.78, respectively). CONCLUSIONS These results indicate the importance of using an appropriate dosage of MMF in kidney transplant recipients.
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Affiliation(s)
- S-M Ji
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - K-N Xie
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - J-S Chen
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - J-Q Wen
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | | | - D-P Cheng
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - X Li
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - X-F Ni
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Z-H Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China. zhihong--
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5
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Yilmaz S. Chronic Allograft Nephropathy (Chronic Allograft Damage): Can It Be Avoided? CURRENT TRANSPLANTATION REPORTS 2014. [DOI: 10.1007/s40472-014-0009-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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6
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Pharmacology and toxicology of mycophenolate in organ transplant recipients: an update. Arch Toxicol 2014; 88:1351-89. [PMID: 24792322 DOI: 10.1007/s00204-014-1247-1] [Citation(s) in RCA: 139] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 04/15/2014] [Indexed: 12/22/2022]
Abstract
This review aims to provide an update of the literature on the pharmacology and toxicology of mycophenolate in solid organ transplant recipients. Mycophenolate is now the antimetabolite of choice in immunosuppressant regimens in transplant recipients. The active drug moiety mycophenolic acid (MPA) is available as an ester pro-drug and an enteric-coated sodium salt. MPA is a competitive, selective and reversible inhibitor of inosine-5'-monophosphate dehydrogenase (IMPDH), an important rate-limiting enzyme in purine synthesis. MPA suppresses T and B lymphocyte proliferation; it also decreases expression of glycoproteins and adhesion molecules responsible for recruiting monocytes and lymphocytes to sites of inflammation and graft rejection; and may destroy activated lymphocytes by induction of a necrotic signal. Improved long-term allograft survival has been demonstrated for MPA and may be due to inhibition of monocyte chemoattractant protein 1 or fibroblast proliferation. Recent research also suggested a differential effect of mycophenolate on the regulatory T cell/helper T cell balance which could potentially encourage immune tolerance. Lower exposure to calcineurin inhibitors (renal sparing) appears to be possible with concomitant use of MPA in renal transplant recipients without undue risk of rejection. MPA displays large between- and within-subject pharmacokinetic variability. At least three studies have now reported that MPA exhibits nonlinear pharmacokinetics, with bioavailability decreasing significantly with increasing doses, perhaps due to saturable absorption processes or saturable enterohepatic recirculation. The role of therapeutic drug monitoring (TDM) is still controversial and the ability of routine MPA TDM to improve long-term graft survival and patient outcomes is largely unknown. MPA monitoring may be more important in high-immunological recipients, those on calcineurin-inhibitor-sparing regimens and in whom unexpected rejection or infections have occurred. The majority of pharmacodynamic data on MPA has been obtained in patients receiving MMF therapy in the first year after kidney transplantation. Low MPA area under the concentration time from 0 to 12 h post-dose (AUC0-12) is associated with increased incidence of biopsy-proven acute rejection although AUC0-12 optimal cut-off values vary across study populations. IMPDH monitoring to identify individuals at increased risk of rejection shows some promise but is still in the experimental stage. A relationship between MPA exposure and adverse events was identified in some but not all studies. Genetic variants within genes involved in MPA metabolism (UGT1A9, UGT1A8, UGT2B7), cellular transportation (SLCOB1, SLCO1B3, ABCC2) and targets (IMPDH) have been reported to effect MPA pharmacokinetics and/or response in some studies; however, larger studies across different ethnic groups that take into account genetic linkage and drug interactions that can alter a patient's phenotype are needed before any clinical recommendations based on patient genotype can be formulated. There is little data on the pharmacology and toxicology of MPA in older and paediatric transplant recipients.
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Issa N, Kukla A, Ibrahim HN. Calcineurin inhibitor nephrotoxicity: a review and perspective of the evidence. Am J Nephrol 2013; 37:602-12. [PMID: 23796509 DOI: 10.1159/000351648] [Citation(s) in RCA: 161] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Accepted: 04/25/2013] [Indexed: 12/31/2022]
Abstract
BACKGROUND There is no doubt that acute calcineurin inhibitor (CNI) nephrotoxicity exists; however, chronic CNI nephrotoxicity is questionable at best. METHODS We reviewed the literature to identify original articles related to the use of CNIs in renal and nonrenal solid organ transplantation in order to examine the available evidence about their chronic nephrotoxicity and contribution to graft failure. RESULTS Early clinical experience and animal studies support the evidence of CNI nephrotoxicity. These findings evolved into the dogma that CNI nephrotoxicity is the major cause of late renal allograft failure. However, in transplanted kidneys the specific role of chronic CNI nephrotoxicity has been questioned. The emerging literature clearly highlights the lack of solid evidence for the role of CNIs as the sole and major injurious agents that cause chronic renal dysfunction and subsequent graft failure. Most of the evidence available to date is against complete CNI avoidance, and minimization appears to be a more viable strategy. It is becoming increasingly clear that the typical pathological lesions linked to chronic CNI use are highly nonspecific, and most of the chronic changes that have been attributed to chronic CNI nephrotoxicity are the consequences of previously unrecognized immunologic injuries. One needs to keep in mind that the potential risk of side effects of CNI use should be balanced against the risk of rejection. CONCLUSIONS More research should focus on addressing the true causes of chronic graft dysfunction rather than focusing on the overexaggerated contribution of CNIs to late graft loss.
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Affiliation(s)
- Naim Issa
- Division of Renal Diseases and Hypertension, University of Minnesota, Minneapolis, MN 55414, USA
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8
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Chapman JR. Do protocol transplant biopsies improve kidney transplant outcomes? Curr Opin Nephrol Hypertens 2013; 21:580-6. [PMID: 23042026 DOI: 10.1097/mnh.0b013e32835903f4] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW The research undertaken on 'protocol' renal transplant biopsies has provided a rich, if not the richest, approach to better understanding of the immune and nonimmune impacts upon the transplant. The purpose of this review is to detail how the direct benefit to the patient also lies in these renamed 'surveillance' biopsies. RECENT FINDINGS Undertaken at fixed time points after transplantation, biopsy provides individual diagnoses with which the clinician can vary immunosuppression both in intensity and in the type of agent used to modify pathological processes early in their course. Initial nonfunction from acute tubular necrosis, subclinical cellular and humoral rejection, calcineurin inhibitor nephrotoxicity, BK virus nephropathy and recurrent glomerulonephritis are all important diagnoses for which early intervention provides better therapeutic outcomes than delaying until they are clinically evident. SUMMARY This review provides the recent evidence that has convinced many transplant units to embark upon surveillance programmes for their patients in order to individualize their immunosuppression and thus gain better outcomes.
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Affiliation(s)
- Jeremy R Chapman
- Department of Renal Medicine, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia.
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9
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Rangel EB. The metabolic and toxicological considerations for immunosuppressive drugs used during pancreas transplantation. Expert Opin Drug Metab Toxicol 2012; 8:1531-48. [DOI: 10.1517/17425255.2012.724058] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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10
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Holdaas H, Midtvedt K, Åsberg A. A drug safety evaluation of everolimus in kidney transplantation. Expert Opin Drug Saf 2012; 11:1013-22. [PMID: 22954349 DOI: 10.1517/14740338.2012.722993] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Calcineurin inhibitors (CNI) have greatly reduced the rate of acute rejection and improved short-term graft survival after organ transplantation, however, long-term survival has hardly changed since their introduction. CNIs are believed to contribute to graft fibrosis, have side effects that adversely affect cardiovascular risk, and are associated with an increased rate of post-transplant malignancies. Everolimus, a mammalian target of rapamycin (mTOR) inhibitor, is not associated with graft fibrosis, has a superior cardiovascular risk profile to CNI therapy and has shown potential for the prevention and treatment of diverse forms of cancer. AREAS COVERED This review summarizes key aspects of everolimus, including its mechanism of action, pharmacokinetics, pharmacodynamics, drug-drug interactions and pivotal clinical studies with a focus on safety and efficacy. EXPERT OPINION Everolimus is effective in improving graft function in selected kidney transplant patients. Most adverse events are present for a short time after the introduction of everolimus, and are manageable. Everolimus has the potential to become an important agent in de novo and maintenance immunotherapy in kidney transplant recipients.
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Affiliation(s)
- Hallvard Holdaas
- Oslo University Hospital, Department of Transplant Medicine, Section of Nephrology, Rikshospitalet, Postbox 4950 Nydalen, N-0424 Oslo, Norway.
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11
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Abstract
The discovery and use of cyclosporine since its inception into clinical use in the late 1970s has played a major role in the advancement of transplant medicine. While it has improved rates of acute rejection and early graft survival, data on long-term survival of renal allografts is less convincing. The finding of acute reversible nephrotoxicity and nephrotoxicity in nonrenal transplants has since led to the widely accepted view that there is a chronic more irreversible component to this agent as well. Since that time, there has been intense interest in finding protocols which seek to minimize and even avoid the use of calcineurin inhibitors altogether. We seek to review cyclosporine in terms of its mechanism of action, pathophysiologic, and histologic features associated with acute and chronic nephrotoxicity and recent studies looking to avoid its toxic side effects.
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12
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13
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Henderson LK, Nankivell BJ, Chapman JR. Surveillance protocol kidney transplant biopsies: their evolving role in clinical practice. Am J Transplant 2011; 11:1570-5. [PMID: 21797971 DOI: 10.1111/j.1600-6143.2011.03677.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Protocol renal allograft biopsies at fixed time points from transplantation have aided research and provided insights into the pathogenesis of early and late allograft injury. Their role is evolving from research to a clinical management tool needed to detect subclinical pathology requiring treatment adjustment. They frequently reveal unexpected findings and influence therapy in the majority of patients. Detection of subclinical rejection (SCR) remains important despite declining prevalence with triple therapy, the evidence favors treatment, if found. Surveillance biopsies in steroid avoidance and calcineurin inhibitor (CNI) withdrawal programs provide an important safety net against the increased rates of late acute and SCR. Individualization of therapy in high-risk patients and safe reduction of immunosuppression in standard risk individuals becomes possible. Other potentially reversible chronic pathologies that may be detected, include chronic T-cell or antibody-mediated rejection, recurrent disease, BK virus-associated nephropathy, interstitial fibrosis and tubular atrophy and CNI nephrotoxicity, allowing modifications of therapy to limit ongoing graft injury. Biopsy is safe and inexpensive compared with costs of earlier graft failure and return to dialysis. This review summarizes current evidence on use of surveillance histology for the clinical practice of renal transplantation.
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Affiliation(s)
- L K Henderson
- Department of Renal Medicine, Westmead Hospital, University of Sydney, Australia
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14
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Affiliation(s)
- Arthur J Matas
- Division of Transplantation, Department of Surgery, University of Minnesota, MN, USA.
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15
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Kornberg A, Küpper B, Thrum K, Krause B, Büchler P, Kornberg J, Sappler A, Altendorf-Hofmann A, Wilberg J, Friess H. Sustained renal response to mycophenolate mofetil and CNI taper promotes survival in liver transplant patients with CNI-related renal dysfunction. Dig Dis Sci 2011; 56:244-51. [PMID: 20824504 DOI: 10.1007/s10620-010-1386-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2010] [Accepted: 08/04/2010] [Indexed: 12/22/2022]
Abstract
AIM The aim of this trial was to evaluate the impact of conversion from a calcineurin-inhibitor (CNI)-based immunosuppressive regimen to mycophenolate mofetil (MMF) and reduced-dose CNI on long-term renal function and survival in a series of 63 liver transplant patients with CNI-induced renal dysfunction. METHODS CNI dosage was significantly tapered after introduction of 2,000 mg MMF per day. Renal function was assessed by determination of serum creatinine levels and calculated creatinine clearance (CCl). The impact of relevant clinical parameters on renal function and survival post-conversion was analyzed by univariate and multivariate analysis. RESULTS At 60 months post-conversion, mean creatinine level had significantly declined from 197.2±58.3 μmol/l at baseline to 160.0±76.5 μmol/l, and mean CCl has significantly increased from 38.4±13.4 ml/min at baseline to 47.9±21.1 ml/min (p<0.001), respectively. Forty-six patients (73.1%) demonstrated sustained renal response to modified immunosuppression. Full-dose MMF medication (p=0.006) and the early conversion (p=0.02) were identified as independent predictors of persistent renal function improvement. Sustained renal response to MMF plus reduced-dose CNI was identified as the most relevant independent promoter of long-term survival (hazard ratio 6.9). Five-year survival rate post-conversion was 93.9% in renal responders and 64.3% in renal non-responders (log rank<0.001). CONCLUSIONS Sustained renal response to MMF and CNI dose reduction promotes long-term survival in liver transplant patients with CNI-induced renal dysfunction.
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Affiliation(s)
- A Kornberg
- Department of Surgery, Klinikum Rechts der Isar, TU Munich, Ismaningerstr. 22, 81675, Munich, Germany.
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16
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Conversion to combined mycophenolate mofetil and low-dose calcineurin inhibitor therapy for renal dysfunction in liver transplant patients: never too late? Dig Dis Sci 2011; 56:4-6. [PMID: 21049289 PMCID: PMC3010221 DOI: 10.1007/s10620-010-1449-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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17
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Blydt-Hansen TD, Gibson IW, Birk PE. Histological progression of chronic renal allograft injury comparing sirolimus and mycophenolate mofetil-based protocols. A single-center, prospective, randomized, controlled study. Pediatr Transplant 2010; 14:909-18. [PMID: 20880093 DOI: 10.1111/j.1399-3046.2010.01374.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
In an effort to mitigate progression of IF/TA associated with chronic renal allograft injury, we hypothesize that adjuvant immunosuppression with sirolimus (SRL) will delay progression compared with MMF. Subjects 5-17 yr old, >1-yr post-transplant with mild or moderate IF/TA (Banff criteria) and tacrolimus dose minimization were randomized to continue MMF or convert to SRL and followed for two yr. For the entire cohort (n = 20), there was significant progression of %GGS, ci, ct, cv, and ah scores over the follow-up period (p < 0.05). There was no difference in rates of progression of Banff scores, %GGS, or % IF over two yr between the two groups, though power was low. Both groups exhibited similar rates of eGFR decline (MMF: -12.3 vs. SRL: -11.8 mL/min/1.73 m²/yr), which was correlated with ct score (p < 0.05). The SRL group had more episodes of acute allograft dysfunction and oral ulcers. Proteinuria at 24 months was significantly increased in the SRL group (6/9 subjects) but was not correlated with eGFR or %GGS. We conclude that neither MMF nor SRL, combined with low-dose tacrolimus, was effective at mitigating progressive histological changes or functional decline associated with chronic renal allograft injury.
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Affiliation(s)
- Tom D Blydt-Hansen
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, MB, Canada.
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18
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Dell'Oglio MP, Zaza G, Rossini M, Divella C, Pontrelli P, Verrienti R, Rutigliano M, Ditonno P, Stifanelli P, Ancona N, Schena FP, Grandaliano G. The anti-fibrotic effect of mycophenolic acid-induced neutral endopeptidase. J Am Soc Nephrol 2010; 21:2157-68. [PMID: 20864690 DOI: 10.1681/asn.2010020181] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Mycophenolic acid (MPA) appears to have anti-fibrotic effects, but the molecular mechanisms underlying this are unknown. We prospectively studied 35 stable kidney transplant recipients maintained on cyclosporine and azathioprine. We converted 20 patients from azathioprine to enteric-coated mycophenolate sodium (EC-MPS) and continued the remaining 15 patients on azathioprine. Exploratory mRNA expression profiling, performed on five randomly selected EC-MPS patients, revealed significant upregulation of neutral endopeptidase (NEP), which is an enzyme that degrades angiotensin II. We confirmed these microarray data by measuring levels of NEP expression in all subjects; in addition, we found that NEP gene expression correlated inversely with proteinuria. In an additional 33 patients, glomerular and tubular NEP protein levels from renal graft biopsies were significantly higher among the 13 patients receiving cyclosporine + EC-MPS than among the 12 patients receiving cyclosporine + azathioprine or 8 patients receiving cyclosporine alone. Glomerular NEP expression inversely correlated with glomerulosclerosis and proteinuria, and tubular NEP expression inversely correlated with interstitial fibrosis. Incubation of human proximal tubular cells with MPA increased NEP gene expression in a dose- and time-dependent manner. Moreover, MPA reduced angiotensin II-induced expression of the profibrotic factor plasminogen activator inhibitor-1, and a specific NEP inhibitor completely reversed this effect. Taken together, our data suggest that MPA directly induces expression of neutral endopeptidase, which may reduce proteinuria and slow the progression of renal damage in kidney transplant recipients.
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Affiliation(s)
- Maria Pia Dell'Oglio
- Renal, Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
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19
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Heilman RL, Mazur MJ, Reddy KS. Immunosuppression in simultaneous pancreas-kidney transplantation: progress to date. Drugs 2010; 70:793-804. [PMID: 20426494 DOI: 10.2165/11535430-000000000-00000] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Simultaneous pancreas-kidney transplantation (SPKT) is the treatment of choice for patients with end-stage renal failure due to type 1 diabetes mellitus. With advances in surgical techniques and immunosuppression management, outcomes have improved, with current 1- and 10-year pancreas graft survival rates of 86% and 53%, respectively. Induction therapy with either alemtuzumab or rabbit antithymocyte globulin (rATG) in combination with a calcineurin inhibitor (CNI) and mycophenolate mofetil (MMF) or sirolimus appears to be safe and effective in the setting of rapid steroid withdrawal (RSW), with excellent graft survival and low rejection rates. There are no large randomized trials between alemtuzumab and rATG to determine whether one is better than the other. Anti-interleukin (IL)-2 receptor antibody induction and no induction in combination with a CNI, MMF or sirolimus, and prednisone have demonstrated excellent graft survival rates but are associated with a higher incidence of acute rejection. The efficacy of anti-IL-2 receptor antibodies or no induction in the setting of RSW is unproven. Both of the CNIs, ciclosporin and tacrolimus, are effective in preventing acute rejection in SPKT recipients; however, pancreas allograft survival may be better with tacrolimus. MMF is more effective than azathioprine in preventing acute rejection. Sirolimus appears to be effective in preventing acute rejection, but the combination of sirolimus with a CNI may accentuate the nephrotoxicity of the CNI. RSW with induction therapy is safe and effective in SPKT recipients, but longer follow-up data on outcomes are needed. Recent analysis of registry data shows that most transplant centres are using an induction agent followed by a combination of tacrolimus, MMF and corticosteroids in SPKT recipients.
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Affiliation(s)
- Raymond L Heilman
- Department of Medicine, Mayo Clinic Arizona, Phoenix, Arizona 85054, USA.
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20
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Semedo P, Donizetti-Oliveira C, Burgos-Silva M, Cenedeze MA, Avancini Costa Malheiros DM, Pacheco-Silva A, Câmara NOS. Bone marrow mononuclear cells attenuate fibrosis development after severe acute kidney injury. J Transl Med 2010; 90:685-95. [PMID: 20308984 DOI: 10.1038/labinvest.2010.45] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
One of the early phases that lead to fibrosis progression is inflammation. Once this stage is resolved, fibrosis might be prevented. Bone marrow mononuclear cells (BMMCs) are emerging as a new therapy for several pathologies, including autoimmune diseases, because they enact immunosuppression. In this study we aimed to evaluate the role of BMMC administration in a model of kidney fibrosis induced by an acute injury. C57Bl6 mice were subjected to unilateral severe ischemia by clamping the left renal pedicle for 1h. BMMCs were isolated from femurs and tibia, and after 6h of reperfusion, 1 x 10(6) cells were administrated intraperitoneally. At 24h after surgery, treated animals showed a significant decrease in creatinine and urea levels when compared with untreated animals. Different administration routes were tested. Moreover, interferon (IFN) receptor knockout BMMCs were used, as this receptor is necessary for BMMC activation. Labeled BMMCs were found in ischemic kidney on FACS analysis. This improved outcome was associated with modulation of inflammation in the kidney and systemic modulation, as determined by cytokine expression profiling. Despite non-amelioration of functional parameters, kidney mRNA expression of interleukin (IL)-6 at 6 weeks was lower in BMMC-treated animals, as were levels of collagen 1, connective tissue growth factor (CTGF), transforming growth factor-beta (TGF-beta) and vimentin. Protective molecules, such as IL-10, heme oxygenase 1 (HO-1) and bone morphogenetic 7 (BMP-7), were increased in treated animals after 6 weeks. Moreover, Masson and Picrosirius red staining analyses showed less fibrotic areas in the kidneys of treated animals. Thus, early modulation of inflammation by BMMCs after an ischemic injury leads to reduced fibrosis through modulation of early inflammation.
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Affiliation(s)
- Patricia Semedo
- Experimental and Clinical Immunology Laboratory, Division of Nephrology, Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, Brazil
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21
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Impact of different long-term maintenance immunosuppressive therapy strategies on patients' outcome after heart transplantation. Transpl Immunol 2010; 23:93-103. [PMID: 20434559 DOI: 10.1016/j.trim.2010.04.007] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2009] [Revised: 04/13/2010] [Accepted: 04/21/2010] [Indexed: 01/09/2023]
Abstract
The introduction of cyclosporine in the early 1980s meant a decisive improvement in post-transplant outcomes for all solid-organ transplants and, in particular, it allowed heart transplantation to emerge as a viable therapeutic option for patients with end-stage cardiac failure. Many factors, including recipient and donor selection, organ preservation and the technical aspects of the transplant itself, influence post-operative outcomes following heart transplantation but the continued need to treat the recipient's immune response plays a key role in determining long-term outcomes. Thereby interactions between immunosuppressive drugs used in different combinations play an important role in patients' outcome. After more than two decades, significant controversy still exists as to the best immunosuppressive regimen for long-term maintenance. During the 1990s and 2000s, newer immunosuppressive medications, specifically, tacrolimus, mycophenolate mofetil, sirolimus, everolimus and the IL-2 receptor blockers (daclizumab and basiliximab), were introduced that allow the clinician several options to try to minimize side effects and maximize the desired therapeutic effects. The side effects involve direct organ toxicity (e.g. renal and hepatic dysfunction), metabolic disturbances, (e.g. diabetes, hyperlipidemia and hypertension), neurotoxicity, and several other significant adverse events, such as cholestasis and myelosuppression. Newer immunosuppressive drugs can impair wound healing, induce lung toxicity and produce various cytopenic states. Steroids continue to plague patients with their well-known side effects. This article reviews the current data on the benefits and risks of the various therapeutic regimens available, which are analyzed under three main themes: calcineurin inhibitor based therapies, calcineurin minimization protocols and calcineurin free regimens.
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22
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Long-Term Improvement of Deceased Donor Renal Allograft Survival Since 1996: A Single Transplant Center Study. Transplantation 2010; 89:714-20. [DOI: 10.1097/tp.0b013e3181c892dd] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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23
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Gaston RS. Chronic calcineurin inhibitor nephrotoxicity: reflections on an evolving paradigm. Clin J Am Soc Nephrol 2009; 4:2029-34. [PMID: 19850771 DOI: 10.2215/cjn.03820609] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Use of the calcineurin inhibitors (CNI) cyclosporine and tacrolimus has revolutionized solid organ transplantation. For more than 30 yr, the transplant community has dealt with nephrotoxicity attributed to these agents. Acute renal vasoconstriction (as described by many investigators, including John Curtis and colleagues) is the unequivocal consequence of their use; chronic CNI nephropathy, although indistinct in terms of histology and pathophysiology, has become accepted as a major cause of late kidney allograft failure. This article examines clinical, laboratory, and histologic findings that evolved into a paradigm that was never fully consistent with observed outcomes and new evidence that may offer an alternative interpretation for adverse events that are attributed to CNI nephrotoxicity in kidney transplant recipients.
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Affiliation(s)
- Robert S Gaston
- Division of Nephrology, 625 THT, University of Alabama at Birmingham, Birmingham, AL 35294, USA.
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24
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Gaston RS, Kaplan B, Shah T, Cibrik D, Shaw LM, Angelis M, Mulgaonkar S, Meier-Kriesche HU, Patel D, Bloom RD. Fixed- or controlled-dose mycophenolate mofetil with standard- or reduced-dose calcineurin inhibitors: the Opticept trial. Am J Transplant 2009; 9:1607-19. [PMID: 19459794 DOI: 10.1111/j.1600-6143.2009.02668.x] [Citation(s) in RCA: 126] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Mycophenolate mofetil (MMF) was developed with cyclosporine as a fixed-dose immunosuppressant. More recent data indicate a relationship between mycophenolic acid (MPA) exposure in individuals and clinical endpoints of rejection and toxicity. This 2-year, open-label, randomized, multicenter trial compared the efficacy and safety of concentration-controlled MMF (MMF(CC)) dosing with a fixed-dose regimen in 720 kidney recipients. Patients received either (A) MMF(CC) and reduced-level calcineurin inhibitor (MMF(CC)/CNI(RL)); (B) MMF(CC) and standard-level CNI (MMF(CC)/CNI(SL)); or (C) fixed-dose MMF and CNI(SL) (MMF(FD)/CNI(SL)). Antibody induction and steroid use were according to center practice. The primary endpoint was noninferiority (alpha= 0.05) of group A versus group C for treatment failure (including biopsy-proven acute rejection [BPAR], graft loss and death) at 1 year. Although mean CNI trough levels in group A did not reach the prespecified targets, they were statistically lower than those in groups B and C (p < or = 0.01 for each comparison). BPAR rates (8.5%) were low across groups. Group A had 19% fewer treatment failures (23% vs. 28%, p = 0.18). MMF doses were highest (p < 0.05), with withdrawals for adverse events the fewest (p = 0.02), in group A. Of the 80% of subjects taking tacrolimus (Tac), those with higher MPA exposure had significantly less rejection (p < 0.001) and diarrhea correlated with Tac, but not with MPA levels. Thus, MMF(CC) with low-dose CNI resulted in outcomes not inferior to those with standard CNI exposure and MMF(FD), indicating potential utility of MMF(CC) in CNI-sparing regimens.
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Affiliation(s)
- R S Gaston
- University of Alabama at Birmingham, Birmingham, AL, USA.
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25
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Lake J, Patel D, David K, Richwine J, Morris J. The association between MMF and risk of progressive renal dysfunction and death in adult liver transplant recipients with HCV. Clin Transplant 2009; 23:108-15. [DOI: 10.1111/j.1399-0012.2008.00916.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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26
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Chaigne-Delalande B, Guidicelli G, Couzi L, Merville P, Mahfouf W, Bouchet S, Molimard M, Pinson B, Moreau JF, Legembre P. The immunosuppressor mycophenolic acid kills activated lymphocytes by inducing a nonclassical actin-dependent necrotic signal. THE JOURNAL OF IMMUNOLOGY 2008; 181:7630-8. [PMID: 19017951 DOI: 10.4049/jimmunol.181.11.7630] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Mycophenolate mofetil (MMF) is an immunosuppressive agent used in transplantation. Over the last decade, MMF has also emerged as an alternative therapeutic regimen for autoimmune diseases, mainly for patients refractory to other therapies. The active compound of MMF, mycophenolic acid (MPA), depletes the intracellular pool of guanosine tri-phosphate through inosine monophosphate dehydrogenase blockade. The molecular mechanism involved in the elimination of T and B lymphocytes upon inhibition of inosine monophosphate dehydrogenase remains elusive. In this study, we showed that in contrast to the immunosuppressors azathioprine, cyclosporin A, and tacrolimus, MPA killed lymphocytes through the activation of a caspase-independent necrotic signal. Furthermore, the MPA-mediated necrotic signal relied on the transmission of a novel intracellular signal involving Rho-GTPase Cdc42 activity and actin polymerization. In addition to its medical interest, this study sheds light on a novel and atypical molecular mechanism leading to necrotic cell death.
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27
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Jorge S, Guerra J, Santana A, Mil-Homens C, Prata MM. Mycophenolate mofetil: ten years' experience of a renal transplant unit. Transplant Proc 2008; 40:700-4. [PMID: 18454991 DOI: 10.1016/j.transproceed.2008.02.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Mycophenolate mofetil (MMF) use in renal transplantation has allowed a significant decrease in early acute rejection rates. We retrospectively evaluated the incidence of acute rejection episodes, renal function at the first year posttransplant, patient and graft survivals, cytomegalovirus (CMV) infection rate, influence of the degree of sensitization, and number of MHC antigen mismatches on graft survival in two groups of patients receiving either MMF or azathioprine. Group 1 included 149 patients receiving cyclosporine, MMF, and prednisolone; group 2 included 191 patients receiving cyclosporine, azathioprine, and prednisolone. The two groups did not differ in terms of age, sex, degree of sensitization (expressed as percentage of antibodies reactive to panel), MHC mismatch number, cold ischemia time, donor age, or anti-thymocyte globulin induction. In group 1 (MMF) there was a significant decrease in early acute rejection rate (19% vs 57%, P < .0001), longer graft survival at 10 years (92% vs 75%, P = .006), and higher rate of CMV infection (22% vs 12%, P = .004). Renal function at the first year posttransplant and patient survival during follow-up did not differ between the groups. The degree of sensitization influenced graft survival in group 2. The number of MHC mismatches did not influence graft survival in either group. With MMF, there was a significant reduction in early acute rejection rate, a significant increase in graft survival at 10-year follow-up, and diminished impact of the degree of sensitization on graft survival.
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Affiliation(s)
- S Jorge
- Serviço de Nefrologia e Transplantação Renal, Hospital de Santa Maria, Lisboa, Portugal.
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28
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Hanvesakul R, Kubal C, Jham S, Sarkar E, Eardley K, Adu D, Cockwell P. Increased incidence of infections following the late introduction of mycophenolate mofetil in renal transplant recipients. Nephrol Dial Transplant 2008; 23:4049-53. [PMID: 18622022 DOI: 10.1093/ndt/gfn387] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Late introduction of mycophenolate mofetil (MMF) is used in renal transplant patients to allow calcineurin inhibitor (CNI) withdrawal. This change in treatment may alter the immunosuppressive load predisposing patients to infections. To assess this we have analysed infection rates in 30 consecutive patients with chronic allograft nephropathy commenced on MMF for CNI withdrawal. Methods and results. The study period was from 12 months pre-commencement to 12 months post-commencement. At commencement, patient mean age was 51.2 +/- 12.9 years and mean time post-transplant was 3170 +/- 2130 days. Estimated glomerular filtration rate (eGFR) at the start of the study period and at conversion was 30.7 +/- 12.1 ml/min and 23.1 +/- 9.9 ml/min, respectively. The mean dose of MMF post-conversion was 1575 +/- 428 mg/day. Estimated GFR had stabilized at 12 months post-conversion to 25.3 +/- 12.2 ml/min. There was a significant increase in infections following conversion: pre-conversion, 26.7% (8/30); post-conversion, 66.6% (20/30) (chi(2) = 24.5, P < 0.0005). There was an inverse correlation between eGFR at conversion and infection rates post-conversion (r = -0.379, P = 0.039). There were no hospitalizations for infection pre-conversion and 6 patients (20%) were hospitalized post-conversion, for a total of 285 days (7-107). CONCLUSION There is significant morbidity associated with an increased incidence of infection after late introduction of MMF at standard doses in renal transplant recipients. This risk may be related to GFR at the time of conversion.
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Affiliation(s)
- Rajesh Hanvesakul
- Department of Nephrology and Renal Transplantation, University Hospital Birmingham, Edgbaston, Birmingham, UK.
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Srinivas TR, Meier-Kriesche HU. Minimizing immunosuppression, an alternative approach to reducing side effects: objectives and interim result. Clin J Am Soc Nephrol 2008; 3 Suppl 2:S101-16. [PMID: 18308998 PMCID: PMC3152278 DOI: 10.2215/cjn.03510807] [Citation(s) in RCA: 107] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Exceptionally low acute rejection rates and excellent graft survival can be achieved with cyclosporine and tacrolimus (CNI)-based immunosuppressive protocols that incorporate antiproliferative immunosuppressants and corticosteroids. However, despite short-term success, long-term attrition of graft function and side effects of immunosuppressive agents continue to be significant problems, leaving clinicians looking for possible interventions. CNI nephrotoxicity is but one of numerous factors that may contribute to long-term damage in transplant kidneys. Metabolic, cosmetic, and neuropsychiatric complications of steroids affect quality of life after transplantation. Newer immunosuppressive agents such as mycophenolate mofetil and sirolimus (Rapa) have raised the possibility of withdrawing or avoiding CNIs or steroids altogether. In this report we review studies that address either CNI or steroid minimization strategies and discuss their risks versus benefits. Given the accumulated experience to date, in our opinion the use of CNIs and steroids as part of immunosuppressive regimens remains the proven standard of care for renal transplant patients. The long-term safety and efficacy of CNI and steroid minimization strategies needs to be further validated in controlled clinical trials with adequate long-term follow-up.
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Affiliation(s)
- Titte R. Srinivas
- Division of Nephrology, Hypertension and Transplantation, University of Florida, Gainesville, Florida
| | - Herwig-Ulf Meier-Kriesche
- Division of Nephrology, Hypertension and Transplantation, University of Florida, Gainesville, Florida
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30
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Cicinnati VR, Yu Z, Klein CG, Sotiropoulos GC, Saner F, Malagó M, Frilling A, Gerken G, Broelsch CE, Beckebaum S. Clinical trial: switch to combined mycophenolate mofetil and minimal dose calcineurin inhibitor in stable liver transplant patients--assessment of renal and allograft function, cardiovascular risk factors and immune monitoring. Aliment Pharmacol Ther 2007; 26:1195-208. [PMID: 17944734 DOI: 10.1111/j.1365-2036.2007.03466.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Calcineurin inhibitor (CNI)-related nephrotoxicity significantly contributes to chronic renal failure after liver transplantation. METHODS In this prospective study, liver transplantation patients with renal dysfunction were randomized either to receive mycophenolate mofetil (MMF) followed by stepwise reduction of CNI with defined minimal CNI-trough levels (MMF group), or to continue their maintenance CNI dose (control group). Immune monitoring was performed in a subgroup of the patients. RESULTS In the MMF group (n = 50), renal function assessed by serum creatinine improved >10% in 62% of patients, was stable in 36% and deteriorated >10% in 2% after 12 months compared with baseline values. Mean serum creatinine levels (+/- s.d.) significantly decreased from 1.90 +/- 0.44 mg/dL to 1.61 +/- 0.39 mg/dL and the corresponding calculated glomerular filtration rate significantly increased from 38.8 +/- 9.6 mL/min/1.73 m(2) to 47.0 +/- 11.8 mL/min/1.73 m(2) over a 12-month follow-up period. Blood pressure and levels of liver enzymes significantly decreased. In the control group (n = 25), there were no significant changes with respect to the investigated parameters. The MMF group had significantly lower numbers of circulating cytotoxic T cells compared with the controls; whereas regulatory T cells significantly increased. CONCLUSION Combined MMF and minimal dose CNI therapy after liver transplantation is nephroprotective and may promote allograft tolerance.
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Affiliation(s)
- V R Cicinnati
- Department of Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany
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31
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Guerra G, Srinivas TR, Meier-Kriesche HU. Calcineurin inhibitor-free immunosuppression in kidney transplantation. Transpl Int 2007; 20:813-27. [PMID: 17645419 DOI: 10.1111/j.1432-2277.2007.00528.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The introduction of calcineurin inhibitors (CNI) revolutionized kidney transplantation (KTx). Exceptionally low acute rejection rates and excellent graft survival could be achieved with CNI-based (cyclosporine and tacrolimus) immunosuppressive protocols. However, despite short-term success, long-term graft attrition continues to be a significant problem, thus leaving clinicians looking for possible interventions. CNI nephrotoxicity is but one of numerous factors that may be contributing to long-term damage in transplant kidneys. Therefore, newer immunosuppressive agents such as mycophenolate mofetil and sirolimus (Rapa) have raised the possibility of withdrawing or avoiding CNIs altogether. Protocols exploring these options have gained greater attention over the last few years. Herein, we review studies addressing either CNI withdrawal or CNI avoidance strategies as well as discuss the risks versus benefits of these protocols. Given the accumulated experience to date, in our opinion, the use of CNIs as a part of immunosuppressive regimens remains the proven standard of care for renal transplant patients. The long-term safety and efficacy of CNI withdrawal and avoidance strategies need to be further validated in controlled clinical trials.
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Affiliation(s)
- Giselle Guerra
- Division of Nephrology, Hypertension and Transplantation, College of Medicine, University of Florida, Gainesville, FL 32610-0224, USA
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