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Butler L, Tomkins-Netzer O, Reiser O, Niederer RL. Management of Scleritis in Older Adults. Drugs Aging 2024; 41:287-302. [PMID: 38441778 PMCID: PMC11021297 DOI: 10.1007/s40266-024-01105-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2024] [Indexed: 04/17/2024]
Abstract
Scleritis, an inflammatory disease of the eye affecting scleral tissue, presents unique challenges in the older adult population. Unlike their younger counterparts, older individuals manifest a distinct spectrum of the disease with different underlying etiologies, co-morbidities, altered immune function, and an increased risk of systemic side effects from medication choices. Addressing these complexities necessitates a comprehensive and multidisciplinary approach. Treatment of choice will depend on any underlying cause but generally involves non-steroidal anti-inflammatory drugs, systemic or local corticosteroids, and potentially disease-modifying anti-rheumatic drugs. Utilization of these therapeutic agents in older adults warrants careful consideration because of their potential side-effect profiles. This article critically examines the specific concerns for the use of these drugs in older patients and reviews the existing literature on their use in this specific cohort.
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Affiliation(s)
- Laura Butler
- Department of Ophthalmology, University of Auckland, 85 Park Road, Grafton, Auckland, 1023, New Zealand
| | - Oren Tomkins-Netzer
- Department of Ophthalmology, Lady Davis Carmel Medical Centre, Haifa, Israel
- Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Or Reiser
- Department of Ophthalmology, Lady Davis Carmel Medical Centre, Haifa, Israel
| | - Rachael L Niederer
- Department of Ophthalmology, University of Auckland, 85 Park Road, Grafton, Auckland, 1023, New Zealand.
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2
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Jallah BP, Kuypers DRJ. Impact of Immunosenescence in Older Kidney Transplant Recipients: Associated Clinical Outcomes and Possible Risk Stratification for Immunosuppression Reduction. Drugs Aging 2024; 41:219-238. [PMID: 38386164 DOI: 10.1007/s40266-024-01100-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2024] [Indexed: 02/23/2024]
Abstract
The number of older individuals receiving a kidney transplant as replacement therapy has significantly increased in the past decades and this increase is expected to continue. Older patients have a lower rate of acute rejection but an increased incidence of death with a functioning graft. Several factors, including an increased incidence of infections, post-transplant malignancy and cardiovascular comorbidity and mortality, contribute to this increased risk. Notwithstanding, kidney transplantation is still the best form of kidney replacement therapy in all patients with chronic kidney disease, including in older individuals. The best form of immunosuppression and the optimal dose of these medications in older recipients remains a topic of discussion. Pharmacological studies have usually excluded older patients and when included, patients were highly selected and their numbers insignificant to draw a reasonable conclusion. The reduced incidence of acute rejection in older recipients has largely been attributed to immunosenescence. Immunosenescence refers to the aging of the innate and adaptive immunity, accumulating in phenotypic and functional changes. These changes influences the response of the immune system to new challenges. In older individuals, immunosenescence is associated with increased susceptibility to infectious pathogens, a decreased response after vaccinations, increased risk of malignancies and cardiovascular morbidity and mortality. Chronic kidney disease is associated with premature immunosenescent changes, and these are independent of aging. The immunosenescent state is associated with low-grade sterile inflammation termed inflammaging. This chronic low-grade inflammation triggers a compensatory immunosuppressive state to avoid further tissue damage, leaving older individuals with chronic kidney disease in an immune-impaired state before kidney transplantation. Immunosuppression after transplantation may further enhance progression of this immunosenescent state. This review covers the role of immunosenescence in older kidney transplant recipients and it details present knowledge of the changes in chronic kidney disease and after transplantation. The impact of immunosuppression on the progression and complications of an immunosenescent state are discussed, and the future direction of a possible clinical implementation of immunosenescence to individualize/reduce immunosuppression in older recipients is laid out.
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Affiliation(s)
- Borefore P Jallah
- Department of Nephrology and Renal Transplantation, University Hospital Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Dirk R J Kuypers
- Department of Nephrology and Renal Transplantation, University Hospital Leuven, Herestraat 49, 3000, Leuven, Belgium.
- Department of Microbiology, Immunology and Transplantation, University of Leuven, Leuven, Belgium.
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3
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Kapse B, Budev MM, Singer JP, Greenland JR. Immune aging: biological mechanisms, clinical symptoms, and management in lung transplant recipients. FRONTIERS IN TRANSPLANTATION 2024; 3:1356948. [PMID: 38993782 PMCID: PMC11235310 DOI: 10.3389/frtra.2024.1356948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 01/23/2024] [Indexed: 07/13/2024]
Abstract
While chronologic age can be precisely defined, clinical manifestations of advanced age occur in different ways and at different rates across individuals. The observed phenotype of advanced age likely reflects a superposition of several biological aging mechanisms which have gained increasing attention as the world contends with an aging population. Even within the immune system, there are multiple age-associated biological mechanisms at play, including telomere dysfunction, epigenetic dysregulation, immune senescence programs, and mitochondrial dysfunction. These biological mechanisms have associated clinical syndromes, such as telomere dysfunction leading to short telomere syndrome (STS), and optimal patient management may require recognition of biologically based aging syndromes. Within the clinical context of lung transplantation, select immune aging mechanisms are particularly pronounced. Indeed, STS is increasingly recognized as an indication for lung transplantation. At the same time, common aging phenotypes may be evoked by the stress of transplantation because lung allografts face a potent immune response, necessitating higher levels of immune suppression and associated toxicities, relative to other solid organs. Age-associated conditions exacerbated by lung transplant include bone marrow suppression, herpes viral infections, liver cirrhosis, hypogammaglobulinemia, frailty, and cancer risk. This review aims to dissect the molecular mechanisms of immune aging and describe their clinical manifestations in the context of lung transplantation. While these mechanisms are more likely to manifest in the context of lung transplantation, this mechanism-based approach to clinical syndromes of immune aging has broad relevance to geriatric medicine.
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Affiliation(s)
- Bhavya Kapse
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Marie M. Budev
- Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Jonathan P. Singer
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - John R. Greenland
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
- San Francisco VA Health Care System, Medicine, San Francisco, CA, United States
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Abderahmene A, Francke MI, Andrews LM, Hesselink DA, Amor D, Sahtout W, Ajmi M, Mastouri H, Bouslama A, Zellama D, Omezzine A, De Winter BCM. A Population Pharmacokinetic Model to Predict the Individual Starting Dose of Tacrolimus for Tunisian Adults after Renal Transplantation. Ther Drug Monit 2024; 46:57-66. [PMID: 38018879 DOI: 10.1097/ftd.0000000000001147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 07/23/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Tacrolimus is the most frequently used immunosuppressive drug for preventing renal rejection. However, its use is hampered by its narrow therapeutic index and large intra and interpatient variability in pharmacokinetics. The objective of this study was to externally validate a tacrolimus population pharmacokinetic model developed for the Dutch population and adjust the model for the Tunisian population for use in predicting the starting dose requirement after kidney transplantation. METHODS Data on tacrolimus exposure were obtained from kidney transplant recipients (KTRs) during the first 3 months post-transplantation. External validation of the Dutch model and its adjustment for the Tunisian population was performed using nonlinear mixed-effects modeling. RESULTS In total, 1901 whole-blood predose tacrolimus concentrations from 196 adult KTRs were analyzed. According to a visual predictive check, the Dutch model underestimated the starting dose for the Tunisian adult population. The effects of age, together with the CYP3A5*3 and CYP3A4*22 genotypes on tacrolimus clearance were significantly different in the Tunisian population than in the Dutch population. Based on a bodyweight-based dosing, only 21.9% of tacrolimus concentrations were within the target range, whereas this was estimated to be 54.0% with the newly developed model-based dosing. After adjustment, the model was successfully validated internally in a Tunisian population. CONCLUSIONS A starting-dose population pharmacokinetic model of tacrolimus for Tunisian KTRs was developed based on a previously published Dutch model. Using this starting dose could potentially increase the percentage of patients achieving target tacrolimus concentrations after the initial starting dose.
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Affiliation(s)
- Amani Abderahmene
- Department of Biochemistry , LR12SP11, Sahloul University Hospital, Sousse, University of Monastir Faculty of Pharmacy of Monastir, Monastir, Tunisia
- Rotterdam Clinical Pharmacometrics Group, Rotterdam, the Netherlands
| | - Marith I Francke
- Rotterdam Clinical Pharmacometrics Group, Rotterdam, the Netherlands
- Division of Nephrology and Transplantation, Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
- Erasmus MC Transplant Institute, Rotterdam, the Netherlands
| | - Louise M Andrews
- Department of Hospital Pharmacy, Meander MC, Amersfoort, the Netherlands
| | - Dennis A Hesselink
- Division of Nephrology and Transplantation, Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
- Erasmus MC Transplant Institute, Rotterdam, the Netherlands
| | - Dorra Amor
- Department of Biochemistry , LR12SP11, Sahloul University Hospital, Sousse, University of Monastir Faculty of Pharmacy of Monastir, Monastir, Tunisia
| | - Wissal Sahtout
- Department of Nephrology, Sahloul University Hospital, Sousse, Tunisia; and
| | - Marwa Ajmi
- Department of Biochemistry , LR12SP11, Sahloul University Hospital, Sousse, University of Monastir Faculty of Pharmacy of Monastir, Monastir, Tunisia
| | - Hayfa Mastouri
- Department of Biochemistry , LR12SP11, Sahloul University Hospital, Sousse, University of Monastir Faculty of Pharmacy of Monastir, Monastir, Tunisia
| | - Ali Bouslama
- Department of Biochemistry , LR12SP11, Sahloul University Hospital, Sousse, University of Monastir Faculty of Pharmacy of Monastir, Monastir, Tunisia
| | - Dorsaf Zellama
- Department of Nephrology, Sahloul University Hospital, Sousse, Tunisia; and
| | - Asma Omezzine
- Department of Biochemistry , LR12SP11, Sahloul University Hospital, Sousse, University of Monastir Faculty of Pharmacy of Monastir, Monastir, Tunisia
| | - Brenda C M De Winter
- Rotterdam Clinical Pharmacometrics Group, Rotterdam, the Netherlands
- Erasmus MC Transplant Institute, Rotterdam, the Netherlands
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, the Netherlands
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De Simone P, Battistella S, Lai Q, Ducci J, D'Arcangelo F, Marchetti P, Russo FP, Burra P. Immunosuppression for older liver transplant recipients. Transplant Rev (Orlando) 2024; 38:100817. [PMID: 38128152 DOI: 10.1016/j.trre.2023.100817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 12/10/2023] [Accepted: 12/12/2023] [Indexed: 12/23/2023]
Abstract
Older liver transplant recipients have a lower risk of acute rejection than younger patients (9% for patients aged ≥65 years versus 23% for those aged 18-34 years) and are more vulnerable to immunosuppression-related complications. The number of liver transplant recipients ≥65 years has risen to 22% in Europe and the US, but limited information is available on the optimal immunosuppressive regimen for these patients. In this review, we discuss the appropriate management of immunosuppressive agents in older adults to minimize adverse events while avoiding acute rejection. The way the body processes drugs greatly depends on age. In the case of calcineurin inhibitor drugs, aging reduces hepatic metabolism, leading to changes in their pharmacokinetics. Corticosteroids also show decreased clearance as the patient ages. In severe cases of hypoalbuminemia, dose adjustment of mycophenolate acid derivatives may be necessary. However, the pharmacokinetic profiles of the mammalian target of rapamycin inhibitors, basiliximab, and rabbit anti-thymocyte globulin remain unaffected by age. Furthermore, age-related frailty may impact drug metabolism and require tailored interventions and closer follow-up. Although there is limited research, elderly liver transplant recipients require less immunosuppression with double or triple-agent regimens, lower exposure to calcineurin inhibitors, and a shorter course of corticosteroids. The usage of mammalian target of rapamycin inhibitors in older transplant populations has not been specifically investigated, and thus their usage should align with indications for younger patient groups.
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Affiliation(s)
- Paolo De Simone
- Liver Transplant Program, University of Pisa Medical School Hospital, Pisa, Italy; Department of Surgical, Medical, Biochemical Pathology and Intensive Care, University of Pisa, Italy.
| | - Sara Battistella
- Gastroenterology, Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Quirino Lai
- General Surgery and Organ Transplantation Unit, La Sapienza University of Rome, Italy
| | - Juri Ducci
- Liver Transplant Program, University of Pisa Medical School Hospital, Pisa, Italy
| | - Francesca D'Arcangelo
- Gastroenterology, Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Piero Marchetti
- Diabetology Unit, University of Pisa Medical School Hospital, Pisa, Italy
| | - Francesco Paolo Russo
- Gastroenterology, Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Patrizia Burra
- Gastroenterology, Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
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Degraeve AL, Bindels LB, Haufroid V, Moudio S, Boland L, Delongie KA, Dewulf JP, Eddour DC, Mourad M, Elens L. Tacrolimus Pharmacokinetics is Associated with Gut Microbiota Diversity in Kidney Transplant Patients: Results from a Pilot Cross-Sectional Study. Clin Pharmacol Ther 2024; 115:104-115. [PMID: 37846607 DOI: 10.1002/cpt.3077] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 09/30/2023] [Indexed: 10/18/2023]
Abstract
Clinical use of tacrolimus (TAC), an essential immunosuppressant following transplantation, is complexified by its high pharmacokinetic (PK) variability. The gut microbiota gains growing interest but limited investigations have evaluated its contribution to TAC PKs. Here, we explore the associations between the gut microbiota composition and TAC PKs. In this pilot cross-sectional study (Clinicaltrial.gov NCT04360031), we recruited 93 CYP3A5 non-expressers stabilized kidney transplant recipients. Gut microbiota composition was characterized by 16S rRNA gene sequencing, TAC PK parameters were computed, and additional demographic and medical covariates were collected. Associations between PK parameters or diabetic status and the gut microbiota composition, as reflected by α- and β-diversity metrics, were evaluated. Patients with higher TAC area under the curve AUC/(dose/kg) had higher bacterial richness, and TAC PK parameters were associated with specific bacterial taxa (e.g., Bilophila) and amplicon sequence variant (ASV; e.g., ASV 1508 and ASV 1982 (Veillonella/unclassified Sporomusaceae); ASV 664 (unclassified Oscillospiraceae)). Building a multiple linear regression model showed that ASV 1508 (co-abundant with ASV 1982) and ASV 664 explained, respectively, 16.0% and 4.6% of the interindividual variability in TAC AUC/(dose/kg) in CYP3A5 non-expresser patients, when adjusting for hematocrit and age. Anaerostipes relative abundance was decreased in patients with diabetes. Altogether, this pilot study revealed unprecedented links between the gut microbiota composition and diversity and TAC PKs in stable kidney transplant recipients. It supports the relevance of studying the gut microbiota as an important contributor to TAC PK variability. Elucidating the causal relationship will offer new perspectives to predict TAC inter- and intra-PK variability.
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Affiliation(s)
- Alexandra L Degraeve
- Department of Integrated PharmacoMetrics, PharmacoGenomics and PharmacoKinetics, Louvain Drug Research Institute, Université Catholique de Louvain, Brussels, Belgium
- Metabolism and Nutrition Research Group, Louvain Drug Research Institute, Université Catholique de Louvain, Brussels, Belgium
| | - Laure B Bindels
- Metabolism and Nutrition Research Group, Louvain Drug Research Institute, Université Catholique de Louvain, Brussels, Belgium
| | - Vincent Haufroid
- Louvain centre for Toxicology and Applied Pharmacology, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
- Department of Clinical Chemistry, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Serge Moudio
- Department of Integrated PharmacoMetrics, PharmacoGenomics and PharmacoKinetics, Louvain Drug Research Institute, Université Catholique de Louvain, Brussels, Belgium
| | - Lidvine Boland
- Department of Integrated PharmacoMetrics, PharmacoGenomics and PharmacoKinetics, Louvain Drug Research Institute, Université Catholique de Louvain, Brussels, Belgium
- Louvain centre for Toxicology and Applied Pharmacology, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
- Department of Clinical Chemistry, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | | | - Joseph P Dewulf
- Louvain centre for Toxicology and Applied Pharmacology, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
- Department of Clinical Chemistry, Cliniques Universitaires Saint-Luc, Brussels, Belgium
- Institute of Rare Diseases, Cliniques Universitaires Saint-Luc, Brussels, Belgium
- Department of Biochemistry, de Duve Institute, Université Catholique de Louvain, Brussels, Belgium
| | - Djamila Chaib Eddour
- Kidney and Pancreas Transplantation Unit, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Michel Mourad
- Kidney and Pancreas Transplantation Unit, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Laure Elens
- Department of Integrated PharmacoMetrics, PharmacoGenomics and PharmacoKinetics, Louvain Drug Research Institute, Université Catholique de Louvain, Brussels, Belgium
- Louvain centre for Toxicology and Applied Pharmacology, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
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7
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Henkel L, Jehn U, Thölking G, Reuter S. Tacrolimus-why pharmacokinetics matter in the clinic. FRONTIERS IN TRANSPLANTATION 2023; 2:1160752. [PMID: 38993881 PMCID: PMC11235362 DOI: 10.3389/frtra.2023.1160752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 08/07/2023] [Indexed: 07/13/2024]
Abstract
The calcineurin inhibitor (CNI) Tacrolimus (Tac) is the most prescribed immunosuppressant drug after solid organ transplantation. After renal transplantation (RTx) approximately 95% of recipients are discharged with a Tac-based immunosuppressive regime. Despite the high immunosuppressive efficacy, its adverse effects, narrow therapeutic window and high intra- and interpatient variability (IPV) in pharmacokinetics require therapeutic drug monitoring (TDM), which makes treatment with Tac a major challenge for physicians. The C/D ratio (full blood trough level normalized by daily dose) is able to classify patients receiving Tac into two major metabolism groups, which were significantly associated with the clinical outcomes of patients after renal or liver transplantation. Therefore, the C/D ratio is a simple but effective tool to identify patients at risk of an unfavorable outcome. This review highlights the challenges of Tac-based immunosuppressive therapy faced by transplant physicians in their daily routine, the underlying causes and pharmacokinetics (including genetics, interactions, and differences between available Tac formulations), and the latest data on potential solutions to optimize treatment of high-risk patients.
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Affiliation(s)
- Lino Henkel
- Department of Medicine D, University of Münster, Münster, Germany
| | - Ulrich Jehn
- Department of Medicine D, University of Münster, Münster, Germany
| | - Gerold Thölking
- Department of Medicine D, University of Münster, Münster, Germany
- Department of Internal Medicine and Nephrology, University Hospital of Münster Marienhospital Steinfurt, Steinfurt, Germany
| | - Stefan Reuter
- Department of Medicine D, University of Münster, Münster, Germany
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Schagen MR, Volarevic H, Francke MI, Sassen SDT, Reinders MEJ, Hesselink DA, de Winter BCM. Individualized dosing algorithms for tacrolimus in kidney transplant recipients: current status and unmet needs. Expert Opin Drug Metab Toxicol 2023; 19:429-445. [PMID: 37642358 DOI: 10.1080/17425255.2023.2250251] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 08/17/2023] [Indexed: 08/31/2023]
Abstract
INTRODUCTION Tacrolimus is a potent immunosuppressive drug with many side effects including nephrotoxicity and post-transplant diabetes mellitus. To limit its toxicity, therapeutic drug monitoring (TDM) is performed. However, tacrolimus' pharmacokinetics are highly variable within and between individuals, which complicates their clinical management. Despite TDM, many kidney transplant recipients will experience under- or overexposure to tacrolimus. Therefore, dosing algorithms have been developed to limit the time a patient is exposed to off-target concentrations. AREAS COVERED Tacrolimus starting dose algorithms and models for follow-up doses developed and/or tested since 2015, encompassing both adult and pediatric populations. Literature was searched in different databases, i.e. Embase, PubMed, Web of Science, Cochrane Register, and Google Scholar, from inception to February 2023. EXPERT OPINION Many algorithms have been developed, but few have been prospectively evaluated. These performed better than bodyweight-based starting doses, regarding the time a patient is exposed to off-target tacrolimus concentrations. No benefit in reduced tacrolimus toxicity has yet been observed. Most algorithms were developed from small datasets, contained only a few tacrolimus concentrations per person, and were not externally validated. Moreover, other matrices should be considered which might better correlate with tacrolimus toxicity than the whole-blood concentration, e.g. unbound plasma or intra-lymphocytic tacrolimus concentrations.
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Affiliation(s)
- Maaike R Schagen
- Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Erasmus MC, Rotterdam Clinical Pharmacometrics Group, Rotterdam, the Netherlands
| | - Helena Volarevic
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Marith I Francke
- Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Sebastiaan D T Sassen
- Erasmus MC, Rotterdam Clinical Pharmacometrics Group, Rotterdam, the Netherlands
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Marlies E J Reinders
- Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Dennis A Hesselink
- Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Brenda C M de Winter
- Erasmus MC, Rotterdam Clinical Pharmacometrics Group, Rotterdam, the Netherlands
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
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Souwer ETD, Sanchez-Spitman A, Moes DJAR, Gelderblom H, Swen JJ, Portielje JEA, Guchelaar HJ, van Gelder T. Tamoxifen pharmacokinetics and pharmacodynamics in older patients with non-metastatic breast cancer. Breast Cancer Res Treat 2023; 199:471-478. [PMID: 37067610 PMCID: PMC10175413 DOI: 10.1007/s10549-023-06925-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 03/16/2023] [Indexed: 04/18/2023]
Abstract
BACKGROUND We aimed to study the pharmacokinetics and -dynamics of tamoxifen in older women with non-metastatic breast cancer. METHODS Data for this analysis were derived from the CYPTAM study (NTR1509) database. Patients were stratified by age (age groups < 65 and 65 and older). Steady-state trough concentrations were measured of tamoxifen, N-desmethyltamoxifen, 4-hydroxy-tamoxifen, and endoxifen. CYP2D6 and CYP3A4 phenotypes were assessed for all patients by genotyping. Multiple linear regression models were used to analyze tamoxifen and endoxifen variability. Outcome data included recurrence-free survival at time of tamoxifen discontinuation (RFSt) and overall survival (OS). RESULTS 668 patients were included, 141 (21%) were 65 and older. Demographics and treatment duration were similar across age groups. Older patients had significantly higher concentrations of tamoxifen 129.4 ng/ml (SD 53.7) versus 112.2 ng/ml (SD 42.0) and endoxifen 12.1 ng/ml (SD 6.6) versus 10.7 ng/ml (SD 5.7, p all < 0.05), independently of CYP2D6 and CYP3A4 gene polymorphisms. Age independently explained 5% of the variability of tamoxifen (b = 0.95, p < 0.001, R2 = 0.051) and 0.1% of the variability in endoxifen concentrations (b = 0.45, p = 0.12, R2 = 0.007). Older patients had worse RFSt (5.8 versus 7.3 years, p = 0.01) and worse OS (7.8 years versus 8.7 years, p = 0.01). This was not related to differences in endoxifen concentration (HR 1.0, 95% CI 0.96-1.04, p = 0.84) or CYP polymorphisms. CONCLUSION Serum concentrations of tamoxifen and its demethylated metabolites are higher in older patients, independent of CYP2D6 or CYP3A4 gene polymorphisms. A higher bioavailability of tamoxifen in older patients may explain the observed differences. However, clinical relevance of these findings is limited and should not lead to a different tamoxifen dose in older patients.
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Affiliation(s)
- E T D Souwer
- Department of Medical Oncology, Leiden University Medical Center, Albinusdreef 2, P.O. Box 9600, 2300 RC, Leiden, The Netherlands.
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands.
| | - A Sanchez-Spitman
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - D J A R Moes
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - H Gelderblom
- Department of Medical Oncology, Leiden University Medical Center, Albinusdreef 2, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - J J Swen
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - J E A Portielje
- Department of Medical Oncology, Leiden University Medical Center, Albinusdreef 2, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - H J Guchelaar
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - T van Gelder
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
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10
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McGovern KE, Sonar SA, Watanabe M, Coplen CP, Bradshaw CM, Nikolich JŽ. The aging of the immune system and its implications for transplantation. GeroScience 2023:10.1007/s11357-022-00720-2. [PMID: 36626019 PMCID: PMC9838392 DOI: 10.1007/s11357-022-00720-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 12/21/2022] [Indexed: 01/11/2023] Open
Abstract
By the last third of life, most mammals, including humans, exhibit a decline in immune cell numbers, immune organ structure, and immune defense of the organism, commonly known as immunosenescence. This decline leads to clinical manifestations of increased susceptibility to infections, particularly those caused by emerging and reemerging microorganisms, which can reach staggering levels-infection with SARS-CoV-2 has been 270-fold more lethal to older adults over 80 years of age, compared to their 18-39-year-old counterparts. However, while this would be expected to be beneficial to situations where hyporeactivity of the immune system may be desirable, this is not always the case. Here, we discuss the cellular and molecular underpinnings of immunosenescence as they pertain to outcomes of solid organ and hematopoietic transplantation.
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Affiliation(s)
- Kathryn E McGovern
- Department of Immunobiology, University of Arizona, Tucson, AZ, 85724, USA
- Arizona Center On Aging, The University of Arizona, University of Arizona College of Medicine-Tucson, Tucson, AZ, 85724, USA
- BIO5 Institute, University of Arizona, Tucson, AZ, USA
| | - Sandip A Sonar
- Department of Immunobiology, University of Arizona, Tucson, AZ, 85724, USA
- Arizona Center On Aging, The University of Arizona, University of Arizona College of Medicine-Tucson, Tucson, AZ, 85724, USA
| | - Makiko Watanabe
- Department of Immunobiology, University of Arizona, Tucson, AZ, 85724, USA
- Arizona Center On Aging, The University of Arizona, University of Arizona College of Medicine-Tucson, Tucson, AZ, 85724, USA
| | - Christopher P Coplen
- Department of Immunobiology, University of Arizona, Tucson, AZ, 85724, USA
- Arizona Center On Aging, The University of Arizona, University of Arizona College of Medicine-Tucson, Tucson, AZ, 85724, USA
| | - Christine M Bradshaw
- Department of Immunobiology, University of Arizona, Tucson, AZ, 85724, USA
- Arizona Center On Aging, The University of Arizona, University of Arizona College of Medicine-Tucson, Tucson, AZ, 85724, USA
| | - Janko Ž Nikolich
- Department of Immunobiology, University of Arizona, Tucson, AZ, 85724, USA.
- Arizona Center On Aging, The University of Arizona, University of Arizona College of Medicine-Tucson, Tucson, AZ, 85724, USA.
- BIO5 Institute, University of Arizona, Tucson, AZ, USA.
- The Aegis Consortium for Pandemic-free Future, University of Arizona Health Sciences, University of Arizona, Tucson, 85719, USA.
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11
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Liao M, Wang M, Zhu X, Zhao L, Zhao M. Tacrolimus Population Pharmacokinetic Model in Adult Chinese Patients with Nephrotic Syndrome and Dosing Regimen Identification Using Monte Carlo Simulations. Ther Drug Monit 2022; 44:615-624. [PMID: 36101928 DOI: 10.1097/ftd.0000000000001008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 03/13/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The study aimed to establish a population pharmacokinetic (PPK) model of tacrolimus for Chinese patients with nephrotic syndrome using the patient's genotype and Wuzhi capsule dosage as the main test factors. METHODS Ninety-six adult patients with nephrotic syndrome, who were receiving tacrolimus treatment, were enrolled. A nonlinear mixed-effects model was used to determine the influencing factors of interindividual tacrolimus metabolism variation and establish a PPK model. To optimize the tacrolimus dosage, 10,000 Monte Carlo simulations were performed. RESULTS The 1-chamber model of first-order absorption and elimination was the most suitable model for the data in this study. The typical population tacrolimus clearance (CL/F) value was 16.9 L/h. The percent relative standard error (RSE%) of CL/F was 12%. Increased Wuzhi capsule and albumin doses both decreased the tacrolimus CL/F. In CYP3A5 homozygous mutation carriers, the CL/F was 39% lower than that of carriers of the wild-type and heterozygous mutation. The tacrolimus CL/F in patients who were coadministered glucocorticoids was 1.23-fold higher than that of the control. According to the patient genotype and combined use of glucocorticoids, 26 combinations of Wuzhi capsule and tacrolimus doses were matched. The Monte Carlo simulation identified the most suitable combination scheme. CONCLUSIONS An improved tacrolimus PPK model for patients with nephrotic syndrome was established, and the most suitable combination of Wuzhi capsule and tacrolimus doses was identified, thus, facilitating the selection of a more economical and safe administration regimen.
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Affiliation(s)
- Minghao Liao
- Department of Pharmacy, Shengjing Hospital of China Medical University ; and
- School of Life Science and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China
| | - Minglu Wang
- Department of Pharmacy, Shengjing Hospital of China Medical University ; and
| | - Xu Zhu
- Department of Pharmacy, Shengjing Hospital of China Medical University ; and
| | - Limei Zhao
- Department of Pharmacy, Shengjing Hospital of China Medical University ; and
- School of Life Science and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China
| | - Mingming Zhao
- Department of Pharmacy, Shengjing Hospital of China Medical University ; and
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12
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Cheung CY, Tang SCW. Personalized immunosuppression after kidney transplantation. Nephrology (Carlton) 2022; 27:475-483. [PMID: 35238110 DOI: 10.1111/nep.14035] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/15/2022] [Accepted: 02/27/2022] [Indexed: 11/29/2022]
Abstract
With advances in immunosuppressive therapy, there have been significant improvements in acute rejection rates and short-term allograft survival in kidney transplant recipients. However, this success has not been translated into long-term benefits by the same magnitude. Optimization of immunosuppression is important to improve the clinical outcome of transplant recipients. It is important to note that each patient has unique attributes and immunosuppression management should not be a one-size-fits-all approach. Elderly transplant patients are less likely to develop acute rejection but more likely to die from infectious and cardiovascular causes than younger patients. For those with post-transplant cancers and BK polyomavirus-associated nephropathy, reduction of immunosuppression can increase the risk of rejection. Therapeutic drug monitoring (TDM) is routinely used for dosage adjustment of several immunosuppressive drugs. It has been hoped that pharmacogenetics can be used to complement TDM in optimizing drug exposure. Among the various drug-genotype pairs being investigated, tacrolimus and CYP3A5 gives the most promising results. Different studies have consistently shown that CYP3A5 expressers require a higher tacrolimus dose and take longer time to achieve target blood tacrolimus levels than nonexpressers. However, for pharmacogenetics to be widely used clinically, further trials are necessary to demonstrate the clinical benefits of genotype-guided dosing such as reduction of rejection and drug-related toxicities. The development of different biomarkers in recent years may help to achieve true personalized therapy in transplant patients.
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Affiliation(s)
- Chi Yuen Cheung
- Renal Unit, Department of Medicine, Queen Elizabeth Hospital, Hong Kong SAR
| | - Sydney Chi Wai Tang
- Division of Nephrology, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR
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13
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Heart Transplant in Older Adults. CURRENT TRANSPLANTATION REPORTS 2022; 9:48-54. [PMID: 35039790 PMCID: PMC8755401 DOI: 10.1007/s40472-022-00358-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2021] [Indexed: 11/22/2022]
Abstract
Purpose of Review Older adults with end-stage heart failure may be candidates for heart transplantation (HT) and changing guidelines and institutional policies have increased the availability of HT for septuagenarians. This review explores historical, pre-HT evaluation, and post-HT outcomes for older adult HT recipients. Recent Findings Rates of HT in older adults have increased in the past decade and more than 800 septuagenarians have undergone HT. Older adult HT recipients have similar survival, rehospitalization, and graft failure rates when compared to younger patients despite additional comorbidities and higher risk donors. Summary HT is feasible in carefully selected older adults. As the number of older adults who are considered for HT increases, additional research into population-specific assessment tools will be needed. Furthermore, age-related immune changes warrant population-specific studies on immunosuppressive regimens.
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14
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Williams ML, Weeks HL, Beck C, Birdwell KA, Van Driest SL, Choi L. Sensitivity of Estimated Tacrolimus Population Pharmacokinetic Profile to Assumed Dose Timing and Absorption in Real World Data and Simulated Data. Br J Clin Pharmacol 2022; 88:2863-2874. [PMID: 34997625 DOI: 10.1111/bcp.15218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 12/21/2021] [Accepted: 12/22/2021] [Indexed: 11/28/2022] Open
Abstract
A population pharmacokinetic (PK) study with 363 subjects was performed using real-world data extracted from electronic heath records (EHRs) to estimate the tacrolimus population PK profile. Data were extracted and built using our automated system, EHR2PKPD, suitable for quickly constructing large PK datasets from the EHR. Population PK studies for oral medications performed using EHR data often assume a regular dosing schedule as prescribed without incorporating exact dosing time. We assessed the sensitivity of the PK parameter estimates to assumptions about dose timing using last-dose times extracted by our own natural language processing system, medExtractR. We also investigated the sensitivity of estimates to absorption rate constants that are often fixed at a published value in tacrolimus population PK analyses. There was no appreciable difference in parameter estimates with assumed vs. extracted last-dose time, and our sensitivity analysis revealed little difference between parameters estimated across a range of assumed absorption rate constants. We conducted simulation studies to investigate how drug PK profiles and experimental designs such as concentration measurements design affect sensitivity to incorrect assumptions about dose timing and absorption rates. Our findings suggest that drugs with a slower elimination rate (or a longer half-life) are less sensitive to dose timing errors and that experimental designs which only allow for trough blood concentrations are usually insensitive to deviation in absorption rate.
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Affiliation(s)
- Michael L Williams
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Hannah L Weeks
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Cole Beck
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Kelly A Birdwell
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Sara L Van Driest
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN.,Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Leena Choi
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
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15
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Almalki B, Kane C, Cunningham K, D'Agostino C, Novak A, Kapugi M, Ladner D, Schulte J. Evaluation of rejection, infection, and malignancy outcomes in elderly liver transplant recipients receiving a similar level of immunosuppression compared to a younger group. Transpl Immunol 2021; 69:101485. [PMID: 34673200 DOI: 10.1016/j.trim.2021.101485] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 10/12/2021] [Accepted: 10/15/2021] [Indexed: 10/20/2022]
Abstract
Elderly liver transplant (LTx) recipients at a lower risk of acute rejection compared to younger recipients due to immunosenescence. As such, they may benefit from reduced immunosuppression (IS) to minimize infectious and malignant complications. We aimed to evaluate outcomes in LTx recipients ≥60 years compared to a younger group of LTx recipients aged 18-59 years maintained on a similar level of IS. This was a single-center retrospective evaluation of adult LTx recipients from 2013 to 2018 who received methylprednisolone induction and were maintained on tacrolimus, mycophenolate mofetil (MMF), and a prednisone taper. A total of 143 LTx recipients were evaluated. Mean age in the older group was 65 ± 3.8 compared to 49 ± 10.4 years in the younger group (p < 0.0001). Mean tacrolimus levels and the duration of MMF and steroids were comparable. Both groups had a similar incidence of first rejection within 1 year (19.2% in the elderly group vs. 23.1% in the younger group, p = 0.57). There were no statistical difference in terms of infection, malignancy, or patient survival. In conclusion, our data suggests that elderly LTx recipients, when treated with a similar level of IS, had similar 1 year incidence of rejection, infection, malignancy, and patient survival as younger LTx recipients.
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Affiliation(s)
- Bassem Almalki
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, United States; Department of Pharmacy, Prince Sultan Military Medical City, Riyadh, Saudi Arabia.
| | - Clare Kane
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, United States
| | - Kathleen Cunningham
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, United States
| | - Carly D'Agostino
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, United States
| | - Antonia Novak
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, United States
| | - Michelle Kapugi
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, United States
| | - Daniela Ladner
- Division of Transplant Surgery, Northwestern Memorial Hospital, Chicago, IL, United States
| | - Jamie Schulte
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, United States
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16
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Kuan WYJ, Châteauvert N, Leclerc V, Drolet B. Tacrolimus Dose-Conversion Ratios Based on Switching of Formulations for Patients with Solid Organ Transplants. Can J Hosp Pharm 2021; 74:317-326. [PMID: 34602619 DOI: 10.4212/cjhp.v74i4.3193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Background Tacrolimus may be administered during hospitalization as an IV formulation or oral suspension. However, literature suggesting appropriate ratios for conversion from these formulations to capsules is limited. Objective To evaluate conversion ratios after a switch in formulation of tacrolimus for solid-organ transplant recipients. Methods This single-centre observational longitudinal study involved hospitalized patients who underwent a switch in formulation of tacrolimus according to 1 of 3 possible scenarios: IV to oral suspension, IV to capsule, or oral suspension to capsule. Data were collected from the earliest accessible electronic file (January 2009) to January 1, 2019. Conversion ratios were calculated for each of the 3 groups using data for blood concentrations and doses before and after the switch. The calculated ratios were then compared with recommended conversion ratios: 1:5 (i.e., 1 mg of IV tacrolimus is converted to 5 mg of oral tacrolimus, expressed as "5") for either of the switches involving an IV formulation and 1:1 (i.e., same amount, expressed as "1") for the switch from oral formulation to capsules. Results For the group who underwent switching from the IV formulation to oral suspension, the mean calculated conversion ratio was 3.04, which was significantly different from the recommended ratio of 5. For the group who underwent switching from the IV formulation to capsules, the calculated conversion ratio was 5.18, which was not significantly different from the recommended ratio of 5. For the group who underwent switching from oral suspension to capsules, the calculated conversion ratio was 1.17, which was not significantly different from the recommended ratio of 1. Conclusion In this small retrospective study of tacrolimus therapy, the calculated conversion ratio was significantly different from the recommended ratio for patients who were switched from IV administration to oral suspension, but not for those switched from IV administration or oral suspension to capsules. Therapeutic drug monitoring therefore appears indispensable, regardless of conversion ratios.
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Affiliation(s)
- Wen-Yuan Johnson Kuan
- , PharmD, MSc, is a Pharmacist with the Department of Pharmacy, Centre intégré de santé et de services sociaux des Laurentides, Hôpital de Saint-Eustache, Saint-Eustache, Quebec, and Chargé d'enseignement clinique (Clinical Preceptor) with the Faculty of Pharmacy, Université Laval, Québec, Quebec
| | - Nathalie Châteauvert
- , BPharm, MSc, is a Pharmacist with the Department of Pharmacy, Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval (IUCPQ-UL), and Clinical Professor with the Faculty of Pharmacy, Université Laval, Québec, Quebec
| | - Vincent Leclerc
- , BPharm, MSc, is a Pharmacist with the Department of Pharmacy, Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval (IUCPQ-UL), and Chargé d'enseignement clinique (Clinical Preceptor) with the Faculty of Pharmacy, Université Laval, Québec, Quebec
| | - Benoît Drolet
- , BPharm, PhD, is an Investigator with the Research Centre, Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval (IUCPQ-UL), and Professor with the Faculty of Pharmacy, Université Laval, Québec, Quebec
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17
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Tan T, Bunnapradist S. Comparing the pharmacokinetics of extended-release tacrolimus (LCP-TAC) to immediate-release formulations in kidney transplant patients. Expert Opin Drug Metab Toxicol 2021; 17:1175-1186. [PMID: 34459696 DOI: 10.1080/17425255.2021.1974399] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION One of the most commonly used immunosuppressants in organ transplant, tacrolimus exhibits wide interpatient and intrapatient variability and narrow therapeutic index that necessitates routine concentration monitoring and dosage adjustments. Availability of modified -release tacrolimus products offer once-daily dosing options. The objective of this review is to highlight and compare available pharmacokinetic (PK) data of extended-release tacrolimus tablets (LCP-TAC) to immediate-release tacrolimus (IR-TAC) in kidney transplant recipients. AREAS COVERED A review of the literature was performed using PubMed and Embase search to identify relevant articles evaluating PK data for LCP-TAC compared to IR-TAC in kidney transplant patients including special populations. EXPERT OPINION LCP-TAC's unique PK profile may be more favorable than IR-TAC. While the clinical impact of these PK differences have not been established, several outcomes are being evaluated in ongoing studies. Results of these studies will add information incrementally to care for kidney transplant patients. Larger prospective studies evaluating kidney and patient survival differences are needed but it is unlikely that they will be conducted. Given that the patent exclusivity of LCP-TAC for the next several years and imminent loss of exclusivity of PR-TAC, our opinion is the use of LCP-TAC will be increasing, especially in Europe.
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Affiliation(s)
- Teresa Tan
- Department of Pharmaceutical Services, Ronald Reagan UCLA Medical Center, Los Angeles, CA
| | - Suphamai Bunnapradist
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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18
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Al-Kofahi M, Oetting WS, Schladt DP, Remmel RP, Guan W, Wu B, Dorr CR, Mannon RB, Matas AJ, Israni AK, Jacobson PA. Precision Dosing for Tacrolimus Using Genotypes and Clinical Factors in Kidney Transplant Recipients of European Ancestry. J Clin Pharmacol 2021; 61:1035-1044. [PMID: 33512723 PMCID: PMC11240873 DOI: 10.1002/jcph.1823] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 01/26/2021] [Indexed: 12/14/2022]
Abstract
Genetic variation in the CYP3A4 and CYP3A5 (CYP3A4/5) genes, which encode the key enzymes in tacrolimus metabolism, is associated with tacrolimus clearance and dose requirements. Tacrolimus has a narrow therapeutic index with high intra- and intersubject variability, in part because of genetic variation. High tacrolimus clearance and low trough concentration are associated with a greater risk for rejection, whereas high troughs are associated with calcineurin-induced toxicity. The objective of this study was to develop a model of tacrolimus clearance with a dosing equation accounting for genotypes and clinical factors in adult kidney transplant recipients of European ancestry that could preemptively guide dosing. Recipients receiving immediate-release tacrolimus for maintenance immunosuppression from 2 multicenter studies were included. Participants in the GEN03 study were used for tacrolimus model development (n = 608 recipients) and was validated by prediction performance in the DeKAF Genomics study (n = 1361 recipients). Nonlinear mixed-effects modeling was used to develop the apparent oral tacrolimus clearance (CL/F) model. CYP3A4/5 genotypes and clinical covariates were tested for their influence on CL/F. The predictive performance of the model was determined by assessing the bias (median prediction error [ME] and median percentage error [MPE]) and the precision (root median squared error [RMSE]) of the model. CYP3A5*3, CYP3A4*22, corticosteroids, calcium channel blocker and antiviral drug use, age, and diabetes significantly contributed to the interindividual variability of oral tacrolimus apparent clearance. The bias (ME, MPE) and precision (RMSE) of the final model was good, 0.49 ng/mL, 6.5%, and 3.09 ng/mL, respectively. Prospective testing of this equation is warranted.
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Affiliation(s)
- Mahmoud Al-Kofahi
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
| | - William S Oetting
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
| | - David P Schladt
- Hennepin Health Research Institute, Minneapolis, Minnesota, USA
| | - Rory P Remmel
- Department of Medicinal Chemistry, University of Minnesota, Minneapolis, Minnesota, USA
| | - Weihua Guan
- Department of Biostatistics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Baolin Wu
- Department of Biostatistics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Casey R Dorr
- Hennepin Health Research Institute, Minneapolis, Minnesota, USA
- Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA
| | - Roslyn B Mannon
- Division of Nephrology, University of Nebraska, Omaha, Nebraska, USA
| | - Arthur J Matas
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ajay K Israni
- Hennepin Health Research Institute, Minneapolis, Minnesota, USA
- Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA
- Department of Epidemiology & Community Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Pamala A Jacobson
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
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Lentine KL, Cheungpasitporn W, Xiao H, McAdams-DeMarco M, Lam NN, Segev DL, Bae S, Ahn JB, Hess GP, Caliskan Y, Randall HB, Kasiske BL, Schnitzler MA, Axelrod DA. Immunosuppression Regimen Use and Outcomes in Older and Younger Adult Kidney Transplant Recipients: A National Registry Analysis. Transplantation 2021; 105:1840-1849. [PMID: 33214534 PMCID: PMC10576532 DOI: 10.1097/tp.0000000000003547] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Although the population of older transplant recipients has increased dramatically, there are limited data describing the impact of immunosuppression regimen choice on outcomes in this recipient group. METHODS National data for US Medicare-insured adult kidney recipients (N = 67 362; 2005-2016) were examined to determine early immunosuppression regimen and associations with acute rejection, death-censored graft failure, and mortality using multivariable regression analysis in younger (18-64 y) and older (>65 y) adults. RESULTS The use of antithymocyte globulin (TMG) or alemtuzumab (ALEM) induction with triple maintenance immunosuppression (reference) was less common in older compared with younger (36.9% versus 47.0%) recipients, as was TMG/ALEM + steroid avoidance (19.2% versus 20.1%) and mammalian target of rapamycin inhibitor (mTORi)-based (6.7% versus 7.7%) treatments. Conversely, older patients were more likely to receive interleukin (IL)-2-receptor antibody (IL2rAb) + triple maintenance (21.1% versus 14.7%), IL2rAb + steroid avoidance (4.1% versus 1.8%), and cyclosporine-based (8.3% versus 6.6%) immunosuppression. Compared with older recipients treated with TMG/ALEM + triple maintenance (reference regimen), those managed with TMG/ALEM + steroid avoidance (adjusted odds ratio [aOR], 0.440.520.61) and IL2rAb + steroid avoidance (aOR, 0.390.550.79) had lower risk of acute rejection. Older patients experienced more death-censored graft failure when managed with Tac + antimetabolite avoidance (adjusted hazard [aHR], 1.411.782.25), mTORi-based (aHR, 1.702.142.71), and cyclosporine-based (aHR, 1.411.782.25) regimens, versus the reference regimen. mTORi-based and cyclosporine-based regimens were associated with increased mortality in both older and younger patients. CONCLUSIONS Lower-intensity immunosuppression regimens (eg, steroid-sparing) appear beneficial for older kidney transplant recipients, while mTORi and cyclosporine-based maintenance immunosuppression are associated with higher risk of adverse outcomes.
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Affiliation(s)
| | | | | | | | | | | | - Sunjae Bae
- Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - JiYoon B. Ahn
- Johns Hopkins School of Medicine, Baltimore, MD, USA
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20
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Gu TM, Lewis JS, Le H, Bubalo JS. Comparative effects of fluconazole, posaconazole, and isavuconazole upon tacrolimus and cyclosporine serum concentrations. J Oncol Pharm Pract 2021; 28:1357-1362. [PMID: 34192963 DOI: 10.1177/10781552211029046] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Calcineurin inhibitors are commonly used in hematopoietic stem cell transplant (HSCT) patients to prevent graft versus host disease, but as CYP3A4 substrates they are frequently involved in drug-drug interactions. The purpose of this study is to characterize the effects of isavuconazole, fluconazole, and posaconazole on tacrolimus and cyclosporine serum concentrations and dose adjustments in allogeneic HSCT patients. METHODS This retrospective study included patients admitted to Oregon Health and Science University between April 2008 and December 2018 who underwent hematopoietic stem cell transplantation and received concomitant tacrolimus or cyclosporine and fluconazole, isavuconazole or posaconazole therapy. Data on patient characteristics, drug dosing, and serum drug concentrations were collected through chart review, and descriptive statistics were used to summarize the results. RESULTS A total of 139 patients were included in this study. We found fluconazole initiation leads to a 25% reduction in both tacrolimus and cyclosporine doses in order to maintain goal serum concentrations. Posaconazole and isavuconazole initiation requires tacrolimus dose reductions by 53% and 21%, respectively. CONCLUSIONS Based on our experience, FLC, POS, and ISA initiation may require CNI dose reductions and close monitoring of CNI levels to ensure levels remain within goal serum concentrations. Larger studies are needed to fully quantify the percentage in CNI dose reductions and characterize differences among these antifungals.
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Affiliation(s)
- Tina M Gu
- Department of Pharmacy, University of California San Francisco, San Francisco, USA
| | - James S Lewis
- Department of Pharmacy, Oregon Health & Science University, Portland, USA
| | - Henry Le
- Department of Pharmacy, Yale New Haven Hospital, New Haven, USA
| | - Joseph S Bubalo
- Department of Pharmacy, Oregon Health & Science University, Portland, USA
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21
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Cheungpasitporn W, Lentine KL, Tan JC, Kaufmann M, Caliskan Y, Bunnapradist S, Lam NN, Schnitzler M, Axelrod DA. Immunosuppression Considerations for Older Kidney Transplant Recipients. CURRENT TRANSPLANTATION REPORTS 2021; 8:100-110. [PMID: 34211822 PMCID: PMC8244945 DOI: 10.1007/s40472-021-00321-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2021] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW While kidney transplantation improves the long-term survival of the majority of patients with end-stage kidney disease (ESKD), age-related immune dysfunction and associated comorbidities make older transplant recipients more susceptible to complications related to immunosuppression. In this review, we discuss appropriate management of immunosuppressive agents in older adults to minimize adverse events, avoid acute rejection, and maximize patient and graft survival. RECENT FINDINGS Physiological changes associated with senescence can impact drug metabolism and increase the risk of posttransplant infection and malignancy. Clinical trials assessing the safety and efficacy of immunosuppressive agents in older adults are lacking. Recent findings from U.S. transplant registry-based studies suggest that risk-adjusted death-censored graft failure is higher among older patients who received antimetabolite avoidance, mammalian target of rapamycin inhibitor (mTORi)-based, and cyclosporine-based regimens. Observational data suggest that risk-adjusted mortality may be increased in older patients who receive mTORi-based and cyclosporine-based regimens but lower in those managed with T-cell induction and maintenance steroid avoidance/withdrawal. SUMMARY Tailored immunosuppression management to improve patient and graft survival in older transplant recipients is an important goal of personalized medicine. Lower intensity immunosuppression, such as steroid-sparing regimens, appear beneficial whereas mTORi- and cyclosporine-based maintenance are associated with greater potential for adverse effects. Prospective clinical trials to assess the safety and efficacy of immunosuppression agents in older recipients are urgently needed.
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22
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Cossart AR, Isbel NM, Scuderi C, Campbell SB, Staatz CE. Pharmacokinetic and Pharmacodynamic Considerations in Relation to Calcineurin Usage in Elderly Kidney Transplant Recipients. Front Pharmacol 2021; 12:635165. [PMID: 33912051 PMCID: PMC8072471 DOI: 10.3389/fphar.2021.635165] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 02/12/2021] [Indexed: 12/28/2022] Open
Abstract
This review summarizes how possible age-related changes in tacrolimus and cyclosporine pharmacokinetics and pharmacodynamics may influence drug dosing and monitoring in the elderly, and highlights how micro-sampling may be useful in this cohort in the future. Advancing biological age leads to physiological changes that can affect drug absorption, distribution, metabolism and excretion, as well as immune system responsiveness. Some studies have shown that elderly recipients may have higher dose-adjusted exposure and/or lower clearance of the calcineurin inhibitors, suggesting that doses may need to be lowered in elderly recipients. Only one study has examined how aging effects drug target enzyme activity and demonstrated that age does not correlate with the calcineurin inhibitor half-maximal inhibitory concentration. Several studies have shown elderly kidney transplant recipients have increased risk of both morbidity and mortality, compared to younger adults due to increased susceptibility to immunosuppressant side effects, particularly cardiovascular disease, infection and malignancy. Current immunosuppressant dosing and monitoring protocols often make no adjustments for age. Lower maintenance immunosuppressant targets in elderly recipients may decrease patient susceptibility to drug side effects, however, further studies are required and appropriate targets need to be established. Blood draw by micro-sampling may be useful for drug monitoring in this cohort in the future, as blood collection is minimally invasive and less painful than venepuncture. Micro-sampling could also make further pharmacokinetic, pharmacodynamics and outcome studies in the elderly more feasible.
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Affiliation(s)
- Amelia R Cossart
- School of Pharmacy, University of Queensland, Brisbane, QLD, Australia
| | - Nicole M Isbel
- Department of Nephrology, University of Queensland at the Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Carla Scuderi
- School of Pharmacy, University of Queensland, Brisbane, QLD, Australia.,Kidney Health Service, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Scott B Campbell
- Department of Nephrology, University of Queensland at the Princess Alexandra Hospital, Brisbane, QLD, Australia
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January SE, Hagopian JC, Nesselhauf NM, Progar K, Horwedel TA, Santos RD. Clinical Experience with Extended-Release Tacrolimus in Older Adult Kidney Transplant Recipients: A Retrospective Cohort Study. Drugs Aging 2021; 38:397-406. [PMID: 33755934 DOI: 10.1007/s40266-021-00842-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Extended-release tacrolimus (LCP-Tac) prescribing information states that there is insufficient data in older adult patients from which to make recommendations on use in this population. This study sought to provide information on de novo use of LCP-Tac in the older adult kidney transplant population. METHODS This single-center retrospective study had two distinct objectives; to determine if weight-based doses of LCP-Tac differ based on recipient age and to compare safety and efficacy between LCP-Tac and immediate-release tacrolimus (IR-Tac) in older adult transplant recipients. Data was obtained through electronic chart review up to 2 years after transplant with censoring for graft loss and death. RESULTS Weight-based doses were compared between patients aged ≥ 65 years (n = 84), 36-64 years (n = 64), and ≤35 years (n = 44). LCP-Tac weight-based doses were lower at all time points in patients ≥ 65 years of age. Both age and race significantly impacted required dose on linear regression. The doses required to achieve therapeutic tacrolimus troughs were significantly lower in all age groups compared with the current FDA de novo dosing recommendation. In the older adult population, graft outcomes and infectious and metabolic complications were compared between recipients of LCP-Tac (n = 84) and IR-Tac (n = 42). Within this cohort, there were no differences between LCP-Tac and IR-Tac on graft function, rejection, graft loss, death, cytomegalovirus viremia, BK viremia, hypertension, diabetes, alopecia, or tremor up to 2 years after transplant. CONCLUSIONS Older adult recipients required significantly lower LCP-Tac doses compared with younger recipients and with the FDA-labeled starting dose. There were no differences in graft outcomes or adverse effects in older adult patients who received LCP-Tac versus IR-Tac.
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Affiliation(s)
- Spenser E January
- Department of Pharmacy, Barnes-Jewish Hospital, 1 Barnes-Jewish Hospital Plaza, Mailstop 90-52-411, Saint Louis, MO, 63130, USA.
| | - Jennifer C Hagopian
- Department of Pharmacy, Barnes-Jewish Hospital, 1 Barnes-Jewish Hospital Plaza, Mailstop 90-52-411, Saint Louis, MO, 63130, USA
| | - Nicole M Nesselhauf
- Department of Pharmacy, Barnes-Jewish Hospital, 1 Barnes-Jewish Hospital Plaza, Mailstop 90-52-411, Saint Louis, MO, 63130, USA
| | - Kristin Progar
- Department of Pharmacy, Barnes-Jewish Hospital, 1 Barnes-Jewish Hospital Plaza, Mailstop 90-52-411, Saint Louis, MO, 63130, USA
| | | | - Rowena Delos Santos
- Division of Nephrology, Washington University in Saint Louis, Saint Louis, MO, USA
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Ben-Fredj N, Hannachi I, Chadli Z, Ben-Romdhane H, A Boughattas N, Ben-Fadhel N, Aouam K. Dosing algorithm for Tacrolimus in Tunisian Kidney transplant patients: Effect of CYP 3A4*1B and CYP3A4*22 polymorphisms. Toxicol Appl Pharmacol 2020; 407:115245. [DOI: 10.1016/j.taap.2020.115245] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 08/28/2020] [Accepted: 09/14/2020] [Indexed: 11/28/2022]
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Wiebe C, Rush DN, Gibson IW, Pochinco D, Birk PE, Goldberg A, Blydt‐Hansen T, Karpinski M, Shaw J, Ho J, Nickerson PW. Evidence for the alloimmune basis and prognostic significance of Borderline T cell-mediated rejection. Am J Transplant 2020; 20:2499-2508. [PMID: 32185878 PMCID: PMC7496654 DOI: 10.1111/ajt.15860] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 03/05/2020] [Accepted: 03/07/2020] [Indexed: 02/06/2023]
Abstract
Prognostic biomarkers of T cell-mediated rejection (TCMR) have not been adequately studied in the modern era. We evaluated 803 renal transplant recipients and correlated HLA-DR/DQ molecular mismatch alloimmune risk categories (low, intermediate, high) with the severity, frequency, and persistence of TCMR. Allograft survival was reduced in recipients with Banff Borderline (hazard ratio [HR] 2.4, P = .003) and Banff ≥ IA TCMR (HR 4.3, P < .0001) including a subset who never developed de novo donor-specific antibodies (P = .002). HLA-DR/DQ molecular mismatch alloimmune risk categories were multivariate correlates of Banff Borderline and Banff ≥ IA TCMR and correlated with the severity and frequency of rejection episodes. Recipient age, HLA-DR/DQ molecular mismatch category, and cyclosporin vs tacrolimus immunosuppression were independent correlates of Banff Borderline and Banff ≥ IA TCMR. In the subset treated with tacrolimus (720/803) recipient age, HLA-DR/DQ molecular mismatch category, and tacrolimus coefficient of variation were independent correlates of TCMR. The correlation of HLA-DR/DQ molecular mismatch category with TCMR, including Borderline, provides evidence for their alloimmune basis. HLA-DR/DQ molecular mismatch may represent a precise prognostic biomarker that can be applied to tailor immunosuppression or design clinical trials based on individual patient risk.
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Affiliation(s)
- Chris Wiebe
- Department of MedicineUniversity of ManitobaWinnipegCanada
- Shared Health Services ManitobaWinnipegCanada
- Department of ImmunologyUniversity of ManitobaWinnipegCanada
| | - David N. Rush
- Department of MedicineUniversity of ManitobaWinnipegCanada
| | - Ian W. Gibson
- Shared Health Services ManitobaWinnipegCanada
- Department of PathologyUniversity of ManitobaWinnipegCanada
| | | | - Patricia E. Birk
- Department of Pediatrics and Child HealthUniversity of ManitobaWinnipegCanada
| | - Aviva Goldberg
- Department of Pediatrics and Child HealthUniversity of ManitobaWinnipegCanada
| | - Tom Blydt‐Hansen
- Department of PediatricsUniversity of British ColumbiaWinnipegCanada
| | | | - Jamie Shaw
- Department of MedicineUniversity of ManitobaWinnipegCanada
| | - Julie Ho
- Department of MedicineUniversity of ManitobaWinnipegCanada
- Department of ImmunologyUniversity of ManitobaWinnipegCanada
| | - Peter W. Nickerson
- Department of MedicineUniversity of ManitobaWinnipegCanada
- Shared Health Services ManitobaWinnipegCanada
- Department of ImmunologyUniversity of ManitobaWinnipegCanada
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26
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Cai X, Song H, Jiao Z, Yang H, Zhu M, Wang C, Wei D, Shi L, Wu B, Chen J. Population pharmacokinetics and dosing regimen optimization of tacrolimus in Chinese lung transplant recipients. Eur J Pharm Sci 2020; 152:105448. [PMID: 32621968 DOI: 10.1016/j.ejps.2020.105448] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 06/24/2020] [Accepted: 06/30/2020] [Indexed: 01/16/2023]
Abstract
We aimed to (i) develop a population pharmacokinetic model of tacrolimus in Chinese lung transplant recipients and (ii) propose model-based dosing regimens for individualized treatment. We obtained 807 tacrolimus steady-state whole blood concentrations from 52 lung transplant patients and genotyped CYP3A5*3. Population pharmacokinetic analysis was performed using nonlinear mixed-effects modeling. Monte Carlo simulations were employed to determine the initial dosing regimens. Tacrolimus pharmacokinetics was described by a one-compartment model with first-order absorption and elimination processes. In CYP3A5*3/*3 70-kg patients with 30% hematocrit and voriconazole-free therapy, the mean estimated apparent clearance was 13.1 l h-1 with 20.1% between-subject variability, which was lower than that in Caucasian lung transplant patients (17.5-36.5 l h-1). Hematocrit, postoperative days, tacrolimus daily dose, voriconazole concomitant therapy, and CYP3A5*3 genotype were identified as significant covariates for tacrolimus clearance. To achieve target trough concentration (10-15 ng ml-1) on the 8th day post-transplant, a higher initial dosage than the current regimen of 0.04 mg kg-1 every 12 h is recommended for CYP3A5*1/*3 patients without voriconazole concomitant therapy. Given the nonlinear kinetics of tacrolimus and large variability, population pharmacokinetic model should be combined with therapeutic drug monitoring to optimize individualized therapy.
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Affiliation(s)
- Xiaojun Cai
- Department of Pharmacy, the Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi 214023, PR China; Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai 200040, PR China
| | - Huizhu Song
- Department of Pharmacy, the Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi 214023, PR China
| | - Zheng Jiao
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200030, PR China.
| | - Hang Yang
- Lung Transplant Center, the Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi 214023, PR China
| | - Min Zhu
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200030, PR China; School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing 211198, PR China
| | - Chengyu Wang
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200030, PR China
| | - Dong Wei
- Lung Transplant Center, the Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi 214023, PR China
| | - Lingzhi Shi
- Lung Transplant Center, the Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi 214023, PR China
| | - Bo Wu
- Lung Transplant Center, the Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi 214023, PR China.
| | - Jingyu Chen
- Lung Transplant Center, the Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi 214023, PR China.
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Evaluation of Tacrolimus Trough Level in Patients Who Developed Post-transplant Diabetes Mellitus After Kidney Transplantation: A Retrospective Single-Center Study in Saudi Arabia. Transplant Proc 2020; 52:3160-3167. [PMID: 32636070 DOI: 10.1016/j.transproceed.2020.05.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 02/19/2020] [Accepted: 05/12/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Post-transplant diabetes mellitus (PTDM) is a complication after kidney transplantation. Studies showed an association between high trough levels of tacrolimus FK506 and PTDM. This study aims to investigate the association between FK506 trough levels during the first year after kidney transplant and the incidence of PTDM. METHODS This retrospective study included adult kidney transplant patients who were not diabetic before transplantation from 2011 to 2014. The analysis evaluated FK506 trough levels at different time points post-transplant, as well as other variables to determine whether they were associated with PTDM. RESULTS The cumulative incidence of PTDM was 22.5% with a median time to PTDM diagnosis of 10 months. PTDM patients had higher first FK506 (ng/mL) levels (P = .001), and more patients in the PTDM group had FK506 level >10 ng/mL during the first 3 months (P = .004). After 12 months of transplant, PTDM patients had higher body mass index (BMI) 28.3 ± 6.9 kg/m2 compared to non-PTDM patients 26.4 ± 6.7 kg/m2 (P = .015). Binary logistic regression analysis showed that age ≥40 years (odds ratio [OR] = 2.75, P = .004), BMI ≥25 kg/m2 (OR = 2.04, P = .040), and FK506 level ≥10 ng/mL during the first 3 months (OR = 2.65, P = .009) were significantly related to PTDM development. CONCLUSION Patients with FK506 trough level >10 ng/mL during the first 3 months after transplantation are at higher risk of PTDM, especially in patients >40 years of age and/or who are overweight. These results may strengthen the notion that there is a connection between high FK506 trough levels and PTDM development.
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Abstract
T-cell immunity undergoes a complex and continuous remodeling with aging. Understanding those dynamics is essential in refining immunosuppression. Aging is linked to phenotypic and metabolic changes in T-cell immunity, many resulting into impaired function and compromised effectiveness. Those changes may impact clinical immunosuppression with evidences suggesting age-specific efficacies of some (CNI and mammalian target of rapamycin inhibitors) but not necessarily all immunosuppressants. Metabolic changes of T cells with aging have only recently been appreciated and may provide novel ways of immunosuppression. Here, we provide an update on changes of T-cell immunity in aging.
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Salvadori M, Tsalouchos A. Pharmacogenetics of immunosuppressant drugs: A new aspect for individualized therapy. World J Transplant 2020; 10:90-103. [PMID: 32864355 PMCID: PMC7428791 DOI: 10.5500/wjt.v10.i5.90] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 03/26/2020] [Accepted: 04/23/2020] [Indexed: 02/06/2023] Open
Abstract
In recent years, pharmacogenetics has emerged as an important tool for choosing the right immunosuppressant drug and its appropriate dose. Indeed, pharmacogenetics may exert its action on immunosuppressant drugs at three levels. Pharmacogenetics identifies and studies the genes involved in encoding the proteins involved in drug pharmacokinetics and in encoding the enzymes involved in drug degradation. Pharmacogenetics is also relevant in encoding the enzymes and proteins involved in codifying the transmembrane proteins involved in transmembrane passage favoring the absorption and intracellular action of several immunosuppressants. Pharmacogenetics concern the variability of genes encoding the proteins involved as immunosuppressant triggers in the pharmacodynamic pathways. Of course, not all genes have been discovered and studied, but some of them have been clearly examined and their relevance together with other factors such as age and race has been defined. Other genes on the basis of relevant studies have been proposed as good candidates for future studies. Unfortunately, to date, clear conclusions may be drawn only for those drugs that are metabolized by CYP3A5 and its genotyping before kidney, heart and lung transplantation is recommended. The conclusions of the studies on the recommended candidate genes, together with the development of omics techniques could in the future allow us to choose the right dose of the right immunosuppressant for the right patient.
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Affiliation(s)
- Maurizio Salvadori
- Department of Renal Transplantation, Careggi University Hospital, Florence 50139, Italy
| | - Aris Tsalouchos
- Nephrology and Dialysis Unit, Saints Cosmas and Damian Hospital, Pescia 51017, Italy
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Artemov DV, Zulkarnaev AB, Vatazin AV. Age-related features of the pattern of lymphocyte subpopulations and functional activity of peripheral blood mononuclear cells in patients with chronic kidney disease before and after transplantation. RUSSIAN JOURNAL OF TRANSPLANTOLOGY AND ARTIFICIAL ORGANS 2020. [DOI: 10.15825/1995-1191-2020-1-40-49] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- D. V. Artemov
- M.F. Vladimirsky Moscow Regional Clinical and Research Institute
| | - A. B. Zulkarnaev
- M.F. Vladimirsky Moscow Regional Clinical and Research Institute
| | - A. V. Vatazin
- M.F. Vladimirsky Moscow Regional Clinical and Research Institute
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31
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Camilleri B, Pararajasingam R, Buttigieg J, Halawa A. Immunosuppression strategies in elderly renal transplant recipients. Transplant Rev (Orlando) 2020; 34:100529. [DOI: 10.1016/j.trre.2020.100529] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 11/09/2019] [Accepted: 12/18/2019] [Indexed: 01/23/2023]
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Dreyer GJ, de Fijter JW. Transplanting the Elderly: Mandatory Age- and Minimal Histocompatibility Matching. Front Immunol 2020; 11:359. [PMID: 32226428 PMCID: PMC7080649 DOI: 10.3389/fimmu.2020.00359] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 02/14/2020] [Indexed: 12/16/2022] Open
Abstract
Worldwide over 40% of patients receiving renal replacement therapy (RRT) are aged 65 years or older, a number that is still increasing. Renal transplantation is the preferred RRT, providing substantial survival benefit over those remaining on dialysis, including the elderly. Only 3% of patients aged 65 years or older accepted on the waiting list actually received a kidney transplant offer within the Eurotransplant allocation region. To increase the chance for elderly to receive a timely kidney transplant, the Eurotransplant Senior Program was introduced. The ESP supports local allocation of older kidneys to older donors in order to decrease cold ischemia time, while disregarding former exchange principles based on matching for HLA antigens. As a consequence, more elderly received a kidney transplant and a relative higher incidence of acute rejection resulted in additional courses of high steroids and/or depleting antibody therapy. Since death with a functioning graft due to infections is the dominant reason of graft loss in elderly, more intense clinical immunosuppression to prevent or treat acute rejection is not a very attractive option. Therefore in elderly kidney transplant candidates, we advocate reintroduction of minimal histocompatibility criteria (i.e., HLA-DR matching) followed by age-matching with mandatory local/regional allocation to also facilitate short cold ischemia.
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Affiliation(s)
- Geertje J Dreyer
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, Netherlands
| | - Johan W de Fijter
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, Netherlands
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Oberbauer R, Bestard O, Furian L, Maggiore U, Pascual J, Rostaing L, Budde K. Optimization of tacrolimus in kidney transplantation: New pharmacokinetic perspectives. Transplant Rev (Orlando) 2020; 34:100531. [PMID: 31955920 DOI: 10.1016/j.trre.2020.100531] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 11/05/2019] [Accepted: 12/08/2019] [Indexed: 02/07/2023]
Abstract
Tacrolimus is the cornerstone of immunosuppressive therapy after kidney transplantation (KT), but its use is complicated by a narrow therapeutic index and high inter- and intra-patient pharmacokinetic variability. There are three available oral formulations of tacrolimus: immediate-release tacrolimus (IR-Tac), extended-release tacrolimus (ER-Tac) and a MeltDose® (LCPT) formulation, the latter favoring a prolonged drug release and increased bioavailability. The time-concentration curves of these formulations are different. Compared with IR-Tac and ER-Tac, LCPT has a relatively flat pharmacokinetic profile with less fluctuation between trough and peak exposures, and a delayed peak concentration. This translates to a more stable delivery of tacrolimus and may alleviate the risk of underexposure and allograft rejection or overexposure and toxicity. The once-daily formulation of both ER-TAC and LCPT may also offer a potential advantage on patient adherence. Fast metabolizers of tacrolimus, the elderly, and human leukocyte antigen-sensitized patients are at risk of poorer outcomes after KT, possibly associated with a different exhibited pharmacokinetics of tacrolimus or different requirements in terms of exposure. Simple, practical strategies are needed to identify patients at risk of suboptimal KT outcomes and those who would benefit from a more proactively personalized approach to tacrolimus treatment. This review aims to increase awareness of the link between the pharmacokinetics of oral tacrolimus formulations and the clinical needs of patients after KT, particularly among those who have clinically significant pharmacokinetic variation of tacrolimus.
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Affiliation(s)
- Rainer Oberbauer
- Department of Nephrology, Medical University of Vienna, Vienna, Austria
| | - Oriol Bestard
- Kidney Transplant Unit, Nephrology department, Bellvitge University Hospital, Barcelona, Spain
| | - Lucrezia Furian
- Kidney and Pancreas Transplantation Unit, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Italy
| | - Umberto Maggiore
- Kidney and Kidney-Pancreas Transplant Unit (Department of Nephrology), Parma University Hospital, Parma, Italy
| | - Julio Pascual
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
| | - Lionel Rostaing
- Nephrology and Transplantation Department, CHU Grenoble, Grenoble, France
| | - Klemens Budde
- Department of Nephrology, Internal Intensive Care Medicine, Campus Charité Mitte, Berlin, Germany.
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Mohamed ME, Schladt DP, Guan W, Wu B, van Setten J, Keating B, Iklé D, Remmel RP, Dorr CR, Mannon RB, Matas AJ, Israni AK, Oetting WS, Jacobson PA. Tacrolimus troughs and genetic determinants of metabolism in kidney transplant recipients: A comparison of four ancestry groups. Am J Transplant 2019; 19:2795-2804. [PMID: 30953600 PMCID: PMC6763344 DOI: 10.1111/ajt.15385] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 03/04/2019] [Accepted: 03/28/2019] [Indexed: 02/06/2023]
Abstract
Tacrolimus trough and dose requirements vary dramatically between individuals of European and African American ancestry. These differences are less well described in other populations. We conducted an observational, prospective, multicenter study from which 2595 kidney transplant recipients of European, African, Native American, and Asian ancestry were studied for tacrolimus trough, doses, and genetic determinants of metabolism. We studied the well-known variants and conducted a CYP3A4/5 gene-wide analysis to identify new variants. Daily doses, and dose-normalized troughs were significantly different between the four groups (P < .001). CYP3A5*3 (rs776746) was associated with higher dose-normalized tacrolimus troughs in all groups but occurred at different allele frequencies and had differing effect sizes. The CYP3A5*6 (rs10264272) and *7 (rs413003343) variants were only present in African Americans. CYP3A4*22 (rs35599367) was not found in any of the Asian ancestry samples. We identified seven suggestive variants in the CYP3A4/5 genes associated with dose-normalized troughs in Native Americans (P = 1.1 × 10-5 -8.8 × 10-6 ) and one suggestive variant in Asian Americans (P = 5.6 × 10-6 ). Tacrolimus daily doses and dose-normalized troughs vary significantly among different ancestry groups. We identified potential new variants important in Asians and Native Americans. Studies with larger populations should be conducted to assess the importance of the identified suggestive variants.
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Affiliation(s)
- Moataz E. Mohamed
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA,Department of Pharmacy Practice, Faculty of Pharmacy, Helwan University, Cairo, Egypt
| | | | - Weihua Guan
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Baolin Wu
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Jessica van Setten
- Department of Cardiology, University Medical Center Utrecht, University of Utrecht, Utrecht, Netherlands
| | - Brendan Keating
- Department of Surgery, School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Rory P. Remmel
- Department of Medicinal Chemistry, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
| | - Casey R. Dorr
- Hennepin Healthcare Research Institute, Minneapolis, MN, USA,Department of Medicine, University of Minnesota, Hennepin Healthcare, Minneapolis, MN
| | | | - Arthur J. Matas
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Ajay K. Israni
- Hennepin Healthcare Research Institute, Minneapolis, MN, USA,Department of Medicine, University of Minnesota, Hennepin Healthcare, Minneapolis, MN,Department of Epidemiology & Community Health, University of Minnesota, Minneapolis, MN, USA
| | - William S. Oetting
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
| | - Pamala A. Jacobson
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
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Nowicka M, Górska M, Nowicka Z, Edyko K, Edyko P, Wiślicki S, Zawiasa-Bryszewska A, Strzelczyk J, Matych J, Kurnatowska I. Tacrolimus: Influence of the Posttransplant Concentration/Dose Ratio on Kidney Graft Function in a Two-Year Follow-Up. Kidney Blood Press Res 2019; 44:1075-1088. [PMID: 31522184 DOI: 10.1159/000502290] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 07/22/2019] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Tacrolimus (TAC) metabolism rate has the potential to impact graft function after kidney transplantation (KTx). We aimed to analyze the relationship between the early post-KTx TAC C/D ratio (blood trough concentration normalized by total daily dose) and kidney graft function in a 2-year follow-up. METHODS We retrospectively analyzed data from 101 post-KTx patients at 3, 6, 12, and 24 months after KTx to identify the C/D ratio cutoff value optimal for dividing patients into fast and slow TAC metabolizers. We investigated the relationship between their TAC metabolism rate and graft function. RESULTS Patients were divided based on the TAC C/D ratio at 6 months after KTx of 1.47 ng/mL * 1 mg. Fast metabolizers (C/D ratio <1.47 ng/mL * 1 mg) presented with significantly worse graft function throughout the whole study period (p < 0.05 at each timepoint) and were significantly less likely to develop good graft function (estimated glomerular filtration rate ≥45 mL/min/1.73 m2) than slow metabolizers. Our model based on donor and recipient age, recipient sex and slow/fast metabolism status allowed for identification of patients with compromised graft function in 2-year follow-up with 66.7% sensitivity and 94.6% specificity. CONCLUSION Estimating TAC C/D ratio at 6 months post-KTx might help identify patients at risk of developing deteriorated graft function in a 2-year follow-up.
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Affiliation(s)
- Maja Nowicka
- Department of Clinical Pharmacology, Medical University of Lodz, Lodz, Poland
| | - Monika Górska
- Department of Clinical Pharmacology, Medical University of Lodz, Lodz, Poland
| | - Zuzanna Nowicka
- Department of Clinical Pharmacology, Medical University of Lodz, Lodz, Poland.,Department of Biostatistics and Translational Medicine, Medical University of Lodz, Lodz, Poland
| | - Krzysztof Edyko
- Department of Clinical Pharmacology, Medical University of Lodz, Lodz, Poland
| | - Piotr Edyko
- Department of Urology and Kidney Transplantation, N Pirogov Provincial Specialist Hospital, Lodz, Poland
| | - Sebastian Wiślicki
- Clinical Department of Anesthesiology and Intensive Care and Pain Management, University Clinical Hospital No 1 N Barlicki in Lodz, Lodz, Poland
| | - Anna Zawiasa-Bryszewska
- Department of Clinical Pharmacology, Medical University of Lodz, Lodz, Poland.,Department of Nephrology, University Clinical Hospital No 1 N Barlicki in Lodz, Lodz, Poland
| | - Janusz Strzelczyk
- Department of General and Transplant Surgery, Medical University of Lodz, Lodz, Poland
| | - Józef Matych
- Department of Urology and Kidney Transplantation, N Pirogov Provincial Specialist Hospital, Lodz, Poland
| | - Ilona Kurnatowska
- Department of Clinical Pharmacology, Medical University of Lodz, Lodz, Poland, .,Department of Nephrology, University Clinical Hospital No 1 N Barlicki in Lodz, Lodz, Poland,
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36
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Cossart AR, Cottrell WN, Campbell SB, Isbel NM, Staatz CE. Characterizing the pharmacokinetics and pharmacodynamics of immunosuppressant medicines and patient outcomes in elderly renal transplant patients. Transl Androl Urol 2019; 8:S198-S213. [PMID: 31236338 DOI: 10.21037/tau.2018.10.16] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
This review examines what is currently known about the pharmacokinetics and pharmacodynamics of commonly prescribed immunosuppressant medicines, tacrolimus, cyclosporine, mycophenolate and prednisolone, in elderly renal transplant recipients, and reported patient outcomes in this cohort. Renal transplantation is increasing rapidly in the elderly, however, currently, long-term patient outcomes are relatively poor compared to younger adults. Some studies have suggested that elderly recipients may have higher dose-adjusted exposure and/or lower clearance of the calcineurin inhibitors tacrolimus and cyclosporine; with one study reporting up to 50% reduction in tacrolimus exposure in the elderly. Elderly transplant recipients do not appear to have higher dosage-adjusted exposure to mycophenolic acid (MPA). The effects of ageing on the pharmacokinetics of prednisolone are unknown. Only one study has examined how aging effects drug target enzymes, reporting no difference in baseline inosine 5'-monophosphate dehydrogenase (IMPDH) activity and MPA-induced IMPDH activity in elderly compared to younger adult renal transplant recipients. In elderly transplant recipients, immunosenescence likely lowers the risk of acute rejection, but increases the risk of drug-related adverse effects. Currently, the three main causes of death in elderly renal transplant recipients are cardiovascular disease, infection and malignancy. One study has showed that renal transplant recipients aged over 65 years are seven times more likely to die with a functioning graft compared with young adults (aged 18-29 years). This suggests that an optimal balance between immunosuppressant medicine efficacy and toxicity is not achieved in elderly recipients, and further studies are needed to foster long-term graft and patient survival. Lower maintenance immunosuppressant targets in elderly recipients may decrease patient susceptibility to drug side effects, however, further studies are required and appropriate targets need to be established.
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Affiliation(s)
- Amelia R Cossart
- School of Pharmacy, University of Queensland, Brisbane, Australia
| | - W Neil Cottrell
- School of Pharmacy, University of Queensland, Brisbane, Australia
| | - Scott B Campbell
- Department of Nephrology, University of Queensland at the Princess Alexandra Hospital, Brisbane, Australia
| | - Nicole M Isbel
- Department of Nephrology, University of Queensland at the Princess Alexandra Hospital, Brisbane, Australia
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Hemmersbach-Miller M, Alexander BD, Sudan DL, Pieper C, Schmader KE. Infections after kidney transplantation. Does age matter? Clin Transplant 2019; 33:e13516. [PMID: 30849194 DOI: 10.1111/ctr.13516] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 02/19/2019] [Indexed: 12/19/2022]
Abstract
Infections threaten successful outcomes after kidney transplantation. Our aim was to determine if the number, types of infections and the risk factors for common infections differed between older compared to younger kidney transplant (KT) recipients in the first year after surgery. We performed a single-center retrospective cohort study. Between 2011 and 2015, 91 KTs were performed in patients ≥65 years of age; these were matched 1:1 (by year of transplantation, sex and race) to controls aged 40-60 years. Over 90% of both groups had an infectious complication. Urinary tract infections (UTIs) and cytomegalovirus (CMV) viremia were significantly more frequent in older recipients. Older adults had more late onset UTIs, including after stent removal. CMV viremia was more frequent in older adults in the 1-6 months post-transplant period. Due to our center-specific protocol utilizing pre-emptive monitoring in the CMV recipient-seropositive population, the higher CMV incidence in the aged recipient was driven by this subpopulation of older adults. No difference in pneumonias or bloodstream infections were found, nor in surgical complications, rejection or graft loss. Mortality was higher at 1-year post-transplant in the older recipients (9.9% vs 1.1%; P = 0.018). Prophylactic and immunosuppressive strategies may need to be altered for older KT recipients.
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Affiliation(s)
- Marion Hemmersbach-Miller
- Infectious Diseases Division, Duke University Medical Center, Durham, North Carolina.,Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Barbara D Alexander
- Infectious Diseases Division, Duke University Medical Center, Durham, North Carolina
| | - Debra L Sudan
- Division of Abdominal Transplant Surgery, Duke University Medical Center, Durham, North Carolina
| | - Carl Pieper
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Kenneth E Schmader
- Division of Geriatrics, Duke University Medical Center, Durham, North Carolina.,Geriatric Research Education and Clinical Center (GRECC), Durham VA, Durham, North Carolina
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38
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Peeters LEJ, Kester MP, Feyz L, Van Den Bemt PMLA, Koch BCP, Van Gelder T, Versmissen J. Pharmacokinetic and pharmacodynamic considerations in the treatment of the elderly patient with hypertension. Expert Opin Drug Metab Toxicol 2019; 15:287-297. [PMID: 30880496 DOI: 10.1080/17425255.2019.1588249] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Hypertension is an important risk factor for developing cardiovascular diseases. It is more prevalent in the elderly population. Recently updated American and European guidelines recommend treating every elderly patient with hypertension independent of age, starting with a low dose of antihypertensive drugs. However, little information is available on the optimal dosages of antihypertensive drugs to treat the elderly safely. Areas covered: Comorbidities, co-medication and frailty status can alter the clinical outcome of drug treatment and can cause adverse events in the elderly. Also, due to pharmacokinetic and pharmacodynamic changes the interpatient variability when using antihypertensive drugs is considerable. In this review, an overview is given on the extent to which the previously mentioned parameters are changed in elderly patients and what this means for the exposure to antihypertensive medication. Also, recommendations on the starting dose of the most frequently used antihypertensive drugs are given based on literature data. Expert opinion: We believe that recommendations on starting dosages followed by a stepwise increase of dosages will lead to improved blood pressure control and less adverse drug reactions in the elderly patient. This may improve adherence to antihypertensive therapy.
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Affiliation(s)
- L E J Peeters
- a Department of Hospital Pharmacy , Erasmus MC, University Medical Center Rotterdam , Rotterdam , The Netherlands.,b Department of Internal Medicine , Erasmus MC, University Medical Center Rotterdam , Rotterdam , The Netherlands
| | - M P Kester
- b Department of Internal Medicine , Erasmus MC, University Medical Center Rotterdam , Rotterdam , The Netherlands
| | - L Feyz
- c Department of Cardiology , Erasmus MC, University Medical Center Rotterdam , Rotterdam , The Netherlands
| | - P M L A Van Den Bemt
- a Department of Hospital Pharmacy , Erasmus MC, University Medical Center Rotterdam , Rotterdam , The Netherlands
| | - B C P Koch
- a Department of Hospital Pharmacy , Erasmus MC, University Medical Center Rotterdam , Rotterdam , The Netherlands
| | - T Van Gelder
- a Department of Hospital Pharmacy , Erasmus MC, University Medical Center Rotterdam , Rotterdam , The Netherlands.,b Department of Internal Medicine , Erasmus MC, University Medical Center Rotterdam , Rotterdam , The Netherlands
| | - J Versmissen
- b Department of Internal Medicine , Erasmus MC, University Medical Center Rotterdam , Rotterdam , The Netherlands
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Nian Y, Maenosono R, Iske J, Elkhal A, Tullius SG. A Contraindication for Transplantation? Consequences of Frailty on Immunity and Immunosuppression. CURRENT TRANSPLANTATION REPORTS 2019. [DOI: 10.1007/s40472-019-0228-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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40
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Hemmersbach-Miller M, Wolfe CR, Schmader KE. Solid organ transplantation in older adults. Infectious and other age-related considerations. ACTA ACUST UNITED AC 2019; 3. [PMID: 34113803 PMCID: PMC8189398 DOI: 10.21926/obm.transplant.1901046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In the U.S., older adults aged 65 or above comprise nearly one quarter of the solid organ transplant (SOT) waitlists, and the number of transplants performed in this age group continues to increase. There are no specific guidelines for the assessment and follow up of the older SOT candidate or recipient. Older adults are at increased risk of infectious complications after SOT. Despite these complications and even with the use of suboptimal donors, overall outcomes are favorable. We provide an overview to specific consideration as they relate to the older SOT candidate and recipient.
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Affiliation(s)
- Marion Hemmersbach-Miller
- Division of Infectious Diseases, Duke University Medical Center, Durham NC, USA.,Duke Clinical Research Institute, Durham NC, USA
| | - Cameron R Wolfe
- Division of Infectious Diseases, Duke University Medical Center, Durham NC, USA
| | - Kenneth E Schmader
- Division of Geriatrics, Duke University Medical Center, Durham NC, USA.,GRECC, Durham VA, Durham NC. USA
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41
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Andrews LM, Hesselink DA, van Schaik RHN, van Gelder T, de Fijter JW, Lloberas N, Elens L, Moes DJAR, de Winter BCM. A population pharmacokinetic model to predict the individual starting dose of tacrolimus in adult renal transplant recipients. Br J Clin Pharmacol 2019; 85:601-615. [PMID: 30552703 PMCID: PMC6379219 DOI: 10.1111/bcp.13838] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 11/30/2018] [Accepted: 12/10/2018] [Indexed: 12/16/2022] Open
Abstract
Aims The aims of this study were to describe the pharmacokinetics of tacrolimus immediately after kidney transplantation, and to develop a clinical tool for selecting the best starting dose for each patient. Methods Data on tacrolimus exposure were collected for the first 3 months following renal transplantation. A population pharmacokinetic analysis was conducted using nonlinear mixed‐effects modelling. Demographic, clinical and genetic parameters were evaluated as covariates. Results A total of 4527 tacrolimus blood samples collected from 337 kidney transplant recipients were available. Data were best described using a two‐compartment model. The mean absorption rate was 3.6 h−1, clearance was 23.0 l h–1 (39% interindividual variability, IIV), central volume of distribution was 692 l (49% IIV) and the peripheral volume of distribution 5340 l (53% IIV). Interoccasion variability was added to clearance (14%). Higher body surface area (BSA), lower serum creatinine, younger age, higher albumin and lower haematocrit levels were identified as covariates enhancing tacrolimus clearance. Cytochrome P450 (CYP) 3A5 expressers had a significantly higher tacrolimus clearance (160%), whereas CYP3A4*22 carriers had a significantly lower clearance (80%). From these significant covariates, age, BSA, CYP3A4 and CYP3A5 genotype were incorporated in a second model to individualize the tacrolimus starting dose:
Dosemg=222nghml–1*22.5lh–1*1.0ifCYP3A5*3/*3or1.62ifCYP3A5*1/*3orCYP3A5*1/*1*1.0ifCYP3A4*1or unknownor0.814ifCYP3A4*22*Age56−0.50*BSA1.930.72/1000Both models were successfully internally and externally validated. A clinical trial was simulated to demonstrate the added value of the starting dose model. Conclusions For a good prediction of tacrolimus pharmacokinetics, age, BSA, CYP3A4 and CYP3A5 genotype are important covariates. These covariates explained 30% of the variability in CL/F. The model proved effective in calculating the optimal tacrolimus dose based on these parameters and can be used to individualize the tacrolimus dose in the early period after transplantation.
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Affiliation(s)
- L M Andrews
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - D A Hesselink
- Department of Internal Medicine, Division of Nephrology & Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Rotterdam Transplant Group, Rotterdam, The Netherlands
| | - R H N van Schaik
- Department of Clinical Chemistry, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - T van Gelder
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.,Department of Internal Medicine, Division of Nephrology & Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Rotterdam Transplant Group, Rotterdam, The Netherlands
| | - J W de Fijter
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | - N Lloberas
- Department of Nephrology, IDIBELL, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - L Elens
- Department of Integrated PharmacoMetrics, PharmacoGenomics and PharmacoKinetics (PMGK), Louvain Drug Research Institute (LDRI), Université Catholique de Louvain (UCL), Brussels, Belgium
| | - D J A R Moes
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - B C M de Winter
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
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Lemaitre F, Lorcy N, Tron C, Golbin L, Petitcollin A, Verdier MC, Vigneau C, Bellissant E. Tacrolimus overexposure in kidney transplant recipients during the first post-operative week: caution is required in older patients. Fundam Clin Pharmacol 2018; 33:347-354. [PMID: 30431672 DOI: 10.1111/fcp.12432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 10/22/2018] [Accepted: 11/12/2018] [Indexed: 11/28/2022]
Abstract
In liver transplantation, tacrolimus trough concentrations (Cmin) above 20 ng/mL during the first days led to worse outcome at 1 year but data in the kidney transplant (KT) era are scarce. The aim of this study was to evaluate the impact of tacrolimus overexposure during the first week post-transplantation on the kidney function (KF) of KT recipients. In this retrospective study, 105 KT recipients were attributed to overexposure group (OG) or normal group according to their Cmin during the first week of treatment. KF was evaluated by comparing the rate of delayed graft function (DGF) and by collecting plasma creatinine from day 1, 2, 3, 4, 5, 6, 7, 14, 21, 28 and at 1 year. Risk factors for developing DGF were also investigated using a multivariate model. DGF was more frequent in OG (43% of patients; P = 0.027) which has higher plasma creatinine on day 7, 14, and 21. OG patients were older with more extended criteria donor's grafts. In the multivariate analysis, only cold ischemia time (CIT) remained associated with DGF (OR = 1.003), while TAC overexposure did not reach significance (P = 0.06; OR = 3.9). In this study, we confirmed the predominant role of CIT as a risk factor for the onset of DGF in kidney transplantation. 43% of KT recipients were overexposed with more DGF, especially older patients.
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Affiliation(s)
- Florian Lemaitre
- Department of Clinical and Biological Pharmacology, Pharmacovigilance, Pharmacoepidemiology and Drug Information Center, Rennes University Hospital, 2, rue Henri Le Guilloux, 35000, Rennes, France.,Faculty of Medicine, Laboratory of Experimental and Clinical Pharmacology, Rennes 1 University, 2 avenue du Professeur Léon Bernard, 35000, Rennes, France.,Inserm, CIC-P 1414 Clinical Investigation Center, 2, rue Henri Le Guilloux, 35000, Rennes, France
| | - Nolwen Lorcy
- Division of Nephrology, Rennes University Hospital, 2, rue Henri Le Guilloux, 35000, Rennes, France
| | - Camille Tron
- Department of Clinical and Biological Pharmacology, Pharmacovigilance, Pharmacoepidemiology and Drug Information Center, Rennes University Hospital, 2, rue Henri Le Guilloux, 35000, Rennes, France.,Faculty of Medicine, Laboratory of Experimental and Clinical Pharmacology, Rennes 1 University, 2 avenue du Professeur Léon Bernard, 35000, Rennes, France.,Inserm, CIC-P 1414 Clinical Investigation Center, 2, rue Henri Le Guilloux, 35000, Rennes, France
| | - Léonard Golbin
- Division of Nephrology, Rennes University Hospital, 2, rue Henri Le Guilloux, 35000, Rennes, France
| | - Antoine Petitcollin
- Department of Clinical and Biological Pharmacology, Pharmacovigilance, Pharmacoepidemiology and Drug Information Center, Rennes University Hospital, 2, rue Henri Le Guilloux, 35000, Rennes, France.,Faculty of Medicine, Laboratory of Experimental and Clinical Pharmacology, Rennes 1 University, 2 avenue du Professeur Léon Bernard, 35000, Rennes, France.,Inserm, CIC-P 1414 Clinical Investigation Center, 2, rue Henri Le Guilloux, 35000, Rennes, France
| | - Marie-Clémence Verdier
- Department of Clinical and Biological Pharmacology, Pharmacovigilance, Pharmacoepidemiology and Drug Information Center, Rennes University Hospital, 2, rue Henri Le Guilloux, 35000, Rennes, France.,Faculty of Medicine, Laboratory of Experimental and Clinical Pharmacology, Rennes 1 University, 2 avenue du Professeur Léon Bernard, 35000, Rennes, France.,Inserm, CIC-P 1414 Clinical Investigation Center, 2, rue Henri Le Guilloux, 35000, Rennes, France
| | - Cécile Vigneau
- Division of Nephrology, Rennes University Hospital, 2, rue Henri Le Guilloux, 35000, Rennes, France.,Irset (Institut de Recherche en Santé, Environnement et Travail) - UMR 1085, 9 avenue du Professeur Léon Bernard, 35000, Rennes, France
| | - Eric Bellissant
- Department of Clinical and Biological Pharmacology, Pharmacovigilance, Pharmacoepidemiology and Drug Information Center, Rennes University Hospital, 2, rue Henri Le Guilloux, 35000, Rennes, France.,Faculty of Medicine, Laboratory of Experimental and Clinical Pharmacology, Rennes 1 University, 2 avenue du Professeur Léon Bernard, 35000, Rennes, France.,Inserm, CIC-P 1414 Clinical Investigation Center, 2, rue Henri Le Guilloux, 35000, Rennes, France
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43
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Identification of genetic variants associated with tacrolimus metabolism in kidney transplant recipients by extreme phenotype sampling and next generation sequencing. THE PHARMACOGENOMICS JOURNAL 2018; 19:375-389. [PMID: 30442921 PMCID: PMC6522337 DOI: 10.1038/s41397-018-0063-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 09/11/2018] [Accepted: 09/27/2018] [Indexed: 12/26/2022]
Abstract
An extreme phenotype sampling (EPS) model with targeted next-generation sequencing (NGS) identified genetic variants associated with tacrolimus (Tac) metabolism in subjects from the Deterioration of Kidney Allograft Function (DeKAF) Genomics cohort which included 1,442 European Americans (EA) and 345 African Americans (AA). This study included 48 subjects separated into 4 groups of 12 (AA high, AA low, EA high, EA low). Groups were selected by the extreme phenotype of dose-normalized Tac trough concentrations after adjusting for common genetic variants and clinical factors. NGS spanned >3 Mb of 28 genes and identified 18,661 genetic variants (3,961 previously unknown). A group of 125 deleterious variants, by SIFT analysis, were associated with Tac troughs in EAs (burden test, p=0.008), CYB5R2 was associated with Tac troughs in AAs (SKAT, p=0.00079). In CYB5R2, rs61733057 (increased allele frequency in AAs) was predicted to disrupt protein function by SIFT and PolyPhen2 analysis. The variants merit further validation.
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Immunosuppressive drugs and the gastrointestinal tract in renal transplant patients. Transplant Rev (Orlando) 2018; 33:55-63. [PMID: 30473173 DOI: 10.1016/j.trre.2018.11.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 11/07/2018] [Accepted: 11/10/2018] [Indexed: 12/26/2022]
Abstract
Gastrointestinal (GI) discomfort is common after renal transplantation and can be caused by the use of various immunosuppressive drugs. GI symptoms affect the quality of life, lead to an impaired graft survival and an increased mortality. Moreover, diseases and disturbances of the GI tract also affect the pharmacokinetics of immunosuppressive drugs. This review addresses the interaction between immunosuppressive agents and GI disorders. The GI tract is involved in the metabolism of several immunosuppressive drugs. Calcineurin inhibitors, mTor inhibitors, and corticosteroids are subjected to metabolism by the intestinal cytochrome P450 (CYP3A) and by the drug efflux pump ABCB1. Mycophenolate is partly metabolized in the stomach and intestine and undergoes enterohepatic recirculation. Gastrointestinal disturbances can lead to a modified exposure to immunosuppressive drugs. In the first and second part of this review, we focus on the role of the GI tract in the pharmacokinetics of the immunosuppressive drugs and how to adjust immunosuppressive therapy in patients with vomiting, need for tube feeding, delayed gastric emptying, intestinal resection, and diarrhea. In the third part, we review the GI adverse effects of the various immunosuppressive drugs, with special attention for diarrhea and dyspepsia. Finally, we discuss the effects of drugs used for relief of GI complaints on the exposure to immunosuppressive agents.
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45
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Campagne O, Mager DE, Tornatore KM. Population Pharmacokinetics of Tacrolimus in Transplant Recipients: What Did We Learn About Sources of Interindividual Variabilities? J Clin Pharmacol 2018; 59:309-325. [PMID: 30371942 DOI: 10.1002/jcph.1325] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 09/18/2018] [Indexed: 12/24/2022]
Abstract
Tacrolimus, a calcineurin inhibitor, is a common immunosuppressant prescribed after organ transplantation and has notable inter- and intrapatient pharmacokinetic variability. The sources of variability have been investigated using population pharmacokinetic modeling over the last 2 decades. This article provides an updated synopsis on published nonlinear mixed-effects analyses developed for tacrolimus in transplant recipients. The objectives were to establish a detailed overview of the current data and to investigate covariate relationships determined by the models. Sixty-three published analyses were reviewed, and data regarding the study design, modeling approach, and resulting findings were extracted and summarized. Most of the studies investigated tacrolimus pharmacokinetics in adult and pediatric renal and liver transplants after administration of the immediate-release formulation. Model structures largely depended on the study sampling strategy, with ∼50% of studies developing a 1-compartment model using trough concentrations and a 2-compartment model with delayed absorption from intensive sampling. The CYP3A5 genotype, as a covariate, consistently impacted tacrolimus clearance, and dosing adjustments were required to achieve similar drug exposure among patients. Numerous covariates were identified as sources of interindividual variability on tacrolimus pharmacokinetics with limited consistency across these studies, which may be the result of the study designs. Additional analyses are required to further evaluate the potential impact of these covariates and the clinical implementation of these models to guide tacrolimus dosing recommendations. This article may be useful for guiding the design of future population pharmacokinetic studies and provides recommendations for the selection of an existing optimal model to individualize tacrolimus therapy.
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Affiliation(s)
- Olivia Campagne
- Department of Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA.,Faculty of Pharmacy, Universités Paris Descartes-Paris Diderot, Paris, France
| | - Donald E Mager
- Department of Pharmaceutical Sciences, University at Buffalo, SUNY, Buffalo, NY, USA
| | - Kathleen M Tornatore
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, Immunosuppressive Pharmacology Research Program, Translational Pharmacology Research Core, NYS Center of Excellence in Bioinformatics and Life Sciences, University at Buffalo, Buffalo, NY, USA
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46
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Alsheikh R, Gabardi S. Post-Renal Transplantation Outcomes in Elderly Patients Compared to Younger Patients in the Setting of Early Steroid Withdrawal. Prog Transplant 2018; 28:322-329. [PMID: 30213228 DOI: 10.1177/1526924818800039] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Previous studies reported improved outcomes for renal recipients undergoing early steroid withdrawal (ESW), with significantly lower rates of new-onset diabetes, cytomegalovirus (CMV), and malignancy. As renal transplants in older adults has increased, studies have shown similar outcomes between elderly and younger patients. We aim to evaluate post-renal transplantation outcomes in elderly patients compared to younger patients who have undergone ESW. METHODS A retrospective analysis of adults who received transplants between January 2004 and December 2014 and received either basiliximab or antithymocyte globulin for induction, underwent ESW, and received tacrolimus and mycophenolate for maintenance. Patients were stratified based on age (≥60 vs <60). The 1-year primary end point was a composite of patient survival, graft survival, biopsy-proven acute rejection, and serum creatinine. The secondary outcomes included renal function, the incidence of opportunistic infections, malignancies, diabetes, and cardiovascular complications. Cox regression was used to evaluate variables that may affect rejection. RESULTS The sample included 292 patients; 72 were elderly individuals and 220 were younger adults. No significant differences were found in the primary end point or incidence of CMV, BK virus, or malignancy ( P = 1.0, .82, and .06, respectively). The use of blood pressure medications and the need for lipid-lowering agents were significantly higher in elderly patients at last follow-up. Diabetes was more common in elderly patients (15.2% vs 8.41%, P = .11). The induction agent used did not show any significant effect on rejection risk. CONCLUSION We report similar outcomes in elderly patients compared to younger patients in the setting of ESW.
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Affiliation(s)
- Razan Alsheikh
- 1 Clinical Pharmacy Department, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia.,2 Department of Pharmacy Practice and Science, University of Arizona, Tucson, AZ, USA
| | - Steven Gabardi
- 3 Departments of Transplant Surgery and Pharmacy Services, and the Renal Division, Brigham and Women's Hospital, Boston, MA, USA.,4 Harvard Medical School, Boston, MA, USA
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47
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Krzyżowska K, Kolonko A, Giza P, Chudek J, Więcek A. No Significant Influence of Reduced Initial Tacrolimus Dose on Risk of Underdosing and Early Graft Function in Older and Overweight Kidney Transplant Recipients. Transplant Proc 2018; 50:1755-1759. [PMID: 30056895 DOI: 10.1016/j.transproceed.2018.02.108] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 02/06/2018] [Accepted: 02/19/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Nowadays, a reduced initial daily dose of tacrolimus (Tac) (0.1-0.15 mg/kg) is recommended for the majority of kidney transplant recipients (KTRs). The aim of the study was to analyze the safety of such a regimen, including the risk of first inadequately low Tac blood level, acute rejection (AR) occurrence, or early graft dysfunction. METHODS In 2011, we introduced a modified (0.1-0.15 mg/kg/d) initial Tac dosing regimen in older (>55 years) and/or overweight KTRs. To assure the safety of this protocol, we monitored the risk of inadequately low blood Tac level (<6 ng/mL) and incidence of AR or delayed graft function (DGF). The historical cohort with the higher Tac dosing regimen (0.2 mg/kg/d, n = 208) served as a control group. RESULTS The mean Tac daily dose in 78 KTRs (group with reduced dosing) was 0.133 (95% confidence interval [CI], 0.130-0.136) mg/kg and was significantly lower than the standard, previously prescribed dose of 0.195 (95% CI, 0.194-0.197) mg/kg. Of note, induction therapy was employed twice more often in the reduced Tac dosing group. The dose reduction resulted in a slight, nonsignificant decrease in first Tac trough level. The percentages of patients with first Tac troughs <6 ng/mL (5.1% vs 4.8%), AR (6.4% vs 5.8%), and DGF (25.6% vs 31.2%) were similar in the reduced and standard dosing groups. CONCLUSION The currently recommended reduction in Tac initial dosing does not increase the risk of inadequate immunosuppression and does not affect the early graft function. Regardless of Tac dose reduction, there is still a substantial risk of Tac overdosing in older or overweight KTRs.
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Affiliation(s)
- K Krzyżowska
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
| | - A Kolonko
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland.
| | - P Giza
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
| | - J Chudek
- Department of Internal Diseases and Oncological Chemotherapy, Medical University of Silesia, Katowice, Poland
| | - A Więcek
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland
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48
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Dücker CM, Brockmöller J. Genomic Variation and Pharmacokinetics in Old Age: A Quantitative Review of Age- vs. Genotype-Related Differences. Clin Pharmacol Ther 2018; 105:625-640. [PMID: 29498032 PMCID: PMC6585622 DOI: 10.1002/cpt.1057] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 02/20/2018] [Indexed: 01/01/2023]
Abstract
Older persons may particularly benefit from pharmacogenetic diagnostics, but there is little clinical evidence on that question. We quantitatively analyzed the effects of age and genotype in drugs with consensus on a therapeutically relevant impact of a genotype. Assuming additive effects of age and genotype, drugs may be classified in groups with different priorities to consider either age, or genotype, or both, in therapy. Particularly interesting were those studies specifically analyzing the age‐by‐genotype interaction.
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Affiliation(s)
- Christof M Dücker
- Institute for Clinical Pharmacology, University Medical Center, Georg-August University, Göttingen, Germany
| | - Jürgen Brockmöller
- Institute for Clinical Pharmacology, University Medical Center, Georg-August University, Göttingen, Germany
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Andreu F, Colom H, Elens L, van Gelder T, van Schaik RHN, Hesselink DA, Bestard O, Torras J, Cruzado JM, Grinyó JM, Lloberas N. A New CYP3A5*3 and CYP3A4*22 Cluster Influencing Tacrolimus Target Concentrations: A Population Approach. Clin Pharmacokinet 2018; 56:963-975. [PMID: 28050888 DOI: 10.1007/s40262-016-0491-3] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Single nucleotide polymorphisms (SNPs) in the CYP3A5 and CYP3A4 genes have been reported to be an important cause of variability in the pharmacokinetics of tacrolimus in renal transplant patients. The aim of this study was to merge all of the new genetic information available with tacrolimus pharmacokinetics to generate a more robust population model with data from renal transplant recipients. METHODS Tacrolimus exposure data from 304 renal transplant recipients were collected throughout the first year after transplantation and were simultaneously analyzed with a population pharmacokinetic approach using NONMEM® version 7.2. RESULTS The tacrolimus whole-blood concentration versus time data were best described by a two-open-compartment model with inter-occasion variability assigned to plasma clearance. The following factors led to the final model, which significantly decreased the minimum objective function value (p < 0.001): a new genotype cluster variable combining the CYP3A5*3 and CYP3A4*22 SNPs defined as extensive, intermediate, and poor metabolizers; the standardization of tacrolimus whole blood concentrations to a hematocrit value of 45%; and age included as patients <63 years versus patients ≥63 years. External validation confirmed the prediction ability of the model with median bias and precision values of 1.17 ng/mL (95% confidence interval [CI] -3.68 to 4.50) and 1.64 ng/mL (95% CI 0.11-5.50), respectively. Simulations showed that, for a given age and hematocrit at the same fixed dose, extensive metabolizers required the highest doses followed by intermediate metabolizers and then poor metabolizers. CONCLUSIONS Tacrolimus disposition in renal transplant recipients was described using a new population pharmacokinetic model that included the CYP3A5*3 and CYP3A4*22 genotype, age, and hematocrit.
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Affiliation(s)
- Franc Andreu
- Laboratory 4122, Nephrology Service and Laboratory of Experimental Nephrology, University of Barcelona, Campus Bellvitge, Pavelló de Govern, Feixa Llarga, s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain.,Biopharmaceutics and Pharmacokinetics Unit, Department of Pharmacy and Pharmaceutical Technology Department, School of Pharmacy, University of Barcelona, Barcelona, Spain
| | - Helena Colom
- Biopharmaceutics and Pharmacokinetics Unit, Department of Pharmacy and Pharmaceutical Technology Department, School of Pharmacy, University of Barcelona, Barcelona, Spain
| | - Laure Elens
- Department of Integrated PharmacoMetrics, PharmacoGenomics and PharmacoKinetics (PMGK), Louvain Drug Research Institute (LDRI), Université Catholique de Louvain (UCL), Brussels, Belgium.,Department of Clinical Chemistry, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Teun van Gelder
- Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.,Department of Hospital Pharmacy, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.,Department of Clinical Chemistry, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Ronald H N van Schaik
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.,Department of Clinical Chemistry, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Dennis A Hesselink
- Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.,Department of Clinical Chemistry, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Oriol Bestard
- Laboratory 4122, Nephrology Service and Laboratory of Experimental Nephrology, University of Barcelona, Campus Bellvitge, Pavelló de Govern, Feixa Llarga, s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Joan Torras
- Laboratory 4122, Nephrology Service and Laboratory of Experimental Nephrology, University of Barcelona, Campus Bellvitge, Pavelló de Govern, Feixa Llarga, s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Josep M Cruzado
- Laboratory 4122, Nephrology Service and Laboratory of Experimental Nephrology, University of Barcelona, Campus Bellvitge, Pavelló de Govern, Feixa Llarga, s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Josep M Grinyó
- Laboratory 4122, Nephrology Service and Laboratory of Experimental Nephrology, University of Barcelona, Campus Bellvitge, Pavelló de Govern, Feixa Llarga, s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Nuria Lloberas
- Laboratory 4122, Nephrology Service and Laboratory of Experimental Nephrology, University of Barcelona, Campus Bellvitge, Pavelló de Govern, Feixa Llarga, s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain.
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50
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Abstract
Immunosuppression management after lung transplantation continues to evolve, with an increasing number of agents available for use in various combinations allowing for more choice and individualization of immunosuppressive therapy. Therapeutic developments have led to improved outcomes including lower acute rejection rates and improved survival. However, a one size fits all approach for any immunosuppressive strategy may not be best suited to the individual patient and ultimately patient specific factors must be considered when designing the immunosuppressive regimen. Recipient factors including age, race, co-morbidities, immunologic risk, genetic polymorphisms, concomitant and previous pharmacotherapy, and overall immunosuppression burden should be considered. There are several significant drug-drug interactions with select immunosuppressive agents utilized in lung transplant pharmacotherapy that must be considered when choosing and devising a dosing strategy for an individual immunosuppressive agent. Herein, considerations for immunosuppression management in the individual patient will be reviewed.
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Affiliation(s)
- Jennifer K McDermott
- Richard DeVos Heart and Lung Transplant Program, Spectrum Health, Grand Rapids, Michigan.,Michigan State University College of Human Medicine, Grand Rapids, Michigan
| | - Reda E Girgis
- Michigan State University College of Human Medicine, Grand Rapids, Michigan
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