1
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Datrino LN, Boccuzzi ML, Silva RM, Castilho PHBT, Riva WJ, Rocha JS, Tustumi F. Safety and Efficacy of Mycophenolate Mofetil Associated With Tacrolimus for Kidney-pancreas and Kidney Transplantation: A Systematic Review and Meta-Analysis of Randomized Studies. Transplant Proc 2024; 56:1066-1076. [PMID: 38853029 DOI: 10.1016/j.transproceed.2024.05.014] [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: 12/08/2023] [Revised: 05/13/2024] [Accepted: 05/17/2024] [Indexed: 06/11/2024]
Abstract
INTRODUCTION This study evaluated the efficacy and safety of mycophenolate mofetil (MMF) associated with tacrolimus (TAC) in patients undergoing kidney-pancreas and kidney transplants, in comparison with cyclosporine (CyA), azathioprine (AZA), everolimus (EVL), sirolimus (SRL), manitimus (MAN), mizoribine (MZR), and enteric-coated mycophenolate sodium (ECMPS) in combination or monotherapy. METHODS A systematic review and meta-analysis of randomized clinical trials was performed. The outcomes comprised acute rejection, graft loss, and adverse events. RESULTS Thirty studies were included. The main adverse events related to the TAC+MMF scheme were infection (36%; 95%CI: 26%-46%), including cytomegalovirus (CMV) (14%; 95%CI: 8%-20%); anemia (20%; 95%CI: 2%-37%); leukopenia (18%; 95%CI: 3%-33%); nausea (20%; 95%CI: 1%-39%); and diarrhea (26%; 95%CI:13%-40%). TAC+MMF was compared to the schemes AZA+TAC, CyA+AZA, CyA+MMF, CyA+SRL, ECMPS, EVL, MAN+TAC, MMF+SRL, MZR, TAC+AZA, TAC+EVR, TAC+MZR, TAC +SRL and TAC. TAC+MMF was associated with a lower risk of rejection than MMF monotherapy (RD: -0.24; 95%CI -0.46; -0.02). Comparing TAC+MMF with the other regimens, no significant difference was found for graft loss. TAC+MMF was associated with a higher risk of infections than MZR (RD: 0.174; 95%CI: 0.25; 0.323) and TAC monotherapy (RD: 0.07; 95%CI 0.003; 0.138). CONCLUSION Gastrointestinal and hematological adverse events and infections are the most common with TAC+MMF for kidney-pancreas and kidney. TAC+MMF effectively prevents acute cellular rejection, and alternatives with AZA, CyA, SRL, ECMPS, EVL, MAN, and MSR have similar efficacy and safety profiles. TAC monotherapy and MZR may be associated with a lower risk of infections.
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Affiliation(s)
| | - Matheus Lopes Boccuzzi
- Department of Evidenced-based Medicine, Centro Universitário Lusíada, Santos, SP, Brazil
| | - Rafael Matosinho Silva
- Department of Evidenced-based Medicine, Centro Universitário Lusíada, Santos, SP, Brazil
| | | | - Wagner José Riva
- Department of Evidenced-based Medicine, Centro Universitário Lusíada, Santos, SP, Brazil
| | - Jéssica Silva Rocha
- Department of Surgery, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Francisco Tustumi
- Department of Surgery, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil; Department of Gastroenterology, Universidade de São Paulo, São Paulo, SP, Brazil.
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2
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Vidigal AC, de Lucena DD, Beyerstedt S, Rangel ÉB. A comprehensive update of the metabolic and toxicological considerations for immunosuppressive drugs used during pancreas transplantation. Expert Opin Drug Metab Toxicol 2023; 19:405-427. [PMID: 37542452 DOI: 10.1080/17425255.2023.2243808] [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: 03/26/2023] [Revised: 07/24/2023] [Accepted: 07/28/2023] [Indexed: 08/07/2023]
Abstract
INTRODUCTION Despite significant advancements in immunosuppressive regimens and surgical techniques, the prevalence of adverse events related to immunosuppression remains a major challenge affecting the long-term survival rates of pancreas and kidney allografts. AREAS COVERED This article presents a comprehensive review of the literature and knowledge (Jan/2012-Feb/2023) concerning glucose metabolism disorders and nephrotoxicity associated with tacrolimus and mammalian target of rapamycin inhibitors (mTORi). Novel signaling pathways potentially implicated in these adverse events are discussed. Furthermore, we extensively examine the findings from clinical trials evaluating the efficacy and safety of tacrolimus, mTORi, and steroid minimization. EXPERT OPINION Tacrolimus-based regimens continue to be the standard treatment following pancreas transplants. However, prolonged use of tacrolimus and mTORi may lead to hyperglycemia and nephrotoxicity. Understanding and interpreting experimental data, particularly concerning novel signaling pathways beyond calcineurin-NFAT and mTOR pathways, can offer valuable insights for therapeutic interventions to mitigate hyperglycemia and nephrotoxicity. Additionally, critically analyzing clinical trial results can identify opportunities for personalized safety-based approaches to minimize side effects. It is imperative to conduct randomized-controlled studies to assess the impact of mTORi use and steroid-free protocols on pancreatic allograft survival. Such studies will aid in tailoring treatment strategies for improved transplant outcomes.
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Affiliation(s)
- Ana Cláudia Vidigal
- Nephrology Division, Department of Medicine, Federal University of São Paulo, SP, Brazil
| | - Débora D de Lucena
- Nephrology Division, Department of Medicine, Federal University of São Paulo, SP, Brazil
| | - Stephany Beyerstedt
- Albert Einstein Research and Education Institute, Hospital Israelita Albert Einstein, SP, São Paulo, Brazil
| | - Érika B Rangel
- Nephrology Division, Department of Medicine, Federal University of São Paulo, SP, Brazil
- Albert Einstein Research and Education Institute, Hospital Israelita Albert Einstein, SP, São Paulo, Brazil
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3
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Nelson J, Alvey N, Bowman L, Schulte J, Segovia M, McDermott J, Te HS, Kapila N, Levine DJ, Gottlieb RL, Oberholzer J, Campara M. Consensus recommendations for use of maintenance immunosuppression in solid organ transplantation: Endorsed by the American College of Clinical Pharmacy, American Society of Transplantation, and the International Society for Heart and Lung Transplantation. Pharmacotherapy 2022; 42:599-633. [DOI: 10.1002/phar.2716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 03/29/2022] [Accepted: 04/08/2022] [Indexed: 12/17/2022]
Affiliation(s)
- Joelle Nelson
- Department of Pharmacotherapy and Pharmacy Services University Health San Antonio Texas USA
- Pharmacotherapy Education and Research Center University of Texas Health San Antonio San Antonio Texas USA
- Department of Pharmacy, Pharmacotherapy Division, College of Pharmacy The University of Texas at Austin Austin Texas USA
| | - Nicole Alvey
- Department of Pharmacy Rush University Medical Center Chicago Illinois USA
- Science and Pharmacy Roosevelt University College of Health Schaumburg Illinois USA
| | - Lyndsey Bowman
- Department of Pharmacy Tampa General Hospital Tampa Florida USA
| | - Jamie Schulte
- Department of Pharmacy Services Thomas Jefferson University Hospital Philadelphia Pennsylvania USA
| | | | - Jennifer McDermott
- Richard DeVos Heart and Lung Transplant Program, Spectrum Health Grand Rapids Michigan USA
- Department of Medicine, Michigan State University College of Human Medicine Grand Rapids Michigan USA
| | - Helen S. Te
- Liver Transplantation, Center for Liver Diseases, Department of Medicine University of Chicago Medical Center Chicago Illinois USA
| | - Nikhil Kapila
- Department of Transplant Hepatology Duke University Hospital Durham North Carolina USA
| | - Deborah Jo Levine
- Division of Critical Care Medicine, Department of Medicine The University of Texas Health Science Center at San Antonio San Antonio Texas USA
| | - Robert L. Gottlieb
- Baylor University Medical Center and Baylor Scott and White Research Institute Dallas Texas USA
| | - Jose Oberholzer
- Department of Surgery/Division of Transplantation University of Virginia Charlottesville Virginia USA
| | - Maya Campara
- Department of Surgery University of Illinois Chicago Chicago Illinois USA
- Department of Pharmacy Practice University of Illinois Chicago Chicago Illinois USA
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4
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Kennedy BJ, Lato AM, Fisch AR, Burke SJ, Kirkland JK, Prevatte CW, Dunlap LE, Smith RT, Vogiatzis KD, Collier JJ, Campagna SR. Potent Anti-Inflammatory, Arylpyrazole-Based Glucocorticoid Receptor Agonists That Do Not Impair Insulin Secretion. ACS Med Chem Lett 2021; 12:1568-1577. [PMID: 34676039 DOI: 10.1021/acsmedchemlett.1c00379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Indexed: 11/28/2022] Open
Abstract
Glucocorticoids (GCs) are widely used in medicine for their role in the treatment of autoimmune-mediated conditions, certain cancers, and organ transplantation. The transcriptional activities GCs elicit include transrepression, postulated to be responsible for the anti-inflammatory activity, and transactivation, proposed to underlie the undesirable side effects associated with long-term use. A GC analogue that could elicit only transrepression and beneficial transactivation properties would be of great medicinal value and is highly sought after. In this study, a series of 1-(4-substituted phenyl)pyrazole-based GC analogues were synthesized, biologically screened, and evaluated for SARs leading to the desired activity. Activity observed in compounds bearing an electron deficient arylpyrazole moiety showed promise toward a dissociated steroid, displaying transrepression while having limited transactivation activity. In addition, compounds 11aa and 11ab were found to have anti-inflammatory efficacy comparable to that of dexamethasone at 10 nM, with minimal transactivation activity and no reduction of insulin secretion in cultured rat 832/13 beta cells.
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Affiliation(s)
- Brandon J. Kennedy
- Department of Chemistry, University of Tennessee, Knoxville, Tennessee 37996, United States
| | - Ashley M. Lato
- Department of Chemistry, University of Tennessee, Knoxville, Tennessee 37996, United States
| | - Alexander R. Fisch
- Department of Chemistry, University of Tennessee, Knoxville, Tennessee 37996, United States
| | - Susan J. Burke
- Pennington Biomedical Research Center, Baton Rouge, Louisiana 70808, United States
| | - Justin K. Kirkland
- Department of Chemistry, University of Tennessee, Knoxville, Tennessee 37996, United States
| | - Carson W. Prevatte
- Department of Chemistry, University of Tennessee, Knoxville, Tennessee 37996, United States
| | - Lee E. Dunlap
- Department of Chemistry, University of Tennessee, Knoxville, Tennessee 37996, United States
| | - Russell T. Smith
- Department of Chemistry, University of Tennessee, Knoxville, Tennessee 37996, United States
| | | | - J. Jason Collier
- Pennington Biomedical Research Center, Baton Rouge, Louisiana 70808, United States
| | - Shawn R. Campagna
- Department of Chemistry, University of Tennessee, Knoxville, Tennessee 37996, United States
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5
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Boggi U, Vistoli F, Andres A, Arbogast HP, Badet L, Baronti W, Bartlett ST, Benedetti E, Branchereau J, Burke GW, Buron F, Caldara R, Cardillo M, Casanova D, Cipriani F, Cooper M, Cupisti A, Davide J, Drachenberg C, de Koning EJP, Ettorre GM, Fernandez Cruz L, Fridell JA, Friend PJ, Furian L, Gaber OA, Gruessner AC, Gruessner RW, Gunton JE, Han D, Iacopi S, Kauffmann EF, Kaufman D, Kenmochi T, Khambalia HA, Lai Q, Langer RM, Maffi P, Marselli L, Menichetti F, Miccoli M, Mittal S, Morelon E, Napoli N, Neri F, Oberholzer J, Odorico JS, Öllinger R, Oniscu G, Orlando G, Ortenzi M, Perosa M, Perrone VG, Pleass H, Redfield RR, Ricci C, Rigotti P, Paul Robertson R, Ross LF, Rossi M, Saudek F, Scalea JR, Schenker P, Secchi A, Socci C, Sousa Silva D, Squifflet JP, Stock PG, Stratta RJ, Terrenzio C, Uva P, Watson CJ, White SA, Marchetti P, Kandaswamy R, Berney T. First World Consensus Conference on pancreas transplantation: Part II - recommendations. Am J Transplant 2021; 21 Suppl 3:17-59. [PMID: 34245223 PMCID: PMC8518376 DOI: 10.1111/ajt.16750] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 06/25/2021] [Accepted: 06/26/2021] [Indexed: 02/07/2023]
Abstract
The First World Consensus Conference on Pancreas Transplantation provided 49 jury deliberations regarding the impact of pancreas transplantation on the treatment of diabetic patients, and 110 experts' recommendations for the practice of pancreas transplantation. The main message from this consensus conference is that both simultaneous pancreas-kidney transplantation (SPK) and pancreas transplantation alone can improve long-term patient survival, and all types of pancreas transplantation dramatically improve the quality of life of recipients. Pancreas transplantation may also improve the course of chronic complications of diabetes, depending on their severity. Therefore, the advantages of pancreas transplantation appear to clearly surpass potential disadvantages. Pancreas after kidney transplantation increases the risk of mortality only in the early period after transplantation, but is associated with improved life expectancy thereafter. Additionally, preemptive SPK, when compared to SPK performed in patients undergoing dialysis, appears to be associated with improved outcomes. Time on dialysis has negative prognostic implications in SPK recipients. Increased long-term survival, improvement in the course of diabetic complications, and amelioration of quality of life justify preferential allocation of kidney grafts to SPK recipients. Audience discussions and live voting are available online at the following URL address: http://mediaeventi.unipi.it/category/1st-world-consensus-conference-of-pancreas-transplantation/246.
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6
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Bikhet M, Iwase H, Yamamoto T, Jagdale A, Foote JB, Ezzelarab M, Anderson DJ, Locke JE, Eckhoff DE, Hara H, Cooper DKC. What Therapeutic Regimen Will Be Optimal for Initial Clinical Trials of Pig Organ Transplantation? Transplantation 2021; 105:1143-1155. [PMID: 33534529 DOI: 10.1097/tp.0000000000003622] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
We discuss what therapeutic regimen might be acceptable/successful in the first clinical trial of genetically engineered pig kidney or heart transplantation. As regimens based on a calcineurin inhibitor or CTLA4-Ig have proved unsuccessful, the regimen we administer to baboons is based on induction therapy with antithymocyte globulin, an anti-CD20 mAb (Rituximab), and cobra venom factor, with maintenance therapy based on blockade of the CD40/CD154 costimulation pathway (with an anti-CD40 mAb), with rapamycin, and a corticosteroid. An anti-inflammatory agent (etanercept) is administered for the first 2 wk, and adjuvant therapy includes prophylaxis against thrombotic complications, anemia, cytomegalovirus, and pneumocystis. Using this regimen, although antibody-mediated rejection certainly can occur, we have documented no definite evidence of an adaptive immune response to the pig xenograft. This regimen could also form the basis for the first clinical trial, except that cobra venom factor will be replaced by a clinically approved agent, for example, a C1-esterase inhibitor. However, none of the agents that block the CD40/CD154 pathway are yet approved for clinical use, and so this hurdle remains to be overcome. The role of anti-inflammatory agents remains unproven. The major difference between this suggested regimen and those used in allotransplantation is the replacement of a calcineurin inhibitor with a costimulation blockade agent, but this does not appear to increase the complications of the regimen.
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Affiliation(s)
- Mohamed Bikhet
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Hayato Iwase
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Takayuki Yamamoto
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Abhijit Jagdale
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Jeremy B Foote
- Department of Microbiology and Animal Resources Program, University of Alabama at Birmingham, Birmingham, AL
| | - Mohamed Ezzelarab
- Department of Surgery, Thomas E. Starzl Transplantation Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Douglas J Anderson
- Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Jayme E Locke
- Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Devin E Eckhoff
- Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Hidetaka Hara
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - David K C Cooper
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
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7
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Clinical Correlates and Outcomes of Dual Basiliximab and Antithymocyte Globulin Induction in Kidney Transplant Recipients: A National Study. Transplant Direct 2021; 7:e736. [PMID: 35836670 PMCID: PMC9276156 DOI: 10.1097/txd.0000000000001190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 05/19/2021] [Indexed: 11/26/2022] Open
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8
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Kovac D, Choe J, Liu E, Scheffert J, Hedvat J, Anamisis A, Salerno D, Lange N, Jennings DL. Immunosuppression considerations in simultaneous organ transplant. Pharmacotherapy 2021; 41:59-76. [PMID: 33325558 DOI: 10.1002/phar.2495] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 10/21/2020] [Accepted: 12/01/2020] [Indexed: 12/12/2022]
Abstract
Solid organ transplantation is a life-saving procedure for patients in the end stage of heart, lung, kidney, and liver failure. For patients with more than one failing organ, simultaneous organ transplantation has emerged as a viable treatment option. Immunosuppression strategies and outcomes for simultaneous organ transplant recipients have been reported, but often involve limited populations. Transplanting dual organs poses challenges in terms of balancing immunosuppression with immunologic risk and allograft damage from surgical complications. Furthermore, transplanting certain organs can impose considerations on the management of immunosuppression. For example, liver allografts may confer immunologic privilege and lower rates of rejection of other allografts. This review article evaluates immunosuppression strategies for simultaneous kidney-pancreas, liver-kidney, heart-kidney, heart-liver, heart-lung, lung-liver, and lung-kidney transplants. To date, no comprehensive review exists to address immunosuppressive strategies in simultaneous organ transplant populations. Our review summarizes the available literature and provides evidence-based recommendations regarding immunosuppression strategies in simultaneous organ transplant recipients.
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Affiliation(s)
- Danielle Kovac
- Department of Pharmacy, NewYork-Presbyterian Columbia University Irving Medical Center, New York, New York, USA
| | - Jason Choe
- Department of Pharmacy, NewYork-Presbyterian Columbia University Irving Medical Center, New York, New York, USA
| | - Esther Liu
- Department of Pharmacy, NewYork-Presbyterian Weill Cornell Medical Center, New York, New York, USA
| | - Jenna Scheffert
- Department of Pharmacy, NewYork-Presbyterian Columbia University Irving Medical Center, New York, New York, USA
| | - Jessica Hedvat
- Department of Pharmacy, NewYork-Presbyterian Columbia University Irving Medical Center, New York, New York, USA
| | - Anastasia Anamisis
- Department of Pharmacy, NewYork-Presbyterian Columbia University Irving Medical Center, New York, New York, USA
| | - David Salerno
- Department of Pharmacy, NewYork-Presbyterian Weill Cornell Medical Center, New York, New York, USA
| | - Nicholas Lange
- Department of Pharmacy, NewYork-Presbyterian Columbia University Irving Medical Center, New York, New York, USA
| | - Douglas L Jennings
- Department of Pharmacy, NewYork-Presbyterian Columbia University Irving Medical Center, New York, New York, USA.,Division of Pharmacy Practice, Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, New York, New York, USA
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9
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Ibáñez JM, Robledo AB, López-Andujar R. Late complications of pancreas transplant. World J Transplant 2020; 10:404-414. [PMID: 33437673 PMCID: PMC7769730 DOI: 10.5500/wjt.v10.i12.404] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 08/18/2020] [Accepted: 10/09/2020] [Indexed: 02/06/2023] Open
Abstract
To summarize the long-term complications after pancreas transplantation that affect graft function, a literature search was carried out on the long-term complications of pancreatic transplantation, namely, complications from postoperative 3rd mo onwards, in terms of loss of graft function, late infection and vascular complications as pseudoaneurysms. The most relevant reviews and studies were selected to obtain the current evidence on these topics. The definition of graft failure varies among different studies, so it is difficult to evaluate, a standardized definition is of utmost importance to know the magnitude of the problem in all worldwide series. Chronic rejection is the main cause of long-term graft failure, occurring in 10% of patients. From the 3rd mo of transplantation onwards, the main risk factor for late infections is immunosuppression, and patients have opportunistic infections like: Cytomegalovirus, hepatitis B and C viruses, Epstein-Barr virus and varicella-zoster virus; opportunistic bacteria, reactivation of latent infections as tuberculosis or fungal infections. Complete preoperative studies and serological tests should be made in all recipients to avoid these infections, adding perioperative prophylactic treatments when indicated. Pseudoaneurysm are uncommon, but one of the main causes of late bleeding, which can be fatal. The treatment should be performed with radiological endovascular approaches or open surgery in case of failure. Despite all therapeutic options for the complications mentioned above, transplantectomy is a necessary option in approximately 50% of relaparotomies, especially in life-threatening complications. Late complications in pancreatic transplantation threatens long-term graft function. An exhaustive follow-up as well as a correct immunosuppression protocol are necessary for prevention.
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Affiliation(s)
- Javier Maupoey Ibáñez
- Hepato-Pancreatico-Biliary Surgery and Transplant Unit, La Fe University Hospital, Valencia 46026, Spain
| | - Andrea Boscà Robledo
- Hepato-Pancreatico-Biliary Surgery and Transplant Unit, La Fe University Hospital, Valencia 46026, Spain
| | - Rafael López-Andujar
- Hepato-Pancreatico-Biliary Surgery and Transplant Unit, La Fe University Hospital, Valencia 46026, Spain
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10
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Cantarovich D, Kervella D, Karam G, Dantal J, Blancho G, Giral M, Garandeau C, Houzet A, Ville S, Branchereau J, Delbos F, Guillot-Gueguen C, Volteau C, Leroy M, Renaudin K, Soulillou JP, Hourmant M. Tacrolimus- versus sirolimus-based immunosuppression after simultaneous pancreas and kidney transplantation: 5-year results of a randomized trial. Am J Transplant 2020; 20:1679-1690. [PMID: 32022990 DOI: 10.1111/ajt.15809] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 01/10/2020] [Accepted: 01/28/2020] [Indexed: 01/25/2023]
Abstract
Tacrolimus, the cornerstone immunosuppression after simultaneous pancreas and -kidney (SPK) transplantation, may exert nephrotoxic and diabetogenic effects. We therefore prospectively compared in an open-label, randomized, monocentric, 5-year follow-up study, a tacrolimus- and a sirolimus-based immunosuppressive regimen. Randomization using the block method allowing a blind allocation was done at the time of surgery. All patients received anti-thymocyte globulin and maintenance therapy with tacrolimus, mycophenolate mofetil, and steroids. At month 3, tacrolimus was continued or replaced by sirolimus. The primary endpoint was kidney and pancreas graft survival at 1 and 5 years. Fifty patients were included in the final analysis in each group. At 1 year, differences for kidney and pancreas graft survival between sirolimus and tacrolimus were 0% (90% confidence interval -4.61% to 4.61%) and 6% (90% confidence interval -6.32% to 18.32%), respectively. There was no difference in renal and pancreas graft survival at 5 years. Thirty-four patients (68%) in the sirolimus group vs three (6%) in the tacrolimus group needed definitive withdrawal of the study drug. Despite noninferiority of sirolimus compared to tacrolimus for kidney and pancreas graft survival, the high rate of sirolimus discontinuation does not favor its use as cornerstone therapy after SPK transplantation (NCT00693446).
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Affiliation(s)
- Diego Cantarovich
- CHU Nantes, Université de Nantes, Inserm, Centre de Recherche en Transplantation et Immunologie, UMR 1064, ITUN, Nantes, France.,CHU Nantes, Université de Nantes, Institut de Transplantation, Urologie, Néphrologie, Nantes, France
| | - Delphine Kervella
- CHU Nantes, Université de Nantes, Inserm, Centre de Recherche en Transplantation et Immunologie, UMR 1064, ITUN, Nantes, France
| | - Georges Karam
- CHU Nantes, Université de Nantes, Institut de Transplantation, Urologie, Néphrologie, Nantes, France
| | - Jacques Dantal
- CHU Nantes, Université de Nantes, Inserm, Centre de Recherche en Transplantation et Immunologie, UMR 1064, ITUN, Nantes, France.,CHU Nantes, Université de Nantes, Institut de Transplantation, Urologie, Néphrologie, Nantes, France
| | - Gilles Blancho
- CHU Nantes, Université de Nantes, Inserm, Centre de Recherche en Transplantation et Immunologie, UMR 1064, ITUN, Nantes, France.,CHU Nantes, Université de Nantes, Institut de Transplantation, Urologie, Néphrologie, Nantes, France
| | - Magali Giral
- CHU Nantes, Université de Nantes, Inserm, Centre de Recherche en Transplantation et Immunologie, UMR 1064, ITUN, Nantes, France.,CHU Nantes, Université de Nantes, Institut de Transplantation, Urologie, Néphrologie, Nantes, France
| | - Claire Garandeau
- CHU Nantes, Université de Nantes, Institut de Transplantation, Urologie, Néphrologie, Nantes, France
| | - Aurélie Houzet
- CHU Nantes, Université de Nantes, Inserm, Centre de Recherche en Transplantation et Immunologie, UMR 1064, ITUN, Nantes, France.,CHU Nantes, Université de Nantes, Institut de Transplantation, Urologie, Néphrologie, Nantes, France
| | - Simon Ville
- CHU Nantes, Université de Nantes, Inserm, Centre de Recherche en Transplantation et Immunologie, UMR 1064, ITUN, Nantes, France.,CHU Nantes, Université de Nantes, Institut de Transplantation, Urologie, Néphrologie, Nantes, France
| | - Julien Branchereau
- CHU Nantes, Université de Nantes, Inserm, Centre de Recherche en Transplantation et Immunologie, UMR 1064, ITUN, Nantes, France.,CHU Nantes, Université de Nantes, Institut de Transplantation, Urologie, Néphrologie, Nantes, France
| | - Florent Delbos
- Laboratoire d'Histocompatibilité, Etablissement Français du Sang, EFS, Pays de la Loire, Nantes, France
| | - Cécile Guillot-Gueguen
- CHU Nantes, Université de Nantes, Institut de Transplantation, Urologie, Néphrologie, Nantes, France
| | - Christelle Volteau
- Plateforme de Méthodologie et de Biostatistique, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Maxime Leroy
- Plateforme de Méthodologie et de Biostatistique, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Karine Renaudin
- CHU Nantes, Université de Nantes, Inserm, Centre de Recherche en Transplantation et Immunologie, UMR 1064, ITUN, Nantes, France.,Service d'Anatomie et de Cytologie Pathologique, Centre Hospitalier Universitaire Nantes, Nantes, France
| | - Jean-Paul Soulillou
- CHU Nantes, Université de Nantes, Inserm, Centre de Recherche en Transplantation et Immunologie, UMR 1064, ITUN, Nantes, France
| | - Maryvonne Hourmant
- CHU Nantes, Université de Nantes, Institut de Transplantation, Urologie, Néphrologie, Nantes, France
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11
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Marcella-Neto R, de Sá JR, Melaragno CS, Gonzalez AM, Salzedas-Neto A, Linhares MM, Medina-Pestana JO, Rangel ÉB. Late Conversion to Sirolimus or Everolimus After Pancreas Transplant. Transplant Proc 2020; 52:1376-1379. [PMID: 32213293 DOI: 10.1016/j.transproceed.2020.02.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 02/05/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Pancreas transplant is an effective treatment for insulin-dependent diabetic individuals with end-stage renal disease, yet immunosuppression-associated adverse events may adversely affect patient and graft survival. The aim of the study was to document whether mammalian target of rapamycin inhibitors (mTORi) are safe and effective as a second-line drug after pancreas transplant. METHODOLOGY An observational single-center study was performed in a cohort of 490 simultaneous pancreas-kidney transplant and 45 pancreas-after-kidney transplant individuals after conversion to mTORi (n = 13) owing to adverse events of either tacrolimus or mycophenolate. RESULTS mTORi conversion was performed 11.5 ± 10.1 (range, 1-28) months after pancreas transplant, mainly owing to cytomegalovirus infection and gastrointestinal intolerance. We frequently observed clinical complications after mTORi conversion, yet creatinine, eGFR, proteinuria, fasting plasma glucose, HbA1c, and C-peptide remained stable throughout the study (mean follow-up 8.2 ± 5, range 1-17) years, as did the lipid profile (P > .05). However, graft loss occurred in almost 20% of patients owing to chronic alterations. LIMITATIONS The small number of patients and a single-center cohort were limitations of the study. CONCLUSIONS Late mTORi conversion is a safe and effective approach when tacrolimus or mycophenolate-mediated adverse events occur after pancreas transplant.
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Affiliation(s)
- Rubens Marcella-Neto
- Nephrology Division, Federal University of São Paulo/Hospital do Rim e Hipertensão, São Paulo, SP, Brazil
| | - João R de Sá
- Endocrinology Division, Federal University of São Paulo, São Paulo, SP, Brazil
| | - Cláudio S Melaragno
- Nephrology Division, Federal University of São Paulo/Hospital do Rim e Hipertensão, São Paulo, SP, Brazil
| | - Adriano M Gonzalez
- Surgery Department, Federal University of São Paulo, São Paulo, SP, Brazil
| | | | - Marcelo M Linhares
- Surgery Department, Federal University of São Paulo, São Paulo, SP, Brazil
| | - José O Medina-Pestana
- Nephrology Division, Federal University of São Paulo/Hospital do Rim e Hipertensão, São Paulo, SP, Brazil
| | - Érika B Rangel
- Nephrology Division, Federal University of São Paulo/Hospital do Rim e Hipertensão, São Paulo, SP, Brazil.
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Girman P, Lipár K, Kočík M, Voska L, Kožnarová R, Marada T, Lánská V, Saudek F. Sirolimus vs mycophenolate mofetil (MMF) in primary combined pancreas and kidney transplantation. Results of a long-term prospective randomized study. Am J Transplant 2020; 20:779-787. [PMID: 31561278 DOI: 10.1111/ajt.15622] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 09/15/2019] [Accepted: 09/20/2019] [Indexed: 01/25/2023]
Abstract
The study was intended to compare pancreas graft survival rates in two groups of pancreas and kidney transplant recipients prospectively randomized to treatment either with sirolimus or MMF. From 2002 to 2013, 238 type 1 diabetic recipients with end-stage kidney disease were randomized 1:1 to sirolimus or MMF treatment. Noncensored pancreas survival at 5 years was 76.4 and 71.6% for sirolimus and MMF groups, respectively (P > .05). Death-censored pancreas survival was better in the sirolimus group (P = .037). After removal of early graft losses pancreas survival did not differ between groups (MMF 83.1% vs sirolimus 91.6%, P = .11). Nonsignificantly more grafts were lost due to rejection in the MMF group (10 vs 5; P = .19). Cumulative patient 5-year survival was 96% in the MMF group and 91% in the sirolimus group (P > .05). Five-year cumulative noncensored kidney graft survival rates did not statistically differ (85.6% in the sirolimus group and 88.8% in MMF group). Recipients treated with MMF had significantly more episodes of gastrointestinal bleeding (7 vs 0, P = .007). More recipients in the sirolimus group required corrective surgery due to incisional hernias (21 vs 12, P = .019). ClinicalTrials No.: NCT03582878.
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Affiliation(s)
- Peter Girman
- Diabetes Center, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Květoslav Lipár
- Transplantation Surgery Department, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Matěj Kočík
- Transplantation Surgery Department, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Luděk Voska
- Clinical and Transplant Pathology Center, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Radomíra Kožnarová
- Diabetes Center, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Tomáš Marada
- Transplantation Surgery Department, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Věra Lánská
- Department for Data Analysis and Statistics, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - František Saudek
- Diabetes Center, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
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Use of Mammalian Target of Rapamycin Inhibitors for Pancreas Transplant Immunosuppression Is Associated With Improved Allograft Survival and Improved Early Patient Survival. Pancreas 2019; 48:644-651. [PMID: 31091210 DOI: 10.1097/mpa.0000000000001322] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVES Mammalian targets of rapamycin inhibitors (mTORi) are considered second-line immunosuppression agents because of associated increases in rejection and impaired wound healing. Recent reports indicate mTORi have been linked to improved survival, decreased inflammatory response in pancreatitis, and antiproliferative and antiangiogenic activity. Mammalian targets of rapamycin inhibitors have not been extensively analyzed in pancreas transplant recipients. METHODS Adults with pancreas and kidney-pancreas transplants from 1987 to 2016 in the United Network for Organ Sharing database were analyzed (N = 25,837). Subjects were stratified into 2 groups: use of mTORi (n = 4174) and use of non-mTORi-based immunosuppression (n = 21,663). The log-rank test compared survival rates. Univariate and multivariate Cox regression analyses assessed patient and graft survival. RESULTS Mammalian targets of rapamycin inhibitors were associated with a 7% risk reduction in allograft failure (hazard ratio, 0.931; P = 0.006). Allograft survival rates were significantly different between mTORi versus non-mTORi (P < 0.0001).The mTORi group showed a significantly higher patient survival rate 1, 3, 5, and 10 years posttransplant compared. Patient survival at 15 years was not significantly different. CONCLUSIONS The use of mTORi for immunosuppression in pancreas transplant is associated with improved allograft survival and early patient survival posttransplant (up to 10 years).
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Burke GW, Ciancio G, Morsi M, Figueiro J, Chen L, Vendrame F, Pugliese A. Type 1 Diabetes Recurrence After Simultaneous Pancreas-Kidney
Transplantation. CURRENT TRANSPLANTATION REPORTS 2018. [DOI: 10.1007/s40472-018-0210-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Knight RJ, Graviss EA, Nguyen DT, Kuten SA, Patel SJ, Gaber L, Gaber AO. Conversion from tacrolimus-mycophenolate mofetil to tacrolimus-mTOR immunosuppression after kidney-pancreas transplantation reduces the incidence of both BK and CMV viremia. Clin Transplant 2018; 32:e13265. [PMID: 29676018 DOI: 10.1111/ctr.13265] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND We sought to determine whether conversion from tacrolimus/mycophenolate mofetil (TAC-MMF) into tacrolimus/mTOR inhibitor (TAC-mTOR) immunosuppression would reduce the incidences of BK and CMV viremia after kidney/pancreas (KP) transplantation. METHODS In this single-center review, the TAC-mTOR cohort (n = 39) was converted at 1 month post-transplant to an mTOR inhibitor and reduced-dose tacrolimus. Outcomes were compared to a cohort of KP recipients (n = 40) maintained on TAC-MMF. RESULTS At 3 years post-transplant, KP survivals and incidences of kidney/pancreas rejection were equivalent between mTOR and MMF-treated cohorts. (P = ns). BK viremia-free survival was better for the mTOR vs MMF-treated group (P = .004). In multivariate analysis, MMF vs mTOR immunosuppression was an independent risk factor for BK viremia (hazard ratio 12.27, P = .02). Similarly, mTOR-treated recipients displayed better CMV infection-free survival compared to the MMF-treated cohort (P = .01). MMF vs mTOR immunosuppression (hazard ratio 18.77, P = .001) and older recipient age (hazard ratio 1.13 per year, P = .006) were independent risk factors for CMV viremia. Mean estimated GFR and HgbA1c levels were equivalent between groups at 1, 2, and 3 years post-transplantation. CONCLUSION Conversion from TAC/MMF into TAC/mTOR immunosuppression after KP transplantation reduced the incidences of BK and CMV viremia with an equivalent risk of acute rejection and similar renal/pancreas function.
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Affiliation(s)
- Richard J Knight
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Edward A Graviss
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - Duc T Nguyen
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - Samantha A Kuten
- Department of Pharmacy, Houston Methodist Hospital, Houston, TX, USA
| | - Samir J Patel
- Department of Pharmacy, Houston Methodist Hospital, Houston, TX, USA
| | - Lillian Gaber
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - A Osama Gaber
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
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Differentiation of human dendritic cell subsets for immune tolerance induction. Transfus Clin Biol 2018; 25:90-95. [DOI: 10.1016/j.tracli.2017.08.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 08/25/2017] [Indexed: 12/21/2022]
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Ciancio G, Gaynor JJ, Guerra G, Sageshima J, Roth D, Chen L, Kupin W, Mattiazzi A, Tueros L, Flores S, Hanson L, Ruiz P, Vianna R, Burke GW. Randomized trial of rATg/Daclizumab vs. rATg/Alemtuzumab as dual induction therapy in renal transplantation: Results at 8years of follow-up. Transpl Immunol 2016; 40:42-50. [PMID: 27888093 DOI: 10.1016/j.trim.2016.11.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 11/16/2016] [Accepted: 11/17/2016] [Indexed: 01/28/2023]
Abstract
Our goal in using dual induction therapy is to bring the kidney transplant recipient closer (through more effectively timed lymphodepletion) to an optimally immunosuppressed state. Here, we report long-term results of a prospective randomized trial comparing (Group I,N=100) rATG/Dac (3 rATG, 2 Dac doses) vs. (Group II,N=100) rATG/Alemtuzumab(C1H) (1 dose each), using reduced tacrolimus dosing, EC-MPS, and early corticosteroid withdrawal. Lower EC-MPS dosing was targeted in Group II to avoid severe leukopenia. Median follow-up was 96mo post-transplant. There were no differences in 1st BPAR (including borderline) rates: 10/100 vs. 9/100 in Groups I and II during the first 12mo(P=0.54), and 20/100 vs. 20/100 throughout the study(P=0.90). Equally favorable renal function was maintained in both treatment arms(N.S.). While not significant, more patients in Group II experienced graft loss, 25/100 vs. 18/100 in Group I(P=0.23). Actuarial patient/graft survival at 96mo was 92%/83% vs. 85%/73% in Groups I and II(N.S.). DWFG-due-to-infection(N.S.), EC-MPS withholding-due-to-leukopenia during the first 2mo(P=0.03), and incidence of viral infections(P=0.09) were higher in Group II, whereas EC-MPS withholding-due-to-GI symptoms was higher in Group I(P=0.009). No other adverse event differences were observed. While long-term anti-rejection and renal function efficacy were demonstrated in both treatment arms, slight over-immunosuppression of Group II patients occurred.
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Affiliation(s)
- Gaetano Ciancio
- The Lillian Jean Kaplan Renal Transplant Center and the Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.
| | - Jeffrey J Gaynor
- The Lillian Jean Kaplan Renal Transplant Center and the Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.
| | - Giselle Guerra
- Division of Nephrology of the Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA.
| | - Junichiro Sageshima
- The Lillian Jean Kaplan Renal Transplant Center and the Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.
| | - David Roth
- Division of Nephrology of the Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA.
| | - Linda Chen
- The Lillian Jean Kaplan Renal Transplant Center and the Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.
| | - Warren Kupin
- Division of Nephrology of the Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA.
| | - Adela Mattiazzi
- Division of Nephrology of the Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA.
| | - Lissett Tueros
- The Lillian Jean Kaplan Renal Transplant Center and the Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.
| | - Sandra Flores
- The Lillian Jean Kaplan Renal Transplant Center and the Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.
| | - Lois Hanson
- The Lillian Jean Kaplan Renal Transplant Center and the Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.
| | - Phillip Ruiz
- The Lillian Jean Kaplan Renal Transplant Center and the Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Rodrigo Vianna
- The Lillian Jean Kaplan Renal Transplant Center and the Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.
| | - George W Burke
- The Lillian Jean Kaplan Renal Transplant Center and the Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.
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Early Kidney Allograft Dysfunction (Threatened Allograft): Comparative Effectiveness of Continuing Versus Discontinuation of Tacrolimus and Use of Sirolimus to Prevent Graft Failure: A Retrospective Patient-Centered Outcome Study. Transplant Direct 2016; 2:e98. [PMID: 27795990 PMCID: PMC5068206 DOI: 10.1097/txd.0000000000000585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 03/14/2016] [Indexed: 12/02/2022] Open
Abstract
Supplemental digital content is available in the text. Background Due to lack of treatment options for early acute allograft dysfunction in the presence of tubular-interstitial injury without histological features of rejection, kidney transplant recipients are often treated with sirolimus-based therapy to prevent cumulative calcineurin inhibitor exposure and to prevent premature graft failure. Methods We analyzed transplant recipients treated with sirolimus-based (n = 220) compared with continued tacrolimus-based (n = 276) immunosuppression in recipients of early-onset graft dysfunction (threatened allograft) with the use of propensity score-based inverse probability treatment weighted models to balance for potential confounding by indication between 2 nonrandomized groups. Results Weighted odds for death-censored graft failure (odds ratio [OR], 1.20; 95% confidence interval [95% CI], 0.66-2.19, P = 0.555) was similar in the 2 groups, but a trend for increased risk of greater than 50% loss in estimated glomerular filtration rate from baseline in sirolimus group (OR, 1.90; 95% CI, 0.96-3.76; P = 0.067) compared with tacrolimus group. Sirloimus group compared with tacrolimus group had increased risk for death with functioning graft (OR, 2.01; 95% CI, 1.29-3.14; P = 0.002) as well as increased risk of late death (death after graft failure while on dialysis) (OR, 2.39; 95% CI, 1.59-3.59; P < 0.001). Analysis of subgroups based on the absence or presence of T cell–mediated rejection or tubulointerstitial inflammation in the index biopsy, or the use of different types of induction agents, and all subgroups had increased risk of death with functioning graft and late death if exposed to sirolimus-based therapy. Conclusions Use of sirolimus compared with tacrolimus in recipients with early allograft dysfunction during the first year of transplant may not prevent worsening of allograft function and could potentially lead to poor survival along with increased risk of late death.
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Fernandes-Silva G, Ivani de Paula M, Rangel ÉB. mTOR inhibitors in pancreas transplant: adverse effects and drug-drug interactions. Expert Opin Drug Metab Toxicol 2016; 13:367-385. [DOI: 10.1080/17425255.2017.1239708] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Gabriel Fernandes-Silva
- Universidade Federal de São Paulo/Hospital do Rim e Hipertensão, Nephrology Department, São Paulo, SP, Brazil
| | - Mayara Ivani de Paula
- Universidade Federal de São Paulo/Hospital do Rim e Hipertensão, Nephrology Department, São Paulo, SP, Brazil
| | - Érika B. Rangel
- Universidade Federal de São Paulo/Hospital do Rim e Hipertensão, Nephrology Department, São Paulo, SP, Brazil
- Hospital Israelita Albert Einstein, Instituto Israelita de Ensino e Pesquisa, São Paulo, SP, Brazil
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Abstract
PURPOSE OF REVIEW The review analyzes the current biomarkers used in monitoring pancreas transplant, from the simple and time-tested, to more sophisticated, including markers of allo- and autoimmunity, that are likely to play a larger role in future studies. RECENT FINDINGS Evaluation of alloimmunity includes serum levels of donor-specific antibody, and, ultimately, pancreas transplant biopsies with C4d staining. Our center has focused on markers of autoimmunity, including assessment of autoantibodies and autoreactive T cells. We have found that conversion of autoantibodies (including GAD65, IA-2, and ZnT8), or the development of a new positive autoantibody, particularly ZnT8, are associated with type 1 diabetes (T1D) recurrence in the pancreas transplant. Autoreactive T cells have also been identified in the peripheral blood, pancreas transplant and peripancreas transplant-lymph nodes, that have the potential to mediate human β/islet cell destruction in vivo. SUMMARY The monitoring of pancreas transplant biomarkers, particularly those associated with autoimmunity, has led to new insights into the pathogenesis of T1D. Progress in the elucidation of mechanisms of autoimmunity may lead to novel therapeutic approaches to both T1D recurrence of the pancreas transplant and perhaps also new onset T1D.
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Kitchens WH, Turgeon NA. Immunosuppression in Pancreas Transplantation: What Has Changed in 20 Years? CURRENT TRANSPLANTATION REPORTS 2016. [DOI: 10.1007/s40472-016-0098-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Vendrame F, Hopfner Y, Diamantopoulos S, Virdi SK, Allende G, Snowhite IV, Reijonen HK, Chen L, Ruiz P, Ciancio G, Hutton JC, Messinger S, Burke GW, Pugliese A. Risk Factors for Type 1 Diabetes Recurrence in Immunosuppressed Recipients of Simultaneous Pancreas-Kidney Transplants. Am J Transplant 2016; 16:235-45. [PMID: 26317167 PMCID: PMC5053280 DOI: 10.1111/ajt.13426] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 05/29/2015] [Accepted: 06/15/2015] [Indexed: 01/25/2023]
Abstract
Patients with type 1 diabetes (T1D) who are recipients of pancreas transplants are believed to rarely develop T1D recurrence in the allograft if effectively immunosuppressed. We evaluated a cohort of 223 recipients of simultaneous pancreas-kidney allografts for T1D recurrence and its risk factors. With long-term follow-up, recurrence was observed in approximately 7% of patients. Comparing the therapeutic regimens employed in this cohort over time, lack of induction therapy was associated with recurrence, but this occurs even with the current regimen, which includes induction; there was no influence of maintenance regimens. Longitudinal testing for T1D-associated autoantibodies identified autoantibody positivity, number of autoantibodies, and autoantibody conversion after transplantation as critical risk factors. Autoantibodies to the zinc transporter 8 had the strongest and closest temporal association with recurrence, which was not explained by genetically encoded amino acid sequence donor-recipient mismatches for this autoantigen. Genetic risk factors included the presence of the T1D-predisposing HLA-DR3/DR4 genotype in the recipient and donor-recipient sharing of HLA-DR alleles, especially HLA-DR3. Thus, T1D recurrence is not uncommon and is developing in patients treated with current immunosuppression. The risk factors identified in this study can be assessed in the transplant clinic to identify recurrent T1D and may lead to therapeutic advances.
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Affiliation(s)
- F. Vendrame
- Diabetes Research InstituteLeonard Miller School of MedicineUniversity of MiamiMiamiFL
| | - Y‐Y. Hopfner
- Diabetes Research InstituteLeonard Miller School of MedicineUniversity of MiamiMiamiFL
| | - S. Diamantopoulos
- Diabetes Research InstituteLeonard Miller School of MedicineUniversity of MiamiMiamiFL,Department of Pediatrics, Leonard Miller School of MedicineUniversity of MiamiMiamiFL
| | - S. K. Virdi
- Diabetes Research InstituteLeonard Miller School of MedicineUniversity of MiamiMiamiFL
| | - G. Allende
- Diabetes Research InstituteLeonard Miller School of MedicineUniversity of MiamiMiamiFL
| | - I. V. Snowhite
- Diabetes Research InstituteLeonard Miller School of MedicineUniversity of MiamiMiamiFL
| | | | - L. Chen
- Department of Surgery, Division of Transplantation, Leonard Miller School of MedicineUniversity of MiamiMiamiFL
| | - P. Ruiz
- Department of Surgery, Division of Transplantation, Leonard Miller School of MedicineUniversity of MiamiMiamiFL
| | - G. Ciancio
- Department of Surgery, Division of Transplantation, Leonard Miller School of MedicineUniversity of MiamiMiamiFL
| | - J. C. Hutton
- Barbara Davis Center for Childhood DiabetesUniversity of Colorado DenverAuroraCO
| | - S. Messinger
- Department of Epidemiology and Public Health Sciences, Division of Biostatistics, Leonard Miller School of MedicineUniversity of MiamiMiamiFL
| | - G. W. Burke
- Diabetes Research InstituteLeonard Miller School of MedicineUniversity of MiamiMiamiFL,Department of Surgery, Division of Transplantation, Leonard Miller School of MedicineUniversity of MiamiMiamiFL
| | - A. Pugliese
- Diabetes Research InstituteLeonard Miller School of MedicineUniversity of MiamiMiamiFL,Department of Medicine, Division of Endocrinology and Metabolism, Leonard Miller School of MedicineUniversity of MiamiMiamiFL,Department of Microbiology and ImmunologyLeonard Miller School of MedicineUniversity of MiamiMiamiFL
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Burke GW, Vendrame F, Virdi SK, Ciancio G, Chen L, Ruiz P, Messinger S, Reijonen HK, Pugliese A. Lessons From Pancreas Transplantation in Type 1 Diabetes: Recurrence of Islet Autoimmunity. Curr Diab Rep 2015; 15:121. [PMID: 26547222 DOI: 10.1007/s11892-015-0691-5] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Type 1 diabetes recurrence (T1DR) affecting pancreas transplants was first reported in recipients of living-related pancreas grafts from twins or HLA identical siblings; given HLA identity, recipients received no or minimal immunosuppression. This observation provided critical evidence that type 1 diabetes (T1D) is an autoimmune disease. However, T1DR is traditionally considered very rare in immunosuppressed recipients of pancreas grafts from organ donors, representing the majority of recipients, and immunological graft failures are ascribed to chronic rejection. We have been performing simultaneous pancreas-kidney (SPK) transplants for over 25 years and find that 6-8 % of our recipients develop T1DR, with symptoms usually becoming manifest on extended follow-up. T1DR is typically characterized by (1) variable degree of insulitis and loss of insulin staining, on pancreas transplant biopsy (with most often absent), minimal to moderate and rarely severe pancreas, and/or kidney transplant rejection; (2) the conversion of T1D-associated autoantibodies (to the autoantigens GAD65, IA-2, and ZnT8), preceding hyperglycemia by a variable length of time; and (3) the presence of autoreactive T cells in the peripheral blood, pancreas transplant, and/or peripancreatic transplant lymph nodes. There is no therapeutic regimen that so far has controlled the progression of islet autoimmunity, even when additional immunosuppression was added to the ongoing chronic regimens; we hope that further studies and, in particular, in-depth analysis of pancreas transplant biopsies with recurrent diabetes will help identify more effective therapeutic approaches.
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Affiliation(s)
- George W Burke
- Miami Transplant Institute, 1801 NW 9th Ave, Highland Professional Building, Miami, FL, 33136, USA.
- Department of Surgery, Division of Transplantation, University of Miami Miller School of Medicine, Miami, FL, USA.
| | - Francesco Vendrame
- Department of Medicine, Division of Endocrinology and Metabolism, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Sahil K Virdi
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - G Ciancio
- Miami Transplant Institute, 1801 NW 9th Ave, Highland Professional Building, Miami, FL, 33136, USA
- Department of Surgery, Division of Transplantation, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Linda Chen
- Miami Transplant Institute, 1801 NW 9th Ave, Highland Professional Building, Miami, FL, 33136, USA
- Department of Surgery, Division of Transplantation, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Phillip Ruiz
- Miami Transplant Institute, 1801 NW 9th Ave, Highland Professional Building, Miami, FL, 33136, USA
- Department of Surgery, Division of Transplantation, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Shari Messinger
- Department of Epidemiology and Public Health Sciences, Division of Biostatistics, University of Miami Miller School of Medicine, Miami, FL, USA
| | | | - Alberto Pugliese
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL, USA
- Department of Medicine, Division of Endocrinology and Metabolism, University of Miami Miller School of Medicine, Miami, FL, USA
- Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, FL, USA
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Rangel EB. Tacrolimus in pancreas transplant: a focus on toxicity, diabetogenic effect and drug–drug interactions. Expert Opin Drug Metab Toxicol 2014; 10:1585-605. [DOI: 10.1517/17425255.2014.964205] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Stratta RJ, Farney AC, Rogers J, Orlando G. Immunosuppression for pancreas transplantation with an emphasis on antibody induction strategies: review and perspective. Expert Rev Clin Immunol 2014; 10:117-32. [PMID: 24236648 DOI: 10.1586/1744666x.2014.853616] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
A review of recent literature was performed to identify trends and evaluate outcomes with respect to immunosuppression in pancreas transplantation (PTX). In the past decade, the majority of PTXs were performed with depleting antibody induction, particularly in the setting of either calcineurin inhibitor minimization, corticosteroid withdrawal or both. Maintenance immunosuppression consisted of predominantly tacrolimus (TAC)/mycophenolatemofetil, TAC/mycophenolic acid or TAC/sirolimus with or without corticosteroids. Depending on PTX category, donor and recipient risk factors, case mix and immunosuppressive regimen, the 1-year incidence of acute rejection has decreased to 5-20%. Current 1-year rates of immunological pancreas graft loss range between 1.8 and 6%. Depleting antibody induction and either TAC/mycophenolatemofetil or TAC/sirolimus maintenance therapy with early steroid withdrawal have become the mainstay of immunosuppression in PTX. However, the development of non-nephrotoxic, nondiabetogenic, and nongastrointestinal toxic regimens is highly desirable to improve quality of life in all solid organ transplant recipients.
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Affiliation(s)
- Robert J Stratta
- Department of General Surgery, Section of Transplantation, Wake Forest School of Medicine, Medical Center Blvd., Winston-Salem, NC27157, USA
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Liu F, Zhang H, Zhang K, Wang X, Li S, Yin Y. Rapamycin promotes Schwann cell migration and nerve growth factor secretion. Neural Regen Res 2014; 9:602-9. [PMID: 25206862 PMCID: PMC4146242 DOI: 10.4103/1673-5374.130101] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2014] [Indexed: 11/04/2022] Open
Abstract
Rapamycin, similar to FK506, can promote neural regeneration in vitro. We assumed that the mechanisms of action of rapamycin and FK506 in promoting peripheral nerve regeneration were similar. This study compared the effects of different concentrations of rapamycin and FK506 on Schwann cells and investigated effects and mechanisms of rapamycin on improving peripheral nerve regeneration. Results demonstrated that the lowest rapamycin concentration (1.53 nmol/L) more significantly promoted Schwann cell migration than the highest FK506 concentration (100μmol/L). Rapamycin promoted the secretion of nerve growth factors and upregulated growth-associated protein 43 expression in Schwann cells, but did not significantly affect Schwann cell proliferation. Therefore, rapamycin has potential application in peripheral nerve regeneration therapy.
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Affiliation(s)
- Fang Liu
- Department of Orthopedics, Second Hospital of Yueyang, Yueyang, Hunan Province, China
| | - Haiwei Zhang
- Department of Orthopedics, Second Hospital of Yueyang, Yueyang, Hunan Province, China
| | - Kaiming Zhang
- Department of Orthopedics, Second Hospital of Yueyang, Yueyang, Hunan Province, China
| | - Xinyu Wang
- State Key Laboratory of Advanced Technology for Materials Synthesis and Processing, and Biomedical Materials and Engineering Center, Wuhan University of Technology, Wuhan, Hunan Province, China
| | - Shipu Li
- State Key Laboratory of Advanced Technology for Materials Synthesis and Processing, and Biomedical Materials and Engineering Center, Wuhan University of Technology, Wuhan, Hunan Province, China
| | - Yixia Yin
- State Key Laboratory of Advanced Technology for Materials Synthesis and Processing, and Biomedical Materials and Engineering Center, Wuhan University of Technology, Wuhan, Hunan Province, China
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Sageshima J, Ciancio G, Chen L, Dohi T, El-Hinnawi A, Paloyo S, Misawa R, Ekwenna O, Yatawatta A, Burke GW. Everolimus with low-dose tacrolimus in simultaneous pancreas and kidney transplantation. Clin Transplant 2014; 28:797-801. [PMID: 24779669 DOI: 10.1111/ctr.12381] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2014] [Indexed: 02/06/2023]
Abstract
The efficacy and safety of everolimus (EVR) in simultaneous pancreas and kidney transplantation (SPKT) is unclear. We retrospectively evaluated 25 consecutive SPKT recipients at our center from November 2011 to March 2013. All patients received dual induction (Thymoglobulin/basiliximab) and low-dose tacrolimus plus corticosteroids. Nine patients who received EVR were compared with 14 patients who received enteric-coated mycophenolate sodium (EC-MPS); two patients who received sirolimus were excluded from the analysis. With a median follow-up of 14 months, the pancreas graft survival rate was 100% in both groups, and the kidney graft survival rate was 100% and 93% in EVR and EC-MPS patients, respectively. One EC-MPS patient lost her kidney graft from proteinuric kidney disease. Another EC-MPS patient received treatment for clinically diagnosed pancreas and kidney graft rejection. No rejection was observed in EVR patients. Serum creatinine and HbA1c levels were similar between the groups. There was no significant difference of surgical or medical complications. In conclusion, EVR seems to provide comparable short-term outcome to EC-MPS when combined with low-dose tacrolimus/steroids and dual induction therapy. A larger study with a longer follow-up is required to further assess this combination.
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Affiliation(s)
- Junichiro Sageshima
- Division of Kidney and Pancreas Transplantation, Dewitt Daughtry Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA; Miami Transplant Institute at the Jackson Memorial Hospital and University of Miami, Miami, FL, USA
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Chang JW, Sageshima J, Ciancio G, Mattiazzi A, Chen L, Tsai HL, Ruiz P, Burke GW. Successful treatment for graft-versus-host disease after pancreas transplantation. Clin Transplant 2014; 28:217-22. [PMID: 24433450 DOI: 10.1111/ctr.12300] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2013] [Indexed: 11/29/2022]
Abstract
Graft-versus-host disease (GVHD) after pancreas transplantation is a rare but serious complication: All previously reported cases were fatal. We herein report three cases of GVHD after pancreas transplantation with favorable outcomes. Patients with a history of kidney (and pancreas) transplantation subsequently received a pancreas (and kidney) transplantation (i.e., pancreas retransplantation or pancreas after kidney transplantation) and developed acute GVHD. All of them responded to increased immunosuppression (e.g., steroid bolus, antithymocyte globulin) and retained normal graft function. Because the clinical manifestations are non-specific, vigilance is necessary to make an accurate diagnosis. We underscored the importance of a biopsy of involved organs and the clinicopathologic correlation in the early diagnosis of GVHD. Augmented immunosuppression to prevent progression from a self-limited disease to life-threatening pancytopenia or sepsis may be most critical to improve outcome.
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Affiliation(s)
- Jei wen Chang
- Division of Kidney and Pancreas Transplantation, Dewitt Daughtry Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA; Department of Pediatrics and Surgery, School of Medicine, Taipei Veterans General Hospital Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
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30
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Abstract
Transplantation of the whole vascularized pancreas can provide insulin secretion in patients with insulin-dependent, type 1 diabetes mellitus (T1D). It restores euglycemia in most patients, with the potential to impact the chronic diabetic complications and quality of life. Pancreas transplantation (PT) is presently controversial for type 2 diabetes mellitus (T2D). For those patients with severe glycemic dysregulation, T2D can be associated with the same life-threatening sequelae as T1D such as severe hypoglycemia and kidney failure that could be corrected by pancreas (and kidney) transplantation. Thus, clinical indications and patient selection criteria are very important. This chapter will review the current status of PT for T2D and discuss the options and evolution of transplant perspectives.
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Affiliation(s)
- Gaetano Ciancio
- The DeWitt Daughtry Family Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA,
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Barlow AD, Nicholson ML, Herbert TP. Evidence for rapamycin toxicity in pancreatic β-cells and a review of the underlying molecular mechanisms. Diabetes 2013; 62:2674-82. [PMID: 23881200 PMCID: PMC3717855 DOI: 10.2337/db13-0106] [Citation(s) in RCA: 147] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Rapamycin is used frequently in both transplantation and oncology. Although historically thought to have little diabetogenic effect, there is growing evidence of β-cell toxicity. This Review draws evidence for rapamycin toxicity from clinical studies of islet and renal transplantation, and of rapamycin as an anticancer agent, as well as from experimental studies. Together, these studies provide evidence that rapamycin has significant detrimental effects on β-cell function and survival and peripheral insulin resistance. The mechanism of action of rapamycin is via inhibition of mammalian target of rapamycin (mTOR). This Review describes the complex mTOR signaling pathways, which control vital cellular functions including mRNA translation, cell proliferation, cell growth, differentiation, angiogenesis, and apoptosis, and examines molecular mechanisms for rapamycin toxicity in β-cells. These mechanisms include reductions in β-cell size, mass, proliferation and insulin secretion alongside increases in apoptosis, autophagy, and peripheral insulin resistance. These data bring into question the use of rapamycin as an immunosuppressant in islet transplantation and as a second-line agent in other transplant recipients developing new-onset diabetes after transplantation with calcineurin inhibitors. It also highlights the importance of close monitoring of blood glucose levels in patients taking rapamycin as an anticancer treatment, particularly those with preexisting glucose intolerance.
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Affiliation(s)
- Adam D Barlow
- Department of Transplant Surgery, University Hospitals of Leicester, Leicester, UK.
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