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Galvez C, Boza P, González M, Hormazabal C, Encina M, Azócar M, Castañeda LE, Rojo A, Ceballos ML, Krall P. Evaluation of limited-sampling strategies to calculate AUC(0–24) and the role of CYP3A5 in Chilean pediatric kidney recipients using extended-release tacrolimus. Front Pharmacol 2023; 14:1044050. [PMID: 36998611 PMCID: PMC10043346 DOI: 10.3389/fphar.2023.1044050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 02/21/2023] [Indexed: 03/16/2023] Open
Abstract
Background: Kidney transplantation (KTx) requires immunosuppressive drugs such as Tacrolimus (TAC) which is mainly metabolized by CYP3A5. TAC is routinely monitored by trough levels (C0) although it has not shown to be a reliable marker. The area-under-curve (AUC) is a more realistic measure of drug exposure, but sampling is challenging in pediatric patients. Limited-sampling strategies (LSS) have been developed to estimate AUC. Herein, we aimed to determine AUC(0–24) and CYP3A5 genotype in Chilean pediatric kidney recipients using extended-release TAC, to evaluate different LSS-AUC(0–24) formulas and dose requirements.Patients and methods: We analyzed pediatric kidney recipients using different extended-release TAC brands to determine their trapezoidal AUC(0–24) and CYP3A5 genotypes (SNP rs776746). Daily TAC dose (TAC-D mg/kg) and AUC(0–24) normalized by dose were compared between CYP3A5 expressors (*1/*1 and *1/*3) and non-expressors (*3/*3). We evaluated the single and combined time-points to identify the best LSS-AUC(0–24) model. We compared the performance of this model with two pediatric LSS-AUC(0–24) equations for clinical validation.Results: Fifty-one pharmacokinetic profiles were obtained from kidney recipients (age 13.1 ± 2.9 years). When normalizing AUC(0–24) by TAC-D significant differences were found between CYP3A5 expressors and non-expressors (1701.9 vs. 2718.1 ng*h/mL/mg/kg, p < 0.05). C0 had a poor fit with AUC(0–24) (r2 = 0.5011). The model which included C0, C1 and C4, showed the best performance to predict LSS-AUC(0–24) (r2 = 0.8765) and yielded the lowest precision error (7.1% ± 6.4%) with the lowest fraction (9.8%) of deviated AUC(0–24), in comparison to other LSS equations.Conclusion: Estimation of LSS-AUC(0–24) with 3 time-points is an advisable and clinically useful option for pediatric kidney recipients using extended-release TAC to provide better guidance of decisions if toxicity or drug inefficacy is suspected. The different CYP3A5 genotypes associated with variable dose requirements reinforce considering genotyping before KTx. Further multi-centric studies with admixed cohorts are needed to determine the short- and long-term clinical benefits.
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Affiliation(s)
- Carla Galvez
- Unidad de Nefrología, Hospital Luis Calvo Mackenna, Santiago de Chile, Chile
| | - Pía Boza
- Laboratorio Clínico, Hospital Luis Calvo Mackenna, Santiago de Chile, Chile
| | - Mariluz González
- Unidad de Nefrología, Hospital Luis Calvo Mackenna, Santiago de Chile, Chile
| | - Catalina Hormazabal
- Unidad de Nefrología, Hospital Luis Calvo Mackenna, Santiago de Chile, Chile
| | - Marlene Encina
- Laboratorio Clínico, Hospital Luis Calvo Mackenna, Santiago de Chile, Chile
| | - Manuel Azócar
- Servicio de Farmacia Clínica, Hospital Luis Calvo Mackenna, Santiago de Chile, Chile
| | - Luis E. Castañeda
- Programa de Genética Humana, Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Santiago de Chile, Chile
| | - Angélica Rojo
- Unidad de Nefrología, Hospital Luis Calvo Mackenna, Santiago de Chile, Chile
| | - María Luisa Ceballos
- Unidad de Nefrología, Hospital Luis Calvo Mackenna, Santiago de Chile, Chile
- Departamento de Pediatría y Cirugía Infantil Oriente, Facultad de Medicina, Universidad de Chile, Santiago de Chile, Chile
- *Correspondence: María Luisa Ceballos, ; Paola Krall,
| | - Paola Krall
- Departamento de Pediatría y Cirugía Infantil Oriente, Facultad de Medicina, Universidad de Chile, Santiago de Chile, Chile
- Instituto de Medicina, Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile
- *Correspondence: María Luisa Ceballos, ; Paola Krall,
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Rubik J, Debray D, Kelly D, Iserin F, Webb NJA, Czubkowski P, Vondrak K, Sellier-Leclerc AL, Rivet C, Riva S, Tönshoff B, D'Antiga L, Marks SD, Reding R, Kazeem G, Undre N. Efficacy and safety of prolonged-release tacrolimus in stable pediatric allograft recipients converted from immediate-release tacrolimus - a Phase 2, open-label, single-arm, one-way crossover study. Transpl Int 2019; 32:1182-1193. [PMID: 31325368 PMCID: PMC6852421 DOI: 10.1111/tri.13479] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 01/21/2019] [Accepted: 07/11/2019] [Indexed: 12/11/2022]
Abstract
There are limited clinical data regarding prolonged‐release tacrolimus (PR‐T) use in pediatric transplant recipients. This Phase 2 study assessed the efficacy and safety of PR‐T in stable pediatric kidney, liver, and heart transplant recipients (aged ≥5 to ≤16 years) over 1 year following conversion from immediate‐release tacrolimus (IR‐T), on a 1:1 mg total‐daily‐dose basis. Endpoints included the incidence of acute rejection (AR), a composite endpoint of efficacy failure (death, graft loss, biopsy‐confirmed AR, and unknown outcome), and safety. Tacrolimus dose and whole‐blood trough levels (target 3.5–15 ng/ml) were also evaluated. Overall, 79 patients (kidney, n = 48; liver, n = 29; heart, n = 2) were assessed. Following conversion, tacrolimus dose and trough levels remained stable; however, 7.6–17.7% of patients across follow‐up visits had trough levels below the target range. Two (2.5%) patients had AR, and 3 (3.8%) had efficacy failure. No graft loss or deaths were reported. No new safety signals were identified. Drug‐related treatment‐emergent adverse events occurred in 28 patients (35.4%); most were mild, and all resolved. This study suggests that IR‐T to PR‐T conversion is effective and well tolerated over 1 year in pediatric transplant recipients and highlights the importance of therapeutic drug monitoring to maintain target tacrolimus trough levels.
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Affiliation(s)
- Jacek Rubik
- Department of Nephrology, Kidney Transplantation and Hypertension, The Children's Memorial Health Institute, Warsaw, Poland
| | - Dominique Debray
- Pediatric Hepatology Unit, APHP-Hôpital Universitaire Necker, Paris, France
| | - Deirdre Kelly
- The Liver Unit, Birmingham Women's & Children's Hospital, Birmingham, UK
| | - Franck Iserin
- Pediatric Cardiology Unit, APHP-Hôpital Universitaire Necker, Paris, France
| | - Nicholas J A Webb
- Department of Pediatric Nephrology, NIHR/Wellcome Trust Manchester Clinical Research Facility, Manchester Academic Health Science Centre, Royal Manchester Children's Hospital, University of Manchester, Manchester, UK
| | - Piotr Czubkowski
- Department of Gastroenterology, Hepatology, Nutritional Disturbances and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Karel Vondrak
- Department of Pediatrics, Second School of Medicine, University Hospital Motol, Charles University, Prague, Czech Republic
| | - Anne-Laure Sellier-Leclerc
- Department of Nephrology, Rheumatology, and Dermatology, Center for Rare Diseases, Civil Hospice of Lyon, 'Woman-Mother-Child' Hospital, Bron Cedex, France
| | - Christine Rivet
- Pediatric Hepatology, Gastroenterology and Transplantation, Civil Hospice of Lyon, Lyon, France
| | - Silvia Riva
- Department of Pediatrics, ISMETT-IRCCS, Palermo, Italy
| | - Burkhard Tönshoff
- Department of Pediatrics I, University Children's Hospital Heidelberg, Heidelberg, Germany
| | - Lorenzo D'Antiga
- Pediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Stephen D Marks
- Department of Pediatric Nephrology, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Raymond Reding
- Unité de Chirurgie et Transplantation Pédiatrique, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Gbenga Kazeem
- BENKAZ Consulting Ltd, Cambridge, UK.,Astellas Pharma Europe Ltd, Chertsey, UK
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Abstract
The goal of immunosuppressive therapy post-transplantation in pediatric renal transplant recipients is to prevent acute and chronic rejection while minimizing drug side effects. Most therapies alter immune response mechanisms but are not immunologically specific, and a careful balance is required to find the dose that prevents rejection of the graft while minimizing the risks of overimmunosuppression leading to infection and cancer. While this chapter because of space constraints focuses on immunosuppressive therapy in pediatric renal transplant recipients, many aspects can be applied on pediatric recipients of other solid organ transplants such as the liver and heart. The major maintenance immunosuppressive agents currently used in various combination regimens are tacrolimus, cyclosporine, mycophenolate mofetil, azathioprine, everolimus, sirolimus, and glucocorticoids (steroids). Although data from adult renal transplantation trials are used to help guide management decisions in pediatric patients, immunosuppressive therapy in pediatric renal transplant recipients often must be modified because of the unique dosage requirements and clinical effects of these agents in children, including their impact on growth and development. The optimal immunosuppressive therapy post-transplant is not established. The goal remains to find the best combination of immunosuppressive agents that optimizes allograft survival by preventing acute rejection while limiting drug toxicities.
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