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Chen H, Liu S, Yu L, Hou X, Zhao R. Factors and interventions affecting tacrolimus intrapatient variability: A systematic review and meta-analysis. Transplant Rev (Orlando) 2024; 38:100878. [PMID: 39260119 DOI: 10.1016/j.trre.2024.100878] [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: 07/10/2024] [Revised: 08/16/2024] [Accepted: 08/17/2024] [Indexed: 09/13/2024]
Abstract
BACKGROUNDS Tacrolimus is a cornerstone of posttransplantation immunosuppressive regimens. Despite routine monitoring, the efficacy of its trough concentrations in reflecting drug concentration fluctuations is limited. Intrapatient variability (IPV) emerges as a novel monitoring marker for predicting clinical outcomes. However, understanding the factors affecting IPV and assessing interventions to address it remain enigmatic, posing a conundrum in clinical management. OBJECTIVES This systematic review aimed to investigate a spectrum of factors affecting IPV and assess the effect of strategic interventions, thereby charting a course for enhanced clinical stewardship. METHODS We electronically searched of PubMed, Embase, and the Cochrane Library databases for studies investigating factors and interventions affecting IPV up to October 2023. Two reviewers independently screened literature, extracted data, and assessed quality, using RevMan 5.4.1 software for meta-analysis. RESULTS A total of 15 randomized controlled trials (RCTs), 34 cohort studies, and 20 self-controlled studies were included. The results indicated that IPV was significantly higher in cytochrome P450 3A5 (CYP3A5) expressers, nonadherent patients, patients taking proton pump inhibitors or statins, and Black or African American recipients, whereas recipients consuming extended-release formulation exhibited lower IPV. Additionally, the participation of pharmacists had a positive effect on improving IPV. CONCLUSIONS Factors affecting IPV encompassed genotype, formulation, adherence, drug combinations, and ethnicity, with each factor exerting varying degrees of effect. Identifying these factors was crucial for developing targeted intervention strategies. While the participation of pharmacists held a promise in improving IPV, further investigation of interventions such as mobile technology, educational measures to enhance adherence, and personalized dosing regimens was warranted.
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Affiliation(s)
- Hongsheng Chen
- Department of Pharmacy, Peking University Third Hospital, Beijing, China; Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China.
| | - Shuang Liu
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - Lingling Yu
- Department of Pharmacy, Peking University Third Hospital, Beijing, China; Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Xiaofei Hou
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Rongsheng Zhao
- Department of Pharmacy, Peking University Third Hospital, Beijing, China.
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Bae EK, Chandran MM, Everitt MD, Benz E, Bock M. LCP-Tacrolimus Extended-Release (Envarsus XR) Use in Adolescent and Young Adult Solid Organ Transplant Recipients. Clin Transplant 2024; 38:e15417. [PMID: 39087462 DOI: 10.1111/ctr.15417] [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: 03/27/2024] [Revised: 06/30/2024] [Accepted: 07/15/2024] [Indexed: 08/02/2024]
Abstract
INTRODUCTION Limited published experience describes once daily, extended-release tacrolimus (LCP-Tac) use in pediatric solid organ transplantation (SOT), particularly nonrenal SOT. LCP-Tac can simplify immunosuppression (IS) regimens, minimize immediate release-tacrolimus (IR-Tac)-associated adverse effects, and promote adherence. This study describes the successful use of LCP-Tac in adolescent and young adult (AYA) SOT populations. METHODS A single-center, retrospective chart review of AYA SOT recipients (age < 25 years) converted from IR-Tac to LCP-Tac. Graft survival, biopsy-proven acute rejection (BPAR), infection rates, estimated glomerular filtration rate (eGFR), and pill burden were assessed at five time points postconversion (1, 3, 6, 12, and 24 months). Intrapatient variability of tacrolimus, as assessed by coefficient of variability (CV%), was also analyzed. RESULTS Twenty-nine AYA SOT recipients (19 heart, 6 kidney, and 4 liver) were converted to LCP-Tac, with a median age of 17.4 years at conversion. Conversion, mainly due to perceived or identified medication nonadherence, occurred at a median of 5.4 years posttransplant. No graft loss occurred within 24 months of conversion, and BPAR incidence rate was consistent with previous reports for these populations. Only one patient experienced CMV infection. Renal function remained stable postconversion. CONCLUSION Successful conversion from IR-Tac to LCP-Tac was demonstrated in AYA heart, kidney, and liver transplant recipients. These AYA SOT recipients experienced reduced pill burden and improved tacrolimus trough concentration variability. However, the impact on medication adherence warrants further investigation. Future research should explore the targeted use of LCP-Tac to enhance IS tolerability and medication adherence in young SOT populations.
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Affiliation(s)
- Esther K Bae
- Pharmacy, Children's Hospital Colorado, Aurora, Colorado, USA
| | | | - Melanie D Everitt
- Heart Institute, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Eric Benz
- Nephrology, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Margret Bock
- Nephrology, Children's Hospital Colorado, Aurora, Colorado, USA
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Xie W, Fan S, Liu R, Yan W, Su C, Zheng K, Wang X, Wang Z. Tacrolimus intra-patient variability measures and its associations with allograft clinical outcomes in kidney transplantation. Transplant Rev (Orlando) 2024; 38:100842. [PMID: 38537484 DOI: 10.1016/j.trre.2024.100842] [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: 12/11/2023] [Revised: 03/14/2024] [Accepted: 03/15/2024] [Indexed: 06/16/2024]
Abstract
AIMS Tacrolimus (Tac) is commonly prescribed in solid organ transplantation to prevent immune-mediated damage to the graft. However, its pharmacokinetics show substantial variability between and within patients. Intra-patient variability of tacrolimus (Tac-IPV) has emerged as a novel marker to predict transplant outcomes. Numerous studies report varying associations between Tac-IPV and clinical outcomes, with Tac-IPV measures showing wide discrepancies among these studies. This inconsistency could be a significant factor that influences the various outcomes reported in different studies. Our review comprehensively assesses the relationship between various Tac-IPV measures and their associations with clinical outcomes in transplant patients. METHODS A comprehensive literature search was conducted using the PubMed and Embase databases, covering the period from 2004 to March 31, 2023. The search focused on studies that examined the relationship between Tac-IPV and clinical outcomes in kidney transplantation (KT). The inclusion criteria were specific to studies addressing Tac-IPV, including measures such as standard deviation (SD), coefficient of variation (CV), time-weighted coefficient of variability (CV), mean absolute deviation (MAD), and Tac variability score (TVS). Clinical outcomes included the development of de novo donor-specific antibodies (dnDSA), rejection episodes, graft loss, and graft failure. RESULTS Among the 33 studies that met the inclusion criteria, a notable proportion presented conflicting findings in their assessment of various Tac-IPV measures regarding dnDSA, rejection episodes, graft loss, and graft failure. CONCLUSIONS Most studies have identified a correlation between high Tac-IPV and poor clinical outcomes; however, this relationship is multifactorial. Influencing factors include the metabolic status of KT patients, the timing of Tac-IPV calculations, and the criteria for defining high and low Tac-IPV thresholds, including the size and selection method. CV, MAD, and TWCV are the metrics that are most frequently used to determine Tac-IPV. Additionally, most of the methods for establishing Tac-IPV thresholds typically employ receiver operating characteristic (ROC) curves and median values. It is also notable that studies examining the clinical significance of Tac-IPV often include tacrolimus levels measured six months after kidney transplantation.
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Affiliation(s)
- Wenmin Xie
- Department of Pharmacy, Shanghai Changhai Hospital, Naval Medical University, Shanghai, People's Republic of China; College of life sciences and Biopharmaceuticals, Shenyang Pharmaceutical University, Shenyang, People's Republic of China
| | - Shupan Fan
- Department of Pharmacy, Shanghai Changhai Hospital, Naval Medical University, Shanghai, People's Republic of China; Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Naval Medical University, Shanghai, People's Republic of China
| | - Ruolin Liu
- Department of Pharmacy, Shanghai Changhai Hospital, Naval Medical University, Shanghai, People's Republic of China; College of life sciences and Biopharmaceuticals, Shenyang Pharmaceutical University, Shenyang, People's Republic of China
| | - Wencheng Yan
- Department of Pharmacy, Shanghai Changhai Hospital, Naval Medical University, Shanghai, People's Republic of China; School of Pharmacy, Bengbu Medical University, Bengbu, People's Republic of China
| | - Chengxin Su
- Department of Pharmacy, Shanghai Changhai Hospital, Naval Medical University, Shanghai, People's Republic of China; College of life sciences and Biopharmaceuticals, Shenyang Pharmaceutical University, Shenyang, People's Republic of China
| | - Kaile Zheng
- Department of Pharmacy, Shanghai Changhai Hospital, Naval Medical University, Shanghai, People's Republic of China; School of Pharmacy, Bengbu Medical University, Bengbu, People's Republic of China
| | - Xuebin Wang
- Department of pharmacy, Shanghai Children's Hospital, School of medicine, Shanghai Jiao Tong University, Shanghai, People's Republic of China.
| | - Zhuo Wang
- Department of Pharmacy, Shanghai Changhai Hospital, Naval Medical University, Shanghai, People's Republic of China; College of life sciences and Biopharmaceuticals, Shenyang Pharmaceutical University, Shenyang, People's Republic of China; Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Naval Medical University, Shanghai, People's Republic of China; School of Pharmacy, Bengbu Medical University, Bengbu, People's Republic of China.
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Kim JJ, Lawless L, Marshall D, Maxted A, Lunn A, Mallik M, Williams A. Pharmacokinetics of Envarsus in pediatric kidney transplant recipients - phase 1 pilot conversion study. Pediatr Transplant 2024; 28:e14703. [PMID: 38433334 DOI: 10.1111/petr.14703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 01/10/2024] [Accepted: 01/22/2024] [Indexed: 03/05/2024]
Abstract
INTRODUCTION Tacrolimus is the standard immunosuppressant for pediatric kidney transplants and is routinely administered twice daily (BD-tac). Envarsus (LCP-tac), an extended-release formulation, is approved for adults but not for pediatric patients. METHODS We conducted a pilot open-label phase 1 study in stable pediatric kidney transplant recipients (age < 18 at the time of study). Our primary objective was to compare the pharmacokinetics (Pk) of LCP-tac versus BD-tac. We conducted two 24-h Pk studies: pre-conversion (BD-tac) and 4 weeks post-conversion to LCP-tac. Patients were followed for 6 months, with the option to continue LCP-tac. RESULTS Five patients completed the study, with no returns to BD-tac. Median age was 15 years (range 11-17). LCP-tac exhibited an extended-release profile versus the bimodal profile of BD-tac. Time to maximum concentration was delayed (5 h vs. 1 h), and maximum concentration was lower (9.9 ng/mL vs. 14.4 ng/mL). Tacrolimus area under the curve (24 h) was comparable (141 ± 46.5 ng/mL vs. 164 ± 27.8 ng/mL). No new safety concerns arose. There were no rejection and no difference in eGFR at the study's end (1.5 mL/min/1.73 m2 , range - 1.7 to 2.3 mL/min/1.73 m2 ). Concentration/dose ratio was higher in LCP-tac (1.8 ± 0.64 vs. 0.8 ± 0.39). The final conversion ratio was 0.6 (BD-tac: LCP-tac). CONCLUSION Our pilot study confirms the extended-release Pk profile and improved absorption of LCP-tac compared to BD-tac. A larger study is needed to further evaluate the population Pk characteristics in children.
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Affiliation(s)
- Jon Jin Kim
- Department of Paediatric Nephrology, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Department of Surgery, University of Cambridge, Cambridge, UK
| | - Laura Lawless
- Research and Innovation, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - David Marshall
- Department of Clinical Biochemistry, Wythenshawe Hospital, Manchester, UK
| | - Andrew Maxted
- Department of Paediatric Nephrology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Andrew Lunn
- Department of Paediatric Nephrology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Meeta Mallik
- Department of Paediatric Nephrology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Alun Williams
- Department of Paediatric Nephrology, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Becker-Cohen R. Pathophysiological Implications of Variability in Blood Tacrolimus Levels in Pediatric and Adolescent Kidney Transplant Recipients. Clin J Am Soc Nephrol 2022; 17:1105-1106. [PMID: 35882507 PMCID: PMC9435984 DOI: 10.2215/cjn.06640622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Rachel Becker-Cohen
- Pediatric Nephrology, Shaare Zedek Medical Center, Jerusalem, Israel, and Hebrew University School of Medicine, Jerusalem, Israel
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