Impact of a Clinical Solid Organ Transplant Pharmacist on Tacrolimus Nephrotoxicity, Therapeutic Drug Monitoring, and Institutional Revenue Generation in Adult Kidney Transplant Recipients

Solid organ transplantation and gut microbiota: a review of the potential immunomodulatory properties of short-chain fatty acids in graft maintenance

Transplantation is the treatment of choice for several end-stage organ defects: it considerably improves patient survival and quality of life. However, post-transplant recipients may experience episodes of rejection that can favor or ultimately lead to graft loss. Graft maintenance requires a complex and life-long immunosuppressive treatment. Different immunosuppressive drugs (i.e., calcineurin inhibitors, glucocorticoids, biological immunosuppressive agents, mammalian target of rapamycin inhibitors, and antiproliferative or antimetabolic agents) are used in combination to mitigate the immune response against the allograft. Unfortunately, the use of these antirejection agents may lead to opportunistic infections, metabolic (e.g., post-transplant diabetes mellitus) or cardiovascular (e.g., arterial hypertension) disorders, cancer (e.g., non-Hodgkin lymphoma) and other adverse effects. Lately, immunosuppressive drugs have also been associated with gut microbiome alterations, known as dysbiosis, and were shown to affect gut microbiota-derived short-chain fatty acids (SCFA) production. SCFA play a key immunomodulatory role in physiological conditions, and their impairment in transplant patients could partly counterbalance the effect of immunosuppressive drugs leading to the activation of deleterious pathways and graft rejection. In this review, we will first present an overview of the mechanisms of graft rejection that are prevented by the immunosuppressive protocol. Next, we will explain the dynamic changes of the gut microbiota during transplantation, focusing on SCFA. Finally, we will describe the known functions of SCFA in regulating immune-inflammatory reactions and discuss the impact of SCFA impairment in immunosuppressive drug treated patients.

Impact of transplant pharmacists on length of stay and 30-day hospital readmission rate: a single-centre retrospective cohort study

OBJECTIVES

Our study was conducted to evaluate the impact of clinical transplant pharmacy services on the kidney transplant programme at our centre, following the introduction of these services in terms of inpatient length of stay (LOS) and all-cause 30-day readmission rates by comparing these data to data from before (and therefore in the absence of) the services.

METHODS

This was a single-centre retrospective cohort analysis. Data were collected in two phases: phase I (pre-transplant pharmacist period, that is, transplant pharmacist service was not available) comprised transplant patients between 1 October 2015 and 30 September 2016 and phase II (post-transplant pharmacist period) comprised transplant patients between 1 October 2016 and 30 September 2017. Patients ≥18 years of age, who received a kidney transplant in our centre, and received steroids, tacrolimus and mycophenolate for maintenance immunosuppression, were included. Transplant pharmacy services provided followed the expectations of the Centers for Medicare & Medicaid Services for transplant centres. Primary outcomes were LOS after transplant surgery and all-cause 30-day hospital readmission rate. Secondary outcomes included the number of pharmacy notes, the achievement of therapeutic levels of tacrolimus at day 7 post-surgery and delayed graft function.

RESULTS

The two groups (n=101 in phase I and n=104 in phase II) had similar demographics and transplant characteristics at baseline. There was a statistically significant difference in the inpatient LOS (6.58 vs 5.76 days; p=0.041) between phase I and phase II, respectively. However, this did not pan out in the rate of 30-day hospital readmission (36 (35.6%) vs 27 (25.9%); p=0.133) between the two phases. The number of transplant pharmacist notes pre-transplant, post-surgery and on discharge were significantly higher in the post-transplant pharmacist group. There was no significant difference in tacrolimus concentration at day 7 (mean 7.15 ng/mL in phase I vs 6.95 ng/mL in phase II; p=0.673) or delayed graft function.

CONCLUSION

Our study showed a favourable inpatient LOS and comparable 30-day hospital readmission rate before and after the implementation of transplant pharmacy services.

The impact of an electronic hospital system on therapeutic drug monitoring

WHAT IS KNOWN AND OBJECTIVE

Australian hospitals have undergone a transformation with both a review and expansion of traditional roles of healthcare professionals and the implementation of an ieMR. The implementation of an ieMR brings large scale organizational change within the health system especially for staff with direct patient contact. This is changing the future of healthcare and the roles of healthcare professionals. There is minimal research on the impact of these electronic systems on the people and processes required to realise the improvements in patient care such as therapeutic drug monitoring (TDM) and the role of the pharmacist within the TDM process. The literature has discussed the use of computerised programs to assist with the interpretation of results and calculating of doses but the impact of an ieMR on the TDM process has not been discussed. This study undertook a retrospective analysis at an Australian tertiary hospital to investigate the impact of a digital hospital system on TDM within the facility.

METHODS

A 2-year retrospective audit was conducted on TDM at an Australian Tertiary Hospital. The periods were 2016 (a paper-based hospital) and 2018 (ieMR). Patients were identified using the pathology database. Patients were excluded if under the age of 18, in an outpatient setting or the emergency department. Progress notes, medication charts, ieMR and other relevant pathology were reviewed. They were assessed for appropriateness of the timing of collection, compliance to recommended TDM guidelines, and pharmacist documentation.

RESULTS AND DISCUSSION

A total of 2926 observations were included in the analysis. There was as similar percentage of appropriately collected samples between the paper-based system (2016) and the digital hospital system (2018) with 59% and 58% respectively. Results of logistic regression analysis models show the effect of year was not significant with regards to TDM for either a sample being appropriate or the dose adjustment being appropriate. Samples for TDM were more likely to be appropriate if the pharmacist had documented advice but less likely with regards to appropriate dose adjustment. This study considered the effect of introducing a hospital wide digital system on TDM processes. Overall, the results indicate no difference between the paper-based system and ieMR for appropriate samples and doses adjustments.

WHAT IS NEW AND CONCLUSION

To our knowledge, this is the first study of this kind looking at the impact of a digital hospital system on TDM. The introduction of a digital hospital system does not appear to have made improvement on the effective use of TDM. Inappropriate sampling as seen in this study can lead to ineffective clinical management of patients, inefficient use of time, and waste of financial resources. Further work is required to incorporate specific guidance and recommendations within the digital system to optimize TDM.

A survey of therapeutic drug monitoring in a teaching hospital

Objectives

Therapeutic drug monitoring (TDM) is one of the tools that aim to improve and ensure the best therapeutic effects while avoiding drug toxicity. This study aimed to identify the clinical utilization and application of TDM at a major teaching hospital in Jeddah.

Methods

A cross sectional survey of the clinical utilization and application of TDM at King Abdulaziz University Teaching Hospital across nurses in medical, surgical, pediatric, and intensive care units. The sample size (n = 130) represented 30% of the nursing population. The collection of questionnaires started on the 31st of January 2019 and was completed by the 10th of March 2019.

Results

The indication to use TDM was well-known to respondents. However, only 64% of respondents reported collection and measuring of the correct drug levels at a precise sampling time with no specific protocols being followed for each drug. Moreover, only 53% reported that the drug levels were being re-measured and adequately monitored for the right indication and proper sampling time. Regarding the presence of clinical pharmacists, 70% of the respondents indicated that no clinical pharmacist worked in their department.

Conclusion

Results demonstrate that appropriate sampling time was not used for the majority of monitored drugs. In the absence of a TDM request form, this finding probably indicates the lack of national or local TDM guidelines. In conclusion, TDM services, which include standardized forms, references, and an active clinical pharmacist will likely improve the application of TDM.

Appropriateness of tacrolimus therapeutic drug monitoring timing in the emergency department

PURPOSE

Evaluate the appropriateness of the timing of serum samples collected in the emergency department (ED) for tacrolimus (TAC) measurement.

METHODS

Single-center, retrospective review of TAC samples collected in the ED from September 1 to October 31, 2017. The primary evaluation was incidence of inappropriate sample collection for TAC measurement, defined as samples not collected 12 h (±2 h; 10-14 h) after the last dose, or within 2 h of the next dose if last known dose time was not documented. Incidence of repeat TAC measurements obtained within 24 h of ED presentation (if initial sample collection inappropriate), inappropriate TAC regimen adjustments, and healthcare costs of inappropriate TAC measurements was evaluated. Data collection included patient demographics, ED visit information, TAC measurement and timing related to last or next dose, changes to TAC regimen, and ED disposition. Descriptive data are reported.

RESULTS

Sixty-two patients were included. Forty-one (66%) initial TAC measurements were collected inappropriately in the ED. No patients had a regimen adjustment as a result of inappropriate concentration collection, but 32 patients (78%) did require a repeat measurement within 24 h of ED presentation due to initial inappropriate collection. Costs associated with incorrectly collected TAC measurements were $2,647.78 for the two-month time period and this is extrapolated to an estimated $15,886.68 annual expense for patients.

CONCLUSIONS

Inappropriate sample collection for TAC measurements was common in the ED, resulting in frequent repeat laboratory draws and increased healthcare costs.

Cynomolgus monkeys (Macaca fascicularis) experimentally and naturally infected with hepatitis E virus: The bone marrow as a possible new viral target

Hepatitis E virus (HEV) transmission through infected blood and blood products has already been described. However, little is known about the bone marrow (BM) as source of HEV infection. Our study aimed to investigate the presence of HEV antigen (Ag) and histological changes in BM of cynomolgus monkeys (Macaca fascicularis) experimentally and naturally infected with HEV. Four cynomolgus monkeys with acute, and two with chronic hepatitis E ─ after immunosuppressive therapy with tacrolimus ─ were compared with one colony-bred animal naturally infected. Both, natural and experimental infections were characterized by anti-HEV IgG seroconversion detected by ELISA, and viral RNA isolation confirmed by RT-qPCR and qualitative nested RT-PCR. BM biopsies were collected from all animals, submitted to histology and indirect immunofluorescence techniques and observed, respectively, by light and confocal microscopy. The HEV Ag-fluorescent-labeled cells were detected from BM biopsies obtained from three monkeys with acute and one with chronic hepatitis E, and also from the naturally infected monkey. In the experimentally infected animals with acute hepatitis, HEV Ag detection occurred at 160 days post-infection, even after viral clearance in serum, feces, and liver. Double-stranded RNA, a replicative marker, was detected in BM cells from both acute and chronically infected animals. Major histological findings included vacuolization in mononuclear and endosteal cells, an absence of organized inflammatory infiltrates, and also some fields suggesting displasic focal BM disease. These findings support the hypothesis of BM cells as secondary target sites of HEV persistence. Further experimental studies should be carried out to confirm the assumption of HEV transmission through BM transplantation.

Lack of Association Between TGF-β1 and MDR1 Genetic Polymorphisms and Cyclosporine-Induced Gingival Overgrowth in Kidney Transplant Recipients: A Meta-analysis

BACKGROUND

Gingival overgrowth (GO) induced by cyclosporine (CsA), one of the common complications after kidney transplantation, is associated with a genetic component. However, the effect of TGF-β1 and MDR1 gene polymorphisms on the pathogenesis of CsA-induced GO remains to be determined. This study aimed to determine the association between TGF-β1 and MDR1 gene polymorphisms and CsA-induced GO in kidney transplant recipients.

METHODS

The Pubmed, Embase, Cochrane Library, and Chinese CNKI (China National Knowledge Infrastructure) and Wanfang databases were comprehensively searched. Data were extracted and pooled results estimated from odds ratios (ORs) and 95% confidence intervals (CIs). In addition, quality assessment and publication bias of each eligible study were examined.

RESULTS

Three trials focusing on the relationship between TGF-β1 +869T>C and +915G>C and 3 studies on MDR1 C3435T gene polymorphisms and the onset of CsA-induced GO were included. No association between the +869T>C polymorphism and CsA-induced GO was found in the dominant model (TT+TC vs CC: OR, 0.77; 95% CI, 0.29-2.10; P = .614). In the recessive model, no association was found between the +915G>C polymorphism and CsA-induced GO (CC vs GG+GC: OR, 1.40; 95% CI, 0.81-2.43; P = .225). And in the dominant model, no significance was calculated between MDR1 C3435T gene polymorphisms and CsA-induced GO in kidney transplant recipients (TT vs CC+CT: OR, 1.14; 95% CI, 0.62-2.09; P = .68).

CONCLUSIONS

No significant association exists between TGF-β1 +869T>C, and +915G>C and MDR1 C3435T gene polymorphisms and the pathogenesis of CsA-induced GO in kidney transplant recipients.

Cynomolgus monkeys are successfully and persistently infected with hepatitis E virus genotype 3 (HEV-3) after long-term immunosuppressive therapy

Epidemiological studies found that hepatitis E virus genotype 3 (HEV-3) infection was associated with chronic hepatitis and cirrhosis in immunocompromised patients. Our study aimed to investigate the relationship between the host immunosuppressive status and the occurrence of HEV-related chronic hepatitis. Here we describe a successful experimental study, using cynomolgus monkeys previously treated with tacrolimus, a potent calcineurin inhibitor immunosuppressant, and infected with a Brazilian HEV-3 strain isolated from naturally infected pigs. HEV infected monkeys were followed up during 160 days post infection (dpi) by clinical signs; virological, biochemical and haematological parameters; and liver histopathology. The tacrolimus blood levels were monitored throughout the experiment. Immunosuppression was confirmed by clinical and laboratorial findings, such as: moderate weight loss, alopecia, and herpes virus opportunistic infection. In this study, chronic HEV infection was characterized by the mild increase of liver enzymes serum levels; persistent RNA viremia and viral faecal shedding; and liver histopathology. Three out of four immunosuppressed monkeys showed recurrent HEV RNA detection in liver samples, evident hepatocellular ballooning degeneration, mild to severe macro and microvesicular steatosis (zone 1), scattered hepatocellular apoptosis, and lobular focal inflammation. At 69 dpi, liver biopsies of all infected monkeys revealed evident ballooning degeneration (zone 3), discrete hepatocellular apoptosis, and at most mild portal and intra-acinar focal inflammation. At 160 dpi, the three chronically HEV infected monkeys showed microscopic features (piecemeal necrosis) corresponding to chronic hepatitis in absence of fibrosis and cirrhosis in liver parenchyma. Within 4-months follow up, the tacrolimus-immunosuppressed cynomolgus monkeys infected with a Brazilian swine HEV-3 strain exhibited more severe hepatic lesions progressing to chronic hepatitis without liver fibrosis, similarly as shown in tacrolimus-immunosuppressed solid organ transplant (SOT) recipients. The cause-effect relationship between HEV infection and tacrolimus treatment was confirmed in this experiment.