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Attachaipanich T, Chattipakorn SC, Chattipakorn N. Cardiovascular toxicities by calcineurin inhibitors: Cellular mechanisms behind clinical manifestations. Acta Physiol (Oxf) 2024; 240:e14199. [PMID: 38984711 DOI: 10.1111/apha.14199] [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: 02/21/2024] [Revised: 06/19/2024] [Accepted: 06/25/2024] [Indexed: 07/11/2024]
Abstract
Calcineurin inhibitors (CNI), including cyclosporine A (CsA) and tacrolimus (TAC), are cornerstones of immunosuppressive therapy in solid organ transplant recipients. While extensively recognized for their capacity to induce nephrotoxicity, hypertension, and dyslipidemia, emerging reports suggest potential direct cardiovascular toxicities associated with CNI. Evidence from both in vitro and in vivo studies has demonstrated direct cardiotoxic impact of CNI, manifesting itself as induction of cardiomyocyte apoptosis, enhanced oxidative stress, inflammatory cell infiltration, and cardiac fibrosis. CNI enhances cellular apoptosis through CaSR via activation of the p38 MAPK pathway and deactivation of the ERK pathway, and enhancement of miR-377 axis. Although CNI could attenuate cardiac hypertrophy in certain animal models, CNI concurrently impaired systolic function, enhanced cardiac fibrosis, and increased the risk of heart failure. Evidence from in vivo studies demonstrated that CNI prolong the duration of action potentials through a decrease in potassium current. CNI also exerted direct effects on endothelial cell injury, inducing apoptosis and enhancing oxidative stress. CNI may induce vascular inflammation through TLR4 via MyD88 and TRIF pathways. In addition, CNI affects vascular function by impairing endothelial-dependent vasodilation and promoting vasoconstriction. Clinical studies in transplant patients also revealed an increased incidence of cardiac remodeling. However, the evidence is constrained by the limited number of participants and potential confounding factors. Several studies indicate differing cardiovascular toxicity profiles between CsA and TAC, and these could be potentially due to their different interactions with calcineurin subunits and calcineurin-independent effects. Further studies are needed to clarify these mechanisms to improve cardiovascular outcomes for transplant patients with CNI.
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Affiliation(s)
- Tanawat Attachaipanich
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, Chiang Mai, Thailand
| | - Siriporn C Chattipakorn
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, Chiang Mai, Thailand
| | - Nipon Chattipakorn
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, Chiang Mai, Thailand
- Cardiac Electrophysiology Research Unit, Department of Physiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Chowdhary P, Kale S, Kumar S, Patel M. Tacrolimus-induced nonischemic dilated cardiomyopathy in a postrenal transplant recipient - A case report. INDIAN JOURNAL OF TRANSPLANTATION 2022. [DOI: 10.4103/ijot.ijot_20_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Left Ventricular Hypertrophy and Hypertrophic Cardiomyopathy in Adult Solid Organ Transplant Recipients. Transplant Direct 2021; 8:e1279. [PMID: 34912951 PMCID: PMC8670585 DOI: 10.1097/txd.0000000000001279] [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: 07/19/2021] [Revised: 11/03/2021] [Accepted: 11/21/2021] [Indexed: 11/26/2022] Open
Abstract
Background. Hypertrophic cardiomyopathy (HCM) in pediatric solid organ transplant recipients has been reported in association with use of calcineurin inhibitors. However, data on the incidence and prevalence of HCM in adult posttransplant patients are limited. We sought to describe the clinical characteristics of solid organ transplant recipients who were diagnosed with HCM from 2011 to 2021 at a single center. Methods. Patients who had undergone solid organ transplant and exhibited left ventricular hypertrophy with left ventricular wall thickness ≥13 mm on transthoracic echocardiography were included. Clinical history, pedigree analysis, clinical genetic testing, transthoracic echocardiography, cardiac magnetic resonance imaging, treatment, and follow-up testing results were collected. Categorical variables were described as n (%). Continuous variables were described with medians and interquartile ranges and compared using the Wilcoxon rank-sum and Kruskal-Wallis tests. A 2-sided P < 0.05 was considered statistically significant. Results. Three lung, 5 kidney, and 4 liver transplant recipients from 12 different families were included. Seven patients (58%) did not carry a preexisting diagnosis of hypertension, and none had a history of aortic or subaortic stenosis. A majority of patients exhibited asymmetric septal hypertrophy (67%; medial septal thickness versus left ventricular posterior wall thickness 17 versus 13 mm; P < 0.001) and dynamic left ventricular outflow tract (LVOT) obstruction (58%). All patients were managed long term with calcineurin inhibitors. Clinical genetic testing in 6 patients identified 2 with disease-causing variants in 2 sarcomere genes, myosin binding protein-C and myosin heavy chain 7. Four patients (33%) underwent successful septal reduction therapy for treatment of symptomatic LVOT obstruction. Conclusions. Symptomatic HCM with dynamic LVOT obstruction can develop in solid organ transplant recipients, and genetic testing can identify individuals with sarcomeric HCM. Medical management and septal reduction therapies are treatment options for severe symptomatic disease.
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Kanazawa K, Iwai-Takano M, Kimura S, Ohira T. Blood concentration of tacrolimus and age predict tacrolimus-induced left ventricular dysfunction after bone marrow transplantation in adults. J Med Ultrason (2001) 2019; 47:97-105. [PMID: 31792638 DOI: 10.1007/s10396-019-00990-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 11/11/2019] [Indexed: 01/11/2023]
Abstract
PURPOSE Tacrolimus (TAC) is used for the prophylaxis and treatment of acute graft-versus-host disease after bone marrow transplantation (BMT). However, few have reported on TAC-induced left ventricular hypertrophy. This study aimed to assess the relationship between blood concentration of TAC and development of TAC-induced left ventricular (TI-LV) dysfunction in adult BMT patients with hematologic malignant diseases, and to evaluate whether TAC concentration can predict TI-LV dysfunction occurrence in these patients. METHODS We enrolled 16 consecutive patients (mean age 44.6 ± 13.0 years) who received TAC after BMT. Echocardiography was performed before and after BMT, and blood concentrations of TAC were evaluated in terms of AUC15 (area sum of TAC > 15 ng/ml during follow-up). We assessed the relationship between AUC15 and development of TI-LV dysfunction after TAC. RESULTS During the follow-up period (mean duration 47.6 ± 13.7 days), interventricular septum thickness (IVST, P = 0.001) and posterior wall thickness (PWT, P < 0.001) increased, and E' decreased (P = 0.006). AUC15 was associated with post-IVST (R = 0.627, P = 0.009), post-PWT (R = 0.669, P = 0.005), and post-E' (R = - 0.767, P = 0.001). In multivariate analysis, AUC15 and age independently predicted the increase in IVST and PWT and decrease in E' after BMT. The combination of AUC15 and older age predicted post-PWT with a sensitivity of 77.8% and specificity of 71.4%. CONCLUSION TAC concentrations should be maintained at < 15 ng/ml and age should be considered in patients undergoing BMT to avoid TI-LV dysfunction.
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Affiliation(s)
- Kohko Kanazawa
- Division of Cardiology, Ohta Nishinouchi Hospital, 2-5-20, Nishinouchi, Koriyama, 963-8022, Japan.
| | - Masumi Iwai-Takano
- Department of Epidemiology, Fukushima Medical University, Fukushima, Japan
- Fukushima Prefectural General Hygiene Institute, Fukushima, Japan
- Division of Cardiovascular Surgery, Fukushima Medical University, Fukushima, Japan
| | - Satoru Kimura
- Division of Hematology, Ohta Nishinouchi Hospital, Koriyama, Japan
| | - Tetsuya Ohira
- Department of Epidemiology, Fukushima Medical University, Fukushima, Japan
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Bowman LJ, Brennan DC, Delos-Santos R, LaRue SJ, Anwar S, Klein CL. Tacrolimus-Induced Cardiomyopathy in an Adult Renal Transplant Recipient. Pharmacotherapy 2015; 35:1109-16. [PMID: 26616582 DOI: 10.1002/phar.1666] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Tacrolimus-induced cardiomyopathy (TICM) is a rare but serious adverse effect of tacrolimus, which has been described primarily in pediatric non-renal transplant recipients. We describe a case of TICM in an adult renal transplant recipient that resulted in allograft dysfunction and multiple hospital admissions for heart failure exacerbation. Prompt and complete reversal of TICM occurred after tacrolimus discontinuation. Although tacrolimus-induced cardiomyopathy is reversible, availability of alternative immunosuppressants is limited, particularly in the setting of renal dysfunction. Available studies and patient-specific factors must be considered when determining an alternative maintenance immunosuppression regimen. We chose to use belatacept as alternative immunosuppression in this patient with TICM. Over the next 3 years, the patient remained free of hospital admissions and acute rejection, and demonstrated superior renal allograft function than was observed before her first heart failure admission. We believe that belatacept is an acceptable alternative to tacrolimus therapy for resolution of TICM.
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Affiliation(s)
- Lyndsey J Bowman
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Daniel C Brennan
- Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Rowena Delos-Santos
- Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Shane J LaRue
- Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Siddiq Anwar
- Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Christina L Klein
- Department of Medicine, Piedmont Transplant Institute, Atlanta, Georgia
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Al-Harbi NO, Imam F, Nadeem A, Al-Harbi MM, Iqbal M, Rahman S, Al-Hosaini KA, Bahashwan S. Protection against tacrolimus-induced cardiotoxicity in rats by olmesartan and aliskiren. Toxicol Mech Methods 2014; 24:697-702. [DOI: 10.3109/15376516.2014.963773] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Gibson PH, Khandekar SA, Taylor D, Becher H. Hypertrophic cardiomyopathy with intermittent free mitral regurgitation-a surgical dilemma. Echocardiography 2014; 31:E107-10. [PMID: 24446781 DOI: 10.1111/echo.12519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
We describe the case of a 52-year-old woman presenting with non-ST elevation myocardial infarction, atrial fibrillation, and a new diagnosis of hypertrophic cardiomyopathy. Transesophageal echocardiography following hemodynamic deterioration revealed completely restricted mitral leaflet motion with free mitral regurgitation, and severe left ventricular outflow tract (LVOT) obstruction. Surgical intervention was considered; however, repeat imaging following a period of clinical stability revealed resolution of the findings suggesting a transient ischemic etiology. The case is supported by clinical and echocardiographic images with movie clips, and a discussion of the likely pathology in the context of the underlying condition.
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Amyloid Fibril Composition as a Predictor of Development of Cardiomyopathy After Liver Transplantation for Hereditary Transthyretin Amyloidosis. Transplantation 2012; 93:1017-23. [PMID: 22395298 DOI: 10.1097/tp.0b013e31824b3749] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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ACE inhibitors and persistent left ventricular hypertrophy after renal transplantation: a randomized clinical trial. Am J Kidney Dis 2007; 50:133-42. [PMID: 17591533 DOI: 10.1053/j.ajkd.2007.04.013] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2006] [Accepted: 04/13/2007] [Indexed: 12/13/2022]
Abstract
BACKGROUND Interventional studies of left ventricular hypertrophy (LVH) in renal transplant recipients are scarce and to date evaluated only patients immediately after renal transplantation. STUDY DESIGN Randomized controlled trial that assessed the effectiveness of angiotensin-converting enzyme (ACE) inhibitors in regressing persistent LVH after successful transplantation. SETTING & PARTICIPANTS 70 renal transplant recipients (47 men; age, 30 to 68 years) without diabetes previously randomly assigned to either cyclosporine or tacrolimus therapy, with LVH persisting 3 to 6 months after transplantation. INTERVENTION Subjects were randomly assigned to either lisinopril (ACE-inhibitor group; 36 patients) or no therapy (control group; 34 subjects). OUTCOMES Main outcome was change in left ventricular mass index (LVMi) at month 18. RESULTS A consistent decrease in both systolic (SBP) and diastolic blood pressure (DBP) was observed in both groups (between-group differences, -1.7 +/- 3.3 mm Hg; 95% confidence interval [CI], -4.8 to 8.2; P = 0.6 for SBP; 0.3 +/- 2.2 mm Hg; 95% CI, -4.8 to 4.1; P = 0.9 for DBP), whereas LVMi regressed more in the ACE-inhibitor group (between-group difference, 10.1 +/- 16.3 g/m(2.7); 95% CI, 4.2 to 16.1; P < 0.01). A significant interaction of ACE inhibitors with cyclosporine in affecting LVMi change was shown by means of post hoc multiple regression analysis (P < 0.01; differences between cyclosporine and tacrolimus group, 13.3 +/- 3.9 g/m(2.7); 95% CI, 5.3 to 21.2; P < 0.01 in the ACE-inhibitor group; 3.7 +/- 4.2 g/m(2.7); 95% CI, -4.7 to 12.2; P = 0.4 in the control group). LIMITATIONS Single-center study with small sample size. Interaction of ACE inhibitors with cyclosporine treatment emerged from post hoc analysis. CONCLUSION A prolonged course of ACE-inhibitor therapy is effective in regressing the persistent LVH of renal transplant recipients by mechanisms independent of effects on BP. This regression seems to be at least in part the effect of an interaction between ACE inhibitors and cyclosporine.
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Turska-Kmieć A, Jankowska I, Pawłowska J, Kaliciński P, Kawalec W, Tomyn M, Markiewicz M, Teisseyre J, Czubkowski P, Rekawek J, Socha J. Reversal of tacrolimus-related hypertrophic cardiomyopathy after conversion to rapamycin in a pediatric liver transplant recipient. Pediatr Transplant 2007; 11:319-23. [PMID: 17430490 DOI: 10.1111/j.1399-3046.2006.00633.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Tacrolimus (Tac)-related hypertrophic cardiomyopathy (HCM) has been reported to be an unusual but serious complication affecting pediatric patients after solid organ transplantation. Herein, we present a case of young liver transplant recipient with Tac-induced HCM, treated by discontinuation of Tac followed by conversion to rapamycin (Rap). Our case report points out the potential but rather low risk of HCM during Tac immunosuppression in pediatric liver transplants and demonstrates that replacement of calcineurin inhibitors with mammalian target of Rap (mTOR) inhibitors may be an efficacious therapeutic tool to effect regression of established cardiac hypertrophy.
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Affiliation(s)
- Anna Turska-Kmieć
- Department of Cardiology, The Children's Memorial Health Institute, Warsaw, Poland.
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Peura JL, Zile MR, Feldman DS, VanBakel AB, McClure C, Uber W, Haynes H, Pereira NL. Effects of Conversion from Cyclosporine to Tacrolimus on Left Ventricular Structure in Cardiac Allograft Recipients. J Heart Lung Transplant 2005; 24:1969-72. [PMID: 16297806 DOI: 10.1016/j.healun.2005.02.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2004] [Revised: 01/17/2005] [Accepted: 02/08/2005] [Indexed: 11/26/2022] Open
Abstract
Twelve heart transplant recipients selected for conversion from cyclosporine to tacrolimus because of adverse effects of cyclosporine therapy underwent echocardiography at baseline and 6 months after conversion. Left ventricular mass decreased by 24% and left ventricular geometry returned toward normal at 6 months after conversion, without significant changes in blood pressure.
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Affiliation(s)
- Jennifer L Peura
- Division of Cardiology, Department of Internal Medicine, Medical University of South Carolina, Gazes Cardiac Research Institute, Charleston 29425, USA
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Jarzembowski TM, John E, Panaro F, Manzelli A, Cabrera A, Greco A, Varga P, Sankary H, Testa G, Benedetti E. Reversal of tacrolimus-related hypertrophic obstructive cardiomyopathy 5 years after kidney transplant in a 6-year-old recipient. Pediatr Transplant 2005; 9:117-21. [PMID: 15667624 DOI: 10.1111/j.1399-3046.2005.00260.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Hypertrophic obstructive cardiomyopathy (HOCM) is an unusual but serious side-effect of tacrolimus (TAC) based immunosuppression primarily affecting pediatric patients after solid organ transplant. TAC-induced HOCM has already been described in patients after liver, bowel and heart transplant shortly after the procedure. Herein, we present the first case report of TAC-induced HOCM in a young renal transplant recipient 5 yr after renal transplant. The condition was diagnosed by ECHO and EKG and successfully treated by discontinuation of TAC followed by conversion to cyclosporine (CsA).
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Affiliation(s)
- Tomasz M Jarzembowski
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, IL 60612, USA
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Abstract
This article briefly discusses the cardiac status of liver transplant recipients and their preoperative cardiac evaluation. It describes in detail perioperative and early and late postoperative complications as well as the cardiac problems associated with immunosuppression. The preoperative cardiovascular status of patients is important in determining how they cope with the stresses imposed by liver transplantation. Minor early cardiac events are common and may influence longer term cardiac morbidity. Immunosuppressive therapy may have short term effects but is likely to adversely affect long term cardiac risk.
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Scott LJ, McKeage K, Keam SJ, Plosker GL. Tacrolimus: a further update of its use in the management of organ transplantation. Drugs 2003; 63:1247-97. [PMID: 12790696 DOI: 10.2165/00003495-200363120-00006] [Citation(s) in RCA: 309] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
UNLABELLED Extensive clinical use has confirmed that tacrolimus (Prograf) is a key option for immunosuppression after transplantation. In large, prospective, randomised, multicentre trials in adults and children receiving solid organ transplants, tacrolimus was at least as effective or provided better efficacy than cyclosporin microemulsion in terms of patient and graft survival, treatment failure rates and the incidence of biopsy-proven acute and corticosteroid-resistant rejection episodes. Notably, the lower incidence of rejection episodes after renal transplantation in tacrolimus recipients was reflected in improved cost effectiveness. In bone marrow transplant (BMT) recipients, the incidence of tacrolimus grade II-IV graft-versus-host disease was significantly lower with tacrolimus than cyclosporin treatment. Efficacy was maintained in renal and liver transplant recipients after total withdrawal of corticosteroid therapy from tacrolimus-based immunosuppression, with the incidence of acute rejection episodes at up to 2 years' follow-up being similar with or without corticosteroids. Tacrolimus provided effective rescue therapy in transplant recipients with persistent acute or chronic allograft rejection or drug-related toxicity associated with cyclosporin treatment. Typically, conversion to tacrolimus reversed rejection episodes and/or improved the tolerability profile, particularly in terms of reduced hyperlipidaemia. In lung transplant recipients with obliterative bronchiolitis, conversion to tacrolimus reduced the decline in and/or improved lung function in terms of forced expiratory volume in 1 second. Tolerability issues may be a factor when choosing a calcineurin inhibitor. Cyclosporin tends to be associated with a higher incidence of significant hypertension, hyperlipidaemia, hirsutism, gingivitis and gum hyperplasia, whereas the incidence of some types of neurotoxicity, disturbances in glucose metabolism, diarrhoea, pruritus and alopecia may be higher with tacrolimus treatment. Renal function, as assessed by serum creatinine levels and glomerular filtration rates, was better in tacrolimus than cyclosporin recipients at up to 5 years' follow-up. CONCLUSION Recent well designed trials have consolidated the place of tacrolimus as an important choice for primary immunosuppression in solid organ transplantation and in BMT. Notably, in adults and children receiving transplants, tacrolimus-based primary immunosuppression was at least as effective or provided better efficacy than cyclosporin microemulsion treatment in terms of patient and graft survival, treatment failure and the incidence of acute and corticosteroid-resistant rejection episodes. The reduced incidence of rejection episodes in renal transplant recipients receiving tacrolimus translated into a better cost effectiveness relative to cyclosporin microemulsion treatment. The optimal immunosuppression regimen is ultimately dependent on balancing such factors as the efficacy of the individual drugs, their tolerability, potential for drug interactions and pharmacoeconomic issues.
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Romero Tarín E, Martín Fernández M, Simarro García C, Brime Casanueva JI. [Cardiac hypertrophy in kidney transplanted female patient treated with tacrolimus]. Med Clin (Barc) 2002; 119:715. [PMID: 12459112 DOI: 10.1016/s0025-7753(02)73548-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Current awareness in pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2002; 11:169-74. [PMID: 12004884 DOI: 10.1002/pds.658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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