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Ozeki M, Endo S, Yasue S, Nozawa A, Asada R, Saito AM, Hashimoto H, Fujimura T, Yamada Y, Kuroda T, Ueno S, Watanabe S, Nosaka S, Miyasaka M, Umezawa A, Matsuoka K, Maekawa T, Hirakawa S, Furukawa T, Fumino S, Tajiri T, Takemoto J, Souzaki R, Kinoshita Y, Fujino A. Sirolimus treatment for intractable lymphatic anomalies: an open-label, single-arm, multicenter, prospective trial. Front Med (Lausanne) 2024; 11:1335469. [PMID: 38390569 PMCID: PMC10881825 DOI: 10.3389/fmed.2024.1335469] [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: 11/09/2023] [Accepted: 01/23/2024] [Indexed: 02/24/2024] Open
Abstract
Introduction Intractable lymphatic anomalies (LAs) include cystic lymphatic malformation (LM; macrocystic, microcystic, or mixed), generalized lymphatic anomaly, and Gorham-Stout disease. LAs can present with severe symptoms and poor prognosis. Thus, prospective studies for treatments are warranted. We conducted a prospective clinical trial of sirolimus for intractable LAs. Methods This was an open-label, single-arm, multicenter, prospective trial involving five institutions in Japan. All patients with LAs received oral sirolimus once daily, and the dose was adjusted to ensure that the trough concentration remained within 5-15 ng/mL. We prospectively assessed the drug response (response rate for radiological volumetric change in target lesion), performance state, change in respiratory function, visceral impairment (pleural effusion, ascites, bleeding, pain), laboratory examination data, quality of life (QOL), and safety at 12, 24, and 52 weeks of administration. Results Eleven patients with LAs (9 generalized lymphatic anomaly, 1 cystic LM, 1 Gorham-Stout disease) were treated with sirolimus, of whom 6 (54.5%; 95% confidence interval: 23.4-83.3%) demonstrated a partial response on radiological examination at 52 weeks of administration. No patients achieved a complete response. At 12 and 24 weeks of administration, 8 patients (72.7%) already showed a partial response. However, patients with stable disease showed minor or no reduction after 12 weeks. Adverse events, such as stomatitis, acneiform dermatitis, diarrhea, and fever, were common with sirolimus. Sirolimus was safe and tolerable. Conclusion Sirolimus can reduce the lymphatic tissue volume in LAs and may lead to improvements in clinical symptoms and QOL.
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Affiliation(s)
- Michio Ozeki
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
- Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Saori Endo
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Shiho Yasue
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Akifumi Nozawa
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Ryuta Asada
- Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
- Innovative and Clinical Research Promotion Center, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Akiko M Saito
- Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Hiroya Hashimoto
- Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
- Core Laboratory, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Takumi Fujimura
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yohei Yamada
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Tatsuo Kuroda
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Shigeru Ueno
- Department of Pediatric Surgery, Tokai University School of Medicine, Hiratsuka, Japan
| | - Shoji Watanabe
- Department of Plastic Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Shunsuke Nosaka
- Department of Radiology, National Center for Child Health and Development, Tokyo, Japan
| | - Mikiko Miyasaka
- Department of Radiology, National Center for Child Health and Development, Tokyo, Japan
| | - Akihiro Umezawa
- National Center for Child Health and Development, Research Institute, Tokyo, Japan
| | - Kentaro Matsuoka
- Department of Pathology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Takanobu Maekawa
- Department of General Pediatrics and Interdisciplinary Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Satoshi Hirakawa
- Department of Dermatology, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Taizo Furukawa
- Department of Pediatric Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Shigehisa Fumino
- Department of Pediatric Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tatsuro Tajiri
- Department of Pediatric Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
- Department of Pediatric Surgery, Developmental Surgery and Intestinal Transplant Surgery, Kyushu University Hospital, Fukuoka, Japan
| | - Junkichi Takemoto
- Department of Pediatric Surgery, Developmental Surgery and Intestinal Transplant Surgery, Kyushu University Hospital, Fukuoka, Japan
| | - Ryota Souzaki
- Department of Pediatric Surgery, Developmental Surgery and Intestinal Transplant Surgery, Kyushu University Hospital, Fukuoka, Japan
| | - Yoshiaki Kinoshita
- Department of Pediatric Surgery, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Akihiro Fujino
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
- Division of Surgery, Department of Surgical Subspecialties, National Center for Child Health and Development, Tokyo, Japan
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Zhang Y, Quan Y, Wang D, Cassady K, Zou W, Xiong J, Yao H, Deng X, Wang P, Yang S, Zhang X, Feng Y. Optimizing the therapeutic window of sirolimus by monitoring blood concentration for the treatment of immune thrombocytopenia. Platelets 2023; 34:2277831. [PMID: 38050853 DOI: 10.1080/09537104.2023.2277831] [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: 08/15/2023] [Accepted: 10/26/2023] [Indexed: 12/07/2023]
Abstract
Previous studies have demonstrated that sirolimus (SRL) is an effective agent for the treatment of refractory/relapsed (R/R) ITP. However, the therapeutic window of sirolimus in the treatment of ITP has not been established. As the toxicity of sirolimus increases with higher blood concentrations, it is crucial to determine the optimal therapeutic concentration of SRL for the treatment of ITP. Thus, in this study, we used a retrospective cohort of ITP patients treated with sirolimus to propose the therapeutic dosage window for sirolimus. A total of 275 laboratory results of SRL blood concentration from 63 ITP patients treated with SRL were analyzed retrospectively. The ITP patients were divided into five groups based on their SRL blood concentration: 0-4 ng/ml, 4-8 ng/ml, 8-12 ng/ml, 12-16 ng/ml and ≥16 ng/ml. In addition to the SRL blood concentration, platelet counts and adverse events that occurred during the first 6 weeks of SRL treatment were analyzed. These findings were then used to establish the decision matrix tables and ROC curves, which helped identify the therapeutic window of SRL. Based on the values and trends of true-positive rate (TPR) and false-positive rate (FPR) in the ROC curve, patients who achieved a SRL blood concentration of 4-12 ng/ml displayed a higher response rate compared to those with a SRL concentration of 0-4 ng/ml or ≥16ng/ml. Additionally, the response rate was better for patients with a SRL concentration of 8-12 ng/ml compared to 4-8 ng/ml. Adverse events were related to the concentration of SRL; however, there was no significant difference in the incidence of adverse events between the concentrations of 4-8 ng/ml and 8-12 ng/ml (P > .05). Regression analysis suggested that the concentration of SRL correlated with the patient's age, PLT count at the start of SRL administration, and the dose of SRL. It is suggested that the optimal blood concentration of SRL monotherapy for managing ITP is 8-12 ng/ml. This range may achieve a favorable balance between clinical efficacy and the severity of adverse events.
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Affiliation(s)
- Yun Zhang
- Medical Center of Hematology, The Xinqiao Hospital of Army Medical University, Chongqing, China
- Department of Clinical Laboratory, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Yao Quan
- Medical Center of Hematology, The Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Dan Wang
- Medical Center of Hematology, The Xinqiao Hospital of Army Medical University, Chongqing, China
- Department of Hematology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | | | - Wenhang Zou
- Department of Infectious Disease, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Jingkang Xiong
- Medical Center of Hematology, The Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Han Yao
- Medical Center of Hematology, The Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Xiaojuan Deng
- Medical Center of Hematology, The Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Ping Wang
- Medical Center of Hematology, The Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Shijie Yang
- Medical Center of Hematology, The Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Xi Zhang
- Medical Center of Hematology, The Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Yimei Feng
- Medical Center of Hematology, The Xinqiao Hospital of Army Medical University, Chongqing, China
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Yenebere P, Doraiswamy M, Gundroo A. Overview of pregnancy in solid-organ transplantation. Curr Opin Organ Transplant 2023; 28:271-278. [PMID: 37219085 DOI: 10.1097/mot.0000000000001075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
PURPOSE OF REVIEW Pregnancy in solid organ transplantation (SOT) is a very complex part of transplant medicine wherein there is scarce information available in the literature. Solid organ transplant recipients often have comorbidities, such as hypertension and diabetes, which add additional risk to a pregnancy. RECENT FINDINGS We present this review article on the various aspects of different types of immunosuppressant medications used in pregnancy with added inputs on contraception and fertility after transplant. We described the antepartum and postpartum considerations and discussed the adverse effects of the immunosuppressive medications. Maternal and fetal complications of each SOT have been also discussed in this article. SUMMARY This article will serve as the primary review articles for the use of immunosuppressive medications during pregnancy with consideration during pregnancy after SOT.
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Affiliation(s)
- Priya Yenebere
- Transplant Nephrology, Department of Internal Medicine, Indiana University, Indianapolis, Indiana
| | - Mohankumar Doraiswamy
- Nephrology - Critical Care, Department of Internal Medicine, Mercy Hospital, Fort Smith, Arkansas
| | - Aijaz Gundroo
- Transplant Nephrology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Reynolds AC, McKenzie LJ. Cancer Treatment-Related Ovarian Dysfunction in Women of Childbearing Potential: Management and Fertility Preservation Options. J Clin Oncol 2023; 41:2281-2292. [PMID: 36888938 PMCID: PMC10115556 DOI: 10.1200/jco.22.01885] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 12/22/2022] [Accepted: 01/24/2023] [Indexed: 03/10/2023] Open
Abstract
PURPOSE To review the complex concerns of oncofertility created through increased cancer survivorship and the long-term effects of cancer treatment in young adults. DESIGN Review chemotherapy-induced ovarian dysfunction, outline how fertility may be addressed before treatment initiation, and discuss barriers to oncofertility treatment and guidelines for oncologists to provide this care to their patients. CONCLUSION In women of childbearing potential, ovarian dysfunction resulting from cancer therapy has profound short- and long-term implications. Ovarian dysfunction can manifest as menstrual abnormalities, hot flashes, night sweats, impaired fertility, and in the long term, increased cardiovascular risk, bone mineral density loss, and cognitive deficits. The risk of ovarian dysfunction varies between drug classes, number of received lines of therapy, chemotherapy dosage, patient age, and baseline fertility status. Currently, there is no standard clinical practice to evaluate patients for their risk of developing ovarian dysfunction with systemic therapy or means to address hormonal fluctuations during treatment. This review provides a clinical guide to obtain a baseline fertility assessment and facilitate fertility preservation discussions.
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Affiliation(s)
| | - Laurie J. McKenzie
- Baylor College of Medicine Houston, Houston, TX
- The University of Texas MD Anderson Cancer Center, Houston, TX
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Tartarin P, Keller M, Guibert E, Trives E, Bourdon G, Chamero P, Negre D, Cornilleau F, Guillory V, JeanPierre E, Costa C, Migrenne S, Dupont J, Froment P. Knockdown of regulatory associated protein of TOR (raptor) in hypothalamus-stimulated folliculogenesis and induced ovarian cysts. Reprod Fertil Dev 2023; 35:307-320. [PMID: 36593258 DOI: 10.1071/rd21260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 11/24/2022] [Indexed: 01/04/2023] Open
Abstract
CONTEXT Mammalian target of rapamycin complex 1 (mTORC1) is an essential sensor that regulates fundamental biological processes like cell growth, proliferation and energy metabolism. The treatment of disease by sirolimus, a mTORC1 inhibitor, causes adverse effects, such as female fertility disorders. AIMS The objective of the study was to decipher the reproductive consequences of a downregulation of mTORC1 in the hypothalamus. METHODS The reduced expression of mTORC1 was induced after intracerebroventricular injection of lentivirus expressing a short hairpin RNA (shRNA) against regulatory associated protein of TOR (raptor) in adult female mice (ShRaptor mice). KEY RESULTS The ShRaptor mice were fertile and exhibited a 15% increase in the litter size compared with control mice. The histological analysis showed an increase in antral, preovulatory follicles and ovarian cysts. In the hypothalamus, the GnRH mRNA and FSH levels in ShRaptor mice were significantly elevated. CONCLUSIONS These results support the hypothesis that mTORC1 in the central nervous system participates in the regulation of female fertility and ovarian function by influencing the GnRH neuronal activity. IMPLICATIONS These results suggest that a lower mTORC1 activity directly the central nervous system leads to a deregulation in the oestrous cycle and an induction of ovarian cyst development.
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Affiliation(s)
- Pauline Tartarin
- CNRS, IFCE, INRAE, Université de Tours, PRC, Nouzilly F-37380, France
| | - Matthieu Keller
- CNRS, IFCE, INRAE, Université de Tours, PRC, Nouzilly F-37380, France
| | - Edith Guibert
- CNRS, IFCE, INRAE, Université de Tours, PRC, Nouzilly F-37380, France
| | - Elliott Trives
- CNRS, IFCE, INRAE, Université de Tours, PRC, Nouzilly F-37380, France
| | - Guillaume Bourdon
- CNRS, IFCE, INRAE, Université de Tours, PRC, Nouzilly F-37380, France
| | - Pablo Chamero
- CNRS, IFCE, INRAE, Université de Tours, PRC, Nouzilly F-37380, France
| | - Didier Negre
- Université de Lyon, IFR 128, INSERM-U758, Ecole Normale Supérieure de Lyon, Lyon F-69007, France
| | - Fabien Cornilleau
- CNRS, IFCE, INRAE, Université de Tours, PRC, Nouzilly F-37380, France
| | - Vanaique Guillory
- INRA ISP, Université François Rabelais de Tours, UMR 1282, Nouzilly, France
| | - Eric JeanPierre
- CNRS, IFCE, INRAE, Université de Tours, PRC, Nouzilly F-37380, France
| | - Caroline Costa
- Université de Lyon, IFR 128, INSERM-U758, Ecole Normale Supérieure de Lyon, Lyon F-69007, France
| | - Stéphanie Migrenne
- University Paris Diderot-Paris 7-Unit of Functional and Adaptive Biology (BFA) EAC 7059 CNRS, Paris, France
| | - Joelle Dupont
- CNRS, IFCE, INRAE, Université de Tours, PRC, Nouzilly F-37380, France
| | - Pascal Froment
- CNRS, IFCE, INRAE, Université de Tours, PRC, Nouzilly F-37380, France
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Mowrey K, Northrup H, Hashmi SS, Rodriguez-Buritica D. Expanding Our Knowledge of Menstrual Irregularities Reported by Females With Tuberous Sclerosis Complex. FRONTIERS IN REPRODUCTIVE HEALTH 2022; 4:798983. [DOI: 10.3389/frph.2022.798983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 01/25/2022] [Indexed: 11/13/2022] Open
Abstract
PurposeThe purpose of our study is to expand the knowledge regarding intrinsic reproductive dysfunction in females with TSC and to explore the impact of mTOR inhibitors (mTORi) on menstrual irregularity in the Tuberous Sclerosis Complex (TSC) community.MethodsAn electronic survey composed of author-designed questions set out to evaluate reproductive history, presence of menstrual irregularities, mTORi use, as well as maternal reproductive history among females with TSC.ResultsOf the 68 responses from females with TSC regarding age of menarche, the average age was 12.3 years. 56.5% (n = 48) of respondents reported irregular menstrual cycles and noted a total of 102 menstrual irregularities. There was a cohort of 35 women with a reported history of mTORi use. Of these women, 68.6% (n = 24) reported irregular menstrual cycles after taking mTORi. In comparison, among the females with no history of mTORi use (n = 50) only 48% reported irregular menstrual cycles (n = 24).ConclusionsOur data expands the knowledge regarding intrinsic menstrual dysregulation present in women with TSC, demonstrates a rate of menstrual irregularities among females taking mTORi, and identifies a tendency toward early menarche that may be a previously unrecognized feature of TSC.
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Pagliarini R, Podrini C. Metabolic Reprogramming and Reconstruction: Integration of Experimental and Computational Studies to Set the Path Forward in ADPKD. Front Med (Lausanne) 2021; 8:740087. [PMID: 34901057 PMCID: PMC8652061 DOI: 10.3389/fmed.2021.740087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 10/25/2021] [Indexed: 12/17/2022] Open
Abstract
Metabolic reprogramming is a key feature of Autosomal Dominant Polycystic Kidney Disease (ADPKD) characterized by changes in cellular pathways occurring in response to the pathological cell conditions. In ADPKD, a broad range of dysregulated pathways have been found. The studies supporting alterations in cell metabolism have shown that the metabolic preference for abnormal cystic growth is to utilize aerobic glycolysis, increasing glutamine uptake and reducing oxidative phosphorylation, consequently resulting in ADPKD cells shifting their energy to alternative energetic pathways. The mechanism behind the role of the polycystin proteins and how it leads to disease remains unclear, despite the identification of numerous signaling pathways. The integration of computational data analysis that accompanies experimental findings was pivotal in the identification of metabolic reprogramming in ADPKD. Here, we summarize the important results and argue that their exploitation may give further insights into the regulative mechanisms driving metabolic reprogramming in ADPKD. The aim of this review is to provide a comprehensive overview on metabolic focused studies and potential targets for treatment, and to propose that computational approaches could be instrumental in advancing this field of research.
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Affiliation(s)
- Roberto Pagliarini
- Molecular Basis of Cystic Kidney Disorders Unit, Division of Genetics and Cell Biology, IRCCS-San Raffaele Scientific Institute, Milan, Italy
| | - Christine Podrini
- Molecular Basis of Cystic Kidney Disorders Unit, Division of Genetics and Cell Biology, IRCCS-San Raffaele Scientific Institute, Milan, Italy
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Updated International Tuberous Sclerosis Complex Diagnostic Criteria and Surveillance and Management Recommendations. Pediatr Neurol 2021; 123:50-66. [PMID: 34399110 DOI: 10.1016/j.pediatrneurol.2021.07.011] [Citation(s) in RCA: 234] [Impact Index Per Article: 78.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 07/20/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND Tuberous sclerosis complex (TSC) is an autosomal dominant genetic disease affecting multiple body systems with wide variability in presentation. In 2013, Pediatric Neurology published articles outlining updated diagnostic criteria and recommendations for surveillance and management of disease manifestations. Advances in knowledge and approvals of new therapies necessitated a revision of those criteria and recommendations. METHODS Chairs and working group cochairs from the 2012 International TSC Consensus Group were invited to meet face-to-face over two days at the 2018 World TSC Conference on July 25 and 26 in Dallas, TX, USA. Before the meeting, working group cochairs worked with group members via e-mail and telephone to (1) review TSC literature since the 2013 publication, (2) confirm or amend prior recommendations, and (3) provide new recommendations as required. RESULTS Only two changes were made to clinical diagnostic criteria reported in 2013: "multiple cortical tubers and/or radial migration lines" replaced the more general term "cortical dysplasias," and sclerotic bone lesions were reinstated as a minor criterion. Genetic diagnostic criteria were reaffirmed, including highlighting recent findings that some individuals with TSC are genetically mosaic for variants in TSC1 or TSC2. Changes to surveillance and management criteria largely reflected increased emphasis on early screening for electroencephalographic abnormalities, enhanced surveillance and management of TSC-associated neuropsychiatric disorders, and new medication approvals. CONCLUSIONS Updated TSC diagnostic criteria and surveillance and management recommendations presented here should provide an improved framework for optimal care of those living with TSC and their families.
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Parazzini F, Gerli S, Favilli A, Vignali M, Ricci E, Cipriani S, Chiaffarino F, Dell'acqua A, Harari S, Bianchi S. mTOR inhibitors and risk of ovarian cysts: a systematic review and meta-analysis. BMJ Open 2021; 11:e048190. [PMID: 34561260 PMCID: PMC8475133 DOI: 10.1136/bmjopen-2020-048190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE To summarise the available evidence on frequency of ovarian cyst development during mammalian target of rapamycin inhibitors (mTORi) treatment. METHODS PubMed/Medline and EMBASE databases were searched, from 1990 up to March 2020, using the following keywords: 'tacrolimus', 'sirolimus', 'temsirolimus', 'everolimus', 'deforolimus', 'mTOR' and 'ovarian cysts' (Limit: Human, English, full article). Studies were selected for the review if they met the following criteria: clinical studies, studies reporting original data, studies reporting the number of patients using mTORi, studies reporting the number of patients with ovarian cysts.We selected 7 of 20 retrieved studies. Study design, population, sample size, criteria for diagnosis of ovarian cysts, drug doses and follow-up length were extracted. Pooled estimate of incidence was calculated for ovarian cysts as a percentage, with 95% CI. RESULTS Four hundred-six women were included in the selected studies. The pooled incidence was 37.0% (95% CI 16.0% to 58.1%) for all ovarian cysts, and 17.3% (95% CI 5.6% to 29.1%) for clinically significant ovarian cysts. Based on two articles, comparing mTORi and non-mTORi for immunosuppression, pooled OR for ovarian cyst incidence was 4.62 (95% CI 2.58 to 8.28). CONCLUSION Ovarian cyst development is a common adverse event during immunosuppression treatment with mTORi. These cysts are benign conditions, but they require pelvic ultrasound follow-up and in some cases hospital admission and surgery.
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Affiliation(s)
- Fabio Parazzini
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano Facoltà di Medicina e Chirurgia, Milano, Lombardia, Italy
| | - Sandro Gerli
- Department of Obstetrics and Gynecology, S.M. Della Misericordia Hospital, Perugia, Italy
| | - Alessandro Favilli
- Department of Obstetrics and Gynecology, S.M. Della Misericordia Hospital, Perugia, Italy
| | - Michele Vignali
- Department of Biomedical Sciences for Health, Università degli Studi di Milano Facoltà di Medicina e Chirurgia, Milano, Lombardia, Italy
| | - Elena Ricci
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano Facoltà di Medicina e Chirurgia, Milano, Lombardia, Italy
| | - Sonia Cipriani
- Gynaecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesca Chiaffarino
- Gynaecology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Dell'acqua
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano Facoltà di Medicina e Chirurgia, Milano, Lombardia, Italy
| | - Sergio Harari
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano Facoltà di Medicina e Chirurgia, Milano, Lombardia, Italy
| | - Stefano Bianchi
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano Facoltà di Medicina e Chirurgia, Milano, Lombardia, Italy
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Bussies PL, Richards EG, Rotz SJ, Falcone T. Targeted cancer treatment and fertility: effect of immunotherapy and small molecule inhibitors on female reproduction. Reprod Biomed Online 2021; 44:81-92. [PMID: 34674940 DOI: 10.1016/j.rbmo.2021.09.004] [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: 05/29/2021] [Revised: 08/04/2021] [Accepted: 09/06/2021] [Indexed: 12/15/2022]
Abstract
Targeted cancer therapy is rapidly evolving the landscape of personalized health care. Novel approaches to selectively impeding tumour growth carry significant potential to improve survival outcomes, particularly for reproductive-aged patients harbouring treatment refractory disease. Current agents fall within two classes: immunotherapy and small molecule inhibitors. These are collectively divided into the following subclasses: monoclonal antibodies; immunomodulators; adoptive cell therapy; treatment vaccines; kinase inhibitors; proteasome inhibitors; metalloproteinase and heat shock protein inhibitors; and promoters of apoptosis. The short- and long-term effects of these treatments on the female reproductive system are not well understood. As a result, clinicians are rendered unable to appropriately counsel women on downstream effects to their fertility. Data-driven consensus recommendations are desperately needed. This review aims to characterize the effect of targeted cancer therapy on the female hypothalamic-pituitary-ovary axis, direct ovarian function and conception.
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Affiliation(s)
- Parker L Bussies
- Cleveland Clinic FoundNation, Department of Obstetrics and Gynecology, Cleveland OH, USA
| | - Elliott G Richards
- Cleveland Clinic FoundNation, Department of Obstetrics and Gynecology, Cleveland OH, USA
| | - Seth J Rotz
- Cleveland Clinic Foundation, Department of Pediatric Hematology, Oncology and Blood and Marrow Transplantation, Cleveland OH, USA
| | - Tommaso Falcone
- Cleveland Clinic FoundNation, Department of Obstetrics and Gynecology, Cleveland OH, USA.
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Patients with Congenital Low-Flow Vascular Malformation Treated with Low Dose Sirolimus. Adv Ther 2021; 38:3465-3482. [PMID: 34003452 PMCID: PMC8190005 DOI: 10.1007/s12325-021-01758-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 04/22/2021] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Patients with congenital vascular malformations often suffer from an impaired quality of life (QoL) because of pain and functional disabilities. Previous studies have shown that the mTOR inhibitor sirolimus can reduce complaints and improve QoL in some patients. High target levels of sirolimus of 10-15 ng/ml were well tolerated; however, in a relative high percentage of patients sirolimus caused serious adverse events (AEs). METHODS A case series of 12 patients with therapy-resistant low-flow vascular malformations was treated with sirolimus, using low target levels of 4-10 ng/ml. Efficacy of sirolimus was evaluated in regard to pain symptoms using the visual analogue scale/numeric rating scale and patients reported QoL. To rule out a placebo effect of sirolimus, sirolimus was stopped after a certain time point and reintroduced as soon as complaints returned. Adverse events were closely monitored and graded using the Common Terminology Criteria for Adverse Events (CTCAE) grading. RESULTS An improvement in symptoms was seen in 92% (n = 11/12) of patients. In nine patients pain complaints returned. Seven out of nine of them (78%) again experienced a reduction of symptoms after restarting sirolimus treatment. Despite low target levels, these response rates are comparable to those found in the literature using higher target levels of sirolimus. However, significantly less serious AEs were observed with low dose sirolimus, suggesting low dose sirolimus might be safer. Unfortunately, young adolescent female patients developed serious menstrual disturbances during treatment with low dose sirolimus. We describe this adverse event for the first time in patients with congenital vascular malformations and this might be specifically related to low dose sirolimus. CONCLUSIONS Low dose sirolimus showed a high efficacy in patients with therapy-resistant and low-flow malformation, with a lower incidence of serious adverse events. At the same time a new adverse event, namely menstrual cycle disturbance, was observed in young adolescents, indicating the need for caution when sirolimus is given. This is extremely relevant to patients with low-flow vascular malformation, who are likely to require lifelong treatment for their condition.
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12
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Fertility and Pregnancy in End Stage Kidney Failure Patients and after Renal Transplantation: An Update. TRANSPLANTOLOGY 2021. [DOI: 10.3390/transplantology2020010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Sexual life and fertility are compromised in end stage kidney disease both in men and in women. Successful renal transplantation may rapidly recover fertility in the vast majority of patients. Pregnancy modifies anatomical and functional aspects in the kidney and represents a risk of sensitization that may cause acute rejection. Independently from the risks for the graft, pregnancy in kidney transplant may cause preeclampsia, gestational diabetes, preterm delivery, and low birth weight. The nephrologist has a fundamental role in correct counseling, in a correct evaluation of the mother conditions, and in establishing a correct time lapse between transplantation and conception. Additionally, careful attention must be given to the antirejection therapy, avoiding drugs that could be dangerous to the newborn. Due to the possibility of medical complications during pregnancy, a correct follow-up should be exerted. Even if pregnancy in transplant is considered a high risk one, several data and studies document that in the majority of patients, the long-term follow-up and outcomes for the graft may be similar to that of non-pregnant women.
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13
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Triana P, López-Gutierrez JC. Menstrual disorders associated with sirolimus treatment. Pediatr Blood Cancer 2021; 68:e28867. [PMID: 33369022 DOI: 10.1002/pbc.28867] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 12/04/2020] [Accepted: 12/07/2020] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Sirolimus has become a pillar in the treatment of vascular anomalies due to its inhibition of the mammalian target of rapamycin (mTOR). Adverse effects include metabolic and hematologic disorders among others, although menstrual disorders have not been well described. MATERIALS AND METHODS Retrospective review of patients with vascular anomalies on sirolimus treatment was performed. Patients presenting menstrual alterations were included. MAIN RESULTS One hundred and thirty-six patients with vascular anomalies on treatment with sirolimus were reviewed, finding seven women out of 74 (9.4%) who presented menstrual alterations attributable to the treatment. These seven patients presented with different vascular malformations and three showed pathogenic variants in phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit alpha (PIK3CA) in affected tissue. Partial response in six and stability in one patient was obtained after treatment, administered for an average of 27.5 months (6-48). Five patients have completed treatment and two patients continue on after 12 and 15 months, respectively. All patients reported regular menstrual cycles prior to sirolimus treatment. One patient presented with amenorrhea for 4 months after treatment initiation that later spontaneously resolved. The other six patients presented with hypermenorrhea, four of them associating metrorrhagia. Most patients presented with mild menstrual alterations, without needing dose reduction or withdrawal, although one discontinued sirolimus due to hypermenorrhea, metrorrhagia, and hematuria. After sirolimus withdrawal, regular menstrual cycles were restored in five patients. CONCLUSION Sirolimus treatment can produce menstrual disorders as adverse effects. Although mild and reversible upon dose reduction or cessation of treatment, patients and physicians should be aware on this potential side effect.
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Affiliation(s)
- Paloma Triana
- Vascular Anomalies Unit, Department of Pediatric Surgery, Children's Hospital La Paz, Madrid, Spain
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14
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Hatano T, Endo K, Tamari M. Efficacy and safety of low-dose everolimus treatment for renal angiomyolipoma associated with tuberous sclerosis complex. Int J Clin Oncol 2020; 26:163-168. [PMID: 32990779 DOI: 10.1007/s10147-020-01792-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 09/22/2020] [Indexed: 01/23/2023]
Abstract
BACKGROUND The aim of this study was to evaluate the safety and efficacy of low-dose everolimus treatment in patients with tuberous sclerosis complex (TSC)-associated angiomyolipoma (AML) with renal dysfunction or low body weight. METHODS We investigated a total of 50 adult patients underwent everolimus treatment for AML associated with TSC. For patients with renal dysfunction (serum creatinine level ≥ 1.5 mg/dl) or low body weight (body weight < 35 kg), 5 mg of everolimus was administered daily (low-dose group). For patients without renal dysfunction or low body weight, 10 mg of everolimus was administered daily (conventional-dose group). The treatment effects and adverse events were compared between the two groups. RESULTS There were 20 patients in the low-dose group, and 30 in the conventional-dose group. The average reduction rate of the AML volume in the low-dose group was 52%, whereas it was 60% in the conventional-dose group. No significant differences were found in the average reduction rate between the groups (P = 0.24). The average blood everolimus trough levels were 7.7 ± 3.1 ng/mL in the low-dose group and 12.2 ± 5.7 ng/mL in the conventional-dose group. The level was significantly higher in the conventional-dose group than in the low-dose group (P = 0.004). The incidences of stomatitis and irregular menstruation were significantly lower in the low-dose group than in the conventional-dose group (P = 0.009, P = 0.045, respectively). CONCLUSIONS The present study demonstrates that low-dose everolimus treatment is safe and effective for TSC-associated AML. This treatment was well tolerated and adverse events were mild in all cases.
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Affiliation(s)
- Takashi Hatano
- Department of Urology, Seirei Yokohama Hospital, Kanagawa, Japan.
- Department of Urology, JR Tokyo General Hospital, 2-1-3 Yoyogi Shibuya-ku, Tokyo, 151-8528, Japan.
| | - Katsuhisa Endo
- Department of Urology, JR Tokyo General Hospital, 2-1-3 Yoyogi Shibuya-ku, Tokyo, 151-8528, Japan
| | - Mayumi Tamari
- Research Center for Medical Science, Division of Molecular Genetics, The Jikei University School of Medicine, Tokyo, Japan
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Santos de Oliveira FL, Vieira Carletti J, Azevedo FFN, Freitas de Sousa FJ, Caetano EWS, Freire VN, Zanatta G. mTOR–mLST8 interaction: hot spot identification through quantum biochemistry calculations. NEW J CHEM 2020. [DOI: 10.1039/d0nj04099a] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Quantum calculation of mTOR–mLST8 interaction.
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Affiliation(s)
| | | | | | | | | | | | - Geancarlo Zanatta
- Department of Physics at Federal University of Ceará
- 60455-760 Fortaleza
- Brazil
- Postgraduate Research Program in Biochemistry at Federal University of Ceará
- Fortaleza
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16
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17
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Abstract
Mammalian target of rapamycin (mTOR) is a conserved serine/threonine kinase of the phosphatidylinositol kinase-related kinase family that regulates cell growth, metabolism, and autophagy. Extensive research has linked mTOR to several human diseases including cancer, neurodegenerative disorders, and aging. In this review, recent publications regarding the mechanisms underlying the role of mTOR in female reproduction under physiological and pathological conditions are summarized. Moreover, we assess whether strategies to improve or suppress mTOR expression could have therapeutic potential for reproductive diseases like premature ovarian failure, polycystic ovarian syndrome, and endometriosis.
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18
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Colla L, Diena D, Rossetti M, Manzione AM, Marozio L, Benedetto C, Biancone L. Immunosuppression in pregnant women with renal disease: review of the latest evidence in the biologics era. J Nephrol 2018; 31:361-383. [DOI: 10.1007/s40620-018-0477-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 02/03/2018] [Indexed: 02/07/2023]
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19
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Singla A, Gupta N, Apewokin S, McCormack FX. Sirolimus for the treatment of lymphangioleiomyomatosis. Expert Opin Orphan Drugs 2017. [DOI: 10.1080/21678707.2017.1391089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- Abhishek Singla
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Nishant Gupta
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Senu Apewokin
- Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Francis X. McCormack
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, USA
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20
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Curatolo P, Bjørnvold M, Dill PE, Ferreira JC, Feucht M, Hertzberg C, Jansen A, Jóźwiak S, Kingswood JC, Kotulska K, Macaya A, Moavero R, Nabbout R, Zonnenberg BA. The Role of mTOR Inhibitors in the Treatment of Patients with Tuberous Sclerosis Complex: Evidence-based and Expert Opinions. Drugs 2016; 76:551-65. [PMID: 26927950 DOI: 10.1007/s40265-016-0552-9] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Tuberous sclerosis complex (TSC) is a genetic disorder arising from mutations in the TSC1 or TSC2 genes. The resulting over-activation of the mammalian target of rapamycin (mTOR) signalling pathway leaves patients with TSC susceptible to the growth of non-malignant tumours in multiple organs. Previously, surgery was the main therapeutic option for TSC. However, pharmacological therapy with mTOR inhibitors such as everolimus and sirolimus is now emerging as an alternate approach. Everolimus and sirolimus have already been shown to be effective in treating subependymal giant cell astrocytoma (SEGA) and renal angiomyolipoma (AML), and everolimus is currently being evaluated in treating TSC-related epilepsy. In November 2013 a group of European experts convened to discuss the current options and practical considerations for treating various manifestations of TSC. This article provides evidence-based recommendations for the treatment of SEGA, TSC-related epilepsy and renal AML, with a focus on where mTOR inhibitor therapy may be considered alongside other treatment options. Safety considerations regarding mTOR inhibitor therapy are also reviewed. With evidence of beneficial effects in neurological and non-neurological TSC manifestations, mTOR inhibitors may represent a systemic treatment for TSC.
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Affiliation(s)
- Paolo Curatolo
- Department of Neurosciences, Child Neurology and Psychiatry Unit, Tor Vergata University Hospital of Rome, Rome, Italy.
| | - Marit Bjørnvold
- National Center for Rare Epilepsy-related Disorders, National Center of Epilepsy, Oslo University Hospital, Oslo, Norway
| | - Patricia E Dill
- Department of Pediatric Neurology and Developmental Medicine, University Children's Hospital Basel, University of Basel, Basel, Switzerland.,INSERM Unité 1511, Paris, France
| | - José Carlos Ferreira
- Neuro Pediatra, Centro Hospitalar Lisboa Ocidental, Hospital São Francisco Xavier, Lisbon, Portugal
| | - Martha Feucht
- Department of Paediatrics, University Hospital Vienna, Vienna, Austria
| | - Christoph Hertzberg
- Diagnose und Behandlungszentrum für Kinder und Jugendliche, Vivantes Klinikum Neukölln, Berlin, Germany
| | - Anna Jansen
- Pediatric Neurology Unit-UZ Brussel, Brussels, Belgium
| | - Sergiusz Jóźwiak
- Department of Child Neurology, Medical University of Warsaw, Warsaw, Poland
| | - J Christopher Kingswood
- Sussex Renal Unit, Royal Sussex County Hospital, Brighton, UK.,The Trafford Department of Renal Medicine, Royal Sussex County Hospital, Brighton, UK
| | - Katarzyna Kotulska
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland
| | - Alfons Macaya
- Servei de Neurologia Pediàtrica, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Romina Moavero
- Department of Neurosciences, Child Neurology and Psychiatry Unit, Tor Vergata University Hospital of Rome, Rome, Italy.,Pediatric Neurology Unit, Department of Neuroscience and Neurorehabilitation, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Rima Nabbout
- Department of Pediatric Neurology, Reference Centre for Rare Epilepsies and Tuberous Sclerosis Complex, Necker-Enfants Malades Hospital, University Paris Descartes, Paris, France
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21
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Bamoulid J, Staeck O, Halleck F, Khadzhynov D, Paliege A, Brakemeier S, Dürr M, Budde K. Immunosuppression and Results in Renal Transplantation. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.eursup.2016.04.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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22
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Sirotkin AV. The Role and Application of Sirtuins and mTOR Signaling in the Control of Ovarian Functions. Cells 2016; 5:cells5040042. [PMID: 27886120 PMCID: PMC5187526 DOI: 10.3390/cells5040042] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Revised: 11/03/2016] [Accepted: 11/04/2016] [Indexed: 12/11/2022] Open
Abstract
The present short review demonstrates the involvement of sirtuins (SIRTs) in the control of ovarian functions at various regulatory levels. External and endocrine factors can affect female reproduction via SIRTs-mammalian target of rapamycin (mTOR) system, which, via hormones and growth factors, can in turn regulate basic ovarian functions (proliferation, apoptosis, secretory activity of ovarian cells, their response to upstream hormonal regulators, ovarian folliculo- and oogenesis, and fecundity). SIRTs and SIRTs-related signaling molecules and drugs regulating mTOR can be used for characterization, prediction, and regulation of ovarian functions, as well as for diagnostics and treatment of ovarian disorders.
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Affiliation(s)
- Alexander V Sirotkin
- Department of Zoology and Anthropology, Constantine the Philosopher University, 94974 Nitra, Slovakia.
- Research Institute of Animal Production, 941 51 Lužianky, Slovakia.
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23
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Mallett A, Lee VW, Mai J, Lopez-Vargas P, Rangan GK. KHA-CARI Autosomal Dominant Polycystic Kidney Disease Guideline: Pharmacological Management. Semin Nephrol 2016; 35:582-589.e17. [PMID: 26718162 DOI: 10.1016/j.semnephrol.2015.10.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Andrew Mallett
- Kidney Health Service and Conjoint Kidney Research Laboratory, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; Centre for Kidney Disease Research, Centre for Chronic Disease and CKD, School of Medicine and Centre for Rare Diseases Research, Institute for Molecular Bioscience, The University of Queensland, Brisbane, Queensland, Australia.
| | - Vincent W Lee
- Department of Renal Medicine, Westmead Hospital, Western Sydney Local Health District, Sydney, Australia; Centre for Transplant and Renal Research, Westmead Institute for Medical Research, University of Sydney, Westmead, Sydney, Australia
| | - Jun Mai
- Department of Nephrology, Liverpool and Bankstown Hospital, South Western Sydney Local Health District, Sydney, Australia
| | - Pamela Lopez-Vargas
- KHA-CARI Guidelines, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Sydney, Australia; Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Gopala K Rangan
- Centre for Transplant and Renal Research, Westmead Institute for Medical Research, University of Sydney, Westmead, Sydney, Australia; Department of Renal Medicine, Westmead Hospital, Western Sydney Local Health District, Sydney, Australia
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24
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Hatano T, Chikaraishi K, Inaba H, Endo K, Egawa S. Outcomes of everolimus treatment for renal angiomyolipoma associated with tuberous sclerosis complex: A single institution experience in Japan. Int J Urol 2016; 23:833-838. [PMID: 27480662 DOI: 10.1111/iju.13168] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 06/17/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To evaluate the efficacy and toxicity profiles of everolimus in Japanese patients with renal angiomyolipoma associated with tuberous sclerosis complex. METHODS Patients with a 4-cm or larger angiomyolipoma meeting the diagnostic criteria of tuberous sclerosis complex were selected as participants of our investigation. In each case, we assessed tuberous sclerosis complex-associated symptoms, the treatment effect and adverse events. The treatment effect was evaluated by measuring the tumor volume reduction rate using abdominal computed tomography or magneitc resonance imaging. Adverse events were investigated using CTCAE v4.0-JCOG. The dose of everolimus was set at 10 mg once a day for adults. For childhood angiomyolipoma, everolimus administration was initiated at a dose of 5 mg once a day. Blood everolimus level was measured, and the dose was adjusted to maintain this within a range of 5-15 ng/mL. RESULTS The angiomyolipoma volume decreased in 46 of 47 cases, and the mean reduction rate for all cases was 60% in 12 months. The angiomyolipoma volume markedly decreased in the first 3 months, and the size leveled off after 6 months. The main adverse events related to everolimus treatment were stomatitis (91%) and irregular menstruation (65%). Grade 3 or severer adverse events were noted in three cases (6%). All patients developed some adverse events in the first 6 months. The incidence markedly decreased to 40-50% after 13 months. CONCLUSION The tumor volume-reducing effect of everolimus in a Japanese population was equivalent to or higher than that in Western populations. A wide variety of everolimus treatment-related adverse events can be observed, but most cases are very mild. Special attention should be given to stomatitis, irregular menstruation and interstitial lung disease as adverse events.
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Affiliation(s)
- Takashi Hatano
- Department of Urology, JR Tokyo General Hospital, Tokyo, Japan.
| | | | - Hiroyuki Inaba
- Department of Urology, JR Tokyo General Hospital, Tokyo, Japan
| | - Katsuhisa Endo
- Department of Urology, JR Tokyo General Hospital, Tokyo, Japan
| | - Shin Egawa
- Department of Urology, Jikei University School of Medicine, Tokyo, Japan
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25
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Hakim S, Dyson JM, Feeney SJ, Davies EM, Sriratana A, Koenig MN, Plotnikova OV, Smyth IM, Ricardo SD, Hobbs RM, Mitchell CA. Inpp5e suppresses polycystic kidney disease via inhibition of PI3K/Akt-dependent mTORC1 signaling. Hum Mol Genet 2016; 25:2295-2313. [PMID: 27056978 DOI: 10.1093/hmg/ddw097] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 03/17/2016] [Indexed: 12/20/2022] Open
Abstract
Polycystic kidney disease (PKD) is a common cause of renal failure with few effective treatments. INPP5E is an inositol polyphosphate 5-phosphatase that dephosphorylates phosphoinositide 3-kinase (PI3K)-generated PI(3,4,5)P3 and is mutated in ciliopathy syndromes. Germline Inpp5e deletion is embryonically lethal, attributed to cilia stability defects, and is associated with polycystic kidneys. However, the molecular mechanisms responsible for PKD development upon Inpp5e loss remain unknown. Here, we show conditional inactivation of Inpp5e in mouse kidney epithelium results in severe PKD and renal failure, associated with a partial reduction in cilia number and hyperactivation of PI3K/Akt and downstream mammalian target of rapamycin complex 1 (mTORC1) signaling. Treatment with an mTORC1 inhibitor improved kidney morphology and function, but did not affect cilia number or length. Therefore, we identify Inpp5e as an essential inhibitor of the PI3K/Akt/mTORC1 signaling axis in renal epithelial cells, and demonstrate a critical role for Inpp5e-dependent mTORC1 regulation in PKD suppression.
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Affiliation(s)
- Sandra Hakim
- Cancer Program, Department of Biochemistry and Molecular Biology, Monash Biomedicine Discovery Institute, Monash University, Clayton, VIC 3800, Australia
| | - Jennifer M Dyson
- Cancer Program, Department of Biochemistry and Molecular Biology, Monash Biomedicine Discovery Institute, Monash University, Clayton, VIC 3800, Australia
| | - Sandra J Feeney
- Cancer Program, Department of Biochemistry and Molecular Biology, Monash Biomedicine Discovery Institute, Monash University, Clayton, VIC 3800, Australia
| | - Elizabeth M Davies
- Cancer Program, Department of Biochemistry and Molecular Biology, Monash Biomedicine Discovery Institute, Monash University, Clayton, VIC 3800, Australia
| | - Absorn Sriratana
- Cancer Program, Department of Biochemistry and Molecular Biology, Monash Biomedicine Discovery Institute, Monash University, Clayton, VIC 3800, Australia
| | - Monica N Koenig
- Cancer Program, Department of Biochemistry and Molecular Biology, Monash Biomedicine Discovery Institute, Monash University, Clayton, VIC 3800, Australia
| | - Olga V Plotnikova
- Cancer Program, Department of Biochemistry and Molecular Biology, Monash Biomedicine Discovery Institute, Monash University, Clayton, VIC 3800, Australia
| | - Ian M Smyth
- Cancer Program, Department of Biochemistry and Molecular Biology, Monash Biomedicine Discovery Institute, Monash University, Clayton, VIC 3800, Australia Development and Stem Cell program, Department of Anatomy and Developmental Biology, Monash University, Clayton, VIC 3800, Australia
| | - Sharon D Ricardo
- Development and Stem Cell program, Department of Anatomy and Developmental Biology, Monash University, Clayton, VIC 3800, Australia
| | - Robin M Hobbs
- Development and Stem Cell program, Department of Anatomy and Developmental Biology, Monash University, Clayton, VIC 3800, Australia Australian Regenerative Medicine Institute, Monash University, Clayton, VIC 3800, Australia
| | - Christina A Mitchell
- Cancer Program, Department of Biochemistry and Molecular Biology, Monash Biomedicine Discovery Institute, Monash University, Clayton, VIC 3800, Australia
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Leroy C, Rigot JM, Leroy M, Decanter C, Le Mapihan K, Parent AS, Le Guillou AC, Yakoub-Agha I, Dharancy S, Noel C, Vantyghem MC. Immunosuppressive drugs and fertility. Orphanet J Rare Dis 2015; 10:136. [PMID: 26490561 PMCID: PMC4618138 DOI: 10.1186/s13023-015-0332-8] [Citation(s) in RCA: 112] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2015] [Accepted: 08/30/2015] [Indexed: 12/16/2022] Open
Abstract
Immunosuppressive drugs are used in the treatment of inflammatory and autoimmune diseases, as well as in transplantation. Frequently prescribed in young people, these treatments may have deleterious effects on fertility, pregnancy outcomes and the unborn child. This review aims to summarize the main gonadal side effects of immunosuppressants, to detail the effects on fertility and pregnancy of each class of drug, and to provide recommendations on the management of patients who are seen prior to starting or who are already receiving immunosuppressive treatment, allowing them in due course to bear children. The recommendations for use are established with a rather low level of proof, which needs to be taken into account in the patient management. Methotrexate, mycophenolate, and le- and teri-flunomide, cyclophosphamide, mitoxanthrone are contraindicated if pregnancy is desired due to their teratogenic effects, as well as gonadotoxic effects in the case of cyclophosphamide. Anti-TNF-alpha and mTOR-inhibitors are to be used cautiously if pregnancy is desired, since experience using these drugs is still relatively scarce. Azathioprine, glucocorticoids, mesalazine, anticalcineurins such as cyclosporine and tacrolimus, ß-interferon, glatiramer-acetate and chloroquine can be used during pregnancy, bearing in mind however that side effects may still occur. Experience is limited concerning natalizumab, fingolimod, dimethyl-fumarate and induction treatments. Conclusion: At the time of prescription, patients must be informed of the possible consequences of immunosuppressants on fertility and of the need for contraception. Pregnancy must be planned and the treatment modified if necessary in a pre-conception time period adapted to the half-life of the drug, imperatively in relation with the prescriber of the immunosuppressive drugs.
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Affiliation(s)
- Clara Leroy
- Endocrinology and Metabolism, Hôpital Huriez, Lille University Hospital, 59037, Lille Cedex, France.
- Andrology, Hôpital Calmette, Lille University Hospital, 59037, Lille Cedex, France.
| | - Jean-Marc Rigot
- Andrology, Hôpital Calmette, Lille University Hospital, 59037, Lille Cedex, France.
| | - Maryse Leroy
- Gynaecology -Obstetrics, Hôpital Jeanne de Flandres, Lille University Hospital, 59037, Lille Cedex, France.
| | - Christine Decanter
- Endocrine Gynaecology, Hôpital Jeanne de Flandres, Lille University Hospital, 59037, Lille Cedex, France.
| | - Kristell Le Mapihan
- Endocrinology and Metabolism, Hôpital Huriez, Lille University Hospital, 59037, Lille Cedex, France.
| | - Anne-Sophie Parent
- Endocrinology and Metabolism, Hôpital Huriez, Lille University Hospital, 59037, Lille Cedex, France.
| | - Anne-Claire Le Guillou
- Endocrinology and Metabolism, Hôpital Huriez, Lille University Hospital, 59037, Lille Cedex, France.
| | - Ibrahim Yakoub-Agha
- Hematology, Hôpital Huriez, Lille University Hospital, 59037, Lille Cedex, France.
| | - Sébastien Dharancy
- Liver Diseases and Gastroenterology, Hôpital Huriez, Lille University Hospital, 59037, Lille Cedex, France.
| | - Christian Noel
- Nephrology Hôpital Huriez, Lille University Hospital, 59037, Lille Cedex, France.
| | - Marie-Christine Vantyghem
- Endocrinology and Metabolism, Hôpital Huriez, Lille University Hospital, 59037, Lille Cedex, France.
- InsermU859 Biotherapies of Diabetes, Lille University Hospital, 59037, Lille Cedex, France.
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Bolignano D, Palmer SC, Ruospo M, Zoccali C, Craig JC, Strippoli GFM. Interventions for preventing the progression of autosomal dominant polycystic kidney disease. Cochrane Database Syst Rev 2015; 2015:CD010294. [PMID: 26171904 PMCID: PMC8406618 DOI: 10.1002/14651858.cd010294.pub2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Autosomal dominant polycystic kidney disease (ADPKD) is the most common inherited disorder causing kidney disease. Current clinical management of ADPKD focuses primarily on symptom control and reducing associated complications, particularly hypertension. In recent years, improved understanding of molecular and cellular mechanisms involved in kidney cyst growth and disease progression has resulted in new pharmaceutical agents to target disease pathogenesis to prevent progressive disease. OBJECTIVES We aimed to evaluate the effects of interventions for preventing ADPKD progression on kidney function, kidney endpoints, kidney structure, patient-centred endpoints (such as cardiovascular events, sudden death, all-cause mortality, hospitalisations, BP control, quality of life, and kidney pain), as well as the general and specific adverse effects related to their use. SEARCH METHODS We searched the Cochrane Renal Group's Specialised Register to 6 June 2015 using relevant search terms. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing any interventions for preventing the progression of ADPKD with other interventions or placebo were considered for inclusion without language restriction. DATA COLLECTION AND ANALYSIS Two authors independently assessed study risks of bias and extracted data. We summarised treatment effects on clinical outcomes, kidney function and structure and adverse events using random effects meta-analysis. We assessed heterogeneity in estimated treatment effects using the Cochran Q test and I(2) statistic. Summary treatment estimates were calculated as a mean difference (MD) or standardised mean difference (SMD) for continuous outcomes and a risk ratio (RR) for dichotomous outcomes together with their 95% confidence intervals. MAIN RESULTS We included 30 studies (2039 participants) that investigated 11 pharmacological interventions (angiotensin-converting enzyme inhibitors (ACEi), angiotensin receptor blockers (ARBs), calcium channel blockers, beta blockers, vasopressin receptor 2 (V2R) antagonists, mammalian target of rapamycin (mTOR) inhibitors, somatostatin analogues, antiplatelet agents, eicosapentaenoic acids, statins and vitamin D compounds) in this review.ACEi significantly reduced diastolic blood pressure (9 studies, 278 participants: MD -4.96 mm Hg, 95% CI -8.88 to -1.04), but had uncertain effects on kidney volumes (MD -42.50 mL, 95% CI -115.68 to 30.67), GFR (MD -3.41 mL/min/1.73 m(2), 95% CI -15.83 to 9.01), and SCr (MD -0.02 mg/dL, 95% CI -0.14 to 0.09), in data largely restricted to children. ACEi did not show different effects on GFR (MD -8.19 mL/min/1.73 m(2), 95% CI -29.46 to 13.07) and albuminuria (SMD -0.19, 95% CI -1.77 to 1.39) when compared with beta-blockers, or SCr (MD 0.00 mg/dL, 95% CI -0.09 to 0.10) when compared with ARBs.Data for effects of V2R antagonists on kidney function and volumes compared to placebo were limited to narrative information within a single study while these agents increased thirst (1444 participants: RR 2.70, 95% CI 2.24 to 3.24) and dry mouth (1455 participants: RR 1.33, 95% CI 1.01 to 1.76).Compared with no treatment, mTOR inhibitors had uncertain effects on kidney function (2 studies, 115 participants: MD 4.45 mL/min/1.73 m(2), 95% CI -3.20 to 12.11) and kidney volume (MD -0.08 L, 95% CI -0.75 to 0.59) but in three studies (560 participants) caused angioedema (RR 13.39, 95% CI 2.56 to 70.00), oral ulceration (RR 6.77, 95% CI 4.42 to 10.38), infections (RR 1.14, 95% CI 1.04 to 1.25) and diarrhoea (RR 1.70, 95% CI 1.26 to 2.29).Somatostatin analogues (6 studies, 138 participants) slightly improved SCr (MD -0.43 mg/dL, 95% CI -0.86 to -0.01) and total kidney volume (MD -0.62 L, 95% CI -1.22 to -0.01) but had no definite effects on GFR (MD 9.50 mL/min, 95% CI -4.45 to 23.44) and caused diarrhoea (RR 3.72, 95% CI 1.43 to 9.68).Data for calcium channel blockers, eicosapentaenoic acids, statins, vitamin D compounds and antiplatelet agents were sparse and inconclusive.Random sequence generation was adequate in eight studies, and in almost half of the studies, blinding was not present or not specified. Most studies did not adequately report outcomes, which adversely affected our ability to assess this bias. The overall drop-out rate was over 10% in nine studies, and few were conducted using intention-to-treat analyses. AUTHORS' CONCLUSIONS Although several interventions are available for patients with ADPKD, at present there is little or no evidence that treatment improves patient outcomes in this population and is associated with frequent adverse effects. Additional large randomised studies focused on patient-centred outcomes are needed.
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Affiliation(s)
- Davide Bolignano
- CNR ‐ Italian National Council of ResearchInstitute of Clinical PhysiologyCNR‐IFC Via Vallone Petrara c/o Ospedali RiunitiReggio CalabriaItaly89100
| | - Suetonia C Palmer
- University of Otago ChristchurchDepartment of Medicine2 Riccarton AvePO Box 4345ChristchurchNew Zealand8140
| | - Marinella Ruospo
- DiaverumMedical Scientific OfficeLundSweden
- Amedeo Avogadro University of Eastern PiedmontDivision of Nephrology and Transplantation, Department of Translational MedicineVia Solaroli 17NovaraItaly28100
| | - Carmine Zoccali
- CNR ‐ Italian National Council of ResearchInstitute of Clinical PhysiologyCNR‐IFC Via Vallone Petrara c/o Ospedali RiunitiReggio CalabriaItaly89100
| | - Jonathan C Craig
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
| | - Giovanni FM Strippoli
- DiaverumMedical Scientific OfficeLundSweden
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- Diaverum AcademyBariItaly
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28
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Bamoulid J, Staeck O, Halleck F, Khadzhynov D, Brakemeier S, Dürr M, Budde K. The need for minimization strategies: current problems of immunosuppression. Transpl Int 2015; 28:891-900. [PMID: 25752992 DOI: 10.1111/tri.12553] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 12/30/2014] [Accepted: 02/27/2015] [Indexed: 12/31/2022]
Abstract
New immunosuppressants and the better use of immunosuppressant combination therapy have led to significant improvements in renal allograft outcomes over the last decades. Yet, despite dramatic reduction in rejection rates and improvement in 1-year graft survival, long-term graft attrition rates remained rather constant. Current immunosuppressant combinations are frequently leading to overimmunosuppression and are increasing cardiovascular risk. Importantly, calcineurin inhibitors are nephrotoxic, contribute to cardiovascular risk and chronic allograft dysfunction. Furthermore, immunosuppressant-associated toxicities aggravate immune-mediated nephron injury and side effects lead to nonadherence, an identified important reason for late acute and chronic antibody-mediated rejections. The frequent development of a chronic humoral response indicates rather insufficient immunosuppression of current combinations than simple under-immunosuppression. While there is no evidence that increasing immunosuppressive doses will improve outcomes or reduce de novo HLA-antibody formation, there is clear evidence that adequate minimization strategies will reduce side effect burden. Because of low rejection risk, but frequent side effects, drug minimization is particularly relevant for the many maintenance patients. In summary, new therapeutic strategies need to be developed from adequately powered clinical trials for reduction of the many side effects of immunosuppressants. Such evidence-based and time-dependent immunosuppressive minimization strategies are needed to achieve better long-term outcomes in the future.
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Affiliation(s)
- Jamal Bamoulid
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Oliver Staeck
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Fabian Halleck
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Dmytri Khadzhynov
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Susanne Brakemeier
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Michael Dürr
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Klemens Budde
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
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Abstract
Lymphangioleiomyomatosis (LAM) is an uncommon disease presented as diffuse thin-walled cystic changes in the lung. The main differential diagnoses include pulmonary Langerhans’ histiocytosis (PLCH), Birt-Hogg-Dubé syndrome (BHD), lymphoid interstitial pneumonia (LIP), and amyloidosis. A combination of clinical, radiological, and pathological approaches as well as genetic testing will clarify the diagnosis in most cases. LAM is a disease almost exclusively in women. Dyspnea, pneumothorax, and hemoptysis are common presentations in LAM patients. LAM is also a lymphatic disorder affecting lymphatic vessels and lymph nodes. Chylothorax, chylous ascites, and lymphangiomyomas are frequently seen. LAM can present sporadically as a single entity or as part of tuberous sclerosis complex (TSC). Angiomyolipoma (AML) is a characteristic extra-pulmonary lesion, either found in association with sporadic or TSC-related LAM. High-risk populations should be screened for LAM, including adult women with TSC and female patients with spontaneous pneumothorax, AMLs in the kidney, and diffuse cystic lung diseases. Definitive diagnosis of LAM is based on a high level of clinical suspicion on presentation supported by pathological findings or by a distinct feature, such as a history of TSC, AMLs in the kidney, chylothorax, or chylous ascites. Vascular endothelial growth factor-D (VEGF-D) in serum is a noninvasive and reliable diagnostic biomarker. In experienced centers, trans-bronchial lung biopsy (TBLB) provides a convenient and safe way to obtain lung specimens for diagnostic purposes. An effective treatment for LAM is now available, namely using a mechanistic target of rapamycin (mTOR) inhibitor such as sirolimus. Efficacy of sirolimus has been confirmed in clinical trials. Research in other molecular-targeted therapies is under investigation. A previously little-known rare disease with no cure is now better understood with regards to its pathogenesis, diagnosis, and management. In this review, current knowledge in diagnosis and differential diagnosis of LAM will be discussed, followed by the discussion of therapy with mTOR inhibitors.
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Affiliation(s)
- Kai-Feng Xu
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Beijing, People's Republic of China
| | - Bee Hong Lo
- Developmental Pediatrician, PECAT, Children's Hospital Westmead, Sydney, NSW, Australia
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30
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Strategies for the management of adverse events associated with mTOR inhibitors. Transplant Rev (Orlando) 2014; 28:126-33. [PMID: 24685370 DOI: 10.1016/j.trre.2014.03.002] [Citation(s) in RCA: 197] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Revised: 03/04/2014] [Accepted: 03/08/2014] [Indexed: 12/29/2022]
Abstract
Mammalian target of rapamycin (mTOR) inhibitors are used as potent immunosuppressive agents in solid-organ transplant recipients (everolimus and sirolimus) and as antineoplastic therapies for various cancers (eg, advanced renal cell carcinoma; everolimus, temsirolimus, ridaforolimus). Relevant literature, obtained from specific PubMed searches, was reviewed to evaluate the incidence and mechanistic features of specific adverse events (AEs) associated with mTOR inhibitor treatment, and to present strategies to effectively manage these events. The AEs examined in this review include stomatitis and other cutaneous AEs, wound-healing complications (eg, lymphocele, incisional hernia), diabetes/hyperglycemia, dyslipidemia, proteinuria, nephrotoxicity, delayed graft function, pneumonitis, anemia, hypertension, gonadal dysfunction, and ovarian toxicity. Strategies for selecting appropriate patients for mTOR inhibitor therapy and minimizing the risks of AEs are discussed, along with best practices for identifying and managing side effects. mTOR inhibitors are promising therapeutic options in immunosuppression and oncology; most AEs can be effectively detected and managed or reversed with careful monitoring and appropriate interventions.
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