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Divard G, Aubert O, Debiais-Deschamp C, Raynaud M, Goutaudier V, Sablik M, Sayeg C, Legendre C, Obert J, Anglicheau D, Lefaucheur C, Loupy A. Long-Term Outcomes after Conversion to a Belatacept-Based Immunosuppression in Kidney Transplant Recipients. Clin J Am Soc Nephrol 2024; 19:628-637. [PMID: 38265815 PMCID: PMC11108246 DOI: 10.2215/cjn.0000000000000411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 01/19/2024] [Indexed: 01/25/2024]
Abstract
BACKGROUND Conversion to a belatacept-based immunosuppression is currently used as a calcineurin inhibitor (CNI) avoidance strategy when the CNI-based standard-of-care immunosuppression is not tolerated after kidney transplantation. However, there is a lack of evidence on the long-term benefit and safety after conversion to belatacept. METHODS We prospectively enrolled 311 kidney transplant recipients from 2007 to 2020 from two referral centers, converted from CNI to belatacept after transplant according to a prespecified protocol. Patients were matched at the time of conversion to patients maintained with CNIs, using optimal matching. The primary end point was death-censored allograft survival at 7 years. The secondary end points were patient survival, eGFR, and safety outcomes, including serious viral infections, immune-related complications, antibody-mediated rejection, T-cell-mediated rejection, de novo anti-HLA donor-specific antibody, de novo diabetes, cardiovascular events, and oncologic complications. RESULTS A total of 243 patients converted to belatacept (belatacept group) were matched to 243 patients maintained on CNIs (CNI control group). All recipient, transplant, functional, histologic, and immunologic parameters were well balanced between the two groups with a standardized mean difference below 0.05. At 7 years post-conversion to belatacept, allograft survival was 78% compared with 63% in the CNI control group ( P < 0.001 for log-rank test). The safety outcomes showed a similar rate of patient death (28% in the belatacept group versus 36% in the CNI control group), active antibody-mediated rejection (6% versus 7%), T-cell-mediated rejection (4% versus 4%), major adverse cardiovascular events, and cancer occurrence (9% versus 11%). A significantly higher rate of de novo proteinuria was observed in the belatacept group as compared with the CNI control group (37% versus 21%, P < 0.001). CONCLUSIONS This real-world evidence study shows that conversion to belatacept post-transplant was associated with lower risk of graft failure and acceptable safety outcomes compared with patients maintained on CNIs. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER Long-term Outcomes after Conversion to Belatacept, NCT04733131 .
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Affiliation(s)
- Gillian Divard
- INSERM U970 PARCC, Pa`ris Institute for Transplantation and Organ Regeneration, Université Paris Cité, Paris, France
- Kidney Transplant Department, Saint-Louis Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Olivier Aubert
- INSERM U970 PARCC, Pa`ris Institute for Transplantation and Organ Regeneration, Université Paris Cité, Paris, France
- Kidney Transplant Department, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Charlotte Debiais-Deschamp
- INSERM U970 PARCC, Pa`ris Institute for Transplantation and Organ Regeneration, Université Paris Cité, Paris, France
- Kidney Transplant Department, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Marc Raynaud
- INSERM U970 PARCC, Pa`ris Institute for Transplantation and Organ Regeneration, Université Paris Cité, Paris, France
| | - Valentin Goutaudier
- INSERM U970 PARCC, Pa`ris Institute for Transplantation and Organ Regeneration, Université Paris Cité, Paris, France
| | - Marta Sablik
- INSERM U970 PARCC, Pa`ris Institute for Transplantation and Organ Regeneration, Université Paris Cité, Paris, France
| | - Caroline Sayeg
- Kidney Transplant Department, Saint-Louis Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Christophe Legendre
- INSERM U970 PARCC, Pa`ris Institute for Transplantation and Organ Regeneration, Université Paris Cité, Paris, France
- Kidney Transplant Department, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Julie Obert
- INSERM U970 PARCC, Pa`ris Institute for Transplantation and Organ Regeneration, Université Paris Cité, Paris, France
| | - Dany Anglicheau
- Kidney Transplant Department, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
- Necker-Enfants Malades Institute, INSERM U1151, Université de Paris Cité, Paris, France
| | - Carmen Lefaucheur
- INSERM U970 PARCC, Pa`ris Institute for Transplantation and Organ Regeneration, Université Paris Cité, Paris, France
- Kidney Transplant Department, Saint-Louis Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Alexandre Loupy
- INSERM U970 PARCC, Pa`ris Institute for Transplantation and Organ Regeneration, Université Paris Cité, Paris, France
- Kidney Transplant Department, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
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Sridharan K, Shah S, Hammad MA, Mohammed FA, Veeramuthu S, Taher MA, Hammad MM, Jawad L, Farid E. Correlations between serum kidney injury molecule-1, cystatin C and immunosuppressants: A cross-sectional study of renal transplant patients in Bahrain. J Biomed Res 2024; 38:269-277. [PMID: 38528676 PMCID: PMC11144937 DOI: 10.7555/jbr.37.20220211] [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: 09/25/2022] [Revised: 10/24/2022] [Accepted: 11/06/2022] [Indexed: 03/27/2024] Open
Abstract
Renal transplant patients receive several immunosuppressive drug regimens that are potentially nephrotoxic for treatment. Serum creatinine is the standard for monitoring kidney function; however, cystatin C (Cys C) and kidney injury molecule-1 (KIM-1) have been found to indicate kidney injury earlier than serum creatinine and provide a better reflection of kidney function. Here, we assessed Cys C and KIM-1 serum levels in renal transplant patients receiving mycophenolate mofetil, tacrolimus, sirolimus, everolimus, or cyclosporine to evaluate kidney function. We used both the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) 2021 equation, which is based on creatinine and combined creatinine with Cys C, and the CKD-EPI 2012 equation, which is based on Cys C alone, to estimate glomerular filtration rate (GFR). Then, we assessed the association between serum KIM-1 and GFR < 90 mL per minute per 1.73 m 2. We observed significantly higher serum Cys C levels in patients with the elevated serum creatinine, compared with those with normal serum creatinine. The estimated GFRs based on creatinine were significantly higher than those based on the other equations, while a significant positive correlation was observed among all equations. Serum KIM-1 levels were negatively correlated with the estimated GFRs by the CKD-EPI Cys C and the combined creatinine with Cys C equations. A serum KIM-1 level above 0.71 ng/mL is likely to indicate GFR < 90 mL per minute per 1.73 m 2. We observed a significant correlation between serum creatinine and Cys C in our renal transplant patients. Therefore, serum KIM-1 may be used to monitor renal function when using potentially nephrotoxic drugs in renal transplants.
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Affiliation(s)
- Kannan Sridharan
- Department of Pharmacology and Therapeutics, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Kingdom of Bahrain
| | - Shamik Shah
- Department of Nephrology, Salmaniya Medical Complex, Manama, Kingdom of Bahrain
- Department of Internal Medicine, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Kingdom of Bahrain
| | | | - Fatima Ali Mohammed
- Department of Nephrology, Salmaniya Medical Complex, Manama, Kingdom of Bahrain
| | - Sindhan Veeramuthu
- Department of Pharmacology and Therapeutics, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Kingdom of Bahrain
| | - Mona Abdulla Taher
- Department of Nephrology, Salmaniya Medical Complex, Manama, Kingdom of Bahrain
| | | | - Lamees Jawad
- Department of Laboratory Medicine, Salmaniya Medical Complex, Manama, Kingdom of Bahrain
| | - Eman Farid
- Department of Laboratory Medicine, Salmaniya Medical Complex, Manama, Kingdom of Bahrain
- Department of Microbiology, Immunology, and Infectious Diseases, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Kingdom of Bahrain
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Jallah BP, Kuypers DRJ. Impact of Immunosenescence in Older Kidney Transplant Recipients: Associated Clinical Outcomes and Possible Risk Stratification for Immunosuppression Reduction. Drugs Aging 2024; 41:219-238. [PMID: 38386164 DOI: 10.1007/s40266-024-01100-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2024] [Indexed: 02/23/2024]
Abstract
The number of older individuals receiving a kidney transplant as replacement therapy has significantly increased in the past decades and this increase is expected to continue. Older patients have a lower rate of acute rejection but an increased incidence of death with a functioning graft. Several factors, including an increased incidence of infections, post-transplant malignancy and cardiovascular comorbidity and mortality, contribute to this increased risk. Notwithstanding, kidney transplantation is still the best form of kidney replacement therapy in all patients with chronic kidney disease, including in older individuals. The best form of immunosuppression and the optimal dose of these medications in older recipients remains a topic of discussion. Pharmacological studies have usually excluded older patients and when included, patients were highly selected and their numbers insignificant to draw a reasonable conclusion. The reduced incidence of acute rejection in older recipients has largely been attributed to immunosenescence. Immunosenescence refers to the aging of the innate and adaptive immunity, accumulating in phenotypic and functional changes. These changes influences the response of the immune system to new challenges. In older individuals, immunosenescence is associated with increased susceptibility to infectious pathogens, a decreased response after vaccinations, increased risk of malignancies and cardiovascular morbidity and mortality. Chronic kidney disease is associated with premature immunosenescent changes, and these are independent of aging. The immunosenescent state is associated with low-grade sterile inflammation termed inflammaging. This chronic low-grade inflammation triggers a compensatory immunosuppressive state to avoid further tissue damage, leaving older individuals with chronic kidney disease in an immune-impaired state before kidney transplantation. Immunosuppression after transplantation may further enhance progression of this immunosenescent state. This review covers the role of immunosenescence in older kidney transplant recipients and it details present knowledge of the changes in chronic kidney disease and after transplantation. The impact of immunosuppression on the progression and complications of an immunosenescent state are discussed, and the future direction of a possible clinical implementation of immunosenescence to individualize/reduce immunosuppression in older recipients is laid out.
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Affiliation(s)
- Borefore P Jallah
- Department of Nephrology and Renal Transplantation, University Hospital Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Dirk R J Kuypers
- Department of Nephrology and Renal Transplantation, University Hospital Leuven, Herestraat 49, 3000, Leuven, Belgium.
- Department of Microbiology, Immunology and Transplantation, University of Leuven, Leuven, Belgium.
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Guo P, Zhang R, Zhou J, Li P, Liu Y, Shi S. Intracellular tacrolimus concentration correlates with impaired renal function through regulation of the IS-AHR-ABC transporter in peripheral blood mononuclear cells. Int Immunopharmacol 2024; 126:111233. [PMID: 37979449 DOI: 10.1016/j.intimp.2023.111233] [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: 07/19/2023] [Revised: 11/11/2023] [Accepted: 11/12/2023] [Indexed: 11/20/2023]
Abstract
BACKGROUNDS Tacrolimus (TAC) concentration in peripheral blood mononuclear cells (PBMCs) is regarded as a better predictor of its immunosuppressive effect than the TAC concentration in whole blood. However, whether the exposure of TAC in PBMCs or WB was altered in post-transplant recipients with renal impairment remains unclear. METHODS We investigated the relationship of trough TAC concentration in WB and PBMCs with renal functions in post-transplant recipients. The pharmacokinetic profiles of TAC in PBMCs and WB in the two chronic kidney disease (CKD) rat models were examined using UPLC-MS/MS. Western blotting and reverse transcription-quantitative polymerase chain reaction (RT-qPCR) were used to analyze the expression of proteins and mRNAs related to TAC metabolism and transport, respectively. In addition, the effects of uremic toxins on human PBMCs were investigated using whole-transcriptome sequencing (RNA sequencing [RNA-seq]). RESULTS We observed a decrease in the trough TAC concentration in PBMCs in the recipients with estimated glomerular filtration rate (eGFR) < 90 mL/min, compared with those of recipients with eGFR > 90 mL/min, but there was no difference in blood based on TAC concentrations (C0Blood). In a 150-patient post-transplant cohort, no significant relationship was observed between PBMCs and WB concentrations of TAC, and the eGFR value was correlated with TAC C0PBMCs but not with TAC C0Blood. In two CKD rat models, the TAC pharmacokinetic profile in the PBMCs was significantly lower than that in the control group; however, the blood TAC pharmacokinetic profiles in the two groups were similar. Transcriptome results showed that co-incubation of human PBMCs with uremic toxins upregulated the expression of AHR, ABCB1, and ABCC2. Compared to control rats, plasma IS increased by 1.93- and 2.26-fold and the expression of AHR, P-gp, and MRP2 in PBMCs was higher in AD and 5/6 nephrectomy (NX) rats, without modifying the expression of other proteins related to TAC exposure. CONCLUSION The pharmacokinetics of TAC in PBMCs changed with a decline in renal function. Uremic toxins accumulate during renal insufficiency, which activates AHR, upregulates the expression of P-gp and MRP2, and affects their intracellular concentrations. Our findings suggest that monitoring TAC concentrations in PBMCs is more important than monitoring WB concentrations in post-transplant recipients with renal impairment.
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Affiliation(s)
- Pengpeng Guo
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
| | - Rui Zhang
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
| | - Jinping Zhou
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
| | - Peixia Li
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
| | - Yani Liu
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China.
| | - Shaojun Shi
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China.
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Schrezenmeier E, Dörner T, Halleck F, Budde K. Cellular Immunobiology and Molecular Mechanisms in Alloimmunity-Pathways of Immunosuppression. Transplantation 2024; 108:148-160. [PMID: 37309030 DOI: 10.1097/tp.0000000000004646] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Current maintenance immunosuppression commonly comprises a synergistic combination of tacrolimus as calcineurin inhibitor (CNI), mycophenolic acid, and glucocorticoids. Therapy is often individualized by steroid withdrawal or addition of belatacept or inhibitors of the mechanistic target of rapamycin. This review provides a comprehensive overview of their mode of action, focusing on the cellular immune system. The main pharmacological action of CNIs is suppression of the interleukin-2 pathway that leads to inhibition of T cell activation. Mycophenolic acid inhibits the purine pathway and subsequently diminishes T and B cell proliferation but also exerts a variety of effects on almost all immune cells, including inhibition of plasma cell activity. Glucocorticoids exert complex regulation via genomic and nongenomic mechanisms, acting mainly by downregulating proinflammatory cytokine signatures and cell signaling. Belatacept is potent in inhibiting B/T cell interaction, preventing formation of antibodies; however, it lacks the potency of CNIs in preventing T cell-mediated rejections. Mechanistic target of rapamycin inhibitors have strong antiproliferative activity on all cell types interfering with multiple metabolic pathways, partly explaining poor tolerability, whereas their superior effector T cell function might explain their benefits in the case of viral infections. Over the past decades, clinical and experimental studies provided a good overview on the underlying mechanisms of immunosuppressants. However, more data are needed to delineate the interaction between innate and adaptive immunity to better achieve tolerance and control of rejection. A better and more comprehensive understanding of the mechanistic reasons for failure of immunosuppressants, including individual risk/benefit assessments, may permit improved patient stratification.
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Affiliation(s)
- Eva Schrezenmeier
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Academy, Clinician Scientist Program Universitätsmedizin Berlin, Berlin, Germany
| | - Thomas Dörner
- Department of Rheumatology and Clinical Immunology - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Deutsches Rheumaforschungszentrum (DRFZ), Berlin, Germany
| | - Fabian Halleck
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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Takada Y, Tanabe T, Sasaki H, Tsujimoto T, Hotta K, Okada K, Shiono Y, Minami K, Tanaka H, Harada H. Kidney donor age of 50 years or above is a risk factor for calcineurin inhibitor-induced nephrotoxicity. Clin Transplant 2024; 38:e15196. [PMID: 37975424 DOI: 10.1111/ctr.15196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 09/28/2023] [Accepted: 10/27/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION Calcineurin inhibitor (CNI)-induced nephrotoxicity (CNI-T) is a post-transplantation complication that leads to graft dysfunction. Older-donor kidney grafts may be susceptible to chronic CNI exposure because of long-term arteriolar damage. The primary aim of this study was to examine the CNI-T incidence and time-course changes in the graft function according to donor age. METHODS We included 334 kidney transplant recipients. CNI-T was defined by Banff arteriolar hyaline thickening scores of ≥2 based on allograft protocol biopsy. Depending on donor age, participants were divided into the D > 70 (≥70 years), D60 (60-69 years), D50 (50-59 years), and D < 49: (≤49 years) groups. We investigated the extent to which CNI-T affected the transplanted kidney function. Patients who did not develop CNI-T during the study period were included in the non-CNI-T group; the remaining were grouped into the CNI-T group. RESULTS The CNI-T incidence was higher in donors aged >50 years. Compared to D < 49, the CNI-T risk was 1.86 times higher in D50 and 2.9 times higher in D > 70. Furthermore, the CNI-T group exhibited a significantly lower graft function 10 years after transplantation. CONCLUSION CNI-T incidence increases in donors aged ≥50 years and affects renal function after 10 years.
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Affiliation(s)
- Yusuke Takada
- Department of Kidney Transplant Surgery and Urology, Sapporo City General Hospital, Sapporo, Hokkaido, Japan
| | - Tatsu Tanabe
- Department of Kidney Transplant Surgery and Urology, Sapporo City General Hospital, Sapporo, Hokkaido, Japan
| | - Hajime Sasaki
- Department of Kidney Transplant Surgery and Urology, Sapporo City General Hospital, Sapporo, Hokkaido, Japan
| | - Takashi Tsujimoto
- Department of Pharmacy, Sapporo City General Hospital, Sapporo, Hokkaido, Japan
| | - Kiyohiko Hotta
- Department of Urology, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Kazufumi Okada
- Data Science Center, Promotion Unit, Institute of Health Science Innovation for Medical Care, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Yutaka Shiono
- Department of Kidney Transplant Surgery and Urology, Sapporo City General Hospital, Sapporo, Hokkaido, Japan
| | - Keita Minami
- Department of Kidney Transplant Surgery and Urology, Sapporo City General Hospital, Sapporo, Hokkaido, Japan
| | - Hiroshi Tanaka
- Department of Kidney Transplant Surgery and Urology, Sapporo City General Hospital, Sapporo, Hokkaido, Japan
| | - Hiroshi Harada
- Department of Kidney Transplant Surgery and Urology, Sapporo City General Hospital, Sapporo, Hokkaido, Japan
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Ume AC, Wenegieme TY, Shelby JN, Paul-Onyia CDB, Waite AMJ, Kamau JK, Adams DN, Susuki K, Bennett ES, Ren H, Williams CR. Tacrolimus induces fibroblast-to-myofibroblast transition via a TGF-β-dependent mechanism to contribute to renal fibrosis. Am J Physiol Renal Physiol 2023; 324:F433-F445. [PMID: 36927118 PMCID: PMC10085566 DOI: 10.1152/ajprenal.00226.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 02/07/2023] [Accepted: 03/09/2023] [Indexed: 03/18/2023] Open
Abstract
Use of immunosuppressant calcineurin inhibitors (CNIs) is limited by irreversible kidney damage, hallmarked by renal fibrosis. CNIs directly damage many renal cell types. Given the diverse renal cell populations, additional targeted cell types and signaling mechanisms warrant further investigation. We hypothesized that fibroblasts contribute to CNI-induced renal fibrosis and propagate profibrotic effects via the transforming growth factor-β (TGF-β)/Smad signaling axis. To test this, kidney damage-resistant mice (C57BL/6) received tacrolimus (10 mg/kg) or vehicle for 21 days. Renal damage markers and signaling mediators were assessed. To investigate their role in renal damage, mouse renal fibroblasts were exposed to tacrolimus (1 nM) or vehicle for 24 h. Morphological and functional changes in addition to downstream signaling events were assessed. Tacrolimus-treated kidneys displayed evidence of renal fibrosis. Moreover, α-smooth muscle actin expression was significantly increased, suggesting the presence of fibroblast activation. TGF-β receptor activation and downstream Smad2/3 signaling were also upregulated. Consistent with in vivo findings, tacrolimus-treated renal fibroblasts displayed a phenotypic switch known as fibroblast-to-myofibroblast transition (FMT), as α-smooth muscle actin, actin stress fibers, cell motility, and collagen type IV expression were significantly increased. These findings were accompanied by concomitant induction of TGF-β signaling. Pharmacological inhibition of the downstream TGF-β effector Smad3 attenuated tacrolimus-induced phenotypic changes. Collectively, these findings suggest that 1) tacrolimus inhibits the calcineurin/nuclear factor of activated T cells axis while inducing TGF-β1 ligand secretion and receptor activation in renal fibroblasts; 2) aberrant TGF-β receptor activation stimulates Smad-mediated production of myofibroblast markers, notable features of FMT; and 3) FMT contributes to extracellular matrix expansion in tacrolimus-induced renal fibrosis. These results incorporate renal fibroblasts into the growing list of CNI-targeted cell types and identify renal FMT as a process mediated via a TGF-β-dependent mechanism.NEW & NOTEWORTHY Renal fibrosis, a detrimental feature of irreversible kidney damage, remains a sinister consequence of long-term calcineurin inhibitor (CNI) immunosuppressive therapy. Our study not only incorporates renal fibroblasts into the growing list of cell types negatively impacted by CNIs but also identifies renal fibroblast-to-myofibroblast transition as a process mediated via a TGF-β-dependent mechanism. This insight will direct future studies investigating the feasibility of inhibiting TGF-β signaling to maintain CNI-mediated immunosuppression while ultimately preserving kidney health.
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Affiliation(s)
- Adaku C Ume
- Department of Neuroscience, Cell Biology, and Physiology, Boonshoft School of Medicine and College of Science and Mathematics, Wright State University, Dayton, Ohio, United States
| | - Tara Y Wenegieme
- Department of Neuroscience, Cell Biology, and Physiology, Boonshoft School of Medicine and College of Science and Mathematics, Wright State University, Dayton, Ohio, United States
| | - Jennae N Shelby
- Department of Neuroscience, Cell Biology, and Physiology, Boonshoft School of Medicine and College of Science and Mathematics, Wright State University, Dayton, Ohio, United States
| | - Chiagozie D B Paul-Onyia
- Department of Neuroscience, Cell Biology, and Physiology, Boonshoft School of Medicine and College of Science and Mathematics, Wright State University, Dayton, Ohio, United States
| | - Aston M J Waite
- Department of Neuroscience, Cell Biology, and Physiology, Boonshoft School of Medicine and College of Science and Mathematics, Wright State University, Dayton, Ohio, United States
| | - John K Kamau
- Department of Biochemistry and Molecular Biology, Boonshoft School of Medicine and College of Science and Mathematics, Wright State University, Dayton, Ohio, United States
| | - Danielle N Adams
- Department of Neuroscience, Cell Biology, and Physiology, Boonshoft School of Medicine and College of Science and Mathematics, Wright State University, Dayton, Ohio, United States
| | - Keiichiro Susuki
- Department of Neuroscience, Cell Biology, and Physiology, Boonshoft School of Medicine and College of Science and Mathematics, Wright State University, Dayton, Ohio, United States
| | - Eric S Bennett
- Department of Neuroscience, Cell Biology, and Physiology, Boonshoft School of Medicine and College of Science and Mathematics, Wright State University, Dayton, Ohio, United States
- Department of Biochemistry and Molecular Biology, Boonshoft School of Medicine and College of Science and Mathematics, Wright State University, Dayton, Ohio, United States
| | - Hongmei Ren
- Department of Biochemistry and Molecular Biology, Boonshoft School of Medicine and College of Science and Mathematics, Wright State University, Dayton, Ohio, United States
| | - Clintoria R Williams
- Department of Neuroscience, Cell Biology, and Physiology, Boonshoft School of Medicine and College of Science and Mathematics, Wright State University, Dayton, Ohio, United States
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Spasovski G, Trajceska L, Rambabova-Bushljetik I. Pharmacotherapeutic options for the prevention of kidney transplant rejection: the evidence to date. Expert Opin Pharmacother 2022; 23:1397-1412. [PMID: 35835450 DOI: 10.1080/14656566.2022.2102418] [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: 11/04/2022]
Abstract
INTRODUCTION Although early rejection episodes are successfully controlled, the problem of unrecognized production of de novo anti HLA antibodies and associated chronic rejection still persists. AREAS COVERED In addition to the standard induction and maintenance therapy, we present a couple of new drugs as induction (Alemtuzumab), CNI free protocol (Belatacept, Sirolimus, Everolimus), maintenance treatment in transplant patients with various type of malignancies (T cell targeted immunomodulators blocking the immune checkpoints CTLA-4, PD1/PDL1) and TMA (aHUS) -eculizimab, and IL6 receptor antagonists in antibody mediated rejection (AMR). EXPERT OPINION There are couple of issues still preventing improvement in kidney transplant long-term outcomes with current and anticipated future immunosuppression: patient more susceptible to infection and CNI nephrotoxicity in kidneys obtained from elderly donors, highly sensitized patients with limited chances to get appropriate kidney and a higher risk for late AMR. A lower rate of CMV/BK virus infections has been observed in everolimus treated patients. Belatacept use has been justified only in EBV seropositive kidney transplants due to the increased risk of PTLD. Eculizumab upon recurrence of aHUS is a sole cost-effective option. A new IL-6 blocking drug (clazakizumab/tocilizumab) is promising option for prevention/treatment of AMR. Clinical experience in tailoring immunosuppression for as long as possible graft and patient survival is inevitable.
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Affiliation(s)
- Goce Spasovski
- University Department of Nephrology, Medical Faculty, University Sts Cyril and Methodius, Skopje, N. Macedonia
| | - Lada Trajceska
- University Department of Nephrology, Medical Faculty, University Sts Cyril and Methodius, Skopje, N. Macedonia
| | - Irena Rambabova-Bushljetik
- University Department of Nephrology, Medical Faculty, University Sts Cyril and Methodius, Skopje, N. Macedonia
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Nordheim E, Raki M, Midtvedt K. Case Report: Let Us Not Forget the Treatment That Some Patients Have Received-The Brief 50-Year History of a Kidney Transplant Survivor. Front Med (Lausanne) 2022; 9:906925. [PMID: 35685423 PMCID: PMC9170981 DOI: 10.3389/fmed.2022.906925] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 05/03/2022] [Indexed: 11/23/2022] Open
Abstract
Background There has been a considerable improvement in post-transplant care since the early 1960s. Some patients we meet in the clinic have personally experienced this progress and have histories to tell that one must not forget. This is the brief history of a long-time “transplant survivor.” Case Presentation In 1970, a young woman developed acute oedema, proteinuria, hypertension and oliguria during pregnancy. Labor was induced, but neither the child nor the kidney function could be saved. Our patient started dialysis, and 4 years later received a kidney transplant donated by her father (then 55 years of age). Maintenance immunosuppression consisted of prednisolone and azathioprine until 2011, when azathioprine was switched to everolimus due to skin cancer. Before this, our patient was highly satisfied with prednisolone/azathioprine, despite discussions regarding newer immunosuppressive drugs, and always reminded the treating physician that one should “never change a winning team.” Retrospectively, the avoidance of calcineurin inhibitors might have been beneficial for this patient who still has preserved an excellent renal function with s-creatinine levels around 100 μmol/L and just had sparse fibrosis detected in a recently performed transplant biopsy. The transplanted kidney is now 101 years old and is still working 24/7. Conclusions Our patient received a kidney transplant for 46 years ago and still has a remarkably stable transplant function with s-creatinine levels around 100 μmol/L. This case report illustrates the potential endurance of the kidneys and is a reminder to keep taking individualized treatment decisions even though new treatment alternatives promise superiority.
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Affiliation(s)
- Espen Nordheim
- Department of Transplantation Medicine, Section of Nephrology, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,Department of Nephrology, Oslo University Hospital, Oslo, Norway
| | - Melinda Raki
- Department of Pathology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Karsten Midtvedt
- Department of Transplantation Medicine, Section of Nephrology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
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10
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Warzyszyńska K, Zawistowski M, Karpeta E, Jałbrzykowska A, Kosieradzki M. Renal Cyp3a5-Expressing Genotype Decreases Tacrolimus-to-Dose Ratio in Small Cohort of Renal Transplant Recipients—Preliminary Report. Transplant Proc 2022; 54:960-967. [DOI: 10.1016/j.transproceed.2022.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 02/10/2022] [Accepted: 02/18/2022] [Indexed: 11/29/2022]
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11
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Karolin A, Escher G, Rudloff S, Sidler D. Nephrotoxicity of Calcineurin Inhibitors in Kidney Epithelial Cells is Independent of NFAT Signaling. Front Pharmacol 2022; 12:789080. [PMID: 35140605 PMCID: PMC8819135 DOI: 10.3389/fphar.2021.789080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 12/29/2021] [Indexed: 01/01/2023] Open
Abstract
Background: Calcineurin inhibitors (CNIs) such as cyclosporine A and tacrolimus are commonly used after renal transplantation to suppress the immune system. In lymphoid cells, cyclosporine A acts via the calcineurin/nuclear factor of activated T-cell (NFAT) axis. In non-lymphoid cells, such as kidney epithelial cells, cyclosporine A induces calcineurin inhibitor toxicity. It is unknown via which off-targets cyclosporine A induces calcineurin inhibitor toxicity in kidney epithelial cells. Methods: To measure a compound’s potential to induce nephrotoxicity, the expression of the surrogate marker Fn14 was measured by flow cytometry. Compounds were tested for their potential to induce Fn14 either chemically or plasmid-mediated. Mice were injected with various compounds, and changes in nephrotoxic gene expression levels of the kidney epithelial cells were then analyzed. Results: Fn14 is specifically upregulated due to calcineurin inhibitor toxicity inducing agents. Inhibition of the NFAT axis showed no increase of the Fn14 expression on the surface of kidney cells. However, inhibition of p38 MAPK, phosphoinositide-3-kinase (PI3K)/Akt, protein kinase C (PKC), and inhibitor of nuclear factor-κB (IκB) kinase (IKK) showed clear induction of Fn14 and increased expressions of nephrotoxic, inflammatory, and fibrotic genes in vitro and in vivo. Conclusions: These findings show that cyclosporine A acts independently of NFAT on kidney epithelial cells. Moreover, inhibition of serine/threonine protein kinases mimics cyclosporine A’s activity on kidney epithelial cells. This mimicking effect indicates that these protein kinases are off-targets of cyclosporine A and damage structural renal cells when inhibited and therefore contributes likely to the development and progression of calcineurin inhibitor toxicity.
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Affiliation(s)
- Andrea Karolin
- Department for Nephrology and Hypertension, University Hospital Insel Bern, Bern, Switzerland
- Graduate School for Cellular and Biomedical Sciences, University of Bern, Bern, Switzerland
| | - Geneviève Escher
- Department for Nephrology and Hypertension, University Hospital Insel Bern, Bern, Switzerland
| | - Stefan Rudloff
- Department for Nephrology and Hypertension, University Hospital Insel Bern, Bern, Switzerland
| | - Daniel Sidler
- Department for Nephrology and Hypertension, University Hospital Insel Bern, Bern, Switzerland
- *Correspondence: Daniel Sidler,
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12
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Song JY, Lee KW, Kim K, Kim KD, Yang J, Kwon JE, Lee O, Park JB. Recipient efficacy and safety of kidney transplantation from older living donor: consideration for using older kidney as a solution to the shortage of organs. KOREAN JOURNAL OF TRANSPLANTATION 2021; 35:238-246. [PMID: 35769855 PMCID: PMC9235463 DOI: 10.4285/kjt.21.0020] [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: 08/27/2021] [Revised: 09/16/2021] [Accepted: 10/20/2021] [Indexed: 11/30/2022] Open
Abstract
Background As a solution to organ shortages, studies on kidney transplantation (KT) from older donors are being conducted. However, many controversies remain about its safety and efficacy. Methods In Samsung Medical Center, from January 2000 to May 2015, 1,141 patients underwent living KT. Cases of retransplantation, recipient and donor aged younger than 18 years, and multiorgan transplantation were excluded, and a total of 859 cases were selected. Analysis was performed by dividing the patents into two groups a younger donor group (donors <60 years old; n=826) and an older donor group (donors ≥60 years old; n=33). Results There were no significant differences between the two groups in patient death (log-rank P=0.173) or in postoperative complications. The older donor group had a higher acute rejection (P=0.034; hazard ratio [HR], 1.704) and graft failure rate (P=0.029, HR=2.352). There was no significant difference in the trend of estimated glomerular filtration rate over time (P=0.189). Conclusions KT using kidneys from old-aged donors is safe, but there is room for improvement due to problems with higher acute rejection and graft failure rate.
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Affiliation(s)
- Ji Yeon Song
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyo Won Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyunga Kim
- Biomedical Statistics Center, Data Science Research Institute, Research Institute for Future Medicine, Samsung Medical Center, Seoul, Korea
- Department of Digital Health, Samsung Advanced Institute for Health Sciences and Technology, Sungkyunkwan University, Seoul, Korea
| | - Kyeong Deok Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jaehun Yang
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji Eun Kwon
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Okjoo Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Berm Park
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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13
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Ramazani Y, Knops N, Berlingerio SP, Adebayo OC, Lismont C, Kuypers DJ, Levtchenko E, van den Heuvel LP, Fransen M. Therapeutic concentrations of calcineurin inhibitors do not deregulate glutathione redox balance in human renal proximal tubule cells. PLoS One 2021; 16:e0250996. [PMID: 33930094 PMCID: PMC8087105 DOI: 10.1371/journal.pone.0250996] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 04/18/2021] [Indexed: 12/16/2022] Open
Abstract
The calcineurin inhibitors (CNI) cyclosporine A and tacrolimus comprise the basis of immunosuppressive regimes in all solid organ transplantation. However, long-term or high exposure to CNI leads to histological and functional renal damage (CNI-associated nephrotoxicity). In the kidney, proximal tubule cells are the only cells that metabolize CNI and these cells are believed to play a central role in the origin of the toxicity for this class of drugs, although the underlying mechanisms are not clear. Several studies have reported oxidative stress as an important mediator of CNI-associated nephrotoxicity in response to CNI exposure in different available proximal tubule cell models. However, former models often made use of supra-therapeutic levels of tissue drug exposure. In addition, they were not shown to express the relevant enzymes (e.g., CYP3A5) and transporters (e.g., P-glycoprotein) for the metabolism of CNI in human proximal tubule cells. Moreover, the used methods for detecting ROS were potentially prone to false positive results. In this study, we used a novel proximal tubule cell model established from human allograft biopsies that demonstrated functional expression of relevant enzymes and transporters for the disposition of CNI. We exposed these cells to CNI concentrations as found in tissue of stable solid organ transplant recipients with therapeutic blood concentrations. We measured the glutathione redox balance in this cell model by using organelle-targeted variants of roGFP2, a highly sensitive green fluorescent reporter protein that dynamically equilibrates with the glutathione redox couple through the action of endogenous glutaredoxins. Our findings provide evidence that CNI, at concentrations commonly found in allograft biopsies, do not alter the glutathione redox balance in mitochondria, peroxisomes, and the cytosol. However, at supra-therapeutic concentrations, cyclosporine A but not tacrolimus increases the ratio of oxidized/reduced glutathione in the mitochondria, suggestive of imbalances in the redox environment.
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Affiliation(s)
- Yasaman Ramazani
- Laboratory of Pediatric Nephrology, Department of Growth and Regeneration, University of Leuven, Leuven, Belgium
| | - Noël Knops
- Laboratory of Pediatric Nephrology, Department of Growth and Regeneration, University of Leuven, Leuven, Belgium
- Department of Pediatric Nephrology and Solid Organ Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Sante Princiero Berlingerio
- Laboratory of Pediatric Nephrology, Department of Growth and Regeneration, University of Leuven, Leuven, Belgium
| | | | - Celien Lismont
- Laboratory of Peroxisome Biology and Intracellular Communication, Department of Cellular and Molecular Medicine, University of Leuven, Leuven, Belgium
| | - Dirk J. Kuypers
- Department of Nephrology and Renal Transplantation and Department of Microbiology, Immunology and Transplantation, University of Leuven, Leuven, Belgium
| | - Elena Levtchenko
- Laboratory of Pediatric Nephrology, Department of Growth and Regeneration, University of Leuven, Leuven, Belgium
- Department of Pediatric Nephrology and Solid Organ Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Lambert P. van den Heuvel
- Laboratory of Pediatric Nephrology, Department of Growth and Regeneration, University of Leuven, Leuven, Belgium
- Translational Metabolic Laboratory and Department of Pediatric Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marc Fransen
- Laboratory of Peroxisome Biology and Intracellular Communication, Department of Cellular and Molecular Medicine, University of Leuven, Leuven, Belgium
- * E-mail:
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14
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Wang S, Wang Y, Qiu K, Zhu J, Wu Y. RCAN1 in cardiovascular diseases: molecular mechanisms and a potential therapeutic target. Mol Med 2020; 26:118. [PMID: 33267791 PMCID: PMC7709393 DOI: 10.1186/s10020-020-00249-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 11/26/2020] [Indexed: 02/07/2023] Open
Abstract
Cardiovascular diseases (CVDs) are the leading cause of mortality worldwide. Considerable efforts are needed to elucidate the underlying mechanisms for the prevention and treatment of CVDs. Regulator of calcineurin 1 (RCAN1) is involved in both development/maintenance of the cardiovascular system and the pathogenesis of CVDs. RCAN1 reduction protects against atherosclerosis by reducing the uptake of oxidized low-density lipoproteins, whereas RCAN1 has a protective effect on myocardial ischemia/reperfusion injury, myocardial hypertrophy and intramural hematoma/aortic rupture mainly mediated by maintaining mitochondrial function and inhibiting calcineurin and Rho kinase activity, respectively. In this review, the regulation and the function of RCAN1 are summarized. Moreover, the dysregulation of RCAN1 in CVDs is reviewed. In addition, the beneficial role of RCAN1 reduction in atherosclerosis and the protective role of RCAN1 in myocardial ischemia/reperfusion injury, myocardial hypertrophy and intramural hematoma /aortic rupture are discussed, as well as underlying mechanisms. Furthermore, the therapeutic potential and challenges of targeting RCAN1 for CVDs treatment are also discussed.
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Affiliation(s)
- Shuai Wang
- Shandong Collaborative Innovation Center for Diagnosis, Treatment and Behavioral Interventions of Mental Disorders, Institute of Mental Health, Jining Medical University, Jianshe South Road No. 45, Rencheng District, Jining, 272013, Shandong, China.,Shandong Key Laboratory of Behavioral Medicine, School of Mental Health, Jining Medical University, Jianshe South Road No. 45, Rencheng District, Jining, 272013, Shandong, China
| | - Yuqing Wang
- Shandong Collaborative Innovation Center for Diagnosis, Treatment and Behavioral Interventions of Mental Disorders, Institute of Mental Health, Jining Medical University, Jianshe South Road No. 45, Rencheng District, Jining, 272013, Shandong, China.,Shandong Key Laboratory of Behavioral Medicine, School of Mental Health, Jining Medical University, Jianshe South Road No. 45, Rencheng District, Jining, 272013, Shandong, China.,Cheeloo College of Medicine, Shandong University, Wenhua West Road No. 44, Lixia District, JinanShandong, 250012, China
| | - Kaixin Qiu
- Shandong Collaborative Innovation Center for Diagnosis, Treatment and Behavioral Interventions of Mental Disorders, Institute of Mental Health, Jining Medical University, Jianshe South Road No. 45, Rencheng District, Jining, 272013, Shandong, China.,Shandong Key Laboratory of Behavioral Medicine, School of Mental Health, Jining Medical University, Jianshe South Road No. 45, Rencheng District, Jining, 272013, Shandong, China.,Cheeloo College of Medicine, Shandong University, Wenhua West Road No. 44, Lixia District, JinanShandong, 250012, China
| | - Jin Zhu
- Shandong Collaborative Innovation Center for Diagnosis, Treatment and Behavioral Interventions of Mental Disorders, Institute of Mental Health, Jining Medical University, Jianshe South Road No. 45, Rencheng District, Jining, 272013, Shandong, China.,Shandong Key Laboratory of Behavioral Medicine, School of Mental Health, Jining Medical University, Jianshe South Road No. 45, Rencheng District, Jining, 272013, Shandong, China
| | - Yili Wu
- Shandong Collaborative Innovation Center for Diagnosis, Treatment and Behavioral Interventions of Mental Disorders, Institute of Mental Health, Jining Medical University, Jianshe South Road No. 45, Rencheng District, Jining, 272013, Shandong, China. .,Shandong Key Laboratory of Behavioral Medicine, School of Mental Health, Jining Medical University, Jianshe South Road No. 45, Rencheng District, Jining, 272013, Shandong, China.
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15
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Ambarsari CG, Hidayati EL, Hasan I, Grace A, Oswari H. Successful Treatment of Hepatitis C Virus Infection Using Direct-Acting Antiviral Agents (DAAs) in Adolescents with Kidney Transplantation: A Case Series. Int J Nephrol Renovasc Dis 2020; 13:139-146. [PMID: 32606888 PMCID: PMC7292374 DOI: 10.2147/ijnrd.s248632] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 05/14/2020] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Hepatitis C virus (HCV) infection is common among end-stage renal disease patients undergoing hemodialysis. The standard treatment for HCV infection has been interferon-ribavirin combination prior to renal transplantation. However, compared to direct-acting antiviral agents (DAAs), the risk of graft rejection is higher with interferon therapy. Many recent studies have investigated the efficacy and safety of DAAs for treating HCV infection in kidney disease in adults; however, it has not been established in pediatric patients. To the best of our knowledge, this is the first report describing successful treatment using the DAAs sofosbuvir/daclatasvir in two pediatric kidney transplant recipients who had HCV genotype 1a infection without liver fibrosis. CASE PRESENTATION Case 1 describes a 13-year-old Indonesian boy who had undergone hemodialysis since 2014 after being diagnosed with end-stage renal disease (ESRD) secondary to bilateral renal hypoplasia. Later, he had HCV infection and was treated with interferon-based therapy with ribavirin prior to living-related renal transplantation (LRRT). The HCV was undetected and his liver function normalized six months after treatment initiation. However, 10 months after treatment initiation, he had HCV virological breakthrough, leading to cessation of interferon therapy. Plans for LRRT were continued and HCV treatment using DAAs was set up to be given post LRRT. Case 2 describes a 14-year-old Indonesian girl who also had hemodialysis prior to LRRT after she was diagnosed with ESRD secondary to nephrotic syndrome. Later, she had HCV infection and was treated with interferon and ribavirin prior to the live-unrelated renal transplantation. HCV infection did not resolve, in addition, she experienced thrombocytopenia-which is a side effect of interferon-resulting in termination of interferon treatment. Both cases were treated with DAAs one year following renal transplantation after reaching stable graft function, leading to achievement of sustained virological response at 24 weeks. CONCLUSION Post-transplantation treatment of chronic HCV is preferred in KTRs. The sofosbuvir/daclatasvir regimen as an interferon-free therapy is a safe, effective option for HCV infection in pediatric KTRs, who can tolerate sofosbuvir/daclatasvir well and respond favorably without significant adverse events.
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Affiliation(s)
- Cahyani Gita Ambarsari
- Department of Child Health, Faculty of Medicine, Universitas Indonesia - Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Eka Laksmi Hidayati
- Department of Child Health, Faculty of Medicine, Universitas Indonesia - Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Irsan Hasan
- Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Angela Grace
- Department of Child Health, Faculty of Medicine, Universitas Indonesia - Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Hanifah Oswari
- Department of Child Health, Faculty of Medicine, Universitas Indonesia - Cipto Mangunkusumo Hospital, Jakarta, Indonesia
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16
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Gao P, Guan XL, Huang R, Shang-Guan XF, Luan JW, Liu MC, Xu H, Wang XW. Risk factors and clinical characteristics of tacrolimus-induced acute nephrotoxicity in children with nephrotic syndrome: a retrospective case-control study. Eur J Clin Pharmacol 2019; 76:277-284. [PMID: 31745585 DOI: 10.1007/s00228-019-02781-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 10/10/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE Acute nephrotoxicity is a common adverse reaction of tacrolimus therapy; however, its risk factors in pediatric nephrotic syndrome (NS) remain to be evaluated. The objective of this study was to investigate the risk factors and characteristics of tacrolimus-induced acute nephrotoxicity in children with NS. METHODS Past records of children with NS admitted to our hospital from 2014 to 2018 were reviewed. The incidence and characteristics of nephrotoxicity were analyzed. Multivariate logistic regression analysis was used to identify the risk factors of nephrotoxicity. A clinically applicable risk score was developed and validated. RESULTS Tacrolimus-induced nephrotoxicity occurred in 25 of 129 patients, 13 patients were grade 1, and the renal function was recovered in 22 patients. Multivariate regression analysis showed that the maximum trough concentrations (C12h) of tacrolimus (OR, 1.48; 95% CI, 1.16 to 1.88; P < 0.001), huaiqihuang granules (OR, 0.095; 95% CI, 0.014 to 0.66; P = 0.017), and diarrhea (OR, 22.00; 95% CI, 1.58 to 306.92; P = 0.022) were independently associated with tacrolimus-induced nephrotoxicity. The maximum C12h were significantly higher in patients with nephrotoxicity (median 9.0 ng/ml) and the cut-off value for acute nephrotoxicity was 6.5 ng/ml. The area under the receiver operating characteristic curve was 0.821 for the proposed model based on the observations used to create the model and 0.817 obtained from k-fold cross-validation. CONCLUSIONS High trough concentration of tacrolimus and diarrhea can potentiate the risk of tacrolimus-induced acute nephrotoxicity in children with NS, while huaiqihuang granules can protect this condition.
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Affiliation(s)
- Ping Gao
- Department of Clinical Pharmacy, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xin-Lei Guan
- Department of Pharmacy, Wuhan Fourth Hospital, Puai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Rui Huang
- School of Pharmacy, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiao-Fang Shang-Guan
- School of Pharmacy, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jiang-Wei Luan
- Department of Nephrology, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Mao-Chang Liu
- Department of Clinical Pharmacy, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hua Xu
- Department of Clinical Pharmacy, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Xiao-Wen Wang
- Department of Nephrology, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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17
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mTOR Inhibitor in Combination with Cyclosporine as Primary Maintenance Immunosuppression in Combined Kidney/Pancreas Transplant Recipients. CURRENT TRANSPLANTATION REPORTS 2019. [DOI: 10.1007/s40472-019-00246-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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18
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Sen A, Callisen H, Libricz S, Patel B. Complications of Solid Organ Transplantation: Cardiovascular, Neurologic, Renal, and Gastrointestinal. Crit Care Clin 2018; 35:169-186. [PMID: 30447778 DOI: 10.1016/j.ccc.2018.08.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Despite improvements in overall graft function and patient survival rates after solid organ transplantation, complications can lead to significant morbidity and mortality. Cardiovascular complications include heart failure, arrhythmias leading to sudden death, hypertension, left ventricular hypertrophy, and allograft vasculopathy in heart transplantation. Neurologic complications include stroke, posterior reversible encephalopathy syndrome, infections, neuromuscular disease, seizure disorders, and neoplastic disease. Acute kidney injury occurs from immunosuppression with calcineurin inhibitors or as a result of graft failure after kidney transplantation. Gastrointestinal complications include infections, malignancy, mucosal ulceration, perforation, biliary tract disease, pancreatitis, and diverticular disease. Immunosuppression can predispose to infections and malignancy.
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Affiliation(s)
- Ayan Sen
- Department of Critical Care Medicine, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA.
| | - Hannelisa Callisen
- Department of Critical Care Medicine, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Stacy Libricz
- Department of Critical Care Medicine, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Bhavesh Patel
- Department of Critical Care Medicine, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
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