Low Content of Cyclosporine A and Its Metabolites in the Colostrum of Post-Transplant Mothers

Drugs in Human Milk Part 1: Practical and Analytical Considerations in Measuring Drugs and Metabolites in Human Milk

Human milk is a remarkable biofluid that provides essential nutrients and immune protection to newborns. Breastfeeding women consuming medications could pass the drug through their milk to neonates. Drugs can be transferred to human milk by passive diffusion or active transport. The physicochemical properties of the drug largely impact the extent of drug transfer into human milk. A comprehensive understanding of the physiology of human milk formation, composition of milk, mechanisms of drug transfer, and factors influencing drug transfer into human milk is critical for appropriate selection and use of medications in lactating women. Quantification of drugs in the milk is essential for assessing the safety of pharmacotherapy during lactation. This can be achieved by developing specific, sensitive, and reproducible analytical methods using techniques such as liquid chromatography coupled with mass spectrometry. The present review briefly discusses the physiology of human milk formation, composition of human milk, mechanisms of drug transfer into human milk, and factors influencing transfer of drugs from blood to milk. We further expand upon and critically evaluate the existing analytical approaches/assays used for the quantification of drugs in human milk.

Metabolic network and proteomic expression perturbed by cyclosporine A to model microbe Escherichia coli

Cyclosporine A (CsA) is a model drug that has caused great concern due to its widespread use and abuse in the environment. However, the potential harm of CsA to organisms also remains largely unknown, and this issue is exceptionally important for the health risk assessment of antibiotics. To address this concern, the crosstalk between CsA stress and cellular metabolism at the proteomic level in Escherichia coli was investigated and dissected in this study. The results showed that CsA inhibited E. coli growth in a time-dependent manner. CsA induced reactive oxygen species (ROS) overproduction in a dose- and time-dependent manner, leading to membrane depolarization followed by cell apoptosis. In addition, translation, the citric acid cycle, amino acid biosynthesis, glycolysis and responses to oxidative stress and heat were the central metabolic pathways induced by CsA stress. The upregulated proteins, including PotD, PotF and PotG, controlled cell growth. The downregulated proteins, including SspA, SspB, CstA and DpS, were regulators of self-feedback during the starvation process. And the up- and downregulated proteins, including AtpD, Adk, GroS, GroL and DnaK, controlled energy production. These results provide an important reference for the environmental health risk assessment of CsA.

Breastfeeding by a mother taking cyclosporine for nephrotic syndrome

Background

Cyclosporine is widely used for immunosuppressive treatment of various systematic and local autoimmune diseases. Breastfeeding is conventionally contraindicated when treating with cyclosporine due to its excretion into breast milk, which may cause immune suppression of exposed infants and affect infants` growth. A few cases have tested cyclosporine levels in random breast milk samples and concluded the infants exposed to safe cyclosporine levels during breastfeeding. Since infants do not maintain a fixed feeding schedule, we monitored cyclosporine levels in breast milk at different times of the day to assess the safety of breast milk for infants throughout the day.

Case presentation

A 32-year-old dichorionic twin-pregnancy woman had nephrotic syndrome with renal biopsy confirmed type V lupus nephritis for over five years. She was treated only with prednisone 10 mg a day before pregnancy and during early pregnancy. Cyclosporine was added in her regimen from 22 weeks gestation and was adjusted to 225 mg a day from 28 weeks gestation. After parturition, she partially breastfed her twin infants while being treated with cyclosporine 3 mg/kg a day as well as prednisone and hydroxychloroquine sulfate. The cyclosporine level in maternal blood was determined, and several breast milk samples were collected for consecutive 48 h beginning on the ninth day after parturition. The concentration of cyclosporine in breast milk was measured and ranged from 0.443 to 5.307 mcg/L. Both infants grew and developed normally at the three-month follow-up, with no adverse effects observed. The study was conducted at West China Second University Hospital of Sichuan University, started in September 2021, with the consent of the participant and the approval of the ethics committee.

Conclusion

In this case, cyclosporine levels in breast milk were low at all times of the day. The growth and development of both infants were normal at three months postpartum. Thus, breastfeeding may still be an option for mothers with nephrotic syndrome who are treated with cyclosporine.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13006-022-00514-4.

Outcomes of Children with Fetal and Lactation Immunosuppression Exposure Born to Female Transplant Recipients

Solid organ transplantation (SOT) is a lifesaving procedure for those with end-stage kidney, liver, heart, lung, and intestinal diseases, including females of childbearing age who wish to proceed with pregnancy following transplantation. While there is clear risk associated with use of mycophenolate during pregnancy, the risks associated with use of other immunosuppressant agents are less well understood, and the timing of use in pregnancy may be pertinent when considering the risk versus benefit for individual patients. In addition to overall fetal outcomes, including gestational age, birth weight, and mortality, this review summarizes published literature on additional complications that have been examined in association with maternal use during pregnancy and postpartum while breastfeeding. Compared with non-transplant pregnancies, pregnancies in transplant recipients are associated with lower birth weight and earlier gestational age. Effects associated with particular immunosuppressant agents in the infant include renal dysfunction from calcineurin inhibitors, myelosuppression from azathioprine, and decreased circulating immune cells with several agents. However, these effects are noted to primarily be transient, though the decrease in immune cells may predispose the infant to increased infectious complications in the first year of life. Utilizing relative infant dose estimations, nearly all commonly utilized immunosuppressants are likely safe during breastfeeding given the limited exposure to the infant.