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Fan Y, Wang Y, Xiao H, Sun H. Advancements in understanding the role of intestinal dysbacteriosis mediated mucosal immunity in IgA nephropathy. BMC Nephrol 2024; 25:203. [PMID: 38907188 PMCID: PMC11191200 DOI: 10.1186/s12882-024-03646-3] [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: 04/14/2024] [Accepted: 06/18/2024] [Indexed: 06/23/2024] Open
Abstract
IgA nephropathy, presently recognized as the foremost primary glomerular disorder, emerges as a principal contributor to renal failure globally, with its pathogenesis yet to be fully elucidated. Extensive research has highlighted the critical role of gut microbiome in the onset and progression of IgA nephropathy, underscoring its importance in accurately delineating the disease's etiology. For example, gut microbiome dysbacteriosis can lead to the production of nephritogenic IgA1 antibodies, which form immune complexes that deposit in the kidneys, causing inflammation and damage. The gut microbiome, a source of numerous bioactive compounds, interacts with the host and plays a regulatory role in gut-immune axis modulation, earning it the moniker of the "second brain." Recent investigations have particularly emphasized a significant correlation between IgA nephropathy and gut microbiome dysbacteriosis. This article offers a detailed overview of the pathogenic mechanisms of IgA nephropathy, specifically focusing on elucidating how alterations in the gut microbiome are associated with anomalies in the intestinal mucosal system in IgA nephropathy. Additionally, it describes the possible influence of gut microbiome on recurrent IgA nephropathy following kidney transplantation. Furthermore, it compiles potential therapeutic interventions, offering both theoretical and practical foundations for the management of IgA nephropathy. Lastly, the challenges currently faced in the therapeutic approaches to IgA nephropathy are discussed.
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Affiliation(s)
- Yitao Fan
- The Second Clinical Medical College of Lanzhou University, Lanzhou, 730030, Gansu, China
- Cuiying Biomedical Research Center, Lanzhou University Second Hospital, Lanzhou, 730030, Gansu, China
| | - Yan Wang
- The Second Clinical Medical College of Lanzhou University, Lanzhou, 730030, Gansu, China
- Cuiying Biomedical Research Center, Lanzhou University Second Hospital, Lanzhou, 730030, Gansu, China
| | - Han Xiao
- The Second Clinical Medical College of Lanzhou University, Lanzhou, 730030, Gansu, China
- Cuiying Biomedical Research Center, Lanzhou University Second Hospital, Lanzhou, 730030, Gansu, China
| | - Hui Sun
- The Second Clinical Medical College of Lanzhou University, Lanzhou, 730030, Gansu, China.
- Cuiying Biomedical Research Center, Lanzhou University Second Hospital, Lanzhou, 730030, Gansu, China.
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2
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Verona P, Edwards J, Hubert K, Avorio F, Re VL, Di Stefano R, Carollo A, Johnson H, Provenzani A. Tacrolimus-Induced Neurotoxicity After Transplant: A Literature Review. Drug Saf 2024; 47:419-438. [PMID: 38353884 DOI: 10.1007/s40264-024-01398-5] [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: 01/18/2024] [Indexed: 04/17/2024]
Abstract
Tacrolimus, a calcineurin inhibitor, is an immunosuppressant used globally to prevent rejection after organ transplantation. Although it significantly improves outcomes for solid organ transplant patients, it is associated with various side effects such as nephrotoxicity and neurotoxicity. Tacrolimus-induced neurotoxicity is frequently encountered in clinical practice and can present with a variety of symptoms that may occur even at therapeutic levels. Although tacrolimus-induced neurotoxicity is well documented, there is limited literature available on pharmacologic management. Twenty-eight case reports of tacrolimus-induced neurotoxicity were identified and analyzed in addition to other literature including reviews, retrospective studies, and animal model studies. The severity of cases of tacrolimus-induced neurotoxicity reported ranged from mild symptoms that could be managed with symptomatic treatment to conditions such as posterior reversible encephalopathy syndrome and chronic inflammatory demyelinating polyradiculoneuropathy that may require more immediate intervention. This information was utilized in addition to clinical experience to compile potential management options for prevention and treatment of neurotoxic adverse events. This review is limited by the utilization of primarily retrospective studies and case reports. The available literature on the subject is largely narrative and there are no guidelines on treatment of tacrolimus-induced neurotoxicity at the time of this research. This comprehensive review may guide further studies to investigate the pathophysiology of tacrolimus-induced neurotoxicity and to define patient-specific strategies for mitigation or minimization of neurotoxicity. This is especially important given that management of tacrolimus-induced neurotoxicity can include changes to immunosuppression that can result in an increased risk of rejection.
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Affiliation(s)
- Paige Verona
- School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jocelyn Edwards
- School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kassidy Hubert
- School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Federica Avorio
- Neurology Unit, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
| | - Vincenzina Lo Re
- Neurology Unit, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
| | - Roberta Di Stefano
- Clinical Pharmacy Service, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Via E.Tricomi n. 5, 90127, Palermo, Italy
| | - Anna Carollo
- Clinical Pharmacy Service, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Via E.Tricomi n. 5, 90127, Palermo, Italy
| | - Heather Johnson
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, 3501 Terrace Street, Pittsburgh, PA, USA
| | - Alessio Provenzani
- Clinical Pharmacy Service, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Via E.Tricomi n. 5, 90127, Palermo, Italy.
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3
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Fragoulakis V, Koufaki MI, Joefield-Roka C, Sunder-Plassmann G, Mitropoulou C. Cost-utility analysis of pharmacogenomics-guided tacrolimus treatment in Austrian kidney transplant recipients participating in the U-PGx PREPARE study. THE PHARMACOGENOMICS JOURNAL 2024; 24:10. [PMID: 38499549 DOI: 10.1038/s41397-024-00330-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 02/17/2024] [Accepted: 03/05/2024] [Indexed: 03/20/2024]
Abstract
Chronic kidney disease (CKD) is a global health issue. Kidney failure patients may undergo a kidney transplantation (KTX) and prescribed an immunosuppressant medication i.e., tacrolimus. Tacrolimus' efficacy and toxicity varies among patients. This study investigates the cost-utility of pharmacogenomics (PGx) guided tacrolimus treatment compared to the conventional approach in Austrian patients undergone KTX, participating in the PREPARE UPGx study. Treatment's effectiveness was determined by mean survival, and utility values were based on a Visual Analog Scale score. Incremental Cost-Effectiveness Ratio was also calculated. PGx-guided treatment arm was found to be cost-effective, resulting in reduced cost (3902 euros less), 6% less hospitalization days and lower risk of adverse drug events compared to the control arm. The PGx-guided arm showed a mean 0.900 QALYs (95% CI: 0.862-0.936) versus 0.851 QALYs (95% CI: 0.814-0.885) in the other arm. In conclusion, PGx-guided tacrolimus treatment represents a cost-saving option in the Austrian healthcare setting.
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Affiliation(s)
| | - Margarita-Ioanna Koufaki
- Department of Pharmacy, Laboratory of Pharmacogenomics and Individualized Therapy, University of Patras, School of Health Sciences, Patras, Greece
| | - Candace Joefield-Roka
- Department of Medicine III, Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Gere Sunder-Plassmann
- Department of Medicine III, Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Christina Mitropoulou
- The Golden Helix Foundation, London, UK.
- Department of Genetics and Genomics, United Arab Emirates University, College of Medicine and Health Sciences, Al-Ain, Abu Dhabi, United Arab Emirates.
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4
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Al-Bahou R, Bruner J, Moore H, Zarrinpar A. Quantitative methods for optimizing patient outcomes in liver transplantation. Liver Transpl 2024; 30:311-320. [PMID: 38153309 DOI: 10.1097/lvt.0000000000000325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 12/11/2023] [Indexed: 12/29/2023]
Abstract
Liver transplantation (LT) is a lifesaving yet complex intervention with considerable challenges impacting graft and patient outcomes. Despite best practices, 5-year graft survival is only 70%. Sophisticated quantitative techniques offer potential solutions by assimilating multifaceted data into insights exceeding human cognition. Optimizing donor-recipient matching and graft allocation presents additional intricacies, involving the integration of clinical and laboratory data to select the ideal donor and recipient pair. Allocation must balance physiological variables with geographical and logistical constraints and timing. Quantitative methods can integrate these complex factors to optimize graft utilization. Such methods can also aid in personalizing treatment regimens, drawing on both pretransplant and posttransplant data, possibly using continuous immunological monitoring to enable early detection of graft injury or infected states. Advanced analytics is thus poised to transform management in LT, maximizing graft and patient survival. In this review, we describe quantitative methods applied to organ transplantation, with a focus on LT. These include quantitative methods for (1) utilizing and allocating donor organs equitably and optimally, (2) improving surgical planning through preoperative imaging, (3) monitoring graft and immune status, (4) determining immunosuppressant doses, and (5) establishing and maintaining the health of graft and patient after LT.
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Affiliation(s)
- Raja Al-Bahou
- Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Julia Bruner
- Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Helen Moore
- Department of Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Ali Zarrinpar
- Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
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5
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Shenoy MT, Manavalan J, A H, K S, Mohanty PK. Tacrolimus Concentration/Dose Ratio: A Tool for Guiding Tacrolimus Dosage Post-renal Transplantation. Cureus 2024; 16:e53421. [PMID: 38435193 PMCID: PMC10908598 DOI: 10.7759/cureus.53421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2024] [Indexed: 03/05/2024] Open
Abstract
Background The calcineurin inhibitor, Tacrolimus (Tac), exhibits variable absorption and undergoes first-pass metabolism when administered orally. The narrow therapeutic window and individual variability of this immunosuppressive agent make therapeutic drug monitoring essential. We hypothesized that the Tac metabolism rate - defined as the blood concentration normalized by its daily dose (the C/D ratio) - is associated with post-renal transplant (RTx) function. Methodology A retrospective observational study was conducted including 40 RTx patients. Clinical reports from four follow-up ambulatory appointments at one, three, six, and 12 months were analyzed. Tac dose and its blood levels were used to calculate the Tac concentration/dose (C/D) ratio. Patients with a Tac C/D ratio <1.05 ng/mL x 1/mg and a C/D ratio >1.05 ng/mL x 1/mg were categorized as fast and slow metabolizers. Serum creatinine levels were compared between the two groups, and their association with the Tac C/D ratio was analyzed. Student's unpaired t-test and the Mann-Whitney U test were used to analyze the difference in the C/D ratio between the groups. Spearman correlation analysis was conducted to analyze the association of the C/D ratio with serum creatinine in both groups. A P-value of <0.05 was considered statistically significant. Results Fast metabolizers showed increased serum creatinine (P < 0.05), and the C/D ratio correlated with creatinine levels. ROC analysis used to identify fast metabolizers for the C/D ratio at three months had an area of 0.925 (P < 0.01). Conclusions The Tac C/D ratio can be used as an earlier diagnostic tool to predict the development of nephrotoxicity in RTx patients.
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Affiliation(s)
- Mamatha T Shenoy
- Biochemistry, Velammal Medical College Hospital and Research Institute, Madurai, IND
| | - Jeyakumar Manavalan
- Biochemistry, Sri Manakulavinayagar Medical College and Hospital, Puducherry, IND
| | - Hariharan A
- Biochemistry, Velammal Medical College Hospital and Research Institute, Madurai, IND
| | - Suganthy K
- Biochemistry, Velammal Medical College Hospital and Research Institute, Madurai, IND
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Bilbao I, Gómez Bravo MÁ, Otero A, Lladó L, Montero JL, González Dieguez L, Graus J, Pons Miñano JA. Effectiveness and safety of once-daily tacrolimus formulations in de novo liver transplant recipients: The PRETHI study. Clin Transplant 2023; 37:e15105. [PMID: 37615653 DOI: 10.1111/ctr.15105] [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: 04/24/2023] [Revised: 07/14/2023] [Accepted: 08/13/2023] [Indexed: 08/25/2023]
Abstract
Data comparing long-term effectiveness and safety of once-daily tacrolimus formulations in de novo liver transplantation are scarce. We compared the effectiveness, pharmacokinetic profile, and safety of LCPT (Envarsus) and PR-Tac (Advagraf) for up to 12 months post-transplant. Adult de novo liver transplant recipients who started IR-Tac (Prograf) and were converted to LCPT or PR-Tac 3-5 days post-transplant were included. Data from 163 patients were analyzed, 87 treated with LCPT and 76 with PR-Tac. The incidence of treatment failure was 30.5% in the LCPT group versus 23.0% in the PR-Tac group (p = .291). Biopsy-proven acute rejection (BPAR) was reported in 26.8% of patients in the LCPT group and 17.6% in the PR-Tac group (p = .166). Graft loss was experienced in one patient (1.2%) in the LCPT group and three patients (4.1%) in the PR-Tac group (p = .346). Death was registered in three patients (3.7%) in the LCPT group and three patients (4.1%) in the PR-Tac group (p > .999). Patients in the LCPT group showed 45.7% higher relative bioavailability (Cmin /total daily dose [TDD]; p < .01) with similar Cmin and 33.3% lower TDD versus PR-Tac (p < .01). The evolution of renal function, safety profile, and the incidence of post-transplant renal failure, dyslipidemia, obesity, hypertension, and diabetes mellitus were similar in patients treated with LCPT and PR-Tac. In de novo liver transplant patients, LCPT and PR-Tac showed comparable effectiveness with higher relative bioavailability, similar Cmin and lower TDD in the LCPT group. Renal function, safety, and post-transplant complications were comparable in LCPT and PR-Tac groups.
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Affiliation(s)
- Itxarone Bilbao
- Servicio de Cirugía Hepatobiliopancreática y Trasplantes Digestivos, Hospital Universitario Vall d'Hebron, VHIR, Universidad Autónoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| | | | | | - Laura Lladó
- Hospital U Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
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Wanas H, Kamel MH, William EA, Fayad T, Abdelfattah ME, Elbadawy HM, Mikhael ES. The impact of CYP3A4 and CYP3A5 genetic variations on tacrolimus treatment of living-donor Egyptian kidney transplanted patients. J Clin Lab Anal 2023; 37:e24969. [PMID: 37789683 PMCID: PMC10681408 DOI: 10.1002/jcla.24969] [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: 01/18/2023] [Revised: 08/21/2023] [Accepted: 09/20/2023] [Indexed: 10/05/2023] Open
Abstract
BACKGROUND Tacrolimus (TAC) is the mainstay of immunosuppressive regimen for kidney transplantations. Its clinical use is complex due to high inter-individual variations which can be partially attributed to genetic variations at the metabolizing enzymes CYP3A4 and CYP3A5. Two single nucleotide polymorphisms (SNPs), CYP3A4*22 and CYP3A5*3, have been reported as important causes of differences in pharmacokinetics that can affect efficacy and/or toxicity of TAC. OBJECTIVE Investigating the effect of CYP3A4*22 and CYP3A5*3 SNPs individually and in combination on the TAC concentration in Egyptian renal recipients. METHODS Overall, 72 Egyptian kidney transplant recipients were genotyped for CYP3A4*22 G>A and CYP3A5*3 T>C. According to the functional defect associated with CYP3A variants, patients were clustered into: poor (PM) and non-poor metabolizers (Non-PM). The impact on dose adjusted through TAC concentrations (C0) and daily doses at different time points after transplantation was evaluated. RESULTS Cyp3A4*1/*22 and PM groups require significantly lower dose of TAC (mg/kg) at different time points with significantly higher concentration/dose (C0/D) ratio at day 10 in comparison to Cyp3A4*1/*1 and Non-PM groups respectively. However, CyP3A5*3 heterozygous individuals did not show any significant difference in comparison to CyP3A5*1/*3 individuals. By comparing between PM and Non-PM, the PM group had a significantly lower rate of recipients not reaching target C0 at day 14. CONCLUSION This is the first study on Egyptian population to investigate the impact of CYP3A4*22 and CYP3A5*3 SNPs individually and in combination on the TAC concentration. This study and future multicenter studies can contribute to the individualization of TAC dosing in Egyptian patients.
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Affiliation(s)
- Hanaa Wanas
- Medical Pharmacology DepartmentFaculty of Medicine Cairo UniversityCairoEgypt
- Pharmacology and Toxicology Department, Faculty of PharmacyTaibah UniversityMadinahSaudi Arabia
| | - Mai Hamed Kamel
- Clinical and Chemical Pathology DepartmentFaculty of Medicine Cairo UniversityCairoEgypt
| | - Emad Adel William
- National Research Centre, Medical Research and Clinical Studies InstituteCairoEgypt
| | - Tarek Fayad
- Internal Medicine DepartmentFaculty of Medicine Cairo UniversityCairoEgypt
| | | | | | - Emily Samir Mikhael
- Clinical and Chemical Pathology DepartmentFaculty of Medicine Cairo UniversityCairoEgypt
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Feinberg K, Tajdaran K, Mirmoeini K, Daeschler SC, Henriquez MA, Stevens KE, Mulenga CM, Hussain A, Hamrah P, Ali A, Gordon T, Borschel GH. The Role of Sensory Innervation in Homeostatic and Injury-Induced Corneal Epithelial Renewal. Int J Mol Sci 2023; 24:12615. [PMID: 37628793 PMCID: PMC10454376 DOI: 10.3390/ijms241612615] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 08/02/2023] [Accepted: 08/05/2023] [Indexed: 08/27/2023] Open
Abstract
The cornea is the window through which we see the world. Corneal clarity is required for vision, and blindness occurs when the cornea becomes opaque. The cornea is covered by unique transparent epithelial cells that serve as an outermost cellular barrier bordering between the cornea and the external environment. Corneal sensory nerves protect the cornea from injury by triggering tearing and blink reflexes, and are also thought to regulate corneal epithelial renewal via unknown mechanism(s). When protective corneal sensory innervation is absent due to infection, trauma, intracranial tumors, surgery, or congenital causes, permanent blindness results from repetitive epithelial microtraumas and failure to heal. The condition is termed neurotrophic keratopathy (NK), with an incidence of 5:10,000 people worldwide. In this report, we review the currently available therapeutic solutions for NK and discuss the progress in our understanding of how the sensory nerves induce corneal epithelial renewal.
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Affiliation(s)
- Konstantin Feinberg
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Kiana Tajdaran
- Program in Neurosciences and Mental Health, Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
| | - Kaveh Mirmoeini
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA
- Program in Neurosciences and Mental Health, Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
| | - Simeon C. Daeschler
- Program in Neurosciences and Mental Health, Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Hospital, Department of Plastic and Hand Surgery, University of Heidelberg, 67071 Ludwigshafen, Germany
| | - Mario A. Henriquez
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Katelyn E. Stevens
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Chilando M. Mulenga
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Arif Hussain
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Pedram Hamrah
- Cornea Service, New England Eye Center, Tufts Medical Center, Department of Ophthalmology, Tufts University School of Medicine, Boston, MA 02111, USA
- Center for Translational Ocular Immunology, Department of Ophthalmology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA 02111, USA
| | - Asim Ali
- Department of Ophthalmology and Vision Sciences, Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON M5T 3A9, Canada
| | - Tessa Gordon
- Program in Neurosciences and Mental Health, Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
| | - Gregory H. Borschel
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA
- Department of Ophthalmology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
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Provenzani A, Re VL. Tacrolimus-induced akinetic mutism and persistent dysarthria following orthotopic liver transplantation. Neurol Sci 2023; 44:2983-2984. [PMID: 36949300 DOI: 10.1007/s10072-023-06760-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 03/15/2023] [Indexed: 03/24/2023]
Affiliation(s)
- Alessio Provenzani
- Clinical Pharmacy Service, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy.
| | - Vincenzina Lo Re
- Neurology Unit, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
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10
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Alotaibi N. CYP3A5 Polymorphisms Leading to Tacrolimus Toxicity Following an Adult Renal Transplant. SAUDI JOURNAL OF KIDNEY DISEASES AND TRANSPLANTATION 2023; 34:250-253. [PMID: 38231720 DOI: 10.4103/1319-2442.393998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024] Open
Abstract
Tacrolimus is one of the calcineurin inhibitors used for maintaining immuno-suppression in thoracic and abdominal transplantations including heart, lung, liver, intestine, pancreas, and renal transplants. It has a narrow therapeutic window requiring therapeutic drug monitoring (TDM). Genetic polymorphism in the expression of cytochrome P3A5 enzyme plays a significant role in the bioavailability of tacrolimus in patients, leading to toxicity or rejection. In this case, we studied a renal transplant patient who received a standard dose of tacrolimus and experienced toxicity related to the poor expression of cytochrome P450 3A5 (CYP3A5), which required the withholding of tacrolimus and cutting the dose for several days with more frequent TDM. Similar cases have been reported before, yet there is no consensus on the appropriate dosage. The projected cost of additional TDM and hospitalization significantly exceeds the one-time cost of genetic CYP3A5 testing. In high-risk renal transplant recipients, pharmacogenetic testing must be considered to cut the time to limit TDM, prevent extended hospitalization, and reduce the total cost of transplantation.
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Affiliation(s)
- Nouf Alotaibi
- College of Pharmacy, Umm Al-Qura University, Makkah, Saudi Arabia
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11
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Figueroa SM, Bertocchio JP, Nakamura T, El-Moghrabi S, Jaisser F, Amador CA. The Mineralocorticoid Receptor on Smooth Muscle Cells Promotes Tacrolimus-Induced Renal Injury in Mice. Pharmaceutics 2023; 15:pharmaceutics15051373. [PMID: 37242615 DOI: 10.3390/pharmaceutics15051373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 04/26/2023] [Accepted: 04/27/2023] [Indexed: 05/28/2023] Open
Abstract
Tacrolimus (Tac) is a calcineurin inhibitor commonly used as an immunosuppressor after solid organ transplantation. However, Tac may induce hypertension, nephrotoxicity, and an increase in aldosterone levels. The activation of the mineralocorticoid receptor (MR) is related to the proinflammatory status at the renal level. It modulates the vasoactive response as they are expressed on vascular smooth muscle cells (SMC). In this study, we investigated whether MR is involved in the renal damage generated by Tac and if the MR expressed in SMC is involved. Littermate control mice and mice with targeted deletion of the MR in SMC (SMC-MR-KO) were administered Tac (10 mg/Kg/d) for 10 days. Tac increased the blood pressure, plasma creatinine, expression of the renal induction of the interleukin (IL)-6 mRNA, and expression of neutrophil gelatinase-associated lipocalin (NGAL) protein, a marker of tubular damage (p < 0.05). Our study revealed that co-administration of spironolactone, an MR antagonist, or the absence of MR in SMC-MR-KO mice mitigated most of the unwanted effects of Tac. These results enhance our understanding of the involvement of MR in SMC during the adverse reactions of Tac treatment. Our findings provided an opportunity to design future studies considering the MR antagonism in transplanted subjects.
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Affiliation(s)
- Stefanny M Figueroa
- Institute of Biomedical Sciences, Universidad Autónoma de Chile, Santiago 8910060, Chile
| | - Jean-Philippe Bertocchio
- INSERM UMRS1138, Sorbonne Université, Université de Paris, Centre de Recherche des Cordeliers, 75006 Paris, France
| | - Toshifumi Nakamura
- INSERM UMRS1138, Sorbonne Université, Université de Paris, Centre de Recherche des Cordeliers, 75006 Paris, France
| | - Soumaya El-Moghrabi
- INSERM UMRS1138, Sorbonne Université, Université de Paris, Centre de Recherche des Cordeliers, 75006 Paris, France
| | - Frédéric Jaisser
- INSERM UMRS1138, Sorbonne Université, Université de Paris, Centre de Recherche des Cordeliers, 75006 Paris, France
| | - Cristián A Amador
- Faculty of Medicine and Science, Universidad San Sebastián, Santiago 7510156, Chile
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Lukanov T, Ivanova M, Yankova P, Al Hadra B, Mihaylova A, Genova M, Svinarov D, Naumova E. Impact of CYP3A7, CYP2D6 and ABCC2/ABCC3 polymorphisms on tacrolimus steady state concentrations in Bulgarian kidney transplant recipients. BIOTECHNOL BIOTEC EQ 2022. [DOI: 10.1080/13102818.2022.2081517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Tsvetelin Lukanov
- Department of Clinical Immunology, Faculty of Medicine, Medical University of Sofia, Sofia, Bulgaria
- Department of Clinical Immunology and Stem Cell Bank, University Hospital Alexandrovska, Sofia, Bulgaria
| | - Milena Ivanova
- Department of Clinical Immunology, Faculty of Medicine, Medical University of Sofia, Sofia, Bulgaria
| | - Petya Yankova
- Department of Clinical Immunology, Faculty of Medicine, Medical University of Sofia, Sofia, Bulgaria
| | - Bushra Al Hadra
- Department of Clinical Immunology and Stem Cell Bank, University Hospital Alexandrovska, Sofia, Bulgaria
| | - Anastasiya Mihaylova
- Department of Clinical Immunology and Stem Cell Bank, University Hospital Alexandrovska, Sofia, Bulgaria
| | - Marianka Genova
- Department of Clinical Laboratory & Clinical Pharmacology, University Hospital Alexandrovska, Sofia, Bulgaria
- Department of Clinical Laboratory, Faculty of Medicine, Medical University of Sofia, Sofia, Bulgaria
| | - Dobrin Svinarov
- Department of Clinical Laboratory & Clinical Pharmacology, University Hospital Alexandrovska, Sofia, Bulgaria
- Department of Clinical Laboratory, Faculty of Medicine, Medical University of Sofia, Sofia, Bulgaria
| | - Elisaveta Naumova
- Department of Clinical Immunology, Faculty of Medicine, Medical University of Sofia, Sofia, Bulgaria
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Guimbellot JS, Nichols DP, Brewington JJ. Novel Applications of Biomarkers and Personalized Medicine in Cystic Fibrosis. Clin Chest Med 2022; 43:617-630. [PMID: 36344070 DOI: 10.1016/j.ccm.2022.06.005] [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: 11/06/2022]
Abstract
As routine care in cystic fibrosis (CF) becomes increasingly personalized, new opportunities to further focus care on the individual have emerged. These opportunities are increasingly filled through research in tools aiding drug selection, drug monitoring and titration, disease-relevant biomarkers, and evaluation of therapeutic benefits. Herein, we will discuss such research tools presently being translated into the clinic to improve the personalization of care in CF.
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Affiliation(s)
- Jennifer S Guimbellot
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham; 1600 7th Avenue South, ACC 620, Birmingham, AL 35233, USA
| | - David P Nichols
- Department of Pediatrics, Division of Pulmonary Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Building Cure, 1920 Terry Avenue, Office 4-209, Seattle, WA 98109, USA
| | - John J Brewington
- Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH 45267, USA; Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2021, Cincinnati, OH 45229, USA.
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14
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Galeev SR, Gautier SV. Risks and ways of preventing kidney dysfunction in drug-induced immunosuppression in solid organ recipients. RUSSIAN JOURNAL OF TRANSPLANTOLOGY AND ARTIFICIAL ORGANS 2022. [DOI: 10.15825/1995-1191-2022-4-24-38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Immunosuppressive therapy (IMT) is the cornerstone of treatment after transplantation. The goal of immunosuppression is to prevent acute and chronic rejection while maximizing patient survival and long-term graft function. However, the expected effects of IMT must be balanced against the major adverse effects of these drugs and their toxicity. The purpose of this review is to summarize world experience on current immunosuppressive strategies and to assess their effects on renal function.
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Affiliation(s)
- Sh. R. Galeev
- Shumakov National Medical Research Center of Transplantology and Artificial Organs
| | - S. V. Gautier
- Shumakov National Medical Research Center of Transplantology and Artificial Organs; Sechenov University
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15
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Daeschler SC, Mirmoeini K, Gordon T, Chan K, Zhang J, Ali A, Feinberg K, Borschel GH. Sustained Release of Tacrolimus From a Topical Drug Delivery System Promotes Corneal Reinnervation. Transl Vis Sci Technol 2022; 11:20. [PMID: 35984668 PMCID: PMC9419461 DOI: 10.1167/tvst.11.8.20] [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] [Indexed: 11/24/2022] Open
Abstract
Purpose Corneal nerve fibers provide sensation and maintain the epithelial renewal process. Insufficient corneal innervation can cause neurotrophic keratopathy. Here, topically delivered tacrolimus is evaluated for its therapeutic potential to promote corneal reinnervation in rats. Methods A compartmentalized neuronal cell culture was used to determine the effect of locally delivered tacrolimus on sensory axon regeneration in vitro. The regenerating axons but not the cell bodies were exposed to tacrolimus (50 ng/mL), nerve growth factor (50 ng/mL), or a vehicle control. Axon area and length were measured after 48 hours. Then, a biodegradable nanofiber drug delivery system was fabricated via electrospinning of a tacrolimus-loaded polycarbonate–urethane polymer. Biocompatibility, degradation, drug biodistribution, and therapeutic effectiveness were tested in a rat model of neurotrophic keratopathy induced by stereotactic trigeminal nerve ablation. Results Sensory neurons whose axons were exposed to tacrolimus regenerated significantly more and longer axons compared to vehicle-treated cultures. Trigeminal nerve ablation in rats reliably induced corneal denervation. Four weeks after denervation, rats that had received tacrolimus topically showed similar limbal innervation but a significantly higher nerve fiber density in the center of the cornea compared to the non-treated control. Topically applied tacrolimus was detectable in the ipsilateral vitreal body, the plasma, and the ipsilateral trigeminal ganglion but not in their contralateral counterparts and vital organs after 4 weeks of topical release. Conclusions Locally delivered tacrolimus promotes axonal regeneration in vitro and corneal reinnervation in vivo with minimal systemic drug exposure. Translational Relevance Topically applied tacrolimus may provide a readily translatable approach to promote corneal reinnervation.
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Affiliation(s)
- Simeon C Daeschler
- Neurosciences & Mental Health Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Kaveh Mirmoeini
- Neurosciences & Mental Health Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Tessa Gordon
- Neurosciences & Mental Health Program, SickKids Research Institute, Toronto, Ontario, Canada.,Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Katelyn Chan
- Neurosciences & Mental Health Program, SickKids Research Institute, Toronto, Ontario, Canada.,Institute of Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer Zhang
- Neurosciences & Mental Health Program, SickKids Research Institute, Toronto, Ontario, Canada.,Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Asim Ali
- Department of Ophthalmology and Vision Science, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Konstantin Feinberg
- Neurosciences & Mental Health Program, SickKids Research Institute, Toronto, Ontario, Canada.,Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Gregory H Borschel
- Neurosciences & Mental Health Program, SickKids Research Institute, Toronto, Ontario, Canada.,Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,Institute of Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada.,Department of Ophthalmology and Vision Science, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.,Department of Ophthalmology, Indiana University School of Medicine, Indianapolis, IN, USA
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16
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Use of Pharmacogenetics to Optimize Immunosuppressant Therapy in Kidney-Transplanted Patients. Biomedicines 2022; 10:biomedicines10081798. [PMID: 35892699 PMCID: PMC9332547 DOI: 10.3390/biomedicines10081798] [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: 06/21/2022] [Revised: 07/18/2022] [Accepted: 07/22/2022] [Indexed: 12/17/2022] Open
Abstract
Immunosuppressant drugs (ISDs) are routinely used in clinical practice to maintain organ transplant survival. However, these drugs are characterized by a restricted therapeutic index, a high inter- and intra-individual pharmacokinetic variability, and a series of severe adverse effects. In particular, genetic factors have been estimated to play a role in this variability because of polymorphisms regarding genes encoding for enzymes and transporters involved in the ISDs pharmacokinetic. Several studies showed important correlations between genetic polymorphisms and ISDs blood levels in transplanted patients; therefore, this review aims to summarize the pharmacogenetics of approved ISDs. We used PubMed database to search papers on pharmacogenetics of ISDs in adults or pediatric patients of any gender and ethnicity receiving immunosuppressive therapy after kidney transplantation. We utilized as search term: “cyclosporine or tacrolimus or mycophenolic acid or sirolimus or everolimus and polymorphism and transplant”. Our data showed that polymorphisms in CYP3A5, CYP3A4, ABCB1, and UGT1A9 genes could modify the pharmacokinetics of immunosuppressants, suggesting that patient genotyping could be a helpful strategy to select the ideal ISDs dose for each patient.
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17
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Sridharan K, Shah S, Jassim A, Hammad M, Ebrahim Al Gadhban J, Al Segai O. Evaluation of Pharmacogenetics of Drug-Metabolizing Enzymes and Drug Efflux Transporter in Renal Transplants Receiving Immunosuppressants. J Pers Med 2022; 12:jpm12050823. [PMID: 35629245 PMCID: PMC9147030 DOI: 10.3390/jpm12050823] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 05/12/2022] [Accepted: 05/14/2022] [Indexed: 02/06/2023] Open
Abstract
Cytochrome P450 (CYP) enzymes, such as CYP3A4, and CYP3A5, P450 oxidoreductase (POR), peroxisome proliferator activated receptor alpha (PPAR-alpha), and drug transporter (ABCB1) were observed to influence concentrations of immunosuppressants (cyclosporine, everolimus, sirolimus, and tacrolimus) and outcomes in renal transplants. We carried out the present study to evaluate the prevalence and impact of these single nucleotide polymorphisms (SNPs) in adult renal transplants. SNPs were evaluated using commercial TaqMan® assays. Serum drug concentrations were estimated using immunoassays. One hundred and forty-six patients were recruited. SNPs in CYP3A5*3 were significantly associated with greater dose-adjusted cyclosporine and tacrolimus concentrations. SNPs in POR*28 were observed with significantly lower dose-adjusted concentrations, particularly with cyclosporine and tacrolimus. ABCB1 homozygous polymorphisms were observed with significantly lower time spent in the therapeutic range with cyclosporine and everolimus/sirolimus. Cyclosporine was observed in a significantly greater proportion of patients with elevated GGT, and SNPs in PPAR-alpha were significantly associated with an increased risk of this adverse event. Hypertriglyceridemia with everolimus was significantly associated with POR*28 polymorphisms. There is a need to validate the influence of these SNPs in a prospective study and develop an algorithm predicting the achievement of target concentrations.
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Affiliation(s)
- Kannan Sridharan
- Department of Pharmacology & Therapeutics, College of Medicine & Medical Sciences, Arabian Gulf University, Manama 328, Bahrain
- Correspondence: ; Tel.: +973-33453123
| | - Shamik Shah
- Department of Nephrology, Salmaniya Medical Complex, Manama 328, Bahrain; (S.S.); (J.E.A.G.)
- Department of Internal Medicine, College of Medicine & Medical Sciences, Arabian Gulf University, Manama 328, Bahrain
| | - Anfal Jassim
- Department of Molecular Medicine, College of Medicine and Medical Sciences, Arabian Gulf University, Manama 328, Bahrain;
| | - Mona Hammad
- Salmaniya Medical Complex, Manama 328, Bahrain;
| | | | - Ola Al Segai
- Department of Biochemistry, Salmaniya Medical Complex, Manama 328, Bahrain;
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18
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Šimičević L, Canjuga I, Zibar L, Borić-Bilušić A, Ganoci L, Božina N. Rapid clearance of tacrolimus blood concentration triggered by variant pharmacogenes. J Clin Pharm Ther 2022; 47:1461-1465. [PMID: 35342959 DOI: 10.1111/jcpt.13650] [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: 01/04/2022] [Revised: 02/21/2022] [Accepted: 03/04/2022] [Indexed: 11/28/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Tacrolimus (TAC) is an immunosuppressant with large interpatient pharmacokinetic variability and a narrow therapeutic index. We report a case of acute cellular rejection (ACR) type IB with insufficient TAC blood concentrations (TAC C0 ). CASE SUMMARY ACR developed on the eighth postoperative day of kidney transplantation. During this period, TAC C0 were insufficient. This referred pharmacogenetic assessment disclosed the patient as a CYP3A5 expresser and CYP3A4*1B carrier. According to the genotype, higher doses of TAC, 15 mg twice daily, were administered and targeted TAC C0 were achieved. WHAT IS NEW AND CONCLUSION Our case presents an association of TAC rapid clearance and two alleles modifying greater CYP3A enzyme activity.
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Affiliation(s)
- Livija Šimičević
- Department of Laboratory Diagnostics, Division of Pharmacogenomics & Therapy Individualization, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Iva Canjuga
- Department of Nephrology, University Hospital Merkur, Internal Clinic, Zagreb, Croatia
| | - Lada Zibar
- Department of Nephrology, University Hospital Merkur, Internal Clinic, Zagreb, Croatia
| | - Ana Borić-Bilušić
- Croatian Agency for Medicinal Products and Medical Devices, Zagreb, Croatia
| | - Lana Ganoci
- Department of Laboratory Diagnostics, Division of Pharmacogenomics & Therapy Individualization, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Nada Božina
- School of Medicine, University of Zagreb, Zagreb, Croatia
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19
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Srinivas L, Gracious N, Nair RR. Pharmacogenetics Based Dose Prediction Model for Initial Tacrolimus Dosing in Renal Transplant Recipients. Front Pharmacol 2021; 12:726784. [PMID: 34916931 PMCID: PMC8669916 DOI: 10.3389/fphar.2021.726784] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 11/09/2021] [Indexed: 01/08/2023] Open
Abstract
Tacrolimus, an immunosuppressant used in solid organ transplantation, has a narrow therapeutic index and exhibits inter-individual pharmacokinetic variability. Achieving and maintaining a therapeutic level of the drug by giving appropriate doses is crucial for successful immunosuppression, especially during the initial post-transplant period. We studied the effect of CYP3A5, CYP3A4, and ABCB1 gene polymorphisms on tacrolimus trough concentrations in South Indian renal transplant recipients from Kerala to formulate a genotype-based dosing equation to calculate the required starting daily dose of tacrolimus to be given to each patient to attain optimal initial post-transplant period drug level. We also investigated the effect of these genes on drug-induced adverse effects and rejection episodes and looked into the global distribution of allele frequencies of these polymorphisms. One hundred forty-five renal transplant recipients on a triple immunosuppressive regimen of tacrolimus, mycophenolate mofetil, and steroid were included in this study. Clinical data including tacrolimus daily doses, trough levels (C0) and dose-adjusted tacrolimus trough concentration (C0/D) in blood at three time points (day 6, 6 months, and 1-year post-transplantation), adverse drug effects, rejection episodes, serum creatinine levels, etc., were recorded. The patients were genotyped for CYP3A5*3, CYP3A4*1B, CYP3A4*1G, ABCB1 G2677T, and ABCB1 C3435T polymorphisms by the PCR-RFLP method. We found that CYP3A5*3 polymorphism was the single most strongly associated factor determining the tacrolimus C0/D in blood at all three time points (p < 0.001). Using multiple linear regression, we formulated a simple and easy to compute equation that will help the clinician calculate the starting tacrolimus dose per kg body weight to be administered to a patient to attain optimal initial post-transplant period tacrolimus level. CYP3A5 expressors had an increased chance of rejection than non-expressors (p = 0.028), while non-expressors had an increased risk for new-onset diabetes mellitus after transplantation (NODAT) than expressors (p = 0.018). Genotype-guided initial tacrolimus dosing would help transplant recipients achieve optimal initial post-transplant period tacrolimus levels and thus prevent the adverse effects due to overdose and rejection due to inadequate dose. We observed inter-population differences in allele frequencies of drug metabolizer and transporter genes, emphasizing the importance of formulating population-specific dose prediction models to draw results of clinical relevance.
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Affiliation(s)
- Lekshmy Srinivas
- Laboratory Medicine and Molecular Diagnostics, Rajiv Gandhi Centre for Biotechnology, Thiruvananthapuram, India
| | - Noble Gracious
- Department of Nephrology, Government Medical College, Thiruvananthapuram, India
| | - Radhakrishnan R. Nair
- Laboratory Medicine and Molecular Diagnostics, Rajiv Gandhi Centre for Biotechnology, Thiruvananthapuram, India
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20
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CYP3A-status is associated with blood concentration and dose-requirement of tacrolimus in heart transplant recipients. Sci Rep 2021; 11:21389. [PMID: 34725418 PMCID: PMC8560807 DOI: 10.1038/s41598-021-00942-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 10/20/2021] [Indexed: 01/08/2023] Open
Abstract
High inter-individual variability in tacrolimus clearance is attributed to genetic polymorphisms of CYP3A enzymes. However, due to CYP3A phenoconversion induced by non-genetic factors, continuous changes in tacrolimus-metabolizing capacity entail frequent dose-refinement for optimal immunosuppression. In heart transplant recipients, the contribution of patients' CYP3A-status (CYP3A5 genotype and CYP3A4 expression) to tacrolimus blood concentration and dose-requirement was evaluated in the early and late post-operative period. In low CYP3A4 expressers carrying CYP3A5*3/*3, the dose-corrected tacrolimus level was significantly higher than in normal CYP3A4 expressers or in those with CYP3A5*1. Modification of the initial tacrolimus dose was required for all patients: dose reduction by 20% for low CYP3A4 expressers, a 40% increase for normal expressers and a 2.4-fold increase for CYP3A5*1 carriers. The perioperative high-dose corticosteroid therapy was assumed to ameliorate the low initial tacrolimus-metabolizing capacity during the first month. The fluctuation of CYP3A4 expression and tacrolimus blood concentration (C0/D) was found to be associated with tapering and cessation of corticosteroid in CYP3A5 non-expressers, but not in those carrying CYP3A5*1. Although monitoring of tacrolimus blood concentration cannot be omitted, assaying recipients' CYP3A-status can guide optimization of the initial tacrolimus dose, and can facilitate personalized tacrolimus therapy during steroid withdrawal in the late post-operative period.
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21
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Microbiome analysis, the immune response and transplantation in the era of next generation sequencing. Hum Immunol 2021; 82:883-901. [PMID: 34364710 DOI: 10.1016/j.humimm.2021.07.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 07/01/2021] [Accepted: 07/14/2021] [Indexed: 12/14/2022]
Abstract
The human gastrointestinal tract, skin and mucosal surfaces are inhabited by a complex system of bacteria, viruses, fungi, archaea, protists, and eukaryotic parasites with predominance of bacteria and bacterial viruses (bacteriophages). Collectively these microbes form the microbiota of the microecosystem of humans. Recent advancement in technologies for nucleic acid isolation from various environmental samples, feces and body secretions and advancements in shotgun throughput massive parallel DNA and RNA sequencing along with 16S ribosomal gene sequencing have unraveled the identity of otherwise unknown microbial entities constituting the human microecosystem. The improved transcriptome analysis, technological developments in biochemical analytical methods and availability of complex bioinformatics tools have allowed us to begin to understand the metabolome of the microbiome and the biochemical pathways and potential signal transduction pathways in human cells in response to microbial infections and their products. Also, developments in human whole genome sequencing, targeted gene sequencing of histocompatibility genes and other immune response associated genes by Next Generation Sequencing (NGS) have allowed us to have a better conceptualization of immune responses, and alloimmune responses. These modern technologies have enabled us to dive into the intricate relationship between commensal symbiotic and pathogenic microbiome and immune system. For the most part, the commensal symbiotic microbiota helps to maintain normal immune homeostasis besides providing healthy nutrients, facilitating digestion, and protecting the skin, mucosal and intestinal barriers. However, changes in diets, administration of therapeutic agents like antibiotics, chemotherapeutic agents, immunosuppressants etc. along with certain host factors including human histocompatibility antigens may alter the microbial ecosystem balance by causing changes in microbial constituents, hierarchy of microbial species and even dysbiosis. Such alterations may cause immune dysregulation, breach of barrier protection and lead to immunopathogenesis rather than immune homeostasis. The effects of human microbiome on immunity, health and disease are currently under intense research with cutting edge technologies in molecular biology, biochemistry, and bioinformatics along with tremendous ability to characterize immune response at single cell level. This review will discuss the contemporary status on human microbiome immune system interactions and their potential effects on health, immune homeostasis and allograft transplantation.
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22
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Chen Z, Cheng X, Zhang L, Tang L, Fang Y, Chen H, Zhang L, Shen A. The impact of IL-10 and CYP3A5 gene polymorphisms on dose-adjusted trough blood tacrolimus concentrations in early post-renal transplant recipients. Pharmacol Rep 2021; 73:1418-1426. [PMID: 34089513 DOI: 10.1007/s43440-021-00288-2] [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: 01/11/2021] [Revised: 05/22/2021] [Accepted: 05/26/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The strong inter-individual pharmacokinetic variability and the narrow therapeutic window of tacrolimus (TAC) have hampered the clinical application. Gene polymorphisms play an important role in TAC pharmacokinetics. Here, we investigate the influence of genotypes of IL-10, CYP3A5, CYP2C8, and ABCB1 on dose-adjusted trough blood concentrations (the C0/D ratio) of TAC to reveal unclear genetic factors that may affect TAC dose requirements for renal transplant recipients. METHODS Genetic polymorphisms of IL-10, CYP3A5, CYP2C8, and ABCB1 in 188 renal transplant recipients were determined using Kompetitive Allele Specific PCR (KASP). Statistical analysis was applied to examine the effect of genetic variation on the TAC C0/D at 5, 10, 15, and 30 days after transplantation. RESULTS Recipients carrying the IL-10 -819C > T TT genotype showed a significantly higher TAC C0/D than those with the TC/CC genotype (p < 0.05). Additionally, the TAC C0/D values of recipients with the capacity for low IL-10 activity (-819 TT) engrafted with CYP3A5 non-expressers were higher compared to the intermediate/high activity of IL-10 -819C > T TC or CC carrying CYP3A5 expressers, and the difference was statistically significant at different time points (p < 0.05). CONCLUSIONS Genetic polymorphisms of IL-10 -819C > T and CYP3A5 6986A > G influence the TAC C0/D, which may contribute to variation in TAC dose requirements during the early post-transplantation period. Detecting IL-10 -819C > T and CYP3A5 6986A > G polymorphisms may allow determination of individualized tacrolimus dosage regimens for renal transplant recipients during the early post-transplantation period.
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Affiliation(s)
- Zhaolin Chen
- Division of Life Sciences and Medicine, Department of Pharmacy, The First Affiliated Hospital of USTC, Anhui Provincial Hospital, University of Science and Technology of China, Hefei, Anhui, 230001, People's Republic of China
| | - Xi Cheng
- Division of Life Sciences and Medicine, Department of Pharmacy, The First Affiliated Hospital of USTC, Anhui Provincial Hospital, University of Science and Technology of China, Hefei, Anhui, 230001, People's Republic of China
| | - Liwen Zhang
- Department of Data & Analytics, WuXi Diagnostics Limited Corporation, Shanghai, 200131, People's Republic of China
| | - Liqin Tang
- Division of Life Sciences and Medicine, Department of Pharmacy, The First Affiliated Hospital of USTC, Anhui Provincial Hospital, University of Science and Technology of China, Hefei, Anhui, 230001, People's Republic of China
| | - Yan Fang
- Division of Life Sciences and Medicine, Department of Pharmacy, The First Affiliated Hospital of USTC, Anhui Provincial Hospital, University of Science and Technology of China, Hefei, Anhui, 230001, People's Republic of China
| | - Hongxiao Chen
- Division of Life Sciences and Medicine, Department of Pharmacy, The First Affiliated Hospital of USTC, Anhui Provincial Hospital, University of Science and Technology of China, Hefei, Anhui, 230001, People's Republic of China
| | - Lei Zhang
- Division of Life Sciences and Medicine, Department of Pharmacy, The First Affiliated Hospital of USTC, Anhui Provincial Hospital, University of Science and Technology of China, Hefei, Anhui, 230001, People's Republic of China.
| | - Aizong Shen
- Division of Life Sciences and Medicine, Department of Pharmacy, The First Affiliated Hospital of USTC, Anhui Provincial Hospital, University of Science and Technology of China, Hefei, Anhui, 230001, People's Republic of China.
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23
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Renaud-Picard B, Koutsokera A, Cabanero M, Martinu T. Acute Rejection in the Modern Lung Transplant Era. Semin Respir Crit Care Med 2021; 42:411-427. [PMID: 34030203 DOI: 10.1055/s-0041-1729542] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Acute cellular rejection (ACR) remains a common complication after lung transplantation. Mortality directly related to ACR is low and most patients respond to first-line immunosuppressive treatment. However, a subset of patients may develop refractory or recurrent ACR leading to an accelerated lung function decline and ultimately chronic lung allograft dysfunction. Infectious complications associated with the intensification of immunosuppression can also negatively impact long-term survival. In this review, we summarize the most recent evidence on the mechanisms, risk factors, diagnosis, treatment, and prognosis of ACR. We specifically focus on novel, promising biomarkers which are under investigation for their potential to improve the diagnostic performance of transbronchial biopsies. Finally, for each topic, we highlight current gaps in knowledge and areas for future research.
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Affiliation(s)
- Benjamin Renaud-Picard
- Division of Respirology and Toronto Lung Transplant Program, University of Toronto and University Health Network, Toronto, Canada
| | - Angela Koutsokera
- Division of Pulmonology, Lung Transplant Program, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Michael Cabanero
- Department of Pathology, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Tereza Martinu
- Division of Respirology and Toronto Lung Transplant Program, University of Toronto and University Health Network, Toronto, Canada
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24
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Azam F, Khan M, Khaliq T, Bhatti ABH. Influence of ABCB1 gene polymorphism on concentration to dose ratio and adverse effects of tacrolimus in Pakistani liver transplant recipients. Pak J Med Sci 2021; 37:689-694. [PMID: 34104149 PMCID: PMC8155444 DOI: 10.12669/pjms.37.3.3898] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Objective To evaluate the possible association of ABCB1 single nucleotide polymorphism (SNPs) of the ABCB1 gene with tacrolimus dosages, concentration-to-dose ratios (CDR) and adverse effects in Pakistani liver transplant recipients. Methods This observational study was conducted at Shifa International Hospital, Shifa Tameer-e-Millat University, Islamabad and Basic Medical Sciences Institute, Karachi from September 2016 to July 2020. Eighty-one liver transplant recipients were included. Demographics, clinical data, tacrolimus trough levels and doses were monitored. Electrochemiluminescence immunoassay (ECLIA) was used to measure tacrolimus trough levels. Transplant recipients were genotyped for three ABCB1 SNPs (rs1045642, rs2032582 and rs1128503). Acute cellular rejection (ACR), sepsis and other adverse events were monitored. Results ABCB1 rs1045642 CC genotype showed lower tacrolimus CDR as compared to CT and TT genotype in the first week of the post-transplantation period (p=0.02). There was a significant association of polymorphisms in rs1045642, rs2032582 and rs1128503 with psychosis, sepsis and ACR respectively. Conclusion Identification of ABCB1 rs1045642 polymorphism may shorten the time to achieve optimum levels of tacrolimus during dose titration. ABCB1 polymorphism rs1045642, rs2032582 and rs1128503 may predict adverse effects in liver transplant recipients receiving tacrolimus.
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Affiliation(s)
- Fahad Azam
- Dr. Fahad Azam, M.Phil, Associate Professor, Pharmacology & Therapeutics, Shifa Tameer-e-Millat University, Islamabad
| | - Moosa Khan
- Dr. Moosa Khan, PhD, Professor, Pharmacology and Therapeutics, Shaheed Zulfiqar Ali Bhutto Medical University, Islamabad
| | - Tanwir Khaliq
- Dr. Tanwir Khaliq, FCPS, Professor, Department of Surgery, Shaheed Zulfiqar Ali Bhutto Medical University, Islamabad
| | - Abu Bakar Hafeez Bhatti
- Dr. Abu Bakar Hafeez Bhatti, FCPS, FRCS Consultant, Liver Transplant, Shifa International Hospital, Islamabad
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25
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Early impact of donor CYP3A5 genotype and Graft-to-Recipient Weight Ratio on tacrolimus pharmacokinetics in pediatric liver transplant patients. Sci Rep 2021; 11:443. [PMID: 33432012 PMCID: PMC7801660 DOI: 10.1038/s41598-020-79574-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 10/20/2020] [Indexed: 02/07/2023] Open
Abstract
Tacrolimus (TAC) pharmacokinetics is influenced by the donor CYP3A5 genotype and the age of pediatric liver recipients. However, an optimization of a genotype-based algorithm for determining TAC starting is needed to earlier achieve stable target levels. As the graft itself is responsible for its metabolism, the Graft-to-Recipient Weight Ratio (GRWR) might play a role in TAC dose requirements. A single-center study was carried out in a cohort of 49 pediatric recipients to analyse the impact of patient and graft characteristics on TAC pharmacokinetics during the first 15 post-transplant days. Children < 2 years received grafts with a significantly higher GRWR (4.2%) than children between 2–8 (2.6%) and over 8 (2.7%). TAC concentration/weight-adjusted dose ratio was significantly lower in recipients from CYP3A5*1/*3 donors or with extra-large (GRWR > 5%) or large (GRWR 3–5%) grafts. The donor CYP3A5 genotype and GRWR were the only significant predictors of the TAC weight adjusted doses. Patients with a GRWR > 4% had a higher risk of acute rejection, observed in 20/49 (41%) patients. In conclusion, TAC starting dose could be guided according to the donor CYP3A5 genotype and GRWR, allowing for a quicker achievement of target concentrations and eventually reducing the risk of rejection.
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Ong PW, Kee T, Ho QY. Impact of tacrolimus versus cyclosporine on one-year renal transplant outcomes: A single-centre retrospective cohort study. PROCEEDINGS OF SINGAPORE HEALTHCARE 2020. [DOI: 10.1177/2010105820957370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Background:Calcineurin inhibitors are the cornerstone of maintenance immunosuppression after kidney transplant. While studies on predominantly Caucasian populations recommend tacrolimus over cyclosporine, the effects on Singapore’s local population remain unclear.Objectives:This study aimed to compare the impact of tacrolimus against cyclosporine on post-transplant outcomes in our local kidney transplant population.Methods:A single-centre retrospective chart review was conducted on ABO- and human leucocyte antigen (HLA)-compatible kidney transplantations between 1 January 2011 and 15 August 2018. Patients who received basiliximab induction, prednisolone, mycophenolate and either tacrolimus or cyclosporine were included and followed up for at least one year. Recipients of transplantations at other institutions or other immunosuppressive regimens were excluded. Patient and graft outcomes and adverse effects were collected.Results:Overall, 120 patients on tacrolimus and 49 on cyclosporine were included. Patients on tacrolimus were older. This group had more deceased donor transplants, a higher proportion with donor-specific antibodies (DSAs) present and more HLA mismatches. There were no differences in patient and graft survival, graft function and acute rejections at one year, despite adjusting for age, transplant type, presence of DSAs and total HLA mismatches. The tacrolimus group had more infectious admissions (odds ratio=0.27, 95% confidence interval 0.098–0.73, p=0.01) after adjusting for age, transplant type, HLA mismatches, presence of DSAs and acute rejections, with increased severity and more opportunistic infections. More patients on cyclosporine required a change to alternative immunosuppressants (p=0.003).Conclusion:Our study demonstrated comparable short-term post-transplant outcomes between cyclosporine and tacrolimus. Tacrolimus appears more tolerable but may be associated with infection risks.
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Affiliation(s)
- Pei Wen Ong
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Terence Kee
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Quan Yao Ho
- Department of Renal Medicine, Singapore General Hospital, Singapore
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Csikány N, Kiss Á, Déri M, Fekete F, Minus A, Tóth K, Temesvári M, Sárváry E, Bihari L, Gerlei Z, Kóbori L, Monostory K. Clinical significance of personalized tacrolimus dosing by adjusting to donor CYP3A-status in liver transplant recipients. Br J Clin Pharmacol 2020; 87:1790-1800. [PMID: 32986876 DOI: 10.1111/bcp.14566] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 09/02/2020] [Accepted: 09/17/2020] [Indexed: 02/06/2023] Open
Abstract
Donor's CYP3A-status (CYP3A5 genotype and CYP3A4 expression) can provide prognostic information regarding tacrolimus-metabolizing capacity of the liver graft and initial tacrolimus dosing for therapeutic blood concentrations in liver transplants. The present work prospectively investigated whether CYP3A-status guided tacrolimus therapy has any potential clinical benefit for recipients in the early postoperative period. METHODS The contribution of preliminary assaying of donor CYP3A-status to the optimization of initial tacrolimus therapy and to the reduction of adverse events (acute rejection, infection, nephrotoxicity) was investigated in 112 liver transplant recipients (CYPtest group) comparing to 101 control patients on tacrolimus concentration guided therapy. RESULTS The time for achieving therapeutic tacrolimus concentration was significantly reduced, confirming potential benefit of initial tacrolimus therapy adjusted to donor's CYP3A-status over classical clinical practice of tacrolimus concentration guided treatment (4 vs 8 days, P < 0.0001). Acute rejection episodes (3.6 vs 23.8%, P < 0.0001) and tacrolimus induced nephrotoxicity (8 vs 27%, P = 0.0004) were less frequent in CYPtest group than in control patients, whereas occurrence of infectious disease was not influenced by tacrolimus dosing strategy (3.6 vs 5.9% in CYPtest and control groups, P > 0.05). Acute rejection was often accompanied with tacrolimus blood concentrations lower than 10 ng mL-1 (20/24 of control and 2/4 of CYPtest patients), while nephrotoxicity was associated with high tacrolimus concentrations (>20 ng mL-1 ) in the first week after transplantation (13/27 of control and 2/9 of CYPtest patients). CONCLUSION CYP3A-status guided therapy significantly improved the risk of misdosing induced early adverse effects (acute rejection, nephrotoxicity).
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Affiliation(s)
- Nóra Csikány
- Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary.,Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Ádám Kiss
- Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary
| | - Máté Déri
- Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary
| | - Ferenc Fekete
- Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary
| | - Annamária Minus
- Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary
| | - Katalin Tóth
- Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary
| | - Manna Temesvári
- Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary
| | - Enikő Sárváry
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - László Bihari
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Zsuzsa Gerlei
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - László Kóbori
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Katalin Monostory
- Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary
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Khajeh E, Polychronidis G, Ramouz A, Alamdari P, Lemekhova A, Saracevic M, Ali-Hasan-Al-Saegh S, Ghamarnejad O, Majlesara A, Abbasi Dezfouli S, Nickkholgh A, Weiss KH, Rupp C, Mehrabi A, Mieth M. Evaluation of the impact of Tacrolimus-based immunosuppression on Heidelberg liver transplant cohort (HDTACRO): Study protocol for an investigator initiated, non-interventional prospective study. Medicine (Baltimore) 2020; 99:e22180. [PMID: 32991411 PMCID: PMC7523857 DOI: 10.1097/md.0000000000022180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Tacrolimus-based immunosuppression has resulted in enormous improvements on liver transplantation (LTx) outcomes. However, dose adjustment and medication adherence play a key role in post-transplant treatment success. The aim of the present study is to assess the trough levels and the need for adaptation of therapeutic doses in de novo LTx patients treated with Tacrolimus in the clinical routine, without any intervention to the treatment regimen. METHODS AND ANALYSIS This is a pilot, prospective, exploratory, monocentric, non-interventional and non-randomized investigator-initiated study. Prospectively maintained data of 100 patients treated with various oral Tacrolimus-based immunosuppressants (Prograf or Envarsus) will be analyzed. The number of required dose adjustments of Tacrolimus formulations used in clinical routine for achieving the target trough level, Tacrolimus trough level, Tacrolimus dosing, concentration/dose ratio, routine laboratory tests, efficacy data (incl. survival, acute rejection, re-transplantation), patients therapy adherence, and infections requiring the need to reduce individual immunosuppressant dosing will be evaluated for each patient. RESULT This study will evaluate the trough levels and the need for adaptation of therapeutic doses in de novo LTx patients treated with Tacrolimus in the clinical routine, without any intervention to the treatment regimen. CONCLUSION The HDTACRO study will be the first study to systematically and prospectively evaluate various oral Tacrolimus-based immunosuppressants in de novo liver transplanted patients. If a difference between the therapy-subgroups is evident at the end of the trial, a randomized control trial will eventually be designed. Registration number: ClinicalTrials.gov: NCT04444817.
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Affiliation(s)
- Elias Khajeh
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital
| | - Georgios Polychronidis
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital
| | - Ali Ramouz
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital
| | - Parnian Alamdari
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital
| | - Anastasia Lemekhova
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital
| | - Melisa Saracevic
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital
| | | | - Omid Ghamarnejad
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital
| | - Ali Majlesara
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital
| | - Sepehr Abbasi Dezfouli
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital
| | - Arash Nickkholgh
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital
| | - Karl Heinz Weiss
- Department of Gastroenterology and Hepatology, University of Heidelberg
| | - Christian Rupp
- Department of Internal Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital
| | - Markus Mieth
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital
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Deininger KM, Tsunoda SM, Hirsch JD, Anderson H, Lee YM, McIlvennan CK, Page RL, Tran JN, Aquilante CL. National survey of physicians' perspectives on pharmacogenetic testing in solid organ transplantation. Clin Transplant 2020; 34:e14037. [PMID: 32654213 DOI: 10.1111/ctr.14037] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 07/02/2020] [Accepted: 07/07/2020] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Our objective was to evaluate physicians' perspectives on the clinical utility of pharmacogenetic (PGx) testing in kidney, liver, heart, and lung transplantation (KLHL-Tx). METHODS A 36-question web-based survey was developed and administered to medical and surgical directors of US KLHL-Tx centers. RESULTS There were 82 respondents (10% response rate). The majority were men (78%), non-Hispanic whites (70%), medical directors (72%), and kidney transplant physicians (35%). Although 78% of respondents reported having some PGx education, most reported lack of confidence in their PGx knowledge and ability to apply a PGx test. Participants reported mixed views about the clinical utility of PGx testing-most agreed with the efficacy of PGx testing, but not the benefits relative to the risks or standard of care. While 55% reported that testing was available at their institution, only 38% ordered a PGx test in the past year, most commonly thiopurine-S-methyltransferase. Physician-reported barriers to PGx implementation included uncertainty about the clinical value of PGx testing and patient financial burden. CONCLUSION Together, our findings suggest prospective PGx research and pilot implementation programs are needed to elucidate the clinical utility and value of PGx in KLHL-Tx. These initiatives should include educational efforts to inform the use of PGx testing.
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Affiliation(s)
- Kimberly M Deininger
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Shirley M Tsunoda
- University of California San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, CA, USA
| | - Jan D Hirsch
- Department of Pharmaceutical Sciences, University of California Irvine, Irvine, CA, USA
| | - Heather Anderson
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Yee Ming Lee
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Colleen K McIlvennan
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA.,Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Robert L Page
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Jacinda N Tran
- University of California San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, CA, USA
| | - Christina L Aquilante
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
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30
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The First Asian Kidney Transplantation Prediction Models for Long-term Patient and Allograft Survival. Transplantation 2020; 104:1048-1057. [DOI: 10.1097/tp.0000000000002918] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kelava T, Turcic P, Markotic A, Ostojic A, Sisl D, Mrzljak A. Importance of genetic polymorphisms in liver transplantation outcomes. World J Gastroenterol 2020; 26:1273-1285. [PMID: 32256016 PMCID: PMC7109269 DOI: 10.3748/wjg.v26.i12.1273] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 03/01/2020] [Accepted: 03/05/2020] [Indexed: 02/06/2023] Open
Abstract
Although, liver transplantation serves as the only curative treatment for patients with end-stage liver diseases, it is burdened with complications, which affect survival rates. In addition to clinical risk factors, contribution of recipient and donor genetic prognostic markers has been extensively studied in order to reduce the burden and improve the outcomes. Determination of single nucleotide polymorphisms (SNPs) is one of the most important tools in development of personalized transplant approach. To provide a better insight in recent developments, we review the studies published in the last three years that investigated an association of recipient or donor SNPs with most common issues in liver transplantation: Acute cellular rejection, development of new-onset diabetes mellitus and non-alcoholic fatty liver disease, hepatocellular carcinoma recurrence, and tacrolimus concentration variability. Reviewed studies confirmed previously established SNP prognostic factors, such as PNPLA3 rs738409 for non-alcoholic fatty liver disease development, or the role of CYP3A5 rs776746 in tacrolimus concentration variability. They also identified several novel SNPs, with a reasonably strong association, which have the potential to become useful predictors of post-transplant complications. However, as the studies were typically conducted in one center on relatively low-to-moderate number of patients, verification of the results in other centers is warranted to resolve these limitations. Furthermore, of 29 reviewed studies, 28 used gene candidate approach and only one implemented a genome wide association approach. Genome wide association multicentric studies are needed to facilitate the development of personalized transplant medicine.
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Affiliation(s)
- Tomislav Kelava
- Laboratory for Molecular Immunology, Croatian Institute for Brain Research, University of Zagreb, School of Medicine, Zagreb 10000, Croatia
| | - Petra Turcic
- Department of Pharmacology, Faculty of Pharmacy and Biochemistry of University of Zagreb, Zagreb 10000, Croatia
| | - Antonio Markotic
- Center for Clinical Pharmacology, University Clinical Hospital Mostar, Mostar 88000, Bosnia and Herzegovina
| | - Ana Ostojic
- Department of Medicine, Merkur University Hospital, Zagreb 10000, Croatia
| | - Dino Sisl
- Laboratory for Molecular Immunology, Croatian Institute for Brain Research, University of Zagreb, School of Medicine, Zagreb 10000, Croatia
| | - Anna Mrzljak
- Department of Medicine, Merkur University Hospital; School of Medicine, University of Zagreb, Zagreb 10000, Croatia
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Zhu J, Patel T, Miller JA, Torrice CD, Aggarwal M, Sketch MR, Alexander MD, Armistead PM, Coghill JM, Grgic T, Jamieson KJ, Ptachcinski JR, Riches ML, Serody JS, Schmitz JL, Shaw JR, Shea TC, Suzuki O, Vincent BG, Wood WA, Rao KV, Wiltshire T, Weimer ET, Crona DJ. Influence of Germline Genetics on Tacrolimus Pharmacokinetics and Pharmacodynamics in Allogeneic Hematopoietic Stem Cell Transplant Patients. Int J Mol Sci 2020; 21:E858. [PMID: 32013193 PMCID: PMC7037631 DOI: 10.3390/ijms21030858] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 01/24/2020] [Accepted: 01/25/2020] [Indexed: 02/06/2023] Open
Abstract
Tacrolimus exhibits high inter-patient pharmacokinetics (PK) variability, as well as a narrow therapeutic index, and therefore requires therapeutic drug monitoring. Germline mutations in cytochrome P450 isoforms 4 and 5 genes (CYP3A4/5) and the ATP-binding cassette B1 gene (ABCB1) may contribute to interindividual tacrolimus PK variability, which may impact clinical outcomes among allogeneic hematopoietic stem cell transplantation (HSCT) patients. In this study, 252 adult patients who received tacrolimus for acute graft versus host disease (aGVHD) prophylaxis after allogeneic HSCT were genotyped to evaluate if germline genetic variants associated with tacrolimus PK and pharmacodynamic (PD) variability. Significant associations were detected between germline variants in CYP3A4/5 and ABCB1 and PK endpoints (e.g., median steady-state tacrolimus concentrations and time to goal tacrolimus concentration). However, significant associations were not observed between CYP3A4/5 or ABCB1 germline variants and PD endpoints (e.g., aGVHD and treatment-emergent nephrotoxicity). Decreased age and CYP3A5*1/*1 genotype were independently associated with subtherapeutic tacrolimus trough concentrations while CYP3A5*1*3 or CYP3A5*3/*3 genotypes, myeloablative allogeneic HSCT conditioning regimen (MAC) and increased weight were independently associated with supratherapeutic tacrolimus trough concentrations. Future lines of prospective research inquiry are warranted to use both germline genetic and clinical data to develop precision dosing tools that will optimize both tacrolimus dosing and clinical outcomes among adult HSCT patients.
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Affiliation(s)
- Jing Zhu
- The Center for Pharmacogenomics and Individualized Therapy, Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC 27599, USA; (J.Z.); (T.P.); (C.D.T.); (M.A.); (M.R.S.); (O.S.); (T.W.)
| | - Tejendra Patel
- The Center for Pharmacogenomics and Individualized Therapy, Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC 27599, USA; (J.Z.); (T.P.); (C.D.T.); (M.A.); (M.R.S.); (O.S.); (T.W.)
| | - Jordan A. Miller
- Department of Pharmacy, University of North Carolina Hospitals and Clinics, Chapel Hill, NC 27599, USA; (J.A.M.); (M.D.A.); (T.G.); (J.R.P.); (J.R.S.); (K.V.R.)
| | - Chad D. Torrice
- The Center for Pharmacogenomics and Individualized Therapy, Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC 27599, USA; (J.Z.); (T.P.); (C.D.T.); (M.A.); (M.R.S.); (O.S.); (T.W.)
| | - Mehak Aggarwal
- The Center for Pharmacogenomics and Individualized Therapy, Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC 27599, USA; (J.Z.); (T.P.); (C.D.T.); (M.A.); (M.R.S.); (O.S.); (T.W.)
| | - Margaret R. Sketch
- The Center for Pharmacogenomics and Individualized Therapy, Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC 27599, USA; (J.Z.); (T.P.); (C.D.T.); (M.A.); (M.R.S.); (O.S.); (T.W.)
| | - Maurice D. Alexander
- Department of Pharmacy, University of North Carolina Hospitals and Clinics, Chapel Hill, NC 27599, USA; (J.A.M.); (M.D.A.); (T.G.); (J.R.P.); (J.R.S.); (K.V.R.)
- Division of Practice Advancement and Clinical Education, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC 27599, USA
| | - Paul M. Armistead
- Division of Hematology and Oncology, Department of Medicine, University of North Carolina, Chapel Hill, NC 27599, USA; (P.M.A.); (J.M.C.); (K.J.J.); (M.L.R.); (J.S.S.); (T.C.S.); (B.G.V.); (W.A.W.)
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC 27599, USA
| | - James M. Coghill
- Division of Hematology and Oncology, Department of Medicine, University of North Carolina, Chapel Hill, NC 27599, USA; (P.M.A.); (J.M.C.); (K.J.J.); (M.L.R.); (J.S.S.); (T.C.S.); (B.G.V.); (W.A.W.)
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Tatjana Grgic
- Department of Pharmacy, University of North Carolina Hospitals and Clinics, Chapel Hill, NC 27599, USA; (J.A.M.); (M.D.A.); (T.G.); (J.R.P.); (J.R.S.); (K.V.R.)
| | - Katarzyna J. Jamieson
- Division of Hematology and Oncology, Department of Medicine, University of North Carolina, Chapel Hill, NC 27599, USA; (P.M.A.); (J.M.C.); (K.J.J.); (M.L.R.); (J.S.S.); (T.C.S.); (B.G.V.); (W.A.W.)
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Jonathan R. Ptachcinski
- Department of Pharmacy, University of North Carolina Hospitals and Clinics, Chapel Hill, NC 27599, USA; (J.A.M.); (M.D.A.); (T.G.); (J.R.P.); (J.R.S.); (K.V.R.)
- Division of Practice Advancement and Clinical Education, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC 27599, USA
| | - Marcie L. Riches
- Division of Hematology and Oncology, Department of Medicine, University of North Carolina, Chapel Hill, NC 27599, USA; (P.M.A.); (J.M.C.); (K.J.J.); (M.L.R.); (J.S.S.); (T.C.S.); (B.G.V.); (W.A.W.)
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Jonathan S. Serody
- Division of Hematology and Oncology, Department of Medicine, University of North Carolina, Chapel Hill, NC 27599, USA; (P.M.A.); (J.M.C.); (K.J.J.); (M.L.R.); (J.S.S.); (T.C.S.); (B.G.V.); (W.A.W.)
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC 27599, USA
| | - John L. Schmitz
- Department of Pathology & Laboratory Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC 27599, USA; (J.L.S.); (E.T.W.)
| | - J. Ryan Shaw
- Department of Pharmacy, University of North Carolina Hospitals and Clinics, Chapel Hill, NC 27599, USA; (J.A.M.); (M.D.A.); (T.G.); (J.R.P.); (J.R.S.); (K.V.R.)
| | - Thomas C. Shea
- Division of Hematology and Oncology, Department of Medicine, University of North Carolina, Chapel Hill, NC 27599, USA; (P.M.A.); (J.M.C.); (K.J.J.); (M.L.R.); (J.S.S.); (T.C.S.); (B.G.V.); (W.A.W.)
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Oscar Suzuki
- The Center for Pharmacogenomics and Individualized Therapy, Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC 27599, USA; (J.Z.); (T.P.); (C.D.T.); (M.A.); (M.R.S.); (O.S.); (T.W.)
| | - Benjamin G. Vincent
- Division of Hematology and Oncology, Department of Medicine, University of North Carolina, Chapel Hill, NC 27599, USA; (P.M.A.); (J.M.C.); (K.J.J.); (M.L.R.); (J.S.S.); (T.C.S.); (B.G.V.); (W.A.W.)
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC 27599, USA
| | - William A. Wood
- Division of Hematology and Oncology, Department of Medicine, University of North Carolina, Chapel Hill, NC 27599, USA; (P.M.A.); (J.M.C.); (K.J.J.); (M.L.R.); (J.S.S.); (T.C.S.); (B.G.V.); (W.A.W.)
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Kamakshi V. Rao
- Department of Pharmacy, University of North Carolina Hospitals and Clinics, Chapel Hill, NC 27599, USA; (J.A.M.); (M.D.A.); (T.G.); (J.R.P.); (J.R.S.); (K.V.R.)
- Division of Practice Advancement and Clinical Education, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC 27599, USA
| | - Tim Wiltshire
- The Center for Pharmacogenomics and Individualized Therapy, Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC 27599, USA; (J.Z.); (T.P.); (C.D.T.); (M.A.); (M.R.S.); (O.S.); (T.W.)
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Eric T. Weimer
- Department of Pathology & Laboratory Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC 27599, USA; (J.L.S.); (E.T.W.)
| | - Daniel J. Crona
- The Center for Pharmacogenomics and Individualized Therapy, Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC 27599, USA; (J.Z.); (T.P.); (C.D.T.); (M.A.); (M.R.S.); (O.S.); (T.W.)
- Department of Pharmacy, University of North Carolina Hospitals and Clinics, Chapel Hill, NC 27599, USA; (J.A.M.); (M.D.A.); (T.G.); (J.R.P.); (J.R.S.); (K.V.R.)
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC 27599, USA
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Graft and patient survival after renal transplantation in the period from 1996-2017 in Military Medical Academy, Belgrade, Serbia. VOJNOSANIT PREGL 2020. [DOI: 10.2298/vsp190313091v] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Sánchez Fructuoso A, Ruiz JC, Franco A, Diekmann F, Redondo D, Calviño J, Serra N, Aladrén MJ, Cigarrán S, Manonelles A, Ramos A, Gómez G, González Posada JM, Andrés A, Beneyto I, Muñiz AL, Perelló M, Lauzurica R. Effectiveness and safety of the conversion to MeltDose ® extended-release tacrolimus from other formulations of tacrolimus in stable kidney transplant patients: A retrospective study. Clin Transplant 2019; 34:e13767. [PMID: 31815310 PMCID: PMC7050537 DOI: 10.1111/ctr.13767] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 11/14/2019] [Accepted: 11/25/2019] [Indexed: 12/24/2022]
Abstract
Tacrolimus is the cornerstone of immunosuppressive therapy after kidney transplantation. Its narrow therapeutic window mandates serum level strict monitoring and dose adjustments to ensure the optimal risk‐benefit balance. This observational retrospective study analyzed the effectiveness and safety of conversion from twice‐daily immediate‐release tacrolimus (IR‐Tac) or once‐daily prolonged‐release tacrolimus (PR‐Tac) to the recent formulation once‐daily MeltDose® extended‐release tacrolimus (LCP‐Tac) in 365 stable kidney transplant recipients. We compared kidney function three months before and three months after the conversion. Three months after conversion, the total daily dose was reduced ~35% (P < .0001), and improved bioavailability and stable serum LCP‐Tac concentrations were observed. There was no increase in the number of patients requiring tacrolimus dose adjustments after conversion. Renal function was unaltered, and no cases of BPAR were reported. Reports of tremors, as collected in the clinical histories for each patient, decreased from pre‐conversion (20.8%) to post‐conversion (11.8%, P < .0001). LCP‐Tac generated a cost reduction of 63% compared with PR‐Tac. In conclusion, the conversion strategy to LCP‐Tac from other tacrolimus formulations in stable kidney transplant patients showed safety and effectiveness in a real‐world setting, confirming the data from RCTs. The specific pharmacokinetic properties of LCP‐Tac could be potentially advantageous in patients with tacrolimus‐related adverse events.
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Affiliation(s)
| | - Juan Carlos Ruiz
- Nephrology, University Hospital Marqués de Valdecilla, Santander, Spain
| | - Antonio Franco
- Nephrology, University Hospital General, Alicante, Spain
| | - Fritz Diekmann
- Nephrology, University Hospital Clinic, Barcelona, Spain
| | | | | | - Nuria Serra
- Nephrology, Fundación Puigvert, Barcelona, Spain
| | | | | | - Ana Manonelles
- Nephrology, University Hospital Bellvitge, Hospitalet de Llobregat, Spain
| | - Ana Ramos
- Nephrology, Fundación Jiménez Díaz, Madrid, Spain
| | - Gonzalo Gómez
- Nephrology, University Hospital son Espases, Palma de Mallorca, Spain
| | | | - Amado Andrés
- Nephrology, University Hospital Doce de Octubre, Madrid, Spain
| | | | | | - Manel Perelló
- Nephrology, University Hospital Vall de Hebrón, Barcelona, Spain
| | - Ricardo Lauzurica
- Nephrology, University Hospital Germans Trias y Pujol, Badalona, Spain
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Zhang Z, Lu X, Dong L, Ma J, Fan X. Clinical observation on the effect of Wuzhi soft capsule on FK506 concentration in membranous nephropathy patients. Medicine (Baltimore) 2019; 98:e18150. [PMID: 31770256 PMCID: PMC6890353 DOI: 10.1097/md.0000000000018150] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The current research aimed to investigate the correlation between the effect of Wuzhi soft capsule (WZC) on FK506 concentration and CYP3A5 gene polymorphism in patients with membranous nephropathy (MN).Seventy-five patients with idiopathic MN were enrolled and divided according to the expression of CYP3A5 gene metabolic enzyme into group A (CP3A5 metabolic enzyme function expression types CYP3A5*1/*1 type and CYP3A5*1/*3 type), and group B (non-expression type CYP3A5*3/*3 type). All patients were given oral administration of tacrolimus capsule at the initial dose of 1 mg for twice a day 1 hour before breakfast and dinner. Afterwards, the oral administration of WZC was added at the dose of 0.5 g for 3 times a day within half an hour after 3 meals.The blood concentrations of FK506 in groups A and B were significantly higher than those before administration. Compared with that before administration, the FK506 blood concentration was increased by 3.051 ± 0.774 ng/ml after adding the WZC. Besides, the blood concentrations of FK506 in group A were lower than those in group B before and after administration; meanwhile, the 24 hours total urine protein and the biochemical indexes in both groups displayed no statistically significant difference. Only 1 case of diarrhea was observed, which was relieved after the reduction of tacrolimus.Wuzhi soft capsule can significantly increase the blood concentration of FK506 in MN patients. Moreover, the CYP3A5 genotyping should be considered when WZC is used to increase the blood concentration of FK506.
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Affiliation(s)
- Zhu Zhang
- Department of Nephrology, Fuwai Central China Cardiovascular Hospital
| | - Xiaobei Lu
- Department of Nephrology, People's Hospital of Zhengzhou, Zhengzhou
| | - Leipeng Dong
- Department of Nephrology, The people's Hospital of Xuchang, Xuchang
| | - Jiwei Ma
- Department of Nephrology, First affiliated Hospital of Henan university of traditional Chinese medicine, Zhengzhou, China
| | - Xiaoguang Fan
- Department of Nephrology, Fuwai Central China Cardiovascular Hospital
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Prasad N, Jaiswal A, Behera MR, Agarwal V, Kushwaha R, Bhadauria D, Kaul A, Gupta A. Melding Pharmacogenomic Effect of MDR1 and CYP3A5 Gene Polymorphism on Tacrolimus Dosing in Renal Transplant Recipients in Northern India. Kidney Int Rep 2019; 5:28-38. [PMID: 31922058 PMCID: PMC6943758 DOI: 10.1016/j.ekir.2019.09.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 08/22/2019] [Accepted: 09/16/2019] [Indexed: 02/07/2023] Open
Abstract
Introduction Tacrolimus (TAC) is the mainstay immunosuppressant for renal transplantation. A narrow therapeutic index, multiple drug interactions, and interindividual variability in pharmacokinetics make it obligatory to monitor therapeutic drug levels. The Multidrug resistance gene 1 (MDR1) and CYP3A5 gene polymorphism may blend to achieve the optimal level. The optimal dose as per body weight is difficult to single out in the early posttransplantation period. In this study, we aimed to analyze the melding effect of both gene polymorphisms and to elicit the dose depending on the combination of genetic single nucleotide polymorphisms (SNPs) in northern Indian transplant recipients, for whom data are limited. Methods The daily TAC dose, weight-adjusted doses (mg/kg per day), TAC trough blood concentration (average of at least 3 levels), dose normalized with a corresponding dose using TAC concentration/weight-adjusted dose ratio (ng/ml per mg/kg per day) of 248 patients were recorded. All recipients were genotyped for the SNPs of CYP3A5 at intron 3 A6986G (the *3 or *1 allele), MDR1 at exons 12 (C1236T), 21 (G2677A/T), and 26 (C3435T). We analyzed the blending effect of mutant SNPs of the MDR gene and CYP3A5 for optimized TAC levels. Results Among CYP3A5 genotypic variants, the dose-adjusted TAC level was significantly lower, and the TAC dose required to achieve the target level was significantly higher, in CYP3A5*1*1 (expressor) than that of CYP3A5*1*3 and CYP3A5*3*3. Of the MDR1 gene SNPs, only the G2677T/A homozygous mutant was significantly associated with TAC level, and it was strongly correlated with P-gp expression.The daily TAC dose requirement was highest with a combination of CYP3A5*1*1 and homozygous mutant TT+AA genotype of G2677T/A, and was lowest with CYP3A5*3*3 and wild-type GG of the G2677T/A genotype. Conclusion Both CYP gene and MDR1 gene polymorphism affect TAC dose requirements, and there is a need to look for both in an individual to achieve the target trough concentration.
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Affiliation(s)
- Narayan Prasad
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Akhilesh Jaiswal
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Manas Ranjan Behera
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Vikas Agarwal
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Ravi Kushwaha
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Dharmendra Bhadauria
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Anupama Kaul
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Amit Gupta
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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Largeau B, Guellec CBL, Longuet H, Lesne P, Bouvarel A, Préteseille L, Marquet P, Halimi JM, Büchler M, Gatault P, Noble J. Comparison of Tacrolimus Starting Doses Based on CYP3A5 Phenotype or Genotype in Kidney Transplant Recipients. Prog Transplant 2019; 29:300-308. [PMID: 31514576 DOI: 10.1177/1526924819873905] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Selection of expected phenotypes (ie, expressers/non-expressers) is currently used in CYP3A5*3 genotype-based tacrolimus dosing. The authors assessed whether a dosing regimen based on the 3 CYP3A5 genotypes may reduce the occurrence of inadequate exposure. METHODS Tacrolimus whole blood trough levels (C 0) were retrieved from a retrospective cohort of 100 kidney transplant recipients treated with a starting dose of 0.15 (non-expressers) or 0.30 (expressers) mg/kg/d. The authors evaluated the occurrence of overexposures (12 < C 0 < 20 ng/mL) or toxic concentrations (C 0 ≥ 20 ng/mL). These results were used to set up a new strategy based on the 3 distinct CYP3A5 genotypes, which relevance was evaluated in a prospective cohort of 107 patients. RESULTS In the retrospective cohort, non-expressers exhibited frequent overexposure (63.6%) or toxic C 0 (20.8%). Among expressers, none of the homozygous *1 carriers exhibited overexposure contrary to 25% of the heterozygotes. Based on these results, new tacrolimus starting doses were set at 0.10, 0.20, and 0.30 mg/kg/d for CYP3A5*3/*3, CYP3A5*1/*3, and CYP3A5*1/*1 genotypes, respectively. Tacrolimus overexposure was reduced in the CYP3A5*3/*3 group (63.6% vs 40%, P = .0038). None of the heterozygous patients exhibited toxic tacrolimus C 0. Clinical outcomes were not different between the 2 periods, whatever the genotype. Our results indicate that the best tacrolimus exposure was obtained for doses of 0.10, 0.20, and 0.20 mg/kg/d for CYP3A5*3/3, CYP3A5*1/*3, and CYP3A5*1/*1, respectively. CONCLUSIONS Our results confirm that selecting tacrolimus dosing regimen according to the expected phenotype is appropriate, but that lower than currently recommended doses may be preferable.
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Affiliation(s)
- Bérenger Largeau
- CHRU de Tours, Laboratoire de Biochimie et Biologie Moléculaire, Tours, France
| | - Chantal Barin-Le Guellec
- Université de Tours, Université de Limoges, INSERM, Individual profiling and prevention of risks with immunosuppressive therapies and transplantation (IPPRITT) - UMR 1248, CHRU de Tours, Laboratoire de Biochimie et Biologie Moléculaire, Tours, France
| | - Hélène Longuet
- CHRU de Tours, Service de Néphrologie-Hypertension artérielle, Dialyses et Transplantation Rénale, FHU SUPORT, Tours, France
| | - Philippe Lesne
- CHRU de Tours, Laboratoire de Biochimie et Biologie Moléculaire, Tours, France
| | - Antoine Bouvarel
- CHRU de Tours, Laboratoire de Biochimie et Biologie Moléculaire, Tours, France
| | - Laura Préteseille
- CHRU de Tours, Laboratoire de Biochimie et Biologie Moléculaire, Tours, France
| | - Pierre Marquet
- Université de Limoges, INSERM, Individual profiling and prevention of risks with immunosuppressive therapies and transplantation (IPPRITT) - UMR 1248, CHU de Limoges, Service de Pharmacologie et Toxicologie, FHU SUPORT, Limoges, France
| | - Jean-Michel Halimi
- Université de Tours, Transplantation, immunologie et inflammation (T2I) - EA4245, CHRU de Tours, Service de Néphrologie-Hypertension artérielle, Dialyses et Transplantation Rénale, FHU SUPORT, Tours, France
| | - Matthias Büchler
- Université de Tours, Transplantation, immunologie et inflammation (T2I) - EA4245, CHRU de Tours, Service de Néphrologie-Hypertension artérielle, Dialyses et Transplantation Rénale, FHU SUPORT, Tours, France
| | - Philippe Gatault
- Université de Tours, Transplantation, immunologie et inflammation (T2I) - EA4245, CHRU de Tours, Service de Néphrologie-Hypertension artérielle, Dialyses et Transplantation Rénale, FHU SUPORT, Tours, France
| | - Johan Noble
- CHRU de Tours, Service de Néphrologie-Hypertension artérielle, Dialyses et Transplantation Rénale, FHU SUPORT, Tours, France
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Nowicka M, Górska M, Nowicka Z, Edyko K, Edyko P, Wiślicki S, Zawiasa-Bryszewska A, Strzelczyk J, Matych J, Kurnatowska I. Tacrolimus: Influence of the Posttransplant Concentration/Dose Ratio on Kidney Graft Function in a Two-Year Follow-Up. Kidney Blood Press Res 2019; 44:1075-1088. [PMID: 31522184 DOI: 10.1159/000502290] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 07/22/2019] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Tacrolimus (TAC) metabolism rate has the potential to impact graft function after kidney transplantation (KTx). We aimed to analyze the relationship between the early post-KTx TAC C/D ratio (blood trough concentration normalized by total daily dose) and kidney graft function in a 2-year follow-up. METHODS We retrospectively analyzed data from 101 post-KTx patients at 3, 6, 12, and 24 months after KTx to identify the C/D ratio cutoff value optimal for dividing patients into fast and slow TAC metabolizers. We investigated the relationship between their TAC metabolism rate and graft function. RESULTS Patients were divided based on the TAC C/D ratio at 6 months after KTx of 1.47 ng/mL * 1 mg. Fast metabolizers (C/D ratio <1.47 ng/mL * 1 mg) presented with significantly worse graft function throughout the whole study period (p < 0.05 at each timepoint) and were significantly less likely to develop good graft function (estimated glomerular filtration rate ≥45 mL/min/1.73 m2) than slow metabolizers. Our model based on donor and recipient age, recipient sex and slow/fast metabolism status allowed for identification of patients with compromised graft function in 2-year follow-up with 66.7% sensitivity and 94.6% specificity. CONCLUSION Estimating TAC C/D ratio at 6 months post-KTx might help identify patients at risk of developing deteriorated graft function in a 2-year follow-up.
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Affiliation(s)
- Maja Nowicka
- Department of Clinical Pharmacology, Medical University of Lodz, Lodz, Poland
| | - Monika Górska
- Department of Clinical Pharmacology, Medical University of Lodz, Lodz, Poland
| | - Zuzanna Nowicka
- Department of Clinical Pharmacology, Medical University of Lodz, Lodz, Poland.,Department of Biostatistics and Translational Medicine, Medical University of Lodz, Lodz, Poland
| | - Krzysztof Edyko
- Department of Clinical Pharmacology, Medical University of Lodz, Lodz, Poland
| | - Piotr Edyko
- Department of Urology and Kidney Transplantation, N Pirogov Provincial Specialist Hospital, Lodz, Poland
| | - Sebastian Wiślicki
- Clinical Department of Anesthesiology and Intensive Care and Pain Management, University Clinical Hospital No 1 N Barlicki in Lodz, Lodz, Poland
| | - Anna Zawiasa-Bryszewska
- Department of Clinical Pharmacology, Medical University of Lodz, Lodz, Poland.,Department of Nephrology, University Clinical Hospital No 1 N Barlicki in Lodz, Lodz, Poland
| | - Janusz Strzelczyk
- Department of General and Transplant Surgery, Medical University of Lodz, Lodz, Poland
| | - Józef Matych
- Department of Urology and Kidney Transplantation, N Pirogov Provincial Specialist Hospital, Lodz, Poland
| | - Ilona Kurnatowska
- Department of Clinical Pharmacology, Medical University of Lodz, Lodz, Poland, .,Department of Nephrology, University Clinical Hospital No 1 N Barlicki in Lodz, Lodz, Poland,
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Yanik MV, Seifert ME, Locke JE, Hauptfeld-Dolejsek V, Crowley MR, Cutter GR, Mannon RB, Feig DI, Limdi NA. CYP3A5 genotype affects time to therapeutic tacrolimus level in pediatric kidney transplant recipients. Pediatr Transplant 2019; 23:e13494. [PMID: 31124575 PMCID: PMC8009482 DOI: 10.1111/petr.13494] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 03/30/2019] [Accepted: 04/23/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Optimal management of immunosuppression in kidney transplantation requires a delicate balance of efficacy and toxicity. Tacrolimus (TAC) dose requirements are significantly impacted by genetic variation in CYP3A5 polymorphisms, however the impact that genotype has on clinical outcomes in the pediatric kidney transplant population remains unclear. METHODS We evaluated a retrospective cohort of 98 pediatric kidney transplant recipients. The primary exposure was CYP3A5 genotype, which classified each recipient into the expresser (at least one CYP3A5*1 allele) or non-expresser group (only CYP3A5*3 alleles). The primary outcome was time to achieve a steady therapeutic TAC concentration. Secondary outcomes include incidence of early allograft rejection and calcineurin inhibitor (CNI) nephrotoxicity during the first year post-transplant. RESULTS The study cohort included 55 (56%) expressers and 43 (44%) non-expressers of the CYP3A5*1 allele. Expressers had a significantly longer time to achieve a steady therapeutic TAC concentration than non-expressers (log rank, P = 0.03). Expressers had a trend for higher incidence of early allograft rejection (29.1% vs 16.3%, log rank, P = 0.16). Early biopsy-proven CNI nephrotoxicity was seen in 60% of recipients, with no differences in the rate between expressers and non-expressers. CONCLUSIONS Pediatric kidney transplant recipients with the CYP3A5*1 allele (expressers) take a longer time to achieve therapeutic TAC levels than those with the CYP3A5*3 allele (non-expressers). However, we observed no significant differences in acute rejection or CNI nephrotoxicity based on CYP3A5 genotype. Thus CYP3A5 genotype was not observed to have an immediate impact on early transplant outcomes.
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Affiliation(s)
- Megan V. Yanik
- Division of Nephrology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Michael E. Seifert
- Division of Nephrology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jayme E. Locke
- Department of Surgery, Division of Transplantation, University of Alabama at Birmingham, Birmingham, Alabama
| | - Vera Hauptfeld-Dolejsek
- Department of Surgery, Division of Transplantation, University of Alabama at Birmingham, Birmingham, Alabama
| | - Michael R. Crowley
- Heflin Center for Genomic Science, University of Alabama at Birmingham, Birmingham, Alabama
| | - Gary R. Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Roslyn B. Mannon
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Daniel I. Feig
- Division of Nephrology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Nita A. Limdi
- Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama
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40
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Chen L, Lu X, Tan G, Zhu L, Liu Y, Li M. Impact of body composition on pharmacokinetics of tacrolimus in liver transplantation recipients. Xenobiotica 2019; 50:186-191. [PMID: 30995884 DOI: 10.1080/00498254.2019.1607918] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Lu Chen
- Pharmaceutical College, Tianjin Medical University, Tianjin, China
| | - Xiaoqing Lu
- Pharmaceutical College, Tianjin Medical University, Tianjin, China
| | - Guijun Tan
- Department of Nutrition, Tianjin First Central Hospital, Tianjin, China
| | - Liqin Zhu
- Pharmaceutical College, Tianjin Medical University, Tianjin, China
- Department of Pharmacy, Tianjin First Central Hospital, Tianjin, China
| | - Yihe Liu
- Department of Transplantation, Tianjin First Central Hospital, Tianjin, China
| | - Mengxue Li
- Pharmaceutical College, Tianjin Medical University, Tianjin, China
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Long-lasting immunosuppressive effects of tacrolimus-loaded micelle NK61060 in preclinical arthritis and colitis models. Ther Deliv 2018; 9:711-729. [PMID: 30277135 DOI: 10.4155/tde-2018-0044] [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: 11/17/2022] Open
Abstract
AIM Tacrolimus (TAC) is an important drug for inflammatory diseases. However, TAC has several limitations, such as variable trough concentrations among individuals and a high medication frequency. In this study, we created NK61060, a novel micellar TAC formulation, to circumvent these disadvantages. MATERIALS & METHODS Immunosuppressive activity of NK61060 was determined in the collagen-induced arthritis rat model, mannan-induced arthritis mouse model and dextran sodium sulfate-induced colitis mouse model. The pharmacokinetics and toxicology of NK61060 were evaluated in those models. RESULTS In arthritis and colitis models, NK61060 exhibited superior immunosuppressive activity compared with that of TAC. Pharmacokinetic and toxicological analyses indicated that NK61060 had a wider safety margin and could be administered at a reduced medication frequency. CONCLUSION NK61060 mitigates the trough concentration variability and the medication frequency and it may be a safer and more effective option for use in clinical settings. Further studies are needed to determine its clinical usefulness.
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Phupradit A, Vadcharavivad S, Ingsathit A, Kantachuvesiri S, Areepium N, Sra-Ium S, Auamnoy T, Sukasem C, Sumethkul V, Kitiyakara C. Impact of POR and CYP3A5 Polymorphisms on Trough Concentration to Dose Ratio of Tacrolimus in the Early Post-operative Period Following Kidney Transplantation. Ther Drug Monit 2018; 40:549-557. [PMID: 29878980 DOI: 10.1097/ftd.0000000000000542] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Tacrolimus, a critical dose drug, is widely used in transplantation. Knowing the contribution of genetic factors, which significantly influence tacrolimus variability, is beneficial in the personalization of its starting dose. The significant impact of CYP3A5*3 polymorphisms on tacrolimus exposure has been reported. Conflicting results of the additional influence of POR*28 polymorphisms on tacrolimus pharmacokinetic interindividual variability have been observed among different populations. The objective of this study was to explore the interaction between POR*28 and CYP3A5*3 polymorphisms and their main effects on tacrolimus trough concentration to dose ratios on day 7 after kidney transplantation. METHODS Two hundred sixteen adult kidney transplant recipients participated in this retrospective study. All participants received a twice daily tacrolimus regimen. Blood samples and data were collected on day 7 after transplantation. A 2-way analysis of covariance was performed. Tested covariates were age, hemoglobin, serum albumin, and prednisolone dose. RESULTS A 2 × 2 analysis of covariance revealed that the interaction between CYP3A5 polymorphisms (CYP3A5 expresser and CYP3A5 nonexpresser) and POR polymorphisms (POR*28 carrier and POR*28 noncarrier) was not significant (F(1, 209) = 2.473, P = 0.117, (Equation is included in full-text article.)= 0.012). The predicted main effect of CYP3A5 and POR polymorphisms was significant (F(1, 209) = 105.565, P < 0.001, (Equation is included in full-text article.)= 0.336 and F(1, 209) = 4.007, P = 0.047, (Equation is included in full-text article.)= 0.019, respectively). Hemoglobin, age, and steroid dose influenced log C0/dose of tacrolimus (F(1, 209) = 20.612, P < 0.001, (Equation is included in full-text article.)= 0.090; F(1, 209) = 14.360, P < 0.001, (Equation is included in full-text article.)= 0.064; and F(1, 209) = 5.512, P = 0.020, (Equation is included in full-text article.)= 0.026, respectively). CONCLUSIONS After adjusting for the influences of hemoglobin, age, and prednisolone dose, significant impacts of the CYP3A5 and POR polymorphisms on tacrolimus exposure were found. The effect of POR*28 and CYP3A5*3 polymorphisms during the very early period after kidney transplantation is independent of each other.
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Affiliation(s)
- Annop Phupradit
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
- Pharmacy Division, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Somratai Vadcharavivad
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
| | - Atiporn Ingsathit
- Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Surasak Kantachuvesiri
- Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nutthada Areepium
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
| | - Supasil Sra-Ium
- Pharmacy Division, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Titinun Auamnoy
- Faculty of Pharmaceutical Sciences, Burapha University, Chon Buri, Thailand
| | - Chonlaphat Sukasem
- Division of Pharmacogenomics and Personalized Medicine, Department of Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Vasant Sumethkul
- Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chagriya Kitiyakara
- Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Influence of donor liver CYP3A4*20 loss-of-function genotype on tacrolimus pharmacokinetics in transplanted patients. Pharmacogenet Genomics 2018; 28:41-48. [PMID: 29256966 DOI: 10.1097/fpc.0000000000000321] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Cytochrome P450 3A4 (CYP3A4) metabolizes about half of all drugs on the market; however, the impact of CYP3A4 loss-of-function variants on drug exposures remains poorly characterized. Here, we report the effect of the CYP3A4*20 frameshift allele in two Spanish liver transplant patients treated with tacrolimus. PATIENTS AND METHODS A series of 90 transplanted patients (with DNA available for 89 of the recipients and 76 of the liver donors) treated with tacrolimus were included in the study. The genotypes of liver donors and of the recipients for CYP3A4*20 (rs67666821), CYP3A4*22 (rs35599367) and CYP3A5*3 (rs776746) were compared with weight-adjusted tacrolimus dose (D), tacrolimus trough concentration (C0), and dose-adjusted tacrolimus trough concentrations (C0/D) using the Mann-Whitney U-nonparametric test. RESULTS The CYP3A4*20 allele was detected in two of the liver donors. This genotype yielded at all times higher C0/D (2.6-fold, average) than intermediate CYP3A metabolizers (CYP3A4*1/*1 and CYP3A5*3/*3) (P=0.045, 90 days after transplantation). CYP3A4*22 carriers showed a 1.9-fold average increase in C0/D (P=0.047, 0.025, and 0.053; at days 7, 14, and 30 after transplantation, respectively) compared with intermediate metabolizers. In terms of recipients' genotype, CYP3A5*1 had reduced (P=0.025) and CYP3A4*22 increased C0/D (P=0.056) 7 days after transplantation. The incidence of biopsy-proven acute rejection was 0, 12, and 20% for livers with poor, intermediate, and extensive CYP3A-metabolizing capacity, respectively (P=0.0995). CONCLUSION This first description of CYP3A4*20 null genotype in liver-transplanted patients, supports the relevance of CYP3A genotyping in tacrolimus therapy.
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Lancia P, Aurich B, Ha P, Maisin A, Baudouin V, Jacqz-Aigrain E. Adverse Events under Tacrolimus and Cyclosporine in the First 3 Years Post-Renal Transplantation in Children. Clin Drug Investig 2018; 38:157-171. [PMID: 29236209 DOI: 10.1007/s40261-017-0594-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Progress in immunosuppression has reduced acute rejection, graft loss and mortality after renal transplantation. Adverse drug reactions are well described in adults but few data are available in children. Our objectives were to analyse the adverse events reported in the first 3 years post-transplantation in children receiving tacrolimus or cyclosporine-based immunosuppression and compare them with the information of the Summary of Product Characteristics. METHODS This retrospective study included all children who underwent a renal transplant at Hospital Robert Debré between 2002 and 2015. Initial immunosuppression was based on induction, calcineurin inhibitor, mycophenolate mofetil and corticosteroids. Adverse events were collected from medical records and coded using the Medical Dictionary for Regulatory Activities and the implications of tacrolimus and cyclosporine analysed. Statistical analyses were performed using SAS 9.4. RESULTS One hundred and twenty-five children were included. During the observation period [2.7 years (0.6-4.3)], 105 patients received tacrolimus and 39 received cyclosporine. The incidence rate for gastrointestinal disorders was 0.128 and 0.056 by patient-years of exposure (p < 0.05), under tacrolimus and cyclosporine schedules. For neutropenia, it was 0.064 and 0.014 (p < 0.05). The frequencies of toxic nephropathy and gastrointestinal pain were higher than those in the Summary of Product Characteristics of tacrolimus (> 20%) and cyclosporine (> 10%). Cosmetic events for cyclosporine and neutropenia for tacrolimus were frequently observed (18 and 14.3%, respectively), although uncommon in the Summary of Product Characteristics. CONCLUSIONS The exposure-adjusted incidence rate of gastrointestinal disorders and neutropenia was higher in children under the tacrolimus schedule. Our findings contribute to the evaluation of the benefit-risk balance of immunosuppressive therapy following paediatric renal transplantation.
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Affiliation(s)
- Pauline Lancia
- Department of Paediatric Pharmacology and Pharmacogenetics, Hospital Robert Debré, APHP, 48 Boulevard Sérurier, 75019, Paris, France
| | - Beate Aurich
- Department of Paediatric Pharmacology and Pharmacogenetics, Hospital Robert Debré, APHP, 48 Boulevard Sérurier, 75019, Paris, France
| | - Phuong Ha
- Department of Paediatric Pharmacology and Pharmacogenetics, Hospital Robert Debré, APHP, 48 Boulevard Sérurier, 75019, Paris, France
| | - Anne Maisin
- Department of Paediatric Nephrology, Hospital Robert Debré, APHP, 48 Boulevard Sérurier, 75019, Paris, France
| | - Véronique Baudouin
- Department of Paediatric Nephrology, Hospital Robert Debré, APHP, 48 Boulevard Sérurier, 75019, Paris, France
| | - Evelyne Jacqz-Aigrain
- Department of Paediatric Pharmacology and Pharmacogenetics, Hospital Robert Debré, APHP, 48 Boulevard Sérurier, 75019, Paris, France. .,Clinical Investigation Center CIC1426, INSERM, Paris, France. .,Paris Diderot University, Sorbonne Paris Cité, Paris, France.
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Andreu F, Colom H, Elens L, van Gelder T, van Schaik RHN, Hesselink DA, Bestard O, Torras J, Cruzado JM, Grinyó JM, Lloberas N. A New CYP3A5*3 and CYP3A4*22 Cluster Influencing Tacrolimus Target Concentrations: A Population Approach. Clin Pharmacokinet 2018; 56:963-975. [PMID: 28050888 DOI: 10.1007/s40262-016-0491-3] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Single nucleotide polymorphisms (SNPs) in the CYP3A5 and CYP3A4 genes have been reported to be an important cause of variability in the pharmacokinetics of tacrolimus in renal transplant patients. The aim of this study was to merge all of the new genetic information available with tacrolimus pharmacokinetics to generate a more robust population model with data from renal transplant recipients. METHODS Tacrolimus exposure data from 304 renal transplant recipients were collected throughout the first year after transplantation and were simultaneously analyzed with a population pharmacokinetic approach using NONMEM® version 7.2. RESULTS The tacrolimus whole-blood concentration versus time data were best described by a two-open-compartment model with inter-occasion variability assigned to plasma clearance. The following factors led to the final model, which significantly decreased the minimum objective function value (p < 0.001): a new genotype cluster variable combining the CYP3A5*3 and CYP3A4*22 SNPs defined as extensive, intermediate, and poor metabolizers; the standardization of tacrolimus whole blood concentrations to a hematocrit value of 45%; and age included as patients <63 years versus patients ≥63 years. External validation confirmed the prediction ability of the model with median bias and precision values of 1.17 ng/mL (95% confidence interval [CI] -3.68 to 4.50) and 1.64 ng/mL (95% CI 0.11-5.50), respectively. Simulations showed that, for a given age and hematocrit at the same fixed dose, extensive metabolizers required the highest doses followed by intermediate metabolizers and then poor metabolizers. CONCLUSIONS Tacrolimus disposition in renal transplant recipients was described using a new population pharmacokinetic model that included the CYP3A5*3 and CYP3A4*22 genotype, age, and hematocrit.
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Affiliation(s)
- Franc Andreu
- Laboratory 4122, Nephrology Service and Laboratory of Experimental Nephrology, University of Barcelona, Campus Bellvitge, Pavelló de Govern, Feixa Llarga, s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain.,Biopharmaceutics and Pharmacokinetics Unit, Department of Pharmacy and Pharmaceutical Technology Department, School of Pharmacy, University of Barcelona, Barcelona, Spain
| | - Helena Colom
- Biopharmaceutics and Pharmacokinetics Unit, Department of Pharmacy and Pharmaceutical Technology Department, School of Pharmacy, University of Barcelona, Barcelona, Spain
| | - Laure Elens
- Department of Integrated PharmacoMetrics, PharmacoGenomics and PharmacoKinetics (PMGK), Louvain Drug Research Institute (LDRI), Université Catholique de Louvain (UCL), Brussels, Belgium.,Department of Clinical Chemistry, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Teun van Gelder
- Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.,Department of Hospital Pharmacy, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.,Department of Clinical Chemistry, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Ronald H N van Schaik
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.,Department of Clinical Chemistry, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Dennis A Hesselink
- Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.,Department of Clinical Chemistry, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Oriol Bestard
- Laboratory 4122, Nephrology Service and Laboratory of Experimental Nephrology, University of Barcelona, Campus Bellvitge, Pavelló de Govern, Feixa Llarga, s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Joan Torras
- Laboratory 4122, Nephrology Service and Laboratory of Experimental Nephrology, University of Barcelona, Campus Bellvitge, Pavelló de Govern, Feixa Llarga, s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Josep M Cruzado
- Laboratory 4122, Nephrology Service and Laboratory of Experimental Nephrology, University of Barcelona, Campus Bellvitge, Pavelló de Govern, Feixa Llarga, s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Josep M Grinyó
- Laboratory 4122, Nephrology Service and Laboratory of Experimental Nephrology, University of Barcelona, Campus Bellvitge, Pavelló de Govern, Feixa Llarga, s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Nuria Lloberas
- Laboratory 4122, Nephrology Service and Laboratory of Experimental Nephrology, University of Barcelona, Campus Bellvitge, Pavelló de Govern, Feixa Llarga, s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain.
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Blatter JA, Sweet SC, Conrad C, Danziger-Isakov LA, Faro A, Goldfarb SB, Hayes D, Melicoff E, Schecter M, Storch G, Visner GA, Williams NM, Wang D. Anellovirus loads are associated with outcomes in pediatric lung transplantation. Pediatr Transplant 2018; 22:10.1111/petr.13069. [PMID: 29082660 PMCID: PMC5811341 DOI: 10.1111/petr.13069] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/11/2017] [Indexed: 12/17/2022]
Abstract
Anelloviruses are DNA viruses ubiquitously present in human blood. Due to their elevated levels in immunosuppressed patients, anellovirus levels have been proposed as a marker of immune status. We hypothesized that low anellovirus levels, reflecting relative immunocompetence, would be associated with adverse outcomes in pediatric lung transplantation. We assayed blood samples from 57 patients in a multicenter study for alpha- and betatorquevirus, two anellovirus genera. The primary short-term outcome of interest was acute rejection, and longer-term outcomes were analyzed individually and as "composite" (death, chronic rejection, or retransplant within 2 years). Patients with low alphatorquevirus levels at 2 weeks post-transplantation were more likely to develop acute rejection within 3 months after transplant (P = .013). Low betatorquevirus levels at 6 weeks and 6 months after transplant were associated with death (P = .047) and the composite outcome (P = .017), respectively. There was an association between low anellovirus levels and adverse outcomes in pediatric lung transplantation. Alphatorquevirus levels were associated with short-term outcomes (ie, acute rejection), while betatorquevirus levels were associated with longer-term outcomes (ie, death, or composite outcome within 2 years). These observations suggest that anelloviruses may serve as useful biomarkers of immune status and predictors of adverse outcomes.
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Affiliation(s)
- Joshua A. Blatter
- Department of Pediatrics, Washington University School of Medicine, St. Louis MO,Correspondence and reprint requests to: Joshua A. Blatter, MD, MPH, Department of Pediatrics, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8116, Saint Louis, MO 63110, Phone: 314-454-2694, Fax: 314-454-2515,
| | - Stuart C. Sweet
- Department of Pediatrics, Washington University School of Medicine, St. Louis MO
| | - Carol Conrad
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Lara A. Danziger-Isakov
- Division of Infectious Diseases, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | | | | | - Don Hayes
- Department of Pediatrics, The Ohio State University, Columbus, OH
| | | | - Marc Schecter
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH
| | - Gregory Storch
- Department of Pediatrics, Washington University School of Medicine, St. Louis MO
| | - Gary A. Visner
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | | | - David Wang
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis MO,Department of Molecular Microbiology, Washington University School of Medicine, Saint Louis MO
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Helal M, Obada M, Elrazek WA, Safan M, El-Hakim TA, El-Said H. Effect of ABCB1 (3435C>T) and CYP3A5 (6986A>G) genes polymorphism on tacrolimus concentrations and dosage requirements in liver transplant patients. EGYPTIAN JOURNAL OF MEDICAL HUMAN GENETICS 2017. [DOI: 10.1016/j.ejmhg.2016.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Wang W, Shahzad KA, Li M, Zhang A, Zhang L, Xu T, Wan X, Shen C. An Antigen-Presenting and Apoptosis-Inducing Polymer Microparticle Prolongs Alloskin Graft Survival by Selectively and Markedly Depleting Alloreactive CD8 + T Cells. Front Immunol 2017. [PMID: 28649247 PMCID: PMC5465244 DOI: 10.3389/fimmu.2017.00657] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Selectively depleting the pathogenic T cells is a fundamental strategy for the treatment of allograft rejection and autoimmune disease since it retains the overall immune function of host. The concept of killer artificial antigen-presenting cells (KaAPCs) has been developed by co-coupling peptide–major histocompatibility complex (pMHC) multimer and anti-Fas monoclonal antibody (mAb) onto the polymeric microparticles (MPs) to induce the apoptosis of antigen-specific T cells. But little information is available about its in vivo therapeutic potential and mechanism. In this study, polyethylenimine (PEI)-coated poly lactic-co-glycolic acid microparticle (PLGA MP) was fabricated as a cell-sized scaffold to covalently co-couple H-2Kb-Ig dimer and anti-Fas mAb for the generation of alloantigen-presenting and apoptosis-inducing MPs. Intravenous infusions of the biodegradable KaAPCs prolonged the alloskin graft survival for 43 days in a single MHC-mismatched murine model, depleted the most of H-2Kb-alloreactive CD8+ T cells in peripheral blood, spleen, and alloskin graft in an antigen-specific manner and anti-Fas-dependent fashion. The cell-sized KaAPCs circulated throughout vasculature into liver, kidney, spleen, lymph nodes, lung, and heart, but few ones into local allograft at early stage, with a retention time up to 36 h in vivo. They colocalized with CD8+ T cells in secondary lymphoid organs while few ones contacted with CD4+ T cells, B cells, macrophage, and dendritic cells, or internalized by phagocytes. Importantly, the KaAPC treatment did not significantly impair the native T cell repertoire or non-pathogenic immune cells, did not obviously suppress the overall immune function of host, and did not lead to visible organ toxicity. Our results strongly document the high potential of PLGA MP-based KaAPCs as a novel antigen-specific immunotherapy for allograft rejection and autoimmune disorder. The in vivo mechanism of alloinhibition, tissue distribution, and biosafety were also initially characterized, which will facilitate its translational studies from bench to bedside.
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Affiliation(s)
- Wei Wang
- Department of Microbiology and Immunology, Southeast University Medical School, Nanjing, China
| | - Khawar Ali Shahzad
- Department of Microbiology and Immunology, Southeast University Medical School, Nanjing, China
| | - Miaochen Li
- Department of Microbiology and Immunology, Southeast University Medical School, Nanjing, China
| | - Aifeng Zhang
- Department of Pathology, Southeast University Medical School, Nanjing, China
| | - Lei Zhang
- Department of Microbiology and Immunology, Southeast University Medical School, Nanjing, China
| | - Tao Xu
- Department of Microbiology and Immunology, Southeast University Medical School, Nanjing, China
| | - Xin Wan
- Department of Microbiology and Immunology, Southeast University Medical School, Nanjing, China
| | - Chuanlai Shen
- Department of Microbiology and Immunology, Southeast University Medical School, Nanjing, China
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Practical Recommendations for Long-term Management of Modifiable Risks in Kidney and Liver Transplant Recipients: A Guidance Report and Clinical Checklist by the Consensus on Managing Modifiable Risk in Transplantation (COMMIT) Group. Transplantation 2017; 101:S1-S56. [PMID: 28328734 DOI: 10.1097/tp.0000000000001651] [Citation(s) in RCA: 197] [Impact Index Per Article: 28.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Short-term patient and graft outcomes continue to improve after kidney and liver transplantation, with 1-year survival rates over 80%; however, improving longer-term outcomes remains a challenge. Improving the function of grafts and health of recipients would not only enhance quality and length of life, but would also reduce the need for retransplantation, and thus increase the number of organs available for transplant. The clinical transplant community needs to identify and manage those patient modifiable factors, to decrease the risk of graft failure, and improve longer-term outcomes.COMMIT was formed in 2015 and is composed of 20 leading kidney and liver transplant specialists from 9 countries across Europe. The group's remit is to provide expert guidance for the long-term management of kidney and liver transplant patients, with the aim of improving outcomes by minimizing modifiable risks associated with poor graft and patient survival posttransplant.The objective of this supplement is to provide specific, practical recommendations, through the discussion of current evidence and best practice, for the management of modifiable risks in those kidney and liver transplant patients who have survived the first postoperative year. In addition, the provision of a checklist increases the clinical utility and accessibility of these recommendations, by offering a systematic and efficient way to implement screening and monitoring of modifiable risks in the clinical setting.
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Influence of the CYP3A4/5 genetic score and ABCB1 polymorphisms on tacrolimus exposure and renal function in Brazilian kidney transplant patients. Pharmacogenet Genomics 2017; 26:462-72. [PMID: 27434656 DOI: 10.1097/fpc.0000000000000237] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Polymorphisms in genes encoding transport proteins and metabolizing enzymes involved in tacrolimus (TAC) disposition may be important sources of individual variability during treatment. OBJECTIVE The aim of this study was to investigate the effect of combined CYP3A4 and CYP3A5 variants, using a CYP3A4/5 genetic score, and ABCB1 polymorphisms on therapeutic TAC monitoring and their relationship with clinical outcomes. MATERIAL AND METHODS Brazilian kidney transplant recipients (n=151), who received TAC over 3 months after transplantation, were genotyped for CYP3A4 rs2242480 (g.20230G>A), CYP3A5 rs15524 (g.31611C>T) and rs776746 (g.6986A>G), ABCB1 rs1128503 (c.1236C>T), rs1045642 (c.3435C>T), and rs2032582 (c.2677G>T/A) polymorphisms. RESULTS Frequencies of CYP3A4 g.20230A, CYP3A5 g.31611C, and g.6986A were 0.37, 0.26, and 0.28, respectively. These alleles were associated with TAC rapid metabolization and were used for CYP3A4/5 genetic score construction. A higher CYP3A4/5 genetic score was associated with higher TAC dose and lower concentrations for dose administered (Co/D, P<0.05). Ninety days after transplantation, the presence of two or more rapid metabolization alleles contributed toward 27.7% of Co/D variability and was associated with a lower estimated glomerular filtration rate values (P<0.05). For ABCB1, the frequencies of c.1236T, c.3435T, and c.2677T/A alleles were 0.42, 0.42, and 0.33/0.04. At 30 days after transplantation, patients carrying ABCB1 c.1236TT+c.3435TT+(c.2677TT+TA) genotypes had higher TAC Co/D than those with common or heterozygous genotypes (P<0.05). CONCLUSION The results show the impact of the CYP3A4/5 genetic score on TAC exposure and renal function in Brazilian patients. Furthermore, ABCB1 polymorphisms, in a combined analysis, influenced TAC Co/D at 30 days after transplantation.
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