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Chen H, Liu S, Yu L, Hou X, Zhao R. Factors and interventions affecting tacrolimus intrapatient variability: A systematic review and meta-analysis. Transplant Rev (Orlando) 2024; 38:100878. [PMID: 39260119 DOI: 10.1016/j.trre.2024.100878] [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: 07/10/2024] [Revised: 08/16/2024] [Accepted: 08/17/2024] [Indexed: 09/13/2024]
Abstract
BACKGROUNDS Tacrolimus is a cornerstone of posttransplantation immunosuppressive regimens. Despite routine monitoring, the efficacy of its trough concentrations in reflecting drug concentration fluctuations is limited. Intrapatient variability (IPV) emerges as a novel monitoring marker for predicting clinical outcomes. However, understanding the factors affecting IPV and assessing interventions to address it remain enigmatic, posing a conundrum in clinical management. OBJECTIVES This systematic review aimed to investigate a spectrum of factors affecting IPV and assess the effect of strategic interventions, thereby charting a course for enhanced clinical stewardship. METHODS We electronically searched of PubMed, Embase, and the Cochrane Library databases for studies investigating factors and interventions affecting IPV up to October 2023. Two reviewers independently screened literature, extracted data, and assessed quality, using RevMan 5.4.1 software for meta-analysis. RESULTS A total of 15 randomized controlled trials (RCTs), 34 cohort studies, and 20 self-controlled studies were included. The results indicated that IPV was significantly higher in cytochrome P450 3A5 (CYP3A5) expressers, nonadherent patients, patients taking proton pump inhibitors or statins, and Black or African American recipients, whereas recipients consuming extended-release formulation exhibited lower IPV. Additionally, the participation of pharmacists had a positive effect on improving IPV. CONCLUSIONS Factors affecting IPV encompassed genotype, formulation, adherence, drug combinations, and ethnicity, with each factor exerting varying degrees of effect. Identifying these factors was crucial for developing targeted intervention strategies. While the participation of pharmacists held a promise in improving IPV, further investigation of interventions such as mobile technology, educational measures to enhance adherence, and personalized dosing regimens was warranted.
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Affiliation(s)
- Hongsheng Chen
- Department of Pharmacy, Peking University Third Hospital, Beijing, China; Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China.
| | - Shuang Liu
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - Lingling Yu
- Department of Pharmacy, Peking University Third Hospital, Beijing, China; Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Xiaofei Hou
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Rongsheng Zhao
- Department of Pharmacy, Peking University Third Hospital, Beijing, China.
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Arns W, Philippe A, Ditt V, Hauser IA, Thaiss F, Sommerer C, Suwelack B, Dragun D, Hillen J, Schiedel C, Elsässer A, Nashan B. Everolimus plus reduced calcineurin inhibitor prevents de novo anti-HLA antibodies and humoral rejection in kidney transplant recipients: 12-month results from the ATHENA study. FRONTIERS IN TRANSPLANTATION 2023; 2:1264903. [PMID: 38993866 PMCID: PMC11235221 DOI: 10.3389/frtra.2023.1264903] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 10/05/2023] [Indexed: 07/13/2024]
Abstract
Background Studies prospectively monitoring de novo donor-specific antibodies (dnDSAs) and their clinical impact are sparse. This substudy of ATHENA was initiated to evaluate the effect of everolimus (EVR) or mycophenolic acid (MPA) in combination with reduced calcineurin inhibitor (CNI, tacrolimus [TAC] or cyclosporine [CsA]) on the formation of human leukocyte antibodies (HLA), including dnDSA, and the impact on clinical outcomes in kidney transplant (KTx) recipients. Methods All eligible patients were randomized 1:1:1 to receive either EVR + TAC, EVR + CsA or MPA + TAC, with basiliximab induction plus steroids after transplantation up to Month 12. The incidence of dnDSA by treatment group and the association with clinical events were evaluated descriptively as an exploratory objective in the intent-to-treat (ITT) and per-protocol (PP) populations with at least one antibody assessment. Results Overall, none of the patients in the EVR + TAC group had either dnDSA or antibody mediated rejection (PP or ITT population) and only one patient with dnDSA in the TAC + MPA group had antibody mediated rejection. Conclusion The EVR regimen was comparable to MPA regimen with an extremely low incidence of dnDSA over 1 year of treatment.
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Affiliation(s)
- Wolfgang Arns
- Department of Nephrology and Transplantation, Cologne Merheim Medical Center, Cologne, Germany
| | - Aurélie Philippe
- BIH Biomedical Innovation Academy, Berlin Institute of Health at Charité—Universitätsmedizin Berlin, Berlin, Germany
- Department of Nephrology and Medical Intensive Care, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Vanessa Ditt
- Institute of Transfusion Medicine, Kliniken der Stadt Köln, Cologne, Germany
| | - Ingeborg A. Hauser
- Department of Nephrology, Goethe-University Frankfurt, Frankfurt, Germany
| | - Friedrich Thaiss
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Claudia Sommerer
- Nephrology Unit, University Hospital Heidelberg, Heidelberg, Germany
| | - Barbara Suwelack
- Department of Internal Medicine, Transplant Nephrology, University Hospital of Münster, Münster, Germany
| | - Duska Dragun
- Department of Nephrology and Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Jan Hillen
- Department of Immunology, Novartis Pharma GmbH, Nürnberg, Germany
| | | | - Anja Elsässer
- Department of Immunology, Novartis Pharma GmbH, Nürnberg, Germany
| | - Björn Nashan
- Department of Hepatobiliary Surgery and Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Organ Transplantation Center, Anhui Provincial Hospital, The First Affiliated Hospital of University of Science and Technology of China, Hefei, China
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Wang TS, Huang KH, Hsueh KC, Chen HA, Tam KW, Sun SH, Chen CF, Wang CY, Tung MC, Wang YH. Efficacy and safety of once-daily prolonged-release tacrolimus versus twice-daily tacrolimus in kidney transplant recipients: A meta-analysis and trial sequential analysis. J Chin Med Assoc 2023; 86:842-849. [PMID: 37458375 DOI: 10.1097/jcma.0000000000000960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/09/2023] Open
Abstract
BACKGROUND Kidney transplantation is the most important treatment for end-stage renal disease. Immunosuppressive therapies can prevent acute rejection for kidney transplant recipients. Tacrolimus is usually administered to prevent graft rejection after transplantation. Previous studies have indicated that once-daily tacrolimus may improve medication adherence. Therefore, this meta-analysis aimed to compare clinical outcomes between once-daily and twice-daily tacrolimus in de novo renal transplant patients. METHODS Eligible studies were identified from the Cochrane Library Database, PubMed, and Embase until July 2022. Those randomized controlled trials (RCTs) evaluating once-daily versus twice-daily tacrolimus formulations in de novo renal transplantation were included. A summary risk ratio (RR) and standardized mean difference (SMD) with the 95% confidence interval (CI) were estimated using a random-effects model. RESULTS In total, nine RCTs were included. There were no differences in biopsy-confirmed acute rejection rates between patients with once-daily and those with twice-daily tacrolimus (RR, 0.91; 95% CI, 0.73-1.13) in 12 months. Regarding renal function, there was no significant difference between the once-daily and twice-daily tacrolimus groups (SMD, -0.03; 95% CI, -0.12 to 0.07). In addition, the risk of graft failure, death, and adverse events in the first year was similar for the once-daily and twice-daily tacrolimus groups. CONCLUSION Our major findings suggest that de novo renal transplantation recipients receiving once-daily tacrolimus immediately after transplantation have comparable efficacy and safety with those recipients who received twice-daily tacrolimus. Therefore, once-daily tacrolimus medication can be an alternative for de novo renal transplantation recipients.
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Affiliation(s)
- Tair-Shin Wang
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan, ROC
- Department of Pharmacy, Far Eastern Memorial Hospital, New Taipei City, Taiwan, ROC
| | - Kuan-Hua Huang
- Department of Urology, Chi Mei Medical Center, Tainan, Taiwan, ROC
| | - Kuan-Chun Hsueh
- Division of General Surgery, Department of Surgery, Tungs' Taichung MetroHarbor Hospital, Taichung, Taiwan, ROC
| | - Hsin-An Chen
- Division of General Surgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan, ROC
- TMU Research Center of Urology and Kidney, Taipei Medical University, Taipei, Taiwan, ROC
| | - Ka-Wai Tam
- Division of General Surgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan, ROC
| | - Shu-Hui Sun
- Department of Pharmacy, Far Eastern Memorial Hospital, New Taipei City, Taiwan, ROC
| | - Cheng-Fong Chen
- Department of Surgery, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Chien-Ying Wang
- Department of Critical Care Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Min-Che Tung
- Division of Urology, Department of Surgery, Tungs' Taichung MetroHarbor Hospital, Taichung, Taiwan, ROC
| | - Yuan-Hung Wang
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan, ROC
- Department of Medical Research, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan, ROC
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Ha YP, Divard G, Mitra N, Putt ME, Pallet N, Loupy A, Anglicheau D, Trofe-Clark J, Legendre C, Bloom RD, Reese PP. Outcomes in kidney transplant recipients treated with immediate-release tacrolimus capsules versus extended-release tacrolimus capsules: A cohort study. Clin Transplant 2023; 37:e14840. [PMID: 36374204 PMCID: PMC10290232 DOI: 10.1111/ctr.14840] [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: 03/24/2022] [Revised: 10/11/2022] [Accepted: 10/14/2022] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Prior randomized trials and observational studies have generally reported similar outcomes in kidney transplant recipients (KTRs) treated with immediate-release tacrolimus (IR-TAC) versus extended-release tacrolimus (ER-TAC). However, many of these previous studies focused on patients with low immunological risks, had small sample sizes and brief follow-up periods, and excluded outcomes associated with graft loss, such as chronic rejection. METHODS To address these limitations, we conducted a cohort study of 848 KTRs at a single transplantation center who had generally high immunological risks and were treated with either IR-TAC capsules (589 patients, 65.9%) or ER-TAC capsules (289 patients, 34.1%). All patients received their designated maintenance immunosuppressive regimen for at least 3 months post-transplantation. Afterwards, tacrolimus formulation was at the discretion of each patient's transplant nephrologist. For the two treatment groups, we compared the hazards of experiencing a composite outcome of acute or chronic antibody-mediated rejection (AMR), acute or chronic T-cell-mediated rejection, de novo DSA, and/or graft loss over a 3-year period starting at 3 months post-transplantation. RESULTS In a multivariable Cox proportional hazards regression model, KTRs treated with IR-TAC capsules had an increased hazard of experiencing the composite outcome when compared to patients treated with ER-TAC capsules; however, this result was not significant (adj HR 1.24, 95% CI .92-1.68, p = .163). Similar results were obtained with inverse probability of treatment weighting (IPTW) using a propensity score (adj HR 1.25, 95% CI .93-1.68, p = .146). CONCLUSION These findings suggest that when compared to IR-TAC capsules, ER-TAC capsules do not reduce the hazard of poor outcomes in KTRs with generally high immunological risks.
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Affiliation(s)
- Yoonhee P. Ha
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gillian Divard
- Institut National de la Santé et de la Recherche Médicale, Paris-Cardiovascular Research Center, Paris Translational Research Center for Organ Transplantation, Université de Paris, Paris, France
- Kidney Transplant Department, Necker Hospital, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Nandita Mitra
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mary E. Putt
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nicolas Pallet
- Department of Clinical Chemistry, Hôpital Européen Georges Pompidou, Assistance Publique Hôpitaux de Paris, University of Paris, Paris, France
- CRC (UMR_S_1138/U1138), Centre de Recherche des Cordeliers, Université de Paris, Paris, France
| | - Alexandre Loupy
- Institut National de la Santé et de la Recherche Médicale, Paris-Cardiovascular Research Center, Paris Translational Research Center for Organ Transplantation, Université de Paris, Paris, France
- Kidney Transplant Department, Necker Hospital, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Dany Anglicheau
- Kidney Transplant Department, Necker Hospital, Assistance Publique–Hôpitaux de Paris, Paris, France
- Necker-Enfants Malades Institute, Institut National de la Santé et de la Recherche Médicale U1151, Université de Paris, Paris, France
| | - Jennifer Trofe-Clark
- Department of Pharmacy Services, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Renal-Electrolyte and Hypertension, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christophe Legendre
- Institut National de la Santé et de la Recherche Médicale, Paris-Cardiovascular Research Center, Paris Translational Research Center for Organ Transplantation, Université de Paris, Paris, France
- Kidney Transplant Department, Necker Hospital, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Roy D. Bloom
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Renal-Electrolyte and Hypertension, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Peter P. Reese
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Institut National de la Santé et de la Recherche Médicale, Paris-Cardiovascular Research Center, Paris Translational Research Center for Organ Transplantation, Université de Paris, Paris, France
- Division of Renal-Electrolyte and Hypertension, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Parodi EL, La Porta E, Russo R, Marsano L, Bellino D, Paoletti E, Massarino F, Sofia A, Garibotto G, Esposito P, Murugavel A, Cappadona F, Fontana I, Viazzi F, Picciotto D. Ten-Year Efficacy and Safety of Once-Daily Tacrolimus in Kidney Transplant: A Prospective Cohort Study. Transplant Proc 2020; 52:3112-3117. [PMID: 32680595 DOI: 10.1016/j.transproceed.2020.02.149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 02/09/2020] [Accepted: 02/15/2020] [Indexed: 02/07/2023]
Abstract
Tacrolimus is a cornerstone in the immunosuppressive therapy of kidney transplantation. The once-daily formulation of tacrolimus has been shown to improve adherence of patients without affecting short-term efficacy. However, long-term proof of once-daily tacrolimus efficacy and safety is still lacking. From January 2009 to November 2013, 170 clinically stable kidney transplant patients were offered to change from the ongoing twice-daily tacrolimus (TDT) formulation to a once-daily tacrolimus (ODT) regimen. Kidney transplant recipients agreeing to the change to be treated with an ODT regimen (n = 105, estimated glomerular filtration rate [eGFR] 57.1 ± 1.6 mL/min/1.73 m2) and patients continuing on a TDT formulation (n = 65, eGFR 52.0 ± 2.2 mL/min/1.73 m2) were prospectively followed (median follow-up time 10.4 and 12.6 years in the ODT and TDT groups, respectively, P = not significant). At the end of the follow-up, patients in both groups experienced similar eGFR (50.4 ± 2.2 vs 48.0 ± 2.7 mL/min/1.73 m2 in the ODT and TDT groups, respectively, P = not significant). No differences were observed in biopsy-proven acute rejection, overall graft survival, doubling of serum creatinine, and new onset of proteinuria. The 2 groups also had a comparable rate of death, sepsis, and neoplasia. In conclusion, ODT appears safe and effective in stable kidney graft recipients even 10 years after transplantation. These findings support the use of ODT as a primary tacrolimus formulation in patients with kidney transplantation.
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Affiliation(s)
- E L Parodi
- Clinica Nefrologica, Dialisi, Trapianto, IRCCS Ospedale Policlinico San Martino, Genova, Italy; University of Genoa, DiMI, Genova GE, Italy
| | - E La Porta
- Clinica Nefrologica, Dialisi, Trapianto, IRCCS Ospedale Policlinico San Martino, Genova, Italy; University of Genoa, DiMI, Genova GE, Italy
| | - R Russo
- Clinica Nefrologica, Dialisi, Trapianto, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - L Marsano
- Clinica Nefrologica, Dialisi, Trapianto, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - D Bellino
- Clinica Nefrologica, Dialisi, Trapianto, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - E Paoletti
- Clinica Nefrologica, Dialisi, Trapianto, IRCCS Ospedale Policlinico San Martino, Genova, Italy; University of Genoa, DiMI, Genova GE, Italy
| | - F Massarino
- Clinica Nefrologica, Dialisi, Trapianto, IRCCS Ospedale Policlinico San Martino, Genova, Italy; University of Genoa, DiMI, Genova GE, Italy
| | - A Sofia
- Clinica Nefrologica, Dialisi, Trapianto, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - G Garibotto
- Clinica Nefrologica, Dialisi, Trapianto, IRCCS Ospedale Policlinico San Martino, Genova, Italy; University of Genoa, DiMI, Genova GE, Italy.
| | - P Esposito
- Clinica Nefrologica, Dialisi, Trapianto, IRCCS Ospedale Policlinico San Martino, Genova, Italy; University of Genoa, DiMI, Genova GE, Italy
| | - A Murugavel
- Clinica Nefrologica, Dialisi, Trapianto, IRCCS Ospedale Policlinico San Martino, Genova, Italy; University of Genoa, DiMI, Genova GE, Italy
| | - F Cappadona
- Clinica Nefrologica, Dialisi, Trapianto, IRCCS Ospedale Policlinico San Martino, Genova, Italy; University of Genoa, DiMI, Genova GE, Italy
| | - I Fontana
- UOS Chirurgia del Trapianto di Rene, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - F Viazzi
- Clinica Nefrologica, Dialisi, Trapianto, IRCCS Ospedale Policlinico San Martino, Genova, Italy; University of Genoa, DiMI, Genova GE, Italy
| | - D Picciotto
- Clinica Nefrologica, Dialisi, Trapianto, IRCCS Ospedale Policlinico San Martino, Genova, Italy; University of Genoa, DiMI, Genova GE, Italy
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6
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Vadcharavivad S, Saengram W, Phupradit A, Poolsup N, Chancharoenthana W. Once-Daily versus Twice-Daily Tacrolimus in Kidney Transplantation: A Systematic Review and Meta-analysis of Observational Studies. Drugs 2020; 79:1947-1962. [PMID: 31713065 PMCID: PMC6900208 DOI: 10.1007/s40265-019-01217-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Tacrolimus is the most commonly prescribed medication in initial immunosuppressive regimens to prevent acute rejection in kidney transplant recipients (KTRs). Tacrolimus was originally available as an immediate-release formulation (IR-Tac) given twice daily. Extended-release tacrolimus (ER-Tac) given once daily was later developed with the expectation of improved medication adherence. Data from observational studies, which compared outcomes between ER-Tac and IR-Tac in different populations of KTRs including those who are unlikely to be enrolled in randomized clinical trials, have been reported. PURPOSE To evaluate the incidence of biopsy-proven acute rejection (BPAR) at 12 months together with other outcomes reported in observational studies among adult KTRs who received ER-Tac compared to IR-Tac. METHODS In accordance with the recommendations of the Cochrane Collaboration and the Meta-analysis of Observational Studies in Epidemiology, we systematically reviewed all observational studies that compared clinical outcomes between ER-Tac and IR-Tac in KTRs. The systematic searches were conducted on PubMed, EMBASE, Scopus, and Web of Science without language restriction. Reference lists were also searched and reviewed. Data were extracted for BPAR, graft survival, patient survival, estimated glomerular filtration rate (eGFR), serum creatinine (Scr), creatinine clearance (CrCl), at different times after kidney transplantation (KT). A meta-analysis was performed to integrate the results from the eligible studies. This study is registered with PROSPERO, number CRD42019135705. RESULTS From the 1401 articles screened, 10 observational studies in KTRs who received tacrolimus were included. The pooled results showed significantly lower BPAR with ER-Tac than with IR-Tac at 12 months post-KT (5 studies, n = 659; RR, 0.69; 95% CI 0.51-0.95; p = 0.02; I2 = 0%). No significant differences in BPAR at other time points after KT were found. Graft survival, patient survival, Scr, and eGFR were comparable between groups at different times over approximately 1 year after transplantation. CONCLUSIONS Based upon currently available evidence in observational studies, 30% lower risk of BPAR was observed in ER-Tac group compared with IR-Tac group at 12 months post-KT, while there was no significant difference in BPAR risk at any other studied time points. No differences in graft- and patient-survival rates and kidney function were found. Given the limitations of observational studies to make causal inference, as well as quality limitations among the included studies, caution should be exercised in interpreting these findings.
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Affiliation(s)
- Somratai Vadcharavivad
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, 10330, Thailand.
| | - Warangkana Saengram
- Pharmacy Department, Thammasat University Hospital, Pathumthani, 12120, Thailand
| | - Annop Phupradit
- Pharmacy Division, Ramathibodi Hospital, Mahidol University, Bangkok, 10400, Thailand
| | - Nalinee Poolsup
- Samrejvittaya School, Aranyaprathet, Sakaeo, 27120, Thailand
| | - Wiwat Chancharoenthana
- Immunology Unit, Department of Microbiology, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand
- Nephrology Research Unit, Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400, Thailand
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