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Taber DJ, Bartlett F, Patel N, Sprague T, Patel S, Newman J, Andrade E, Rao N, Salas MAP, Casey M, Dubay D, Rohan V. Impact of converting adult kidney transplant recipients with high tacrolimus variability from twice daily immediate release tacrolimus to once daily LCP-Tacrolimus. Clin Transplant 2023; 37:e14941. [PMID: 36809653 DOI: 10.1111/ctr.14941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 01/14/2023] [Accepted: 02/08/2023] [Indexed: 02/23/2023]
Abstract
BACKGROUND The influence of converting to once daily, extended-release LCP-Tacrolimus (Tac) for those with high tacrolimus variability in kidney transplant recipients (KTRs) is not well-studied. METHODS Single-center, retrospective cohort study of adult KTRs converted from Tac immediate release to LCP-Tac 1-2 years post-transplant. Primary measures were Tac variability, using the coefficient of variation (CV) and time in therapeutic range (TTR), as well as clinical outcomes (rejection, infections, graft loss, death). RESULTS A total of 193 KTRs included with a follow-up of 3.2 ± .7 years and 1.3 ± .3 years since LCP-Tac conversion. Mean age was 52 ± 13 years; 70% were African American, 39% were female, 16% living donor and 12% donor after cardiac death (DCD). In the overall cohort, tac CV was 29.5% before conversion, which increased to 33.4% after LCP-Tac (p = .008). In those with Tac CV >30% (n = 86), conversion to LCP-Tac reduced variability (40.6% vs. 35.5%; p = .019) and for those with Tac CV >30% and nonadherence or med errors (n = 16), LCP-Tac conversion substantially reduced Tac CV (43.4% vs. 29.9%; p = .026). TTR significantly improved for those with Tac CV >30% with (52.4% vs. 82.8%; p = .027) or without nonadherence or med errors (64.8% vs. 73.2%; p = .005). CMV, BK, and overall infections were significantly higher prior to LCP-Tac conversion. In the overall cohort, 3% had rejection before conversion and 2% after (p = NS). At end of follow-up, graft and patient survival were 94% and 96%, respectively. CONCLUSIONS In those with high Tac CV, conversion to LCP-Tac is associated with a significant reduction in variability and improvement in TTR, particularly in those with nonadherence or medication errors.
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Affiliation(s)
- David J Taber
- Department of Surgery, Division of Transplant Surgery, MUSC, Charleston, South Carolina, USA
| | - Felicia Bartlett
- Department of Pharmacy Services, MUSC, Charleston, South Carolina, USA
| | - Neha Patel
- Department of Pharmacy Services, MUSC, Charleston, South Carolina, USA
| | - Taylor Sprague
- Department of Pharmacy Services, MUSC, Charleston, South Carolina, USA
| | - Shikha Patel
- Department of Pharmacy Services, MUSC, Charleston, South Carolina, USA
| | - Jessica Newman
- Department of Pharmacy Services, MUSC, Charleston, South Carolina, USA
| | - Erika Andrade
- College of Medicine, MUSC, Charleston, South Carolina, USA
| | - Nikhil Rao
- Department of Surgery, Division of Transplant Surgery, MUSC, Charleston, South Carolina, USA
| | | | - Michael Casey
- Department of Medicine, Division of Nephrology, MUSC, Charleston, South Carolina, USA
| | - Derek Dubay
- Department of Surgery, Division of Transplant Surgery, MUSC, Charleston, South Carolina, USA
| | - Vinayak Rohan
- Department of Surgery, Division of Transplant Surgery, MUSC, Charleston, South Carolina, USA
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2
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Vondrak K, Parisi F, Dhawan A, Grenda R, Webb NJA, Marks SD, Debray D, Holt RCL, Lachaux A, Kelly D, Kazeem G, Undre N. Efficacy and safety of tacrolimus in de novo pediatric transplant recipients randomized to receive immediate- or prolonged-release tacrolimus. Clin Transplant 2019; 33:e13698. [PMID: 31436896 PMCID: PMC6900073 DOI: 10.1111/ctr.13698] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 08/06/2019] [Accepted: 08/19/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS This multicenter trial compared immediate-release tacrolimus (IR-T) vs prolonged-release tacrolimus (PR-T) in de novo kidney, liver, and heart transplant recipients aged <16 years. Each formulation had similar pharmacokinetic (PK) profiles. Follow-up efficacy and safety results are reported herein. MATERIALS AND METHODS Patients, randomized 1:1, received once-daily, PR-T or twice-daily, IR-T within 4 days of surgery. After a 4-week PK assessment, patients continued randomized treatment for 48 additional weeks. At Year 1, efficacy assessments included the number of clinical acute rejections, biopsy-confirmed acute rejection (BCAR) episodes (including severity), patient and graft survival, and efficacy failure (composite of death, graft loss, BCAR, or unknown outcome). Adverse events were assessed throughout. RESULTS The study included 44 children. At Year 1, mean ± standard deviation tacrolimus trough levels were 6.6 ± 2.2 and 5.4 ± 1.6 ng/mL, and there were 2 and 7 acute rejection episodes in the PR-T and IR-T groups, respectively. No cases of graft loss or death were reported during the study. The overall efficacy failure rate was 18.2% (PR-T n = 1; IR-T n = 7). CONCLUSIONS In pediatric de novo solid organ recipients, the low incidence of BCAR and low efficacy failure rate suggest that PR-T-based immunosuppression is effective and well tolerated to 1-year post-transplantation.
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Affiliation(s)
| | | | | | - Ryszard Grenda
- The Children's Memorial Health Institute, Warsaw, Poland
| | | | - Stephen D Marks
- Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | | | | | - Alain Lachaux
- Université Lyon 1 et Hospices Civils de Lyon, Lyon, France
| | - Deirdre Kelly
- Birmingham Women's & Children's Hospital, Birmingham, UK
| | - Gbenga Kazeem
- Astellas Pharma Europe Ltd, Chertsey, UK.,BENKAZ Consulting Ltd, Cambridge, UK
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3
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Rubik J, Debray D, Kelly D, Iserin F, Webb NJA, Czubkowski P, Vondrak K, Sellier-Leclerc AL, Rivet C, Riva S, Tönshoff B, D'Antiga L, Marks SD, Reding R, Kazeem G, Undre N. Efficacy and safety of prolonged-release tacrolimus in stable pediatric allograft recipients converted from immediate-release tacrolimus - a Phase 2, open-label, single-arm, one-way crossover study. Transpl Int 2019; 32:1182-1193. [PMID: 31325368 PMCID: PMC6852421 DOI: 10.1111/tri.13479] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 01/21/2019] [Accepted: 07/11/2019] [Indexed: 12/11/2022]
Abstract
There are limited clinical data regarding prolonged‐release tacrolimus (PR‐T) use in pediatric transplant recipients. This Phase 2 study assessed the efficacy and safety of PR‐T in stable pediatric kidney, liver, and heart transplant recipients (aged ≥5 to ≤16 years) over 1 year following conversion from immediate‐release tacrolimus (IR‐T), on a 1:1 mg total‐daily‐dose basis. Endpoints included the incidence of acute rejection (AR), a composite endpoint of efficacy failure (death, graft loss, biopsy‐confirmed AR, and unknown outcome), and safety. Tacrolimus dose and whole‐blood trough levels (target 3.5–15 ng/ml) were also evaluated. Overall, 79 patients (kidney, n = 48; liver, n = 29; heart, n = 2) were assessed. Following conversion, tacrolimus dose and trough levels remained stable; however, 7.6–17.7% of patients across follow‐up visits had trough levels below the target range. Two (2.5%) patients had AR, and 3 (3.8%) had efficacy failure. No graft loss or deaths were reported. No new safety signals were identified. Drug‐related treatment‐emergent adverse events occurred in 28 patients (35.4%); most were mild, and all resolved. This study suggests that IR‐T to PR‐T conversion is effective and well tolerated over 1 year in pediatric transplant recipients and highlights the importance of therapeutic drug monitoring to maintain target tacrolimus trough levels.
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Affiliation(s)
- Jacek Rubik
- Department of Nephrology, Kidney Transplantation and Hypertension, The Children's Memorial Health Institute, Warsaw, Poland
| | - Dominique Debray
- Pediatric Hepatology Unit, APHP-Hôpital Universitaire Necker, Paris, France
| | - Deirdre Kelly
- The Liver Unit, Birmingham Women's & Children's Hospital, Birmingham, UK
| | - Franck Iserin
- Pediatric Cardiology Unit, APHP-Hôpital Universitaire Necker, Paris, France
| | - Nicholas J A Webb
- Department of Pediatric Nephrology, NIHR/Wellcome Trust Manchester Clinical Research Facility, Manchester Academic Health Science Centre, Royal Manchester Children's Hospital, University of Manchester, Manchester, UK
| | - Piotr Czubkowski
- Department of Gastroenterology, Hepatology, Nutritional Disturbances and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
| | - Karel Vondrak
- Department of Pediatrics, Second School of Medicine, University Hospital Motol, Charles University, Prague, Czech Republic
| | - Anne-Laure Sellier-Leclerc
- Department of Nephrology, Rheumatology, and Dermatology, Center for Rare Diseases, Civil Hospice of Lyon, 'Woman-Mother-Child' Hospital, Bron Cedex, France
| | - Christine Rivet
- Pediatric Hepatology, Gastroenterology and Transplantation, Civil Hospice of Lyon, Lyon, France
| | - Silvia Riva
- Department of Pediatrics, ISMETT-IRCCS, Palermo, Italy
| | - Burkhard Tönshoff
- Department of Pediatrics I, University Children's Hospital Heidelberg, Heidelberg, Germany
| | - Lorenzo D'Antiga
- Pediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Stephen D Marks
- Department of Pediatric Nephrology, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Raymond Reding
- Unité de Chirurgie et Transplantation Pédiatrique, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Gbenga Kazeem
- BENKAZ Consulting Ltd, Cambridge, UK.,Astellas Pharma Europe Ltd, Chertsey, UK
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4
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Asempa TE, Rebellato LM, Hudson S, Briley K, Maldonado AQ. Impact of CYP3A5 genomic variances on clinical outcomes among African American kidney transplant recipients. Clin Transplant 2017; 32. [PMID: 29161757 DOI: 10.1111/ctr.13162] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2017] [Indexed: 01/22/2023]
Abstract
Little is known about the impact of CYP3A5 polymorphisms on transplantation outcomes among African American (AA) kidney transplant recipients (KTRs). To assess this issue, clinical outcomes were compared between AA CYP3A5*1 expressers and nonexpressers. This retrospective cohort study analyzed AA KTRs. Biopsy-proven acute rejection (BPAR), delayed graft function (DGF), glomerular filtration rate (GFR), infections, and tacrolimus dosing requirements were examined in 106 immunologically high-risk AA kidney transplant patients over a 2-year follow-up period. In CYP3A5*1 expressers compared to nonexpressers, the incidence of BPAR was significantly higher in the first 6 months (13% vs 0%; P = .016) compared to 24 months (13% vs 7%; P = .521). Tacrolimus total daily dose at first therapeutic level was significantly higher in CYP3A5*1 expressers (12 mg/day) compared to nonexpressers (8 mg/day; P < .001). Compared to CYP3A5*1 nonexpressers, DGF incidence was significantly higher among CYP3A5*1 expressers (27.6% vs 6.7%; P = .006). By contrast, median GFR was significantly higher in CYP3A5*1 expressers compared to nonexpressers (54.5 mL/min vs 50.0 mL/min; P = .003) at 24 months. The findings from this retrospective study suggest that AAs with CYP3A5*1 expression require 50% more tacrolimus and have an increased incidence of DGF and acute rejection.
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Affiliation(s)
- Tomefa E Asempa
- Department of Pharmacy, Vidant Medical Center, Greenville, NC, USA
| | - Lorita M Rebellato
- Department of Pathology & Laboratory Medicine, The Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Suzanne Hudson
- Department of Biostatistics, East Carolina University, Greenville, NC, USA
| | - Kimberly Briley
- Department of Pathology & Laboratory Medicine, The Brody School of Medicine at East Carolina University, Greenville, NC, USA
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5
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Jin J, Jin L, Luo K, Lim SW, Chung BH, Yang CW. Effect of Empagliflozin on Tacrolimus-Induced Pancreas Islet Dysfunction and Renal Injury. Am J Transplant 2017; 17:2601-2616. [PMID: 28422431 DOI: 10.1111/ajt.14316] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Revised: 03/10/2017] [Accepted: 04/01/2017] [Indexed: 01/25/2023]
Abstract
An inhibitor of sodium glucose co-transporter type 2 (SGLT-2) is recommended in type 2 diabetes mellitus (DM) but its use is still undetermined in tacrolimus (TAC)-induced DM. We evaluated the effect of empagliflozin (Em) on TAC-induced pancreatic islet dysfunction and renal injury in an experimental model of TAC-induced DM and in vitro. TAC induced a twofold increase in SGLT-2 expression, while Em decreased SGLT-2 expression and further increased urinary glucose excretion compared to the TAC group. Em reduced hyperglycemia and increased plasma insulin level, pancreatic islet size, and glucose-stimulated insulin secretion compared to the TAC group. In kidney, Em alleviated TAC-induced renal dysfunction and decreased albumin excretion and histological injury compared with the TAC group. Increased oxidative stress and apoptotic cell death by TAC was remarkably decreased with Em in serum and pancreatic and renal tissues. In in vitro study, TAC decreased cell viability and increased reactive oxygen species (ROS) production in both insulin-secreting beta-cell derived (INS-1) and human kidney-2 (HK-2) cell lines. Addition of Em increased cell viability and decreased ROS production in HK-2 but not in INS-1 cell lines. This suggests that Em is effective in controlling TAC-induced hyperglycemia and has direct protective effect on TAC-induced renal injury.
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Affiliation(s)
- J Jin
- Transplantation Research Center, Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea.,Convergent Research Consortium for Immunologic Disease, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - L Jin
- Transplantation Research Center, Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea.,Convergent Research Consortium for Immunologic Disease, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - K Luo
- Transplantation Research Center, Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea.,Convergent Research Consortium for Immunologic Disease, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - S W Lim
- Convergent Research Consortium for Immunologic Disease, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - B H Chung
- Transplantation Research Center, Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea.,Convergent Research Consortium for Immunologic Disease, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - C W Yang
- Transplantation Research Center, Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea.,Convergent Research Consortium for Immunologic Disease, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
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6
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Vanhove T, Bouwsma H, Hilbrands L, Swen JJ, Spriet I, Annaert P, Vanaudenaerde B, Verleden G, Vos R, Kuypers DRJ. Determinants of the Magnitude of Interaction Between Tacrolimus and Voriconazole/Posaconazole in Solid Organ Recipients. Am J Transplant 2017; 17:2372-2380. [PMID: 28224698 DOI: 10.1111/ajt.14232] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 01/30/2017] [Accepted: 02/07/2017] [Indexed: 01/25/2023]
Abstract
Administration of azole antifungals to tacrolimus-treated solid organ recipients results in a major drug-drug interaction characterized by increased exposure to tacrolimus. The magnitude of this interaction is highly variable but cannot currently be predicted. We performed a retrospective analysis of 126 solid organ recipients (95 lung, 31 kidney) co-treated with tacrolimus and voriconazole (n = 100) or posaconazole (n = 26). Predictors of the change in tacrolimus dose-corrected trough concentrations (C/D) between baseline and tacrolimus-azole co-therapy were assessed using linear mixed modeling. Patients were genotyped for relevant polymorphisms in CYP3A4, CYP3A5, MDR1, CYP2C19, POR, and UGT1A4. Tacrolimus C/D increased by a factor 5.0 ± 2.7 (range 1.0-20.2) for voriconazole and 4.4 ± 2.6 (range 0.9-18.0) for posaconazole, suggesting that a 66% dose reduction is insufficient for the majority of patients. Change in C/D was blunted in CYP3A5 expressors (estimated effect: -43%, p = 0.017) and affected by hematocrit (+8% per %, p = 0.004), baseline C/D (-14% per 100% increase, p < 0.001), and age (+1%, p = 0.008). However, the final model explained only 22% of interindividual variability in C/D change. In conclusion, CYP3A5 genotype and several clinical variables were identified as modulators of the tacrolimus-azole interaction, but these did not permit accurate predictions in individual patients.
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Affiliation(s)
- T Vanhove
- Department of Microbiology and Immunology, KU Leuven-University of Leuven, Leuven, Belgium.,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - H Bouwsma
- Department of Nephrology, Leiden University Medical Center, Leiden, the Netherlands
| | - L Hilbrands
- Department of Internal Medicine: Nephrology and Kidney Transplantation, St Radboud University Medical Center, Nijmegen, the Netherlands
| | - J J Swen
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, the Netherlands
| | - I Spriet
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium.,Department of Pharmaceutical and Pharmacological Sciences, Clinical Pharmacology and Pharmacotherapy, University of Leuven, Leuven, Belgium
| | - P Annaert
- Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven-University of Leuven, Leuven, Belgium
| | - B Vanaudenaerde
- Lung Transplant Unit, Division of Respiratory Disease, Department of Clinical and Experimental Medicine, KU Leuven-University of Leuven, Leuven, Belgium
| | - G Verleden
- Lung Transplant Unit, Division of Respiratory Disease, Department of Clinical and Experimental Medicine, KU Leuven-University of Leuven, Leuven, Belgium
| | - R Vos
- Lung Transplant Unit, Division of Respiratory Disease, Department of Clinical and Experimental Medicine, KU Leuven-University of Leuven, Leuven, Belgium
| | - D R J Kuypers
- Department of Microbiology and Immunology, KU Leuven-University of Leuven, Leuven, Belgium.,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
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7
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Shihab F, Qazi Y, Mulgaonkar S, McCague K, Patel D, Peddi VR, Shaffer D. Association of Clinical Events With Everolimus Exposure in Kidney Transplant Patients Receiving Low Doses of Tacrolimus. Am J Transplant 2017; 17:2363-2371. [PMID: 28141897 PMCID: PMC5600116 DOI: 10.1111/ajt.14215] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 01/04/2017] [Accepted: 01/24/2017] [Indexed: 01/25/2023]
Abstract
A key objective in the use of immunosuppression after kidney transplantation is to attain the optimal balance between efficacy and safety. In a phase 3b, multicenter, randomized, open-label, noninferiority study, the incidences of clinical events, renal dysfunction, and adverse events (AEs) were analyzed at 12 months in 309 de novo renal transplant recipients receiving everolimus (EVR), low-dose tacrolimus (LTac), and prednisone. Cox proportional hazard regression modeling was used to estimate the probability of clinical events at specified combinations of time-normalized EVR and Tac trough concentrations. At 12 months, the highest incidence of treated biopsy-proven acute rejection (tBPAR) and graft loss occurred most often in patients with EVR trough concentration <3 ng/mL (64.7% and 10.5%, respectively). At 1 month and 12 months, increasing EVR levels were associated with fewer tBPAR events (both p < 0.0001). Low estimated glomerular filtration rate (eGFR) and decreased eGFR occurred more often in patients with lower EVR and higher Tac levels. AEs were most often observed in patients with EVR levels <3 ng/mL. This study supports maintaining an EVR trough concentration of 3-8 ng/mL, when combined with LTac, to achieve balanced efficacy and safety in renal transplant recipients. TRIAL REGISTRATION NCT01025817.
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Affiliation(s)
| | - Y. Qazi
- University of Southern CaliforniaLos AngelesCA
| | | | - K. McCague
- Novartis Pharmaceuticals CorporationEast HanoverNJ
| | - D. Patel
- Novartis Pharmaceuticals CorporationEast HanoverNJ
| | - V. R. Peddi
- California Pacific Medical CenterSan FranciscoCA
| | - D. Shaffer
- Vanderbilt University Medical CenterNashvilleTN
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8
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Saliba F. Everolimus-Based Immunosuppression in Liver Transplant Recipients. Am J Transplant 2017; 17:2489. [PMID: 28654719 DOI: 10.1111/ajt.14388] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 05/23/2017] [Accepted: 06/04/2017] [Indexed: 01/25/2023]
Affiliation(s)
- F Saliba
- Centre Hépato-Biliaire, AP-HP Hôpital Paul Brousse, INSERM, Unité 1193, Villejuif, France
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9
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Affiliation(s)
- F Lemaitre
- Service de Pharmacologie Clinique et épidémiologique, Centre Hospitalier Universitaire Pontchaillou, Rennes, France.,INSERM, CIC1414, Rennes, France.,Faculté de Medecine, Université Rennes 1, Rennes, France
| | - C Tron
- Service de Pharmacologie Clinique et épidémiologique, Centre Hospitalier Universitaire Pontchaillou, Rennes, France.,INSERM, CIC1414, Rennes, France.,Faculté de Medecine, Université Rennes 1, Rennes, France
| | - M Rayar
- INSERM, CIC1414, Rennes, France.,Faculté de Medecine, Université Rennes 1, Rennes, France.,Service de Chirurgie Hepatobiliaire et Digestive, Centre Hospitalier Universitaire Pontchaillou, Rennes, France
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10
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Tremblay S, Nigro V, Woodle ES, Alloway RR. Reply to "Fluctuation Does Not Mean Variability: A Pharmacokinetic Point of View". Am J Transplant 2017; 17:1693. [PMID: 28248455 DOI: 10.1111/ajt.14248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- S Tremblay
- Division of Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - V Nigro
- Veloxis Pharmaceuticals Inc., Edison, NJ
| | - E S Woodle
- Division of Transplantation, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - R R Alloway
- Division of Nephrology, Department of Internal Medicine, Kidney C.A.R.E Program, University of Cincinnati College of Medicine, Cincinnati, OH
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11
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Gatault P, Kamar N, Büchler M, Colosio C, Bertrand D, Durrbach A, Albano L, Rivalan J, Le Meur Y, Essig M, Bouvier N, Legendre C, Moulin B, Heng AE, Weestel PF, Sayegh J, Charpentier B, Rostaing L, Thervet E, Lebranchu Y. Reduction of Extended-Release Tacrolimus Dose in Low-Immunological-Risk Kidney Transplant Recipients Increases Risk of Rejection and Appearance of Donor-Specific Antibodies: A Randomized Study. Am J Transplant 2017; 17:1370-1379. [PMID: 27862923 DOI: 10.1111/ajt.14109] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 10/05/2016] [Accepted: 10/30/2016] [Indexed: 01/25/2023]
Abstract
The aim of this study (ClinicalTrials.gov, NCT01744470) was to determine the efficacy and safety of two different doses of extended-release tacrolimus (TacER) in kidney transplant recipients (KTRs) between 4 and 12 mo after transplantation. Stable steroid-free KTRs were randomized (1:1) after 4 mo: Group A had a 50% reduction in TacER dose with a targeted TacER trough level (C0 ) >3 μg/L; group B had no change in TacER dose (TacER C0 7-12 μg/L). The primary outcome was estimated GFR at 1 year. Of 300 patients, the intent-to-treat analysis included 186 patients (group A, n = 87; group B, n = 99). TacER C0 was lower in group A than in group B at 6 mo (4.1 ± 2.7 vs. 6.7 ± 3.9 μg/L, p < 0.0001) and 12 mo (5.6 ± 2.0 vs. 7.4 ± 2.1 μg/L, p < 0.0001). Estimated GFR was similar in both groups at 12 mo (group A, 56.0 ± 17.5 mL/min per 1.73 m²; group B, 56.0 ± 22.1 mL/min per 1.73 m²). More rejection episodes occurred in group A than group B (11 vs. 3; p = 0.016). At 1 year, subclinical inflammation occurred more frequently in group A than group B (inflammation score [i] >0: 21.4% vs. 8.8%, p = 0.047; tubulitis score [t] >0: 19.6% vs. 8.7%, p = 0.076; i + t: 1.14 ± 1.21 vs. 0.72 ± 1.01, p = 0.038). Anti-HLA donor-specific antibodies appeared only in group A (6 vs. 0 patients, p = 0.008). TacER C0 should be maintained >7 μg/L during the first year after transplantation in low-immunological-risk, steroid-free KTRs receiving a moderate dose of mycophenolic acid.
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Affiliation(s)
- P Gatault
- EA4245 Dendritic Cells, Immunomodulation and Grafts, François-Rabelais University, Tours, France.,Department of Nephrology and Clinical Immunology, CHRU Tours, Tours, France
| | - N Kamar
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse, France.,INSERM U1043, IFR-BMT, CHU Purpan, Toulouse, France.,Université Paul Sabatier, Toulouse, France
| | - M Büchler
- EA4245 Dendritic Cells, Immunomodulation and Grafts, François-Rabelais University, Tours, France.,Department of Nephrology and Clinical Immunology, CHRU Tours, Tours, France
| | - C Colosio
- Department of Kidney Transplantation, CHU Reims, Reims, France
| | - D Bertrand
- Department of Kidney Transplantation, CHU Rouen, Rouen, France
| | - A Durrbach
- Department of Kidney Transplantation, Kremlin-Bicêtre Hospital, Villejuif, France
| | - L Albano
- Department of Kidney Transplantation, CHU Nice, Nice, France
| | - J Rivalan
- Department of Kidney Transplantation, CHU Rennes, Rennes, France
| | - Y Le Meur
- Department of Kidney Transplantation, CHU Brest, Brest, France
| | - M Essig
- Department of Kidney Transplantation, CHU Limoges, Limoges, France
| | - N Bouvier
- Department of Kidney Transplantation, CHU Caen, Caen, France
| | - C Legendre
- Department of Kidney Transplantation, Necker Hospital, Paris, France.,INSERM Unité 845, Paris, France
| | - B Moulin
- Department of Kidney Transplantation, CHRU Strasbourg, Strasbourg, France
| | - A-E Heng
- Department of Kidney Transplantation, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - P-F Weestel
- Department of Kidney Transplantation, CHU Amiens, Amiens, France
| | - J Sayegh
- Department of Kidney Transplantation, CHU Angers, Angers, France
| | - B Charpentier
- Department of Kidney Transplantation, Kremlin-Bicêtre Hospital, Villejuif, France
| | - L Rostaing
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse, France.,INSERM U1043, IFR-BMT, CHU Purpan, Toulouse, France.,Université Paul Sabatier, Toulouse, France
| | - E Thervet
- Department of Kidney Transplantation, Georges-Pompidou Hospital, Paris, France
| | - Y Lebranchu
- EA4245 Dendritic Cells, Immunomodulation and Grafts, François-Rabelais University, Tours, France.,Department of Nephrology and Clinical Immunology, CHRU Tours, Tours, France
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12
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Affiliation(s)
- J J Fung
- University of Chicago, Chicago, IL
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13
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Qazi Y, Shaffer D, Kaplan B, Kim DY, Luan FL, Peddi VR, Shihab F, Tomlanovich S, Yilmaz S, McCague K, Patel D, Mulgaonkar S. Efficacy and Safety of Everolimus Plus Low-Dose Tacrolimus Versus Mycophenolate Mofetil Plus Standard-Dose Tacrolimus in De Novo Renal Transplant Recipients: 12-Month Data. Am J Transplant 2017; 17:1358-1369. [PMID: 27775865 DOI: 10.1111/ajt.14090] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 09/11/2016] [Accepted: 10/07/2016] [Indexed: 01/25/2023]
Abstract
In this 12-month, multicenter, randomized, open-label, noninferiority study, de novo renal transplant recipients (RTxRs) were randomized (1:1) to receive everolimus plus low-dose tacrolimus (EVR+LTac) or mycophenolate mofetil plus standard-dose Tac (MMF+STac) with induction therapy (basiliximab or rabbit anti-thymocyte globulin). Noninferiority of composite efficacy failure rate (treated biopsy-proven acute rejection [tBPAR]/graft loss/death/loss to follow-up) in EVR+LTac versus MMF+STac was missed by 1.4%, considering the noninferiority margin of 10% (24.6% vs. 20.4%; 4.2% [-3.0, 11.4]). Incidence of tBPAR (19.1% vs. 11.2%; p < 0.05) was significantly higher, while graft loss (1.3% vs. 3.9%; p < 0.05) and composite of graft loss/death/lost to follow-up (6.1% vs. 10.5%, p = 0.05) were significantly lower in EVR+LTac versus MMF+STac groups, respectively. Mean estimated glomerular filtration rate was similar between EVR+LTac and MMF+STac groups (63.1 [22.0] vs. 63.1 [19.5] mL/min/1.73 m2 ) and safety was comparable. In conclusion, EVR+LTac missed noninferiority versus MMF+STac based on the 10% noninferiority margin. Further studies evaluating optimal immunosuppression for improved efficacy will guide appropriate dosing and target levels of EVR and LTac in RTxRs.
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Affiliation(s)
- Y Qazi
- University of Southern California, Los Angeles, CA
| | - D Shaffer
- Division of Kidney and Pancreas Transplantation, Vanderbilt University Medical Center, Nashville, TN
| | - B Kaplan
- Department of Medicine, Mayo Clinic Arizona, Phoenix, AZ
| | - D Y Kim
- Henry Ford Hospital, Detroit, MI
| | - F L Luan
- Universtiy of Michigan, Ann Arbor, MI.,Barnabas Health, Livingston, NJ
| | - V R Peddi
- California Pacific Medical Center, San Francisco, CA
| | - F Shihab
- University of Utah School of Medicine, Salt Lake City, UT
| | | | - S Yilmaz
- University Calgary, Calgary, Alberta, Canada
| | - K McCague
- Novartis Pharmaceuticals Corporation, East Hanover, NJ
| | - D Patel
- Novartis Pharmaceuticals Corporation, East Hanover, NJ
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14
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Affiliation(s)
- D R Kuypers
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - T Vanhove
- Department of Microbiology and Immunology, University of Leuven, Leuven, Belgium
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15
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Damon C, Pallet N. Reply to "Predictive Modeling of Tacrolimus Dose Requirements: All That Is Gold Does Not Glitter". Am J Transplant 2017; 17:1146. [PMID: 27862995 DOI: 10.1111/ajt.14117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- C Damon
- Hypercube Institute, Paris, France
| | - N Pallet
- Paris Descartes University, Paris, France.,Department of Clinical Chemistry, Georges Pompidou European Hospital, Assistance Publique Hôpitaux de Paris, Paris, France.,Institut National pour la Santé et la Recherche Médicale (INSERM) U1147, Paris, France.,Department of Nephrology, Georges Pompidou European Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
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16
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Tremblay S, Nigro V, Weinberg J, Woodle ES, Alloway RR. A Steady-State Head-to-Head Pharmacokinetic Comparison of All FK-506 (Tacrolimus) Formulations (ASTCOFF): An Open-Label, Prospective, Randomized, Two-Arm, Three-Period Crossover Study. Am J Transplant 2017; 17:432-442. [PMID: 27340950 PMCID: PMC5297985 DOI: 10.1111/ajt.13935] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 06/08/2016] [Accepted: 06/18/2016] [Indexed: 02/06/2023]
Abstract
This two-sequence, three-period crossover study is the first pharmacokinetic (PK) study to compare all three innovator formulations of tacrolimus (twice-daily immediate-release tacrolimus capsules [IR-Tac]; once-daily extended-release tacrolimus capsules [ER-Tac]; novel once-daily tacrolimus tablets [LCPT]). Stable renal transplant patients were dosed with each drug for 7 days, and blood samples were obtained over 24 h. Thirty subjects were included in the PK analysis set. A conversion factor of 1:1:0.80 for IR-Tac:ER-Tac:LCPT was used; no dose adjustments were permitted during the study. The median (interquartile range) total daily dose was 6.0 (4.0-8.0) mg for IR-Tac and ER-Tac and 4.8 (3.3-6.3) for LCPT. Significantly higher exposure on a per milligram basis, lower intraday fluctuation and prolonged time (Tmax ) to peak concentration (Cmax ) were found for LCPT versus IR-Tac or ER-Tac. ER-Tac showed no differences versus IR-Tac in exposure, Cmax , Tmax or fluctuation. The observed exposure of IR-Tac was used to normalize exposure for LCPT and ER-Tac, resulting in the following recommended total daily dose conversion rates: IR-Tac:ER-Tac, +8%; IR-Tac:LCPT, -30%; ER-Tac:LCPT, -36%. After exposure normalization, Cmax was ~17% lower for LCPT than for IR-Tac or ER-Tac; Cmin was ~6% lower for LCPT compared with IR-Tac and 3% higher compared with ER-Tac.
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Affiliation(s)
- S. Tremblay
- Department of Internal MedicineDivision of Nephrology and HypertensionUniversity of Cincinnati College of MedicineCincinnatiOH
| | - V. Nigro
- Veloxis Pharmaceuticals, Inc.EdisonNJ
| | | | - E. S. Woodle
- Department of SurgeryDivision of TransplantationUniversity of Cincinnati College of MedicineCincinnatiOH
| | - R. R. Alloway
- Department of Internal MedicineDivision of Nephrology and HypertensionUniversity of Cincinnati College of MedicineCincinnatiOH
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17
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Ling Q, Xie H, Li J, Liu J, Cao J, Yang F, Wang C, Hu Q, Xu X, Zheng S. Donor Graft MicroRNAs: A Newly Identified Player in the Development of New-onset Diabetes After Liver Transplantation. Am J Transplant 2017; 17:255-264. [PMID: 27458792 PMCID: PMC5215980 DOI: 10.1111/ajt.13984] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 07/17/2016] [Accepted: 07/18/2016] [Indexed: 01/25/2023]
Abstract
New-onset diabetes after liver transplantation (NODALT) is a frequent complication with an unfavorable outcome. We previously demonstrated a crucial link between donor graft genetics and the risk of NODALT. We selected 15 matched pairs of NODALT and non-NODALT liver recipients using propensity score matching analysis. The donor liver tissues were tested for the expression of 10 microRNAs (miRNAs) regulating human hepatic glucose homeostasis. The biological functions of potential target genes were predicted using gene ontology and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analysis. Both miR-103 and miR-181a were significantly highly expressed in the NODALT group as compared to the non-NODALT group. The predicted target genes (e.g. Irs2, Pik3r1, Akt2, and Gsk3b) were involved in glucose import and the insulin signaling pathway. We also observed dysregulation of miRNAs (e.g. let-7, miR-26b, miR-145, and miR-183) in cultured human hepatocytes treated with tacrolimus or high glucose, the two independent risk factors of NODALT identified in this cohort. The hepatic miRNA profiles altered by tacrolimus or hyperglycemia were associated with insulin resistance and glucose homeostatic imbalance as revealed by enrichment analysis. The disease susceptibility miRNA expressive pattern could be imported directly from the donor and consolidated by the transplant factors.
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Affiliation(s)
- Q. Ling
- Department of SurgeryCollaborative Innovation Center for Diagnosis and Treatment of Infectious DiseasesFirst Affiliated HospitalCollege of MedicineZhejiang UniversityHangzhouChina,Key Lab of Combined Multi‐Organ TransplantationMinistry of Public HealthHangzhouChina
| | - H. Xie
- Key Lab of Combined Multi‐Organ TransplantationMinistry of Public HealthHangzhouChina
| | - J. Li
- Department of SurgeryCollaborative Innovation Center for Diagnosis and Treatment of Infectious DiseasesFirst Affiliated HospitalCollege of MedicineZhejiang UniversityHangzhouChina
| | - J. Liu
- Department of SurgeryCollaborative Innovation Center for Diagnosis and Treatment of Infectious DiseasesFirst Affiliated HospitalCollege of MedicineZhejiang UniversityHangzhouChina,Department of Pathology and Molecular MedicineFaculty of Health SciencesMcMaster UniversityHamiltonOntarioCanada
| | - J. Cao
- Key Lab of Combined Multi‐Organ TransplantationMinistry of Public HealthHangzhouChina
| | - F. Yang
- Department of SurgeryCollaborative Innovation Center for Diagnosis and Treatment of Infectious DiseasesFirst Affiliated HospitalCollege of MedicineZhejiang UniversityHangzhouChina
| | - C. Wang
- Department of SurgeryCollaborative Innovation Center for Diagnosis and Treatment of Infectious DiseasesFirst Affiliated HospitalCollege of MedicineZhejiang UniversityHangzhouChina
| | - Q. Hu
- Key Lab of Combined Multi‐Organ TransplantationMinistry of Public HealthHangzhouChina
| | - X. Xu
- Department of SurgeryCollaborative Innovation Center for Diagnosis and Treatment of Infectious DiseasesFirst Affiliated HospitalCollege of MedicineZhejiang UniversityHangzhouChina,Key Lab of Combined Multi‐Organ TransplantationMinistry of Public HealthHangzhouChina
| | - S. Zheng
- Department of SurgeryCollaborative Innovation Center for Diagnosis and Treatment of Infectious DiseasesFirst Affiliated HospitalCollege of MedicineZhejiang UniversityHangzhouChina,Key Lab of Combined Multi‐Organ TransplantationMinistry of Public HealthHangzhouChina
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18
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Wen X, Casey MJ, Santos AH, Hartzema A, Womer KL. Comparison of Utilization and Clinical Outcomes for Belatacept- and Tacrolimus-Based Immunosuppression in Renal Transplant Recipients. Am J Transplant 2016; 16:3202-3211. [PMID: 27137884 DOI: 10.1111/ajt.13853] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Revised: 03/27/2016] [Accepted: 04/21/2016] [Indexed: 01/25/2023]
Abstract
The performance of belatacept in a real clinical setting has not been reported. A retrospective cohort study was conducted using registry data comparing 1-year clinical outcomes between belatacept- and tacrolimus-treated adult kidney transplant recipients (KTRs) from January 6, 2011, through January 12, 2014. Of 50 244 total patients, 417 received belatacept plus tacrolimus, 458 received belatacept alone, and 49 369 received tacrolimus alone at discharge. In the overall study cohort, belatacept alone was associated with a higher risk of 1-year acute rejection, with the highest rates associated with non-lymphocyte-depleting induction (adjusted hazard ratio 2.65, 95% confidence interval 1.90-3.70, p < 0.0001). There was no significant difference in rejection rates between belatacept plus tacrolimus and tacrolimus alone. In KTRs who met inclusion criteria for the Belatacept Evaluation of Nephroprotection and Efficacy as First-line Immunosuppression Trial-Extended Criteria Donors (BENEFIT-EXT), 1-year kidney function was higher with belatacept plus tacrolimus and belatacept alone versus tacrolimus alone (mean estimated GFR 65.6, 60.4 and 54.3 mL/min per 1.73 m2 , respectively; p < 0.001). The incidence of new-onset diabetes after transplantation was significantly lower with belatacept plus tacrolimus and belatacept alone versus tacrolimus alone (1.7%, 2.2%, and 3.8%, respectively; p = 0.01). Despite improved graft function and metabolic complications with belatacept alone, it may be advisable to add short-term tacrolimus in the first year after transplant and to consider lymphocyte-depleting induction in patients with high rejection risk, as the risk-benefit ratio allows.
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Affiliation(s)
- X Wen
- Department of Medicine, University of Florida, Gainesville, FL.
| | - M J Casey
- Department of Medicine, University of Florida, Gainesville, FL
| | - A H Santos
- Department of Medicine, University of Florida, Gainesville, FL
| | - A Hartzema
- Department of Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, FL
| | - K L Womer
- Department of Medicine, University of Florida, Gainesville, FL
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19
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Vanhove T, Vermeulen T, Annaert P, Lerut E, Kuypers DRJ. High Intrapatient Variability of Tacrolimus Concentrations Predicts Accelerated Progression of Chronic Histologic Lesions in Renal Recipients. Am J Transplant 2016; 16:2954-2963. [PMID: 27013142 DOI: 10.1111/ajt.13803] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 03/17/2016] [Accepted: 03/19/2016] [Indexed: 01/25/2023]
Abstract
High intrapatient variability (IPV) of tacrolimus concentrations is increasingly recognized as a predictor of poor outcome in solid organ recipients. How it relates to evolution of histology has not been explored. We analyzed tacrolimus IPV using the coefficient of variability (CV) from months 6-12 after transplantation in a cohort of 220 renal recipients for whom paired protocol biopsies at 3 mo and 2 years were available. Recipients in the highest CV tertile had an increased risk of moderate to severe fibrosis and tubular atrophy by 2 years compared with the low-IPV tertile (odds ratio [OR] 2.47, 95% confidence interval [CI] 1.09-5.60, p = 0.031; and OR 2.40, 95% CI 1.03-5.60, p = 0.043, respectively). Other predictors were donor age, severity of chronic lesions at 3 mo, and presence of borderline or subclinical rejection at 3 mo. Chronicity score increased significantly more in the high CV tertile group than in the middle and low tertiles (mean increase 1.97 ± 2.03 vs. 1.18 ± 2.44 and 1.12 ± 1.80, respectively; p < 0.05). CV did not predict evolution of renal function, which did not deteriorate within the 2-year follow-up period. These results indicate that high IPV is related to accelerated progression of chronic histologic lesions before any evidence of renal dysfunction.
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Affiliation(s)
- T Vanhove
- Department of Microbiology and Immunology, KU Leuven - University of Leuven, and Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - T Vermeulen
- Department of Microbiology and Immunology, KU Leuven - University of Leuven, and Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - P Annaert
- Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven - University of Leuven, Leuven, Belgium
| | - E Lerut
- Department of Imaging and Pathology, KU Leuven - University of Leuven, and Department of Pathology, University Hospitals Leuven, Leuven, Belgium
| | - D R J Kuypers
- Department of Microbiology and Immunology, KU Leuven - University of Leuven, and Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
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20
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Pallet N, Etienne I, Buchler M, Bailly E, Hurault de Ligny B, Choukroun G, Colosio C, Thierry A, Vigneau C, Moulin B, Le Meur Y, Heng AE, Legendre C, Beaune P, Loriot MA, Thervet E. Long-Term Clinical Impact of Adaptation of Initial Tacrolimus Dosing to CYP3A5 Genotype. Am J Transplant 2016; 16:2670-5. [PMID: 26990694 DOI: 10.1111/ajt.13788] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 02/12/2016] [Accepted: 03/03/2016] [Indexed: 01/25/2023]
Abstract
Pretransplantation adaptation of the daily dose of tacrolimus to CYP3A5 genotype is associated with improved achievement of target trough concentration (C0 ), but whether this improvement affects clinical outcomes is unknown. In the present study, we have evaluated the long-term clinical impact of the adaptation of initial tacrolimus dosing according to CYP3A5 genotype: The transplantation outcomes of the 236 kidney transplant recipients included in the Tactique study were retrospectively investigated over a period of more than 5 years. In the Tactique study, patients were randomly assigned to receive tacrolimus at either a fixed dosage or a dosage determined by their genotype, and the primary efficacy end point was the proportion of patients for whom tacrolimus C0 was within target range (10-15 ng/mL) at day 10. Our results indicate that the incidence of biopsy-proven acute rejection and graft survival were similar between the control and the adapted tacrolimus dose groups, as well as between the patients who achieve the tacrolimus C0 target ranges earlier. Patients' death, cancer, cardiovascular events, and infections were also similar, and renal function did not change. We conclude that optimization of initial tacrolimus dose using pharmacogenetic testing does not improve clinical outcomes.
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Affiliation(s)
- N Pallet
- Clinical Chemistry Department, Hôpital Européen Georges Pompidou, Assistance Publique Hôpitaux de Paris, Paris, France.,Department of Nephrology, Hôpital Européen Georges Pompidou, Assistance Publique Hôpitaux de Paris, Paris, France.,Paris Descartes University, Paris, France.,Sorbonne Paris Cité, INSERM UMRS 1147, Paris, France
| | - I Etienne
- Department of Nephrology-Clinical Immmunology, CHU Rouen, Rouen, France
| | - M Buchler
- Department of Nephrology, CHU Tours, Tours, France
| | - E Bailly
- Department of Nephrology, CHU Tours, Tours, France
| | | | - G Choukroun
- Department of Nephrology, CHU Amiens, Amiens, France
| | - C Colosio
- Department of Nephrology, CHU Reims, Reims, France
| | - A Thierry
- Department of Nephrology, CHU Poitiers, Poitiers, France
| | - C Vigneau
- Department of Nephrology, CHU Rennes, Rennes, France
| | - B Moulin
- Department of Nephrology, CHU Strasbourg, Strasbourg, France
| | - Y Le Meur
- Department of Nephrology, CHU Brest, Brest, France
| | - A-E Heng
- Department of Nephrology, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - C Legendre
- Department of Nephrology, Necker Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - P Beaune
- Clinical Chemistry Department, Hôpital Européen Georges Pompidou, Assistance Publique Hôpitaux de Paris, Paris, France.,Paris Descartes University, Paris, France.,Sorbonne Paris Cité, INSERM UMRS 1147, Paris, France
| | - M A Loriot
- Clinical Chemistry Department, Hôpital Européen Georges Pompidou, Assistance Publique Hôpitaux de Paris, Paris, France.,Paris Descartes University, Paris, France.,Sorbonne Paris Cité, INSERM UMRS 1147, Paris, France
| | - E Thervet
- Department of Nephrology, Hôpital Européen Georges Pompidou, Assistance Publique Hôpitaux de Paris, Paris, France.,Paris Descartes University, Paris, France.,Sorbonne Paris Cité, INSERM UMRS 1147, Paris, France
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21
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Ferrandiz I, Congy-Jolivet N, Del Bello A, Debiol B, Trébern-Launay K, Esposito L, Milongo D, Dörr G, Rostaing L, Kamar N. Impact of Early Blood Transfusion After Kidney Transplantation on the Incidence of Donor-Specific Anti-HLA Antibodies. Am J Transplant 2016; 16:2661-9. [PMID: 26998676 DOI: 10.1111/ajt.13795] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Revised: 03/08/2016] [Accepted: 03/11/2016] [Indexed: 01/25/2023]
Abstract
Little is known about the impact of posttransplant blood transfusion on the sensitization of anti-HLA antibodies and the formation of donor-specific antibodies (DSAs). The aims of our study were to determine the 1-year incidence of DSAs (assessed using a solid-phase assay) and antibody-mediated rejection (AMR) in kidney transplant patients who had or had not received a blood transfusion during the first year after transplantation. Included were 390 non-HLA-sensitized patients who had received an ABO-compatible kidney transplant and had not previously or simultaneously received a nonkidney transplant. Overall, 64% of patients received a red blood cell transfusion within the first year after transplantation, most within the first month. The overall 1-year incidence of DSAs was significantly higher in patients that had undergone transfusion (7.2% vs. 0.7% in patients with no transfusion, p < 0.0001). AMR occurred more often in the transfusion group (n = 15, 6%) compared with the nontransfusion group (n = 2, 1.4%; p = 0.04). Blood transfusion was an independent predictive factor for de novo DSA formation but not for AMR. Patients who had a transfusion and developed DSAs were more often treated with cyclosporin A (n = 10, 55.5%) rather than tacrolimus (n = 45, 19.4%; p = 0.0001). In conclusion, early posttransplant blood transfusion may increase immunological risk, especially in underimmunosuppressed patients.
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Affiliation(s)
- I Ferrandiz
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse, France.,Université Paul Sabatier, Toulouse, France
| | - N Congy-Jolivet
- Université Paul Sabatier, Toulouse, France.,Molecular Immunogenetics Laboratory, EA 3034, Faculté de Médecine Purpan, IFR150 (INSERM), Toulouse, France.,Department of Immunology, Hôpital de Rangueil, CHU de Toulouse, Toulouse, France
| | - A Del Bello
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse, France.,Université Paul Sabatier, Toulouse, France
| | - B Debiol
- Etablissement Français du Sang, CHU Toulouse, Toulouse, France
| | - K Trébern-Launay
- EA 4275 Biostatistics, Clinical Research and Subjective Measures in Health Sciences, Nantes University, Nantes, France.,Institut de Transplantation Urologie Néphrologie (ITUN), Nantes Hospital and University, INSERM 1064, CENTAURE, Nantes, France.,LabexTransplantex, CIC biotherapy, Nantes, France
| | - L Esposito
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse, France
| | - D Milongo
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse, France
| | - G Dörr
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse, France.,Université Paul Sabatier, Toulouse, France
| | - L Rostaing
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse, France.,Université Paul Sabatier, Toulouse, France.,INSERM U1043, IFR-BMT, CHU Purpan, Toulouse, France
| | - N Kamar
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse, France.,Université Paul Sabatier, Toulouse, France.,INSERM U1043, IFR-BMT, CHU Purpan, Toulouse, France
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22
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Shuker N, Bouamar R, van Schaik RHN, Clahsen-van Groningen MC, Damman J, Baan CC, van de Wetering J, Rowshani AT, Weimar W, van Gelder T, Hesselink DA. A Randomized Controlled Trial Comparing the Efficacy of Cyp3a5 Genotype-Based With Body-Weight-Based Tacrolimus Dosing After Living Donor Kidney Transplantation. Am J Transplant 2016; 16:2085-96. [PMID: 26714287 DOI: 10.1111/ajt.13691] [Citation(s) in RCA: 116] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Revised: 12/06/2015] [Accepted: 12/20/2015] [Indexed: 01/25/2023]
Abstract
Patients expressing the cytochrome P450 (CYP) 3A5 gene require a higher tacrolimus dose to achieve therapeutic exposure compared with nonexpressers. This randomized-controlled study investigated whether adaptation of the tacrolimus starting dose according to CYP3A5 genotype increases the proportion of kidney transplant recipients being within the target tacrolimus predose concentration range (10-15 ng/mL) at first steady-state. Two hundred forty living-donor, renal transplant recipients were assigned to either receive a standard, body-weight-based or a CYP3A5 genotype-based tacrolimus starting dose. At day 3, no difference in the proportion of patients having a tacrolimus exposure within the target range was observed between the standard-dose and genotype-based groups: 37.4% versus 35.6%, respectively; p = 0.79. The proportion of patients with a subtherapeutic (i.e. <10 ng/mL) or a supratherapeutic (i.e. >15 ng/mL) Tac predose concentration in the two groups was also not significantly different. The incidence of acute rejection was comparable between both groups (p = 0.82). Pharmacogenetic adaptation of the tacrolimus starting dose does not increase the number of patients having therapeutic tacrolimus exposure early after transplantation and does not lead to improved clinical outcome in a low immunological risk population.
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Affiliation(s)
- N Shuker
- Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands.,Department of Hospital Pharmacy, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - R Bouamar
- Department of Hospital Pharmacy, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - R H N van Schaik
- Department of Clinical Chemistry, Erasmus Medical Centre, Rotterdam, The Netherlands
| | | | - J Damman
- Department of Pathology, Academic Medical Centre, Amsterdam, The Netherlands
| | - C C Baan
- Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - J van de Wetering
- Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - A T Rowshani
- Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - W Weimar
- Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - T van Gelder
- Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands.,Department of Hospital Pharmacy, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - D A Hesselink
- Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
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23
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Hirsch HH, Yakhontova K, Lu M, Manzetti J. BK Polyomavirus Replication in Renal Tubular Epithelial Cells Is Inhibited by Sirolimus, but Activated by Tacrolimus Through a Pathway Involving FKBP-12. Am J Transplant 2016; 16:821-32. [PMID: 26639422 PMCID: PMC5064607 DOI: 10.1111/ajt.13541] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 09/04/2015] [Accepted: 09/24/2015] [Indexed: 01/25/2023]
Abstract
BK polyomavirus (BKPyV) replication causes nephropathy and premature kidney transplant failure. Insufficient BKPyV-specific T cell control is regarded as a key mechanism, but direct effects of immunosuppressive drugs on BKPyV replication might play an additional role. We compared the effects of mammalian target of rapamycin (mTOR)- and calcineurin-inhibitors on BKPyV replication in primary human renal tubular epithelial cells. Sirolimus impaired BKPyV replication with a 90% inhibitory concentration of 4 ng/mL by interfering with mTOR-SP6-kinase activation. Sirolimus inhibition was rapid and effective up to 24 h postinfection during viral early gene expression, but not thereafter, during viral late gene expression. The mTORC-1 kinase inhibitor torin-1 showed a similar inhibition profile, supporting the notion that early steps of BKPyV replication depend on mTOR activity. Cyclosporine A also inhibited BKPyV replication, while tacrolimus activated BKPyV replication and reversed sirolimus inhibition. FK binding protein 12kda (FKBP-12) siRNA knockdown abrogated sirolimus inhibition and increased BKPyV replication similar to adding tacrolimus. Thus, sirolimus and tacrolimus exert opposite effects on BKPyV replication in renal tubular epithelial cells by a mechanism involving FKBP-12 as common target. Immunosuppressive drugs may therefore contribute directly to the risk of BKPyV replication and nephropathy besides suppressing T cell functions. The data provide rationales for clinical trials aiming at reducing the risk of BKPyV replication and disease in kidney transplantation.
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Affiliation(s)
- H. H. Hirsch
- Transplantation & Clinical VirologyDepartment of Biomedicine (Haus Petersplatz)University of BaselBaselSwitzerland,Division Infection DiagnosticsDepartment of Biomedicine (Haus Petersplatz)University of BaselBaselSwitzerland,Infectious Diseases & Hospital EpidemiologyUniversity Hospital BaselBaselSwitzerland
| | - K. Yakhontova
- Transplantation & Clinical VirologyDepartment of Biomedicine (Haus Petersplatz)University of BaselBaselSwitzerland
| | - M. Lu
- Transplantation & Clinical VirologyDepartment of Biomedicine (Haus Petersplatz)University of BaselBaselSwitzerland
| | - J. Manzetti
- Transplantation & Clinical VirologyDepartment of Biomedicine (Haus Petersplatz)University of BaselBaselSwitzerland
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24
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Sikma MA, van Maarseveen EM, van de Graaf EA, Kirkels JH, Verhaar MC, Donker DW, Kesecioglu J, Meulenbelt J. Pharmacokinetics and Toxicity of Tacrolimus Early After Heart and Lung Transplantation. Am J Transplant 2015; 15:2301-13. [PMID: 26053114 DOI: 10.1111/ajt.13309] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Revised: 02/16/2015] [Accepted: 03/08/2015] [Indexed: 01/25/2023]
Abstract
Annually, about 8000 heart and lung transplantations are successfully performed worldwide. However, morbidity and mortality still pose a major concern. Renal failure in heart and lung transplant recipients is an essential adverse cause of morbidity and mortality, often originating in the early postoperative phase. At this time of clinical instability, the kidneys are exposed to numerous nephrotoxic stimuli. Among these, tacrolimus toxicity plays an important role, and its pharmacokinetics may be significantly altered in this critical phase by fluctuating drug absorption, changed protein metabolism, anemia and (multi-) organ failure. Limited understanding of tacrolimus pharmacokinetics in these circumstances is hampering daily practice. Tacrolimus dose adjustments are generally based on whole blood trough levels, which widely vary early after transplantation. Moreover, whole blood trough levels are difficult to predict and are poorly related to the area under the concentration-time curve. Even within the therapeutic range, toxicity may occur. These shortcomings of tacrolimus monitoring may not hold for the unbound tacrolimus plasma concentrations, which may better reflect tacrolimus toxicity. This review focuses on posttransplant tacrolimus pharmacokinetics, discusses relevant factors influencing the unbound tacrolimus concentrations and tacrolimus (nephro-) toxicity in heart and lung transplantation patients.
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Affiliation(s)
- M A Sikma
- Department of Intensive Care Medicine and National Poisons Information Center, University Medical Center of Utrecht, the Netherlands
| | - E M van Maarseveen
- Department of Clinical Pharmacy, University Medical Center of Utrecht, the Netherlands
| | - E A van de Graaf
- Department of Lung Transplantation, University Medical Center of Utrecht, the Netherlands
| | - J H Kirkels
- Department of Heart Transplantation, University Medical Center of Utrecht, the Netherlands
| | - M C Verhaar
- Department of Nephrology and Hypertension, University Medical Center of Utrecht, the Netherlands
| | - D W Donker
- Department of Intensive Care Medicine, University Medical Center of Utrecht, the Netherlands
| | - J Kesecioglu
- Department of Intensive Care Medicine, University Medical Center of Utrecht, the Netherlands
| | - J Meulenbelt
- Department of Intensive Care Medicine, National Poisons Information Center, Institute for Risk Assessment Sciences, University of Utrecht, the Netherlands
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25
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Badri P, Dutta S, Coakley E, Cohen D, Ding B, Podsadecki T, Bernstein B, Awni W, Menon R. Pharmacokinetics and dose recommendations for cyclosporine and tacrolimus when coadministered with ABT-450, ombitasvir, and dasabuvir. Am J Transplant 2015; 15:1313-22. [PMID: 25708713 PMCID: PMC5024008 DOI: 10.1111/ajt.13111] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Revised: 11/16/2014] [Accepted: 11/16/2014] [Indexed: 01/25/2023]
Abstract
ABT-450, ombitasvir, and dasabuvir are direct-acting antiviral agents (DAAs) that have been developed for combination treatment of chronic hepatitis C virus (HCV) infection. Because these DAAs have metabolic and transporter profiles that overlap with cyclosporine and tacrolimus disposition, there is potential for drug interactions. Two Phase 1 studies assessed effects of ABT-450 (150 mg coadministered with ritonavir 100 mg once daily), ombitasvir (25 mg once daily), and dasabuvir (400 mg twice daily) on the pharmacokinetics, safety, and tolerability of a single dose of cyclosporine (30 mg) or tacrolimus (2 mg) in healthy volunteers (N = 12 per study). In the presence of steady-state concentrations of all 3 DAAs, dose-normalized cyclosporine concentration at 24 hours (C₂₄), and area under the concentration-time curve from time 0 to infinity (AUC(∞)) were 15.8-fold and 5.8-fold, respectively, and dose-normalized tacrolimus C₂₄ and AUC(∞) were 17-fold and 57-fold, respectively, of either agent alone. Cyclosporine and tacrolimus half-lives increased from 7 to 25 h and 32 to 232 h, respectively. There were no major safety or tolerability issues in these studies. The results suggest that cyclosporine and tacrolimus doses and dosing frequency should be reduced in HCV-infected posttransplant patients being treated with this 3-DAA regimen.
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26
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Budde K, Bunnapradist S, Grinyo JM, Ciechanowski K, Denny JE, Silva HT, Rostaing L. Novel once-daily extended-release tacrolimus (LCPT) versus twice-daily tacrolimus in de novo kidney transplants: one-year results of Phase III, double-blind, randomized trial. Am J Transplant 2014; 14:2796-806. [PMID: 25278376 DOI: 10.1111/ajt.12955] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 07/11/2014] [Accepted: 07/23/2014] [Indexed: 01/25/2023]
Abstract
This Phase III randomized trial examined efficacy and safety of a novel once-daily extended-release tacrolimus formulation (LCP-Tacro [LCPT]) versus twice-daily tacrolimus in de novo kidney transplantation. Primary efficacy end point was proportion of patients with treatment failure (death, graft failure, biopsy-proven acute rejection or lost to follow-up) within 12 months. Starting doses were, LCPT: 0.17 mg/kg/day and tacrolimus twice-daily: 0.1 mg/kg/day; 543 patients were randomized, LCPT: n = 268; tacrolimus twice-daily: n = 275. At 12 months treatment failure was LCPT: 18.3% and tacrolimus twice-daily: 19.6%; the upper 95% CI of the treatment difference was +5.27%, below the predefined +10% noninferiority criteria. There were no significant differences in the incidence of individual efficacy events or adverse events. Target tacrolimus trough levels were more rapidly achieved in the LCPT group. Following initial dose, 36.6% of patients in the LCPT group had rapidly attained trough levels within 6-11 ng/mL versus 18.5% of tacrolimus twice-daily patients; majority of tacrolimus twice-daily patients (74.7%) had troughs <6 ng/mL compared with 33.5% in the LCPT group. Overall, cumulative study dose was 14% lower for LCPT. Results suggest that use of once-daily LCPT in de novo kidney transplantation is efficacious and safe. Lower LCPT dose reflects the improved absorption provided by the novel formulation.
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Affiliation(s)
- K Budde
- Department of Nephrology, Charité Universitätsmedizin, Berlin, Germany
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