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Sterneck M, Kaiser GM, Heyne N, Richter N, Rauchfuss F, Pascher A, Schemmer P, Fischer L, Klein CG, Nadalin S, Lehner F, Settmacher U, Neuhaus P, Gotthardt D, Loss M, Ladenburger S, Paulus EM, Mertens M, Schlitt HJ. Everolimus and early calcineurin inhibitor withdrawal: 3-year results from a randomized trial in liver transplantation. Am J Transplant 2014; 14:701-10. [PMID: 24502384 PMCID: PMC4285226 DOI: 10.1111/ajt.12615] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [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: 07/19/2013] [Revised: 11/27/2013] [Accepted: 11/27/2013] [Indexed: 01/25/2023]
Abstract
The feasibility of de novo everolimus without calcineurin inhibitor (CNI) therapy following liver transplantation was assessed in a multicenter, prospective, open-label trial. Liver transplant patients were randomized at 4 weeks to start everolimus and discontinue CNI, or continue their current CNI-based regimen. The primary endpoint was adjusted estimated GFR (eGFR; Cockcroft-Gault) at month 11 post randomization. A 24-month extension phase followed 81/114 (71.1%) of eligible patients to month 35 post randomization. The adjusted mean eGFR benefit from randomization to month 35 was 10.1 mL/min (95% confidence interval [CI] -1.3, 21.5 mL/min, p = 0.082) in favor of CNI-free versus CNI using Cockcroft-Gault, 9.4 mL/min/1.73 m(2) (95% CI -0.4, 18.9, p = 0.053) with Modification of Diet in Renal Disease (four-variable) and 9.5 mL/min/1.73 m(2) (95% CI -1.1, 17.9, p = 0.028) using Nankivell. The difference in favor of the CNI-free regimen increased gradually over time due to a small progressive decline in eGFR in the CNI cohort despite a reduction in CNI exposure. Biopsy-proven acute rejection, graft loss and death were similar between groups. Adverse events led to study drug discontinuation in five CNI-free patients and five CNI patients (12.2% vs. 12.5%, p = 1.000) during the extension phase. Everolimus-based CNI-free immunosuppression is feasible following liver transplantation and patients benefit from sustained preservation of renal function versus patients on CNI for at least 3 years.
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Affiliation(s)
- M Sterneck
- Department of Hepatobiliary and Transplant Surgery, University Medical Center Hamburg-EppendorfHamburg, Germany
| | - G M Kaiser
- Department of General, Visceral and Transplantation Surgery, Essen University HospitalEssen, Germany
| | - N Heyne
- Department of General, Visceral and Transplant Surgery, University Hospital TuebingenTuebingen, Germany
| | - N Richter
- Clinic for General, Abdominal and Transplant Surgery, Hannover Medical School (MHH)Hannover, Germany
| | - F Rauchfuss
- Department of General, Abdominal and Vascular Surgery, Jena University HospitalJena, Germany
| | - A Pascher
- Clinic for General, Abdominal and Transplant Surgery, Charité University Medical Center BerlinBerlin, Germany
| | - P Schemmer
- Department of General, Visceral and Transplant Surgery, University Hospital HeidelbergHeidelberg, Germany
| | - L Fischer
- Department of Hepatobiliary and Transplant Surgery, University Medical Center Hamburg-EppendorfHamburg, Germany
| | - C G Klein
- Department of General, Visceral and Transplantation Surgery, Essen University HospitalEssen, Germany
| | - S Nadalin
- Department of General, Visceral and Transplant Surgery, University Hospital TuebingenTuebingen, Germany
| | - F Lehner
- Clinic for General, Abdominal and Transplant Surgery, Hannover Medical School (MHH)Hannover, Germany
| | - U Settmacher
- Department of General, Abdominal and Vascular Surgery, Jena University HospitalJena, Germany
| | - P Neuhaus
- Clinic for General, Abdominal and Transplant Surgery, Charité University Medical Center BerlinBerlin, Germany
| | - D Gotthardt
- Department of General, Visceral and Transplant Surgery, University Hospital HeidelbergHeidelberg, Germany
| | - M Loss
- Department of Surgery, University Hospital RegensburgRegensburg, Germany
| | | | | | - M Mertens
- Novartis Pharma GmbHNürnberg, Germany
| | - H J Schlitt
- Department of Surgery, University Hospital RegensburgRegensburg, Germany,
* Corresponding author: Hans J. Schlitt,
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Bara C, Dengler T, Hack M, Ladenburger S, Lehmkuhl H. A 1-Year Randomized Controlled Study of Everolimus Versus Mycophenolate Mofetil With Reduced-Dose Cyclosporine in Maintenance Heart Transplant Recipients. Transplant Proc 2013; 45:2387-92. [DOI: 10.1016/j.transproceed.2013.03.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Accepted: 03/06/2013] [Indexed: 01/05/2023]
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Fischer L, Klempnauer J, Beckebaum S, Metselaar HJ, Neuhaus P, Schemmer P, Settmacher U, Heyne N, Clavien PA, Muehlbacher F, Morard I, Wolters H, Vogel W, Becker T, Sterneck M, Lehner F, Klein C, Kazemier G, Pascher A, Schmidt J, Rauchfuss F, Schnitzbauer A, Nadalin S, Hack M, Ladenburger S, Schlitt HJ. A randomized, controlled study to assess the conversion from calcineurin-inhibitors to everolimus after liver transplantation--PROTECT. Am J Transplant 2012; 12:1855-65. [PMID: 22494671 DOI: 10.1111/j.1600-6143.2012.04049.x] [Citation(s) in RCA: 146] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Posttransplant immunosuppression with calcineurin inhibitors (CNIs) is associated with impaired renal function, while mTor inhibitors such as everolimus may provide a renal-sparing alternative. In this randomized 1-year study in patients with liver transplantation (LTx), we sought to assess the effects of everolimus on glomerular filtration rate (GFR) after conversion from CNIs compared to continued CNI treatment. Eligible study patients received basiliximab induction, CNI with/without corticosteroids for 4 weeks post-LTx, and were then randomized (if GFR > 50 mL/min) to continued CNIs (N = 102) or subsequent conversion to EVR (N = 101). Mean calculated GFR 11 months postrandomization (ITT population) revealed no significant difference between treatments using the Cockcroft-Gault formula (-2.9 mL/min in favor of EVR, 95%-CI: [-10.659; 4.814], p = 0.46), whereas use of the MDRD formula showed superiority for EVR (-7.8 mL/min, 95%-CI: [-14.366; -1.191], p = 0.021). Rates of mortality (EVR: 4.2% vs. CNI: 4.1%), biopsy-proven acute rejection (17.7% vs. 15.3%), and efficacy failure (20.8% vs. 20.4%) were similar. Infections, leukocytopenia, hyperlipidemia and treatment discontinuations occurred more frequently in the EVR group. No hepatic artery thrombosis and no excess of wound healing impairment were noted. Conversion from CNI-based to EVR-based immunosuppression proved to be a safe alternative post-LTx that deserves further investigation in terms of nephroprotection.
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Affiliation(s)
- L Fischer
- University Medical Center Hamburg-Eppendorf, Department of Hepatobiliary and Transplant Surgery, Hamburg, Germany
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Lehmkuhl H, Hummel M, Kobashigawa J, Ladenburger S, Rothenburger M, Sack F, Dengler T, Hetzer R. Enteric-Coated Mycophenolate-Sodium in Heart Transplantation: Efficacy, Safety, and Pharmacokinetic Compared With Mycophenolate Mofetil. Transplant Proc 2008; 40:953-5. [DOI: 10.1016/j.transproceed.2008.03.046] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Pühler T, Hirt S, Ladenburger S, Cremer J, Haverich A. 36-month results of a international multicentre, randomised doppelblinded study of everolimus vs. Azathioprin in stable patients after lung transplantation. Thorac Cardiovasc Surg 2006. [DOI: 10.1055/s-2006-925690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Höcherl K, Färber L, Ladenburger S, Vosshage D, Stratz T, Müller W, Grobecker H. Effect of tropisetron on circulating catecholamines and other putative biochemical markers in serum of patients with fibromyalgia. Scand J Rheumatol Suppl 2001; 113:46-8. [PMID: 11028831 DOI: 10.1080/030097400446634] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
OBJECTIVE The aim of the study was to assess the influence of the 5HT3-receptor antagonist tropisetron on circulating catecholamines as biochemical markers of the activity of the sympathoadrenal system in fibromyalgia. Moreover, serum concentrations of serotonin, somatomedin C, oxytocin, calcitonin-gene-related-peptide, calcitonin and cholecystokinin were assayed as putative markers in pain-related disorders like primary fibromyalgia. METHODS In 96 patients, who met the ACR classification criteria for fibromyalgia, and in 20 sex and age matched controls concentrations of dopamine, noradrenaline, adrenaline, serotonin and tropisetron were assayed in serum by HPLC with electrochemical detection. All other transmitters were determined by ELISA. RESULTS There was with the exception of tropisetron, calcitonin and dopamine, no correlation between doses of tropisetron 5, 10, 15 mg respectively and significant changes in circulating transmitters or other transmitters as putative biochemicals markers in primary fibromyalgia. Regarding the prediction of pain reduction to tropisetron, patients with elevated dopamine and/or reduced plasma 5-HT concentrations tended to show a higher response rate. CONCLUSION Despite these partly disappointing results another prospective pilot study with selected patients vs. age and sex matched controls, double blind and with comparison of other 5HT3-receptor antagonists e.g. dolasetron and granisetron e.g. after i.v. bolus injection is suggested. Still the data obtained in this preliminary paper provide some evidence regarding the present discussion on subgroups of patients with primary fibromyalgia.
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Affiliation(s)
- K Höcherl
- Department of Pharmacology and Clinical Pharmacology, University of Regensburg, Germany.
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