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Royer B, Launay M, Ciccolini J, Derain L, Parant F, Thomas F, Guitton J. Impact of renal impairment on dihydropyrimidine dehydrogenase (DPD) phenotyping. ESMO Open 2023; 8:101577. [PMID: 37267808 DOI: 10.1016/j.esmoop.2023.101577] [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: 02/16/2023] [Revised: 04/25/2023] [Accepted: 05/02/2023] [Indexed: 06/04/2023] Open
Abstract
BACKGROUND The chemotherapeutic agent 5-fluorouracil (5-FU) is catabolized by dihydropyrimidine dehydrogenase (DPD), the deficiency of which may lead to severe toxicity or death. Since 2019, DPD deficiency testing, based on uracilemia, is mandatory in France and recommended in Europe before initiating fluoropyrimidine-based regimens. However, it has been recently shown that renal impairment may impact uracil concentration and thus DPD phenotyping. PATIENTS AND METHODS The impact of renal function on uracilemia and DPD phenotype was studied on 3039 samples obtained from three French centers. We also explored the influence of dialysis and measured glomerular filtration rate (mGFR) on both parameters. Finally, using patients as their own controls, we assessed as to what extent modifications in renal function impacted uracilemia and DPD phenotyping. RESULTS We observed that uracilemia and DPD-deficient phenotypes increased concomitantly to the severity of renal impairment based on the estimated GFR, independently and more critically than hepatic function. This observation was confirmed with the mGFR. The risk of being classified 'DPD deficient' based on uracilemia was statistically higher in patients with renal impairment or dialyzed if uracilemia was measured before dialysis but not after. Indeed, the rate of DPD deficiency decreased from 86.4% before dialysis to 13.7% after. Moreover, for patients with transient renal impairment, the rate of DPD deficiency dropped dramatically from 83.3% to 16.7% when patients restored their renal function, especially in patients with an uracilemia close to 16 ng/ml. CONCLUSIONS DPD deficiency testing using uracilemia could be misleading in patients with renal impairment. When possible, uracilemia should be reassessed in case of transient renal impairment. For patients under dialysis, testing of DPD deficiency should be carried out on samples taken after dialysis. Hence, 5-FU therapeutic drug monitoring would be particularly helpful to guide dose adjustments in patients with elevated uracil and renal impairment.
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Affiliation(s)
- B Royer
- Laboratoire de Pharmacologie Clinique et Toxicologie, CHU Besançon, Besançon; Univ. Franche-Comté, INSERM, EFS BFC, UMR1098, Interactions Hôte-Greffon-Tumeur/Ingénierie Cellulaire et Génique, Besançon.
| | - M Launay
- Pôle de Biologie-Pathologie, Hôpital Nord-CHU Saint Etienne, Saint Etienne
| | - J Ciccolini
- SMARTc Unit, Centre de Recherche en Cancérologie de Marseille Inserm U1068 Aix Marseille Université and Assistance Publique Hôpitaux de Marseille, Marseille
| | - L Derain
- Service de Néphrologie, Dialyse, Hypertension et Exploration Fonctionnelle Rénale, Hospices Civils de Lyon, Hôpital E. Herriot, Lyon F-69003; University of Lyon 1; CNRS UMR 5305, Lyon
| | - F Parant
- Laboratoire de Biochimie et Toxicologie, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, Pierre-Bénite
| | - F Thomas
- Laboratoire de Pharmacologie, Institut Claudius Regaud, Inserm CRCT, Université de Toulouse, Toulouse Cedex 9
| | - J Guitton
- Laboratoire de Biochimie et Toxicologie, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, Pierre-Bénite; Laboratoire de Toxicologie, ISPB, Faculté de Pharmacie, Université Lyon 1, Université de Lyon, Lyon; Inserm U1052, CNRS UMR5286 Centre de Recherche en Cancérologie de Lyon, Lyon, France
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Laures N, Konecki C, Brugel M, Giffard AL, Abdelli N, Botsen D, Carlier C, Gozalo C, Feliu C, Slimano F, Djerada Z, Bouché O. Impact of Guidelines Regarding Dihydropyrimidine Dehydrogenase (DPD) Deficiency Screening Using Uracil-Based Phenotyping on the Reduction of Severe Side Effect of 5-Fluorouracil-Based Chemotherapy: A Propension Score Analysis. Pharmaceutics 2022; 14:pharmaceutics14102119. [PMID: 36297556 PMCID: PMC9610761 DOI: 10.3390/pharmaceutics14102119] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 09/27/2022] [Accepted: 09/28/2022] [Indexed: 11/07/2022] Open
Abstract
Dihydropyrimidine dehydrogenase (DPD) deficiency is associated with severe fluoropyrimidines-induced toxicity. As of September 2018, French recommendations call for screening for DPD deficiency by plasma uracil quantification prior to all fluoropyrimidine-based chemotherapy. A dose reduction of fluoropyrimidine is recommended when uracil concentration is equal to or greater than 16 ng/mL. This matched retrospective study assessed the impact of DPD screening on the reduction of severe side effects and on the management of DPD-deficient patients. Using a propensity score, we balanced the factors influencing 5-Fluorouracil (5-FU) toxicity. Then, the severity scores (G3 and G4 severity as well as their frequency) of patients who did not benefit from DPD screening were compared with those of patients who benefited from DPD screening for each treatment cycle (from 1 to 4). Among 349 screened patients, 198 treated patients were included. Among them, 31 (15.7%) had DPD deficiency (median uracilemia 19.8 ng/mL (range: 16.1−172.3)). The median toxicity severity score was higher in the unscreened group for each treatment cycle (0 vs. 1, p < 0.001 at each cycle from 1 to 4) as well as the cumulative score during all courses of treatment (p = 0.028). DPD-deficient patients received a significantly lower dose of 5-FU (p < 0.001). This study suggests that pretherapeutic plasmatic uracil assessment, along with 5-FU dosage adjustment, may be beneficial in reducing 5-FU toxicity in real-life patients.
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Affiliation(s)
- Nicolas Laures
- Department of Gastroenterology and Digestive Oncology, CHU Reims, University of Reims Champagne-Ardenne (URCA), 51100 Reims, France
| | - Céline Konecki
- Department of Medical Pharmacology, University of Reims Champagne-Ardenne (URCA), HERVI EA3801, 51097 Reims, France
- Department of Pharmacology and Toxicology, CHU Reims, 51100 Reims, France
| | - Mathias Brugel
- Department of Gastroenterology and Digestive Oncology, CHU Reims, University of Reims Champagne-Ardenne (URCA), 51100 Reims, France
- Department of Hepato-Gastroenterology and Digestive Oncology, Centre Hospitalier Auban-Moët, 51200 Epernay, France
| | - Anne-Lise Giffard
- Department of Gastroenterology and Digestive Oncology, CHU Reims, University of Reims Champagne-Ardenne (URCA), 51100 Reims, France
| | - Naceur Abdelli
- Department of Hepato-Gastroenterology and Digestive Oncology, Centre Hospitalier de Chalons en Champagne, 51000 Chalons en Champagne, France
| | - Damien Botsen
- Department of Gastroenterology and Digestive Oncology, CHU Reims, University of Reims Champagne-Ardenne (URCA), 51100 Reims, France
| | - Claire Carlier
- Department of Gastroenterology and Digestive Oncology, CHU Reims, University of Reims Champagne-Ardenne (URCA), 51100 Reims, France
| | - Claire Gozalo
- Department of Medical Pharmacology, University of Reims Champagne-Ardenne (URCA), HERVI EA3801, 51097 Reims, France
- Department of Pharmacology and Toxicology, CHU Reims, 51100 Reims, France
| | - Catherine Feliu
- Department of Medical Pharmacology, University of Reims Champagne-Ardenne (URCA), HERVI EA3801, 51097 Reims, France
- Department of Pharmacology and Toxicology, CHU Reims, 51100 Reims, France
| | - Florian Slimano
- Department of Pharmacy, CHU Reims, University of Reims Champagne-Ardenne (URCA), 51100 Reims, France
| | - Zoubir Djerada
- Department of Medical Pharmacology, University of Reims Champagne-Ardenne (URCA), HERVI EA3801, 51097 Reims, France
- Department of Pharmacology and Toxicology, CHU Reims, 51100 Reims, France
- Correspondence:
| | - Olivier Bouché
- Department of Medical Pharmacology, University of Reims Champagne-Ardenne (URCA), HERVI EA3801, 51097 Reims, France
- Department of Pharmacology and Toxicology, CHU Reims, 51100 Reims, France
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Carriat L, Quaranta S, Solas C, Rony M, Ciccolini J. Renal impairment and DPD testing: watch out for false-positive results! Br J Clin Pharmacol 2022; 88:4928-4932. [PMID: 35939355 DOI: 10.1111/bcp.15482] [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: 07/06/2022] [Revised: 07/21/2022] [Accepted: 07/29/2022] [Indexed: 11/30/2022] Open
Abstract
Measuring uracil (U) levels in plasma is a convenient surrogate to establish DPD status in patients scheduled with 5-fluorouracil (5-FU) or capecitabine. To what extent renal impairment could impact on U levels and thus be a confounding factor is a rising concern. Here, we report the case of a cancer patient with severe renal impairment scheduled for 5-FU-based regimen. Determination of his DPD status was complicated because of his condition and the influence of intermittent hemodialysis when monitoring U levels. The patient was initially identified as markedly DPD-deficient upon U measurement (i.e., U = 40 ng/ml), but further monitoring between and immediately after dialysis showed mild deficiency only (i.e., U = 34 and U = 19 ng/ml, respectively). Despite this discrepancy, starting dose of 5-FU was cut by 50% upon treatment initiation. Tolerance was good and 5-FU dosing was next shifted to 25% reduction, then further shifted to normal dosing at the 5th course, with still no sign for drug-related toxicities. Further DPYD genotyping showed none of the 4 allelic variants usually associated with loss of DPD activity. Of note, the excellent tolerance upon standard dosing strongly suggests that this patient was actually not DPD-deficient, despite U values always above normal concentrations. This case report highlights how critical is the information regarding the renal function of patients with cancer when phenotyping DPD using U plasma as a surrogate, and that U accumulation in patients with such condition is likely to yield false-positive results.
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Affiliation(s)
- Laure Carriat
- Laboratoire de Pharmacocinétique et Toxicologie, CHU Timone, APHM, Marseille, France.,SMARTc unit, Centre de Recherche en Cancérologie de Marseille, Inserm, Marseille, France
| | - Sylvie Quaranta
- Laboratoire de Pharmacocinétique et Toxicologie, CHU Timone, APHM, Marseille, France
| | - Caroline Solas
- Laboratoire de Pharmacocinétique et Toxicologie, CHU Timone, APHM, Marseille, France
| | - Maelle Rony
- Oncologie Digestive, CHU Timone, APHM, Marseille, France
| | - Joseph Ciccolini
- Laboratoire de Pharmacocinétique et Toxicologie, CHU Timone, APHM, Marseille, France.,SMARTc unit, Centre de Recherche en Cancérologie de Marseille, Inserm, Marseille, France
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Koteswara Rao V. Point of Care Diagnostic Devices for Rapid Detection of Novel Coronavirus (SARS-nCoV19) Pandemic: A Review. FRONTIERS IN NANOTECHNOLOGY 2021. [DOI: 10.3389/fnano.2020.593619] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Coronaviruses are recognized as causative agents of human diseases worldwide. In Wuhan, China, an outbreak of Severe acute respiratory syndrome novel Coronavirus (SARS-nCoV-2) was reported at the end of December 2019, causing 63 million COVID cases and 1.3 million deaths globally by 2 December, 2020. The transmission risk forecasts and the SARS-nCoV-2 epidemic pattern are progressive. Unfortunately, there is no specific FDA approved drugs or vaccines available currently to treat SARS-nCoV-2. In response to nCoV-2 spread, the rapid detection is crucial for estimating the severity of the disease and treatment of patients. Currently, there are several RT-PCR based diagnostic kits available for SARS-nCoV-2 detection, which are time-consuming, expensive, need advanced equipment facilities and trained personnel. The cost of diagnosis and the unavailability of sufficient test kits may prevent to check community transmission. Furthermore, expanding the testing facilities in asymptomatic cases in hotspots require more Point of Care (PoC) devices. Therefore, fast, inexpensive, and reliable methods of detection of SARS-nCoV-2 virus infection in humans is urgently required. The rapid and easy-to-use devices will facilitate onsite testing. In this review, nucleic acid assays, serological assays, multiplex assays, and PoC devices are discussed to understand various diagnostic approaches to reduce the spread and mortality rate in the future. Aptamer based detection is most specific, inexpensive and rapid detection of SARS-nCoV-2 without laboratory tools. To the best of our knowledge more than 900 SARS-nCoV-2 test kits are in pipeline, among 395 test kits are molecular bested test kits and only few test kits are developed using Aptamer technology https://www.finddx.org/covid-19/pipeline/.
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Wu D, Shu T, Yang X, Song JX, Zhang M, Yao C, Liu W, Huang M, Yu Y, Yang Q, Zhu T, Xu J, Mu J, Wang Y, Wang H, Tang T, Ren Y, Wu Y, Lin SH, Qiu Y, Zhang DY, Shang Y, Zhou X. Plasma metabolomic and lipidomic alterations associated with COVID-19. Natl Sci Rev 2020; 7:1157-1168. [PMID: 34676128 PMCID: PMC7197563 DOI: 10.1093/nsr/nwaa086] [Citation(s) in RCA: 212] [Impact Index Per Article: 53.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 04/15/2020] [Accepted: 04/23/2020] [Indexed: 12/19/2022] Open
Abstract
The pandemic of the coronavirus disease 2019 (COVID-19) has become a global public health crisis. The symptoms of COVID-19 range from mild to severe, but the physiological changes associated with COVID-19 are barely understood. In this study, we performed targeted metabolomic and lipidomic analyses of plasma from a cohort of patients with COVID-19 who had experienced different symptoms. We found that metabolite and lipid alterations exhibit apparent correlation with the course of disease in these patients, indicating that the development of COVID-19 affected their whole-body metabolism. In particular, malic acid of the TCA cycle and carbamoyl phosphate of the urea cycle result in altered energy metabolism and hepatic dysfunction, respectively. It should be noted that carbamoyl phosphate is profoundly down-regulated in patients who died compared with patients with mild symptoms. And, more importantly, guanosine monophosphate (GMP), which is mediated not only by GMP synthase but also by CD39 and CD73, is significantly changed between healthy subjects and patients with COVID-19, as well as between the mild and fatal cases. In addition, dyslipidemia was observed in patients with COVID-19. Overall, the disturbed metabolic patterns have been found to align with the progress and severity of COVID-19. This work provides valuable knowledge about plasma biomarkers associated with COVID-19 and potential therapeutic targets, as well as an important resource for further studies of the pathogenesis of COVID-19.
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Affiliation(s)
- Di Wu
- Joint Laboratory of Infectious Diseases and Health, Wuhan Institute of Virology & Wuhan Jinyintan Hospital, Wuhan Institute of Virology, Center for Biosafety Mega-Science, Chinese Academy of Sciences (CAS), Wuhan 430023, China
- State Key Laboratory of Virology, Wuhan Institute of Virology, Center for Biosafety Mega-Science, CAS, Wuhan 430071, China
| | - Ting Shu
- State Key Laboratory of Virology, Wuhan Institute of Virology, Center for Biosafety Mega-Science, CAS, Wuhan 430071, China
- Center for Translational Medicine, Jinyintan Hospital, Wuhan 430023, China
- Joint Laboratory of Infectious Diseases and Health, Wuhan Institute of Virology & Wuhan Jinyintan Hospital, Wuhan Jinyintan Hospital, Wuhan 430023, China
| | - Xiaobo Yang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Jian-Xin Song
- Department of Infectious Diseases, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | | | - Chengye Yao
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Wen Liu
- Center for Translational Medicine, Jinyintan Hospital, Wuhan 430023, China
- Joint Laboratory of Infectious Diseases and Health, Wuhan Institute of Virology & Wuhan Jinyintan Hospital, Wuhan Jinyintan Hospital, Wuhan 430023, China
| | - Muhan Huang
- Joint Laboratory of Infectious Diseases and Health, Wuhan Institute of Virology & Wuhan Jinyintan Hospital, Wuhan Institute of Virology, Center for Biosafety Mega-Science, Chinese Academy of Sciences (CAS), Wuhan 430023, China
- State Key Laboratory of Virology, Wuhan Institute of Virology, Center for Biosafety Mega-Science, CAS, Wuhan 430071, China
| | - Yuan Yu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Qingyu Yang
- State Key Laboratory of Virology, Wuhan Institute of Virology, Center for Biosafety Mega-Science, CAS, Wuhan 430071, China
- Center for Translational Medicine, Jinyintan Hospital, Wuhan 430023, China
- Joint Laboratory of Infectious Diseases and Health, Wuhan Institute of Virology & Wuhan Jinyintan Hospital, Wuhan Jinyintan Hospital, Wuhan 430023, China
| | - Tingju Zhu
- Center for Translational Medicine, Jinyintan Hospital, Wuhan 430023, China
- Joint Laboratory of Infectious Diseases and Health, Wuhan Institute of Virology & Wuhan Jinyintan Hospital, Wuhan Jinyintan Hospital, Wuhan 430023, China
| | - Jiqian Xu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Jingfang Mu
- Joint Laboratory of Infectious Diseases and Health, Wuhan Institute of Virology & Wuhan Jinyintan Hospital, Wuhan Institute of Virology, Center for Biosafety Mega-Science, Chinese Academy of Sciences (CAS), Wuhan 430023, China
- State Key Laboratory of Virology, Wuhan Institute of Virology, Center for Biosafety Mega-Science, CAS, Wuhan 430071, China
| | - Yaxin Wang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Hong Wang
- Wuhan Metware Biotechnology Co., Ltd., Wuhan 430075, China
| | - Tang Tang
- Wuhan Metware Biotechnology Co., Ltd., Wuhan 430075, China
| | - Yujie Ren
- Joint Laboratory of Infectious Diseases and Health, Wuhan Institute of Virology & Wuhan Jinyintan Hospital, Wuhan Institute of Virology, Center for Biosafety Mega-Science, Chinese Academy of Sciences (CAS), Wuhan 430023, China
- State Key Laboratory of Virology, Wuhan Institute of Virology, Center for Biosafety Mega-Science, CAS, Wuhan 430071, China
| | - Yongran Wu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Shu-Hai Lin
- State Key Laboratory of Cellular Stress Biology, Innovation Center for Cell Signaling Network, School of Life Sciences, Xiamen University, Xiamen 361005, China
| | - Yang Qiu
- Joint Laboratory of Infectious Diseases and Health, Wuhan Institute of Virology & Wuhan Jinyintan Hospital, Wuhan Institute of Virology, Center for Biosafety Mega-Science, Chinese Academy of Sciences (CAS), Wuhan 430023, China
- State Key Laboratory of Virology, Wuhan Institute of Virology, Center for Biosafety Mega-Science, CAS, Wuhan 430071, China
- Center for Translational Medicine, Jinyintan Hospital, Wuhan 430023, China
- University of Chinese Academy of Sciences, Beijing 100049, China
| | - Ding-Yu Zhang
- Center for Translational Medicine, Jinyintan Hospital, Wuhan 430023, China
- Joint Laboratory of Infectious Diseases and Health, Wuhan Institute of Virology & Wuhan Jinyintan Hospital, Wuhan Jinyintan Hospital, Wuhan 430023, China
| | - You Shang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
- Center for Translational Medicine, Jinyintan Hospital, Wuhan 430023, China
- Joint Laboratory of Infectious Diseases and Health, Wuhan Institute of Virology & Wuhan Jinyintan Hospital, Wuhan Jinyintan Hospital, Wuhan 430023, China
| | - Xi Zhou
- Joint Laboratory of Infectious Diseases and Health, Wuhan Institute of Virology & Wuhan Jinyintan Hospital, Wuhan Institute of Virology, Center for Biosafety Mega-Science, Chinese Academy of Sciences (CAS), Wuhan 430023, China
- State Key Laboratory of Virology, Wuhan Institute of Virology, Center for Biosafety Mega-Science, CAS, Wuhan 430071, China
- Center for Translational Medicine, Jinyintan Hospital, Wuhan 430023, China
- University of Chinese Academy of Sciences, Beijing 100049, China
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Fujino C, Sanoh S, Tateno C, Ohta S, Kotake Y. Coordinated cytochrome P450 expression in mouse liver and intestine under different dietary conditions during liver regeneration after partial hepatectomy. Toxicol Appl Pharmacol 2019; 370:133-144. [PMID: 30880217 DOI: 10.1016/j.taap.2019.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 02/20/2019] [Accepted: 03/12/2019] [Indexed: 02/06/2023]
Abstract
Liver resection is performed to remove tumors in patients with liver cancer, but the procedure's suitability depends on the regenerative ability of the liver. It is important to consider the effects of exogenous factors, such as diets, on liver regeneration for the recovery of function. The evaluation of drug metabolism during liver regeneration is also necessary because liver dysfunction is generally observed after the operation. Here, we investigated the influence of a purified diet (AIN-93G) on liver regeneration and changes in the mRNA expression of several cytochrome P450 (CYP) isoforms in the liver and small intestine using a two-thirds partial hepatectomy (PH) mouse model fed with a standard diet (MF) and a purified diet. Liver regeneration was significantly delayed in the purified diet group relative to that in the standard diet group. The liver Cyp2c55 and Cyp3a11 expression was increased at 3 day after PH especially in the purified diet group. Bile acid may partly cause the differences in liver regeneration and CYP expression between two types of diets. On the other hand, Cyp3a13 expression in the small intestine was transiently increased at day 1 after PH in both diet groups. The findings suggest that compensatory induction of the CYP expression occurred in the small intestine after attenuation of drug metabolism potential in the liver. The present results highlight the importance of the relationship between liver regeneration, drug metabolism, and exogenous factors for the effective treatment, including surgery and medication, in patients after liver resection or transplantation.
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Affiliation(s)
- Chieri Fujino
- Graduate School of Biomedical and Health Sciences, Hiroshima University, 734-8553, Japan
| | - Seigo Sanoh
- Graduate School of Biomedical and Health Sciences, Hiroshima University, 734-8553, Japan.
| | - Chise Tateno
- R&D Dept., PhoenixBio, Co., Ltd., 739-0046, Japan; Research Center for Hepatology and Gastroenterology, Hiroshima University, 739-8511, Japan
| | - Shigeru Ohta
- Graduate School of Biomedical and Health Sciences, Hiroshima University, 734-8553, Japan; Wakayama Medical University, 641-8509, Japan
| | - Yaichiro Kotake
- Graduate School of Biomedical and Health Sciences, Hiroshima University, 734-8553, Japan
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