1
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Han DK, Hong SK, Yun IH, Yan JJ, Park J, Kim SW, Seok SH, Kim H, Ji G, Choi Y, Lee KW, Suh KS, Yang J, Yi NJ. Anti-intercellular adhesion molecule 1 monomaintenance therapy induced long-term liver allograft survival without chronic rejection. Am J Transplant 2024; 24:1772-1783. [PMID: 38561059 DOI: 10.1016/j.ajt.2024.03.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 03/14/2024] [Accepted: 03/27/2024] [Indexed: 04/04/2024]
Abstract
Calcineurin inhibitors (CNIs) are essential in liver transplantation (LT); however, their long-term use leads to various adverse effects. The anti-intercellular adhesion molecule (ICAM)-1 monoclonal antibody MD3 is a potential alternative to CNI. Despite its promising results with short-term therapy, overcoming the challenge of chronic rejection remains important. Thus, we aimed to investigate the outcomes of long-term MD3 therapy with monthly MD3 monomaintenance in nonhuman primate LT models. Rhesus macaques underwent major histocompatibility complex-mismatched allogeneic LT. The conventional immunosuppression group (Con-IS, n = 4) received steroid, tacrolimus, and sirolimus by 4 months posttransplantation. The induction MD3 group (IN-MD3, n = 5) received short-term MD3 therapy for 3 months with Con-IS. The maintenance MD3 group (MA-MD3, n = 4) received MD3 for 3 months, monthly doses by 2 years, and then quarterly. The MA-MD3 group exhibited stable liver function without overt infection and had significantly better liver allograft survival than the IN-MD3 group. Development of donor-specific antibody and chronic rejection were suppressed in the MA-MD3 group but not in the IN-MD3 group. Donor-specific T cell responses were attenuated in the MA-MD3 group. In conclusion, MD3 monomaintenance therapy without maintenance CNI provides long-term liver allograft survival by suppressing chronic rejection, offering a potential breakthrough for future human trials.
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Affiliation(s)
- Dong Kyu Han
- Graduate School of Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Biomedical Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Suk Kyun Hong
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Il Hee Yun
- Department of Internal Medicine, Yonsei University College of Medicine, Severance Hospital, Seoul, Republic of Korea; The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ji-Jing Yan
- Department of Internal Medicine, Yonsei University College of Medicine, Severance Hospital, Seoul, Republic of Korea; The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jisu Park
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sang Wha Kim
- College of Veterinary Medicine and Institute of Veterinary Science, Kangwon National University, Chuncheon, Gangwon, Republic of Korea; Department of Microbiology and Immunology, and Institute of Endemic Disease, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Seung Hyeok Seok
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Microbiology and Immunology, and Institute of Endemic Disease, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Haeryoung Kim
- Department of Pathology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Gilyong Ji
- Kumho HT, Seongnam, Gyeonggi, Republic of Korea
| | - YoungRok Choi
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kwang-Woong Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jaeseok Yang
- Department of Internal Medicine, Yonsei University College of Medicine, Severance Hospital, Seoul, Republic of Korea; The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Nam-Joon Yi
- Graduate School of Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea.
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2
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Majid Z, Khan SA, Hanif FM, Laeeq M, Tasneem AA, Luck NH, Mubarak M. Management of Tacrolimus-Induced Toxicity With Normal Serum Levels After Liver Transplant. EXP CLIN TRANSPLANT 2024; 22:338-341. [PMID: 38385422 DOI: 10.6002/ect.mesot2023.p8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
Drug-induced liver injury after liver transplant occurs in 1.7% of patients. Tacrolimus is an effective immunosuppressant that is used to treat acute rejection. Although rare, it can cause toxicity, which is demonstrated by cholestatic liver injury. Here, we present a case of a young male patient who was diagnosed with Wilson disease, had penicillaminechelating therapy, and underwent living related liver transplant. Within 1 month posttransplant, he developed deranged, predominantly cholestatic pattern liver function tests. Laboratory parameters showed total bilirubin of 1.12 mg/ dL, alanine aminotransferase of 553 IU/L, gammaglutamyltransferase of 624 IU/L, and tacrolimus level of 10.2 ng/mL. After thorough evaluation, a liver biopsy was performed. Liver biopsy showed hepatocellular necrosis with centrilobular cholestasis without any evidence of graft rejection. However, with normal level of tacrolimus, the biopsy was suggestive of drug-induced liver injury. Thus, tacrolimus dose was reduced, resulting in improved liver function tests and patient discharge from the hospital. Tacrolimus is an effective immunosuppressant after liver transplant and has the ability to treat early acute rejection. The patient's liver biopsy showed hepatocellular necrosis with centrilobular cholestasis without any evidence of graft rejection. Cholestatic liver injury after tacrolimus usually resolves after dose reduction or by switching to another agent. With demonstrated tacrolimus-induced toxicity in liver transplant recipients, despite normal serum levels, transplant physicians should keep high index of suspicion regarding toxicity in the posttransplant setting.
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Affiliation(s)
- Zain Majid
- From the Department of Hepato-Gastroenterology, Sindh Institute of Urology and Transplantation (SIUT), Pakistan
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3
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Gunther M, Jiang S, Banga A, Sher Y. Delayed-Onset Psychosis Secondary to Tacrolimus Neurotoxicity After Lung Transplant: A Case Report and Systematic Review. J Acad Consult Liaison Psychiatry 2023; 64:550-561. [PMID: 37778461 DOI: 10.1016/j.jaclp.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 08/28/2023] [Accepted: 09/25/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Tacrolimus is the most common immunosuppressant used after transplant, yet it can result in moderate-to-severe neurotoxicity in up to 32% of patients. Signs of neurotoxicity can vary from mild (tremor or headache) to severe (posterior reversible encephalopathy syndrome or psychosis. Prompt recognition and management is needed to lead to symptom resolution. OBJECTIVE The objective of this study is to describe the clinical presentation of tacrolimus-induced psychosis, a type of tacrolimus-inducted neurotoxicity, and distinguish it from other central nervous system disturbances, including delirium. METHODS AND RESULTS We present a case of delayed onset tacrolimus-induced psychosis with focus on unique clinical features and management strategies. We conducted a systematic review of cases of tacrolimus-induced psychosis using the PubMed database and included 15 manuscripts in our review. CONCLUSIONS Tacrolimus-induced psychosis is a unique presentation of tacrolimus-related neurotoxicity and can present without the cardinal symptoms of delirium. The data on isolated psychotic symptoms are limited with current literature focusing on more common presentations of tacrolimus-induced neurotoxicity, such as delirium and tremor. Development of psychosis can occur later in the treatment course and at normal tacrolimus serum levels. It can improve with antipsychotic therapies, but primary management should include cross-titration to an alternate immunosuppressant regimen.
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Affiliation(s)
- Matthew Gunther
- Division of Medical Psychiatry, Department of Psychiatry, Stanford University, School of Medicine, Palo Alto, CA.
| | - Shixie Jiang
- Division of Medical Psychiatry, Department of Psychiatry, Stanford University, School of Medicine, Palo Alto, CA
| | - Amit Banga
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Stanford University, School of Medicine, Palo Alto, CA
| | - Yelizaveta Sher
- Division of Medical Psychiatry, Department of Psychiatry, Stanford University, School of Medicine, Palo Alto, CA
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4
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Wang AYL, Chen KH, Lin HC, Loh CYY, Chang YC, Aviña AE, Lee CM, Chu IM, Wei FC. Sustained Release of Tacrolimus Embedded in a Mixed Thermosensitive Hydrogel for Improving Functional Recovery of Injured Peripheral Nerves in Extremities. Pharmaceutics 2023; 15:508. [PMID: 36839830 PMCID: PMC9960741 DOI: 10.3390/pharmaceutics15020508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 01/28/2023] [Accepted: 02/01/2023] [Indexed: 02/05/2023] Open
Abstract
Vascularized composite allotransplantation is an emerging strategy for the reconstruction of unique defects such as amputated limbs that cannot be repaired with autologous tissues. In order to ensure the function of transplanted limbs, the functional recovery of the anastomosed peripheral nerves must be confirmed. The immunosuppressive drug, tacrolimus, has been reported to promote nerve recovery in animal models. However, its repeated dosing comes with risks of systemic malignancies and opportunistic infections. Therefore, drug delivery approaches for locally sustained release can be designed to overcome this issue and reduce systemic complications. We developed a mixed thermosensitive hydrogel (poloxamer (PLX)-poly(l-alanine-lysine with Pluronic F-127) for the time-dependent sustained release of tacrolimus in our previous study. In this study, we demonstrated that the hydrogel drug degraded in a sustained manner and locally released tacrolimus in mice over one month without affecting the systemic immunity. The hydrogel drug significantly improved the functional recovery of injured sciatic nerves as assessed using five-toe spread and video gait analysis. Neuroregeneration was validated in hydrogel-drug-treated mice using axonal analysis. The hydrogel drug did not cause adverse effects in the mouse model during long-term follow-up. The local injection of encapsulated-tacrolimus mixed thermosensitive hydrogel accelerated peripheral nerve recovery without systemic adverse effects.
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Affiliation(s)
- Aline Yen Ling Wang
- Center for Vascularized Composite Allotransplantation, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
| | - Kuan-Hung Chen
- Department of Physical Medicine & Rehabilitation, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Hsiu-Chao Lin
- Department of Chemical Engineering, National Tsing Hua University, Hsinchu 30013, Taiwan
| | - Charles Yuen Yung Loh
- Department of Plastic Surgery, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 0SP, UK
| | - Yun-Ching Chang
- Department of Health Industry Technology Management, Chung Shan Medical University, Taichung 40201, Taiwan
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung 40201, Taiwan
| | - Ana Elena Aviña
- Center for Vascularized Composite Allotransplantation, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
- International Ph.D. Program in Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
| | - Chin-Ming Lee
- Center for Vascularized Composite Allotransplantation, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
| | - I-Ming Chu
- Department of Chemical Engineering, National Tsing Hua University, Hsinchu 30013, Taiwan
| | - Fu-Chan Wei
- Center for Vascularized Composite Allotransplantation, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Department of Plastic Surgery, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
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5
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Tacrolimus-Eluting Disk within the Allograft Enables Vascularized Composite Allograft Survival with Site-Specific Immunosuppression without Systemic Toxicity. Pharm Res 2022; 39:2179-2190. [PMID: 35915321 DOI: 10.1007/s11095-022-03345-4] [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: 12/16/2021] [Accepted: 07/14/2022] [Indexed: 10/16/2022]
Abstract
AIM Widespread clinical application of vascularized composite allotransplantation (VCA) has been limited by the need for lifelong systemic immunosuppression to prevent rejection. Our goal was to develop a site-specific immunosuppressive strategy that promotes VCA allograft survival and minimizes the risk of systemic side effects. METHODS Tacrolimus loaded polycaprolactone (TAC-PCL) disks were prepared and tested for their efficacy in sustaining VCA allograft survival via site-specific immunosuppression. Brown Norway-to-Lewis rat hind limb transplantations were performed; animals received one TAC disk either in the transplanted (DTx) or in the contralateral non-transplanted (DnonTx) limbs. In another group, animals received DTx and lymphadenectomy on Tx side. Blood and allograft levels of TAC were measured using LC-MS/MS. Systemic toxicity was evaluated. RESULTS Animals that received DTx achieved long-term allograft survival (> 200 days) without signs of metabolic and infectious complications. In these animals, TAC blood levels were low but stable between 2 to 5 ng/mL for nearly 100 days. High concentrations of TAC were achieved in the allografts and the draining lymph nodes (DLN). Animals that underwent lymphadenectomy rejected their allograft by 175 days. Animals that received DnonTx rejected their allografts by day 70. CONCLUSION Controlled delivery of TAC directly within the allograft (with a single TAC disk) effectively inhibits rejection and prolongs VCA allograft survival, while mitigating the complications of systemic immunosuppression. There was a survival benefit of delivering TAC within the allograft as compared to a remote site. We believe this approach of local drug delivery has significant implications for drug administration in transplantation.
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6
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McIlwaine S, Cullen A, Stratton L, Oladipo B, Cash J, Carser J, Braniff C. The use of tacrolimus in the management of checkpoint inhibitor immunotherapy-induced hepatitis. J R Coll Physicians Edinb 2022; 52:20-23. [DOI: 10.1177/14782715221088911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Immune-mediated hepatitis is recognised as a frequently occurring complication with the use of checkpoint inhibitor immunotherapy drugs. The mainstay of treatment involves the use of immunosuppressive agents, such as corticosteroids. Mycophenolate mofetil is added when steroid resistant. However, there are limited data to guide further management when the hepatitis remains refractory to these therapies. We present two patients who developed severe immunotherapy-induced hepatitis and required prolonged immunosuppressive therapy with three agents in combination before resolution was achieved. We demonstrate that the addition of tacrolimus can be successful when other drugs fail. We also illustrate how a subsequent wean off immunosuppression can be safely performed and highlight the use of concordant antimicrobial prophylaxis to mitigate against opportunistic infections.
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Affiliation(s)
- Stuart McIlwaine
- Hepatology Unit, Royal Victoria Hospital, Belfast, Northern Ireland
| | - Anna Cullen
- Hepatology Unit, Royal Victoria Hospital, Belfast, Northern Ireland
| | - Leanne Stratton
- Hepatology Unit, Royal Victoria Hospital, Belfast, Northern Ireland
| | - Bode Oladipo
- Oncology, Belfast Health and Social Care Trust, Belfast, Northern Ireland
| | - Johnny Cash
- Hepatology Unit, Royal Victoria Hospital, Belfast, Northern Ireland
| | - Judith Carser
- Oncology, Belfast Health and Social Care Trust, Belfast, Northern Ireland
| | - Conor Braniff
- Hepatology Unit, Royal Victoria Hospital, Belfast, Northern Ireland
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7
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Du Y, Song W, Xiong XF, Ge WH, Huai-Jun Z. Population pharmacokinetics and dosage optimization of tacrolimus coadministration with Wuzhi capsule in adult liver transplant patients. Xenobiotica 2022; 52:274-283. [PMID: 35502774 DOI: 10.1080/00498254.2022.2073851] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
1. This study aimed to establish a population pharmacokinetic model of tacrolimus coadministration with Wuzhi capsule and optimize the dosage regimen in adult liver transplant patients.2. Totally 1327 tacrolimus trough concentrations from 116 adult liver transplant patients were obtained for model development. A one-compartment model with first-order absorption and elimination was used to analyse the data, and the final model was internally verified using a goodness-of-fit diagnostic plot, bootstrap methods, and visual prediction test. A total of 29 patients with 250 tacrolimus trough concentrations was used for external validation via prediction-based diagnostics. Additionally, the simulation was used to optimize the recommended dose of tacrolimus and Wuzhi capsules.3. The estimated apparent clearance and volume of the distribution of tacrolimus were 15.4 L/h and 1210 L, respectively. The tacrolimus daily dose, Wuzhi capsule daily dose, postoperative time, alanine transaminase, haemoglobin, total bilirubin, direct bilirubin, estimated glomerular filtration rate, and urea, concomitant with voriconazole and fluconazole, were identified as significant covariates affecting the pharmacokinetic parameters. Internal and external validation showed that the final model was stable and reliable for predicting performance.4. The final model could provide guidance for dosage optimization of tacrolimus coadministered with Wuzhi capsules in adult liver transplantation patients.
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Affiliation(s)
- Yao Du
- Department of Pharmacy, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China.,Nanjing Medical Center for Clinical Pharmacy, Nanjing, China
| | - Wei Song
- Department of Pharmacy, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Xiao-Fu Xiong
- Department of Pharmacy, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Wei-Hong Ge
- Department of Pharmacy, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China.,Nanjing Medical Center for Clinical Pharmacy, Nanjing, China
| | - Zhu Huai-Jun
- Department of Pharmacy, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China.,Nanjing Medical Center for Clinical Pharmacy, Nanjing, China.,Department of Pharmacology, School of Pharmacy, Fudan University, Shanghai, China
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8
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Chaitou AR, Valmiki S, Valmiki M, Zahid M, Aid MA, Fawzy P, Khan S. New-Onset Diabetes Mellitus (NODM) After Liver Transplantation (LT): The Ultimate Non-diabetogenic Immunosuppressive Therapy. Cureus 2022; 14:e23635. [PMID: 35510006 PMCID: PMC9057316 DOI: 10.7759/cureus.23635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 03/29/2022] [Indexed: 11/05/2022] Open
Abstract
New-onset diabetes mellitus (NODM) is a common long-term complication after liver transplantation (LT). It is thought to be drug-induced in most cases, no matter the underlying disease that cause liver failure and indicated transplantation. Standard post-transplantation (PT) immunosuppressive regimens include prolonged use of calcineurin inhibitors (CNIs), namely tacrolimus (TAC), alongside corticosteroids to avoid acute and chronic graft rejection. This combination is well known for its diabetogenicity. Significant differences between the applied regimens stand out concerning the duration and dosages to prevent the metabolic side effects of these drugs in the long run without compromising the graft's survival. Studies were collected after an extensive research of PubMed database for this very specific topic using the following MeSH keywords in multiple combinations: "Liver Transplantation," "Diabetes Mellitus," "NODM," "Tacrolimus," "Cyclosporine A," and "Steroids." In addition, we used the same keywords for regular searches in Google Scholar. Only the relevant English human studies between 2010 and 2020 were collected except for review articles. Duplicates were eliminated using Mendeley software. Twelve relevant studies directly related to the targeted topic were collected and discussed, including five retrospective cohorts, four prospective cohorts, one clinical trial, one prospective pilot, and one case report. Their topics included primarily the factors increasing the risk of new-onset diabetes mellitus after liver transplantation (NODALT), TAC-based immunosuppression and its relative blood levels affecting the possible development of NODALT, the role of cyclosporine in substituting TAC regimen, and the effect of different steroids-avoiding protocols on the prevention of NODALT. The reviewed studies suggested that lowering the serum concentration of tacrolimus (cTAC) throughout the PT period and eliminating the corticosteroids regimen as early as possible, among other measures, can significantly impact the rate of emergence of NODM. This traditional review tackles the most recent studies about NODALT to establish a comprehensive view on this issue and guide clinicians and researchers for the safest immunosuppressive regimen to date, while maintaining a balanced metabolic profile.
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9
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Løhde LW, Bentzon A, Kornblit BT, Roos P, Fink-Jensen A. Possible Tacrolimus-Related Neuropsychiatric Symptoms: One Year After Allogeneic Hematopoietic Cell Transplantation: A Case Report. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2022; 15:11795476221087053. [PMID: 35342316 PMCID: PMC8941686 DOI: 10.1177/11795476221087053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 02/21/2022] [Indexed: 11/17/2022]
Abstract
Tacrolimus is a calcineurin inhibitor (CNI), an immunosuppressive agent used to
prevent graft versus host disease following allogeneic hematopoietic cell
transplantation (HCT). Side-effects of tacrolimus treatment include
neuropsychiatric symptoms, for example, affective disturbances, psychosis, and
akinetic mutism. The onset of side-effects is independent of tacrolimus blood
concentration and can occur years after treatment initiation. To our knowledge,
case-reports describing tacrolimus-induced neuropsychiatric symptoms following
HCT are sparse. This article reports the case of a 60-year-old woman with T-cell
prolymphocytic leukemia, who developed memory loss, affective disturbances, and
delusions, 1-year after HCT, and tacrolimus treatmentinitiation. Upon hospital
admission, she was motionless and mute, albeit easily roused. The routine
physical examination was without pathological findings. Blood work and
microbiological analyses of blood and cerebrospinal fluid were normal. The
neuroimaging showed chronic structural changes without relation to the debut of
neuropsychiatric symptoms. Tacrolimus was discontinued on suspicion of
tacrolimus-induced neuropsychiatric symptoms. The patient recovered within
48 hours of discontinuation. She was switch to prednisone treatment, and there
has been no reemergence of neuropsychiatric symptoms since.
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Affiliation(s)
| | | | | | - Peter Roos
- Department of Neurology and Neuroscience, Rigshospitalet, Denmark
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10
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Decrocq-Rudler MA, Chan Kwong AHXP, Meunier L, Fraisse J, Ursic-Bedoya J, Khier S. Can We Predict Individual Concentrations of Tacrolimus After Liver Transplantation? Application and Tweaking of a Published Population Pharmacokinetic Model in Clinical Practice. Ther Drug Monit 2021; 43:490-498. [PMID: 33560099 DOI: 10.1097/ftd.0000000000000867] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 01/04/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Various population pharmacokinetic models have been developed to describe the pharmacokinetics of tacrolimus in adult liver transplantation. However, their extrapolated predictive performance remains unclear in clinical practice. The purpose of this study was to predict concentrations using a selected literature model and to improve these predictions by tweaking the model with a subset of the target population. METHODS A literature review was conducted to select an adequate population pharmacokinetic model (L). Pharmacokinetic data from therapeutic drug monitoring of tacrolimus in liver-transplanted adults were retrospectively collected. A subset of these data (70%) was exploited to tweak the L-model using the $PRIOR subroutine of the NONMEM software, with 2 strategies to weight the prior information: full informative (F) and optimized (O). An external evaluation was performed on the remaining data; bias and imprecision were evaluated for predictions a priori and Bayesian forecasting. RESULTS Seventy-nine patients (851 concentrations) were enrolled in the study. The predictive performance of L-model was insufficient for a priori predictions, whereas it was acceptable with Bayesian forecasting, from the third prediction (ie, with ≥2 previously observed concentrations), corresponding to 1 week after transplantation. Overall, the tweaked models showed a better predictive ability than the L-model. The bias of a priori predictions was -41% with the literature model versus -28.5% and -8.73% with tweaked F and O models, respectively. The imprecision was 45.4% with the literature model versus 38.0% and 39.2% with tweaked F and O models, respectively. For Bayesian predictions, whatever the forecasting state, the tweaked models tend to obtain better results. CONCLUSIONS A pharmacokinetic model can be used, and to improve the predictive performance, tweaking the literature model with the $PRIOR approach allows to obtain better predictions.
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Affiliation(s)
- Marie-Astrid Decrocq-Rudler
- Pharmacokinetic and Modeling Department, School of Pharmacy, Montpellier University, Montpellier, France
- Probabilities and Statistics Department, Institut Montpellierain Alexander Grothendieck (IMAG), Montpellier University, Montpellier, France
| | - Anna H-X P Chan Kwong
- Pharmacokinetic and Modeling Department, School of Pharmacy, Montpellier University, Montpellier, France
- Probabilities and Statistics Department, Institut Montpellierain Alexander Grothendieck (IMAG), Montpellier University, Montpellier, France
- SMARTc Group, Inserm, CNRS, Institut Paoli-Calmettes, CRCM, Aix-Marseille University, Marseille, France
| | - Lucy Meunier
- Department of Hepato-Gastroenterology and Liver Transplantation, Montpellier University Hospital (Saint Eloi), Montpellier, France ; and
| | | | - José Ursic-Bedoya
- Department of Hepato-Gastroenterology and Liver Transplantation, Montpellier University Hospital (Saint Eloi), Montpellier, France ; and
| | - Sonia Khier
- Pharmacokinetic and Modeling Department, School of Pharmacy, Montpellier University, Montpellier, France
- Probabilities and Statistics Department, Institut Montpellierain Alexander Grothendieck (IMAG), Montpellier University, Montpellier, France
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11
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Functional Improvement of Tacrolimus-Induced Parkinsonism With Amantadine After Liver Transplantation: A Case Report. Clin Neuropharmacol 2021; 44:141-144. [PMID: 33871425 DOI: 10.1097/wnf.0000000000000444] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
ABSTRACT Drug-induced parkinsonism is the most common type of drug-induced movement disorder, whose symptoms can decrease patient quality of life and reduce medication compliance. Tacrolimus is a routinely used immunosuppressant agent after liver transplantation, with a well-known neurotoxic profile. There have been rare reports of tacrolimus-induced parkinsonism, but its pharmacologic management and functional impact remain poorly characterized in the literature. We present a case of tacrolimus-induced parkinsonism in a 62-year-old man after a liver transplant, resulting in significant neurologic impairments and multiple barriers to hospital discharge. His tremor, rigidity, bradykinesia, gait dysfunction, dysphonia, and dysphagia significantly improved after starting low-dose amantadine, with increased functional independence that allowed for a safe discharge. This is the first case in the literature detailing tacrolimus-induced parkinsonism's functional impairments improving with amantadine monotherapy.
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12
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Chin YH, Tan HQM, Ng CH, Tan DJH, Lin SY, Huang DQ, Khoo CM, Muthiah MD. A Time-Based Meta-Analysis on the Incidence of New Onset Diabetes after Liver Transplantation. J Clin Med 2021; 10:jcm10051045. [PMID: 33802465 PMCID: PMC7959476 DOI: 10.3390/jcm10051045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 02/08/2021] [Accepted: 02/24/2021] [Indexed: 12/29/2022] Open
Abstract
NODAT (new-onset diabetes after transplantation) is an important complication after liver transplant, however, there is variation in the reported incidence of NODAT. Therefore, a meta-analysis was performed to estimate the incidence of NODAT in liver transplant. Electronic databases were searched for articles regarding NODAT incidence after liver transplantation. Incidence of NODAT were analyzed at six different timepoints. Summary statistics were calculated using a generalized linear mixed model in random effects. 28 articles were included and out of a pooled population of 71,257 patients, overall incidence of NODAT was found to be 15.51%, 16.09%, 18.30%, 20.86%, 18.08%, 25.05% for three-months, six-months, one-year, three-year, five-year, and ten-year timepoints respectively. After a sensitivity analysis which only included articles with clear definitions of NODAT, the incidence of NODAT was found to be higher at three-year (21.79%), five-year (25.82%), and ten-year (44.95%) timepoints. Subgroup analysis according to ethnicity found no significant differences for all timepoints. However, studies with predominantly Asian participants generally had a higher incidence of NODAT. In conclusion, this meta-analysis provides a pooled estimate of the incidence of NODAT following liver transplantation. Further studies are required to provide a more comprehensive understanding on how ethnicity can affect the incidence of NODAT.
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Affiliation(s)
- Yip Han Chin
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore; (Y.H.C.); (H.Q.M.T.); (D.J.H.T.); (S.Y.L.); (D.Q.H.); (C.M.K.)
| | - Hon Qin Marcus Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore; (Y.H.C.); (H.Q.M.T.); (D.J.H.T.); (S.Y.L.); (D.Q.H.); (C.M.K.)
| | - Cheng Han Ng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore; (Y.H.C.); (H.Q.M.T.); (D.J.H.T.); (S.Y.L.); (D.Q.H.); (C.M.K.)
- Correspondence: or (C.H.N.); (M.D.M.)
| | - Darren Jun Hao Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore; (Y.H.C.); (H.Q.M.T.); (D.J.H.T.); (S.Y.L.); (D.Q.H.); (C.M.K.)
| | - Snow Yunni Lin
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore; (Y.H.C.); (H.Q.M.T.); (D.J.H.T.); (S.Y.L.); (D.Q.H.); (C.M.K.)
| | - Daniel Q. Huang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore; (Y.H.C.); (H.Q.M.T.); (D.J.H.T.); (S.Y.L.); (D.Q.H.); (C.M.K.)
- Department of Medicine, National University Hospital, Singapore 119074, Singapore
- National University Centre for Organ Transplantation, National University Hospital, Singapore 119074, Singapore
| | - Chin Meng Khoo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore; (Y.H.C.); (H.Q.M.T.); (D.J.H.T.); (S.Y.L.); (D.Q.H.); (C.M.K.)
- Department of Medicine, National University Hospital, Singapore 119074, Singapore
| | - Mark Dhinesh Muthiah
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore; (Y.H.C.); (H.Q.M.T.); (D.J.H.T.); (S.Y.L.); (D.Q.H.); (C.M.K.)
- Department of Medicine, National University Hospital, Singapore 119074, Singapore
- National University Centre for Organ Transplantation, National University Hospital, Singapore 119074, Singapore
- Correspondence: or (C.H.N.); (M.D.M.)
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Coe CL, Horst SN, Izzy MJ. Neurologic Toxicities Associated with Tumor Necrosis Factor Inhibitors and Calcineurin Inhibitors. Neurol Clin 2020; 38:937-951. [PMID: 33040870 DOI: 10.1016/j.ncl.2020.07.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The calcineurin inhibitors cyclosporine and tacrolimus are used for their immunosuppressive effects. Neurotoxic side effects include tremor, paresthesia, and headache. Rarer neurotoxicities include seizure, posterior reversible encephalopathy syndrome, and encephalopathy. Tacrolimus tends to be more neurotoxic than cyclosporine. Management of toxicities associated with calcineurin inhibitors includes dose reduction, switching between calcineurin inhibitors, or switching to a calcineurin-free regimen. Tumor necrosis factor (TNF) inhibitors are used in autoimmune diseases. Management of demyelinating conditions among patients treated with anti-TNF should follow standard of care and withdrawal of the anti-TNF. This drug class should be avoided in patients with a history of demyelinating conditions.
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Affiliation(s)
- Christopher L Coe
- Department of Medicine, Section of Hospital Medicine, Vanderbilt University Medical Center, 1161 21st Avenue South, Nashville, TN 37232, USA. https://twitter.com/ccoemd
| | - Sarah N Horst
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, 1211 21st Avenue South, Medical Arts Building, Suite 220, Nashville, TN 37232, USA. https://twitter.com/HorstIBDDoc
| | - Manhal J Izzy
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Transplant Hepatology, 1660 The Vanderbilt Clinic, Nashville, TN 37232, USA.
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Factors Associated With Neurobehavioral Complications in Pediatric Abdominal Organ Transplant Recipients Identified Using Computable Composite Definitions. Pediatr Crit Care Med 2020; 21:804-810. [PMID: 32343104 PMCID: PMC7888546 DOI: 10.1097/pcc.0000000000002355] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Neurologic complications occur in up to 40% of adult abdominal solid organ transplant recipients and are associated with increased mortality. Comparable pediatric data are sparse. This study describes the occurrence of neurologic and behavioral complications (neurobehavioral complications) in pediatric abdominal solid organ transplant recipients. We examine the association of these complications with length of stay, mortality, and tacrolimus levels. DESIGN The electronic health record was interrogated for inpatient readmissions of pediatric abdominal solid organ transplant recipients from 2009 to 2017. A computable composite definition of neurobehavioral complication, defined using structured electronic data for neurologic and/or behavioral phenotypes, was created. SETTING Quaternary children's hospital with an active transplant program. PATIENTS Pediatric abdominal solid organ transplant recipients. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Computable phenotypes demonstrated a specificity 98.7% and sensitivity of 63.0% for identifying neurobehavioral complications. There were 1,542 readmissions among 318 patients, with 65 (20.4%) having at least one admission with a neurobehavioral complication (total 109 admissions). Median time from transplant to admission with neurobehavioral complication was 1.2 years (interquartile range, 0.52-2.28 yr). Compared to encounters without an identified neurobehavioral complication, encounters with a neurobehavioral complication were more likely to experience ICU admission (odds ratio, 3.9; 2.41-6.64; p < 0.001), have longer ICU length of stay (median 10.3 vs 2.2 d; p < 0.001) and hospital length of stay (8.9 vs 4.3 d; p < 0.001), and demonstrate higher maximum tacrolimus level (12.3 vs 9.8 ng/mL; p = 0.001). Patients with a neurobehavioral complication admission were more likely to die (odds ratio, 5.04; 1.49-17.09; p = 0.009). In a multivariable analysis, type of transplant, ICU admission, and tacrolimus levels were independently associated with the presence of a neurobehavioral complication. CONCLUSIONS Common electronic health record variables can be used to accurately identify neurobehavioral complications in the pediatric abdominal solid organ transplant population. Late neurobehavioral complications are associated with increased hospital resource utilization, mortality, and tacrolimus exposure. Additional studies are required to delineate the relationship between maximum tacrolimus level and neurobehavioral complications to guide therapeutic drug monitoring and dosing.
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15
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Leino AD, Pai MP. Maintenance Immunosuppression in Solid Organ Transplantation: Integrating Novel Pharmacodynamic Biomarkers to Inform Calcineurin Inhibitor Dose Selection. Clin Pharmacokinet 2020; 59:1317-1334. [PMID: 32720300 DOI: 10.1007/s40262-020-00923-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Calcineurin inhibitors, the primary immunosuppressive therapy used to prevent alloreactivity of transplanted organs, have a narrow therapeutic index. Currently, treatment is individualized based on clinical assessment of the risk of rejection or toxicity guided by trough concentration monitoring. Advances in immune monitoring have identified potential markers that may have value in understanding calcineurin inhibitor pharmacodynamics. Integration of these markers has the potential to complement therapeutic drug monitoring. Existing pharmacokinetic-pharmacodynamic (PK-PD) data is largely limited to correlation between the biomarker and trough concentrations at single time points. Immune related gene expression currently has the most evidence supporting PK-PD integration. Novel biomarker-based approaches to pharmacodynamic monitoring including development of enhanced PK-PD models are proposed to realize the full clinical benefit.
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Affiliation(s)
- Abbie D Leino
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, 428 Church Street, Rm 3569, Ann Arbor, MI, 48109, USA
| | - Manjunath P Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, 428 Church Street, Rm 3569, Ann Arbor, MI, 48109, USA.
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16
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Min S, Papaz T, Lafreniere-Roula M, Nalli N, Grasemann H, Schwartz SM, Kamath BM, Ng V, Parekh RS, Manlhiot C, Mital S. A randomized clinical trial of age and genotype-guided tacrolimus dosing after pediatric solid organ transplantation. Pediatr Transplant 2018; 22:e13285. [PMID: 30178515 DOI: 10.1111/petr.13285] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 07/03/2018] [Accepted: 07/27/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND Tacrolimus pharmacokinetics are influenced by age and CYP3A5 genotype with CYP3A5 expressors (CYP3A5*1/*1 or *1/*3) being fast metabolizers. However, the benefit of genotype-guided dosing in pediatric solid organ transplantation has been understudied. OBJECTIVE To determine whether age and CYP3A5 genotype-guided starting dose of tacrolimus result in earlier attainment of therapeutic drug concentrations. SETTING Single hospital-based transplant center. METHODS This was a randomized, semi-blinded, 30-day pilot trial. Between 2012 and 2016, pediatric patients listed for solid organ transplant were consented and enrolled into the study. Participants were categorized as expressors, CYP3A5*1/*1 or CYP3A5*1/*3, and nonexpressors, CYP3A5*3/*3. Patients were stratified by age (≤ or > 6 years) and randomized (2:1) after transplant to receive genotype-guided (n = 35) or standard (n = 18) starting dose of tacrolimus for 36-48 hours and were followed for 30 days. RESULTS Median age at transplant in the randomized cohort was 2.1 (0.75-8.0) years; 24 (45%) were male. Participants in the genotype-guided arm achieved therapeutic concentrations earlier at a median (IQR) of 3.4 (2.5-6.6) days compared to those in the standard dosing arm of 4.7 (3.5-8.6) days (P = 0.049), and had fewer out-of-range concentrations [OR (95% CI) = 0.60 (0.44, 0.83), P = 0.002] compared to standard dosing, with no difference in frequency of adverse events between the two groups. CONCLUSIONS CYP3A5 genotype-guided dosing stratified by age resulted in earlier attainment of therapeutic tacrolimus concentrations and fewer out-of-range concentrations.
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Affiliation(s)
- Sandar Min
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Tanya Papaz
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Myriam Lafreniere-Roula
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Nadya Nalli
- Department of Pharmacy, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Hartmut Grasemann
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Steven M Schwartz
- Department of Cardiac Critical Care Medicine, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Binita M Kamath
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Vicky Ng
- Transplant and Regenerative Medicine Centre, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Rulan S Parekh
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,Division of Nephrology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada.,Child Health Evaluative Sciences Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Cedric Manlhiot
- Cardiovascular Data Management Centre (CVDMC) Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Seema Mital
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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17
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van der Merwe Y, Faust AE, Conner I, Gu X, Feturi F, Zhao W, Leonard B, Roy S, Gorantla VS, Venkataramanan R, Washington KM, Wagner WR, Steketee MB. An Elastomeric Polymer Matrix, PEUU-Tac, Delivers Bioactive Tacrolimus Transdurally to the CNS in Rat. EBioMedicine 2017; 26:47-59. [PMID: 29208469 PMCID: PMC5832622 DOI: 10.1016/j.ebiom.2017.11.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 11/10/2017] [Accepted: 11/20/2017] [Indexed: 12/13/2022] Open
Abstract
Central nervous system (CNS) neurons fail to regrow injured axons, often resulting in permanently lost neurologic function. Tacrolimus is an FDA-approved immunosuppressive drug with known neuroprotective and neuroregenerative properties in the CNS. However, tacrolimus is typically administered systemically and blood levels required to effectively treat CNS injuries can lead to lethal, off-target organ toxicity. Thus, delivering tacrolimus locally to CNS tissues may provide therapeutic control over tacrolimus levels in CNS tissues while minimizing off-target toxicity. Herein we show an electrospun poly(ester urethane) urea and tacrolimus elastomeric matrix (PEUU-Tac) can deliver tacrolimus trans-durally to CNS tissues. In an acute CNS ischemia model in rat, the optic nerve (ON) was clamped for 10s and then PEUU-Tac was used as an ON wrap and sutured around the injury site. Tacrolimus was detected in PEUU-Tac wrapped ONs at 24 h and 14 days, without significant increases in tacrolimus blood levels. Similar to systemically administered tacrolimus, PEUU-Tac locally decreased glial fibrillary acidic protein (GFAP) at the injury site and increased growth associated protein-43 (GAP-43) expression in ischemic ONs from the globe to the chiasm, consistent with decreased astrogliosis and increased retinal ganglion cell (RGC) axon growth signaling pathways. These initial results suggest PEUU-Tac is a biocompatible elastic matrix that delivers bioactive tacrolimus trans-durally to CNS tissues without significantly increasing tacrolimus blood levels and off-target toxicity. PEUU-Tac locally delivers tacrolimus to CNS tissues PEUU-Tac positively modulates CNS tissue remodeling PEUU-Tac minimizes off-target tacrolimus toxicity
Central nervous system (CNS) injury typically results in permanently lost neurological function. Tacrolimus is an FDA-approved drug used during organ transplantation that also has CNS neuroprotective and neuroregenerative properties. However, tacrolimus is typically delivered systemically in the blood and delivering effective concentrations to CNS tissues requires tacrolimus blood levels that can lead to adverse side effects in multiple organs. Herein we show that PEUU-Tac, a tacrolimus-eluting matrix, can locally deliver tacrolimus to injured CNS tissues without increasing blood levels, suggesting PEUU-Tac can be used to treat CNS injuries locally while minimizing adverse side effects.
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Affiliation(s)
- Yolandi van der Merwe
- Department of Ophthalmology, University of Pittsburgh, Pittsburgh, PA, United States; McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, United States; Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, United States
| | - Anne E Faust
- Department of Ophthalmology, University of Pittsburgh, Pittsburgh, PA, United States; McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Ian Conner
- Department of Ophthalmology, University of Pittsburgh, Pittsburgh, PA, United States; McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Xinzhu Gu
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, United States; Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Firuz Feturi
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, United States; Department of Pharmaceutical Sciences, University of Pittsburgh, Pittsburgh, PA, United States
| | - Wenchen Zhao
- Department of Pharmaceutical Sciences, University of Pittsburgh, Pittsburgh, PA, United States
| | - Bianca Leonard
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, United States; Department of Neuroscience, University of Pittsburgh, Pittsburgh, PA, United States
| | - Souvik Roy
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, United States; Department of Neuroscience, University of Pittsburgh, Pittsburgh, PA, United States
| | - Vijay S Gorantla
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, United States; Departments of Surgery, Ophthalmology and Bioengineering, Wake Forest School of Medicine, Wake Forest Institute of Regenerative Medicine, Winston Salem, NC, United States
| | - Raman Venkataramanan
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, United States; Department of Pharmaceutical Sciences, University of Pittsburgh, Pittsburgh, PA, United States; Department of Pathology, University of Pittsburgh, Pittsburgh, PA, United States
| | - Kia M Washington
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, United States; Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA, United States; VA Pittsburgh Healthcare System, Pittsburgh, PA, United States
| | - William R Wagner
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, United States; Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, United States; Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Michael B Steketee
- Department of Ophthalmology, University of Pittsburgh, Pittsburgh, PA, United States; Center for Neuroscience, University of Pittsburgh, Pittsburgh, PA, United States; McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, United States; Department of Neuroscience, University of Pittsburgh, Pittsburgh, PA, United States.
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18
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Cognitive Evaluation in Liver Transplant Patients Under Calcineurin Inhibitor Maintenance Therapy. Transplant Direct 2017; 3:e146. [PMID: 28405602 PMCID: PMC5381739 DOI: 10.1097/txd.0000000000000658] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 01/19/2017] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Neurological disorders due to calcineurin inhibitor (CNI) treatment pose a well-known problem after liver transplantation (LTx). In this study, the impact of CNIs on cognitive functioning during maintenance therapy was analyzed. A possible improvement of cognitive functioning, compliance and health-related quality of life (HRQoL) after conversion to a once-daily tacrolimus formulation was prospectively assessed. METHODS In a cross-section analysis cognitive functioning of living donors (LD), waiting list patients and LTx patients was tested using a 4 times trail making test (4-TTMT). In a further investigator-initiated trial a possible improvement of cognitive functioning, HRQoL and compliance after conversion to the once-daily tacrolimus formulation was prospectively assessed over 1 year. HRQoL was assessed using an EORTC-QLQ C30 questionnaire and patient's compliance was assessed by the Basel Assessment of Compliance with Immunosuppressive Medication Scales questionnaire. Correlated data were sex, age, time after surgery, liver disease, model of end-stage liver disease score, creatinine, CNI type, and CNI trough levels. RESULTS Two hundred eleven patients were included in this cross-section analysis. Twenty-seven patients agreed to participate in the investigator-initiated trial. LTx patients completed the 4-TTMT slower than living donor patients and faster than waiting list patients. Patients with twice daily cyclosporine A (CSA) formulation needed longer to finish the 4-TTMT than patients with the once-daily tacrolimus formulation. After drug conversion of a twice-daily CNI formulation to a once-daily tacrolimus formulation, CSA-treated patients needed longer to improve their cognitive functioning. HRQoL and compliance did not improve after drug conversion. CONCLUSIONS Patients with once-daily tacrolimus formulation had a better psychomotor speed than CSA-treated patients. The conversion to once-daily tacrolimus formulation significantly improved cognitive functioning, but had no impact on HRQoL or compliance.
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Qin HZ, Liu L, Liang SS, Shi JS, Zheng CX, Hou Q, Lu YH, Le WB. Evaluating tacrolimus treatment in idiopathic membranous nephropathy in a cohort of 408 patients. BMC Nephrol 2017; 18:2. [PMID: 28056860 PMCID: PMC5216560 DOI: 10.1186/s12882-016-0427-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Accepted: 12/20/2016] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The KDIGO Clinical Practice Guidelines for Glomerulonephritis recommended tacrolimus as an alternative regimen for the initial therapy for Idiopathic membranous nephropathy (IMN), however, large observational studies evaluating tacrolimus treatment in IMN remains rare. METHODS A total of 408 consecutive IMN patients with nephrotic syndrome who were treated with tacrolimus in Jinling Hospital were included. The effectiveness and safety of tacrolimus treatment in IMN were analyzed in this study. RESULTS The cumulative partial or complete remission after tacrolimus therapy were 50%, 63% and 67% at 6, 12 and 24 months, respectively, and the cumulative complete remission rates were 4%, 13% and 23%, respectively. Multivariate logistic analysis showed that higher tacrolimus exposure during induction treatment, female gender, higher eGFR and no history of previous immunosuppressive therapy were independently associated with higher probability of remission. A relapse occurred in 101 of the 271 (37.3%) patients with partial or complete remission, and 18 of the 95 (18.9%) patients with complete remission. Tapering duration of tacrolimus and complete remission versus partial remission status were independent factors associated with risk of relapse. A decline in eGFR was the most frequent adverse event during tacrolimus treatment. During tacrolimus treatment, a ≥40% decrease in eGFR was observed in 43 (10.5%) patients. CONCLUSIONS Low dose tacrolimus is effective for IMN, with a total remission rate of 66% whereas with a rather high rate of relapse. However, the safety of tacrolimus treatment needs to be further validated in large randomized clinical trials.
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Affiliation(s)
- Hua-Zhang Qin
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210002, China
| | - Lei Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210002, China
| | - Shao-Shan Liang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210002, China
| | - Jing-Song Shi
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210002, China
| | - Chun-Xia Zheng
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210002, China
| | - Qing Hou
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210002, China
| | - Ying-Hui Lu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210002, China
| | - Wei-Bo Le
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210002, China.
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Seth S, Khan DA. The Comparative Safety of Multiple Alternative Agents in Refractory Chronic Urticaria Patients. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 5:165-170.e2. [PMID: 27746265 DOI: 10.1016/j.jaip.2016.08.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 07/22/2016] [Accepted: 08/23/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Patients who have failed traditional treatment of chronic urticaria may require trials of alternative medications. Safety profiles, continuous laboratory monitoring, and physician comfort are often barriers to treatment. OBJECTIVES To evaluate the safety of alternative agents used in chronic urticaria. METHODS A retrospective chart review of electronic medical records from a single-center allergy and immunology clinic in a major academic hospital was conducted. One hundred twenty-six charts of patients with chronic urticaria treated with alternative agents were reviewed. RESULTS Adverse effects were reported in 39 of 73 (53%) patients on dapsone, 19 of 47 (40%) patients on sulfasalazine, 15 of 36 (42%) patients on tacrolimus, 7 of 45 (16%) patients on hydroxychloroquine, 9 of 27 (33%) patients on mycophenolate, 6 of 8 (75%) patients on cyclosporine, and 3 of 24 (4%) patients on omalizumab. Most of these adverse effects were mild, did not require discontinuation of the medication, and resolved after stopping the medication or decreasing the dose. CONCLUSIONS The use of alternative agents for the treatment of chronic urticaria angioedema is generally safe when proper laboratory and clinical monitoring is observed.
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Affiliation(s)
- Sharon Seth
- Division of Allergy and Immunology, University of Texas Southwestern Dallas, Dallas, Texas.
| | - David A Khan
- Division of Allergy and Immunology, University of Texas Southwestern Dallas, Dallas, Texas
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Abstract
Liver transplantation is currently in its golden period in India. The number of transplants being performed and the steady increase in the new programs that have emerged over the last decade is a testimony to it. The growth was not smooth, especially in the early years. But a multipronged approach in developing infrastructure and the involvement of multidisciplinary teams in the management of transplant patients has had a major positive impact on the outcome and as a result a positive impetus to the growth of this specialty in India. To date, the majority of transplants performed in India are live donor liver transplants. Deceased donation is more sporadic and concentrated in a couple of regions. With phenomenal increase in transplant activity in India, there is huge potential for streamlining data sharing among programs in India and with the rest of the world to ultimately benefit the transplant community.
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Affiliation(s)
- Gomathy Narasimhan
- National Foundation for Liver Research and Institute of Liver Disease and Transplantation, Global Hospital and Health City, Chennai, India
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22
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Li Z, Sun F, Hu Z, Xiang J, Zhou J, Yan S, Wu J, Zhou L, Zheng S. New-Onset Diabetes Mellitus in Liver Transplant Recipients With Hepatitis C: Analysis of the National Database. Transplant Proc 2016; 48:138-144. [PMID: 26915859 DOI: 10.1016/j.transproceed.2015.11.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 11/04/2015] [Accepted: 11/18/2015] [Indexed: 02/05/2023]
Abstract
BACKGROUND New-onset diabetes mellitus (NODM) after liver transplantation (LT) occurs with increased frequency in recipients with hepatitis C virus (HCV). We compared the incidence and risk factors for NODM in HCV vs non-HCV recipients. METHODS Among 24,956 liver recipients, 18,741 without pretransplantation diabetes were identified. NODM-free survival was analyzed using Kaplan-Meier and log-rank tests, and risk factors for NODM were examined using multivariate Cox regression analysis. RESULTS The overall incidence of NODM was 13.0% at 1 year after LT. At 1, 2, 3, and 5 years after LT, incidence of NODM in HCV recipients was 14.4%, 4.3%, 3.1%, and 3.5%, respectively, compared with 11.9%, 3.5%, 3.2%, and 6.4%, respectively, in non-HCV recipients. HCV recipients had a higher risk of NODM than non-HCV recipients (hazard ratio 1.17 [1.09-1.27], P < .001). Predictors of NODM in HCV recipients were age, body mass index (BMI), tacrolimus and steroid usage at discharge, acute rejection episode, and donor with diabetes mellitus. Risk factors in non-HCV recipients were male recipient, BMI, and recipients with nonalcoholic steatohepatitis diagnosis. CONCLUSIONS HCV recipients have a higher incidence and more risk factors for NODM than non-HCV recipients. Early identification of modifiable risk factors will assist clinical interventions to prevent NODM complications after LT.
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Affiliation(s)
- Z Li
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - F Sun
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Z Hu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China; Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
| | - J Xiang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - J Zhou
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - S Yan
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - J Wu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - L Zhou
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - S Zheng
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China; Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China.
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Tajdaran K, Shoichet MS, Gordon T, Borschel GH. A novel polymeric drug delivery system for localized and sustained release of tacrolimus (FK506). Biotechnol Bioeng 2015; 112:1948-53. [DOI: 10.1002/bit.25598] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 02/17/2015] [Accepted: 03/04/2015] [Indexed: 11/10/2022]
Affiliation(s)
- Kasra Tajdaran
- Division of Plastic and Reconstructive Surgery; The Hospital for Sick Children; 555 University Ave Toronto Ontario Canada M5G1X8
- Institute of Biomaterials and Biomedical Engineering; University of Toronto; Toronto Ontario Canada
| | - Molly S. Shoichet
- Institute of Biomaterials and Biomedical Engineering; University of Toronto; Toronto Ontario Canada
- Department of Chemical Engineering and Applied Chemistry; University of Toronto; Toronto Ontario Canada
| | - Tessa Gordon
- Division of Plastic and Reconstructive Surgery; The Hospital for Sick Children; 555 University Ave Toronto Ontario Canada M5G1X8
- Division of Plastic and Reconstructive Surgery, Department of Surgery; University of Toronto; Toronto Ontario Canada
- Program in Neuroscience; The Hospital for Sick Children Research Institute; Toronto Ontario Canada
| | - Gregory H. Borschel
- Division of Plastic and Reconstructive Surgery; The Hospital for Sick Children; 555 University Ave Toronto Ontario Canada M5G1X8
- Institute of Biomaterials and Biomedical Engineering; University of Toronto; Toronto Ontario Canada
- Division of Plastic and Reconstructive Surgery, Department of Surgery; University of Toronto; Toronto Ontario Canada
- Program in Neuroscience; The Hospital for Sick Children Research Institute; Toronto Ontario Canada
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Yin BS, Li M, Liu BM, Wang SY, Zhang WG. An integrated microfluidic device for screening the effective concentration of locally applied tacrolimus for peripheral nerve regeneration. Exp Ther Med 2014; 9:154-158. [PMID: 25452793 PMCID: PMC4247293 DOI: 10.3892/etm.2014.2082] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 10/16/2014] [Indexed: 11/25/2022] Open
Abstract
The effectiveness of tacrolimus (FK506) for the promotion of nerve regeneration is known. However, at present, due to the fact that systemic application may lead to opportunistic infections and tumors, and that the treatment of peripheral nerve injury with systemic immunosuppression is not generally accepted, FK506 has not been widely used for the treatment of simple or peripheral nerve injury. In this study, a pyramid-shaped microfluidic device was designed and fabricated that was able to analyze the effective concentration of locally applied FK506. After testing the effectiveness of the microfluidic device by measuring the fluorescence intensity of fluorescein isothiocyanate-dextran, rat Schwann cells (SCs) were loaded into the device and cultured for 9 days in the presence of different concentrations of FK506. SC proliferation in the presence of FK506 was concentration-dependent between 0 and 2.5±0.003 ng/ml. The proliferation rate reached a maximum at 1.786±0.014 ng/ml, which was statistically significantly different from the proliferation rate at lower FK506 concentrations. There was no statistically significant difference in the proliferation rate between the 1.786 ng/ml group and groups of higher FK506 concentrations. Furthermore, the SCs in the microfluidic device and a 96-well plate continued to proliferate as the culture time increased. No statistically significant differences were identified between the microfluidic device and a 96-well plate with regard to the proliferation rates in each corresponding group. The results obtained in this study demonstrated that the microfluidic device can be used as an excellent platform for the study of drug concentration at the cellular level, and the effective FK506 concentration for local application is 1.786±0.014 ng/ml.
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Affiliation(s)
- Bao-Sheng Yin
- Department of Orthopedics, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 116011, P.R. China
| | - Ming Li
- Department of Orthopedics, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 116011, P.R. China
| | - Bo-Ming Liu
- Department of Orthopedics, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 116011, P.R. China
| | - Shou-Yu Wang
- Department of Orthopedics, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 116011, P.R. China
| | - Wei-Guo Zhang
- Department of Orthopedics, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 116011, P.R. China
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Nacif LS, David AI, Pinheiro RS, Diniz MA, Andraus W, Cruz RJ, D'Albuquerque LAC. An analysis of tacrolimus-related complications in the first 30 days after liver transplantation. Clinics (Sao Paulo) 2014; 69:745-749. [PMID: 25518032 PMCID: PMC4255082 DOI: 10.6061/clinics/2014(11)07] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Revised: 04/14/2014] [Accepted: 08/14/2014] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES Orthotopic liver transplantation has improved survival in patients with end-stage liver disease; however, therapeutic strategies that achieve ideal immunosuppression and avoid early complications are lacking. To correlate the dose and level of Tacrolimus with early complications, e.g., rejection, infection and renal impairment, after liver transplantation. From November 2011 to May 2013, 44 adult liver transplant recipients were studied in this retrospective comparative study. RESULTS The most frequent indication for liver transplantation was hepatitis C cirrhosis (47.7%), with a higher prevalence observed in male patients (68.18%). The ages of the subjects ranged from 19-71 and the median age was 55.5 years. The mean length of the hospital stay was 16.1±9.32 days and the mean Model for End-stage Liver Disease score was 26.18±4.28. There were five cases of acute cellular rejection (11.37%) and 16 cases of infection (36.37%). The blood samples that were collected and analyzed over time showed a significant correlation between the Tacrolimus blood level and the deterioration of glomerular filtration rate and serum creatinine (p<0.05). Patients with infections had a higher serum level of Tacrolimus (p = 0.012). The dose and presence of rejection were significantly different (p = 0.048) and the mean glomerular filtration rate was impaired in patients who underwent rejection compared with patients who did not undergo rejection (p = 0.0084). CONCLUSION Blood Tacrolimus levels greater than 10 ng/ml were correlated with impaired renal function. Doses greater than 0.15 mg/kg/day were associated with the prevention of acute cellular rejection but predisposed patients to infectious disease.
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Affiliation(s)
- Lucas Souto Nacif
- Faculdade de Medicina da Universidade de São Paulo, Department of Gastroenterology, Liver and Gastrointestinal Transplant Division, São Paulo, SP, Brazil
| | - André Ibrahim David
- Faculdade de Medicina da Universidade de São Paulo, Department of Gastroenterology, Liver and Gastrointestinal Transplant Division, São Paulo, SP, Brazil
| | - Rafael Soares Pinheiro
- Faculdade de Medicina da Universidade de São Paulo, Department of Gastroenterology, Liver and Gastrointestinal Transplant Division, São Paulo, SP, Brazil
| | - Marcio Augusto Diniz
- Faculdade de Medicina da Universidade de São Paulo, Department of Gastroenterology, Liver and Gastrointestinal Transplant Division, São Paulo, SP, Brazil
| | - Wellington Andraus
- Faculdade de Medicina da Universidade de São Paulo, Department of Gastroenterology, Liver and Gastrointestinal Transplant Division, São Paulo, SP, Brazil
| | - Ruy Jorge Cruz
- Faculdade de Medicina da Universidade de São Paulo, Department of Gastroenterology, Liver and Gastrointestinal Transplant Division, São Paulo, SP, Brazil
| | - Luiz A Carneiro D'Albuquerque
- Faculdade de Medicina da Universidade de São Paulo, Department of Gastroenterology, Liver and Gastrointestinal Transplant Division, São Paulo, SP, Brazil
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