Tacrolimus conversion in kidney transplant recipients: analysis of 107 patients

Adverse Effects of Tacrolimus and Its Associated Risk Factors in Renal Transplant Recipients

OBJECTIVES

Tacrolimus, an important constituent of the immunosuppressant regimen for renal transplant recipients, can result in posttransplant diabetes mellitus. The adverse effect profile of tacrolimus is yet to be completely understood. The relationship between the blood level of tacrolimus and development of posttransplant diabetes mellitus has not been clearly elucidated in Indian populations. We conducted this study to investigate the frequency of posttransplant diabetes mellitus and other adverse effects of tacrolimus, to enumerate the risk factors associated with posttransplant diabetes mellitus development, and to correlate the blood levels of tacrolimus with its occurrence.

MATERIALS AND METHODS

This prospective observational study included 77 renal transplant patients receiving tacrolimus. The blood sugar levels (fasting and postprandial) were monitored, and patients were asked regularly about the adverse effects of tacrolimus experienced by them for 6 months posttransplant. Trough levels of tacrolimus in blood were correlated with occurrence of posttransplant diabetes mellitus.

RESULTS

Posttransplant diabetes mellitus developed in 62.3% (48/77) of renal transplant recipients on a tacrolimus-based regimen. Other adverse effects observed included tremors, diarrhea, alopecia, cyto- megalovirus infection, headache, biopsy-proven calci- neurin inhibitor nephrotoxicity, peripheral neuropathy, and BK virus infection. Higher tacrolimus trough level at month 1 posttransplant was significantly associated with the development of posttransplant diabetes mellitus (adjusted odds ratio = 1.379; 95% CI, 1.02-1.86). The best cutoff of tacrolimus trough level at month 1 posttransplant to reduce the risk of posttransplant diabetes mellitus was 8.1 ng/mL. There was a 5 times increased risk of developing posttransplant diabetes mellitus when tacrolimus trough level at month 1 posttransplant was >8.1 ng/mL (adjusted odds ratio = 5.4; 95% CI, 1.4-19.9).

CONCLUSIONS

Posttransplant diabetes mellitus is a common adverse effect of tacrolimus among renal transplant recipients. A trough level >8.1 ng/mL at month 1 posttransplant was an important predictor for posttransplant diabetes mellitus.

A Prediction Model for Tacrolimus Daily Dose in Kidney Transplant Recipients With Machine Learning and Deep Learning Techniques

Tacrolimus is a major immunosuppressor against post-transplant rejection in kidney transplant recipients. However, the narrow therapeutic index of tacrolimus and considerable variability among individuals are challenges for therapeutic outcomes. The aim of this study was to compare different machine learning and deep learning algorithms and establish individualized dose prediction models by using the best performing algorithm. Therefore, among the 10 commonly used algorithms we compared, the TabNet algorithm outperformed other algorithms with the highest R² (0.824), the lowest prediction error [mean absolute error (MAE) 0.468, mean square error (MSE) 0.558, and root mean square error (RMSE) 0.745], and good performance of overestimated (5.29%) or underestimated dose percentage (8.52%). In the final prediction model, the last tacrolimus daily dose, the last tacrolimus therapeutic drug monitoring value, time after transplantation, hematocrit, serum creatinine, aspartate aminotransferase, weight, CYP3A5, body mass index, and uric acid were the most influential variables on tacrolimus daily dose. Our study provides a reference for the application of deep learning technique in tacrolimus dose estimation, and the TabNet model with desirable predictive performance is expected to be expanded and applied in future clinical practice.

Efficacy and safety of long-course tacrolimus treatment for idiopathic membranous nephropathy

The aim of the present study was to observe the efficacy and safety of long-course treatment with tacrolimus combined with low-dose corticosteroids for idiopathic membranous nephropathy (IMN). A total of 76 patients with IMN diagnosed by renal biopsy between March 2012 and January 2016 form The First People's Hospital of Changzhou (Changzhou, China) were selected and randomly divided into a short-course group and a long-course group (each, n=38). Patients in the short-course group were treated with hormone combined with tacrolimus for 12 months, whereas those in the long-course group received the same treatment for 24 months. The efficacy, safety and recurrence of the two groups of patients were observed, and serum ALB, urine protein, Scr and blood glucose were assessed once a month for 24 months by measuring blood biochemistry. A total of 11 patients exhibited adverse effects, 6 of whom were serious and as such were excluded from the study. In the short-course group, 8 of 35 patients demonstrated complete remission (CR), 17 patients exhibited partial remission (PR) and the remaining 10 patients had no remission (NR); however the disease recurred in 8 patients following treatment. In the long-course group, 16 of 35 patients exhibited CR, 14 patients demonstrated PR and the remaining 5 patients had NR. Furthermore, the disease recurred in 4 patients following treatment. Significant differences were observed in urine protein and serum ALB at 18 and 24 months following treatment between the two groups while Scr and blood glucose had no significant differences at any time point. It was concluded that long-course tacrolimus combined with low-dose hormone effectively treats idiopathic membranous nephropathy and that therapy demonstrated a relatively high remission rate, and the recurrence rate of the disease is low.

Human facial allotransplantation: a 2-year follow-up study

BACKGROUND

Progress in composite tissue allotransplantation could provide a new treatment for patients with severe facial disfigurements. We did a partial facial allotransplantation in 2006, and report here the 2 year follow-up of the patient.

METHODS

The recipient, a 30-year-old man from China, had his face severely injured by a bear in October, 2004. Allograft composite tissue transplantation was done in April, 2006, after careful systemic preparation. The surgery included anastomosis of the right mandibular artery and anterior facial vein, whole repair of total nose, upper lip, parotid gland, front wall of the maxillary sinus, part of the infraorbital wall, and zygomatic bone. Facial nerve anastomosis was done during the surgery. Quadruple immunomodulatory therapy was used, containing tacrolimus, mycophenolate mofetil, corticosteroids, and humanised IL-2 receptor monoclonal antibody. Follow-up included T lymphocyte subgroups in peripheral blood, pathological and immunohistochemical examinations, functional progress, and psychological support.

FINDINGS

Composite tissue flap survived well. There were three acute rejection episodes at 3, 5, and 17 months after transplantation, but these were controlled by adjustment of the tacrolimus dose or the application of methylprednisolone pulse therapy. Hepatic and renal functions were normal, and there was no infection. The patient developed hyperglycaemia on day 3 after transplantation, which was controlled by medication.

INTERPRETATION

Facial transplantation could be successful in the short term, but the procedure was not without complications. However, promising results could mean that this procedure might be an option for long-term restoration of severe facial disfigurement.

Predictors of renal function improvement following tacrolimus conversion in cyclosporine-treated kidney transplant recipients

The objective of this study was to evaluate the relationship between variability of cyclosporine (CsA) absorption and tacrolimus (TAC) conversion seeking factors that predict improvement in allograft function after TAC conversion. We performed a retrospective study of 44 adult kidney transplant recipients undergoing conversion from CsA to TAC-based immunosuppression. Before TAC conversion, patients had complete, consecutive, 6 monthly C2 levels and a follow-up duration beyond 6 months after TAC conversion. The patients were divided into 2 groups: one (n=23) with low variability of CsA absorption and one (n=21) with high variability of CsA absorption. At TAC conversion, the estimated glomerular filtration rate (eGFR) was similar in both patient groups. Six months after TAC conversion, eGFR improved in both groups. Stepwise regression analysis revealed the DeltaSCr6 (change in serum creatinine level at 6 months) to be independently associated with the preconversion serum creatinine (SCr; P<.0001) and the percent coefficient of variation (%CV) of SCr (P=.0034). DeltaSCr6 was inversely associated with posttransplantation years (P=.0033), and 6-month TAC blood levels (P=.0053). The DeltaSCr6 was not associated with variability of oral CsA absorption. The cutoff value of baseline SCr at TAC conversion differentiated an increase in or reduction of SCr to be about 1.0 mg/dL. Our study of CsA-treated kidney transplant recipients who underwent TAC conversion showed that a preconversion SCr>1.0 mg/dL, a high variability of SCr, and early TAC conversion predicted greater short-term benefit on graft function.

Role of donor age and acute rejection episodes on long-term graft survival in cadaveric kidney transplantations

Cadaveric donors can provide an effective solution to the problem of organ shortage, and many factors that may affect the functioning and survival of cadaveric kidneys have been studied. We aimed to clarify the impact of donor age and acute rejection episodes on long-term graft and patient survival in patients receiving cadaveric renal transplants. We retrospectively evaluated the long-term outcomes of 207 patients who had received cadaveric renal transplants between 1985 and 2004. Mean recipient age, HLA mismatch, mean donor age, delayed graft function (DGF), mean cold ischemia time, acute rejection episodes in the first 6 months after transplantation, and 1-, 3-, and 5-year graft survivals were evaluated. Two study groups were created according to donor age: group 1 (n = 126) was composed of patients receiving kidneys from donors younger than 50 years, and group 2 (n = 81) was composed of patients receiving kidneys from donors 50 years of age or older. Mean recipient age, HLA mismatch, and mean cold ischemia time between groups were not different. The DGF rate in group 1 was 40% (n = 50) and in group 2 was 46% (n = 37) (P > .05). The 1-, 3-, and 5-year survival rates of patients without acute rejection within the first 6 months after transplantation in group 1 (58/126; 46%) versus those in group 2 (46/81; 57%) were 95% versus 90%, 65% versus 60%, and 40% versus 35%, respectively (P > .05). The 1-, 3-, and 5-year graft survival rates of patients with acute rejection within the first 6 months in group 1 (n = 68) versus those in group 2 (n = 35) were 93% versus 89%, 71% versus 55%, and 44% versus 28%, respectively (P = .005). There was no significant difference in 1-, 3-, and 5-year survival rates between patients with DGF in both groups. Acute rejection episodes within the first 6 months after cadaveric transplantation, especially in patients receiving kidneys from donors older than 50 years, were shown to affect 5-year survival of the kidney graft. However, cadaver age alone had no negative effect on 5-year graft survival rates. Cadaveric donors older than 50 years may be a solution to the organ shortage in the treatment of end-stage renal disease.

The effect of graft nephrectomy on long-term graft function and survival in kidney retransplantation

We retrospectively evaluated the long-term results of 53 (3.5%) recipients who received second allograft among 1486 kidney transplants between November 3, 1975 and June 30, 2004. Two study groups were patients in Group 1 (n = 21) who underwent allograft nephrectomy and those in Group 2 (n = 32) who did not. We assessed demographic features, rejection rates throughout the follow-up period, and serum creatinine levels at 12 months as well as graft and patient survival rates, postoperative complications, time interval between transplantations, and HLA matches. Forty-three patients who underwent retransplantation received kidneys from living-related donors and the remaining 10 from cadaveric donors. Mean serum creatinine levels of Group 1 versus Group 2 were 1.8 mg/dL (range, 0.8 to 6.6 mg/dL) versus 2.1 +/- 1.1 mg/dL (range, 1.1 to 7.1 mg/dL). HLA-AB and HLA-DR mismatches were 1.9 +/- 1.1 versus 1 +/- 0.6, respectively (P = .01). Acute rejection rates were not significantly different between Groups 1 (9/21, 43%) and 2 (12/32, 38%) (P < .05). The average intervals between the first and the second transplantations were 62 +/- 26 months in Group 1 (P = .02) and 32 +/- 11 months in Group 2. One-, 3-, and 5-year graft survival rates in Group 1 versus Group 2 were 83% versus 89% (P > .05); 64% versus 79% (P > .05), and 45% versus 68% (P = .04), respectively. In conclusion, we did not observe any advantage of graft nephrectomy before retransplantation. The length of the interval between the first and the second transplantations may have a negative correlation with second graft survival.

Deep dermatophytosis caused by Trichophyton rubrum with concomitant disseminated nocardiosis in a renal transplant recipient

Deep dermatophytosis and nocardiosis are uncommon infections. This article describes a patient who was immunosuppressed with deep dermatophytosis caused by Trichophyton rubrum and concurrent disseminated nocardiosis. The infections occurred 16 years after the patient underwent renal transplantation, and may have been related to tacrolimus therapy.