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Feist AA, Mariski M, Awdishu L, Bremer M, Yung G, Jung C, Golts E, Afshar K. Sirolimus Long-Term Tolerability and Impact on Kidney Function in Lung Transplantation: A Single-Center Experience. Transplant Proc 2023; 55:2470-2477. [PMID: 37891020 DOI: 10.1016/j.transproceed.2023.09.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 09/22/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND After lung transplant, 2 common complications are calcineurin inhibitor (CNI) induced nephrotoxicity and bronchiolitis obliterans syndrome. The objective of this study was to investigate the long-term effects of sirolimus conversion after lung transplantation. METHODS This was a retrospective cohort study of patients who had undergone lung transplantation at a single center from June 2003 to December 2016. We compared patients converted to a sirolimus-based regimen to those maintained on our standard tacrolimus-based regimen. Kidney function, pulmonary function, and immunosuppression concentrations were compared between the groups. Additionally, indications, toxicity monitoring parameters, and discontinuation rates for sirolimus were collected. RESULTS During the study period, 176 of the 205 patients who underwent lung transplants were converted to a sirolimus-containing regimen (86%). The most common reason for sirolimus initiation was impairment of kidney function or CNI-associated neurotoxicity. Sirolimus was initiated at a median of 150 days post-transplantation and continued for a medium time of 5.02 (2.27-7.85) years. Of those patients converted to sirolimus, 39 (22%) had sirolimus subsequently discontinued secondary to an adverse event. No difference in pulmonary function was found between the groups at 1- and 3-years post-transplantation. In the sirolimus group, the median estimated glomerular filtration rate improved by 8.6 mL/min/1.73 m2 at 3 months post-conversion (P < .001), which was maintained at both 1 and 3 years (P = .014 and .025, respectively). CONCLUSION Sirolimus is a viable immunosuppressant option after lung transplant, which successfully allows for the reduction or withdrawal of the CNI, resulting in sustained improvement in kidney function.
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Affiliation(s)
- Ashley A Feist
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, UC San Diego, La Jolla, California.
| | - Mark Mariski
- Department of Pharmacy, UC San Diego Health, La Jolla, California
| | - Linda Awdishu
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, UC San Diego, La Jolla, California
| | - Michelle Bremer
- Department of Transplantation, UC San Diego Health, La Jolla, California
| | - Gordon Yung
- Division of Pulmonary, Critical Care, Sleep Medicine and Physiology, School of Medicine, UC San Diego, La Jolla, California
| | - Chris Jung
- Department of Transplantation, UC San Diego Health, La Jolla, California
| | - Eugene Golts
- Department of Cardiothoracic Surgery, School of Medicine, UC San Diego, La Jolla, California
| | - Kamyar Afshar
- Division of Pulmonary, Critical Care, Sleep Medicine and Physiology, School of Medicine, UC San Diego, La Jolla, California
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2
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Bos S, Pradère P, Beeckmans H, Zajacova A, Vanaudenaerde BM, Fisher AJ, Vos R. Lymphocyte Depleting and Modulating Therapies for Chronic Lung Allograft Dysfunction. Pharmacol Rev 2023; 75:1200-1217. [PMID: 37295951 PMCID: PMC10595020 DOI: 10.1124/pharmrev.123.000834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 04/27/2023] [Accepted: 06/05/2023] [Indexed: 06/12/2023] Open
Abstract
Chronic lung rejection, also called chronic lung allograft dysfunction (CLAD), remains the major hurdle limiting long-term survival after lung transplantation, and limited therapeutic options are available to slow the progressive decline in lung function. Most interventions are only temporarily effective in stabilizing the loss of or modestly improving lung function, with disease progression resuming over time in the majority of patients. Therefore, identification of effective treatments that prevent the onset or halt progression of CLAD is urgently needed. As a key effector cell in its pathophysiology, lymphocytes have been considered a therapeutic target in CLAD. The aim of this review is to evaluate the use and efficacy of lymphocyte depleting and immunomodulating therapies in progressive CLAD beyond usual maintenance immunosuppressive strategies. Modalities used include anti-thymocyte globulin, alemtuzumab, methotrexate, cyclophosphamide, total lymphoid irradiation, and extracorporeal photopheresis, and to explore possible future strategies. When considering both efficacy and risk of side effects, extracorporeal photopheresis, anti-thymocyte globulin and total lymphoid irradiation appear to offer the best treatment options currently available for progressive CLAD patients. SIGNIFICANCE STATEMENT: Effective treatments to prevent the onset and progression of chronic lung rejection after lung transplantation are still a major shortcoming. Based on existing data to date, considering both efficacy and risk of side effects, extracorporeal photopheresis, anti-thymocyte globulin, and total lymphoid irradiation are currently the most viable second-line treatment options. However, it is important to note that interpretation of most results is hampered by the lack of randomized controlled trials.
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Affiliation(s)
- Saskia Bos
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, United Kingdom (S.B., P.P., A.J.F.); Institute of Transplantation, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, United Kingdom (S.B., A.J.F.); Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph and Paris Saclay University, Department of Respiratory Diseases, Paris, France (P.P.); Department of CHROMETA, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium (H.B., B.M.V., R.V.); Prague Lung Transplant Program, University Hospital Motol, Department of Pneumology, Prague, Czech Republic (A.Z.); and University Hospitals Leuven, Department of Respiratory Diseases, Leuven, Belgium (R.V.)
| | - Pauline Pradère
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, United Kingdom (S.B., P.P., A.J.F.); Institute of Transplantation, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, United Kingdom (S.B., A.J.F.); Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph and Paris Saclay University, Department of Respiratory Diseases, Paris, France (P.P.); Department of CHROMETA, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium (H.B., B.M.V., R.V.); Prague Lung Transplant Program, University Hospital Motol, Department of Pneumology, Prague, Czech Republic (A.Z.); and University Hospitals Leuven, Department of Respiratory Diseases, Leuven, Belgium (R.V.)
| | - Hanne Beeckmans
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, United Kingdom (S.B., P.P., A.J.F.); Institute of Transplantation, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, United Kingdom (S.B., A.J.F.); Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph and Paris Saclay University, Department of Respiratory Diseases, Paris, France (P.P.); Department of CHROMETA, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium (H.B., B.M.V., R.V.); Prague Lung Transplant Program, University Hospital Motol, Department of Pneumology, Prague, Czech Republic (A.Z.); and University Hospitals Leuven, Department of Respiratory Diseases, Leuven, Belgium (R.V.)
| | - Andrea Zajacova
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, United Kingdom (S.B., P.P., A.J.F.); Institute of Transplantation, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, United Kingdom (S.B., A.J.F.); Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph and Paris Saclay University, Department of Respiratory Diseases, Paris, France (P.P.); Department of CHROMETA, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium (H.B., B.M.V., R.V.); Prague Lung Transplant Program, University Hospital Motol, Department of Pneumology, Prague, Czech Republic (A.Z.); and University Hospitals Leuven, Department of Respiratory Diseases, Leuven, Belgium (R.V.)
| | - Bart M Vanaudenaerde
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, United Kingdom (S.B., P.P., A.J.F.); Institute of Transplantation, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, United Kingdom (S.B., A.J.F.); Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph and Paris Saclay University, Department of Respiratory Diseases, Paris, France (P.P.); Department of CHROMETA, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium (H.B., B.M.V., R.V.); Prague Lung Transplant Program, University Hospital Motol, Department of Pneumology, Prague, Czech Republic (A.Z.); and University Hospitals Leuven, Department of Respiratory Diseases, Leuven, Belgium (R.V.)
| | - Andrew J Fisher
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, United Kingdom (S.B., P.P., A.J.F.); Institute of Transplantation, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, United Kingdom (S.B., A.J.F.); Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph and Paris Saclay University, Department of Respiratory Diseases, Paris, France (P.P.); Department of CHROMETA, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium (H.B., B.M.V., R.V.); Prague Lung Transplant Program, University Hospital Motol, Department of Pneumology, Prague, Czech Republic (A.Z.); and University Hospitals Leuven, Department of Respiratory Diseases, Leuven, Belgium (R.V.)
| | - Robin Vos
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, United Kingdom (S.B., P.P., A.J.F.); Institute of Transplantation, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, United Kingdom (S.B., A.J.F.); Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph and Paris Saclay University, Department of Respiratory Diseases, Paris, France (P.P.); Department of CHROMETA, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium (H.B., B.M.V., R.V.); Prague Lung Transplant Program, University Hospital Motol, Department of Pneumology, Prague, Czech Republic (A.Z.); and University Hospitals Leuven, Department of Respiratory Diseases, Leuven, Belgium (R.V.)
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3
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de Souza AR, Dos Santos TAGM, Von Jakitsch CB, de Sant'Anna ALGG, de Claudio JCM, Branco JNR, Giovanazzi RSD, Junior NAH, Pimentel WDS, da Costa SACM, Girones P, Machado RC. Mammalian Target of Rapamycin Inhibitors Vs Calcineurin Inhibitors in Chronic Graft Rejection After Lung Transplantation: A Systematic Review and Meta-Analysis. Transplant Proc 2021; 53:3056-3064. [PMID: 34785027 DOI: 10.1016/j.transproceed.2021.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 08/24/2021] [Accepted: 09/22/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND The number of lung transplantations has been rising constantly. However, use of this therapeutic resource is limited by several issues that are difficult to resolve, such as chronic graft rejection and complications secondary to immunosuppression. METHODS This systematic review compared mammalian target of rapamycin (mTOR) inhibitor immunosuppression associated with low-dose calcineurin inhibitors with isolated calcineurin inhibitor immunosuppression on the new-onset chronic rejection development and mortality 12 months after lung transplantation. Three controlled randomized clinical trials (SHITRIT, NOCTET, and 4EVERLUNG) were selected from electronic databases. RESULTS Meta-analysis of the data at 12 months postintervention showed that only 4EVERLUNG assessed chronic graft rejection, with a higher incidence in the control group; however, the difference was not statistically significant (P = .197). Significant data were related to an increase in the number of adverse events (P = .0064) and improved renal function (P < .0001) in the mTOR inhibitor-based scheme. The other outcomes indicated a trend toward greater risk of death and acute graft rejection with the use of mTORs. CONCLUSIONS The researchers suggest considering the use of mTOR inhibitors, whose greatest benefit is felt by patients with renal dysfunction, in association with the use of calcineurin inhibitors, because of the imminent risk of death among patients with renal failure.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Puri Girones
- Hospital Universitari i Politècnic La Fe, Valencia, Spain
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4
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Amubieya O, Ramsey A, DerHovanessian A, Fishbein GA, Lynch JP, Belperio JA, Weigt SS. Chronic Lung Allograft Dysfunction: Evolving Concepts and Therapies. Semin Respir Crit Care Med 2021; 42:392-410. [PMID: 34030202 DOI: 10.1055/s-0041-1729175] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The primary factor that limits long-term survival after lung transplantation is chronic lung allograft dysfunction (CLAD). CLAD also impairs quality of life and increases the costs of medical care. Our understanding of CLAD continues to evolve. Consensus definitions of CLAD and the major CLAD phenotypes were recently updated and clarified, but it remains to be seen whether the current definitions will lead to advances in management or impact care. Understanding the potential differences in pathogenesis for each CLAD phenotype may lead to novel therapeutic strategies, including precision medicine. Recognition of CLAD risk factors may lead to earlier interventions to mitigate risk, or to avoid risk factors all together, to prevent the development of CLAD. Unfortunately, currently available therapies for CLAD are usually not effective. However, novel therapeutics aimed at both prevention and treatment are currently under investigation. We provide an overview of the updates to CLAD-related terminology, clinical phenotypes and their diagnosis, natural history, pathogenesis, and potential strategies to treat and prevent CLAD.
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Affiliation(s)
- Olawale Amubieya
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Allison Ramsey
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Ariss DerHovanessian
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Gregory A Fishbein
- Department of Pathology, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Joseph P Lynch
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - John A Belperio
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - S Samuel Weigt
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
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5
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Abstract
Lung transplantation is a viable option for those with end-stage lung disease which is evidenced by the continued increase in the number of lung transplantations worldwide. However, patients and clinicians are constantly faced with acute and chronic rejection, infectious complications, drug toxicities, and malignancies throughout the lifetime of the lung transplant recipient. Conventional maintenance immunosuppression therapy consisting of a calcineurin inhibitor (CNI), anti-metabolite, and corticosteroids have become the standard regimen but newer agents and modalities continue to be developed. Here we will review induction agents, maintenance immunosuppressives, adjunctive therapies and other strategies to improve long-term outcomes.
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Affiliation(s)
- Paul A Chung
- Division of Pulmonary and Critical Care, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA
| | - Daniel F Dilling
- Division of Pulmonary and Critical Care, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA
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6
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Sirolimus and mTOR Inhibitors: A Review of Side Effects and Specific Management in Solid Organ Transplantation. Drug Saf 2020; 42:813-825. [PMID: 30868436 DOI: 10.1007/s40264-019-00810-9] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Inhibitors of mechanistic target of rapamycin (mTOR inhibitors) are used as antiproliferative immunosuppressive drugs and have many clinical applications in various drug combinations. Experience in transplantation studies has been gained regarding the side effect profile of these drugs and the potential benefits and limitations compared with other immunosuppressive agents. This article reviews the adverse effects of mTOR inhibitors in solid organ transplantation, with special attention given to mechanisms hypothesized to cause adverse events and their management strategies.
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7
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Chen A, Chen L, Al-Qaisi A, Romond E, Awasthi M, Kadamyan-Melkumyan V, Massarweh S. Everolimus-Induced Hematologic Changes in Patients With Metastatic Breast Cancer. Clin Breast Cancer 2015; 15:48-53. [DOI: 10.1016/j.clbc.2014.07.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 07/09/2014] [Indexed: 10/24/2022]
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8
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Meyer KC, Raghu G, Verleden GM, Corris PA, Aurora P, Wilson KC, Brozek J, Glanville AR. An international ISHLT/ATS/ERS clinical practice guideline: diagnosis and management of bronchiolitis obliterans syndrome. Eur Respir J 2014; 44:1479-503. [PMID: 25359357 DOI: 10.1183/09031936.00107514] [Citation(s) in RCA: 380] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Bronchiolitis obliterans syndrome (BOS) is a major complication of lung transplantation that is associated with poor survival. The International Society for Heart and Lung Transplantation, American Thoracic Society, and European Respiratory Society convened a committee of international experts to describe and/or provide recommendations for 1) the definition of BOS, 2) the risk factors for developing BOS, 3) the diagnosis of BOS, and 4) the management and prevention of BOS. A pragmatic evidence synthesis was performed to identify all unique citations related to BOS published from 1980 through to March, 2013. The expert committee discussed the available research evidence upon which the updated definition of BOS, identified risk factors and recommendations are based. The committee followed the GRADE (Grading of Recommendation, Assessment, Development and Evaluation) approach to develop specific clinical recommendations. The term BOS should be used to describe a delayed allograft dysfunction with persistent decline in forced expiratory volume in 1 s that is not caused by other known and potentially reversible causes of post-transplant loss of lung function. The committee formulated specific recommendations about the use of systemic corticosteroids, cyclosporine, tacrolimus, azithromycin and about re-transplantation in patients with suspected and confirmed BOS. The diagnosis of BOS requires the careful exclusion of other post-transplant complications that can cause delayed lung allograft dysfunction, and several risk factors have been identified that have a significant association with the onset of BOS. Currently available therapies have not been proven to result in significant benefit in the prevention or treatment of BOS. Adequately designed and executed randomised controlled trials that properly measure and report all patient-important outcomes are needed to identify optimal therapies for established BOS and effective strategies for its prevention.
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Affiliation(s)
- Keith C Meyer
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Ganesh Raghu
- School of Medicine, University of Washington, Seattle, WA, USA
| | | | | | - Paul Aurora
- Great Ormond Street Hospital for Children, London, UK
| | | | - Jan Brozek
- McMaster University, Hamilton, ON, Canada
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9
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Scheffert JL, Raza K. Immunosuppression in lung transplantation. J Thorac Dis 2014; 6:1039-53. [PMID: 25132971 DOI: 10.3978/j.issn.2072-1439.2014.04.23] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Accepted: 04/16/2014] [Indexed: 01/10/2023]
Abstract
Lung transplantation can be a life-saving procedure for those with end-stage lung diseases. Unfortunately, long term graft and patient survival are limited by both acute and chronic allograft rejection, with a median survival of just over 6 years. Immunosuppressive regimens are employed to reduce the rate of rejection, and while protocols vary from center to center, conventional maintenance therapy consists of triple drug therapy with a calcineurin inhibitor (cyclosporine or tacrolimus), antiproliferative agents [azathioprine (AZA), mycophenolate, sirolimus (srl), everolimus (evl)], and corticosteroids (CS). Roughly 50% of lung transplant centers also utilize induction therapy, with polyclonal antibody preparations [equine or rabbit anti-thymocyte globulin (ATG)], interleukin 2 receptor antagonists (IL2RAs) (daclizumab or basiliximab), or alemtuzumab. This review summarizes these agents and the data surrounding their use in lung transplantation, as well as additional common and novel therapies in lung transplantation. Despite the progression of the management of lung transplant recipients, they continue to be at high risk of treatment-related complications, and poor graft and patient survival. Randomized clinical trials are needed to allow for the development of better agents, regimens and techniques to address above mentioned issues and reduce morbidity and mortality among lung transplant recipients.
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Affiliation(s)
- Jenna L Scheffert
- 1 NewYork-Presbyterian Hospital/Columbia University Medical Center, Department of Pharmacy, USA ; 2 Lung Transplant Program, Department of Pulmonary, Allergy and Critical Care Medicine, Columbia University Medical Center, USA
| | - Kashif Raza
- 1 NewYork-Presbyterian Hospital/Columbia University Medical Center, Department of Pharmacy, USA ; 2 Lung Transplant Program, Department of Pulmonary, Allergy and Critical Care Medicine, Columbia University Medical Center, USA
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10
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Effects of prophylactic use of sirolimus on bronchiolitis obliterans syndrome development in lung transplant recipients. Ann Thorac Surg 2013; 97:268-74. [PMID: 24119986 DOI: 10.1016/j.athoracsur.2013.07.072] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Revised: 07/16/2013] [Accepted: 07/22/2013] [Indexed: 11/22/2022]
Abstract
BACKGROUND Sirolimus (SIR) has been shown to stabilize the lung function in lung transplant recipients with bronchiolitis obliterans syndrome (BOS). However, there is no long-term data on the prophylactic use of SIR in lung transplant recipients. This retrospective study examines the effects of SIR in the prevention of BOS. METHODS From 1999 to 2009, 24 lung transplant recipients whose maintenance immunosuppression regimen consisted of tacrolimus (Tac), mycophenolate mofetil (MMF) or azathioprine (AZA), and prednisone (Pred), were switched to Tac, SIR, and Pred at 1 year after transplantation. From these 24 patients, 5 developed side effects that necessitated the cessation of SIR within 1 year, while 19 patients tolerated long-term use of SIR. The clinical outcomes of these 19 patients (SIR group) were compared with 22 lung transplant recipients whose immunosuppression regimen consisted of Tac, MMF or AZA, and Pred from the time of transplant (MMF group). Survival rates and freedom from BOS were calculated by the Kaplan-Meier method. RESULTS The SIR group had a lower incidence of BOS and viral infection (p = 0.05), and higher survival rates (p = 0.004). The SIR group had lower levels of Tac and received less Pred. The incidences of acute rejection, carcinoma, hypertension, and diabetes were similar between both groups. CONCLUSIONS Results from this study suggest that conversion to SIR 1 year after lung transplantation improves survival and decreases the development of BOS. Randomized studies with higher number of patients are needed to determine the prophylactic efficacy of sirolimus in preventing the development of BOS.
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11
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Borthwick LA, Corris PA, Mahida R, Walker A, Gardner A, Suwara M, Johnson GE, Moisey EJ, Brodlie M, Ward C, Perry JD, De Soyza A, Mann DA, Fisher AJ. TNFα from classically activated macrophages accentuates epithelial to mesenchymal transition in obliterative bronchiolitis. Am J Transplant 2013; 13:621-33. [PMID: 23331923 DOI: 10.1111/ajt.12065] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Revised: 10/04/2012] [Accepted: 10/08/2012] [Indexed: 01/25/2023]
Abstract
Bronchiolitis obliterans syndrome is characterized by fibrotic obliteration of small airways which severely impairs graft function and survival after lung transplantation. Bronchial epithelial cells from the transplanted lung can undergo epithelial to mesenchymal transition and this can be accentuated by activated macrophages. Macrophages demonstrate significant plasticity and change phenotype in response to their microenvironment. In this study we aimed to identify secretory products from macrophages that might be therapeutic targets for limiting the inflammatory accentuation of epithelial to mesenchymal transition in bronchiolitis obliterans syndrome. TNFα, IL-1β and IL-8 are elevated in bronchoalveolar lavage from lung transplant patients prior to diagnosis of bronchiolitis obliterans syndrome. Classically activated macrophages secrete more TNFα and IL-1β than alternatively activated macrophages and dramatically accentuate TGF-β1-driven epithelial to mesenchymal transition in bronchial epithelial cells isolated from lung transplant patients. Blocking TNFα, but not IL-1β, inhibits the accentuation of epithelial to mesenchymal transition. In a pilot unblinded therapeutic intervention in five patients with progressive bronchiolitis obliterans syndrome, anti-TNFα treatment improved forced expiratory volume in 1 second and 6-min walk distances in four patients. Our data identify TNFα as a potential new therapeutic target in bronchiolitis obliterans syndrome deserving of a randomized placebo controlled clinical trial.
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Affiliation(s)
- L A Borthwick
- Tissue Fibrosis and Repair Group, Institute of Cellular Medicine, Newcastle University, UK
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12
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de Pablo A, Santos F, Solé A, Borro JM, Cifrian JM, Laporta R, Monforte V, Román A, de la Torre M, Ussetti P, Zurbano F. Recommendations on the use of everolimus in lung transplantation. Transplant Rev (Orlando) 2012; 27:9-16. [PMID: 23276646 DOI: 10.1016/j.trre.2012.11.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Accepted: 11/09/2012] [Indexed: 01/05/2023]
Abstract
The antiproliferative effect of everolimus provides a therapeutic option in the immunosuppression therapy of lung transplantation, by reducing both the risk of acute rejection and the process of progressive fibrosis that determines chronic graft rejection. However, few data on the use of everolimus in lung transplantation have been published to date, and the specific indications of the drug, along with the most adequate time for its introduction or dosing, have not been defined yet. The aim of this article is to propose recommendations for the use of everolimus in lung transplant recipients, including indications, dosing schedules and the use of concomitant immunosuppression. This consensus document has been developed by experts of all the Spanish lung transplant groups from the review of the existing literature and the clinical experience.
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Affiliation(s)
- A de Pablo
- University Hospital, Doce de Octubre, Madrid, Spain.
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13
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Sofroniadou S, Goldsmith D. Mammalian target of rapamycin (mTOR) inhibitors: potential uses and a review of haematological adverse effects. Drug Saf 2011; 34:97-115. [PMID: 21247219 DOI: 10.2165/11585040-000000000-00000] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Mammalian target of rapamycin (mTOR) inhibitors (mTORis) constitute a relatively new category of immunosuppressive and antineoplastic drugs. These share a unique mechanism of action that is focused on the inhibition of the mTOR. Their clinical applications have recently expanded significantly to cover a wide spectrum of immune and non-immune-mediated disorders, including, apart from solid organ transplantation, various solid organ and haematological malignancies, rheumatological and auto-immune diseases such as rheumatoid arthritis, systemic lupus erythematosus, fibrotic conditions, e.g. pulmonary and hepatic fibrosis, and even metabolic problems such as diabetes mellitus and obesity. The most challenging and frequent adverse effects of the mTORis are the haematological ones, especially anaemia, leukopenia and thrombocytopenia. A unique characteristic of mTORi-induced anaemia is concurrent marked microcytosis. Recently, mechanisms have been proposed to explain the microcytic appearance of this anaemia; these include globin production defect, erythropoietin resistance, chronic inflammation, dysregulation of cellular iron metabolism and hepcidin-mediated iron homeostasis interference. As the differential diagnosis of microcytic anaemia includes pure iron deficiency, functional iron deficiency and haemoglobinopathies, characterization of the anaemia requires significant investigation, time and costs. Therefore, understanding of the likely interaction between mTORis and patients is valuable in clinical practice. Moreover, this could expand the drugs' therapeutic applications to other disorders, and suggest novel targets for further research.
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Affiliation(s)
- Sofia Sofroniadou
- Department of Renal Medicine and Transplantation, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre (AHSC), London, UK
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14
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Sofroniadou S, Goldsmith D. Mammalian target of rapamycin (mTOR) inhibitors: potential uses and a review of haematological adverse effects. Drug Saf 2011. [PMID: 21247219 DOI: 10.2165/11585040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Mammalian target of rapamycin (mTOR) inhibitors (mTORis) constitute a relatively new category of immunosuppressive and antineoplastic drugs. These share a unique mechanism of action that is focused on the inhibition of the mTOR. Their clinical applications have recently expanded significantly to cover a wide spectrum of immune and non-immune-mediated disorders, including, apart from solid organ transplantation, various solid organ and haematological malignancies, rheumatological and auto-immune diseases such as rheumatoid arthritis, systemic lupus erythematosus, fibrotic conditions, e.g. pulmonary and hepatic fibrosis, and even metabolic problems such as diabetes mellitus and obesity. The most challenging and frequent adverse effects of the mTORis are the haematological ones, especially anaemia, leukopenia and thrombocytopenia. A unique characteristic of mTORi-induced anaemia is concurrent marked microcytosis. Recently, mechanisms have been proposed to explain the microcytic appearance of this anaemia; these include globin production defect, erythropoietin resistance, chronic inflammation, dysregulation of cellular iron metabolism and hepcidin-mediated iron homeostasis interference. As the differential diagnosis of microcytic anaemia includes pure iron deficiency, functional iron deficiency and haemoglobinopathies, characterization of the anaemia requires significant investigation, time and costs. Therefore, understanding of the likely interaction between mTORis and patients is valuable in clinical practice. Moreover, this could expand the drugs' therapeutic applications to other disorders, and suggest novel targets for further research.
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Affiliation(s)
- Sofia Sofroniadou
- Department of Renal Medicine and Transplantation, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners Academic Health Science Centre (AHSC), London, UK
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Bhorade S, Ahya VN, Baz MA, Valentine VG, Arcasoy SM, Love RB, Seethamraju H, Alex CG, Bag R, DeOliveira NC, Husain A, Vigneswaran WT, Charbeneau J, Krishnan JA, Durazo-Arvizu R, Norwick L, Garrity E. Comparison of Sirolimus with Azathioprine in a Tacrolimus-based Immunosuppressive Regimen in Lung Transplantation. Am J Respir Crit Care Med 2011; 183:379-87. [DOI: 10.1164/rccm.201005-0775oc] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
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Sofroniadou S, Kassimatis T, Goldsmith D. Anaemia, microcytosis and sirolimus--is iron the missing link? Nephrol Dial Transplant 2010; 25:1667-1675. [DOI: 10.1093/ndt/gfp674] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Abstract
With the increase in the number of lung transplants, it is expected that there will be a corresponding increase in the number of lung cancers reported in these patients. Longevity of the transplant recipients, lung transplantation for chronic obstructive pulmonary disease and idiopathic pulmonary fibrosis, a history of smoking, and the increasing age of the lung donors make lung cancer more likely. Nodules and masses seen in chest imaging in lung transplant patients call for work up until a final diagnosis is achieved because there is a high likelihood of a serious infection or malignancy. The presence of a native lung is a major risk factor for lung cancer occurring in the transplant setting. Lung cancer of donor origin is rare. Bronchioloalveolar carcinoma confined to one lung can potentially be treated by transplanting the affected lung. Treatment for patients with lung cancer in the lung transplant setting has to be individualized because of the complexity of their medical problems and multiple medications. Attention needs to be focused on detecting lung cancer early in these patients to achieve a favorable outcome.
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Fishbane S, Cohen DJ, Coyne DW, Djamali A, Singh AK, Wish JB. Posttransplant anemia: the role of sirolimus. Kidney Int 2009; 76:376-82. [PMID: 19553912 DOI: 10.1038/ki.2009.231] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Posttransplant anemia is a common problem that may hinder patients' quality of life. It occurs in 12 to 76% of patients, and is most common in the immediate posttransplant period. A variety of factors have been identified that increase the risk of posttransplant anemia, of which the level of renal function is most important. Sirolimus, a mammalian target of rapamycin inhibitor, has been implicated as playing a special role in posttransplant anemia. This review considers anemia associated with sirolimus, including its presentation, mechanisms, and management.
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Affiliation(s)
- Steven Fishbane
- Division of Nephrology, Winthrop-University Hospital, Mineola, New York 11501, USA.
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Serra AL, Kistler AD, Poster D, Krauer F, Senn O, Raina S, Pavik I, Rentsch K, Regeniter A, Weishaupt D, Wuthrich RP. Safety and tolerability of sirolimus treatment in patients with autosomal dominant polycystic kidney disease. Nephrol Dial Transplant 2009; 24:3334-42. [DOI: 10.1093/ndt/gfp280] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Sato M, Keshavjee S. Bronchiolitis obliterans syndrome: alloimmune-dependent and -independent injury with aberrant tissue remodeling. Semin Thorac Cardiovasc Surg 2008; 20:173-82. [PMID: 18707652 DOI: 10.1053/j.semtcvs.2008.05.002] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2008] [Indexed: 12/21/2022]
Abstract
Long-term success in lung transplantation continues to be challenged by chronic graft dysfunction, which is manifest as bronchiolitis obliterans syndrome (BOS). The mechanisms of BOS involve both immune-mediated pathways (rejection, autoimmune-like mechanisms), and alloimmune-independent pathways (infection, aspiration, ischemia, primary graft failure), which lead to a fibroproliferative responses. BOS correlates histologically with obliterative bronchiolitis in terminal bronchioles and evidence of aberrant remodeling in the airway epithelium, vasculature, stroma, and lymphoid system. A potentially important mechanism that supports the progressive and therapy-resistant nature of BOS is a continuous cycle of ongoing injury and aberrant remodeling. Namely, anatomical and functional abnormalities induce and exacerbate immune-mediated and alloimmune-independent pathways through various mechanisms (e.g., epithelial remodeling decreases mucociliary clearance that exacerbates aspiration-related injury). From this viewpoint, we review current therapeutic strategies and revisit the role of transplant surgeons in attenuating the initial transplant-related injuries to prevent the lung grafts from entering the remodeling-injury cycle.
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Affiliation(s)
- Masaaki Sato
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Pham VV, Stichtenoth DO, Borlak J. Graft rejection: pharmacogenetic analysis or drug anamnesis? Br J Clin Pharmacol 2008; 65:959-60. [PMID: 18341681 DOI: 10.1111/j.1365-2125.2008.03129.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
AIMS A 23-year-old Caucasian woman, with cystic fibrosis, bilateral lung-transplantation and immunosuppressive therapy with prednisolone, tacrolimus and sirolimus, presented with clinical symptoms of a chronic transplant rejection. METHODS Since constant sufficient blood level of tacrolimus and sirolimus had never been achieved, a genetic analysis was carried out to clarify drug metabolism. RESULTS The genetic analysis for polymorphisms of cytochrome P450 (CYP) 3A4,5,7 revealed no sequence alterations in the CYP 3A4,5,7 gene. Thus, drug intake was scrutinized in detail, disclosing a missing interval between the intake of both immunosuppressive agents. After a correct drug intake the woman's condition ameliorated and the blood levels reached normal range. CONCLUSIONS This case report highlights the crucial importance of basic medical skills like an accurate and dainty drug anamnesis before high tech approaches were applied.
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Affiliation(s)
- V Vi Pham
- Institute of Clinical Pharmacology, Medizinische Hochschule Hannover and Fraunhofer Institute of Toxicology and Experimental Medicine, Hannover, Germany
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Sánchez Fructuoso A, Calvo N, Moreno MA, Giorgi M, Barrientos A. Study of Anemia After Late Introduction of Everolimus in the Immunosuppressive Treatment of Renal Transplant Patients. Transplant Proc 2007; 39:2242-4. [PMID: 17889151 DOI: 10.1016/j.transproceed.2007.06.032] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION mTOR inhibitors (imTOR) are immunosuppressive drugs that have a concentration-related effects on hematopoiesis, potentially resulting in anemia. The reason is uncertain, but a pathogenic link between sirolimus-induced anemia and the appearance of an inflammatory state was recently suggested. Because inflammation-related anemia is characterized by a functional iron deficiency, we studied whether everolimus influenced iron homeostasis. METHODS We studied iron homeostasis in 43 patients after late introduction of everolimus into the immunosuppressive treatment. Thirty-seven patients (86%) were receiving mycophenolate. Hemoglobin concentration, red blood cell count, mean corpuscular volume, serum iron, ferritin, C-reactive protein levels, and transferrin saturation were evaluated 3 months before and 1, 3, and 6 months after the switch. RESULTS The percentage of anemic patients preconversion was 18.6% and it was 34.9% at 3 months and 18.6% at 6 months. We did not observe a significant reduction in hemoglobin, but there was increased red blood cell count after everolimus introduction, with a significant reduction in mean corpuscular volume. Serum iron and transferrin saturation levels were also markedly reduced after the switch, while ferritin serum concentrations remained stable. An improvement in renal function was observed. CONCLUSIONS The anemia caused by everolimus--microcytosis, low serum iron, despite high ferritinemia, and elevated C-reactive protein levels--was consistent with the anemia of a chronic inflammatory state. This alteration occurred within the first months postconversion and disappeared at 6 months. The combination of mycophenolate and everolimus seemed to be useful without significant secondary effects.
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Mankidy B, Kesavan RB, Silay YS, Haddad TJ, Seethamraju H. Emerging drugs in lung transplantation. Expert Opin Emerg Drugs 2007; 12:61-73. [PMID: 17355214 DOI: 10.1517/14728214.12.1.61] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The balance between immunosuppression to ensure graft tolerance while preventing emergence of infectious complications is key in lung transplantation. Although opportunistic infection may appear to be the most important of these complications, malignancies and severe drug toxicities significantly affect the short- and long-term outcomes of the patients. The present practice is combination therapy using drugs with complementary immunosuppressive action, to achieve synergistic immunosuppression with the lowest possible toxicity. Components of immunosuppression include induction and maintenance regimens. Primary graft failure remains an important cause of mortality and morbidity in the immediate post-transplant period. Acute rejection is a common complication after lung transplant, but responds well to augmented immunosuppression and immunomodulation. Chronic rejection still is the major cause of mortality in patients who survive the initial year post-transplantation. Several new drugs have shown promise in decreasing the rate of loss of graft function. This review discusses the current and emerging therapeutic regimens.
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Affiliation(s)
- Babith Mankidy
- Baylor College of Medicine, Department of Medicine, Pulmonary and Critical Care, Lung transplant program, Houston, Texas, USA
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Faro A, Mallory GB, Visner GA, Elidemir O, Mogayzel PJ, Danziger-Isakov L, Michaels M, Sweet S, Michelson P, Paranjape S, Conrad C, Waltz DA. American Society of Transplantation executive summary on pediatric lung transplantation. Am J Transplant 2007; 7:285-92. [PMID: 17109726 DOI: 10.1111/j.1600-6143.2006.01612.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Lung transplantation in children poses distinctly different challenges from those seen in the adult population. This consensus statement reviews the experience in the field of pediatric lung transplantation and highlights areas that deserve further investigation.
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Affiliation(s)
- A Faro
- Department of Pediatrics, Washington University, St. Louis, MO, USA.
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Pallet N, Beaune P, Thervet E, Legendre C, Anglicheau D. Inhibiteurs de mTOR : Des antiprolifératifs pléiotropiques. Med Sci (Paris) 2006; 22:947-52. [PMID: 17101096 DOI: 10.1051/medsci/20062211947] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Studies of rapamycin properties in yeast led to the discovery of TOR (target of rapamycin) and its mammalian analogue, mTOR. mTOR is a central regulator of cell growth and proliferation in response to environmental stimuli such as growth factors and nutrients. mTOR regulates several pathways, particularly translation process by controlling the activity of two proteins in response to a broad range of mitogenic stimuli, S6K1 and 4E-BP1. Inhibition of cell growth by rapamycine and analogues have been demonstrated in numerous cell types, explaining the broad development of these drugs in clinical practice. Rapamycine is a potent immunosuppressive drug used in solid organ transplantation for the prevention of allograft rejection. In oncology, mTOR inhibitors are currently evaluated in several types of cancers. They are now widely used for coating stents to reduce post-stenting restenosis after coronary angioplasty. Finally, rapamycine is now evaluated in various diseases characterized by cell growth disorders such as phacomatosis and autosomal dominant polycystic kidney disease.
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Affiliation(s)
- Nicolas Pallet
- Service de Transplantation Rénale, Hôpital Necker, AP-HP, Université Paris V-René Descartes, 149, Rue de Sèvres, 75015 Paris, France.
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Lischke R, Simonek J, Matousovic K, Stolz AJ, Schützner J, Vojácek J, Burkert J, Davidová R, Pafko P. Initial Single-Center Experience With Sirolimus After Lung Transplantation. Transplant Proc 2006; 38:3006-11. [PMID: 17112886 DOI: 10.1016/j.transproceed.2006.08.105] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND Standard immunosuppression after lung transplantation includes calcineurin inhibitors, mycophenolate mofetil, and steroids. Long-term survivors of lung transplantation are often confronted with chronic kidney disease, by definition related to the intake of calcineurin inhibitors. Sirolimus has been increasingly proposed as an alternative immunosuppressive agent due to its absence of nephrotoxicity, which could be used in selected patients. METHODS We prospectively administered sirolimus as an alternative to calcineurin inhibitors in 10 lung transplantation recipients with persistent drug nephrotoxicity. They were switched from tacrolimus to sirolimus. Four patients also had bronchiolitis obliterans syndrome. The conversion scheme consisted of an immediate stop of tacrolimus and an 6 to 8-mg loading dose of sirolimus, followed by 4 mg/d. After 5 days, the sirolimus dose was adjusted to maintain trough levels between 12 and 18 ng/mL or 6 and 12 ng/mL for combined sirolimus and tacrolimus. Patients were monitored for renal and graft function as well as clinical status. RESULTS A significant decrease in creatinine was observed after 1 week of treatment (P = .011). Azotemia decreased after 1 month, remaining stable (P < .01). Pulmonary function tests did not show significant modification from before sirolimus, inception in patients with or without bronchiolitis obliterans syndrome. There were seven infections. One patient died of complications related to bronchiolitis obliterans. CONCLUSION Sirolimus was a useful alternative immunosuppressant, allowing significant tacrolimus withdrawal in transplant recipients with renal impairment. Sirolimus administration allowed recovery of renal function with low morbidity; it was useful for rescue of chronic renal impairment after lung transplantation.
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Affiliation(s)
- R Lischke
- 3rd Department of Surgery, Thoracic and Lung Transplantation Division, University Hospital Motol, Prague, Czech Republic.
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Fischereder M, Graeb C, Krüger B, Kammerl MC, Zülke C, Jauch KW, Krämer BK. Conversion from calcineurin inhibitors to sirolimus in patients with chronic renal allograft dysfunction. Transplant Proc 2006; 38:1295-7. [PMID: 16797286 DOI: 10.1016/j.transproceed.2006.03.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2005] [Indexed: 12/25/2022]
Abstract
BACKGROUND Chronic renal transplant dysfunction in part may be due to the nephrotoxic effects of calcineurin inhibitors, which are still the mainstay of immunosuppressive therapy. Sirolimus, a new immunosuppressive compound devoid of significant nephrotoxicity, might therefore exhibit beneficial effects when used in renal transplant recipients with graft dysfunction. METHODS Twelve renal transplant recipients included in this study had all been receiving calcineurin inhibitors for more than 12 months, and were free of rejection for more than 12 months. However, they demonstrated moderate renal dysfunction with serum creatinine values ranging from 1.8 to 4.0 mg/dL (164 to 351 micromol/L). After reaching a sirolimus level of 10 to 20 ng/mL, calcineurin inhibitor therapy was withheld. RESULTS One month after initiation of sirolimus therapy, all patients were off calcineurin inhibitors. The average daily sirolimus dosage was 5.8+/-3.4 mg. No acute rejection episode and no graft failure was observed. No patient required hemodialysis or admission to the hospital. Calculated creatinine clearance increased from 63.4+/-9.9 to 69.2+/-9.7 mL/min (P=.0368) and serum bicarbonate increased from 20.8+/-3.17 to 22.5+/-3.7 meq/L (P=.001). Serum cholesterol increased from 180+/-26.5 to 239+/-28.8 mg/dL (4.65+/-0.69 to 6.18+/-0.74 mmol/L, P<.001), triglycerides increased from 155+/-53 to 289+/-123 mg/dL (1.75+/-0.6 to 3.26+/-1.39 mmol/L) and low-density lipoprotein cholesterol increased from 99+/-32 to 131+/-25.1 mg/dL (2.56+/-0.83 to 3.39+/-0.65 mmol/L, P=.01). Arterial blood pressure remained well controlled (126+/-15.6/74+/-8.9 vs 134+/-16.8/83+/-9.7). CONCLUSION Conversion from calcineurin inhibitor therapy to sirolimus in patients more than 1 year after transplantation with impaired organ function is feasible, safe, and associated with a trend toward improved renal function.
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Hernández RL, Gil PU, Gallo CG, de Pablo Gafas A, Hernández MCC, Alvarez MJF. Rapamycin in lung transplantation. Transplant Proc 2006; 37:3999-4000. [PMID: 16386609 DOI: 10.1016/j.transproceed.2005.09.191] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Rapamycin (RAPA) is a powerful immunosuppressant that also acts as an antiproliferative, which, therefore, could be useful in the treatment and prevention of bronchiolitis obliterans (BOS) in lung transplant recipients. We sought to report our experiences with RAPA in lung transplant patients with BOS that has not responded to the administration of other drugs. MATERIALS AND METHODS We performed a retrospective analysis of the clinical characteristics, pulmonary function, and complications among patients with BOS who received RAPA. RESULTS RAPA was administered to 11 patients, three single-lung transplant and eight bilateral lung transplant recipients, of whom five were women and six men, of mean age 48 years (26 to 65). The median posttransplant time to the initiation of RAPA for progressive BOS was 32 months (4 to 69) with a posttreatment follow-up of 15 months (3 to 34). RAPA was administered to all patients in association with a calcineurin inhibitor (tacrolimus in seven cases, and cyclosporine in four and steroids. Eight of the 11 patients (72%) with progressive deterioration of pulmonary function showed improved and/or stabilized FEV1 figures after introduction of RAPA. Eight patients developed adverse effects, which were possibly related to RAPA, leading to treatment withdrawal in two cases. The most frequent adverse effects were infections among 6 of the 12 cases, and myelosuppression in three. CONCLUSIONS RAPA may be useful to stabilize or improve pulmonary function in patients with BOS. Nevertheless, it was necessary for patients to be closely monitored so that possible adverse effects, and especially infections, may be detected early.
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Groetzner J, Wittwer T, Kaczmarek I, Ueberfuhr P, Strauch J, Nagib R, Meiser B, Franke U, Reichart B, Wahlers T. Conversion to Sirolimus and Mycophenolate Can Attenuate the Progression of Bronchiolitis Obliterans Syndrome and Improves Renal Function after Lung Transplantation. Transplantation 2006; 81:355-60. [PMID: 16477220 DOI: 10.1097/01.tp.0000195781.02268.5e] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Bronchiolitis obliterans syndrome (BOS) is the major problem after lung and heart-lung transplantation (LTx/HLTx). Sirolimus (Sir) and Mycophenolate (MMF) showed a promising efficacy in the treatment of BOS in animal models. The first clinical experience in converting LTx/HLTx-recipients with BOS from calcineurin inhibitor-(CNI)-based immunosuppression to a Sir-MMF based immunosuppression is reported herein. METHODS Six LTx- and five HLTx-recipients (eight men; 0.9 to 8 years after transplantation) with CNI-based immunosuppression (plus MMF) in whom BOS was diagnosed were included in the study. Mean patient age was 37+/-13 years (range 17-62 years). Sir was started with 6 mg and continued adjusted to according target trough levels (8-14 ng/ml). Subsequently, the CNIs were tapered down and finally stopped. Follow up included self determined pulmonary function tests, microbiological screening, chest radiographs, and laboratory studies RESULTS Two acute rejection episodes occurred during the study period. The incidence of infection was 2.2+/-1.3 infections/patient-year after conversion. Mean FEV1 decreased after a mean follow up of 14.8+/-1.4 months: from 2.1+/-0.7 l prior conversion to 1.3+/-0.6l after conversion (P=0.03). However, graft function remained stable in three patients and progression of BOS slowed down in three patients. Overall, 2 of 10 patients died due to ongoing BOS while awaiting retransplantation CONCLUSIONS After BOS was diagnosed, conversion to MMF and Sir stabilized graft function only in some of the converted patients. Therefore, earlier administration of Sir-based immunosuppression might be a more promising approach. Whether conversion to CNI-free immunosuppression can actually ameliorate the extent or progression of BOS has to be investigated in randomized trials.
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Affiliation(s)
- Jan Groetzner
- Department of Cardiothoracic and Vascular Surgery, Friedrich Schiller University Hospital, Jena, Germany.
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Tao R, Wang L, Chen CH, Wang SH, Demarco RA, Lotze MT, Thai NL, Fung JJ, Lu L, Qian S. Mechanistic insights into achievement of cardiac allograft long-term survival by treatment with immature dendritic cells and sub-dose sirolimus. J Heart Lung Transplant 2006; 25:310-9. [PMID: 16507425 DOI: 10.1016/j.healun.2005.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2005] [Revised: 08/29/2005] [Accepted: 10/05/2005] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Administration of immature dendritic cells (DC) prolongs but does not result in indefinite allograft survival. We attempted to achieve this goal by adding a sub-therapeutic dose of immunosuppression. METHODS DC propagated from B10 (H-2(b)) mouse bone marrow (BM) were transfected with nuclear factor-kappaB (NF-kappaB)-binding-site-specific oligodeoxyribonucleotide (ODN). The allostimulatory activity of transfected and normal DC were examined in mixed-lymphocyte reaction (MLR) and cytotoxic T-lymphocyte (CTL) assays in vitro, and their influence on allograft survival by systemic administration of DC in vivo. RESULTS Transfection of DC with NF-kappaB ODN resulted in complete abrogation of NF-kappaB activity and inhibition of co-stimulation. Allogeneic (C3H, H-2(k)) T cells stimulated by ODN DC demonstrated impairment in MLR and CTL activity. Administration of ODN DC significantly prolonged B10 allograft survival. In contrast to cyclosporine, which failed to enhance the effect of ODN DC, a combination of ODN DC with sirolimus at 6 mg/kg/day for 6 days achieved long-term survival in all allografts. This was associated with low CTL activity of either graft-infiltrating cells or splenic T cells and increased TUNEL-positive cells in T-cell areas of recipient mesenteric lymph nodes. Analysis of transcription factor nuclear translocation with Cellomics indicated that stimulation with ODN DC showed inhibited T-cell nuclear translocation of signal transducer and activator of transcription (Stat)1 and Stat3, extracellular signal-related kinase (ERK) and activating transcription factor (ATF)-2, but not NF-kappaB and P38, compared with mature DC. The selective inhibition was enhanced by sirolimus, but not cyclosporine. CONCLUSIONS Sirolimus enhances immature DC tolerogenicity by induction of T-cell apoptosis, and promotes immature DC-induced inhibition of Stat1, ERK and ATF-2 activation.
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Affiliation(s)
- Ran Tao
- Thomas E. Starzl Transplantation Institute and Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, USA
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Kim MJ, Mayr M, Pechula M, Steiger J, Dickenmann M. Marked erythrocyte microcytosis under primary immunosuppression with sirolimus. Transpl Int 2006; 19:12-8. [PMID: 16359372 DOI: 10.1111/j.1432-2277.2005.00190.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The preliminary observation of marked erythrocyte microcytosis in patients treated with sirolimus (SRL) and mycophenolate mofetil (MMF) has been evaluated as part of a prospective study comparing SRL and cyclosporin A (CsA) as a primary immunosuppressant. Normal risk de novo kidney recipients were randomized either to SRL or to CsA. Additional immunosuppressants consisted of MMF and prednisone. In patients with erythrocyte microcytosis, iron deficiency was excluded by measuring serum ferritin and transferrin saturation rate. Fifty-nine patients (30 in SRL and 29 in CsA) were included. Mean corpuscular volume (MCV) (fl) on day 7 was 91.7 +/- 4.8 in SRL group versus 91.4 +/- 4.2 in CsA group (P = 0.77), whereas mean MCV on day 183 post-transplant was 78.5 +/- 3.8 in SRL group versus 88.4 +/- 3.4 in CsA group (P < 0.0001). Hemoglobin concentration (g/dl) was not significantly different. Only two patients in SRL group presented decreased transferrin saturation rate. Marked erythrocyte microcytosis without persistent anemia was observed in patients treated with SRL and MMF.
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Affiliation(s)
- Min-Jeong Kim
- Division of Transplantation Immunology and Nephrology, University Hospital, Basel, Switzerland.
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Pascual J, Boletis IN, Campistol JM. Everolimus (Certican) in renal transplantation: a review of clinical trial data, current usage, and future directions. Transplant Rev (Orlando) 2006. [DOI: 10.1016/j.trre.2005.10.005] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Thaunat O, Beaumont C, Chatenoud L, Lechaton S, Mamzer-Bruneel MF, Varet B, Kreis H, Morelon E. Anemia after Late Introduction of Sirolimus May Correlate with Biochemical Evidence of a Chronic Inflammatory State. Transplantation 2005; 80:1212-9. [PMID: 16314788 DOI: 10.1097/01.tp.0000179106.07382.6a] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND The responsibility of sirolimus (SRL) for postrenal transplant anemia has never been proven, because SRL is usually combined with myelotoxic drugs, and because of the high incidence of anemia in the posttransplant period. METHODS We retrospectively analyzed anemia in 46 renal transplant recipients, who had been switched from calcineurin inhibitors to SRL for biopsy-proven chronic allograft nephropathy. RESULTS The mean decrease in hemoglobin (Hb) after SRL introduction was 2.8 g/dl. The 24 patients, whose Hb fell by >or=2 g/dl, displayed microcytic aregenerative anemia with low serum iron despite high ferritinemia, consistent with anemia of chronic inflammatory states. Fibrinogen and CRP levels increased in these patients after sirolimus introduction. We subsequently focused our study on eight patients without confounding factors of anemia. Anemia improved in all eight after SRL withdrawal. IL6 and TNFalpha at the nadir of anemia were significantly higher than before SRL introduction and after its withdrawal. Decreases in Hb correlated with increases in proinflammatory cytokine levels in a linear regression model. Unchanged serum IL10 levels measured at the nadir of anemia were discordant with the inflammatory state. CONCLUSIONS Late introduction of SRL may induce anemia and correlates with biochemical evidence of a chronic inflammatory state possibly due to defective IL10-dependent inflammatory autoregulation.
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Affiliation(s)
- Olivier Thaunat
- Department of Renal Transplantation, Hôpital Necker Enfants-Malades, Paris, France.
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Villanueva J, Boukhamseen A, Bhorade SM. Successful use in lung transplantation of an immunosuppressive regimen aimed at reducing target blood levels of sirolimus and tacrolimus. J Heart Lung Transplant 2005; 24:421-5. [PMID: 15797743 DOI: 10.1016/j.healun.2004.01.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2003] [Revised: 01/02/2004] [Accepted: 01/20/2004] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The primary aim of this study was to assess the safety and efficacy in lung transplantation of an immunosuppressive regimen aimed at achieving sirolimus and tacrolimus concentrations of 6 to 10 microg/ml and 5 to 7 ng/ml, respectively. METHODS We retrospectively identified 49 lung transplant recipients who were converted to an immunosuppressive regimen consisting of tacrolimus, sirolimus, and prednisone. Data collected included demographic information, laboratory work, episodes of rejection, bronchiolitis obliterans syndrome (BOS) grade, and adverse effects. RESULTS The most common reason for conversion to a sirolimus and tacrolimus regimen was BOS. The most common adverse effects were increased triglycerides (10%), leukopenia (8%), and skin rash (6%). Four patients (8%) experienced acute allograft rejection during the study period. We followed BOS grade for 1 year in 23 patients. Of these, BOS grade improved in 8, 13 patients remained unchanged, and 2 worsened. Eleven patients (22%) discontinued sirolimus because of adverse events. CONCLUSION An immunosuppressive regimen consisting of sirolimus and tacrolimus that aims to keep the trough drug concentrations at 6 to 10 microg/ml and 5 to 7 ng/ml, respectively, provides effective lung allograft protection while maintaining an acceptable side-effect profile. The use of this immunosuppressive combination may have a benefit with regard to BOS.
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Affiliation(s)
- Jaime Villanueva
- Division of Pulmonary and Critical Care, Loyola University Medical Center, Maywood, Illinois 60153, USA.
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Mahé E, Morelon E, Lechaton S, Sang KHLQ, Mansouri R, Ducasse MF, Mamzer-Bruneel MF, de Prost Y, Kreis H, Bodemer C. Cutaneous adverse events in renal transplant recipients receiving sirolimus-based therapy. Transplantation 2005; 79:476-82. [PMID: 15729175 DOI: 10.1097/01.tp.0000151630.25127.3a] [Citation(s) in RCA: 143] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Sirolimus is an immunosuppressive drug recently developed for organ transplantation. Its mechanism of action, independent of calcineurin, is different from that of cyclosporine and tacrolimus, two calcineurin inhibitors (CIs). Because the toxicity of CIs is partly the result of calcineurin blockade, sirolimus exhibits a different toxicity profile. In this study, we evaluated the profile, frequency, and severity of cutaneous adverse events in renal transplant recipients receiving sirolimus-based therapy. PATIENTS AND METHODS A systematic and in-depth evaluation of skin, mucous membranes, nails, and hair was performed in 80 renal transplant recipients receiving sirolimus-based therapy. The mean duration of the graft was 6 years and of sirolimus treatment was 18 months. Mycophenolate mofetil and steroids were combined with sirolimus for 74 patients. Sirolimus was used as first immunosuppressive therapy for 36 patients, and 44 patients were switched from CIs to sirolimus. RESULTS Seventy-nine patients (99%) experienced cutaneous adverse events. Twenty patients (25%) demonstrated serious adverse events, and six patients (7%) stopped sirolimus during the 3 months after the study because of cutaneous events. The most frequent of these were pilosebaceous apparatus involvement, including acne-like eruptions (46%), scalp folliculitis (26%), and hidradenitis suppurativa (12%); edematous complaints, including chronic edemas (55%) and angioedema (15%); mucous membrane disorders, including aphthous ulceration (60%), epistaxis (60%), chronic gingivitis (20%), and chronic fissure of the lips (11%); and last, nail disorders including chronic onychopathy (74%) and periungual infections (16%). CONCLUSIONS Skin disorders are frequent in renal transplant recipients receiving sirolimus as a long-term therapy. Despite the usually mild nature of skin events, they are often the reason for stopping sirolimus.
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Affiliation(s)
- Emmanuel Mahé
- Service de Dermatologie, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris, France.
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Abstract
Bronchiolitis obliterans (BO) in children is a relatively rare diagnosis. The increase in lung and bone marrow transplantation in children, however, has led to a heightened interest in BO, as this is one of the important complications of those procedures. This article will discuss BO as an entity that can follow any of several illnesses or toxic exposures, in addition to following allogeneic lung or bone marrow transplantation. The complex and incompletely understood pathology, pathogenesis, and molecular pathology involved in BO remain the subject of ongoing investigations. As the prognosis for BO is uncertain and treatment is often unsuccessful, the continued need for the recognition of surrogate markers for BO in patients at risk and the development of better forms of therapy are paramount. This review will describe our current understanding of BO, and will call attention to those research areas that require continuing efforts in order to prevent or treat this entity.
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Affiliation(s)
- Geoffrey Kurland
- Division of Pediatric Pulmonology, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania 15213, USA.
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Lobach NE, Pollock-Barziv SM, West LJ, Dipchand AI. Sirolimus immunosuppression in pediatric heart transplant recipients: A single-center experience. J Heart Lung Transplant 2005; 24:184-9. [PMID: 15701435 DOI: 10.1016/j.healun.2004.11.005] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2004] [Revised: 11/03/2004] [Accepted: 11/12/2004] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Sirolimus has been used in heart transplant recipients for treatment of rejection, alternative immunosuppression (IS) and promotion of regression and prevention of graft vasculopathy (coronary artery disease [CAD]). This study reports on our center's experience with 16 children who underwent heart transplantation. METHODS Data were obtained by retrospective review. RESULTS Median age at time of review was 12.3 years (n = 16, 5.1 to 18.0 years; 9 boys, 7 girls), and at time of transplant 7.5 years (6 months to 18.0 years). Median time of sirolimus introduction was 2.7 years (1 month to 8.2 years) post-transplant. Fifteen patients were on steroids, 10 on tacrolimus (FK) and mycophenolate mofetil (MMF), 5 on FK and 1 on MMF with no calcineurin inhibitors (CNIs). The average dose of sirolimus was 0.25 mg/kg or 7.0 mg/m(2) to maintain a target level of 5 to 15 mug/liter. Sirolimus was started for CAD in 6 patients (38%), rejection in 5 (31%), and in 5 with combinations of CNI intolerance, CAD, renal dysfunction and rejection. All 6 who received sirolimus for rejection (International Society for Heart and Lung Transplantation [ISHLT] Grade 3A) showed improvement on follow-up biopsies. Two of 3 who received sirolimus for renal dysfunction showed improvement (glomerular filtration rate [GFR] 43 to 67 and 32 to 106 ml/min per 1.73 m(2), respectively). Side effects included hyperlipidemia (38%), abdominal pain (31%), mouth ulcers (26%), anemia or neutropenia (12.5%), persistent pericardial effusion (6%) and interstitial lung disease (6%). Sirolimus therapy was discontinued in 3 patients due to side effects. CONCLUSIONS In this study sirolimus was found to be a valuable IS agent for the management of rejection, significant renal dysfunction and CNI side effects. These results support the need for prospective studies of the role of sirolimus in primary rejection prophylaxis, primary CAD prophylaxis and CAD regression. There also exists a need to establish an adverse event profile for this drug.
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Affiliation(s)
- Natalia E Lobach
- Division of Cardiology, Department of Pediatrics and Immunology, University of Toronto, Toronto, Ontario, Canada
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Abstract
Sirolimus (rapamycin) is a macrocyclic lactone isolated from a strain of Streptomyces hygroscopicus that inhibits the mammalian target of rapamycin (mTOR)-mediated signal-transduction pathways, resulting in the arrest of cell cycle of various cell types, including T- and B-lymphocytes. Sirolimus has been demonstrated to prolong graft survival in various animal models of transplantation, ranging from rodents to primates for both heterotopic, as well as orthotopic organ grafting, bone marrow transplantation and islet cell grafting. In human clinical renal transplantation, sirolimus in combination with ciclosporin (cyclosporine) efficiently reduces the incidence of acute allograft rejection. Because of the synergistic effect of sirolimus on ciclosporin-induced nephrotoxicity, a prolonged combination of the two drugs inevitably leads to progressive irreversible renal allograft damage. Early elimination of calcineurin inhibitor therapy or complete avoidance of the latter by using sirolimus therapy is the optimal strategy for this drug. Prospective randomised phase II and III clinical studies have confirmed this approach, at least for recipients with a low to moderate immunological risk. For patients with a high immunological risk or recipients exposed to delayed graft function, sirolimus might not constitute the best therapeutic choice--despite its ability to enable calcineurin inhibitor sparing in the latter situation--because of its anti-proliferative effects on recovering renal tubular cells. Whether lower doses of sirolimus or a combination with a reduced dose of tacrolimus would be advantageous in these high risk situations remains to be determined. Clinically relevant adverse effects of sirolimus that require a specific therapeutic response or can potentially influence short- and long-term patient morbidity and mortality as well as graft survival include hypercholesterolaemia, hypertriglyceridaemia, infectious and non-infectious pneumonia, anaemia, lymphocele formation and impaired wound healing. These drug-related adverse effects are important determinants in the choice of a tailor-made immunosuppressive drug regimen that complies with the individual patient risk profile. Equally important in the latter decision is the lack of severe intrinsic nephrotoxicity associated with sirolimus and its advantageous effects on arterial hypertension, post-transplantation diabetes mellitus and esthetic changes induced by calcineurin inhibitors. Mild and transient thrombocytopenia, leukopenia, gastrointestinal adverse effects and mucosal ulcerations are all minor complications of sirolimus therapy that have less impact on the decision for choosing this drug as the basis for tailor-made immunosuppressive therapy. It is clear that sirolimus has gained a proper place in the present-day immunosuppressive armament used in renal transplantation and will contribute to the development of a tailor-made immunosuppressive therapy aimed at fulfilling the requirements outlined by the individual patient profile.
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Affiliation(s)
- Dirk R J Kuypers
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, University of Leuven, B-3000 Leuven, Belgium.
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Abstract
Post-transplantation bronchiolitis obliterans syndrome (BOS) is a clinicopathological syndrome characterised histologically by obliterative bronchiolitis (OB) and physiologically by airflow limitation. It affects long-term survival with no consistently effective treatment strategy.An updated review of risk factors for OB/BOS, and approaches to prevention and treatment was performed through a systematic review of relevant studies between January 1990 and February 2005. The initial search identified 853 publications, with 56 articles reviewed after exclusions. Early acute rejection is the most significant risk factor, with late rejection (> or =3 months) also significant. Lymphocytic bronchitis/bronchiolitis is relevant, with later onset associated with greater risk. Viral infections are identified as significant risk factors. Human leukocyte antigen matching and OB/BOS development is a weaker association, but is stronger with acute rejection. Recipient and donor characteristics have a minor role. There is limited evidence that altering immunosuppression is effective in reducing the rate of decline in lung function. BOS reflects an allo-immunological injury, possibly triggered by cytomegalovirus and respiratory viral infections, or noninfectious injury. Immunological susceptibility may be reflected by more frequent acute rejection episodes. Preventative and therapeutic modifications in immunosuppression remain important. Identifying markers of immunological susceptibility and, hence, risk stratification requires further research.
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Affiliation(s)
- Andrew I R Scott
- Transplant Unit, Papworth Hospital NHS Trust, Papworth Everard, Cambridge, UK
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Abstract
Over the past 15 years, lung transplantation has become an established treatment for a variety of end-stage lung diseases, but medium- and long-term success has been limited by a high incidence of bronchiolitis obliterans syndrome (BOS). Immune mediated injury has been recognized as the leading cause of BOS, and the term is synonymous with chronic rejection. But recently, nonimmune mechanisms, such as gastroesophageal reflux, have been recognized as potential culprits. The results of various treatment options have generally been disappointing, and BOS has emerged as the leading cause of late morbidity and mortality after lung transplantation.
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Affiliation(s)
- Ramsey R Hachem
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA.
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Venuta F, De Giacomo T, Rendina EA, Quattrucci S, Mercadante E, Cimino G, Ibrahim M, Diso D, Bachetoni A, Coloni GF. Recovery of Chronic Renal Impairment With Sirolimus After Lung Transplantation. Ann Thorac Surg 2004; 78:1940-3. [PMID: 15561004 DOI: 10.1016/j.athoracsur.2004.03.018] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/08/2004] [Indexed: 11/22/2022]
Abstract
BACKGROUND Standard immunosuppression after lung transplantation includes calcineurin inhibitors, azathioprine, and steroids. Calcineurin inhibitor administration is associated with an increased renal impairment. Sirolimus shows no renal toxicity and could be used in selected patients. METHODS We have prospectively administered sirolimus as an alternative to calcineurin inhibitors in 15 lung transplantation recipients with persistent drug nephrotoxicity. Eight patients had also bronchiolitis obliterans syndrome. The mean serum creatinine and azotemia were 2.7 +/- 1.1 mg/dL and 111 +/- 39 mg/dL. After starting sirolimus, azathioprine was reduced to 50%-25% of baseline, calcineurin inhibitors were gradually reduced and eventually stopped, and steroids were maintained stable. Patients started sirolimus with 2 to 5 mg/d orally; adjustments were made according to trough levels (4 to 12 ng/mL for combined sirolimus + calcineurin inhibitors; 12 to 20 ng/mL as monotherapy), toxicity, and perceived efficacy. Patients were monitored for renal and graft function and clinical status. RESULTS A significant creatinine decrease was observed after 6 months of treatment (p < 0.02); azotemia decreased after 1 month and remained stable (p < 0.01). Pulmonary function tests did not show any significant modification from before sirolimus baseline in patients without bronchiolitis obliterans syndrome. There were eight infectious complications and 10 episodes of toxicity (4 dermatitis, 2 epistaxis, 1 headache, 1 diarrhea, 1 nausea, 1 laryngeal cancer). Moderate leukocytopenia (n = 3) and hypertriglyceridemia (n = 6) responded to dose reduction. One patient was lost to follow-up. Three patients died of complications related to bronchiolitis obliterans. One patient underwent transplantation again. CONCLUSIONS Sirolimus administration allows amelioration of renal function with a relatively low morbidity and is useful for chronic renal impairment rescue after lung transplantation.
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Affiliation(s)
- Federico Venuta
- Department of Thoracic Surgery, University of Rome La Sapienza, Policlinico Umberto I, Rome, Italy.
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Abstract
Lung transplantation is an option for patients with endstage pulmonary diseases without contraindications. Recent European studies showed a survival benefit for patients with cystic fibrosis, fibrosis and emphysema after lung transplantation. Early mortality has been reduced recently by surgical improvements. Life expectancy after lung transplantation has improved in recent years but is still lower than in patients with other solid organ transplantations. Quality of life is consistently improved but exercise tolerance keeps reduced in comparison to the normal population. Specific problems described in detail are frequent organ rejections and infections, airway problems and a high incidence of malignant diseases. 5-year survival after lung transplantation is in average 60%.
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Affiliation(s)
- J Gottlieb
- Abteilung Pneumologie, Medizinische Hochschule Hannover.
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Abstract
Lung and heart transplantation has become an accepted therapeutic option for patients with end-stage disease. However, the calcineurin-inhibitor-based immunosuppression often causes renal impairment. Therefore, sirolimus, a novel immunosuppressive agent, may serve as an alternative or complementary agent to calcineurin inhibitors. The aim of this review was to summarize the role of sirolimus in lung and heart transplantation. Although only a few, small studies have been conducted so far, the drug's mechanisms of action and low-toxicity profile make it a highly promising option.
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Affiliation(s)
- David Shitrit
- Pulmonary Institute, Rabin Medical Center, School of Medicine, Beilinson Campus, Tel Aviv University, Petah Tiqwa and Sackler Tel Aviv, Israel.
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Ussetti P, Carreño MC, de Pablo A, Gamez P, Varela A. Rapamycin and chronic lung rejection. J Heart Lung Transplant 2004; 23:917-8. [PMID: 15261192 DOI: 10.1016/j.healun.2003.07.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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