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Abstract
Drug-induced interstitial lung disease (DI-ILD) is an increasingly common cause of morbidity and mortality as the list of culprit drugs continues to grow. Unfortunately, DI-ILD is difficult to study, diagnose, prove, and manage. This article attempts to raise awareness of the challenges in DI-ILD and discusses the current clinical landscape.
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Affiliation(s)
- Nicole Ng
- Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Place, PO Box 1232, New York, NY 10029, USA.
| | - Maria L Padilla
- Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Place, PO Box 1232, New York, NY 10029, USA
| | - Philippe Camus
- Pulmonary and Intensive Care at Universite de Bourgogne, 1 Rue Marion, F21079, Dijon, France
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Ivulich S, Paul E, Kirkpatrick C, Dooley M, Snell G. Everolimus Based Immunosuppression Strategies in Adult Lung Transplant Recipients: Calcineurin Inhibitor Minimization Versus Calcineurin Inhibitor Elimination. Transpl Int 2023; 36:10704. [PMID: 36744051 PMCID: PMC9894878 DOI: 10.3389/ti.2023.10704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 01/02/2023] [Indexed: 01/21/2023]
Abstract
Everolimus (EVE) provides an alternative to maintenance immunosuppression when conventional immunosuppression cannot be tolerated. EVE can be utilized with a calcineurin inhibitor (CNI) minimization or elimination strategy. To date, clinical studies investigating EVE after lung transplant (LTx) have primarily focused on the minimization strategy to preserve renal function. The primary aim was to determine the preferred method of EVE utilization for lung transplant recipients (LTR). To undertake this aim, we compared the safety and efficacy outcomes of EVE as part of minimization and elimination immunosuppressant regimens. Single center retrospective study of 217 LTR initiated on EVE (120 CNI minimization and 97 CNI elimination). Survival outcomes were calculated from the date of EVE commencement. On multivariate analysis, LTR who received EVE as part of the CNI elimination strategy had poorer survival outcomes compared to the CNI minimization strategy [HR 1.61, 95% CI: 1.11-2.32, p=0.010]. Utilization of EVE for renal preservation was associated with improved survival compared to other indications [HR 0.64, 95% CI: 0.42-0.97, p=0.032]. EVE can be successfully utilized for maintenance immunosuppression post LTx, particularly for renal preservation. However, immunosuppressive regimens containing low dose CNI had superior survival outcomes, highlighting the importance of retaining a CNI wherever possible.
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Affiliation(s)
- Steven Ivulich
- The Alfred Hospital, Melbourne, VIC, Australia,Centre for Medication Use and Safety, Monash University, Melbourne, VIC, Australia,*Correspondence: Steven Ivulich,
| | - Eldho Paul
- Public Health and Preventative Medicine, Monash University, Melbourne, VIC, Australia
| | - Carl Kirkpatrick
- Centre for Medication Use and Safety, Monash University, Melbourne, VIC, Australia
| | - Michael Dooley
- The Alfred Hospital, Melbourne, VIC, Australia,Centre for Medication Use and Safety, Monash University, Melbourne, VIC, Australia
| | - Greg Snell
- The Alfred Hospital, Melbourne, VIC, Australia
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Schmucki K, Hofmann P, Fehr T, Inci I, Kohler M, Schuurmans MM. Mammalian Target of Rapamycin Inhibitors and Kidney Function After Thoracic Transplantation: A Systematic Review and Recommendations for Management of Lung Transplant Recipients. Transplantation 2023; 107:53-73. [PMID: 36508646 PMCID: PMC9746343 DOI: 10.1097/tp.0000000000004336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/18/2022] [Accepted: 07/19/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Chronic kidney disease (CKD) after lung transplantation is common and limits the survival of transplant recipients. The calcineurin inhibitors (CNI), cyclosporine A, and tacrolimus being the cornerstone of immunosuppression are key mediators of nephrotoxicity. The mammalian target of rapamycin (mTOR) inhibitors, sirolimus and everolimus, are increasingly used in combination with reduced CNI dosage after lung transplantation. METHODS This systematic review examined the efficacy and safety of mTOR inhibitors after lung transplantation and explored their effect on kidney function. RESULTS mTOR inhibitors are often introduced to preserve kidney function. Several clinical trials have demonstrated improved kidney function and efficacy of mTOR inhibitors. The potential for kidney function improvement and preservation increases with early initiation of mTOR inhibitors and low target levels for both mTOR inhibitors and CNI. No defined stage of CKD for mTOR inhibitor initiation exists, nor does severe CKD preclude the improvement of kidney function under mTOR inhibitors. Baseline proteinuria may negatively predict the preservation and improvement of kidney function. Discontinuation rates of mTOR inhibitors due to adverse effects increase with higher target levels. CONCLUSIONS More evidence is needed to define the optimal immunosuppressive regimen incorporating mTOR inhibitors after lung transplantation. Not only the indication criteria for the introduction of mTOR inhibitors are needed, but also the best timing, target levels, and possibly discontinuation criteria must be defined more clearly. Current evidence supports the notion of nephroprotective potential under certain conditions.
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Affiliation(s)
- Katja Schmucki
- Division of Pulmonology, University Hospital Zurich, Zurich, Switzerland
- Department of Internal Medicine, Cantonal Hospital Graubünden, Chur, Switzerland
| | - Patrick Hofmann
- Division of Pulmonology, University Hospital Zurich, Zurich, Switzerland
- Department of Internal Medicine, Cantonal Hospital Graubünden, Chur, Switzerland
| | - Thomas Fehr
- Department of Internal Medicine, Cantonal Hospital Graubünden, Chur, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Ilhan Inci
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
- Department of Thoracic Surgery, Zurich University Hospital, Zurich, Switzerland
| | - Malcolm Kohler
- Division of Pulmonology, University Hospital Zurich, Zurich, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Macé M. Schuurmans
- Division of Pulmonology, University Hospital Zurich, Zurich, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
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Safety Evaluation of Oral Sirolimus in the Treatment of Childhood Diseases: A Systematic Review. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9091295. [PMID: 36138604 PMCID: PMC9497617 DOI: 10.3390/children9091295] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/18/2022] [Accepted: 08/24/2022] [Indexed: 11/17/2022]
Abstract
Background: Sirolimus, a mammalian target of rapamycin inhibitor, has been widely used in pediatric patients, but the safety of sirolimus in pediatric patients has not been well determined. Objective: The objective of this study was to systematically evaluate prospective studies reporting the safety of sirolimus in the treatment of childhood diseases. Methods: The following data were extracted in a standardized manner: study design, demographic characteristics, intervention, and safety outcomes. Results: In total, 9 studies were included, encompassing 575 patients who received oral sirolimus for at least 6 months. Various adverse events occurred. The most common adverse event was oral mucositis (8.2%, 95% CI: 0.054 to 0.110). Through comparative analysis of the subgroups based on the targeted concentration range, we discovered that many adverse events were significantly higher in the high concentration group (≥10 ng/mL) than in the low concentration group (<10 ng/mL) (p < 0.01). More interestingly, we found that oral mucositis was more frequently reported in children with vascular anomalies than tuberous sclerosis complex. Conclusions: This study shows that oral sirolimus in the treatment of childhood diseases is safe and reliable. However, sirolimus treatment in the pediatric population should be strictly monitored to reduce the occurrence of serious or fatal adverse events.
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Taboada RG, Riechelmann RP, Mauro C, Barros M, Hubner RA, McNamara MG, Lamarca A, Valle JW. Everolimus-Induced Pneumonitis in Patients with Neuroendocrine Neoplasms: Real-World Study on Risk Factors and Outcomes. Oncologist 2022; 27:97-103. [PMID: 35641203 PMCID: PMC8895743 DOI: 10.1093/oncolo/oyab024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 09/29/2021] [Indexed: 12/27/2022] Open
Abstract
Abstract
Background
Everolimus-induced pneumonitis (EiP) has been poorly studied in patients with neuroendocrine neoplasms (NEN) outside clinical trials. The aim of this study was to evaluate the incidence, risk factors, and outcomes of EiP in patients with NENs using real-world data.
Methods
Retrospective study of everolimus-treated patients with advanced NENs. Imaging reports were systematically reviewed for the presence of pneumonitis. Clinical features and treatment profiles for EiP were summarized. Overall survival (OS) was calculated from the initiation of everolimus to the date of death or last follow-up using the Kaplan-Meier method.
Results
A total of 122 patients were included. Median age at start of everolimus was 62 (19-86) years, 62% (76/122) were male, and half were from pancreatic origin (62, 51%). Twenty-eight patients (23%) developed EiP: 82% grade (G)1 or G2, 14% G3 and 4% G4. The median time to EiP was 3.6 (0.8-51) months. Primary tumor site, concurrent lung disease, smoking history, and prior therapies were not associated with the onset of EiP. Patients who developed EiP had longer time on everolimus treatment (median 18 months vs 6 months; P = .0018) and OS (77 months vs 52 months; P = .093). Everolimus-induced pneumonitis was a predictor of improved OS by multivariable analysis (HR 0.39, 95% CI 0.19-0.82; P = .013).
Conclusion
Everolimus-induced pneumonitis in the real-world clinical setting is present in one quarter of patients with NENs receiving everolimus and often occurs early. While risk factors for EiP were not identified, patients with EiP had improved survival.
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Affiliation(s)
- Rodrigo G Taboada
- Department of Medical Oncology, A.C.Camargo Cancer Center, São Paulo, Brazil
| | | | - Carine Mauro
- Department of Medical Oncology, A.C.Camargo Cancer Center, São Paulo, Brazil
| | - Milton Barros
- Department of Medical Oncology, A.C.Camargo Cancer Center, São Paulo, Brazil
| | - Richard A Hubner
- Department of Medical Oncology, The Christie NHS Foundation Trust/Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Mairéad G McNamara
- Division of Cancer Sciences, University of Manchester/The Christie NHS Foundation Trust, Manchester, UK
| | - Angela Lamarca
- Department of Medical Oncology, The Christie NHS Foundation Trust/Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Juan W Valle
- Division of Cancer Sciences, University of Manchester/The Christie NHS Foundation Trust, Manchester, UK
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Achromobacter denitrificans pneumonia in a kidney transplant recipient - dose-dependent decrease of phagocytic activity as a potential mechanism for everolimus pulmonary toxicity. Cent Eur J Immunol 2021; 46:405-417. [PMID: 34764816 PMCID: PMC8574107 DOI: 10.5114/ceji.2021.108762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 05/06/2021] [Indexed: 11/17/2022] Open
Abstract
Mammalian target of rapamycin (mTOR) inhibitors inclusive regimens are associated with increased risk of pulmonary toxicity, but the underlying mechanism has not been elucidated so far. We present the case of a 68-year-old man, after deceased-donor kidney transplantation (KTx), maintained on de novo everolimus (EVR) based immunosuppression, who developed Achromobacter denitrificans pneumonia 3 months after KTx. There was clinical improvement with antibiotic treatment, but without a radiological resolution. An additional reduction of the EVR dose resulted only in partial resolution of radiological abnormalities. We performed a functional analysis of peripheral blood neutrophils and monocytes. The ability of phagocytosis and oxidative burst generation against A. denitrificans and Escherichia coli was significantly decreased on EVR treatment as compared to the control healthy person, and significantly improved after 3 weeks of EVR absence. Additionally, these processes were significantly affected by increasing doses of EVR in vitro in the control healthy donor in a dose-dependent manner. EVR discontinuation, with no additional antibiotic treatment, resulted in complete recovery and resolution of pulmonary infiltrates. Our findings suggest that dose-dependent impairment of neutrophil/monocyte phagocytic activity and oxidative burst generation might be a potential mechanism for EVR pulmonary toxicity.
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Granata S, Carratù P, Stallone G, Zaza G. mTOR-Inhibition and COVID-19 in Kidney Transplant Recipients: Focus on Pulmonary Fibrosis. Front Pharmacol 2021; 12:710543. [PMID: 34497515 PMCID: PMC8419255 DOI: 10.3389/fphar.2021.710543] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 08/11/2021] [Indexed: 12/24/2022] Open
Abstract
Kidney transplant recipients are at high risk of developing severe COVID-19 due to the coexistence of several transplant-related comorbidities (e.g., cardiovascular disease, diabetes) and chronic immunosuppression. As a consequence, a large part of SARS-CoV-2 infected patients have been managed with a reduction of immunosuppression. The mTOR-I, together with antimetabolites, have been often discontinued in order to minimize the risk of pulmonary toxicity and to antagonize pharmacological interaction with antiviral/anti-inflammatory drugs. However, at our opinion, this therapeutic strategy, although justified in kidney transplant recipients with severe COVID-19, should be carefully evaluated in asymptomatic/paucisymptomatic patients in order to avoid the onset of acute allograft rejections, to potentially exploit the mTOR-I antiviral properties, to reduce proliferation of conventional T lymphocytes (which could mitigate the cytokine storm) and to preserve Treg growth/activity which could reduce the risk of progression to severe disease. In this review, we discuss the current literature regarding the therapeutic potential of mTOR-Is in kidney transplant recipients with COVID-19 with a focus on pulmonary fibrosis.
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Affiliation(s)
- Simona Granata
- Renal Unit, Department of Medicine, University-Hospital of Verona, Verona, Italy
| | - Pierluigi Carratù
- Division of Internal Medicine, Clinica Medica "A. Murri", Department of Biomedical Sciences and Human Oncology, "Aldo Moro" University of Bari, Bari, Italy
| | - Giovanni Stallone
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Science, University of Foggia, Foggia, Italy
| | - Gianluigi Zaza
- Renal Unit, Department of Medicine, University-Hospital of Verona, Verona, Italy
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Drug-Related Pneumonitis in Cancer Treatment during the COVID-19 Era. Cancers (Basel) 2021; 13:cancers13051052. [PMID: 33801385 PMCID: PMC7958630 DOI: 10.3390/cancers13051052] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 02/24/2021] [Indexed: 12/17/2022] Open
Abstract
Interstitial lung disease is recognized as a group of diseases with a different etiopathogenesis characterized by chronic lung inflammation with the accumulation of inflammatory cells, lymphocytes and macrophages, and the consequent release of proinflammatory cytokines. Various degrees of pulmonary fibrosis can be associated with this inflammatory condition. Interstitial lung disease related to oncological drugs is a relevant problem in clinical practice. The etiopathogenetic mechanisms underlying this adverse event are not completely known but can be partly explained by the mechanism of action of the drug involved. Therefore, knowledge of the relevance of this potentially fatal adverse event supported by the reported safety data of pivotal studies becomes fundamental in the management of patients. The prompt diagnosis of drug-related pneumonia and the consequent differential diagnosis with other forms of pneumonia allow a rapid suspension of treatment and the establishment of an immunosuppressive treatment if necessary. In the context of the health emergency related to SARS CoV2 infection and COVID-19-related interstitial lung disease, such knowledge holds decisive relevance in the conscious choice of cancer treatments. Our intent was to describe the oncological drugs most correlated with this adverse event by reporting, where possible, the percentages of insurgency in pivotal studies to provide an overview and therefore promote greater awareness of this important toxicity related to oncological treatment.
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Baseline effector cells predict response and NKT cells predict pulmonary toxicity in advanced breast cancer patients treated with everolimus and exemestane. Int Immunopharmacol 2021; 93:107404. [PMID: 33524804 DOI: 10.1016/j.intimp.2021.107404] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 12/20/2020] [Accepted: 12/21/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND The mTOR inhibitor everolimus used in cancer has immune-modulating effects, potentially contributing to an antitumor response but also leading to pulmonary toxicity. We studied the association of immunological cell subsets with antitumor response and pulmonary toxicity in breast cancer patients treated with everolimus plus exemestane. METHODS In this exploratory analysis, peripheral blood mononuclear cells (PBMCs) were collected at baseline and 14, 35, 60, and 90 days after start of treatment, and at the moment of pulmonary toxicity. The percentage and absolute number of T-cells, B-cells, NK-cells, monocytes and numerous subtypes were measured in peripheral blood using flow cytometric analysis and were compared using a (paired) t-test. RESULTS From 20 patients, a total of 89 samples were collected. At baseline, responders versus non-responders had 0.86% versus 0.32% CD4+ effector cells (CD45RA+CD27-) (p = 0.1266) and non-response could be predicted with 0.71 sensitivity and 0.82 specificity. Patients who developed pulmonary toxicity compared to patients without pulmonary toxicity had relatively more NKT-cells at baseline (6.0% versus 1.3%, p = 0.0068, 59 k versus 12 k * 109/l, p = 0.0081) and at the moment of toxicity (5.2% versus 1.2%, p = 0.0106 and 47 k versus 16 k * 109/l, p = 0.0466). Baseline percentage NKT cells predicted pulmonary toxicity with 0.78 sensitivity and 1.0 specificity. CONCLUSIONS Our results suggest that baseline CD4+ effector cells may be predictive of antitumor responses and baseline NKT cells may be predictive of pulmonary toxicity. These results warrant further validation.
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Saleemi S, Alothman B, Albaiz F, Alrasheedi S, Shah YZ, Saleemi A. Role of Fluorodeoxyglucose Positron Emission Tomogram Scan in Sirolimus-Induced Lung Toxicity: A Rare Case Report. EXP CLIN TRANSPLANT 2020; 18:847-850. [PMID: 33349211 DOI: 10.6002/ect.2020.0306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Lung toxicity is a rare but serious side effect of sirolimus, a mammalian target of rapamycin inhibitor used as an immunosuppressive agent in solid-organ transplant recipients. We report a case of 67-year-old man who had living-related renal transplant 12 years previously that was complicated by chronic allograft dysfunction. He presented with fever, cough, and shortness of breath, and his chest imaging showed bilateral patchy and ground glass opacities. Before symptoms of lung toxicity, the patient's sirolimus levels were in the range of high normal. Bronchoalveolar lavage ruled out infection, and a transbronchial biopsy was inconclusive. A fluorodeoxyglucose positron emission tomogram scan showed high uptake in the area of lung opacities with a standard uptake value of 4.7. His symptoms improved after he was switched from sirolimus to tacrolimus, and a thoracic computed tomography scan after 6 weeks showed complete resolution. Pulmonary toxicity should be considered in any patient on sirolimus with respiratory symptoms and opacities on chest imaging. The role of fluorodeoxyglucose positron emission tomogram scan in evaluation of sirolimus-induced lung toxicity has not been previously described, and this is the first report of this type of scan finding indicating intense inflammation in this condition.
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Affiliation(s)
- Sarfraz Saleemi
- From the Section of Pulmonary Medicine, Department of Medicine, King Faisal Specialist, Hospital & Research Center, Riyadh, Saudi Arabia
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Gong C, Xiao Q, Li Y, Gu Y, Zhang J, Wang L, Cao J, Tao Z, Zhao Y, Xie Y, Hu X, Wang B. Everolimus-Related Pneumonitis in Patients with Metastatic Breast Cancer: Incidence, Radiographic Patterns, and Relevance to Clinical Outcome. Oncologist 2020; 26:e580-e587. [PMID: 33191524 DOI: 10.1002/onco.13594] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 10/22/2020] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND This study investigated the incidence, radiographic patterns, and relevance to clinical outcome of everolimus-related pneumonitis (ERP) in patients with metastatic breast cancer (MBC). MATERIALS AND METHODS Data of patients with MBC treated with everolimus who had baseline and at least one follow-up chest computed tomography (CT) were obtained from a medical electronic database system. An independent review of the CT scans of these patients was conducted by two radiologists (NCT03730428). Log-rank and Cox proportional hazard regression analyses were used for time-to-event analyses. RESULTS ERP was radiographically detected in 45 of 86 patients (52.3%). In more than 80% of these patients, ERP occurred during the first 4 months of everolimus treatment. Only 14 of the 45 patients with ERP were symptomatic (31.1%). Symptoms included cough, fever, and shortness of breath. Bilateral and lower distribution of the pneumonitis was most common. In most of the cases, ground-glass opacities and reticular opacities were noticed. Elderly patients were more likely to develop ERP. Patients with ERP had significantly longer progression-free survival (PFS; 6.8 vs. 4.1 months, p = .024) and overall survival (OS; 42.8 vs. 21.3 months, p = .016). ERP was a predictor of OS improvement confirmed by multivariate Cox analysis (hazard ratio, 0.49; 95% confidence interval, 0.25-0.97; p = .040). CONCLUSIONS ERP was noted in half of the patients with MBC treated with everolimus. Our data suggested that ERP was associated with improved prognosis and may be used as a biomarker for the efficacy of everolimus in MBC. Close monitoring, prompt diagnosis, and proper treatment for ERP are essential to maintain the quality of life of patients and achieve maximum treatment benefits. IMPLICATIONS FOR PRACTICE Everolimus-related pneumonitis (ERP) is one of the most worrying drug adverse events, especially in Asian patients. However, little has been known about the clinical and radiographic details of ERP in patients with metastatic breast cancers (MBCs) treated with everolimus. The present study investigated the clinical characteristics, radiographic patterns, and its correlation with treatment outcome in patients with MBC. ERP was identified in more than half of patients with MBC during everolimus therapy and was associated with improved outcome. Close monitoring and prompt diagnosis and appropriate treatment for ERP are critical for the preservation of patients' quality of life and achievement of maximal treatment benefits.
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Affiliation(s)
- Chengcheng Gong
- Departments of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Qin Xiao
- Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Yi Li
- Departments of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Yajia Gu
- Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Jian Zhang
- Departments of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Leiping Wang
- Departments of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Jun Cao
- Departments of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Zhonghua Tao
- Departments of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Yannan Zhao
- Departments of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Yizhao Xie
- Departments of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Xichun Hu
- Departments of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Biyun Wang
- Departments of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
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Rodriguez-Cubillo B, de la Higuera MAM, Lucena R, Franci EV, Hurtado M, Romero NC, Moreno AR, Valencia D, Velo M, Fornie IS, Sanchez-Fructuoso AI. Should cyclosporine be useful in renal transplant recipients affected by SARS-CoV-2? Am J Transplant 2020; 20:3173-3181. [PMID: 32529737 PMCID: PMC7307110 DOI: 10.1111/ajt.16141] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 05/26/2020] [Accepted: 06/08/2020] [Indexed: 01/25/2023]
Abstract
Minimization of immunosuppression and administration of antiretrovirals have been recommended for kidney transplant recipients (KTRs) with coronavirus disease 2019 (COVID-19). However, outcomes remain poor. Given the likely benefit of cyclosporine because of its antiviral and immunomodulatory effect, we have been using it as a strategy in KTRs diagnosed with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We studied 29 kidney transplant recipients (KTRs) who were admitted to our institution with COVID-19 between March 15and April, 24, 2020. Mycophenolate and/or mammalian target of rapamycin inhibitors (mTORi) were discontinued in all patients. Two therapeutic strategies were compared: Group 1, minimization of calcineurin inhibitors (N = 6); and Group 2, cyclosporine-based therapy (N = 23), with 15 patients switched from tacrolimus. Hydroxychloroquine was considered in both strategies but antivirals in none. Six patients died after respiratory distress (20.6%). Five required mechanical ventilation (17.2%), and 3 could be weaned. Nineteen patients had an uneventful recovery (65.5%). In group 1, 3 of 6 patients died (50%) and 1 of 6 required invasive mechanical ventilation (16.7%). In group 2, 3 of 23 patients died (12.5%). Renal function did not deteriorate and signs of rejection were not observed in any patient on the second treatment regime. In conclusion, immunosuppressant treatment based on cyclosporine could be safe and effective for KTRs diagnosed with COVID-19.
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Affiliation(s)
- Beatriz Rodriguez-Cubillo
- Nephrology Department, Hospital Clinico San Carlos, Madrid, Spain
- Correspondence Beatriz Rodriguez-Cubillo
| | | | - Rafael Lucena
- Nephrology Department, Hospital Clinico San Carlos, Madrid, Spain
| | - Elena V. Franci
- Nephrology Department, Hospital Clinico San Carlos, Madrid, Spain
| | - Maria Hurtado
- Nephrology Department, Hospital Clinico San Carlos, Madrid, Spain
| | | | | | - Daniela Valencia
- Nephrology Department, Hospital Clinico San Carlos, Madrid, Spain
| | - Mercedes Velo
- Nephrology Department, Hospital Clinico San Carlos, Madrid, Spain
| | - Iñigo S. Fornie
- Internal Medicine Department, Hospital Clinico San Carlos, Madrid, Spain
| | - Ana I. Sanchez-Fructuoso
- Nephrology Department, Hospital Clinico San Carlos, University of Medicine Complutense de Madrid, Madrid, Spain
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13
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The immuno-oncological challenge of COVID-19. ACTA ACUST UNITED AC 2020; 1:946-964. [DOI: 10.1038/s43018-020-00122-3] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 09/02/2020] [Indexed: 02/06/2023]
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14
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Davidson KR, Ha DM, Schwarz MI, Chan ED. Bronchoalveolar lavage as a diagnostic procedure: a review of known cellular and molecular findings in various lung diseases. J Thorac Dis 2020; 12:4991-5019. [PMID: 33145073 PMCID: PMC7578496 DOI: 10.21037/jtd-20-651] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Bronchoalveolar lavage (BAL) is a commonly used procedure in the evaluation of lung disease as it allows for sampling of the lower respiratory tract. In many circumstances, BAL differential cell counts have been reported to be typical of specific lung disorders. In addition, more specific diagnostic tests including molecular assays such as polymerase chain reaction (PCR) or enzyme-linked immunosorbent assay, special cytopathologic stains, or particular microscopic findings have been described as part of BAL fluid analysis. This review focuses on common cellular and molecular findings of BAL in a wide range of lung diseases. Since the performance of the first lung irrigation in 1927, BAL has become a common and important diagnostic tool. While some pulmonary disorders have a highly characteristic signature of BAL findings, BAL results alone often lack specificity and require interpretation along with other clinical and radiographic details. Development of new diagnostic assays is certain to reinforce the utility of BAL in the future. Our review of the BAL literature is intended to serve as a resource to assist clinicians in the care of patients with lung disorders.
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Affiliation(s)
- Kevin R Davidson
- Division of Pulmonary Sciences & Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Duc M Ha
- Division of Pulmonary Sciences & Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, USA.,Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA
| | - Marvin I Schwarz
- Division of Pulmonary Sciences & Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Edward D Chan
- Division of Pulmonary Sciences & Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, USA.,National Jewish Health, Denver, Colorado, USA
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15
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Carrozzo M, Eriksen JG, Bensadoun RJ, Boers-Doets CB, Lalla RV, Peterson DE. Oral Mucosal Injury Caused by Targeted Cancer Therapies. J Natl Cancer Inst Monogr 2020; 2019:5551364. [PMID: 31425602 DOI: 10.1093/jncimonographs/lgz012] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 03/14/2019] [Accepted: 05/01/2019] [Indexed: 02/06/2023] Open
Abstract
Targeted cancer therapies have fundamentally transformed the treatment of many types of cancers over the past decade, including breast, colorectal, lung, and pancreatic cancers, as well as lymphoma, leukemia, and multiple myeloma. The unique mechanisms of action of these agents have resulted in many patients experiencing enhanced tumor response together with a reduced adverse event profile as well. Toxicities do continue to occur, however, and in selected cases can be clinically challenging to manage. Of particular importance in the context of this monograph is that the pathobiology for oral mucosal lesions caused by targeted cancer therapies has only been preliminarily investigated. There is distinct need for novel basic, translational, and clinical research strategies to enhance design of preventive and therapeutic approaches for patients at risk for development of these lesions. The research modeling can be conceptually enhanced by extrapolating "lessons learned" from selected oral mucosal conditions in patients without cancer as well. This approach may permit determination of the extent to which pathobiology and clinical management are either similar to or uniquely distinct from oral mucosal lesions caused by targeted cancer therapies. Modeling associated with oral mucosal disease in non-oncology patients is thus presented in this context as well. This article addresses this emerging paradigm, with emphasis on current mechanistic modeling and clinical treatment. This approach is in turn designed to foster delineation of new research strategies, with the goal of enhancing cancer patient treatment in the future.
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Affiliation(s)
- M Carrozzo
- Center for Oral Health Research, Oral Medicine Department, School of Dental Sciences, Newcastle University, UK
| | - J Grau Eriksen
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - R-J Bensadoun
- Institut Niçois de Cancérologie (INC), Centre de Haute Energie, Nice, France
| | - C B Boers-Doets
- CancerMed, Department of Medical Strategy, Wormer, The Netherlands.,Impaqtt Foundation, Department of Adverse Event Research & Valorisation, Wormer, The Netherlands
| | - R V Lalla
- Section of Oral Medicine, Department of Oral Health & Diagnostic Sciences, School of Dental Medicine, UConn Health, Farmington, CT
| | - D E Peterson
- Section of Oral Medicine, Department of Oral Health & Diagnostic Sciences, School of Dental Medicine & Neag Comprehensive Cancer Center, UConn Health, Farmington, CT
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16
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Kelchtermans J, Chang J, Glaberson W, DeFreitas M, Alba-Sandoval M, Chandar J. A Pediatric Case of Sirolimus-Associated Pneumonitis After Kidney Transplantation. J Pediatr Pharmacol Ther 2020; 25:459-464. [PMID: 32641918 DOI: 10.5863/1551-6776-25.5.459] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Sirolimus is an immunosuppressive medication often used in solid organ transplantation. It has been associated with severe side effects, including pulmonary toxicity. In adult patients, a single center study found that 14% of those treated with sirolimus developed pulmonary pneumonitis; however, the incidence in the pediatric population is not known. Most reports in adult patients indicate that elevated drug concentrations and a prolonged duration of use are associated with pulmonary toxicity. We report a case of a 17-year-old male kidney transplant recipient who developed rapid-onset respiratory failure, necessitating mechanical ventilation and acute renal replacement therapy for ultrafiltration secondary to sirolimus-induced pneumonitis. He had been treated for acute rejection with corticosteroids 17 days prior to the development of pneumonitis. His symptoms developed within 1 week of initiation of sirolimus and with a serum concentration of 1.1 ng/mL. Sirolimus was discontinued, and, following aggressive diuresis and ventilatory support, his respiratory status returned to baseline. Sirolimus-induced pneumonitis is an important diagnosis to be considered in any transplant recipient receiving sirolimus with new onset fever, cough, or dyspnea without an identifiable source, especially if there is a preceding history of treatment with high-dose corticosteroids.
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17
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Willemsen AECAB, Tol J, van Erp NP, Jonker MA, de Boer M, Meek B, de Jong PC, van Moorsel C, Gerritsen WR, Grutters JC, van Herpen CML. Prospective Study of Drug-induced Interstitial Lung Disease in Advanced Breast Cancer Patients Receiving Everolimus Plus Exemestane. Target Oncol 2020; 14:441-451. [PMID: 31325105 PMCID: PMC6684805 DOI: 10.1007/s11523-019-00656-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Everolimus-related interstitial lung disease (ILD) (also: pneumonitis) poses a difficulty for physicians, as it is hard to discriminate ILD from other causes of respiratory symptoms and to decide on safe treatment continuation. OBJECTIVE We investigated the capability of pulmonary function tests (PFT), plasma biomarkers, everolimus pharmacokinetics, and FDG-PET to discriminate between everolimus-related ILD and other causes of respiratory problems and to predict the severity of ILD. PATIENTS AND METHODS Women starting treatment with everolimus plus exemestane for advanced breast cancer were included. At baseline and during the first 3 months, respiratory symptoms, PFT with diffusion capacity of the lungs for carbon monoxide corrected for hemoglobin (DLCOc) and forced vital capacity, serum plasma biomarkers (including SP-D and YKL-40), everolimus trough concentration, and 18F-FDG-PET were prospectively recorded. RESULTS Twenty-seven (out of 29 included) patients were evaluable for analysis. Fifteen patients (56%) developed everolimus-related respiratory signs or symptoms and four patients (15%) needed everolimus discontinuation and received corticosteroids. Change in DLCOc differentiated ILD from alternative diagnoses with 0.91 sensitivity and 0.78 specificity. Decrease in DLCOc (non-significant) was greatest in patients who needed everolimus discontinuation. Serum SP-D and YKL-40 could differentiate ILD from alternative diagnoses with 0.83 and 0.83 sensitivity, and 0.85 and 0.62 specificity, respectively. 18F-FDG-PET abnormalities did not precede clinical symptoms. No relationship between ILD and everolimus trough concentration was found. CONCLUSIONS This study shows that everolimus-related ILD occurs frequently. Prospective monitoring of DLCOc in combination with measurement of serum SP-D and YKL-40 appear useful to discriminate ILD from other causes of respiratory symptoms. Clinicaltrials.gov identifier: NCT01978171.
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Affiliation(s)
- Annelieke E C A B Willemsen
- Department of Medical Oncology, Radboud university medical center, route 452, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Jolien Tol
- Department of Medical Oncology, Jeroen Bosch Hospital, P.O. Box 90153, 5200 ME, 's Hertogenbosch, The Netherlands
| | - Nielka P van Erp
- Department of Pharmacy, Radboud university medical center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Marianne A Jonker
- Department for Health Evidence, Radboud university medical center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Maaike de Boer
- Division of Medical Oncology Department of Internal Medicine, GROW-School of Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Bob Meek
- Department of Pulmonology, St. Antonius Hospital, Centre of Interstitial Lung Diseases, Nieuwegein, The Netherlands
| | - Paul C de Jong
- Department of Medical Oncology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Coline van Moorsel
- Department of Pulmonology, St. Antonius Hospital, Centre of Interstitial Lung Diseases, Nieuwegein, The Netherlands.,Division Heart & Lungs, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Winald R Gerritsen
- Department of Medical Oncology, Radboud university medical center, route 452, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Jan C Grutters
- Department of Pulmonology, St. Antonius Hospital, Centre of Interstitial Lung Diseases, Nieuwegein, The Netherlands.,Division Heart & Lungs, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Carla M L van Herpen
- Department of Medical Oncology, Radboud university medical center, route 452, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
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18
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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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19
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Gatz JD, Spangler R. Evaluation of the Renal Transplant Recipient in the Emergency Department. Emerg Med Clin North Am 2019; 37:679-705. [PMID: 31563202 DOI: 10.1016/j.emc.2019.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Renal transplants are becoming more and more frequent in the United States and worldwide. Studies demonstrate that these patients inevitably end up visiting an emergency department. In addition to typical medical and surgical problems encountered in the general population, this group of patients has unique problems arising from their immunocompromised state and also due to side effects of the medications required. This article discusses these risks and management decisions that the emergency department physician should be aware of in order to prevent adverse outcomes for the patient and transplanted kidney.
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Affiliation(s)
- John David Gatz
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, Sixth Floor, Suite 200, Baltimore, MD 21201, USA
| | - Ryan Spangler
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, Sixth Floor, Suite 200, Baltimore, MD 21201, USA.
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20
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Zhang Y, Yan H, Xu Z, Yang B, Luo P, He Q. Molecular basis for class side effects associated with PI3K/AKT/mTOR pathway inhibitors. Expert Opin Drug Metab Toxicol 2019; 15:767-774. [PMID: 31478386 DOI: 10.1080/17425255.2019.1663169] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: The phosphatidylinositide 3-kinase/AKT/mammalian target of rapamycin (PI3K/AKT/mTOR) signaling pathway has emerged as an important target in cancer therapy. Numerous PI3K/AKT/mTOR pathway inhibitors are extensively studied; some are used clinically, but most of these drugs are undergoing clinical trials. Potential adverse effects, such as severe hepatotoxicity and pneumonitis, have largely restricted the application and clinical significance of these inhibitors. A summary of mechanisms underlying the adverse effects is not only significant for the development of novel PI3K/AKT/mTOR inhibitors but also beneficial for the optimal use of existing drugs. Areas covered: We report a profile of the adverse effects, which we consider the class effects of PI3K/AKT/mTOR inhibitors. This review also discusses potential molecular toxicological mechanisms of these agents, which might drive future drug discovery. Expert opinion: Severe toxicities associated with PI3K/AKT/mTOR inhibitors hinder their approval and limit long-term clinical application of these drugs. A better understanding regarding PI3K/AKT/mTOR inhibitor-induced toxicities is needed. However, the mechanisms underlying these toxicities remain unclear. Future research should focus on developing strategies to reduce toxicities of approved inhibitors as well as accelerating new drug development. This review will be useful to clinical, pharmaceutical, and toxicological researchers.
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Affiliation(s)
- Ying Zhang
- Institute of Pharmacology & Toxicology, College of Pharmaceutical Sciences, Zhejiang University , Hangzhou , China
| | - Hao Yan
- Institute of Pharmacology & Toxicology, College of Pharmaceutical Sciences, Zhejiang University , Hangzhou , China
| | - Zhifei Xu
- Institute of Pharmacology & Toxicology, College of Pharmaceutical Sciences, Zhejiang University , Hangzhou , China
| | - Bo Yang
- Institute of Pharmacology & Toxicology, College of Pharmaceutical Sciences, Zhejiang University , Hangzhou , China
| | - Peihua Luo
- Institute of Pharmacology & Toxicology, College of Pharmaceutical Sciences, Zhejiang University , Hangzhou , China
| | - Qiaojun He
- Institute of Pharmacology & Toxicology, College of Pharmaceutical Sciences, Zhejiang University , Hangzhou , China
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21
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Elmariah H, Fuchs EJ. Post-transplantation cyclophosphamide to facilitate HLA-haploidentical hematopoietic cell transplantation: Mechanisms and results. Semin Hematol 2019; 56:183-189. [DOI: 10.1053/j.seminhematol.2018.09.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Accepted: 09/15/2018] [Indexed: 01/31/2023]
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22
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Joo SJ, Yildirim I, Stenger EO, Anderson EJ. Sirolimus-associated pericardial effusion with cardiac tamponade and interstitial pneumonitis in a hematopoietic stem cell transplant recipient. Pediatr Transplant 2019; 23:e13425. [PMID: 31012209 DOI: 10.1111/petr.13425] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Revised: 02/10/2019] [Accepted: 03/11/2019] [Indexed: 12/24/2022]
Abstract
Sirolimus, a mammalian target of rapamycin (mTOR) inhibitor, is a potent immunosuppressant that is increasingly used in prevention and treatment of graft-vs-host disease (GVHD) in allogeneic hematopoietic stem cell transplant (HSCT) patients. However, data regarding its adverse effects in HSCT patients remain limited. We describe an 18-year-old HSCT patient with a history of invasive fungal infection, who developed pericardial effusion with cardiac tamponade and interstitial pneumonitis while receiving sirolimus for GVHD prophylaxis. Our case illustrates potentially life-threatening complications of sirolimus use in allogeneic HSCT patients.
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Affiliation(s)
- Su Jin Joo
- Division of Pediatric Infectious Diseases, Nationwide Children's Hospital, Columbus, Ohio.,Division of Pediatric Infectious Diseases, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Inci Yildirim
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia.,Rollins School of Public Health, Department of Epidemiology, Emory University, Atlanta, Georgia
| | - Elizabeth O Stenger
- Division of Pediatric Hematology and Oncology, Emory University, Atlanta, Georgia
| | - Evan J Anderson
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia.,Division of Infectious Diseases, Department of Internal Medicine, Emory University School of Medicine, Atlanta, Georgia
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23
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Choudhary NS, Saigal S, Sonavane A, Prakash AK, Pandey A, Saraf N, Soin AS. A Case of Sirolimus-Induced Interstitial Lung Disease After Liver Transplantation. J Clin Exp Hepatol 2019; 9:539-540. [PMID: 31516270 PMCID: PMC6728530 DOI: 10.1016/j.jceh.2018.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 09/26/2018] [Indexed: 12/12/2022] Open
Abstract
Mammalian target of rapamycin inhibitors (mTORis) are immunosuppression agents that are commonly used in solid organ transplantation. Available mTORis include sirolimus and everolimus. Interstitial lung disease (ILD) is an uncommon side effect of mTORis in liver transplantation. A high index of suspicion is needed, and timely intervention can reverse the disease. We present a case of sirolimus-induced ILD that improved after discontinuation of sirolimus.
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Affiliation(s)
- Narendra S. Choudhary
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Sanjiv Saigal
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India,Address for correspondence: Sanjiv Saigal, Director – Hepatology, Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Medanta The Medicity Hospital, Sector 38, Gurgaon, Delhi (NCR), India. Tel.: +919811552928.
| | - Amey Sonavane
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Ashish K. Prakash
- Department of Respiratory Medicine and Sleep Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Arvind Pandey
- Department of Radiodiagnosis, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Neeraj Saraf
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Arvinder S. Soin
- Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
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Li L, Mok H, Jhaveri P, Bonnen MD, Sikora AG, Eissa NT, Komaki RU, Ghebre YT. Anticancer therapy and lung injury: molecular mechanisms. Expert Rev Anticancer Ther 2018; 18:1041-1057. [PMID: 29996062 PMCID: PMC6290681 DOI: 10.1080/14737140.2018.1500180] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Chemotherapy and radiation therapy are two mainstream strategies applied in the treatment of cancer that is not operable. Patients with hematological or solid tumor malignancies substantially benefit from chemotherapeutic drugs and/or ionizing radiation delivered to the site of malignancy. However, considerable adverse effects, including lung inflammation and fibrosis, are associated with the use of these treatment modalities. Areas covered: As we move toward the era of precision health, we are compelled to understand the molecular basis of chemoradiation-induced pathological lung remodeling and to develop effective treatment strategies that mitigate the development of chronic lung disease (i.e. fibrosis) in cancer patients. The review discusses chemotherapeutic agents that are reported to induce or associate with acute and/or chronic lung injury. Expert commentary: There is a need to molecularly understand how chemotherapeutic drugs induce or associate with respiratory toxicities and whether such characteristics are inherently related to their antitumor effect or are collateral. Once such mechanisms have been identified and/or fully characterized, they may be able to guide disease-management decisions including effective intervention strategies for the adverse effects. In the meantime, radiation oncologists should be judicious on the dose of radiation delivered to the lungs, the volume of lung irradiated, and concurrent use of chemotherapeutic drugs.
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Affiliation(s)
- Li Li
- Department of Radiation Oncology, Baylor College of Medicine, Houston, Texas, USA
- Departmet of Endocrinology, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Henry Mok
- Department of Radiation Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - Pavan Jhaveri
- Department of Radiation Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - Mark D Bonnen
- Department of Radiation Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - Andrew G Sikora
- Department of Otolaryngology - Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - N. Tony Eissa
- Department of Medicine, Section on Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Ritsuko U Komaki
- University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
| | - Yohannes T Ghebre
- Department of Radiation Oncology, Baylor College of Medicine, Houston, Texas, USA
- Department of Medicine, Section on Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, Texas, USA
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25
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Granata S, Santoro G, Masola V, Tomei P, Sallustio F, Pontrelli P, Accetturo M, Antonucci N, Carratù P, Lupo A, Zaza G. In Vitro Identification of New Transcriptomic and miRNomic Profiles Associated with Pulmonary Fibrosis Induced by High Doses Everolimus: Looking for New Pathogenetic Markers and Therapeutic Targets. Int J Mol Sci 2018; 19:ijms19041250. [PMID: 29677166 PMCID: PMC5979287 DOI: 10.3390/ijms19041250] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 04/17/2018] [Accepted: 04/17/2018] [Indexed: 12/24/2022] Open
Abstract
The administration of Everolimus (EVE), a mTOR inhibitor used in transplantation and cancer, is often associated with adverse effects including pulmonary fibrosis. Although the underlying mechanism is not fully clarified, this condition could be in part caused by epithelial to mesenchymal transition (EMT) of airway cells. To improve our knowledge, primary bronchial epithelial cells (BE63/3) were treated with EVE (5 and 100 nM) for 24 h. EMT markers (α-SMA, vimentin, fibronectin) were measured by RT-PCR. Transepithelial resistance was measured by Millicell-ERS ohmmeter. mRNA and microRNA profiling were performed by Illumina and Agilent kit, respectively. Only high dose EVE increased EMT markers and reduced the transepithelial resistance of BE63/3. Bioinformatics showed 125 de-regulated genes that, according to enrichment analysis, were implicated in collagen synthesis/metabolism. Connective tissue growth factor (CTGF) was one of the higher up-regulated mRNA. Five nM EVE was ineffective on the pro-fibrotic machinery. Additionally, 3 miRNAs resulted hyper-expressed after 100 nM EVE and able to regulate 31 of the genes selected by the transcriptomic analysis (including CTGF). RT-PCR and western blot for MMP12 and CTGF validated high-throughput results. Our results revealed a complex biological network implicated in EVE-related pulmonary fibrosis and underlined new potential disease biomarkers and therapeutic targets.
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Affiliation(s)
- Simona Granata
- Renal Unit, Department of Medicine, University of Verona, Piazzale Stefani 1, 37126 Verona, Italy.
| | - Gloria Santoro
- Renal Unit, Department of Medicine, University of Verona, Piazzale Stefani 1, 37126 Verona, Italy.
| | - Valentina Masola
- Renal Unit, Department of Medicine, University of Verona, Piazzale Stefani 1, 37126 Verona, Italy.
| | - Paola Tomei
- Renal Unit, Department of Medicine, University of Verona, Piazzale Stefani 1, 37126 Verona, Italy.
| | - Fabio Sallustio
- Department of Emergency and Organ Transplantation, University of Bari "Aldo Moro", Piazza Giulio Cesare 11, 70124 Bari, Italy.
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari "Aldo Moro", Piazza Giulio Cesare 11, 70124 Bari, Italy.
| | - Paola Pontrelli
- Department of Emergency and Organ Transplantation, University of Bari "Aldo Moro", Piazza Giulio Cesare 11, 70124 Bari, Italy.
| | - Matteo Accetturo
- Department of Emergency and Organ Transplantation, University of Bari "Aldo Moro", Piazza Giulio Cesare 11, 70124 Bari, Italy.
| | - Nadia Antonucci
- Renal Unit, Department of Medicine, University of Verona, Piazzale Stefani 1, 37126 Verona, Italy.
| | - Pierluigi Carratù
- Department of Respiratory Diseases, University of Bari "Aldo Moro", Piazza Giulio Cesare 11, 70124 Bari, Italy.
| | - Antonio Lupo
- Renal Unit, Department of Medicine, University of Verona, Piazzale Stefani 1, 37126 Verona, Italy.
| | - Gianluigi Zaza
- Renal Unit, Department of Medicine, University of Verona, Piazzale Stefani 1, 37126 Verona, Italy.
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26
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Almeida F, Amorim S, Sarmento A, Santos L. Life-Threatening Everolimus-Associated Pneumonitis: A Case Report and a Review of the Literature. Transplant Proc 2018; 50:933-938. [PMID: 29588066 DOI: 10.1016/j.transproceed.2017.12.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 12/04/2017] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Noninfective pneumonitis is a class-related effect within mammalian target of rapamycin (mTOR) inhibitors, including everolimus, and can occasionally be severe. CASE REPORT A 62-year-old man, medicated with everolimus due to a heart transplantation 17 years previously and with chronic kidney disease, was admitted to the intensive care unit (ICU) with acute respiratory failure, cardiovascular shock, and impaired renal function requiring dialysis. Computed tomography (CT) scan revealed right upper lobe consolidation. Extensive microbiological workup, autoimmune testing, and cytology were negative and echocardiography showed preserved heart function. Everolimus levels were normal (5.7-6.1 ng/mL) and the drug was suspended at day 9. The patient was difficult to ventilate and responded poorly to broad-spectrum antibiotic and antifungal therapy. On day 25, CT scan and bronchoscopy revealed left-sided alveolar hemorrhage, and corticosteroid pulses were performed. The patient gradually improved. After discharge and 6 months of follow-up, clinical recovery was complete and chest imaging substantially improved. DISCUSSION Pneumonitis occurs in up to 4.3% of transplant recipients using everolimus for immunosuppression. Despite usually presenting as a mild and self-limited disease, severe cases have been described. Alveolar hemorrhage can occur and is associated with poor outcome. Everolimus levels do not seem to accurately predict toxicity. Corticosteroid therapy has been used with success in severe disease. We review the pathophysiological, clinical, and management-related aspects of this entity with emphasis on its potential severity. CONCLUSION Our case was a rare occurrence of severe life-threatening pulmonary disease related to everolimus. Awareness of the potential severity of this entity is important for the management of patients using mTOR inhibitors.
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Affiliation(s)
- F Almeida
- Infectious Diseases Department, Centro Hospitalar de São João, Porto, Portugal.
| | - S Amorim
- Cardiology Department, Centro Hospitalar de São João, Porto, Portugal
| | - A Sarmento
- Infectious Diseases Department, Centro Hospitalar de São João, Alameda Professor Hernani Monteiro, Porto, Portugal; i3S, Instituto de Inovação e Investigação em Saúde, Grupo de I&D em Nefrologia e Doenças Infeciosas, Department of Medicine, Faculty of Medicine, University of Porto, Porto, Portugal
| | - L Santos
- Infectious Diseases Department, Centro Hospitalar de São João, Porto, Portugal
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Alvarez RH, Bechara RI, Naughton MJ, Adachi JA, Reuben JM. Emerging Perspectives on mTOR Inhibitor-Associated Pneumonitis in Breast Cancer. Oncologist 2018; 23:660-669. [PMID: 29487226 DOI: 10.1634/theoncologist.2017-0343] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 01/03/2018] [Indexed: 01/14/2023] Open
Abstract
Substantial improvements in the early detection and treatment of breast cancer have led to improvements in survival, but breast cancer remains a significant cause of morbidity and mortality in women. In 2012, the mammalian target of rapamycin (mTOR) inhibitor everolimus was approved by the U.S. Food and Drug Administration for the treatment of advanced breast cancer in patients resistant to endocrine therapy. Although everolimus is generally well tolerated, mTOR inhibitor-associated pneumonitis is one of the most common adverse drug events leading to treatment discontinuation. To date, the underlying pathophysiology of this toxicity is unclear, and this uncertainty may hinder the optimization of management strategies. However, experiences from breast cancer and renal cell carcinoma clinical trials indicate that mTOR inhibitor-associated pneumonitis can be effectively managed by early detection, accurate diagnosis, and prompt intervention that generally involves everolimus dose reductions, interruptions, or discontinuation. Management can be achieved by a multidisciplinary approach that involves the collaborative efforts of nurses, oncologists, radiologists, infectious disease specialists, pulmonologists, clinical pharmacists, and pathologists. Comprehensive education must be provided to all health care professionals involved in managing patients receiving everolimus therapy. Although general recommendations on the management of mTOR inhibitor-associated pneumonitis have been published, there is a lack of consensus on the optimal management of this potentially serious complication. This article provides an overview of mTOR inhibitor-associated pneumonitis, with a focus on the detection, accurate diagnosis, and optimal management of this class-related complication of mTOR inhibitor therapy. IMPLICATIONS FOR PRACTICE This article summarizes the pathogenesis, clinical presentation, incidence, detection, and optimal management of everolimus-related noninfectious pneumonitis in breast cancer. In particular, this article provides a detailed overview of the important aspects of the detection, accurate diagnosis, and appropriate management of mammalian target of rapamycin inhibitor-associated pneumonitis. In addition, this article emphasizes that effective management of this adverse drug event in patients with breast cancer will require a multidisciplinary approach and collaboration among various health care professionals.
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Affiliation(s)
| | | | - Michael J Naughton
- Siteman Cancer Center, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Javier A Adachi
- The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - James M Reuben
- The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Elmariah H, Kasamon YL, Zahurak M, Macfarlane KW, Tucker N, Rosner GL, Bolaños-Meade J, Fuchs EJ, Wagner-Johnston N, Swinnen LJ, Huff CA, Matsui WH, Gladstone DE, McCurdy SR, Borrello I, Gocke CB, Shanbhag S, Cooke KR, Ali SA, Brodsky RA, DeZern AE, Luznik L, Jones RJ, Ambinder RF. Haploidentical Bone Marrow Transplantation with Post-Transplant Cyclophosphamide Using Non-First-Degree Related Donors. Biol Blood Marrow Transplant 2018; 24:1099-1102. [PMID: 29452245 DOI: 10.1016/j.bbmt.2018.02.005] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Accepted: 02/08/2018] [Indexed: 10/18/2022]
Abstract
Outcomes of nonmyeloablative (NMA) haploidentical (haplo) blood or marrow transplant (BMT) with post-transplantation cyclophosphamide (PTCy) using non-first-degree relatives are unknown. We evaluated 33 consecutive adult patients (median age, 56 years) with hematologic malignancies who underwent NMA haplo T cell-replete BMT with PTCy at Johns Hopkins using second- or third-degree related donors. Donors consisted of 10 nieces (30%), 9 nephews (27%), 7 first cousins (21%), 5 grandchildren (15%), and 2 uncles (6%). Thirty-one patients (94%) reached full donor chimerism by day 60. The estimated cumulative incidence (CuI) of grades II to IV acute graft-versus-host disease (aGVHD) at day 180 was 24% (90% confidence interval [CI], 9% to 38%). Only 1 patient experienced grades III to IV aGVHD. At 1 year the CuI of chronic GVHD was 10% (90% CI, 0% to 21%). The CuI of nonrelapse mortality at 1 year was 5% (90% CI, 0% to 14%). At 1 year the probability of relapse was 31% (90% CI, 12% to 49%), progression-free survival 64% (90% CI, 48% to 86%), and overall survival 95% (90% CI, 87% to 100%). The 1-year probability of GVHD-free, relapse-free survival was 57% (90% CI, 41% to 79%). NMA haplo BMT with PTCy from non-first-degree relatives is an acceptably safe and effective alternative donor platform, with results similar to those seen with first-degree relatives.
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Affiliation(s)
- Hany Elmariah
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Yvette L Kasamon
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Marianna Zahurak
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Karen W Macfarlane
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Noah Tucker
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Gary L Rosner
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Javier Bolaños-Meade
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ephraim J Fuchs
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nina Wagner-Johnston
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lode J Swinnen
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Carol Ann Huff
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - William H Matsui
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Douglas E Gladstone
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Shannon R McCurdy
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ivan Borrello
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christian B Gocke
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Satish Shanbhag
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kenneth R Cooke
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Syed Abbas Ali
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Robert A Brodsky
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Amy E DeZern
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Leo Luznik
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Richard J Jones
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Richard F Ambinder
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
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Gheith O, Cerna M, Halim MA, Nampoory N, Al-Otaibi T, Nair P, Said T, Atteya HA, Katchy K. Sirolimus-Induced Combined Posterior Reversible Encephalopathy Syndrome and Lymphocytic Pneumonitis in a Renal Transplant Recipient: Case Report and Review of the Literature. EXP CLIN TRANSPLANT 2017; 15:170-174. [PMID: 28260460 DOI: 10.6002/ect.mesot2016.p36] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The mammalian target of rapamycin inhibitor sirolimus was introduced into clinical transplant practice in 1999. Dose-related myelosuppression and hyper lipidemia are the most common adverse effects. Pulmonary toxicity has been reported since 2004 and can cause interstitial pneumonitis, organizing pneumonia, and alveolar hemorrhage. Moreover, it can occasionally induce posterior reversible encephalopathy syndrome, as documented in scarce reports. To our knowledge; this is the 1st report of combined posterior reversible encephalopathy syndrome and lymphocytic pneumonitis to be induced by sirolimus. Here, we present a renal transplant recipient with reversible sirolimus-induced brain lesions who was diagnosed after exclusion of infections (viral, bacterial, and fungal), tumors, sarcoidosis, and autoimmune disorders. Both brain lesions and pneumonitis resolved completely after sirolimus discontinuation with excellent patient and graft outcome. Early and gradual sirolimus withdrawal can reverse posterior reversible encephalopathy syndrome and lymphocytic pneumonitis with preservation of stable graft function.
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Affiliation(s)
- Osama Gheith
- Urology and Nephrology Center, Mansoura University, Mansoura, Egypt; the Hamed Al-Essa Organ Transplant Center, Sabah Area, Kuwait
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Matsuki R, Okuda K, Mitani A, Yamauchi Y, Tanaka G, Kume H, Homma Y, Hinata M, Hayashi A, Shibahara J, Fukayama M, Nagase T. A case of delayed exacerbation of interstitial lung disease after discontinuation of temsirolimus. Respir Med Case Rep 2017; 22:158-163. [PMID: 28840097 PMCID: PMC5558510 DOI: 10.1016/j.rmcr.2017.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 08/07/2017] [Accepted: 08/08/2017] [Indexed: 01/29/2023] Open
Abstract
Temsirolimus is an inhibitor of mammalian target of rapamycin and interstitial lung disease (ILD) is known to be one of the adverse events associated with temsirolimus, which usually improves rapidly after discontinuation of the drug and rarely worsens thereafter. Herein, we report a case of delayed exacerbation of ILD after discontinuation of temsirolimus for metastatic renal cell carcinoma in an 86-year-old male with chronic ILD. The patient developed gradually worsening dyspnea five weeks after an initiation of temsirolimus and was admitted to our facility. On his admission, although a pulmonary function test revealed a decreased diffusion capacity, there was no obvious progression of ILD on HRCT scan. His dyspnea once improved after discontinuation of temsirolimus, but it recurred and acute exacerbation of ILD was diagnosed 40 days after his last administration of temsirolimus. He received high-dose steroid therapy, however, he deteriorated and died. Histopathological examination of the lungs at autopsy revealed overlapping diffuse alveolar damage with chronic interstitial changes. In the present case, since there were no specific factors that could have caused acute exacerbation of ILD except for temsirolimus, it was considered to contribute to the exacerbation of underlying ILD. In conclusion, physicians should be aware of the possibility of temsirolimus-induced ILD not only while the medication is administered, but also even after it is discontinued. It is important to carefully interview the patient and to recognize the value of physiological tests, such as respiratory function tests and blood gas analysis, as well as imaging findings on HRCT.
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Key Words
- AaDO2, alveolar-arterial oxygen gradient
- Acute exacerbation
- CMV, cytomegalovirus
- CRP, C-reactive protein
- DAD, diffuse alveolar damage
- DILD, Drug-induced interstitial lung disease
- DLCO/VA, diffusion capacity for carbon monoxide corrected for alveolar volume
- Drug-induced pneumonia
- GGO, ground glass opacities
- HRCT, high resolution computed tomography
- ILD, interstitial lung disease
- IPF, idiopathic pulmonary fibrosis
- Interstitial lung disease
- KL-6, Krebs von den Lungen-6
- LD, lactate dehydrogenase
- NPPV, noninvasive negative pressure ventilation
- PaCO2, carbon dioxide partial pressure
- PaO2, oxygen partial pressure
- Temsirolimus
- UIP, usual interstitial pneumonia
- mPSL, methylprednisolone
- mTOR inhibitor
- mTOR, mammalian target of rapamycin
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Affiliation(s)
- Rei Matsuki
- Department of Respiratory Medicine, The University of Tokyo Hospital, Japan
| | - Kenichi Okuda
- Department of Respiratory Medicine, The University of Tokyo Hospital, Japan
| | - Akihisa Mitani
- Department of Respiratory Medicine, The University of Tokyo Hospital, Japan
| | - Yasuhiro Yamauchi
- Department of Respiratory Medicine, The University of Tokyo Hospital, Japan
| | - Goh Tanaka
- Department of Respiratory Medicine, The University of Tokyo Hospital, Japan
| | - Haruki Kume
- Department of Urology, The University of Tokyo Hospital, Japan
| | - Yukio Homma
- Department of Urology, The University of Tokyo Hospital, Japan
| | - Munetoshi Hinata
- Department of Pathology, The University of Tokyo Hospital, Japan
| | - Akimasa Hayashi
- Department of Pathology, The University of Tokyo Hospital, Japan
| | - Junji Shibahara
- Department of Pathology, The University of Tokyo Hospital, Japan
| | - Masashi Fukayama
- Department of Pathology, The University of Tokyo Hospital, Japan
| | - Takahide Nagase
- Department of Respiratory Medicine, The University of Tokyo Hospital, Japan
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Penttilä P, Donskov F, Rautiola J, Peltola K, Laukka M, Bono P. Everolimus-induced pneumonitis associates with favourable outcome in patients with metastatic renal cell carcinoma. Eur J Cancer 2017; 81:9-16. [DOI: 10.1016/j.ejca.2017.05.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 04/26/2017] [Accepted: 05/01/2017] [Indexed: 01/13/2023]
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Martins D, Lambrescu I, Barucca V, Fazio N. Everolimus-related adverse events in neuroendocrine tumors and comparative considerations with breast and renal cancer: a critical overview. Expert Opin Orphan Drugs 2017. [DOI: 10.1080/21678707.2017.1334550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Diana Martins
- Endocrinology, Diabetes and Metabolism Department of Coimbra Hospital and University Centre, Coimbra, Portugal
| | - Ioana Lambrescu
- Endocrinology Department, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Viola Barucca
- Division of Medical Oncology, Department of Oncology, Misericordia General Hospital, Grosseto, Italy
| | - Nicola Fazio
- Unit of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, European Institute of oncology, IEO, Milan, Italy
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Ji Y, Chen S, Xiang B, Li K, Xu Z, Yao W, Lu G, Liu X, Xia C, Wang Q, Li Y, Wang C, Yang K, Yang G, Tang X, Xu T, Wu H. Sirolimus for the treatment of progressive kaposiform hemangioendothelioma: A multicenter retrospective study. Int J Cancer 2017; 141:848-855. [PMID: 28486787 DOI: 10.1002/ijc.30775] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 04/02/2017] [Accepted: 04/26/2017] [Indexed: 02/05/2023]
Abstract
Kaposiform hemangioendothelioma (KHE) is an aggressive disease with high morbidity and mortality. The aim of this study was to retrospectively evaluate the efficacy and safety of sirolimus for the treatment of progressive KHE. A multicenter, retrospective cohort study was conducted in patients with progressive KHE treated with sirolimus. A total of 52 patients were analyzed. Thirty-seven (71%) patients exhibited Kasabach-Merritt phenomenon (KMP) and were significantly younger than the patients without KMP [95% confidence interval (CI), 14.39-41.61; p < 0.001]. Patients without KMP were all treated with sirolimus alone, whereas 21 KMP patients with severe symptoms received short-term combination therapy with prednisolone. Overall, 96% and 98% of patients showed improved relief of notable symptoms and/or improved complications at 6 and 12 months after treatment, respectively. After sirolimus treatment, significant decreases in mean severity scores occurred at 6 months (95% CI, 2.23-2.54, p < 0.001) and 12 months (95% CI, 1.53-1.90, p < 0.001). Compared to KMP patients, patients without KMP showed a response that was similar to but less pronounced during the 12 months of treatment (95% CI, 40.87-53.80; p < 0.001). For subgroup analysis of KMP patients, there were no significant differences in tumor shrinkage between those treated with combination therapy and those receiving sirolimus alone (95% CI, 18.11-25.02; p > 0.05). No patients permanently discontinued treatment due to toxicity-related events, and no drug-related deaths occurred. Sirolimus was effective and safe for the treatment of progressive KHE. Sirolimus may be considered as a first-line therapy or as part of a multidisciplinary approach for the treatment of KHE.
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Affiliation(s)
- Yi Ji
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Siyuan Chen
- Pediatric Intensive Care Unit, Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Bo Xiang
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Kai Li
- Division of Oncology, Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai, China
| | - Zhicheng Xu
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Wei Yao
- Division of Oncology, Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai, China
| | - Guoyan Lu
- Pediatric Intensive Care Unit, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Xingtao Liu
- Department of Vascular & Interventional Radiology, Chengdu Women and Children's Central Hospital, Chengdu, China
| | - Chuncao Xia
- Department of Radiology, West China Hospital of Sichuan University, Chengdu, China
| | - Qi Wang
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Yanan Li
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Chuan Wang
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Kaiying Yang
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Gang Yang
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China.,Department of Pediatric Surgery, Chengdu Shangjin Nanhu Hospital, Chengdu, China
| | - Xueyang Tang
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Ting Xu
- Department of Pediatric Surgery, Shanghai Children's Hospital, Shanghai, China
| | - Hao Wu
- Vascular Biology Program and Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
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Dettmer S, Grünwald V, Fuehner T, Ganser A, Wacker F, Ivanyi P, Rodt T. CT patterns of organizing pneumonia in patients treated with VEGF/mTOR inhibitors for metastatic renal cell cancer: an observational study. Acta Radiol Open 2017; 6:2058460117694216. [PMID: 28321331 PMCID: PMC5347262 DOI: 10.1177/2058460117694216] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Accepted: 01/24/2017] [Indexed: 12/23/2022] Open
Abstract
Background Targeted therapies are the standard treatment in patients with metastatic renal cell carcinoma (mRCC) and are known to cause adverse pulmonary events. Organizing pneumonia (OP) with its various manifestations in computed tomography (CT) has therefore lately received more attention. Purpose To describe the spectrum of CT patterns of OP in patients with mRCC receiving targeted therapies. Material and Methods Seventeen patients with known therapy-related OP were analyzed retrospectively by two blinded radiologists in consensus. Images were scored according to OP patterns that have previously been described. Additionally, the distribution and the predominant imaging pattern in each patient were determined. Results In our cohort, ground glass opacity was the most common imaging pattern (17/17, 100%) in patients with OP followed by a reticular pattern (12/17, 71%), consolidations (10/17, 59%), nodules (7/17, 41%), crazy paving (5/17, 29%), bronchi(ol)ectasis (4/17, 24%), focal mass (3/17, 18%), and reversed halo (1/17, 6%). The most common imaging pattern was changing multifocal consolidations (8/17, 47%). A bronchocentric and a nodular pattern were found in four patients (24%) each, a progressive fibrotic pattern in none patient, and reversed halo/atoll pattern in one (6%) case. Conclusion OP is the major differential diagnosis to be considered in patients with targeted therapies and pulmonary changes. Knowledge of the variety of imaging findings can facilitate diagnosis.
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Affiliation(s)
- Sabine Dettmer
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Viktor Grünwald
- Department of Haematology, Haemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Thomas Fuehner
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Arnold Ganser
- Department of Haematology, Haemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Frank Wacker
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Philipp Ivanyi
- Department of Haematology, Haemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Thomas Rodt
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
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Zhu J, Liu H, Cui H, Tang Z, Song C, Zhang R. Safety and efficacy of a novel abluminal groove-filled biodegradable polymer sirolimus-eluting stent. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2017; 28:54. [PMID: 28197826 DOI: 10.1007/s10856-017-5864-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 01/30/2017] [Indexed: 06/06/2023]
Abstract
Late stent thrombosis (LST) following drug-eluting stent (DES) implantation in patients with coronary artery disease (CAD) is often associated with delayed vascular healing, resulting from vascular inflammation and hypersensitivity to durable polymers and drugs. Therefore, DES design, materials, and coatings have been technologically revolutionized. Herein, we designed a novel abluminal groove-filled biodegradable polymer sirolimus-eluting stent (AGF-BP-SES), with a sirolimus content of only about one-third of traditional DES. The mechanical performances of AGF-BP-SES during compression and expansion were investigated. The pharmacokinetic (PK) profile of sirolimus was studied in the swine model. The in vivo efficacy of AGF-BP-SES was compared with that of Xience PRIME® stent. The results showed that AGF-BP-SES exhibited mechanical properties similar to traditional DES, including the rebound ratio of radial contraction/direction, rebound ratio of axial contraction/direction, and inhomogeneity of compression/expansion. Despite utilizing a reduced dose of sirolimus, AGF-BP-SES delivered sirolimus to the coronary artery in a controlled and efficient manner. The stent maintained a safe and effective local drug concentration without local or systemic risks. In the swine model, histopathological indicators predicted safety and biocompatibility of AGF-BP-SES. In conclusion, AGF-BP-SES maintained similar mechanical properties as other stents while reducing the drug-loading capacity, and showed a favorable safety and efficacy profile of the targeted DES.
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Affiliation(s)
- Jinzhou Zhu
- Department of Cardiology, Rui Jin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200025, China
| | - Huizhu Liu
- Department of Cardiology, Rui Jin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200025, China
| | - Haipo Cui
- Shanghai Institute for Minimally Invasive Therapy, School of Medical Instrument and Food Engineering, Shanghai Science and Technology University, Shanghai, 200093, China
| | - Zhirong Tang
- Shanghai Institute for Minimally Invasive Therapy, School of Medical Instrument and Food Engineering, Shanghai Science and Technology University, Shanghai, 200093, China
| | - Chengli Song
- Shanghai Institute for Minimally Invasive Therapy, School of Medical Instrument and Food Engineering, Shanghai Science and Technology University, Shanghai, 200093, China.
| | - Ruiyan Zhang
- Department of Cardiology, Rui Jin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200025, China.
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Interstitial Lung Disease After Kidney Transplantation and the Role of Everolimus. Transplant Proc 2017; 48:349-51. [PMID: 27109953 DOI: 10.1016/j.transproceed.2015.12.039] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 12/30/2015] [Indexed: 01/15/2023]
Abstract
BACKGROUND Kidney transplant recipients are at higher risk of developing pulmonary complications related to immunosuppression, and inhibitor of the mammalian target of rapamycin (mTORi) has been reported as a potential cause. METHODS Five hundred kidney-transplanted patients were retrospectively analyzed for pulmonary complications on the basis of clinical and instrumental data (chest radiography, high-resolution computed tomography, broncho-alveolar lavage, oximetry). RESULTS We found 26 interstitial lung diseases (ILD) (16%): 12 cases (46.2%) were from infections (42.8% by Pneumocystis jirovecii) and 14 cases of ILD (53.8%) resulted as drug-induced ILD (DI-ILD). According to anti-rejection protocols, DI-ILD occurred in 8 patients (57%) while on triple regimen including steroids, everolimus (EVL), and cyclosporine (CyA) and in 6 patients on double regimen with steroids and mTORi: EVL or sirolimus (43%). In ILD+ patients, everolimus trough-concentration (EVL(TLC)) and cyclosporine (2nd-hour concentration: CyA(C2)) levels were higher than in patients in the same regimen but with ILD- (EVL(TLC) [ng/mL] 9.84 versus 6.85; CyA(C2) [ng/mL] 303.97 versus 298.56). The formula that used the combined blood levels of both drugs (EVL(TLC) + CyA(C2)/100) resulted in a significant difference between groups of patients (12.88 ± 1.61 versus 9.83 ± 1.91). Applying receiver operator characteristic curve (ROC) analysis to detect risk of developing ILD when on combined protocol with EVL and CyA, we obtained an area under the curve of 0.8622 (P = .0081) and 0.9082 (P = .0028), respectively, when using EVL(TLC) or the combination formula with both drugs. CONCLUSIONS In renal transplant patients, we obtained a relationship of ILD to specific drug concentration. On the basis of ROC analysis, patients on EVL and CyA combined protocol are at risk of ILD when EVL(TLC) is >9.03 ng/mL or >11.41 when a formula with summation of EVL(TLC) and CyA(C2) is used.
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Recent Advances in Mammalian Target of Rapamycin Inhibitor Use in Heart and Lung Transplantation. Transplantation 2016; 100:2558-2568. [DOI: 10.1097/tp.0000000000001432] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Fernandes-Silva G, Ivani de Paula M, Rangel ÉB. mTOR inhibitors in pancreas transplant: adverse effects and drug-drug interactions. Expert Opin Drug Metab Toxicol 2016; 13:367-385. [DOI: 10.1080/17425255.2017.1239708] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Gabriel Fernandes-Silva
- Universidade Federal de São Paulo/Hospital do Rim e Hipertensão, Nephrology Department, São Paulo, SP, Brazil
| | - Mayara Ivani de Paula
- Universidade Federal de São Paulo/Hospital do Rim e Hipertensão, Nephrology Department, São Paulo, SP, Brazil
| | - Érika B. Rangel
- Universidade Federal de São Paulo/Hospital do Rim e Hipertensão, Nephrology Department, São Paulo, SP, Brazil
- Hospital Israelita Albert Einstein, Instituto Israelita de Ensino e Pesquisa, São Paulo, SP, Brazil
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Roles of mTOR complexes in the kidney: implications for renal disease and transplantation. Nat Rev Nephrol 2016; 12:587-609. [PMID: 27477490 DOI: 10.1038/nrneph.2016.108] [Citation(s) in RCA: 139] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The mTOR pathway has a central role in the regulation of cell metabolism, growth and proliferation. Studies involving selective gene targeting of mTOR complexes (mTORC1 and mTORC2) in renal cell populations and/or pharmacologic mTOR inhibition have revealed important roles of mTOR in podocyte homeostasis and tubular transport. Important advances have also been made in understanding the role of mTOR in renal injury, polycystic kidney disease and glomerular diseases, including diabetic nephropathy. Novel insights into the roles of mTORC1 and mTORC2 in the regulation of immune cell homeostasis and function are helping to improve understanding of the complex effects of mTOR targeting on immune responses, including those that impact both de novo renal disease and renal allograft outcomes. Extensive experience in clinical renal transplantation has resulted in successful conversion of patients from calcineurin inhibitors to mTOR inhibitors at various times post-transplantation, with excellent long-term graft function. Widespread use of this practice has, however, been limited owing to mTOR-inhibitor- related toxicities. Unique attributes of mTOR inhibitors include reduced rates of squamous cell carcinoma and cytomegalovirus infection compared to other regimens. As understanding of the mechanisms by which mTORC1 and mTORC2 drive the pathogenesis of renal disease progresses, clinical studies of mTOR pathway targeting will enable testing of evolving hypotheses.
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Zhang X, Ran YG, Wang KJ. Risk of mTOR inhibitors induced severe pneumonitis in cancer patients: a meta-analysis of randomized controlled trials. Future Oncol 2016; 12:1529-39. [PMID: 27067269 DOI: 10.2217/fon-2016-0020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Background: A meta-analysis of randomized controlled trials was performed to determine the overall risk of noninfectious severe pneumonitis associated with mTOR inhibitors (mTORi) in cancer patients. Materials & methods: PubMed, EMBASE and oncology conference proceedings were searched for relevant studies. Results: A total of 8377 patients from 16 randomized controlled trials were included. The incidence of severe pneumonitis associated with mTORi was 1.7% (95% CI: 1.1–2.5%). The use of mTORi significantly increased the risk of severe pneumonitis compared with controls (odds ratio: 3.36; 95% CI: 2.20–5.12). The analysis was stratified for drug types, tumor types, controlled therapy and mTORi-based regimens, but no significant differences in odds ratios were observed. Conclusion: mTORi significantly increase the risk of severe pneumonitis in cancer patients.
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Affiliation(s)
- Xi Zhang
- Department of Radiation Oncology, Affiliated Hospital of Hebei University, Baoding 071000, China
| | - Yu-ge Ran
- Department of Radiation Oncology, Affiliated Hospital of Hebei University, Baoding 071000, China
| | - Kun-jie Wang
- Department of Medical Oncology, Affiliated Hospital of Hebei University, Baoding 071000, China
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Wang X, Pan C, Gong J, Liu X, Li H. Enhancing the Enrichment of Pharmacophore-Based Target Prediction for the Polypharmacological Profiles of Drugs. J Chem Inf Model 2016; 56:1175-83. [PMID: 27187084 DOI: 10.1021/acs.jcim.5b00690] [Citation(s) in RCA: 134] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PharmMapper is a web server for drug target identification by reversed pharmacophore matching the query compound against an annotated pharmacophore model database, which provides a computational polypharmacology prediction approach for drug repurposing and side effect risk evaluation. But due to the inherent nondiscriminative feature of the simple fit scores used for prediction results ranking, the signal/noise ratio of the prediction results is high, posing a challenge for predictive reliability. In this paper, we improved the predictive accuracy of PharmMapper by generating a ligand-target pairwise fit score matrix from profiling all the annotated pharmacophore models against corresponding ligands in the original complex structures that were used to extract these pharmacophore models. The matrix reflects the noise baseline of fit score distribution of the background database, thus enabling estimation of the probability of finding a given target randomly with the calculated ligand-pharmacophore fit score. Two retrospective tests were performed which confirmed that the probability-based ranking score outperformed the simple fit score in terms of identification of both known drug targets and adverse drug reaction related off-targets.
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Affiliation(s)
- Xia Wang
- Shanghai Key Laboratory of New Drug Design, School of Pharmacy, and ‡School of Information Science and Engineering, East China University of Science and Technology , Shanghai 200237, China
| | - Chenxu Pan
- Shanghai Key Laboratory of New Drug Design, School of Pharmacy, and ‡School of Information Science and Engineering, East China University of Science and Technology , Shanghai 200237, China
| | - Jiayu Gong
- Shanghai Key Laboratory of New Drug Design, School of Pharmacy, and ‡School of Information Science and Engineering, East China University of Science and Technology , Shanghai 200237, China
| | - Xiaofeng Liu
- Shanghai Key Laboratory of New Drug Design, School of Pharmacy, and ‡School of Information Science and Engineering, East China University of Science and Technology , Shanghai 200237, China
| | - Honglin Li
- Shanghai Key Laboratory of New Drug Design, School of Pharmacy, and ‡School of Information Science and Engineering, East China University of Science and Technology , Shanghai 200237, China
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Tomei P, Masola V, Granata S, Bellin G, Carratù P, Ficial M, Ventura VA, Onisto M, Resta O, Gambaro G, Chilosi M, Lupo A, Zaza G. Everolimus-induced epithelial to mesenchymal transition (EMT) in bronchial/pulmonary cells: when the dosage does matter in transplantation. J Nephrol 2016; 29:881-891. [PMID: 27026415 DOI: 10.1007/s40620-016-0295-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 03/09/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Everolimus (EVE) is a mammalian target of rapamycin inhibitor (mTOR-I) widely used in transplantation that may determine some severe adverse events, including pulmonary fibrosis. The pathogenic mechanism of mTOR-I-associated pulmonary toxicity is still unclear, but epithelial to mesenchymal transition (EMT) of bronchial/pulmonary cells may play a role. METHODS Three cell lines-human type II pneumocyte-derived A549, normal bronchial epithelial, and bronchial epithelial homozygous for the delta F508 cystic fibrosis-causing mutation-were treated with EVE or tacrolimus at different concentrations. Real-time polymerase chain reaction and immunofluorescence were used to evaluate mRNA and protein levels of EMT markers (alpha-SMA, vimentin, fibronectin). Subsequently, in 13 EVE- and 13 tacrolimus-treated patients we compared the rate of lung fibrosis, estimated by an arbitrary pulmonary fibrosis index score (PFIS). RESULTS Biomolecular experiments demonstrated that high doses of EVE (100 nM) up-regulated EMT markers in all cell lines at both gene- and protein level. High concentrations of EVE were also able to reduce the mRNA levels of epithelial markers (E-cadherin and ZO-1) and to induce the phosphorylation of AKT. In the in vivo part of the study, PFIS was significantly higher in the EVE-group than the tacrolimus-group (p = 0.03) and correlated with trough levels (R2 = 0.35). CONCLUSIONS Our data reveal, for the first time, a dose-dependent EVE-induced EMT in airway cells. They suggest that clinicians should employ, wherever possible, low dosages of mTOR-Is in transplant recipients, assessing periodically their pulmonary function.
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Affiliation(s)
- Paola Tomei
- Department of Medicine, Renal Unit, University of Verona, Piazzale A. Stefani 1, 37126, Verona, VR, Italy
| | - Valentina Masola
- Department of Medicine, Renal Unit, University of Verona, Piazzale A. Stefani 1, 37126, Verona, VR, Italy
| | - Simona Granata
- Department of Medicine, Renal Unit, University of Verona, Piazzale A. Stefani 1, 37126, Verona, VR, Italy
| | - Gloria Bellin
- Department of Medicine, Renal Unit, University of Verona, Piazzale A. Stefani 1, 37126, Verona, VR, Italy
| | | | - Miriam Ficial
- Department of Pathology and Diagnostic, Anatomic Pathology Section, University of Verona, Verona, Italy
| | | | - Maurizio Onisto
- Department of Biomedical Sciences, University of Padova, Padua, Italy
| | - Onofrio Resta
- Institute of Pulmonary Disease, University of Bari, Bari, Italy
| | - Giovanni Gambaro
- Division of Nephrology and Dialysis, School of Medicine Rome, Columbus-Gemelli Hospital Catholic University, Rome, Italy
| | - Marco Chilosi
- Department of Pathology and Diagnostic, Anatomic Pathology Section, University of Verona, Verona, Italy
| | - Antonio Lupo
- Department of Medicine, Renal Unit, University of Verona, Piazzale A. Stefani 1, 37126, Verona, VR, Italy
| | - Gianluigi Zaza
- Department of Medicine, Renal Unit, University of Verona, Piazzale A. Stefani 1, 37126, Verona, VR, Italy.
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Phase 2 study of idelalisib and entospletinib: pneumonitis limits combination therapy in relapsed refractory CLL and NHL. Blood 2016; 127:2411-5. [PMID: 26968534 DOI: 10.1182/blood-2015-12-683516] [Citation(s) in RCA: 115] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 02/29/2016] [Indexed: 12/12/2022] Open
Abstract
Although agents targeting B-cell receptor signaling have provided practice-changing results in relapsed chronic lymphocytic leukemia (CLL) and non-Hodgkin lymphoma (NHL), they require prolonged administration and provide incomplete responses. Given synergistic preclinical activity with phosphatidylinositol 3-kinase δ and spleen tyrosine kinase inhibition, this phase 2 study evaluated the safety and efficacy of the combination of idelalisib and entospletinib. Eligible patients with relapsed or refractory CLL or NHL underwent intrapatient dose escalation with each agent. With a median treatment exposure of 10 weeks, 60% and 36% of patients with CLL or follicular lymphoma, respectively, achieved objective responses. However, the study was terminated early because of treatment-emergent pneumonitis in 18% of patients (severe in 11 of 12 cases). Although most patients recovered with supportive measures and systemic steroids, 2 fatalities occurred and were attributed to treatment-emergent pneumonitis. Increases of interferon-γ and interleukins 6, 7, and 8 occurred over time in patients who developed pneumonitis. Future studies of novel combinations should employ conservative designs that incorporate pharmacodynamics/biomarker monitoring. These investigations should also prospectively evaluate plasma cytokine/chemokine levels in an attempt to validate biomarkers predictive of response and toxicity. This trial was registered at www.clinicaltrials.gov as #NCT01796470.
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Sabet-Baktach M, Schmitz V, Pratschke J. Trauma-Management beim organtransplantierten Patienten. Notf Rett Med 2016. [DOI: 10.1007/s10049-016-0130-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Sharif S, Kong MW, Drakakis J, Cunha BA. Fever of unknown origin (FUO) in a renal transplant recipient due to drug fever from sirolimus. Infection 2016; 44:559-61. [DOI: 10.1007/s15010-016-0877-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 01/17/2016] [Indexed: 11/30/2022]
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Ventura-Aguiar P, Campistol JM, Diekmann F. Safety of mTOR inhibitors in adult solid organ transplantation. Expert Opin Drug Saf 2016; 15:303-19. [PMID: 26667069 DOI: 10.1517/14740338.2016.1132698] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Mammalian target of rapamycin (mTOR) inhibitors (sirolimus and everolimus) are a class of immunosuppressive drugs approved for solid organ transplantation (SOT). By inhibiting the ubiquitous mTOR pathway, they present a peculiar safety profile. The increased incidence of serious adverse events in early studies halted the enthusiasm as a kidney sparing alternative to calcineurin inhibitors (CNI). AREAS COVERED Herein we review mTOR inhibitors safety profile for adult organ transplantation, ranging from acute side effects, such as lymphoceles, delayed wound healing, or cytopenias, to long-term ones which increase morbidity and mortality, such as cancer risk and metabolic profile. Infection, proteinuria, and cutaneous safety profiles are also addressed. EXPERT OPINION In the authors' opinion, mTOR inhibitors are a safe alternative to standard immunosuppression therapy with CNI and mycophenolate/azathioprine. Mild adverse events can be easily managed with an increased awareness and close monitoring of trough levels. Most serious side effects are dose- and organ-dependent. In kidney and heart transplantation mTOR inhibitors may be safely used as either low-dose de novo or through early-conversion. In the liver, conversion 4 weeks post-transplantation may reduce long-term chronic kidney disease secondary to calcineurin nephrotoxicity, without increasing hepatic artery/portal vein thrombosis.
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Affiliation(s)
- Pedro Ventura-Aguiar
- a Department of Nephrology and Renal Transplantation , Hospital Clínic , Villarroel, 170, E-08036 Barcelona , Spain
| | - Josep Maria Campistol
- a Department of Nephrology and Renal Transplantation , Hospital Clínic , Villarroel, 170, E-08036 Barcelona , Spain.,b August Pi i Sunyer Biomedical Research Institute (IDIBAPS) , University of Barcelona , Barcelona , Spain
| | - Fritz Diekmann
- a Department of Nephrology and Renal Transplantation , Hospital Clínic , Villarroel, 170, E-08036 Barcelona , Spain
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Sadowski K, Kotulska K, Jóźwiak S. Management of side effects of mTOR inhibitors in tuberous sclerosis patients. Pharmacol Rep 2016; 68:536-42. [PMID: 26891243 DOI: 10.1016/j.pharep.2016.01.005] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Revised: 01/07/2016] [Accepted: 01/08/2016] [Indexed: 01/20/2023]
Abstract
mTOR inhibitors represent a relatively new therapeutic option in the management of patients affected by tuberous sclerosis complex (TSC). Randomized clinical trials support the use of everolimus in the treatment of subependymal giant cell astrocytomas (SEGA) and renal angiomyolipomas (AML) related to TSC. Accumulating data suggest also systemic disease-modifying potential of mTOR inhibitors. Given that increasing number of patients with TSC receive mTOR inhibitors, the issue of adverse events associated with this therapy becomes practically important. In the present study we provide the overview of clinical manifestations and therapeutic options for the most common adverse events related to mTOR inhibitors in TSC patients.
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Affiliation(s)
- Krzysztof Sadowski
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warszawa, Poland.
| | - Katarzyna Kotulska
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warszawa, Poland.
| | - Sergiusz Jóźwiak
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warszawa, Poland; Department of Pediatric Neurology, Warsaw Medical University, Warszawa, Poland.
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Ratkovic M, Basic-Jukic N, Radunovic D. Possible Sirolimus-Induced Acute Pancreatitis in a Renal Transplant Recipient. Ther Apher Dial 2016; 20:208-9. [DOI: 10.1111/1744-9987.12371] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Revised: 06/05/2015] [Accepted: 08/10/2015] [Indexed: 11/27/2022]
Affiliation(s)
- Marina Ratkovic
- Department of Nephrology and Dialysis; Clinical Centre Montenegro; Podgorica Montenegro
| | - Nikolina Basic-Jukic
- Department of Nephrology and Dialysis; Clinical Centre Montenegro; Podgorica Montenegro
- Department of Nephrology, Arterial Hypertension, Dialysis and Transplantation; University Hospital Centre Zagreb; Zagreb Croatia
| | - Danilo Radunovic
- Department of Nephrology and Dialysis; Clinical Centre Montenegro; Podgorica Montenegro
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Lung Transplantation. PATHOLOGY OF TRANSPLANTATION 2016. [PMCID: PMC7153460 DOI: 10.1007/978-3-319-29683-8_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The therapeutic options for patients with advanced pulmonary parenchymal or vascular disorders are currently limited. Lung transplantation remains one of the few viable interventions, but on account of the insufficient donor pool only a minority of these patients actually undergo the procedure each year. Following transplantation there are a number of early and late allograft complications such as primary graft dysfunction, allograft rejection, infection, post-transplant lymphoproliferative disorder and late injury that is now classified as chronic lung allograft dysfunction. The pathologist plays an essential role in the diagnosis and classification of these myriad complications. Although the transplant procedures are performed in selected centers patients typically return to their local centers. When complications arise it is often the responsibility of the local pathologist to evaluate specimens. Therefore familiarity with the pathology of lung transplantation is important.
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