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Jiménez-Romero C, Justo Alonso I, Caso Maestro O, Manrique Municio A, García-Sesma Á, Calvo Pulido J, Cambra Molero F, Loinaz Segurola C, Martín-Arriscado C, Nutu A, Marcacuzco Quinto A. Indications and Long-Term Outcomes of Using Mycophenolate Mofetil Monotherapy in Substitution for Calcineurin Inhibitors in Liver Transplantation. Transpl Int 2025; 38:13790. [PMID: 40060933 PMCID: PMC11886422 DOI: 10.3389/ti.2025.13790] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2024] [Accepted: 01/27/2025] [Indexed: 05/13/2025]
Abstract
Switching the use of calcineurin inhibitors (CNIs), as basal immunosuppression in liver transplantation (LT) patients, for that of mycophenolate mofetil monotherapy (MMF-MT) is currently considered a good measure in recipients with chronic kidney disease (CKD) and other CNI-related adverse effects. We analyzed a retrospective cohort series of 324 LT patients who underwent long-term follow-up and were switched from CNI immunosuppression to MMF-MT due to CKD and other CNI-related adverse effects (diabetes, hypertension, infection). The median time on MMF-MT was 78 months. The indication for MMF-MT was CKD alone or associated with CNI-related adverse effects in 215 patients, diabetes in 61, hypertension in 42, and recurrent cholangitis in 6. Twenty-four (7.4%) patients developed non-resistant acute rejection post-MMF-MT, and 48 (14.8%) patients experienced MMF-related adverse effects, with MMF-MT withdrawn in only 8 (2.5%) patients. In the comparison between the pre-MMF-MT period and the last outpatient review, using a repeated measures model and taking each patient as its own comparator, we demonstrated a significant increase in GFR and significant decrease in creatinine and ALT values, remaining the other variables (diabetes, hypertension, and hematological and AST) within similar levels. Five-year survival post-MMF-MT conversion was 75.3%. MMF-MT significantly improved renal function, was well tolerated, and had a low rejection rate.
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Affiliation(s)
- Carlos Jiménez-Romero
- Unit of Hepato-Pancreato-Biliary Surgery and Abdominal Organ Transplantation, Doce de Octubre University Hospital, Madrid, Spain
- Department of Surgery, Faculty of Medicine, Complutense University, Madrid, Spain
| | - Iago Justo Alonso
- Unit of Hepato-Pancreato-Biliary Surgery and Abdominal Organ Transplantation, Doce de Octubre University Hospital, Madrid, Spain
- Department of Surgery, Faculty of Medicine, Complutense University, Madrid, Spain
| | - Oscar Caso Maestro
- Unit of Hepato-Pancreato-Biliary Surgery and Abdominal Organ Transplantation, Doce de Octubre University Hospital, Madrid, Spain
- Department of Surgery, Faculty of Medicine, Complutense University, Madrid, Spain
| | - Alejandro Manrique Municio
- Unit of Hepato-Pancreato-Biliary Surgery and Abdominal Organ Transplantation, Doce de Octubre University Hospital, Madrid, Spain
- Department of Surgery, Faculty of Medicine, Complutense University, Madrid, Spain
| | - Álvaro García-Sesma
- Unit of Hepato-Pancreato-Biliary Surgery and Abdominal Organ Transplantation, Doce de Octubre University Hospital, Madrid, Spain
- Department of Surgery, Faculty of Medicine, Complutense University, Madrid, Spain
| | - Jorge Calvo Pulido
- Unit of Hepato-Pancreato-Biliary Surgery and Abdominal Organ Transplantation, Doce de Octubre University Hospital, Madrid, Spain
- Department of Surgery, Faculty of Medicine, Complutense University, Madrid, Spain
| | - Félix Cambra Molero
- Unit of Hepato-Pancreato-Biliary Surgery and Abdominal Organ Transplantation, Doce de Octubre University Hospital, Madrid, Spain
- Department of Surgery, Faculty of Medicine, Complutense University, Madrid, Spain
| | - Carmelo Loinaz Segurola
- Unit of Hepato-Pancreato-Biliary Surgery and Abdominal Organ Transplantation, Doce de Octubre University Hospital, Madrid, Spain
- Department of Surgery, Faculty of Medicine, Complutense University, Madrid, Spain
| | | | - Anisa Nutu
- Unit of Hepato-Pancreato-Biliary Surgery and Abdominal Organ Transplantation, Doce de Octubre University Hospital, Madrid, Spain
- Department of Surgery, Faculty of Medicine, Complutense University, Madrid, Spain
| | - Alberto Marcacuzco Quinto
- Unit of Hepato-Pancreato-Biliary Surgery and Abdominal Organ Transplantation, Doce de Octubre University Hospital, Madrid, Spain
- Department of Surgery, Faculty of Medicine, Complutense University, Madrid, Spain
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Machado-Duque ME, Gaviria-Mendoza A, Valladales-Restrepo LF, Vallejos-Narváez Á, Piragauta-Vargas N, Machado-Alba JE. Prescription Patterns of Mycophenolate Mofetil in a Group of Patients from Colombia. Healthcare (Basel) 2024; 12:2224. [PMID: 39595422 PMCID: PMC11593479 DOI: 10.3390/healthcare12222224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2024] [Revised: 10/22/2024] [Accepted: 11/05/2024] [Indexed: 11/28/2024] Open
Abstract
BACKGROUND Mycophenolate mofetil is used for the prevention of solid organ transplant rejection and for other indications, such as systemic lupus erythematosus (SLE). OBJECTIVE To determine the prescription patterns of mycophenolate mofetil in a group of Colombian patients. METHODS This was a cross-sectional study of patients receiving mycophenolate mofetil between 2021 and 2022. The data were obtained from a drug dispensing database. Sociodemographic, clinical (diagnostic), and pharmacological variables were identified. RESULTS A total of 979 patients who underwent treatment were identified; their mean age was 45.9 ± 17.1 years, and 87.4% were women. The main diagnosis associated with the use of mycophenolate mofetil was SLE (39.1%), followed by other rheumatic diseases (8.5%), nephrotic syndrome (7.5%), and solid organ transplantation (6.4%). The relationship between the mean dose and the defined daily dose was 0.75. Ten percent of patients received mycophenolate alone, whereas 32.9% received mycophenolate in combination therapy with conventional disease-modifying antirheumatic drugs and glucocorticoids. A total of 76.2% had polypharmacy (five or more drugs). CONCLUSIONS Mycophenolate mofetil is used mainly in combination therapy for patients with SLE and other rheumatological diseases and for solid organ transplants at doses lower than those recommended.
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Affiliation(s)
- Manuel Enrique Machado-Duque
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A., Pereira 660003, Risaralda, Colombia; (M.E.M.-D.); (A.G.-M.); (L.F.V.-R.)
- Grupo de Investigación Biomedicina, Facultad de Medicina, Fundación Universitaria Autónoma de las Américas, Pereira 660003, Risaralda, Colombia
| | - Andrés Gaviria-Mendoza
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A., Pereira 660003, Risaralda, Colombia; (M.E.M.-D.); (A.G.-M.); (L.F.V.-R.)
- Grupo de Investigación Biomedicina, Facultad de Medicina, Fundación Universitaria Autónoma de las Américas, Pereira 660003, Risaralda, Colombia
| | - Luis Fernando Valladales-Restrepo
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A., Pereira 660003, Risaralda, Colombia; (M.E.M.-D.); (A.G.-M.); (L.F.V.-R.)
- Grupo de Investigación Biomedicina, Facultad de Medicina, Fundación Universitaria Autónoma de las Américas, Pereira 660003, Risaralda, Colombia
| | | | | | - Jorge Enrique Machado-Alba
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A., Pereira 660003, Risaralda, Colombia; (M.E.M.-D.); (A.G.-M.); (L.F.V.-R.)
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Berg T, Aehling NF, Bruns T, Welker MW, Weismüller T, Trebicka J, Tacke F, Strnad P, Sterneck M, Settmacher U, Seehofer D, Schott E, Schnitzbauer AA, Schmidt HH, Schlitt HJ, Pratschke J, Pascher A, Neumann U, Manekeller S, Lammert F, Klein I, Kirchner G, Guba M, Glanemann M, Engelmann C, Canbay AE, Braun F, Berg CP, Bechstein WO, Becker T, Trautwein C. [Not Available]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:1397-1573. [PMID: 39250961 DOI: 10.1055/a-2255-7246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Affiliation(s)
- Thomas Berg
- Bereich Hepatologie, Medizinischen Klinik II, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Niklas F Aehling
- Bereich Hepatologie, Medizinischen Klinik II, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Tony Bruns
- Medizinische Klinik III, Universitätsklinikum Aachen, Aachen, Deutschland
| | - Martin-Walter Welker
- Medizinische Klinik I Gastroent., Hepat., Pneum., Endokrin. Universitätsklinikum Frankfurt, Frankfurt, Deutschland
| | - Tobias Weismüller
- Klinik für Innere Medizin - Gastroenterologie und Hepatologie, Vivantes Humboldt-Klinikum, Berlin, Deutschland
| | - Jonel Trebicka
- Medizinische Klinik B für Gastroenterologie und Hepatologie, Universitätsklinikum Münster, Münster, Deutschland
| | - Frank Tacke
- Charité - Universitätsmedizin Berlin, Medizinische Klinik m. S. Hepatologie und Gastroenterologie, Campus Virchow-Klinikum (CVK) und Campus Charité Mitte (CCM), Berlin, Deutschland
| | - Pavel Strnad
- Medizinische Klinik III, Universitätsklinikum Aachen, Aachen, Deutschland
| | - Martina Sterneck
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Hamburg, Hamburg, Deutschland
| | - Utz Settmacher
- Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Universitätsklinikum Jena, Jena, Deutschland
| | - Daniel Seehofer
- Klinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Eckart Schott
- Klinik für Innere Medizin II - Gastroenterologie, Hepatologie und Diabetolgie, Helios Klinikum Emil von Behring, Berlin, Deutschland
| | | | - Hartmut H Schmidt
- Klinik für Gastroenterologie und Hepatologie, Universitätsklinikum Essen, Essen, Deutschland
| | - Hans J Schlitt
- Klinik und Poliklinik für Chirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Johann Pratschke
- Chirurgische Klinik, Charité Campus Virchow-Klinikum - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Andreas Pascher
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Münster, Münster, Deutschland
| | - Ulf Neumann
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen, Essen, Deutschland
| | - Steffen Manekeller
- Klinik und Poliklinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Bonn, Deutschland
| | - Frank Lammert
- Medizinische Hochschule Hannover (MHH), Hannover, Deutschland
| | - Ingo Klein
- Chirurgische Klinik I, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Gabriele Kirchner
- Klinik und Poliklinik für Chirurgie, Universitätsklinikum Regensburg und Innere Medizin I, Caritaskrankenhaus St. Josef Regensburg, Regensburg, Deutschland
| | - Markus Guba
- Klinik für Allgemeine, Viszeral-, Transplantations-, Gefäß- und Thoraxchirurgie, Universitätsklinikum München, München, Deutschland
| | - Matthias Glanemann
- Klinik für Allgemeine, Viszeral-, Gefäß- und Kinderchirurgie, Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | - Cornelius Engelmann
- Charité - Universitätsmedizin Berlin, Medizinische Klinik m. S. Hepatologie und Gastroenterologie, Campus Virchow-Klinikum (CVK) und Campus Charité Mitte (CCM), Berlin, Deutschland
| | - Ali E Canbay
- Medizinische Klinik, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Deutschland
| | - Felix Braun
- Klinik für Allgemeine Chirurgie, Viszeral-, Thorax-, Transplantations- und Kinderchirurgie, Universitätsklinikum Schlewswig-Holstein, Kiel, Deutschland
| | - Christoph P Berg
- Innere Medizin I Gastroenterologie, Hepatologie, Infektiologie, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | - Wolf O Bechstein
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Frankfurt, Frankfurt, Deutschland
| | - Thomas Becker
- Klinik für Allgemeine Chirurgie, Viszeral-, Thorax-, Transplantations- und Kinderchirurgie, Universitätsklinikum Schlewswig-Holstein, Kiel, Deutschland
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Liu D, Youssef MM, Grace JA, Sinclair M. Relative carcinogenicity of tacrolimus vs mycophenolate after solid organ transplantation and its implications for liver transplant care. World J Hepatol 2024; 16:650-660. [PMID: 38689747 PMCID: PMC11056899 DOI: 10.4254/wjh.v16.i4.650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 01/30/2024] [Accepted: 03/19/2024] [Indexed: 04/24/2024] Open
Abstract
BACKGROUND De novo malignancy is a leading cause of late morbidity and mortality in liver transplant recipients. Cumulative immunosuppression has been shown to contribute to post-transplant malignancy (PTM) risk. There is emerging evidence on the differential carcinogenic risk profile of individual immunosuppressive drugs, independent of the net effect of immunosuppression. Calcineurin inhibitors such as tacrolimus may promote tumourigenesis, whereas mycophenolic acid (MPA), the active metabolite of mycophenolate mofetil, may limit tumour progression. Liver transplantation (LT) is relatively unique among solid organ transplantation in that immunosuppression monotherapy with either tacrolimus or MPA is often achievable, which makes careful consideration of the risk-benefit profile of these immunosuppression agents particularly relevant for this cohort. However, there is limited clinical data on this subject in both LT and other solid organ transplant recipients. AIM To investigate the relative carcinogenicity of tacrolimus and MPA in solid organ transplantation. METHODS A literature search was conducted using MEDLINE and Embase databases using the key terms "solid organ transplantation", "tacrolimus", "mycophenolic acid", and "carcinogenicity", in order to identify relevant articles published in English between 1st January 2002 to 11th August 2022. Related terms, synonyms and explosion of MeSH terms, Boolean operators and truncations were also utilised in the search. Reference lists of retrieved articles were also reviewed to identify any additional articles. Excluding duplicates, abstracts from 1230 records were screened by a single reviewer, whereby 31 records were reviewed in detail. Full-text articles were assessed for eligibility based on pre-specified inclusion and exclusion criteria. RESULTS A total of 6 studies were included in this review. All studies were large population registries or cohort studies, which varied in transplant era, type of organ transplanted and immunosuppression protocol used. Overall, there was no clear difference demonstrated between tacrolimus and MPA in de novo PTM risk following solid organ transplantation. Furthermore, no study provided a direct comparison of carcinogenic risk between tacrolimus and MPA monotherapy in solid organ transplantation recipients. CONCLUSION The contrasting carcinogenic risk profiles of tacrolimus and MPA demonstrated in previous experimental studies, and its application in solid organ transplantation, is yet to be confirmed in clinical studies. Thus, the optimal choice of immunosuppression drug to use as maintenance monotherapy in LT recipients is not supported by a strong evidence base and remains unclear.
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Affiliation(s)
- Dorothy Liu
- Department of Gastroenterology, Austin Health, Melbourne 3084, Victoria, Australia
- Victorian Liver Transplant Unit, Austin Health, Melbourne 3084, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne 3084, Victoria, Australia.
| | - Mark M Youssef
- Department of Medicine, University of Melbourne, Melbourne 3084, Victoria, Australia
| | - Josephine A Grace
- Department of Gastroenterology, Austin Health, Melbourne 3084, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne 3084, Victoria, Australia
| | - Marie Sinclair
- Department of Gastroenterology, Austin Health, Melbourne 3084, Victoria, Australia
- Victorian Liver Transplant Unit, Austin Health, Melbourne 3084, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne 3084, Victoria, Australia
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5
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Wadhawan M, Gupta C. Immunosuppression Monitoring-What Clinician Needs to Know? J Clin Exp Hepatol 2023; 13:691-697. [PMID: 37440936 PMCID: PMC10333948 DOI: 10.1016/j.jceh.2023.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 01/04/2023] [Indexed: 07/15/2023] Open
Abstract
The liver is well known for its immunotolerance, but rejection without immunosuppression is frequently encountered post liver transplantation, especially in humans.1 Indeed, the amount of immunosuppression required post liver transplant is less compared to other organ transplants like kidney, heart, and intestine.2 Reports of successful weaning of immunosuppression have been reported but are not practiced for fear of unwanted alloimmune response leading to rejection. Life-long immunosuppression is needed in most patients for graft survival but is associated with side effects like renal dysfunction, metabolic abnormalities, or risk of de novo malignancies. Also, the appropriate dose of immunosuppression to achieve adequate graft function and prevention of toxicities is very important. One shoe does not fit all. There are significant individual variations in response and side effect profile. Also, the level of immunosuppression varies with the underlying liver disease like autoimmune disease requires higher immunosuppression. Thus, monitoring the adequate immunosuppression with the minimization of drug toxicity is imperative post-transplant. Unfortunately, the current methods for immunosuppression monitoring rely on testing the immunosuppressive drug levels rather than the immune system activity. We have discussed the concept of alloreactivity, available methods of immunosuppression and drug monitoring and investigational methods in this review.
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Affiliation(s)
- Manav Wadhawan
- Institute of Digestive & Liver Diseases, BLK Superspeciality Hospital Delhi, India
| | - Charu Gupta
- Institute of Digestive & Liver Diseases, BLK Superspeciality Hospital Delhi, India
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Lee SK, Choi JY, Jung ES, Kwon JH, Jang JW, Bae SH, Yoon SK. An Immunological Perspective on the Mechanism of Drug Induced Liver Injury: Focused on Drugs for Treatment of Hepatocellular Carcinoma and Liver Transplantation. Int J Mol Sci 2023; 24:5002. [PMID: 36902432 PMCID: PMC10003078 DOI: 10.3390/ijms24055002] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 03/03/2023] [Indexed: 03/08/2023] Open
Abstract
The liver is frequently exposed to potentially toxic materials, and it is the primary site of clearance of foreign agents, along with many innate and adaptive immune cells. Subsequently, drug induced liver injury (DILI), which is caused by medications, herbs, and dietary supplements, often occurs and has become an important issue in liver diseases. Reactive metabolites or drug-protein complexes induce DILI via the activation of various innate and adaptive immune cells. There has been a revolutionary development of treatment drugs for hepatocellular carcinoma (HCC) and liver transplantation (LT), including immune checkpoint inhibitors (ICIs), that show high efficacy in patients with advanced HCC. Along with the high efficacy of novel drugs, DILI has become a pivotal issue in the use of new drugs, including ICIs. This review demonstrates the immunological mechanism of DILI, including the innate and adaptive immune systems. Moreover, it aims to provide drug treatment targets, describe the mechanisms of DILI, and detail the management of DILI caused by drugs for HCC and LT.
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Affiliation(s)
- Soon Kyu Lee
- Division of Hepatology, Department of Internal Medicine, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
- The Catholic University Liver Research Center, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Jong Young Choi
- The Catholic University Liver Research Center, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
- Division of Hepatology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Eun Sun Jung
- Department of Pathology, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Jung Hyun Kwon
- Division of Hepatology, Department of Internal Medicine, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
- The Catholic University Liver Research Center, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Jeong Won Jang
- The Catholic University Liver Research Center, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
- Division of Hepatology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Si Hyun Bae
- The Catholic University Liver Research Center, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
- Division of Hepatology, Department of Internal Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Seung Kew Yoon
- The Catholic University Liver Research Center, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
- Division of Hepatology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
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7
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Winnicki W, Fichtenbaum A, Mitulovič G, Herkner H, Regele F, Baier M, Zelzer S, Wagner L, Sengoelge G. Individualization of Mycophenolic Acid Therapy through Pharmacogenetic, Pharmacokinetic and Pharmacodynamic Testing. Biomedicines 2022; 10:2882. [PMID: 36359401 PMCID: PMC9687418 DOI: 10.3390/biomedicines10112882] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 11/03/2022] [Accepted: 11/08/2022] [Indexed: 09/09/2024] Open
Abstract
Mycophenolic acid (MPA) is a widely used immunosuppressive agent and exerts its effect by inhibiting inosine 5'-monophosphate dehydrogenase (IMPDH), the main regulating enzyme of purine metabolism. However, significant unexplained differences in the efficacy and tolerability of MPA therapy pose a clinical challenge. Therefore, broad pharmacogenetic, pharmacokinetic, and pharmacodynamic approaches are needed to individualize MPA therapy. In this prospective cohort study including 277 renal transplant recipients, IMPDH2 rs11706052 SNP status was assessed by genetic sequencing, and plasma MPA trough levels were determined by HPLC and IMPDH enzyme activity in peripheral blood mononuclear cells (PBMCs) by liquid chromatography-mass spectrometry. Among the 277 patients, 84 were identified with episodes of biopsy-proven rejection (BPR). No association was found between rs11706052 SNP status and graft rejection (OR 1.808, and 95% CI, 0.939 to 3.479; p = 0.076). Furthermore, there was no association between MPA plasma levels and BPR (p = 0.69). However, the patients with graft rejection had a significantly higher predose IMPDH activity in PBMCs compared to the controls without rejection at the time of biopsy (110.1 ± 50.2 vs. 95.2 ± 45.4 pmol/h; p = 0.001), and relative to the baseline IMPDH activity before transplantation (p = 0.042). Our results suggest that individualization of MPA therapy, particularly through pharmacodynamic monitoring of IMPDH activity in PBMCs, has the potential to improve the clinical outcomes of transplant patients.
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Affiliation(s)
- Wolfgang Winnicki
- Department of Medicine III, Division of Nephrology and Dialysis, Medical University of Vienna, 1090 Vienna, Austria
| | - Andreas Fichtenbaum
- Department of Laboratory Medicine, Medical University of Vienna, 1090 Vienna, Austria
| | - Goran Mitulovič
- Department of Laboratory Medicine, Medical University of Vienna, 1090 Vienna, Austria
| | - Harald Herkner
- Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria
| | - Florina Regele
- Department of Medicine III, Division of Nephrology and Dialysis, Medical University of Vienna, 1090 Vienna, Austria
| | - Michael Baier
- Department of Medicine III, Division of Nephrology and Dialysis, Medical University of Vienna, 1090 Vienna, Austria
| | - Sieglinde Zelzer
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, 8036 Graz, Austria
| | - Ludwig Wagner
- Department of Medicine III, Division of Nephrology and Dialysis, Medical University of Vienna, 1090 Vienna, Austria
| | - Guerkan Sengoelge
- Department of Medicine III, Division of Nephrology and Dialysis, Medical University of Vienna, 1090 Vienna, Austria
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8
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Brodosi L, Petta S, Petroni ML, Marchesini G, Morelli MC. Management of Diabetes in Candidates for Liver Transplantation and in Transplant Recipients. Transplantation 2022; 106:462-478. [PMID: 34172646 PMCID: PMC9904447 DOI: 10.1097/tp.0000000000003867] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 05/31/2021] [Accepted: 06/02/2021] [Indexed: 11/25/2022]
Abstract
Diabetes is common in patients waitlisted for liver transplantation because of end-stage liver disease or hepatocellular cancer as well as in posttransplant phase (posttransplantation diabetes mellitus). In both conditions, the presence of diabetes severely affects disease burden and long-term clinical outcomes; careful monitoring and appropriate treatment are pivotal to reduce cardiovascular events and graft and recipients' death. We thoroughly reviewed the epidemiology of diabetes in the transplant setting and the different therapeutic options, from lifestyle intervention to antidiabetic drug use-including the most recent drug classes available-and to the inclusion of bariatric surgery in the treatment cascade. In waitlisted patients, the old paradigm that insulin should be the treatment of choice in the presence of severe liver dysfunction is no longer valid; novel antidiabetic agents may provide adequate glucose control without the risk of hypoglycemia, also offering cardiovascular protection. The same evidence applies to the posttransplant phase, where oral or injectable noninsulin agents should be considered to treat patients to target, limiting the impact of disease on daily living, without interaction with immunosuppressive regimens. The increasing prevalence of liver disease of metabolic origin (nonalcoholic fatty liver) among liver transplant candidates, also having a higher risk of noncirrhotic hepatocellular cancer, is likely to accelerate the acceptance of new drugs and invasive procedures, as suggested by international guidelines. Intensive lifestyle intervention programs remain however mandatory, both before and after transplantation. Achievement of adequate control is mandatory to increase candidacy, to prevent delisting, and to improve long-term outcomes.
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Affiliation(s)
- Lucia Brodosi
- IRCCS – Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater University, Bologna, Italy
| | - Salvatore Petta
- Section of Gastroenterology and Hepatology, PROMISE, University of Palermo, Palermo, Italy
| | - Maria L. Petroni
- IRCCS – Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater University, Bologna, Italy
| | - Giulio Marchesini
- IRCCS – Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater University, Bologna, Italy
| | - Maria C. Morelli
- IRCCS – Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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Dong V, Nadim MK, Karvellas CJ. Post-Liver Transplant Acute Kidney Injury. Liver Transpl 2021; 27:1653-1664. [PMID: 33963666 DOI: 10.1002/lt.26094] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 04/19/2021] [Accepted: 04/26/2021] [Indexed: 12/13/2022]
Abstract
Acute kidney injury (AKI) is a common condition following liver transplantation (LT). It negatively impacts patient outcomes by increasing the chances of developing chronic kidney disease and reducing graft and patient survival rates. Multiple definitions of AKI have been proposed and used throughout the years, with the International Club of Ascites definition being the most widely now used for patients with cirrhosis. Multiple factors are associated with the development of post-LT AKI and can be categorized into pre-LT comorbidities, donor and recipient characteristics, operative factors, and post-LT factors. Many of these factors can be optimized in an attempt to minimize the risk of AKI occurring and to improve renal function if AKI is already present. A special consideration during the post-LT phase is needed for immunosuppression as certain immunosuppressive medications can be nephrotoxic. The calcineurin inhibitor tacrolimus (TAC) is the mainstay of immunosuppression but can result in AKI. Several strategies including use of the monoclonoal antibody basilixamab to allow for delayed initiation of tacrolimus therapy and minimization through combination and minimization or elimination of TAC through combination with mycophenolate mofetil or mammalian target of rapamycin inhibitors have been implemented to reverse and avoid AKI in the post-LT setting. Renal replacement therapy may ultimately be required to support patients until recovery of AKI after LT. Overall, by improving renal function in post-LT patients with AKI, outcomes can be improved.
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Affiliation(s)
- Victor Dong
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Alberta, Canada.,Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Alberta, Canada
| | - Mitra K Nadim
- Division of Nephrology and Hypertension, University of Southern California, Los Angeles, CA
| | - Constantine J Karvellas
- Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Alberta, Canada.,Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada
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10
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Hirunsatitpron P, Hanprasertpong N, Noppakun K, Pruksakorn D, Teekachunhatean S, Koonrungsesomboon N. Mycophenolic acid and cancer risk in solid organ transplant recipients: Systematic review and meta-analysis. Br J Clin Pharmacol 2021; 88:476-489. [PMID: 34240462 DOI: 10.1111/bcp.14979] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 06/21/2021] [Accepted: 06/30/2021] [Indexed: 12/26/2022] Open
Abstract
AIM Mycophenolic acid (MPA) is an immunosuppressive drug commonly used for prophylaxis of graft rejection in solid organ transplant recipients. The main concern with the prolonged use of immunosuppressive drugs is the risk of developing cancer. However, it remains unclear whether the immunosuppressive regimens containing MPA confer an increased degree of cancer risk. The present study aimed to determine the association between MPA exposure and the incidence of cancer in solid organ transplant recipients. METHODS A systematic search was performed on the PubMed, EMBASE and Cochrane Library databases. Relevant articles that had findings on the incidence (or event) of cancer in cohorts with and without MPA exposure were retrieved for data extraction. A meta-analysis was conducted by means of the random-effects model, and the relative risk (RR) and its 95% confidence interval (95% CI) were used as a summary effect measure. RESULTS A total of 39 studies were eligible for inclusion, with 32 studies that enabled meta-analysis. MPA exposure was significantly associated with a lower risk of cancer when compared to azathioprine exposure (RR = 0.66, 95% CI = 0.53-0.81, P < .001) or no exposure to any additional treatments (RR = 0.85, 95% CI = 0.73-0.99, P = .04). There was no significant difference in cancer risk for the comparison between MPA exposure and mammalian target of rapamycin (mTOR) inhibitor exposure (RR = 1.54, 95% CI = 0.96-2.46, P = .07). CONCLUSIONS MPA exposure was not associated with an increased risk of cancer and may even be associated with a lower risk of cancer when compared to azathioprine or no treatment.
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Affiliation(s)
- Pannaphak Hirunsatitpron
- Department of Pharmacology, Faculty of Medicine, Chiang Mai University, Thailand.,Master's Degree Program in Pharmacology, Faculty of Medicine, Chiang Mai University, Thailand
| | | | - Kajohnsak Noppakun
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Thailand.,Pharmacoepidemiology and Statistics Research Center, Faculty of Pharmacy, Chiang Mai University, Thailand
| | - Dumnoensun Pruksakorn
- Musculoskeletal Science and Translational Research Center, Faculty of Medicine, Chiang Mai University, Thailand.,Omics Center for Health Science, Faculty of Medicine, Chiang Mai University, Thailand.,Biomedical Engineering Institute, Chiang Mai University, Thailand
| | | | - Nut Koonrungsesomboon
- Department of Pharmacology, Faculty of Medicine, Chiang Mai University, Thailand.,Musculoskeletal Science and Translational Research Center, Faculty of Medicine, Chiang Mai University, Thailand
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11
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Mohammad S, Sundaram SS, Mason K, Lobritto S, Martinez M, Turmelle YP, Bucuvalas J, Feng S, Alonso EM. Improvements in Disease-Specific Health-Related Quality of Life of Pediatric Liver Transplant Recipients During Immunosuppression Withdrawal. Liver Transpl 2021; 27:735-746. [PMID: 33280227 PMCID: PMC8185886 DOI: 10.1002/lt.25963] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 10/26/2020] [Accepted: 11/13/2020] [Indexed: 12/31/2022]
Abstract
Long-term immunosuppression (IS) leads to systemic complications affecting health-related quality of life (HRQOL) in pediatric liver transplantation (LT) recipients. We serially assessed HRQOL using the PedsQL Generic and Multidimensional Fatigue Scales and Family Impact and Transplant Modules as part of a multicenter prospective immunosuppression withdrawal (ISW) trial between 2012 and 2018. Participants received a primary LT ≥4 years before the study and were on stable IS with normal liver tests and without rejection in the prior 2 years. IS was withdrawn in 7 steps over 36 to 48 weeks. HRQOL was assessed at regular intervals. The primary endpoint was change in disease-specific HRQOL measured by the PedsQL Transplant Module. Generic HRQOL was measured by the PedsQL Generic Scale and was compared with an age-matched and sex-matched multicenter cohort. Of the 88 participants, 39 were boys, median age was 11 years (range, 8-13), and time since transplant was 9 years (range, 6-11). For 36 months, disease-specific HRQOL improved for all participants, whereas generic HRQOL was unchanged. Neither generic nor disease-specific HRQOL changed for the 35 participants who developed acute rejection during ISW. In the first use of patient-reported outcome measures during an ISW trial, we found improvements in disease-specific HRQOL in all participants and no lasting detrimental effects in those who experienced rejection.
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Affiliation(s)
- Saeed Mohammad
- Siragusa Transplantation Center, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | - Shikha S. Sundaram
- Division of Gastroenterology, Hepatology, and Nutrition, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | | | - Steven Lobritto
- Center for Liver Diseases and Transplantation, Department of Surgery, Columbia University Irving Medical Center, New York, NY
| | - Mercedes Martinez
- Center for Liver Diseases and Transplantation, Department of Surgery, Columbia University Irving Medical Center, New York, NY
| | - Yumirle P. Turmelle
- Division of Gastroenterology, Hepatology, and Nutrition, Washington University School of Medicine, St. Louis, MO
| | - John Bucuvalas
- Mount Sinai Kravis Children’s Hospital and Recanati/Miller Transplantation Institute Mount Sinai Health System, New York, NY
| | - Sandy Feng
- Division of Transplantation, Department of Surgery, University of California San Francisco, San Francisco, CA
| | - Estella M. Alonso
- Siragusa Transplantation Center, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
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12
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Gül-Klein S, Kästner A, Haber PK, Krenzien F, Wabitsch S, Krannich A, Andreou A, Eurich D, Tacke F, Horst D, Pratschke J, Schmelzle M. Recurrence of Hepatocellular Carcinoma After Liver Transplantation is Associated with Episodes of Acute Rejections. J Hepatocell Carcinoma 2021; 8:133-143. [PMID: 33777855 PMCID: PMC7987264 DOI: 10.2147/jhc.s292010] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 01/21/2021] [Indexed: 12/24/2022] Open
Abstract
Purpose The impact of acute rejection (AR) after liver transplantation (LT) for hepatocellular carcinoma (HCC) on patient outcome is uncertain. This aim of this study is to investigate whether AR is associated with HCC relapse and overall survival. Patients and Methods Patients undergoing LT for HCC between 2001 and 2015 were retrospectively analyzed with regard to histopathological proven AR within the median time until recurrence. Cox’s regression analysis was conducted revealing risk factors for HCC recurrence. Results HCC recurred in 47 of 252 analyzed patients with a median time to recurrence of 20 months. Patients with AR (28.6%) had a significantly higher frequency of recurrence compared to patients without AR (13.0%, p=0.002). Multiple Cox regression analyses identified AR within 20 months to be an independent risk factor for HCC recurrence both as dichotomized (HR=2.91, 95%CI: 1.30–6.53; p=0.009) and as a continuous variable (HR=1.81, 95%CI: 1.28–2.54; p=0.001). HCC recurrence and AR were associated with higher grades of liver fibrosis one year after LT, when compared to patients without AR (p=0.019). Conclusion Our results demonstrate an association of AR with HCC recurrence after LT with implications for intervals of monitoring in tumor surveillance. Graft fibrosis and immune mechanisms are potentially related and causal interactions are worth further investigation.
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Affiliation(s)
- Safak Gül-Klein
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Anika Kästner
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Philipp Konstantin Haber
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Felix Krenzien
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Simon Wabitsch
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Alexander Krannich
- Clinical Study Center, Clinical Trial Office, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Andreas Andreou
- Division of Acute Care Surgery, Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Dennis Eurich
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Frank Tacke
- Department of Hepatology/Gastroenterology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - David Horst
- Institute of Pathology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Johann Pratschke
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Moritz Schmelzle
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
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13
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Liberal R, Gaspar R, Lopes S, Macedo G. Long-term outcome of patients with difficult-to-treat autoimmune hepatitis receiving mycophenolate mofetil. Clin Res Hepatol Gastroenterol 2021; 45:101487. [PMID: 32651078 DOI: 10.1016/j.clinre.2020.06.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 05/22/2020] [Accepted: 06/15/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Most patients with autoimmune hepatitis (AIH) respond to a combination of prednisolone and azathioprine. For patients who are intolerant or refractory to azathioprine, proposed alternative therapies are based on scarce data, limited to transplant centres and with short-term follow-up periods. OBJECTIVE To evaluate the long-term efficacy and safety of MMF as a second-line therapy in patients with AIH managed at a tertiary non-transplant centre. METHODS Retrospective analysis of a prospectively collated database identified AIH patients who received MMF from 2006 to 2015. Clinical, biochemical and immunological parameters were assessed at 3-, 6- and 12-months, and at last follow-up. Biochemical response (BR) was defined as improvement of transaminases, complete remission (CR) as normalisation of transaminases and IgG, while others were considered non-responders (NR). RESULTS Eighteen out of 151 (12%) AIH patients received MMF. Nine received MMF due to azathioprine-intolerance (group 1), while nine due to refractory disease (group 2). In group 1, CR and BR was achieved in six (67%) and two (22%) patients respectively. In group 2, CR and BR was achieved in one (11%) and five (56%) patients respectively. Adverse events occurred in eight patients (44%), with one patient requiring drug discontinuation. After a medium follow-up of 78 (31-116) months, there was a significant decrease in transaminase levels, mirrored by decrease in prednisolone dose from 25 to 6.25 mg/day (P<0.05). CONCLUSION Long-term therapy with MMF is safe and effective in AIH patients requiring second-line therapies, and these patients can be effectively managed at tertiary non-liver transplant centres.
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Affiliation(s)
- Rodrigo Liberal
- Gastroenterology and Hepatology Department, Centro Hospitalar Sao Joao, Alameda Prof. Hernani Monteiro, 4200-319 Porto, Portugal; World Gastroenterology Organization (WGO) Porto Training Center, Portugal.
| | - Rui Gaspar
- Gastroenterology and Hepatology Department, Centro Hospitalar Sao Joao, Alameda Prof. Hernani Monteiro, 4200-319 Porto, Portugal; World Gastroenterology Organization (WGO) Porto Training Center, Portugal
| | - Susana Lopes
- Gastroenterology and Hepatology Department, Centro Hospitalar Sao Joao, Alameda Prof. Hernani Monteiro, 4200-319 Porto, Portugal; World Gastroenterology Organization (WGO) Porto Training Center, Portugal
| | - Guilherme Macedo
- Gastroenterology and Hepatology Department, Centro Hospitalar Sao Joao, Alameda Prof. Hernani Monteiro, 4200-319 Porto, Portugal; World Gastroenterology Organization (WGO) Porto Training Center, Portugal
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14
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Lassailly G, Dumortier J, Saint-Marcoux F, El Amrani M, Boulanger J, Boleslawski E, Millet G, Ningarhari M, Truant S, Canva V, Goria O, Boillot O, Louvet A, Mathurin P, Lebuffe G, Pruvot FR, Marquet P, Dharancy S. Real life experience of mycophenolate mofetil monotherapy in liver transplant patients. Clin Res Hepatol Gastroenterol 2021; 45:101451. [PMID: 32536555 DOI: 10.1016/j.clinre.2020.04.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 04/23/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Mycophenolate mofetil (MMF) monotherapy following liver transplantation (LT) remains controversial due to a risk of acute rejection. The aim of this study was to report the largest multicenter experience of the use a MMF monotherapy guided by therapeutic drug monitoring using pharmacoslope modeling and Bayesian estimations of the MPA inter-dose AUC (BEAUCMPA) before withdrawing calcineurin inhibitors (CNI) and to evaluate the benefit of MMF monotherapy. METHODS MMF daily doses were adjusted to reach the BEAUCMPA target of 45μg.h/mL. Then CNI were withdrawn and patients were followed on liver test and clinical outcomes. MAIN FINDINGS From 2000-2014, in 2 transplantation centers, 94 liver transplant recipients received MMF monotherapy 6.5±4 years after LT. The mean BEAUCMPA was 45.5±16μg.h/mL. During follow-up, 4 patients experienced acute rejection (4%). During the first year, estimated glomerular filtration rate (eGFR) improved from 46.2±10.5 to 49.1±11.5mL/kg/min (P=0.025). Benefit persisted at year 5. In patients with metabolic syndrome, eGFR did not improve. CONCLUSION MMF monotherapy regimen appears usually safe and beneficial, with low risk of acute rejection and eGFR improvement. Therapeutic drug monitoring strategy seemed useful by identifying 14% of patients with low MMF exposure.
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Affiliation(s)
- Guillaume Lassailly
- Maladies Appareil Digestif, pole médico-chirurgical, Hôpital Huriez CHU Lille, Inserm U995, Université de Lille, France
| | - Jerome Dumortier
- Fédération des Spécialités Digestives, Hôpital Edouard Herriot, Hospices civils de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Franck Saint-Marcoux
- Département de Pharmacologie Toxicologie, CHU Limoges, Limoges, Inserm UMR 850, Université Limoges, Limoges, France
| | - Medhi El Amrani
- Département de Chirurgie Digestive et de Transplantation, pole médico-chirurgical, Hôpital Huriez CHU Lille, Université de Lille, Lille, France
| | - Juliette Boulanger
- Maladies Appareil Digestif, pole médico-chirurgical, Hôpital Huriez CHU Lille, Inserm U995, Université de Lille, France
| | - Emmanuel Boleslawski
- Département de Chirurgie Digestive et de Transplantation, pole médico-chirurgical, Hôpital Huriez CHU Lille, Université de Lille, Lille, France
| | - Guillaume Millet
- Département de Chirurgie Digestive et de Transplantation, pole médico-chirurgical, Hôpital Huriez CHU Lille, Université de Lille, Lille, France
| | - Massih Ningarhari
- Maladies Appareil Digestif, pole médico-chirurgical, Hôpital Huriez CHU Lille, Inserm U995, Université de Lille, France
| | - Stephanie Truant
- Département de Chirurgie Digestive et de Transplantation, pole médico-chirurgical, Hôpital Huriez CHU Lille, Université de Lille, Lille, France
| | - Valérie Canva
- Maladies Appareil Digestif, pole médico-chirurgical, Hôpital Huriez CHU Lille, Inserm U995, Université de Lille, France
| | - Odile Goria
- Département d'Hépato-gastroentérologie, Hôpital Charles Nicolle, CHU Rouen, Rouen, France
| | - Olivier Boillot
- Fédération des Spécialités Digestives, Hôpital Edouard Herriot, Hospices civils de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Alexandre Louvet
- Maladies Appareil Digestif, pole médico-chirurgical, Hôpital Huriez CHU Lille, Inserm U995, Université de Lille, France
| | - Philippe Mathurin
- Maladies Appareil Digestif, pole médico-chirurgical, Hôpital Huriez CHU Lille, Inserm U995, Université de Lille, France
| | - Gilles Lebuffe
- Département d'Hépato-gastroentérologie, Hôpital Charles Nicolle, CHU Rouen, Rouen, France
| | - François-René Pruvot
- Département de Chirurgie Digestive et de Transplantation, pole médico-chirurgical, Hôpital Huriez CHU Lille, Université de Lille, Lille, France
| | - Pierre Marquet
- Département de Pharmacologie Toxicologie, CHU Limoges, Limoges, Inserm UMR 850, Université Limoges, Limoges, France
| | - Sébastien Dharancy
- Maladies Appareil Digestif, pole médico-chirurgical, Hôpital Huriez CHU Lille, Inserm U995, Université de Lille, France.
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15
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Chevallier E, Jouve T, Rostaing L, Malvezzi P, Noble J. pre-existing diabetes and PTDM in kidney transplant recipients: how to handle immunosuppression. Expert Rev Clin Pharmacol 2020; 14:55-66. [PMID: 33196346 DOI: 10.1080/17512433.2021.1851596] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Preexisting diabetes (PD) and post-transplant diabetes mellitus (PTDM) are common and severe comorbidities posttransplantation. The immunosuppressive regimens are modifiable risk factors. AREAS COVERED We reviewed Pubmed and Cochrane database and we summarize the mechanisms and impacts of available immunosuppressive treatments on the risk of PD and PTDM. We also assess the possible management of these drugs to improve glycemic parameters while considering risks inherent in transplantation. EXPERT OPINION PD i) increases the risk of sepsis, ii) is an independent risk factor for infection-related mortality, and iii) increases acute rejection risk. Regarding PTDM development i) immunosuppressive strategies without corticosteroids significantly reduce the risk but the price may be a higher incidence of rejection; ii) minimization or rapid withdrawal of steroids are two valuable approaches; iii) the diabetogenic role of calcineurin inhibitors(CNIs) is also well-described and is more important for tacrolimus than for cyclosporine. Reducing tacrolimus-exposure may improve glycemic parameters but also has a higher risk of rejection. PTDM risk is higher in patients that receive sirolimus compared to mycophenolate mofetil. Finally, conversion from CNIs to belatacept may offer the best benefits to PTDM-recipients in terms of glycemic parameters, graft and patient-outcomes.
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Affiliation(s)
- Eloi Chevallier
- Service De Néphrologie, Hémodialyse, Aphérèses Et Transplantation Rénale, CHU Grenoble-Alpes , Grenoble, France
| | - Thomas Jouve
- Service De Néphrologie, Hémodialyse, Aphérèses Et Transplantation Rénale, CHU Grenoble-Alpes , Grenoble, France.,Université Grenoble Alpes , Grenoble, France
| | - Lionel Rostaing
- Service De Néphrologie, Hémodialyse, Aphérèses Et Transplantation Rénale, CHU Grenoble-Alpes , Grenoble, France.,Université Grenoble Alpes , Grenoble, France
| | - Paolo Malvezzi
- Service De Néphrologie, Hémodialyse, Aphérèses Et Transplantation Rénale, CHU Grenoble-Alpes , Grenoble, France
| | - Johan Noble
- Service De Néphrologie, Hémodialyse, Aphérèses Et Transplantation Rénale, CHU Grenoble-Alpes , Grenoble, France
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16
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Di Maira T, Little EC, Berenguer M. Immunosuppression in liver transplant. Best Pract Res Clin Gastroenterol 2020; 46-47:101681. [PMID: 33158467 DOI: 10.1016/j.bpg.2020.101681] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 08/31/2020] [Indexed: 02/07/2023]
Abstract
The increasing potency of immunosuppression (IS) agents resulted in significantly decreased rates of steroid resistant rejection and rejection related graft loss in liver transplantation (LT). Currently, more than two thirds of late mortality after LT is unrelated to graft function. However, the increased benefit of more potent IS drugs, coupled with the prolonged survival of transplant recipients led to longer patients exposure to these drugs and their unwanted adverse effects, creating a double-edged sword. In this article the authors describe the mechanism of action and the adverse effects of the most commonly used immunosuppressed drugs, and the most commonly used IS regimens for both induction and maintenance regimens. The balance between the ideal IS regimen to prevent rejection and the need to minimize the dose of IS drugs in order to prevent the adverse effects related to its use requires the knowledge of the science and the experience with the art of medicine. The different protocols aimed at protecting renal function and preventing the development of de novo cancer and metabolic syndrome are discussed here. The main causes of mortality late after liver transplant are associated with prolonged use of IS medications, and clear evidence exists about over-immunosuppression of recipients of liver transplant. The current status of strategies of IS minimization and withdrawal are reviewed in this article, with evaluation of its benefits and pitfalls.
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Affiliation(s)
- Tommaso Di Maira
- Liver Transplantation and Hepatology Unit, Hospital Universitari I Politècnic La Fe, Avda Fernando Abril Martorell, 106 (Torre F5), Valencia, 46026, Spain; CIBERehd, Instituto de Salud Carlos III, Madrid, 28029, Spain; ISS La Fe, Valencia, 46026, Spain.
| | - Ester Coelho Little
- University of Arizona, College of Medicine, 3110 East Minnesona Avenue, Phoenix, AZ, 85016, USA.
| | - Marina Berenguer
- Liver Transplantation and Hepatology Unit, Hospital Universitari I Politècnic La Fe, Avda Fernando Abril Martorell, 106 (Torre F5), Valencia, 46026, Spain; CIBERehd, Instituto de Salud Carlos III, Madrid, 28029, Spain; ISS La Fe, Valencia, 46026, Spain; Universidad de Valencia, Facultad de Medicina, Valencia, 46010, Spain.
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17
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Interventions to Prevent Nonmelanoma Skin Cancers in Recipients of a Solid Organ Transplant: Systematic Review of Randomized Controlled Trials. Transplantation 2020; 103:1206-1215. [PMID: 31246934 DOI: 10.1097/tp.0000000000002641] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Organ transplant recipients are at high risk of developing skin cancer. The benefits and harms of interventions to prevent nonmelanoma skin cancer in solid organ transplant recipients have not been summarized. METHODS We searched MEDLINE, Embase, and CENTRAL through April 2018. Risk of bias was assessed using the Cochrane tool, and evidence certainty was evaluated using the Grades of Recommendation, Assessment, Development, and Evaluation process. Prespecified outcomes were nonmelanoma skin cancer, clearance and prevention of keratotic skin lesions, and intervention-specific adverse events. RESULTS Ninety-two trials (20 012 participants) were included. The evaluated treatments were cancer-specific interventions (acitretin, imiquimod, photodynamic therapy, nicotinamide, topical diclofenac, and selenium) and immunosuppression regimes (azathioprine, mycophenolate mofetil, calcineurin inhibitors, mammalian target of rapamycin [mTOR] inhibitors, belatacept, induction agents, and withdrawal of calcineurin inhibitors or corticosteroids). Effects on nonmelanoma skin cancer were uncertain for photodynamic therapy (3 trials, 93 participants, risk ratio [RR] 1.42 [95% confidence interval (CI), 0.65-3.11]; low certainty evidence), nicotinamide (2 trials, 60 participants), acitretin (2 trials, 61 participants), and imiquimod (1 trial, 20 participants) compared to control. mTOR inhibitors probably reduced skin cancer compared to calcineurin inhibitors (12 trials, 2225 participants, RR 0.62 [95% CI, 0.45-0.85]; moderate certainty evidence). Photodynamic therapy may cause pain at the treatment site (4 trials, 95 patients, RR 17.09 [95% CI, 4.22-69.26]; low certainty evidence). CONCLUSIONS There is limited evidence for the efficacy and safety of specific treatments to prevent nonmelanoma skin cancers among solid organ transplant recipients.
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18
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Tan PS, Muthiah MD, Koh T, Teoh YL, Chan A, Kow A, Zheng Q, Kwon CHD, Lee GH, Lesmana CRA, de Villa V, Fung J, Lim K. Asian Liver Transplant Network Clinical Guidelines on Immunosuppression in Liver Transplantation. Transplantation 2019; 103:470-480. [PMID: 30422953 DOI: 10.1097/tp.0000000000002532] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Most management guidelines and much of the available clinical trial evidence for immunosuppressants in liver transplantation (LT) pertain to Western practice. While evidence from Western studies may not translate to Asian settings, there is a paucity of Asian randomized controlled trials of immunosuppression in liver recipients. Nonetheless, there are notable differences in the indications and procedures for LT between Western and Asian settings. The Asian Liver Transplant Network held its inaugural meeting in Singapore in November 2016 and aimed to provide an Asian perspective on aspects of immunosuppression following LT. Because of their importance to outcome following LT, the meeting focused on (1) reducing the impact of renal toxicity, (2) hepatocellular carcinoma recurrence, and (3) nonadherence with immunosuppressant therapy.
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Affiliation(s)
- Poh Seng Tan
- Division of Gastroenterology and Hepatology, National University Hospital, National University Health System, Singapore
- National University Centre for Organ Transplantation, National University Hospital, National University Health System, Singapore
| | - Mark D Muthiah
- Division of Gastroenterology and Hepatology, National University Hospital, National University Health System, Singapore
- National University Centre for Organ Transplantation, National University Hospital, National University Health System, Singapore
| | - Tsingyi Koh
- Department of Pharmacy, National University Hospital, National University Health System, Singapore
| | | | - Albert Chan
- Division of Hepatobiliary and Pancreatic Surgery, and Liver Transplantation, Department of Surgery, Queen Mary Hospital, Hong Kong
| | - Alfred Kow
- National University Centre for Organ Transplantation, National University Hospital, National University Health System, Singapore
- Division of Hepatopancreatobiliary Surgery and Division of Liver Transplantation, Department of Surgery, University Surgical Cluster, National University Health System, National University of Singapore, Singapore
| | - Qishi Zheng
- Singapore Clinical Research Institute, Singapore
| | - Choon Hyuck David Kwon
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Guan Huei Lee
- Division of Gastroenterology and Hepatology, National University Hospital, National University Health System, Singapore
- National University Centre for Organ Transplantation, National University Hospital, National University Health System, Singapore
| | - Cosmas Rinaldi A Lesmana
- Hepatobiliary Division, Department of Internal Medicine, Cipto Mangunkusumo Hospital, Universitas Indonesia, Jakarta, Indonesia
- Digestive Disease & GI Oncology Center, Medistra Hospital, Jakarta, Indonesia
| | - Vanessa de Villa
- Department of Surgery and Center for Liver Disease Management and Transplantation, The Medical City, Pasig City, Philippines
| | - James Fung
- Department of Medicine, Queen Mary Hospital, Hong Kong
| | - Kieron Lim
- Division of Gastroenterology and Hepatology, National University Hospital, National University Health System, Singapore
- National University Centre for Organ Transplantation, National University Hospital, National University Health System, Singapore
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19
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Leiskau C, Rajanayagam J, Pfister ED, Goldschmidt I, Junge N, Karch A, Lerch C, Richter N, Lehner F, Schrem H, Baumann U. Side effects and efficacy of renal sparing immunosuppression in pediatric liver transplantation-A single center matched cohort study. Pediatr Transplant 2018; 22:e13207. [PMID: 29729061 DOI: 10.1111/petr.13207] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/31/2018] [Indexed: 11/29/2022]
Abstract
Immunosuppressive combination therapy with MMF can reduce CNI associated nephrotoxicity. We investigated effectiveness and safety of de novo MMF-tacrolimus based immunosuppression after pLTx. Patients after pLTx receiving immunosuppression with MMF/tacrolimus (MMF/TAC) were compared to retrospectively selected age- and diagnosis-matched patients with tacrolimus monotherapy (TAC) and cyclosporine/prednisolone therapy (CSA) (19 patients each, n = 57). Effectiveness, renal function and side effects were analyzed for 1 year after pLTx. Tacrolimus reduction in combination therapy (0.7 μg/L over the year) was lower than aspired (2 μg/L). Acute BPAR occurred equally in MMF/TAC and TAC groups (31.6% each), being slightly higher in CSA group (42.1%; OR = 1.5; 95% CI = 0.42-5.44; P = .5). GFR deteriorated comparably in all 3 groups (P < .01 each) without significant differences between the groups. Septicemia was detected significantly more often in MMF/TAC (73.6%) than in TAC (31.6%) (OR 4.17; 1.07-16.27; P = .04). EBV reactivation occurred more often in CSA patients (84.2%) than in MMF/TAC (47.4%; OR 5.16; 0.98-27.19; P = .05) and TAC patients (52.6%; OR 8.16; 1.48-44.89; P = .02) the same was true for other viral infections (47.4% (CSA) vs 15.8% (TAC); OR 4.21; 0.95-18.55; P = .05). Our study does not provide additional evidence for a benefit of initial use of MMF/TAC over TAC regarding renal function, but raises concerns regarding a potentially increased risk of serious infections under MMF/TAC compared to TAC monotherapy at equivalent renal outcome; our study is, however, limited by the minor CNI reduction in combination therapy.
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Affiliation(s)
- Christoph Leiskau
- Division of Pediatric Gastroenterology and Hepatology, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany.,Core Facility Quality Management & Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Jeremy Rajanayagam
- Department of Gastroenterology and Nutrition, Royal Children's Hospital, Melbourne, Australia
| | - Eva-Doreen Pfister
- Division of Pediatric Gastroenterology and Hepatology, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Imeke Goldschmidt
- Division of Pediatric Gastroenterology and Hepatology, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Norman Junge
- Division of Pediatric Gastroenterology and Hepatology, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - André Karch
- Department of Epidemiology, Helmholtz Centre for Infection Research, Braunschweig, Germany
| | - Christian Lerch
- Core Facility Quality Management & Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany.,Division of Pediatric Nephrology, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Nicolas Richter
- General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Frank Lehner
- General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Harald Schrem
- Core Facility Quality Management & Health Technology Assessment in Transplantation, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany.,General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Ulrich Baumann
- Division of Pediatric Gastroenterology and Hepatology, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany.,Birmingham Children´s Hospital, Liver Unit and University of Birmingham, Institute of Immunology and Immunotherapy, UK
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20
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Pflugrad H, Schrader AK, Tryc AB, Ding X, Lanfermann H, Jäckel E, Schrem H, Beneke J, Barg-Hock H, Klempnauer J, Weissenborn K. Longterm calcineurin inhibitor therapy and brain function in patients after liver transplantation. Liver Transpl 2018; 24:56-66. [PMID: 29156491 DOI: 10.1002/lt.24984] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 10/05/2017] [Accepted: 10/19/2017] [Indexed: 02/07/2023]
Abstract
Calcineurin inhibitors (CNIs) frequently induce neurological complications early after orthotopic liver transplantation (OLT). We hypothesize that longterm CNI therapy after OLT causes dose-dependent cognitive dysfunction and alteration of brain structure. In this study, 85 OLT patients (20 with CNI-free, 35 with CNI low-dose, and 30 with standard-dose CNI immunosuppression) underwent psychometric testing and cerebral magnetic resonance imaging approximately 10 years after OLT to assess brain function and structural brain alterations. A total of 33 healthy patients adjusted for age, sex, and education served as controls. Patients receiving CNI showed a significantly worse visuospatial/constructional ability compared with controls (P ≤ 0.04). Furthermore, patients on low-dose CNI therapy had an overall impaired cognitive function compared with controls (P = 0.01). The tacrolimus total dose and mean trough level were negatively correlated to cognitive function. CNI doses had been adjusted in 91% of the patients in the low-dose and CNI-free groups in the past due to CNI-induced kidney damage. Patients treated with CNI showed significantly more white matter hyperintensities (WMH) than patients on CNI-free immunosuppression and controls (P < 0.05). Both the mean cyclosporine A and tacrolimus trough levels correlated significantly with WMH. In conclusion, longterm CNI therapy carries a risk of cognitive dysfunction especially in patients who already showed nephrotoxic side effects indicating an increased susceptibility of these patients against toxic CNI effects. This subgroup of patients might benefit from a change to CNI-free immunosuppression. Liver Transplantation 24 56-66 2018 AASLD.
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Affiliation(s)
- Henning Pflugrad
- Departments of Neurology.,Integrated Research and Treatment Centre Transplantation
| | | | - Anita Blanka Tryc
- Departments of Neurology.,Integrated Research and Treatment Centre Transplantation
| | - Xiaoqi Ding
- Diagnostic and Interventional Neuroradiology
| | | | - Elmar Jäckel
- Gastroenterology, Hepatology and Endocrinology.,Integrated Research and Treatment Centre Transplantation
| | - Harald Schrem
- Core Facility Quality Management Transplantation.,Clinic for Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Jan Beneke
- Core Facility Quality Management Transplantation
| | - Hannelore Barg-Hock
- Clinic for Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Jürgen Klempnauer
- Integrated Research and Treatment Centre Transplantation.,Clinic for Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Karin Weissenborn
- Departments of Neurology.,Integrated Research and Treatment Centre Transplantation
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21
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Abstract
Liver transplantation outcomes have significantly improved over the past few decades owing largely to the introduction of effective immunosuppression medications. Further comprehension of the unique immune microenvironment of the liver has led to the development of newer molecular targeted therapeutics. Understanding the mechanism of action and adverse effect profiles of these medications is crucial for appropriate management of posttransplant patients. In this review, the author describes the immunologic response elicited by liver transplantation, chronicles the various immunosuppressant drug classes, discusses the evidence behind their use, and evaluates the management of special subpopulations of posttransplantation patients.
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Affiliation(s)
- Renumathy Dhanasekaran
- Division of Gastroenterology and Hepatology, Stanford University, 750 Welch Road, Suite 210, Palo Alto, CA 94304, USA.
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22
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Rodríguez‐Perálvarez M, Guerrero‐Misas M, Thorburn D, Davidson BR, Tsochatzis E, Gurusamy KS, Cochrane Hepato‐Biliary Group. Maintenance immunosuppression for adults undergoing liver transplantation: a network meta-analysis. Cochrane Database Syst Rev 2017; 3:CD011639. [PMID: 28362060 PMCID: PMC6464256 DOI: 10.1002/14651858.cd011639.pub2] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND As part of liver transplantation, immunosuppression (suppressing the host immunity) is given to prevent graft rejections resulting from the immune response of the body against transplanted organ or tissues from a different person whose tissue antigens are not compatible with those of the recipient. The optimal maintenance immunosuppressive regimen after liver transplantation remains uncertain. OBJECTIVES To assess the comparative benefits and harms of different maintenance immunosuppressive regimens in adults undergoing liver transplantation through a network meta-analysis and to generate rankings of the different immunosuppressive regimens according to their safety and efficacy. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, World Health Organization International Clinical Trials Registry Platform, and trials registers until October 2016 to identify randomised clinical trials on immunosuppression for liver transplantation. SELECTION CRITERIA We included only randomised clinical trials (irrespective of language, blinding, or publication status) in adult participants undergoing liver transplantation (or liver retransplantation) for any reason. We excluded trials in which participants had undergone multivisceral transplantation or participants with established graft rejections. We considered any of the various maintenance immunosuppressive regimens compared with each other. DATA COLLECTION AND ANALYSIS We performed a network meta-analysis with OpenBUGS using Bayesian methods and calculated the odds ratio, rate ratio, and hazard ratio (HR) with 95% credible intervals (CrI) based on an available-case analysis, according to National Institute of Health and Care Excellence Decision Support Unit guidance. MAIN RESULTS We included a total of 26 trials (3842 participants) in the review, and 23 trials (3693 participants) were included in one or more outcomes in the review. The vast majority of the participants underwent primary liver transplantation. All of the trials were at high risk of bias, and all of the evidence was of low or very low quality. In addition, because of sparse data involving trials at high risk of bias, it is not possible to entirely rely on the results of the network meta-analysis. The trials included mainly participants undergoing primary liver transplantation of varied aetiologies. The follow-up in the trials ranged from 3 to 144 months. The most common maintenance immunosuppression used as a control was tacrolimus. There was no evidence of difference in mortality (21 trials; 3492 participants) or graft loss (15 trials; 2961 participants) at maximal follow-up between the different maintenance immunosuppressive regimens based on the network meta-analysis. In the direct comparison, based on a single trial including 222 participants, tacrolimus plus sirolimus had increased mortality (HR 2.76, 95% CrI 1.30 to 6.69) and graft loss (HR 2.34, 95% CrI 1.28 to 4.61) at maximal follow-up compared with tacrolimus. There was no evidence of differences in the proportion of people with serious adverse events (1 trial; 719 participants), proportion of people with any adverse events (2 trials; 940 participants), renal impairment (8 trials; 2233 participants), chronic kidney disease (1 trial; 100 participants), graft rejections (any) (16 trials; 2726 participants), and graft rejections requiring treatment (5 trials; 1025 participants) between the different immunosuppressive regimens. The network meta-analysis showed that the number of adverse events was lower with cyclosporine A than with many other immunosuppressive regimens (12 trials; 1748 participants), and the risk of retransplantation (13 trials; 1994 participants) was higher with cyclosporine A than with tacrolimus (HR 3.08, 95% CrI 1.13 to 9.90). None of the trials reported number of serious adverse events, health-related quality of life, or costs. FUNDING 14 trials were funded by pharmaceutical companies who would benefit from the results of the trial; two trials were funded by parties who had no vested interest in the results of the trial; and 10 trials did not report the source of funding. AUTHORS' CONCLUSIONS Based on low-quality evidence from a single small trial from direct comparison, tacrolimus plus sirolimus increases mortality and graft loss at maximal follow-up compared with tacrolimus. Based on very low-quality evidence from network meta-analysis, we found no evidence of difference between different immunosuppressive regimens. We found very low-quality evidence from network meta-analysis and low-quality evidence from direct comparison that cyclosporine A causes more retransplantation compared with tacrolimus. Future randomised clinical trials should be adequately powered; performed in people who are generally seen in the clinic rather than in highly selected participants; employ blinding; avoid postrandomisation dropouts or planned cross-overs; and use clinically important outcomes such as mortality, graft loss, renal impairment, chronic kidney disease, and retransplantation. Such trials should use tacrolimus as one of the control groups. Moreover, such trials ought to be designed in such a way as to ensure low risk of bias and low risks of random errors.
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Affiliation(s)
- Manuel Rodríguez‐Perálvarez
- Reina Sofía University Hospital, IMIBIC, CIBERehdHepatology and Liver TransplantationAvenida Menéndez Pidal s/nCórdobaSpain14004
| | - Marta Guerrero‐Misas
- Reina Sofía University Hospital, IMIBIC, CIBERehdHepatology and Liver TransplantationAvenida Menéndez Pidal s/nCórdobaSpain14004
| | - Douglas Thorburn
- Royal Free Hospital and the UCL Institute of Liver and Digestive HealthSheila Sherlock Liver CentrePond StreetLondonUKNW3 2QG
| | - Brian R Davidson
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryPond StreetLondonUKNW3 2QG
| | - Emmanuel Tsochatzis
- Royal Free Hospital and the UCL Institute of Liver and Digestive HealthSheila Sherlock Liver CentrePond StreetLondonUKNW3 2QG
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23
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Hwang S, Song GW, Jung DH, Park GC, Ahn CS, Moon DB, Ha TY, Kim KH, Lee SG. Intra-individual variability of mycophenolic acid concentration according to renal function in liver transplant recipients receiving mycophenolate monotherapy. Ann Hepatobiliary Pancreat Surg 2017; 21:11-16. [PMID: 28317040 PMCID: PMC5353912 DOI: 10.14701/ahbps.2017.21.1.11] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 01/20/2017] [Accepted: 01/25/2017] [Indexed: 01/01/2023] Open
Abstract
BACKGROUNDS/AIMS Mycophenolate mofetil (MMF) has wide inter- and intra-individual variability of mycophenolic acid (MPA) after liver transplantation (LT). On this study, we aimed to analyse the intra-individual variability of MPA concentration in stable adult LT recipients receiving MMF monotherapy and develop a method to determine the target level in the situation of wide intra-individual variability. METHODS This retrospective cross-sectional study included 30 LT recipients. All patients received MMF monotherapy at a dose of 500 mg twice daily for ≥2 years and were divided into two groups based on renal function. MPA concentration-associated values were presented as mean with standard deviation and coefficient of variation (CV). RESULTS The normal renal function group (n=15) showed a mean 12-hour MPA concentration of 2.5±0.5 µg/ml (range, 1.8±0.5 to 3.6±0.7 µg/ml) and a mean CV of 20.4±7.7% (range, 8.7% to 39.4%). In the renal dysfunction group (n=15), the 12-hour MPA concentration fluctuated more widely with a mean value of 3.7±0.9 µg/ml (range, 2.8±0.8 to 5.1±1.2 µg/ml) and a mean CV of 24.5±4.9% (range, 17.1% to 37.5%). The 12-hour MPA concentration was significantly higher in the renal dysfunction group, as compared to the normal renal function group (p=0.001); whereas, the CV was not significantly different between the two groups (p=0.093). CONCLUSIONS We determined the inter- and intra-individual variability of 12-hour MPA concentration after LT. The results suggested that therapeutic drug monitoring of MPA is necessary due to the inter-individual and intra-individual variability of MMF pharmacokinetics, especially in LT recipients with renal dysfunction.
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Affiliation(s)
- Shin Hwang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gi-Won Song
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Hwan Jung
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gil-Chun Park
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chul-Soo Ahn
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Deok-Bog Moon
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae-Yong Ha
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki-Hun Kim
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Gyu Lee
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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24
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Cruz C, Pereira S, Gandara J, Ferreira S, Lopes V, Daniel J, Miranda H. Efficacy and Safety of Monotherapy With Mycophenolate Mofetil in Liver Transplantation Patients With Nephrotoxicity. Transplant Proc 2016; 48:2341-2343. [DOI: 10.1016/j.transproceed.2016.06.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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25
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Levitsky J, O’Leary J, Asrani S, Sharma P, Fung J, Wiseman A, Niemann C. Protecting the Kidney in Liver Transplant Recipients: Practice-Based Recommendations From the American Society of Transplantation Liver and Intestine Community of Practice. Am J Transplant 2016; 16:2532-44. [PMID: 26932352 PMCID: PMC5007154 DOI: 10.1111/ajt.13765] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 02/12/2016] [Accepted: 02/22/2016] [Indexed: 01/25/2023]
Abstract
Both acute and chronic kidney disease are common after liver transplantation and result in significant morbidity and mortality. The introduction of the Model for End-stage Liver Disease score has directly correlated with an increased prevalence of perioperative renal dysfunction and the number of simultaneous liver-kidney transplantations performed. Kidney dysfunction in this population is typically multifactorial and related to preexisting conditions, pretransplantation renal injury, perioperative events, and posttransplantation nephrotoxic immunosuppressive therapies. The management of kidney disease after liver transplantation is challenging, as by the time the serum creatinine level is significantly elevated, few interventions affect the course of progression. Also, immunological factors such as antibody-mediated kidney rejection have become of greater interest given the rising liver-kidney transplant population. Therefore, this review, assembled by experts in the field and endorsed by the American Society of Transplantation Liver and Intestine Community of Practice, provides a critical assessment of measures of renal function and interventions aimed at preserving renal function early and late after liver and simultaneous liver-kidney transplantation. Key points and practice-based recommendations for the prevention and management of kidney injury in this population are provided to offer guidance for clinicians and identify gaps in knowledge for future investigations.
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Affiliation(s)
- J. Levitsky
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - J.G. O’Leary
- Division of Hepatology, Baylor University Medical Center, Dallas, TX
| | - S. Asrani
- Division of Hepatology, Baylor University Medical Center, Dallas, TX
| | - P. Sharma
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Michigan Medical Center, Ann Arbor, MI
| | - J. Fung
- Department of Surgery, Transplantation Center, The Cleveland Clinic, Cleveland, OH
| | - A. Wiseman
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado School of Medicine, Denver, CO
| | - C.U. Niemann
- Department of Anesthesia and Surgery, University of California at San Francisco, San Francisco, CA
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26
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Herzer K, Strassburg CP, Braun F, Engelmann C, Guba M, Lehner F, Nadalin S, Pascher A, Scherer MN, Schnitzbauer AA, Zimmermann T, Nashan B, Sterneck M. Selection and use of immunosuppressive therapies after liver transplantation: current German practice. Clin Transplant 2016; 30:487-501. [PMID: 26855333 DOI: 10.1111/ctr.12708] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2016] [Indexed: 01/01/2023]
Abstract
In recent years, immunosuppression (IS) after liver transplantation (LT) has become increasingly diversified as the choice of agents has expanded and clinicians seek to optimize the balance of immunosuppressive potency with the risk of adverse events in individual patients. Calcineurin inhibitors (CNIs) are the primary agents used for patients undergoing liver transplantation. Other therapeutic agents like interleukin-2 receptor antagonists are not universally administered, but can be considered for the delay or reduction in CNI exposure. An early addition of mycophenolate mofetil (MMF) or the mTOR inhibitor everolimus also allows for the reduction in the CNI dose. To reduce the risk of malignancy, in particular of skin tumors, as well as to prevent the deterioration of renal function, everolimus-based therapy may be advantageous. Apart from patients with autoimmune hepatitis, steroids are withdrawn within 3-6 months after transplantation. Overall, immunosuppression can only be standardized in a limited proportion of patients due to specific clinical requirements and risk factors. Future studies should attempt to refine accurate individualization of the immunosuppressive regimen in specific difficult-to-treat patient subpopulations.
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Affiliation(s)
- Kerstin Herzer
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, University Duisburg-Essen, Essen, Germany.,Department of Gastroenterology and Hepatology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | | | - Felix Braun
- Department for Transplantation Surgery, University Hospital Kiel, Kiel, Germany
| | - Cornelius Engelmann
- Department for Gastroenterology and Rheumatology, Section Hepatology, University of Leipzig, Leipzig, Germany
| | - Markus Guba
- Department for Transplant Surgery, University Hospital Munich, Munich, Germany
| | - Frank Lehner
- Department for Transplant Surgery, University Hospital Hannover, Hannover, Germany
| | - Silvio Nadalin
- Department for General, Visceral and Transplant Surgery, University Hospital Tuebingen, Tuebingen, Germany
| | - Andreas Pascher
- Department of Visceral and Transplant Surgery, Charite-Universitätsmedizin Berlin, Berlin, Germany
| | - Marcus N Scherer
- Department for General-, Visceral- and Transplant Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Andreas A Schnitzbauer
- Clinic for General and Visceral Surgery, Frankfurt University Hospitals, Goethe University Frankfurt/Main, Frankfurt/Main, Germany
| | - Tim Zimmermann
- Department for Gastroenterology and Hepatology, University Hospital Mainz, Mainz, Germany
| | - Björn Nashan
- Department for Hepatobiliary Surgery and Transplantation, University Hospital Hamburg, Hamburg, Germany
| | - Martina Sterneck
- University Transplant Center, University Hospital Hamburg, Hamburg, Germany
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27
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Regelmann MO, Goldis M, Arnon R. New-onset diabetes mellitus after pediatric liver transplantation. Pediatr Transplant 2015; 19:452-9. [PMID: 26032592 DOI: 10.1111/petr.12523] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/15/2015] [Indexed: 12/28/2022]
Abstract
In the first five yr after liver transplant, approximately one in 10 pediatric recipients will develop NODAT. Factors associated with higher risk for NODAT have been difficult to identify due to lack of uniformity in reporting and data collection. Limited studies have reported higher risk in those who are at an older age at transplant, those with high-risk ethnic backgrounds, and in those with particular underlying conditions, such as CF and primary sclerosing cholangitis. Immunosuppressive medications, including tacrolimus, cyclosporine A, GC, and sirolimus, have been implicated as contributing to NODAT, to varying degrees. Identifying those at highest risk, appropriately screening, and diagnosing NODAT is critical to initiating timely treatment and avoiding potential complications. In the pediatric population, treatment is limited primarily to insulin, with some consideration for metformin. Children with NODAT should be monitored carefully for complications of DM, including microalbuminuria, hypertension, hyperlipidemia, and retinopathy.
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Affiliation(s)
- Molly O Regelmann
- Division of Pediatric Endocrinology & Diabetes, Hall Family Center for Diabetes, Kravis Children's Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Marina Goldis
- Division of Pediatric Endocrinology & Diabetes, Hall Family Center for Diabetes, Kravis Children's Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ronen Arnon
- Division of Pediatric Hepatology, Recanati/Miller Transplant Institute, Kravis Children's Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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28
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Xiao M, Xu X, Zhu H, Zhuang R, Xiang P, Wang T, Zhuang L, Wei Q, Wei X, Zhang L, Wu J, Zheng S. Efficacy and safety of basiliximab in liver transplantation for patients with hepatitis B virus-related diseases: a single centre study. INTERNATIONAL JOURNAL OF CLINICAL PRACTICE. SUPPLEMENT 2015; 69:35-42. [PMID: 26177265 DOI: 10.1111/ijcp.12665] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
AIMS We aim to evaluate the efficacy and safety of basiliximab in liver transplantation (LT) for patients with hepatitis B virus-related diseases. METHODS A total of 268 patients with hepatitis B virus-related diseases undergoing LT were enrolled and divided into two groups according to the usage of basiliximab. Total survival, the survival of high-risk patients defined by the posttransplant model for predicting mortality, acute rejection rate, biochemical parameters and other follow-up data were compared between the two groups. RESULTS Group Bas was composed of 131 patients who received basiliximab, and Group Triple enrolled the other 137 patients who did not. Between the two groups, there was no significant difference in the cumulative survival of patients without hepatocellular carcinoma (HCC) or in the cumulative survival of patients with HCC. For patients with benign end-stage liver diseases, Group Bas had more patients with a high risk of short- and medium-term mortality than Group Triple (22.81% vs. 8.85%, p = 0.017), but the survival curves of the two groups were not significantly different. The 1-year incidence of acute rejection was lower in Group Bas, although the difference was not significant (8.75% vs. 15.33%, p > 0.05). In both Group Bas and Group Triple, the level of serum creatinine (Scr) at 1 week posttransplantation was significantly lower than pretransplantation (61.00 vs. 88.50 μmol/l, p < 0.001; 61.50 vs. 74.00 μmol/l, p < 0.001; respectively). There was a significant difference in the pretransplantation Scr between the two groups (88.50 vs. 74.00 μmol/l, p = 0.005), but the values of Scr decreased to the same level 1 week (61.00 vs. 61.50 μmol/l, p > 0.05) and 4 weeks (61.00 vs. 59.00 μmol/l, p > 0.05) after transplantation. Significantly fewer recipients in Group Bas experienced hepatitis B relapse than in Group Triple (2/131 vs. 13/137, p = 0.006). CONCLUSIONS A basiliximab-induced immunosuppressive protocol is a safe regimen that achieves similar survival without increasing the acute rejection rate for LT recipients with hepatitis B virus-related diseases. For patients with benign end-stage liver diseases, this regimen reduces medium-term mortality in high-risk patients. This regimen remarkably improves renal function in the first month after LT and is correlated with a decreased hepatitis B recurrence rate in adult patients after LT.
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Affiliation(s)
- M Xiao
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - X Xu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Zhejiang University, Hangzhou, China
| | - H Zhu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - R Zhuang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - P Xiang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - T Wang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - L Zhuang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Q Wei
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - X Wei
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - L Zhang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - J Wu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - S Zheng
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Zhejiang University, Hangzhou, China
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Park YH, Hwang S, Song GW, Jung DH, Ahn CS, Kim KH, Moon DB, Ha TY, Park GC, Kim N, Lee SG. Correlation between mycophenolic acid blood level and renal dysfunction in stable liver transplant recipients receiving mycophenolate monotherapy. Transplant Proc 2015; 46:811-5. [PMID: 24767354 DOI: 10.1016/j.transproceed.2013.12.042] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2013] [Revised: 11/30/2013] [Accepted: 12/11/2013] [Indexed: 10/25/2022]
Abstract
PURPOSE Mycophenolate mofetil (MMF) is frequently used after liver transplantation (OLT). Mycophenolic acid (MPA) metabolites are eliminated primarily via the kidneys. If renal function declines, clearance is significantly impaired. The aim of this study was to reveal the renal function-dependent changes of MPA level in stable adult OLT recipients receiving MMF monotherapy. METHODS Sixty-five OLT recipients were selected from our OLT database of >3500 cases. All had undergone MMF monotherapy with a daily MMF dose of 1000 mg or 1500 mg for more than 2 years, primarily because they could not tolerate calcineurin inhibitors. Their clinical profiles, including MPA therapeutic drug monitoring (TDM) and renal function, were analyzed as a cross-sectional study. RESULTS For the group treated with 1000 mg MMF (n = 40), the 12-hour MPA trough level was 1.20 ± 0.35 μg/mL with serum creatinine (Cr) level ≤1.4 mg/dL in 13 patients; it was 2.78 ± 1.19 μg/mL with Cr >1.4 mg/dL in 16 patients not undergoing hemodialysis and 3.83 ± 0.87 μg/mL in 11 patients undergoing hemodialysis (P < .001). For the group treated with 1500 mg MMF (n = 25), the MPA trough level was 2.23 ± 0.99 μg/mL with Cr ≤1.4 mg/dL in 6 patients; it was 2.81 ± 0.99 μg/mL with Cr >1.4 mg/dL in 18 patients not undergoing hemodialysis and 3.5 μg/mL in 1 patient undergoing hemodialysis (P = .21). CONCLUSIONS Considering the potential therapeutic range of MPA, the suggested MMF dosage for Korean adult OLT recipients requiring hemodialysis may be set around 1000 mg per day. We suggest adjusting the MMF dosage on an individualized basis according to the results of MPA TDM, particularly for patients with markedly impaired renal function.
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Affiliation(s)
- Y-H Park
- Department of Surgery, Inje University Haeundae Paik Hospital, Busan, Korea
| | - S Hwang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| | - G-W Song
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - D-H Jung
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - C-S Ahn
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - K-H Kim
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - D-B Moon
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - T-Y Ha
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - G-C Park
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - N Kim
- Asan Institute for Life Sciences, Asan Medical Center, Seoul, Korea
| | - S-G Lee
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Gotthardt DN, Bruns H, Weiss KH, Schemmer P. Current strategies for immunosuppression following liver transplantation. Langenbecks Arch Surg 2014; 399:981-988. [PMID: 24748543 DOI: 10.1007/s00423-014-1191-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 03/30/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND New strategies for immunosuppression (IS) after liver transplantation (LTx) are in part responsible for the increased patient and graft survival seen over time. With a few basic exceptions-notably the continued use of steroids and calcineurin inhibitors (CNIs)-IS drugs and regimens being used today are different from those used 30 years ago. While graft loss due to acute or chronic rejection has become rare, the side effect burden of IS drugs exerts a significant toll on patients. CONCEPTS/TRENDS CNIs continue to form the backbone of IS regimens, although their use is hampered by nephrotoxicity and other adverse effects. Consequently, a variety of CNI reduction or withdrawal strategies have formed the basis of clinical trials or entered into clinical practice. These trials have included the use of everolimus, an mTOR inhibitor, and anti-interleukin-2 receptor antibodies. Basiliximab, as well as other lymphocyte nondepleting and depleting agents, have shown benefit in induction regimens. SUMMARY Along with steroid reduction or elimination, current strategies for IS after LTx continue to explore novel combinations of agents, with an aim toward striking a balance between diminution of rejection and the need for avoiding adverse effects of the IS drugs. Long-term maintenance strategies are also discussed in this review, as is development of tolerance and antibody-mediated rejection.
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Affiliation(s)
- Daniel Nils Gotthardt
- Department of Internal Medicine IV, University Hospital of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany,
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Role of mycophenolate mofetil for the treatment of autoimmune hepatitis-an observational study. J Clin Exp Hepatol 2014; 4:221-5. [PMID: 25755564 PMCID: PMC4284212 DOI: 10.1016/j.jceh.2014.05.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Accepted: 05/08/2014] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Eighty percent (80%) of patients with Autoimmune hepatitis (AIH) respond to a combination of prednisolone and Azathioprine (AZA). Choice of treatment is limited for those who do not respond to this standard therapy. We evaluated the role of Mycophenolate mofetil (MMF) as a second line therapy in AIH. METHOD A retrospective observational study was carried out on all patients who received MMF for AIH. RESULTS Twenty out of 117 patients with AIH received MMF due to AZA intolerance (18 patients) or refractory disease (2 patients). Median age of the study patients was 56 (18-79) years, Male, n = 3 (15%) and Female, n = 18 (85%). After a median follow-up period of 47 (5-83) months, 14 (73.6%) patients were still on MMF with biochemical remission, including 4 out of 5 patients with cirrhosis. One patient was lost to follow-up. Three patients were intolerant of MMF due to adverse events, and two had disease refractory to MMF. Both these patients with refractory disease to MMF were initially unresponsive to AZA therapy. CONCLUSION MMF is a safe second line agent in patients with autoimmune hepatitis including those with cirrhosis.
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Kharfan‐Dabaja M, Mhaskar R, Reljic T, Pidala J, Perkins JB, Djulbegovic B, Kumar A, Cochrane Haematological Malignancies Group. Mycophenolate mofetil versus methotrexate for prevention of graft-versus-host disease in people receiving allogeneic hematopoietic stem cell transplantation. Cochrane Database Syst Rev 2014; 2014:CD010280. [PMID: 25061777 PMCID: PMC10945354 DOI: 10.1002/14651858.cd010280.pub2] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Allogeneic hematopoietic stem cell transplantation (allo-HCT) is associated with improved outcomes for people with various hematologic diseases; however, the morbidity and mortality resulting from acute and subsequently chronic graft-versus-host disease (GVHD) pose a serious challenge to wider applicability of allo-HCT. Intravenous methotrexate in combination with a calcineurin inhibitor, cyclosporine or tacrolimus, is a widely used regimen for the prophylaxis of acute GVHD, but the administration of methotrexate is associated with a number of adverse events. Mycophenolate mofetil, in combination with a calcineurin inhibitor, has been used extensively in people undergoing allo-HCT. Conflicting results regarding various clinical outcomes following allo-HCT have been observed when comparing mycophenolate mofetil-based regimens against methotrexate-based regimens for acute GVHD prophylaxis. OBJECTIVES PRIMARY OBJECTIVE to assess the effect of mycophenolate mofetil versus methotrexate for prevention of acute GVHD in people undergoing allo-HCT. SECONDARY OBJECTIVES to evaluate the effect of mycophenolate mofetil versus methotrexate for overall survival, prevention of chronic GVHD, incidence of relapse, treatment-related harms, nonrelapse mortality, and quality of life. SEARCH METHODS We searched Cochrane Central Register of Controlled Trials (CENTRAL) and MEDLINE from inception to March 2014. We handsearched conference abstracts from the last two meetings (2011 and 2012) of relevant societies in the field. We searched ClinicalTrials.gov, Novartis clinical trials database (www.novctrd.com), Roche clinical trial protocol registry (www.roche-trials.com), Australian New Zealand Clinical Trials Registry (ANZCTR), and the metaRegister of Controlled Trials for ongoing trials. SELECTION CRITERIA Two review authors independently reviewed all titles/abstracts and selected full-text articles for inclusion. We included all references that reported results of randomized controlled trials (RCTs) of mycophenolate mofetil versus methotrexate for the prophylaxis of GVHD among people undergoing allo-HCT in this review. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data on outcomes from all studies and compared prior to data entry and analysis. We expressed results as risk ratios (RR) and 95% confidence intervals (CI) for dichotomous outcomes and hazard ratios (HR) and 95% CIs for time-to-event outcomes. We pooled the individual study effects using the random-effects model. Estimates lower than one indicate that mycophenolate mofetil was favored over methotrexate. MAIN RESULTS We included three trials enrolling 177 participants (174 participants analyzed). All participants in the trials by Keihl et al. and Bolwell et al. received cyclosporine while all participants enrolled in the trial by Perkins et al. received tacrolimus. However, the results did not differ by the type of calcineurin inhibitor employed (cyclosporine versus tacrolimus). There was no evidence for a difference between mycophenolate mofetil versus methotrexate for the outcomes of incidence of acute GVHD (RR 1.25; 95% CI 0.75 to 2.09; P value = 0.39, very low quality evidence), overall survival (HR 0.73; 95% CI 0.45 to 1.17; P value = 0.19, low-quality evidence), median days to neutrophil engraftment (HR 0.77; 95% CI 0.51 to 1.17; P value = 0.23, low-quality evidence), incidence of relapse (RR 0.84; 95% CI 0.52 to 1.38; P value = 0.50, low-quality evidence), non-relapse mortality (RR 1.21; 95% CI 0.62 to 2.36; P value = 0.57, low-quality evidence), and incidence of chronic GVHD (RR 0.92; 95% CI 0.65 to 1.30; P value = 0.62, low-quality evidence). There was low-quality evidence that mycophenolate mofetil compared with methotrexate improved platelet engraftment period (HR 0.87; 95% CI 0.81 to 0.93; P value < 0.0001, low-quality evidence). There was low-quality evidence that mycophenolate mofetil compared with methotrexate resulted in decreased incidence of severe mucositis (RR 0.48; 95% CI 0.32 to 0.73; P value = 0.0006, low-quality evidence), use of parenteral nutrition (RR 0.48; 95% CI 0.26 to 0.91; P value = 0.02, low-quality evidence), and medication for pain control (RR 0.76; 95% CI 0.63 to 0.91; P value = 0.002, low-quality evidence). Overall heterogeneity was not detected in the analysis except for the outcome of neutrophil engraftment. None of the included studies reported any outcomes related to quality of life. Overall quality of evidence was low. AUTHORS' CONCLUSIONS The use of mycophenolate mofetil compared with methotrexate for primary prevention of GVHD seems to be associated with a more favorable toxicity profile, without an apparent compromise on disease relapse, transplant-associated mortality, or overall survival. The effects on incidence of GVHD between people receiving mycophenolate mofetil compared with people receiving methotrexate were uncertain. There is a need for additional high-quality RCTs to determine the optimal GVHD prevention strategy. Future studies should take into account a comprehensive view of clinical benefit, including measures of morbidity, symptom burden, and healthcare resource utilization associated with interventions.
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Affiliation(s)
- Mohamed Kharfan‐Dabaja
- H. Lee Moffitt Cancer Center, Division of Oncologic Sciences, University of South FloridaDepartment of Blood and Marrow TransplantationTampaFloridaUSA
- American University of BeirutDivision of Hematology‐Oncology and Bone Marrow Transplantation ProgramBeirutLebanon
| | - Rahul Mhaskar
- University of South FloridaCenter for Evidence Based Medicine and Health Outcomes ResearchTampaFloridaUSA
| | - Tea Reljic
- University of South FloridaCenter for Evidence Based Medicine and Health Outcomes ResearchTampaFloridaUSA
| | - Joseph Pidala
- H. Lee Moffitt Cancer Center, Division of Oncologic Sciences, University of South FloridaDepartment of Blood and Marrow TransplantationTampaFloridaUSA
| | - Janelle B Perkins
- Division of Oncologic Sciences, University of South FloridaDepartment of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center12902 Magnolia Dr.TampaFloridaUSA33612
| | - Benjamin Djulbegovic
- H. Lee Moffitt Cancer Center, Division of Oncologic Sciences, University of South FloridaDepartment of Blood and Marrow TransplantationTampaFloridaUSA
- University of South FloridaUSF Clinical Translational Science Institute, Departments of Medicine, Hematology and Health Outcome Research12901 Bruce B. Downs Boulevard, CMS 3057TampaFloridaUSA33612
| | - Ambuj Kumar
- University of South FloridaCenter for Evidence Based Medicine and Health Outcomes ResearchTampaFloridaUSA
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Peacock WF, Maisel A, Kim J, Ronco C. Neutrophil gelatinase associated lipocalin in acute kidney injury. Postgrad Med 2014; 125:82-93. [PMID: 24200764 DOI: 10.3810/pgm.2013.11.2715] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Neutrophil gelatinase-associated lipocalin (NGAL) is a member of the lipocalin family of proteins. Usually, NGAL is produced and secreted by kidney tubule cells at low levels, but the amount produced and secreted into the urine and serum increases dramatically after ischemic, septic, or nephrotoxic injury of the kidneys. The purpose of our review article is to summarize the role of NGAL in acute kidney injury (AKI), emergent, and intensive care. METHODS A PubMed search was performed (only English-language articles concerning human subjects were considered) using each of the following search term combinations: neutrophil gelatinase-associated lipocalin OR NGAL and acute kidney injury OR AKI; cardiac surgery; heart failure OR cardiology; intensive care; emergency department OR emergency medicine; nephropathy OR nephrotoxicity and transplantation. RESULTS The results of our search yielded 339 articles. Of the 339 articles, 160 were eligible for review based on the predefined criteria for inclusion. CONCLUSION Based on the evidence reviewed, it is clear that patient NGAL level is an appropriate, sensitive, and specific early biomarker of AKI caused by a variety of different etiologies. It is advised that a multidisciplinary group of experts come together to make recommendations and propose a consensus of clinical procedures to advance the most efficacious NGAL monitoring protocol for early detection and treatment of patients with AKI.
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Affiliation(s)
- W Frank Peacock
- Baylor College of Medicine, Houston, TX; Ben Taub General Hospital, Houston, TX.
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Trotter JF, Grafals M, Alsina AE. Early use of renal-sparing agents in liver transplantation: a closer look. Liver Transpl 2013; 19:826-42. [PMID: 23696464 DOI: 10.1002/lt.23672] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Accepted: 04/28/2013] [Indexed: 12/23/2022]
Abstract
Renal dysfunction is a critical issue for liver transplant candidates and recipients. Acute nephrotoxicity and chronic nephrotoxicity, however, are the compromises for the potent immunosuppression provided by calcineurin inhibitors (CNIs). To maintain the graft and patient survival afforded by CNIs while minimizing renal dysfunction in liver transplant patients, the reduction, delay, or elimination of CNIs in immunosuppression regimens is being implemented more frequently by clinicians. The void left by standard-dose CNIs is being filled by nonnephrotoxic immunosuppressants such as mycophenolates and mammalian target of rapamycin inhibitors. The results of studies of renal-sparing regimens in liver transplant recipients have been inconsistent, and this may be explained upon a closer examination of several study-related factors, including the study design and the duration of follow-up.
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Beckebaum S, Cicinnati VR, Radtke A, Kabar I. Calcineurin inhibitors in liver transplantation - still champions or threatened by serious competitors? Liver Int 2013; 33:656-65. [PMID: 23442173 DOI: 10.1111/liv.12133] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2012] [Accepted: 01/29/2013] [Indexed: 12/14/2022]
Abstract
Current strategies for immunosuppression in liver transplant (LT) recipients include the design of protocols targeting a more individualized approach to reduce risk factors such as renal failure, cardiovascular complications and malignancies. Renal injury in LT recipients may be often multifactorial and is associated with increased risk of post-transplant morbidity and mortality. The quest for low toxicity immunosuppressive regimens has been challenging and resulted in CNI minimization protocols or CNI withdrawal and conversion to mycophenolate mofetil (MMF) and/or mammalian target of rapamycin inhibitor-based immunosuppressive regimens. Use of antibody induction to delay CNI administration may be an option in particular in immunocompromized, critically ill patients with high MELD scores. Protocols including MMF introduction and concomitant CNI minimization have the potential to recover renal function even in the medium and long term after LT. We review on hot topics in the prevention and management of acute and chronic renal injury in LT patients. For this purpose, we present and critically discuss results from immunosuppressive studies published in the current literature or presented at recent LT meetings.
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Affiliation(s)
- Susanne Beckebaum
- Department of Transplant Medicine, Muenster University Hospital, Muenster, Germany.
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Abstract
PURPOSE OF REVIEW A persistent challenge facing the transplant community is avoiding renal compromise, whether protecting a newly placed kidney allograft or preserving native renal function after another organ has been implanted. One of the principal ways to achieve this is by altering the immunosuppressive regimen. We review some of the more important recent studies in this area. RECENT FINDINGS Over the past year, two new immunosuppressive agents have received attention. An immunoselective biologic agent, belatacept, continued to demonstrate a sustained benefit in renal function when compared with a cyclosporine-based regimen. In a phase 2 multicenter study, sotrastaurin, a protein kinase C inhibitor, has shown promise in preserving renal graft function but lacks potency as an immunosuppressive agent. A known agent, everolimus, in combination with reduced doses of calcineurin inhibitors or with other agents, continues to be in the forefront as a promising renal-sparing option. Finally, further investigation into mycophenolate mofetil has shown that it has some advantages as a long-term agent when used in monotherapy. SUMMARY The new therapies investigated show some promise as potential alternative agents. As no drug regimen yet demonstrates an overwhelming benefit over calcineurin inhibitors, particularly regarding overall efficacy, efforts should continue to move forward toward the goal of minimizing chronic kidney disease.
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Goralczyk AD, Bari N, Abu-Ajaj W, Lorf T, Ramadori G, Friede T, Obed A. Calcineurin inhibitor sparing with mycophenolate mofetil in liver transplantion: a systematic review of randomized controlled trials. Am J Transplant 2012; 12:2601-7. [PMID: 22813081 DOI: 10.1111/j.1600-6143.2012.04157.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Liver transplant recipients are at high risk of developing acute and chronic renal failure. Moreover, introduction of the model for end-stage liver disease (MELD) score for primary allocation of liver grafts favors patients with pretransplant kidney dysfunction, which in turn have a higher risk of posttransplant renal failure. Calcineurin inhibitors (CNI) further increase the risk of renal failure and therefore sparing CNI with the use of mycophenolate mofetil (MMF) may improve renal function. MMF may either be used de novo in the immediate posttransplant period in combination with low-dose CNI (scenario 1) or patients that receive immunosuppression based on CNI may be converted to MMF in combination with minimization or elimination of CNI (scenario 2). Although many retrospective cohort studies and nonrandomized trials have implicated efficacy of this approach the evidence from randomized controlled studies has not been summarized. In the current review we report the results of a systematic review and meta-analysis of randomized controlled trials.
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Affiliation(s)
- A D Goralczyk
- University Medical Center Göttingen, Göttingen, Germany.
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EMAD YASSER, RAGAB YASSER, EL-SHAARAWY NASHWA. Lichen Planus in Association with Adult-onset Still’s Disease Successfully Treated with Mycophenolate Mofetil. J Rheumatol 2012; 39:1305-6. [DOI: 10.3899/jrheum.120032] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Abstract
PURPOSE OF REVIEW Successful transplant outcomes require optimal patient selection and timing. This review will update clinicians with current status and challenges in liver transplantation. Currently, the major limitation facing liver transplant centers is the shortage of organs. The limited availability of organs has led to long waiting periods for liver transplantation and consequently many patients become seriously ill or die while on the waiting list. RECENT FINDINGS This has major implications in the selection of patients, as well as the timing of transplant, for optimal use of these scarce organs. Indications and contraindications have changed slightly over the years and will be reviewed in this article. SUMMARY Timing for transplantation has changed more dramatically in the recent years because major changes to organ allocation systems have been undertaken to provide clinicians with a better way to prioritize patients for liver transplant.
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