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Safety Evaluation of Oral Sirolimus in the Treatment of Childhood Diseases: A Systematic Review. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9091295. [PMID: 36138604 PMCID: PMC9497617 DOI: 10.3390/children9091295] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/18/2022] [Accepted: 08/24/2022] [Indexed: 11/17/2022]
Abstract
Background: Sirolimus, a mammalian target of rapamycin inhibitor, has been widely used in pediatric patients, but the safety of sirolimus in pediatric patients has not been well determined. Objective: The objective of this study was to systematically evaluate prospective studies reporting the safety of sirolimus in the treatment of childhood diseases. Methods: The following data were extracted in a standardized manner: study design, demographic characteristics, intervention, and safety outcomes. Results: In total, 9 studies were included, encompassing 575 patients who received oral sirolimus for at least 6 months. Various adverse events occurred. The most common adverse event was oral mucositis (8.2%, 95% CI: 0.054 to 0.110). Through comparative analysis of the subgroups based on the targeted concentration range, we discovered that many adverse events were significantly higher in the high concentration group (≥10 ng/mL) than in the low concentration group (<10 ng/mL) (p < 0.01). More interestingly, we found that oral mucositis was more frequently reported in children with vascular anomalies than tuberous sclerosis complex. Conclusions: This study shows that oral sirolimus in the treatment of childhood diseases is safe and reliable. However, sirolimus treatment in the pediatric population should be strictly monitored to reduce the occurrence of serious or fatal adverse events.
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Knoll GA, Kokolo MB, Mallick R, Beck A, Buenaventura CD, Ducharme R, Barsoum R, Bernasconi C, Blydt-Hansen TD, Ekberg H, Felipe CR, Firth J, Gallon L, Gelens M, Glotz D, Gossmann J, Guba M, Morsy AA, Salgo R, Scheuermann EH, Tedesco-Silva H, Vitko S, Watson C, Fergusson DA. Effect of sirolimus on malignancy and survival after kidney transplantation: systematic review and meta-analysis of individual patient data. BMJ 2014; 349:g6679. [PMID: 25422259 PMCID: PMC4241732 DOI: 10.1136/bmj.g6679] [Citation(s) in RCA: 207] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To examine risk of malignancy and death in patients with kidney transplant who receive the immunosuppressive drug sirolimus. DESIGN Systematic review and meta-analysis of individual patient data. DATA SOURCES Medline, Embase, and the Cochrane Central Register of Controlled Trials from inception to March 2013. ELIGIBILITY Randomized controlled trials comparing immunosuppressive regimens with and without sirolimus in recipients of kidney or combined pancreatic and renal transplant for which the author was willing to provide individual patient level data. Two reviewers independently screened titles/abstracts and full text reports of potentially eligible trials to identify studies for inclusion. All eligible trials reported data on malignancy or survival. RESULTS The search yielded 2365 unique citations. Patient level data were available from 5876 patients from 21 randomized trials. Sirolimus was associated with a 40% reduction in the risk of malignancy (adjusted hazard ratio 0.60, 95% confidence interval 0.39 to 0.93) and a 56% reduction in the risk of non-melanoma skin cancer (0.44, 0.30 to 0.63) compared with controls. The most pronounced effect was seen in patients who converted to sirolimus from an established immunosuppressive regimen, resulting in a reduction in risk of malignancy (0.34, 0.28 to 0.41), non-melanoma skin cancer (0.32, 0.24 to 0.42), and other cancers (0.52, 0.38 to 0.69). Sirolimus was associated with an increased risk of death (1.43, 1.21 to 1.71) compared with controls. CONCLUSIONS Sirolimus was associated with a reduction in the risk of malignancy and non-melanoma skin cancer in transplant recipients. The benefit was most pronounced in patients who converted from an established immunosuppressive regimen to sirolimus. Given the risk of mortality, however, the use of this drug does not seem warranted for most patients with kidney transplant. Further research is needed to determine if different populations, such as those at high risk of cancer, might benefit from sirolimus.
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Affiliation(s)
- Greg A Knoll
- Ottawa Hospital Research Institute, Ottawa, ON, Canada University of Ottawa, Ottawa, ON, Canada
| | | | | | - Andrew Beck
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | - Robin Ducharme
- Ottawa Hospital Research Institute, Ottawa, ON, Canada University of Ottawa, Ottawa, ON, Canada
| | | | | | - Tom D Blydt-Hansen
- University of Manitoba, Department of Pediatrics and Child's Health, Winnipeg, MB, Canada
| | - Henrik Ekberg
- Department of Nephrology and Transplantation, Lund University, Malmo, Sweden
| | - Claudia R Felipe
- Hospital do Rim e Hipertensao, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - John Firth
- Department of Renal Medicine, Addenbrooke's Hospital, Cambridge, UK
| | - Lorenzo Gallon
- Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Marielle Gelens
- Maastricht University Medical Centre, Maastricht, Netherlands
| | - Denis Glotz
- Department of Nephrology, Saint-Louis Hospital, Paris, France
| | - Jan Gossmann
- Division of Nephrology, Hospital of J.W. Goethe, Frankfurt, Germany
| | - Markus Guba
- Department of Surgery, University of Munich, Munich, Germany
| | | | - Rebekka Salgo
- Clinic of Dermatology, Venerology and Allergology, JW Goethe Clinic, University of Frankfurt, Germany
| | | | - Helio Tedesco-Silva
- Hospital do Rim e Hipertensao, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Stefan Vitko
- Department of Nephrology, Institutu Klinicke a Experimentalni Mediciny, Prague, Czech Republic
| | - Christopher Watson
- University of Cambridge, Department of Surgery, NIHR Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge, UK
| | - Dean A Fergusson
- Ottawa Hospital Research Institute, Ottawa, ON, Canada University of Ottawa, Ottawa, ON, Canada
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Gallon L, Traitanon O, Sustento-Reodica N, Leventhal J, Ansari MJ, Gehrau RC, Ariyamuthu V, De Serres SA, Alvarado A, Chhabra D, Mathew JM, Najafian N, Mas V. Cellular and molecular immune profiles in renal transplant recipients after conversion from tacrolimus to sirolimus. Kidney Int 2014; 87:828-38. [PMID: 25354238 PMCID: PMC4382402 DOI: 10.1038/ki.2014.350] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Revised: 08/26/2014] [Accepted: 08/28/2014] [Indexed: 02/01/2023]
Abstract
Tacrolimus and Sirolimus are commonly used maintenance immunesuppressants in kidney transplantation. Since their effects on immune cells and allograft molecular profiles have not been elucidated, we characterized the effects of Tacrolimus to Sirolimus conversion on frequency and function of T cells, and on graft molecular profiles. Samples from renal transplant patients in a randomized trial of 18 patients with late Sirolimus conversion and 12 on Tacrolimus maintenance were utilized. Peripheral blood was collected at 0, 6, 12 and 24-months post-randomization with T cell subpopulations analyzed by flow cytometry and T cell alloreactivity tested by IFN-γ ELISPOT. Graft biopsy samples obtained 24-months post-randomization were used for gene expression analysis. Sirolimus conversion led to an increase in CD4+25+++Foxp3+ regulatory T cells. While Tacrolimus-maintained patients showed a decrease in indirect alloreactivity over time post-transplant, Sirolimus conversion increased indirect alloreactive T cell frequencies compared to Tacrolimus-maintained patients. No histological differences were found in graft biopsies, but molecular profiles showed activation of the antigen presentation, IL-12 signaling, oxidative stress, macrophage-derived production pathways, and increased inflammatory and immune response in Sirolimus-converted patients. Thus, chronic immune alterations are induced after Sirolimus conversion. Despite the molecular profile being favorable to calcineurin inhibitor-based regimen, there was no impact in renal function over 30 months of follow-up.
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Affiliation(s)
- Lorenzo Gallon
- 1] Comprehensive Transplant Center, Northwestern University, Chicago, Illinois, USA [2] Department of Medicine-Nephrology, Northwestern University, Chicago, Illinois, USA
| | - Opas Traitanon
- 1] Department of Medicine-Nephrology, Northwestern University, Chicago, Illinois, USA [2] Department of Medicine-Nephrology, Thammasart University Hospital, Pathumthani, Thailand
| | | | - Joseph Leventhal
- Comprehensive Transplant Center, Northwestern University, Chicago, Illinois, USA
| | - M Javeed Ansari
- 1] Comprehensive Transplant Center, Northwestern University, Chicago, Illinois, USA [2] Department of Medicine-Nephrology, Northwestern University, Chicago, Illinois, USA
| | - Ricardo C Gehrau
- University of Virginia, Department of Surgery, Charlottesville, Virginia, USA
| | - Venkatesh Ariyamuthu
- Department of Medicine-Nephrology, Northwestern University, Chicago, Illinois, USA
| | - Sacha A De Serres
- 1] Transplantation Research Center, Division of Nephrology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA [2] Department of Nephrology, Cleveland Clinic Florida, Cleveland, Florida, USA
| | - Antonio Alvarado
- 1] Comprehensive Transplant Center, Northwestern University, Chicago, Illinois, USA [2] Department of Medicine-Nephrology, Northwestern University, Chicago, Illinois, USA
| | - Darshika Chhabra
- Advocate Christ Medical Center, Kidney Transplant, Oak Lawn, Illinois, USA
| | - James M Mathew
- Comprehensive Transplant Center, Northwestern University, Chicago, Illinois, USA
| | - Nader Najafian
- 1] Transplantation Research Center, Division of Nephrology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA [2] Department of Nephrology, Cleveland Clinic Florida, Cleveland, Florida, USA
| | - Valeria Mas
- University of Virginia, Department of Surgery, Charlottesville, Virginia, USA
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Pharmacology and toxicology of mycophenolate in organ transplant recipients: an update. Arch Toxicol 2014; 88:1351-89. [PMID: 24792322 DOI: 10.1007/s00204-014-1247-1] [Citation(s) in RCA: 133] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 04/15/2014] [Indexed: 12/22/2022]
Abstract
This review aims to provide an update of the literature on the pharmacology and toxicology of mycophenolate in solid organ transplant recipients. Mycophenolate is now the antimetabolite of choice in immunosuppressant regimens in transplant recipients. The active drug moiety mycophenolic acid (MPA) is available as an ester pro-drug and an enteric-coated sodium salt. MPA is a competitive, selective and reversible inhibitor of inosine-5'-monophosphate dehydrogenase (IMPDH), an important rate-limiting enzyme in purine synthesis. MPA suppresses T and B lymphocyte proliferation; it also decreases expression of glycoproteins and adhesion molecules responsible for recruiting monocytes and lymphocytes to sites of inflammation and graft rejection; and may destroy activated lymphocytes by induction of a necrotic signal. Improved long-term allograft survival has been demonstrated for MPA and may be due to inhibition of monocyte chemoattractant protein 1 or fibroblast proliferation. Recent research also suggested a differential effect of mycophenolate on the regulatory T cell/helper T cell balance which could potentially encourage immune tolerance. Lower exposure to calcineurin inhibitors (renal sparing) appears to be possible with concomitant use of MPA in renal transplant recipients without undue risk of rejection. MPA displays large between- and within-subject pharmacokinetic variability. At least three studies have now reported that MPA exhibits nonlinear pharmacokinetics, with bioavailability decreasing significantly with increasing doses, perhaps due to saturable absorption processes or saturable enterohepatic recirculation. The role of therapeutic drug monitoring (TDM) is still controversial and the ability of routine MPA TDM to improve long-term graft survival and patient outcomes is largely unknown. MPA monitoring may be more important in high-immunological recipients, those on calcineurin-inhibitor-sparing regimens and in whom unexpected rejection or infections have occurred. The majority of pharmacodynamic data on MPA has been obtained in patients receiving MMF therapy in the first year after kidney transplantation. Low MPA area under the concentration time from 0 to 12 h post-dose (AUC0-12) is associated with increased incidence of biopsy-proven acute rejection although AUC0-12 optimal cut-off values vary across study populations. IMPDH monitoring to identify individuals at increased risk of rejection shows some promise but is still in the experimental stage. A relationship between MPA exposure and adverse events was identified in some but not all studies. Genetic variants within genes involved in MPA metabolism (UGT1A9, UGT1A8, UGT2B7), cellular transportation (SLCOB1, SLCO1B3, ABCC2) and targets (IMPDH) have been reported to effect MPA pharmacokinetics and/or response in some studies; however, larger studies across different ethnic groups that take into account genetic linkage and drug interactions that can alter a patient's phenotype are needed before any clinical recommendations based on patient genotype can be formulated. There is little data on the pharmacology and toxicology of MPA in older and paediatric transplant recipients.
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Ganschow R, Pape L, Sturm E, Bauer J, Melter M, Gerner P, Höcker B, Ahlenstiel T, Kemper M, Brinkert F, Sachse MM, Tönshoff B. Growing experience with mTOR inhibitors in pediatric solid organ transplantation. Pediatr Transplant 2013; 17:694-706. [PMID: 24004351 DOI: 10.1111/petr.12147] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/05/2013] [Indexed: 12/31/2022]
Abstract
Controlled trials of mTOR inhibitors in children following solid organ transplantation are scarce, although evidence from prospective single-arm studies is growing. Everolimus with reduced CNI therapy has been shown to be efficacious and safe in de novo pediatric kidney transplant patients in prospective trials. Prospective and retrospective data in children converted from CNI therapy to mTOR inhibition following kidney, liver, or heart transplantation suggest preservation of immunosuppressive efficacy. Good renal function has been maintained when mTOR inhibitors are used de novo in children following kidney transplantation or after conversion to mTOR inhibition with CNI minimization. mTOR inhibition with reduced CNI exposure is associated with a low risk for developing infection in children. Growth and development do not appear to be impaired during low-dose mTOR inhibition, but more studies are required. No firm conclusions can be drawn as to whether mTOR inhibitors should be discontinued in children requiring surgical intervention or whether mTOR inhibition delays progression of hepatic fibrosis after pediatric liver transplantation. In conclusion, current evidence suggests that use of mTOR inhibitors in children undergoing solid organ transplantation is efficacious and safe, but a number of issues remain unresolved and further studies are required.
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Affiliation(s)
- R Ganschow
- Pädiatrische Hepatologie und Lebertransplantation, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
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Veroux M, Tallarita T, Corona D, D’Assoro A, Gurrieri C, Veroux P. Sirolimus in solid organ transplantation: current therapies and new frontiers. Immunotherapy 2011; 3:1487-97. [DOI: 10.2217/imt.11.143] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
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