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Cho A, Park S, Han A, Ha J, Park JB, Lee KW, Min S. A comparative analysis of clinical outcomes between conversion to mTOR inhibitor and calcineurin inhibitor reduction in managing BK viremia among kidney transplant patients. Sci Rep 2024; 14:12855. [PMID: 38834615 DOI: 10.1038/s41598-024-60695-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 04/26/2024] [Indexed: 06/06/2024] Open
Abstract
BK virus-associated nephropathy (BKVAN) exerts a substantial impact on allograft survival, however, the absence of robust clinical evidence regarding treatment protocols adds to the complexity of managing this condition. This study aimed to compare the two treatment approaches. The study population consisted of patients who underwent kidney transplantation between January 2016 and June 2020 at two tertiary hospitals in Korea. Patients diagnosed with BK viremia were evaluated based on their initial viral load and the treatment methods. The 'Reduction group' involved dose reduction of tacrolimus while the 'Conversion group' included tacrolimus discontinuation and conversion to sirolimus. A total of 175 patients with an initial viral load (iVL) ≥ 3 on the log10 scale were evaluated within two iVL intervals (3-4 and 4-5). In the iVL 4-5 interval, the Reduction group showed potential effectiveness in terms of viral clearance without statistically significant differences. However, within the iVL 3-4 interval, the Reduction group demonstrated superior viral clearance and a lower incidence of biopsy-proven acute rejection (BPAR) than the Conversion group. The renal function over 12 months after BKV diagnosis showed no statistically significant difference. Reducing tacrolimus compared to converting to mTORi would be a more appropriate treatment approach for BK viral clearance in kidney transplantation. Further research is warranted in a large cohort of patients.
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Affiliation(s)
- Ara Cho
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Sunghae Park
- Department of Surgery, Samsung Medical Center, Seoul, South Korea
| | - Ahram Han
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Jongwon Ha
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Jae Berm Park
- Department of Surgery, Samsung Medical Center, Seoul, South Korea
| | - Kyo Won Lee
- Department of Surgery, Samsung Medical Center, Seoul, South Korea
| | - Sangil Min
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea.
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2
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Russo MW, Wheless W, Vrochides D. Management of long-term complications from immunosuppression. Liver Transpl 2024; 30:647-658. [PMID: 38315054 DOI: 10.1097/lvt.0000000000000341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 01/29/2024] [Indexed: 02/07/2024]
Abstract
This review discusses long-term complications from immunosuppressants after liver transplantation and the management of these complications. Common complications of calcineurin inhibitors include nephrotoxicity and metabolic diseases. Nephrotoxicity can be managed by targeting a lower drug level and/or adding an immunosuppressant of a different class. Metabolic disorders can be managed by treating the underlying condition and targeting a lower drug level. Gastrointestinal adverse effects and myelosuppression are common complications of antimetabolites that are initially managed with dose reduction or discontinuation if adverse events persist. Mammalian targets of rapamycin inhibitors are associated with myelosuppression, proteinuria, impaired wound healing, and stomatitis, which may require dose reduction or discontinuation. Induction agents and agents used for steroid-refractory rejection or antibody-mediated rejection are reviewed. Other rare complications of immunosuppressants are discussed as well.
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Affiliation(s)
- Mark W Russo
- Division of Hepatology, Department of Medicine, Carolinas Medical Center Wake Forest, University School of Medicine, Atrium Health, Charlotte, North Carolina, USA
| | - William Wheless
- Division of Hepatology, Department of Medicine, Carolinas Medical Center Wake Forest, University School of Medicine, Atrium Health, Charlotte, North Carolina, USA
| | - Dionisios Vrochides
- Transplant Surgery, Carolinas Medical Center Wake Forest, University School of Medicine, Atrium Health, Charlotte, North Carolina, USA
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3
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Bellini A, Finocchietti M, Rosa AC, Nordio M, Ferroni E, Massari M, Spila Alegiani S, Masiero L, Bedeschi G, Cardillo M, Lucenteforte E, Piccolo G, Leoni O, Pierobon S, Ledda S, Garau D, Davoli M, Addis A, Belleudi V. Effectiveness and safety of immunosuppressive regimens used as maintenance therapy in kidney transplantation: The CESIT study. PLoS One 2024; 19:e0295205. [PMID: 38165971 PMCID: PMC10760756 DOI: 10.1371/journal.pone.0295205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 11/16/2023] [Indexed: 01/04/2024] Open
Abstract
Maintenance immunosuppressive therapy used in kidney transplantation typically involves calcineurin inhibitors, such as tacrolimus or cyclosporine, in combination with mycophenolate or mechanistic target of rapamycin (mTORi) with or without corticosteroids. An Italian retrospective multicentre observational study was conducted to investigate the risk-benefit profile of different immunosuppressive regimens. We identified all subjects who underwent kidney transplant between 2009 and 2019, using healthcare claims data. Patients on cyclosporine and tacrolimus-based therapies were matched 1:1 based on propensity score, and effectiveness and safety outcomes were compared using Cox models (HR; 95%CI). Analyses were also conducted comparing mTORi versus mycophenolate among tacrolimus-treated patients. Patients treated with cyclosporine had a higher risk of rejection or graft loss (HR:1.69; 95%CI:1.16-2.46) and a higher incidence of severe infections (1.25;1.00-1.55), but a lower risk of diabetes (0.66;0.47-0.91) compared to those treated with tacrolimus. Among tacrolimus users, mTORi showed non-inferiority to MMF in terms of mortality (1.01;0.68-1.62), reject/graft loss (0.61;0.36-1.04) and severe infections (0.76;0.56-1.03). In a real-life setting, tacrolimus-based immunosuppressive therapy appeared to be superior to cyclosporine in reducing rejection and severe infections, albeit with an associated increased risk of diabetes. The combination of tacrolimus and mTORi may represent a valid alternative to the combination with mycophenolate, although further studies are needed to confirm this finding.
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Affiliation(s)
- Arianna Bellini
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | | | | | | | | | - Marco Massari
- National Centre for Drug Research and Evaluation, Istituto Superiore Di Sanità, Rome, Italy
| | | | - Lucia Masiero
- Italian National Transplant Centre, Istituto Superiore di Sanità, Rome, Italy
| | - Gaia Bedeschi
- Italian National Transplant Centre, Istituto Superiore di Sanità, Rome, Italy
| | - Massimo Cardillo
- Italian National Transplant Centre, Istituto Superiore di Sanità, Rome, Italy
| | - Ersilia Lucenteforte
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Olivia Leoni
- Department of Health of Lombardy Region, Epidemiology Observatory, Milan, Italy
| | | | - Stefano Ledda
- General Directorate for Health, Sardinia Region, Italy
| | | | - Marina Davoli
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Antonio Addis
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Valeria Belleudi
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
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Granata S, Mercuri S, Troise D, Gesualdo L, Stallone G, Zaza G. mTOR-inhibitors and post-transplant diabetes mellitus: a link still debated in kidney transplantation. Front Med (Lausanne) 2023; 10:1168967. [PMID: 37250653 PMCID: PMC10213242 DOI: 10.3389/fmed.2023.1168967] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 04/25/2023] [Indexed: 05/31/2023] Open
Abstract
The mammalian target of rapamycin inhibitors (mTOR-Is, Sirolimus, and Everolimus) are immunosuppressive drugs widely employed in kidney transplantation. Their main mechanism of action includes the inhibition of a serine/threonine kinase with a pivotal role in cellular metabolism and in various eukaryotic biological functions (including proteins and lipids synthesis, autophagy, cell survival, cytoskeleton organization, lipogenesis, and gluconeogenesis). Moreover, as well described, the inhibition of the mTOR pathway may also contribute to the development of the post-transplant diabetes mellitus (PTDM), a major clinical complication that may dramatically impact allograft survival (by accelerating the development of the chronic allograft damage) and increase the risk of severe systemic comorbidities. Several factors may contribute to this condition, but the reduction of the beta-cell mass, the impairment of the insulin secretion and resistance, and the induction of glucose intolerance may play a pivotal role. However, although the results of several in vitro and in animal models, the real impact of mTOR-Is on PTDM is still debated and the entire biological machinery is poorly recognized. Therefore, to better elucidate the impact of the mTOR-Is on the risk of PTDM in kidney transplant recipients and to potentially uncover future research topics (particularly for the clinical translational research), we decided to review the available literature evidence regarding this important clinical association. In our opinion, based on the published reports, we cannot draw any conclusion and PTDM remains a challenge. However, also in this case, the administration of the lowest possible dose of mTOR-I should also be recommended.
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Affiliation(s)
- Simona Granata
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Silvia Mercuri
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Dario Troise
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Loreto Gesualdo
- Renal, Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area (DIMEPRE-J), University of Bari, Bari, Italy
| | - Giovanni Stallone
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Gianluigi Zaza
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
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Kien TQ, Kien NX, Thang LV, Nghia PB, Van DT, Duc NV, Ha DM, Dung NTT, Ha NTT, Loan VT, Vinh HT, Manh BV, Su HX, Tien TV, Rostaing L, Toan PQ. Stepwise Reduction of Mycophenolate Mofetil with Conversion to Everolimus for the Treatment of Active BKV in Kidney Transplant Recipients: A Single-Center Experience in Vietnam. J Clin Med 2022; 11:jcm11247297. [PMID: 36555914 PMCID: PMC9783583 DOI: 10.3390/jcm11247297] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 11/23/2022] [Accepted: 12/06/2022] [Indexed: 12/13/2022] Open
Abstract
Background: No specific antiviral drug can effectively treat BKV reactivation after kidney transplantation. Thus, we evaluated stepwise-reduced immunosuppression to treat BKV reactivation. Methods: 341 kidney-transplant recipients were monitored for BKV infection (BKV-viremia, BKV-viruria). Positive samples with a significant virus load were nested PCR-genotyped in the VP1 region. In 97/211 patients presenting BKV viremia ≥104 copies/mL and/or BKV viruria ≥107 copies/mL, or BKV-nephropathy immunosuppression (i.e., mycophenolate mofetil [MMF]) was reduced by 50%. If viral load did not decrease within 28 days, MMF dose was further reduced by 25%, although calcineurin-inhibitor (CNI) therapy remained unchanged. If BKV viral load did not decrease within another 28 days, MMF was withdrawn and replaced by everolimus combined with reduced CNIs. Results: Only 41/97 BKV (+) cases completed the 6-month follow-up. Among these, 29 (71%) were in the BKV-I group and 12 (29%) were in BKV-IV. BKV viruria and BKV viremia were significantly decreased from 9.32 to 6.09 log10 copies/mL, and from 3.59 to 2.45 log10 copies/mL (p < 0.001 and p = 0.024, respectively). 11/32 (34.4%) patients were cleared of BKV viremia; 2/32 (6.3%) patients were cleared of BKV in both serum and urine, and 9/9 (100%) only had BKV viruria but did not develop BKV viremia. eGFR remained stable. No patient with BKV-related nephropathy had graft loss. There was a significant inverse relationship between changes in eGFR and serum BKV load (r = −0.314, p = 0.04). Conclusions: This stepwise immunosuppressive strategy proved effective at reducing BKV viral load in kidney transplant recipients that had high BKV loads in serum and/or urine. Renal function remained stable without rejection.
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Affiliation(s)
- Truong Quy Kien
- Department of Nephrology, Military Hospital 103, Vietnam Military Medical University, Hanoi 100000, Vietnam
| | - Nguyen Xuan Kien
- Transplant Centre, Military Hospital 103, Vietnam Military Medical University, Hanoi 100000, Vietnam
| | - Le Viet Thang
- Department of Nephrology, Military Hospital 103, Vietnam Military Medical University, Hanoi 100000, Vietnam
| | - Phan Ba Nghia
- Department of Nephrology, Military Hospital 103, Vietnam Military Medical University, Hanoi 100000, Vietnam
| | - Diem Thi Van
- Department of Nephrology, Military Hospital 103, Vietnam Military Medical University, Hanoi 100000, Vietnam
| | - Nguyen Van Duc
- Department of Nephrology, Military Hospital 103, Vietnam Military Medical University, Hanoi 100000, Vietnam
| | - Do Manh Ha
- Department of Nephrology, Military Hospital 103, Vietnam Military Medical University, Hanoi 100000, Vietnam
| | - Nguyen Thi Thuy Dung
- Department of Nephrology, Military Hospital 103, Vietnam Military Medical University, Hanoi 100000, Vietnam
| | - Nguyen Thi Thu Ha
- Department of Nephrology, Military Hospital 103, Vietnam Military Medical University, Hanoi 100000, Vietnam
| | - Vu Thi Loan
- Department of Endocrinology, 108 Military Central Hospital, Hanoi 100000, Vietnam
| | - Hoang Trung Vinh
- Department of Nephrology, Military Hospital 103, Vietnam Military Medical University, Hanoi 100000, Vietnam
| | - Bui Van Manh
- Center of Emergency, Intensive Care Medicine and Clinical Toxicology, Hanoi 100000, Vietnam
| | - Hoang Xuan Su
- Institute of Biomedicine and Pharmacy, Vietnam Military Medical University, Hanoi 100000, Vietnam
| | - Tran Viet Tien
- Department of Infectious Disease, Vietnam Military Medical University, Hanoi 100000, Vietnam
| | - Lionel Rostaing
- Nephrology, Hemodialysis, Apheresis, and Kidney Transplantation Department, Grenoble University Hospital, CEDEX 9, 38043 Grenoble, France
- Correspondence:
| | - Pham Quoc Toan
- Department of Nephrology, Military Hospital 103, Vietnam Military Medical University, Hanoi 100000, Vietnam
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Everolimus reduces BK polyomavirus infection by suppressing its replication and spread of infection. Antiviral Res 2022; 208:105456. [DOI: 10.1016/j.antiviral.2022.105456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 10/25/2022] [Accepted: 10/27/2022] [Indexed: 11/09/2022]
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Turkkan S, Basaran FC, Sahin MF, Beyoglu MA, Yilmaz E, Ozay HY, Bindal M, Yazicioglu A, Yekeler E. Everolimus Use in Lung Transplant Recipients. Transplant Proc 2022; 54:2317-2324. [PMID: 36192210 DOI: 10.1016/j.transproceed.2022.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 08/09/2022] [Accepted: 08/26/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Most lung transplantation centers prefer triple immunosuppressive therapy with tacrolimus, mycophenolate mofetil, and corticosteroids. However, to prevent complications and comorbidities caused by tacrolimus, replacing the drug with everolimus has been considered. METHODS This is a retrospective observational study investigating everolimus switch for different reasons. The population was divided into 3 groups: chronic lung allograft dysfunction (CLAD), kidney impairment, and malignant neoplasm groups. We investigated whether we achieved the goal of the switch and the frequency of rejection, cytomegalovirus and fungal infections, and everolimus adverse effects. RESULTS Nineteen patients received everolimus therapy, and 5 of these were for CLAD, 7 for tacrolimus nephrotoxicity, and 7 for explant/de novo malignant neoplasm. The patients were followed up for a mean (SD) of 30 (16.7) months under the therapy. The number of acute cellular rejection, cytomegalovirus infection, and aspergillosis infection cases before switch were 7, 13, and 2, respectively, and 7, 2, and 3 after that. The mean values of creatinine and estimated glomerular filtration rate of the whole population after the switch improved with no statistical significance, whereas it was significant in tacrolimus nephrotoxicity group. Three patients in the CLAD group remained stable after switching, whereas 2 progressed. Only 1 of the 7 patients with malignant neoplasms had a recurrence during 31.1 (16.5) months of median follow-up. Eleven cases of everolimus adverse effects occurred in 9 patients (47.3%), with 2 (10.5%) withdrawal events. Kidney impairment (P = .02) and age (P = .05) stood out as significant risk factors for drug adverse effects. CONCLUSIONS After lung transplant, everolimus can be a safe alternative for immunosuppression with acceptable adverse effects.
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Affiliation(s)
- Sinan Turkkan
- Department of Thoracic Surgery and Lung Transplantation, University of Health Sciences, Ankara City Hospital, Ankara, Turkey.
| | - Fatmanur Celik Basaran
- Department of Thoracic Surgery and Lung Transplantation, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Mehmet Furkan Sahin
- Department of Thoracic Surgery and Lung Transplantation, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Muhammet Ali Beyoglu
- Department of Thoracic Surgery and Lung Transplantation, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Emre Yilmaz
- Department of Thoracic Surgery and Lung Transplantation, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Hülya Yigit Ozay
- Department of Anesthesiology and Reanimation, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Mustafa Bindal
- Department of Anesthesiology and Reanimation, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Alkin Yazicioglu
- Department of Thoracic Surgery and Lung Transplantation, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Erdal Yekeler
- Department of Thoracic Surgery and Lung Transplantation, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
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Hirabatake M, Mizuno T, Kato H, Hashida T. Everolimus pharmacokinetics and exposure-response relationship in Japanese patients with advanced breast cancer. Front Pharmacol 2022; 13:984002. [PMID: 36188563 PMCID: PMC9520775 DOI: 10.3389/fphar.2022.984002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 08/24/2022] [Indexed: 12/01/2022] Open
Abstract
Background: Everolimus is one of the key drugs for the treatment of advanced breast cancer. The optimal target concentration range for everolimus therapy in patients with breast cancer has not yet been established. This study aimed to characterize everolimus pharmacokinetics (PK) and determine the relationship between blood concentration and efficacy as well as adverse events in patients with breast cancer. Methods: This was a prospective, observational PK study. Patients receiving everolimus between November 2015 and November 2018 at our hospital were enrolled in this study. The whole blood samples for the everolimus assay were collected at least two weeks after initiation of treatment or the last everolimus dose change. PK parameters were estimated using Bayesian analysis. Statistical differences in everolimus trough concentrations between patient cohorts were assessed using the Mann–Whitney test. Progression-free survival was assessed using the Kaplan-Meier method and the log-rank test. Results: Eighteen patients were enrolled in the study. The median follow-up period was 35 months. The most frequently observed adverse event was stomatitis (all grade 94%). There was high inter-individual variation in PK parameters such as clearance [range: 5.1–21.3 L/h/70 kg and co-efficient of variation (CV): 38.5%] and volume of distribution of the central compartment (range: 9.9–103.6 L/70 kg and CV: 57.8%). The trough concentrations at dose-limiting toxicities were significantly higher than trough concentrations in the absence of these toxicities (p = 0.0058). Progression-free survival was significantly longer in the 10–20 ng/ml group than in the other groups (p = 0.0078). Conclusion: This study characterized the everolimus PK parameters in Japanese patients with breast cancer. High everolimus exposure was found to be associated with poor tolerability. Based on our data, trough concentrations in the range of 10–20 ng/ml may be associated with prolonged progression-free survival. Thus, determining the blood concentration of everolimus and subsequent dose adjustments will potentially reduce side effects and enhance the therapeutic effect in Japanese patients with advanced breast cancer.
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Affiliation(s)
- Masaki Hirabatake
- Department of Pharmacy, Kobe City Medical Center General Hospital, Kobe, Japan
- *Correspondence: Masaki Hirabatake,
| | - Tomoyuki Mizuno
- Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Hironori Kato
- Department of Breast Surgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Tohru Hashida
- Department of Pharmacy, Kobe City Medical Center General Hospital, Kobe, Japan
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Nelson J, Alvey N, Bowman L, Schulte J, Segovia M, McDermott J, Te HS, Kapila N, Levine DJ, Gottlieb RL, Oberholzer J, Campara M. Consensus recommendations for use of maintenance immunosuppression in solid organ transplantation: Endorsed by the American College of Clinical Pharmacy, American Society of Transplantation, and the International Society for Heart and Lung Transplantation. Pharmacotherapy 2022; 42:599-633. [DOI: 10.1002/phar.2716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 03/29/2022] [Accepted: 04/08/2022] [Indexed: 12/17/2022]
Affiliation(s)
- Joelle Nelson
- Department of Pharmacotherapy and Pharmacy Services University Health San Antonio Texas USA
- Pharmacotherapy Education and Research Center University of Texas Health San Antonio San Antonio Texas USA
- Department of Pharmacy, Pharmacotherapy Division, College of Pharmacy The University of Texas at Austin Austin Texas USA
| | - Nicole Alvey
- Department of Pharmacy Rush University Medical Center Chicago Illinois USA
- Science and Pharmacy Roosevelt University College of Health Schaumburg Illinois USA
| | - Lyndsey Bowman
- Department of Pharmacy Tampa General Hospital Tampa Florida USA
| | - Jamie Schulte
- Department of Pharmacy Services Thomas Jefferson University Hospital Philadelphia Pennsylvania USA
| | | | - Jennifer McDermott
- Richard DeVos Heart and Lung Transplant Program, Spectrum Health Grand Rapids Michigan USA
- Department of Medicine, Michigan State University College of Human Medicine Grand Rapids Michigan USA
| | - Helen S. Te
- Liver Transplantation, Center for Liver Diseases, Department of Medicine University of Chicago Medical Center Chicago Illinois USA
| | - Nikhil Kapila
- Department of Transplant Hepatology Duke University Hospital Durham North Carolina USA
| | - Deborah Jo Levine
- Division of Critical Care Medicine, Department of Medicine The University of Texas Health Science Center at San Antonio San Antonio Texas USA
| | - Robert L. Gottlieb
- Baylor University Medical Center and Baylor Scott and White Research Institute Dallas Texas USA
| | - Jose Oberholzer
- Department of Surgery/Division of Transplantation University of Virginia Charlottesville Virginia USA
| | - Maya Campara
- Department of Surgery University of Illinois Chicago Chicago Illinois USA
- Department of Pharmacy Practice University of Illinois Chicago Chicago Illinois USA
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Effect of Sirolimus vs. Everolimus on CMV-Infections after Kidney Transplantation-A Network Meta-Analysis. J Clin Med 2022; 11:jcm11144216. [PMID: 35887977 PMCID: PMC9323040 DOI: 10.3390/jcm11144216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 07/04/2022] [Accepted: 07/06/2022] [Indexed: 11/16/2022] Open
Abstract
(1) Background: Following renal transplantation, infection with cytomegalovirus (CMV) is a common and feared complication. mTOR-inhibitor (mTOR-I) treatment, either alone or in combination with calcineurininhibitors (CNIs), significantly reduces the CMV incidence after organ transplantation. As of now, there is no information on which mTOR-I, sirolimus (SIR) or everolimus (ERL), has a stronger anti-CMV effect. (2) Methods: The current literature was searched for prospective randomized controlled trials in renal transplantation. There were 1164 trials screened, of which 27 could be included (11,655 pts.). We performed a network meta-analysis to analyze the relative risk of different types of mTOR-I treatment on CMV infection 12 months after transplantation compared to CNI treatment. (3) Results: Four different types of mTOR-I treatment were analyzed in network meta-analyses—SIR mono, ERL mono, SIR with CNI, ERL with CNI. The mTOR-I treatment with the strongest anti-CMV effect compared to a regular CNI treatment was ERL in combination with a CNI (relative risk (RR) 0.27, confidence interval (CI) 0.22−0.32, p < 0.0001). The other mTOR-I therapy groups showed a slightly decreased anti-CMV efficacy (SIR monotherapy (mono): RR 0.35, CI 0.22−0.57, p < 0.001; SIR with CNI: RR 0.43, CI 0.29−0.64, p < 0.0001; ERL mono: RR 0.46, CI 0.22−0.93, p = 0.031). (4) Conclusions: The anti-CMV effect of both mTOR-Is (SRL and ERL) is highly effective, irrespective of the combination with other immunosuppressive drugs. Certain differences with respect to the potency against the CMV could be found between SRL and ERL. Data gained from this analysis seem to support that a combination of ERL and CNI has the most potent anti-CMV efficacy.
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Cuadrado-Payán E, Diekmann F, Cucchiari D. Medical Aspects of mTOR Inhibition in Kidney Transplantation. Int J Mol Sci 2022; 23:ijms23147707. [PMID: 35887051 PMCID: PMC9322634 DOI: 10.3390/ijms23147707] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/08/2022] [Accepted: 07/10/2022] [Indexed: 11/16/2022] Open
Abstract
The advances in transplant immunosuppression have reduced substantially the incidence of kidney graft rejection. In recent years, the focus has moved from preventing rejection to preventing the long-term consequences of long-standing immunosuppression, including nephrotoxicity induced by calcineurin inhibitors (CNI), as well as infectious and neoplastic complications. Since the appearance in the late 1990s of mTOR inhibitors (mTORi), these unmet needs in immunosuppression management could be addressed thanks to their benefits (reduced rate of viral infections and cancer). However, management of side effects can be troublesome and hands-on experience is needed. Here, we review all the available information about them. Thanks to all the basic, translational and clinical research achieved in the last twenty years, we now use mTORi as de novo immunosuppression in association with CNI. Another possibility is represented by the conversion of either CNI or mycophenolate (MPA) to an mTORi later on after transplantation in low-risk kidney transplant recipients.
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Affiliation(s)
- Elena Cuadrado-Payán
- Department of Nephrology and Kidney Transplantation, Hospital Clínic, 08036 Barcelona, Spain; (E.C.-P.); (F.D.)
| | - Fritz Diekmann
- Department of Nephrology and Kidney Transplantation, Hospital Clínic, 08036 Barcelona, Spain; (E.C.-P.); (F.D.)
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT), Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
- Red de Investigación Renal (REDINREN), 28029 Madrid, Spain
| | - David Cucchiari
- Department of Nephrology and Kidney Transplantation, Hospital Clínic, 08036 Barcelona, Spain; (E.C.-P.); (F.D.)
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT), Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
- Correspondence: ; Tel.: +34-932-2744103474
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Kaminski H, Kamar N, Thaunat O, Bouvier N, Caillard S, Garrigue I, Anglicheau D, Rérolle JP, Le Meur Y, Durrbach A, Bachelet T, Savel H, Coueron R, Visentin J, Del Bello A, Pellegrin I, Déchanet-Merville J, Merville P, Thiébaut R, Couzi L. Incidence of cytomegalovirus infection in seropositive kidney transplant recipients treated with everolimus: A randomized, open-label, multicenter phase 4 trial. Am J Transplant 2022; 22:1430-1441. [PMID: 34990047 DOI: 10.1111/ajt.16946] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 12/02/2021] [Accepted: 12/28/2021] [Indexed: 01/25/2023]
Abstract
Cytomegalovirus (CMV) persists as the most frequent opportunistic infection among solid organ transplant recipients. This multicenter trial aimed to test whether treatment with everolimus (EVR) could decrease the incidence of CMV DNAemia and disease. We randomized 186 CMV seropositive kidney transplant recipients in a 1:1 ratio to receive EVR or mycophenolic acid (MPA) in association with basiliximab, cyclosporin, and steroids and 87 in each group were analyzed. No universal prophylaxis was administered to either group. The composite primary endpoint was the presence of CMV DNAemia, CMV treatment, graft loss, death, and discontinuation of the study at 6 months posttransplant. In the modified intent-to-treat analysis, 42 (48.3%) and 70 (80.5%) patients in the EVR and MPA groups reached the primary endpoint (OR = 0.21, 95% CI: 0.11-0.43, p < .0001). Fewer patients of the EVR group received treatment for CMV (21.8% vs. 47.1%, p = .0007). EVR was discontinued in 31 (35.6%) patients. Among the 56 patients with ongoing EVR treatment, only 7.4% received treatment for CMV. In conclusion, EVR prevents CMV DNAemia requiring treatment in seropositive recipients as long as it is tolerated and maintained.
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Affiliation(s)
- Hannah Kaminski
- Department of Nephrology, Transplantation, Dialysis and Apheresis, CHU Bordeaux, Bordeaux, France.,UMR 5164-ImmunoConcEpT, University of Bordeaux, CNRS, Bordeaux University, Bordeaux, France
| | - Nassim Kamar
- Department of Nephrology and Organ Transplantation, CHU Toulouse, Toulouse, France.,INSERM U1043, IFR-BMT, Toulouse, France
| | - Olivier Thaunat
- Department of Nephrology, Transplantation and Clinical Immunology of Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon-I University UFR Lyon Est, Lyon, France
| | - Nicolas Bouvier
- Department of Nephrology, Transplantation, Dialysis, CHU Caen, Caen, France
| | - Sophie Caillard
- Department of Nephrology and Transplantation, CHU Strasbourg, Strasbourg, France
| | | | - Dany Anglicheau
- Department of Nephrology and Kidney Transplantation, Necker Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | - Yannick Le Meur
- Department of Nephrology and Transplantation, Brest University Hospital, Brest, France
| | - Antoine Durrbach
- Department of Nephrology and Kidney Transplantation, INSERM 1186, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris, Paris Saclay University, Paris, France
| | - Thomas Bachelet
- Department of Nephrology, Transplantation, Dialysis and Apheresis, CHU Bordeaux, Bordeaux, France
| | - Hélène Savel
- CHU Bordeaux, Service d'information médicale, Bordeaux, France
| | - Roxane Coueron
- CHU Bordeaux, Service d'information médicale, Bordeaux, France
| | - Jonathan Visentin
- UMR 5164-ImmunoConcEpT, University of Bordeaux, CNRS, Bordeaux University, Bordeaux, France.,Laboratory of Immunology and Immunogenetics, CHU Bordeaux, Bordeaux, France
| | - Arnaud Del Bello
- Department of Nephrology and Organ Transplantation, CHU Toulouse, Toulouse, France.,INSERM U1043, IFR-BMT, Toulouse, France
| | - Isabelle Pellegrin
- UMR 5164-ImmunoConcEpT, University of Bordeaux, CNRS, Bordeaux University, Bordeaux, France.,Laboratory of Immunology and Immunogenetics, CHU Bordeaux, Bordeaux, France
| | | | - Pierre Merville
- Department of Nephrology, Transplantation, Dialysis and Apheresis, CHU Bordeaux, Bordeaux, France.,UMR 5164-ImmunoConcEpT, University of Bordeaux, CNRS, Bordeaux University, Bordeaux, France
| | - Rodolphe Thiébaut
- CHU Bordeaux, Service d'information médicale, Bordeaux, France.,INSERM U1219 Bordeaux Population Health Research Center, Inria SISTM, Bordeaux University, Bordeaux, France
| | - Lionel Couzi
- Department of Nephrology, Transplantation, Dialysis and Apheresis, CHU Bordeaux, Bordeaux, France.,UMR 5164-ImmunoConcEpT, University of Bordeaux, CNRS, Bordeaux University, Bordeaux, France
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13
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Mammalian Target of Rapamycin Inhibitors and Wound Healing Complications in Kidney Transplantation: Old Myths and New Realities. J Transplant 2022; 2022:6255339. [PMID: 35265364 PMCID: PMC8901320 DOI: 10.1155/2022/6255339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 12/12/2021] [Accepted: 01/08/2022] [Indexed: 12/13/2022] Open
Abstract
Mammalian target of rapamycin inhibitors (mTOR-I) lacks nephrotoxicity, has antineoplastic effects, and reduces viral infections in kidney transplant recipients. Earlier studies reported a significant incidence of wound healing complications and lymphocele. This resulted in the uncomfortable willingness of transplant clinicians to use these agents in the immediate posttransplant period. As evidence and experience evolved over time, much useful information became available about the optimal use of these agents. Understandably, mTOR-I effects wound healing through their antiproliferative properties. However, there are a lot of other immunological and nonimmunological factors which can also contribute to wound healing complications. These risk factors include obesity, uremia, increasing age, diabetes, smoking, alcoholism, and protein-energy malnutrition. Except for age, the rest of all these risk factors are modifiable. At the same time, mycophenolic acid derivatives, steroids, and antithymocyte globulin (ATG) have also been implicated in wound healing complications. A lot has been learnt about the optimal dose of mTOR-I and their trough levels, its combinations with other immunosuppressive medications, and patients' profile, enabling clinicians to use these agents appropriately for maximum benefits. Recent randomized control trials have further increased the confidence of clinicians to use these agents in immediate posttransplant periods.
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14
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Clinical Outcomes of Everolimus With Reduced-Dose Tacrolimus vs Mycophenolate Mofetil With Standard-Dose Tacrolimus in De Novo ABO-Incompatible Kidney Transplant Recipients: 1-Year Follow-up. Transplant Proc 2022; 54:293-298. [PMID: 35031117 DOI: 10.1016/j.transproceed.2021.08.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 08/26/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND One of the major barriers for long-term renal graft survival is considered to be calcineurin inhibitor nephrotoxicity, contributing to chronic graft dysfunction. Thus, recent immunosuppressive strategies are focused on regimens that can reduce or avoid exposure to calcineurin inhibitors. Herein, we carried out a small-scale pilot study to assess whether everolimus (EVR) with reduced-dose tacrolimus (Tac) is an acceptable immunosuppressive regimen for patients with de novo ABO-incompatible kidney transplant compared with mycophenolate mofetil (MMF) with standard-dose Tac. METHODS This retrospective single-center cohort study included patients who underwent ABO-incompatible kidney transplant at our institution between January 2016 and December 2019. Those whose immunosuppressive regimen was changed by reasons other than rejection during the 1-year follow-up period were excluded. RESULTS A total of 24 patients were enrolled in this study: 10 patients who received an EVR with reduced-dose Tac regimen and 14 patients who received an MMF with standard-dose Tac regimen. Tac trough levels in the EVR group were significantly lower than those in the MMF group (P < .001). No patients died or lost their grafts during the follow-up period. There were no significant differences in renal function, proteinuria, and prevalence of hyperlipidemia between the 2 groups at 1 year after transplant. There were no significant differences in the incidence of rejection (acute cellular rejection, steroid-resistant acute cellular rejection, acute antibody-mediated rejection) and infection (cytomegalovirus viremia, cytomegalovirus disease, BK viremia, BK virus nephropathy) between the 2 groups. CONCLUSIONS Comparable with MMF with standard-dose Tac, EVR with reduced-dose Tac might be an acceptable immunosuppressive regimen for patients with de novo ABO-incompatible kidney transplant.
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15
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Everolimus Reduces Cancer Incidence and Improves Patient and Graft Survival Rates after Kidney Transplantation: A Multi-Center Study. J Clin Med 2022; 11:jcm11010249. [PMID: 35011990 PMCID: PMC8746009 DOI: 10.3390/jcm11010249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 12/27/2021] [Accepted: 12/29/2021] [Indexed: 02/05/2023] Open
Abstract
Kidney transplantation can prevent renal failure and associated complications in patients with end-stage renal disease. Despite the good quality of life, de novo cancers after kidney transplantation are a major complication impacting survival and there is an urgent need to establish immunosuppressive protocols to prevent de novo cancers. We conducted a multi-center retrospective study of 2002 patients who underwent kidney transplantation between 1965 and 2020 to examine patient and graft survival rates and cumulative cancer incidence in the following groups categorized based on specific induction immunosuppressive therapies: group 1, antiproliferative agents and steroids; group 2, calcineurin inhibitors (CNIs), antiproliferative agents and steroids; group 3, CNIs, mycophenolate mofetil, and steroids; and group 4, mammalian target of rapamycin inhibitors including everolimus, CNIs, mycophenolate mofetil, and steroids. The patient and graft survival rates were significantly higher in groups 3 and 4. The cumulative cancer incidence rate significantly increased with the use of more potent immunosuppressants, and the time to develop cancer was shorter. Only one patient in group 4 developed de novo cancer. Potent immunosuppressants might improve graft survival rate while inducing de novo cancer after kidney transplantation. Our data also suggest that everolimus might suppress cancer development after kidney transplantation.
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16
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Tedesco-Silva H, Saliba F, Barten MJ, De Simone P, Potena L, Gottlieb J, Gawai A, Bernhardt P, Pascual J. An overview of the efficacy and safety of everolimus in adult solid organ transplant recipients. Transplant Rev (Orlando) 2021; 36:100655. [PMID: 34696930 DOI: 10.1016/j.trre.2021.100655] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 09/17/2021] [Accepted: 09/17/2021] [Indexed: 12/15/2022]
Abstract
As the risk of graft loss due to acute rejection has declined, the goal of post-transplant management has switched to long-term preservation of organ function. Minimizing calcineurin inhibitor (CNI)-related nephrotoxicity is a key component of this objective. Everolimus is a mammalian target of rapamycin inhibitor/proliferation-signal inhibitor with potent immunosuppressive and anti-proliferative effects. It has been widely investigated in large randomized clinical studies that have shown it to have similar anti-rejection efficacy compared with standard-of-care regimens across organ transplant indications. With demonstrated potential to facilitate the reduction of CNI therapy and preserve renal function, everolimus is an alternative to the current standard-of-care CNI-based regimens used in de novo and maintenance solid organ transplantation recipients. Here, we provide an overview of the evidence from the everolimus clinical study program across kidney, liver, heart, and lung transplants, as well as other key data associated with its use in CNI reduction strategies in adult transplant recipients.
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Affiliation(s)
| | - Faouzi Saliba
- AP-HP_Hôpital Paul Brousse, Hepato-Biliary Centre, Villejuif, France; Université Paris-Saclay, INSERM Unit 1193, France
| | - Markus J Barten
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Hamburg, Germany
| | | | - Luciano Potena
- Heart Failure and Transplant Program, Cardiology Unit, IRCCS Policlinico di Sant'Orsola, Bologna, Italy
| | - Jens Gottlieb
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | | | | | - Julio Pascual
- Department of Nephrology, Hospital del Mar, Barcelona, Spain.
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17
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Granata S, Carratù P, Stallone G, Zaza G. mTOR-Inhibition and COVID-19 in Kidney Transplant Recipients: Focus on Pulmonary Fibrosis. Front Pharmacol 2021; 12:710543. [PMID: 34497515 PMCID: PMC8419255 DOI: 10.3389/fphar.2021.710543] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 08/11/2021] [Indexed: 12/24/2022] Open
Abstract
Kidney transplant recipients are at high risk of developing severe COVID-19 due to the coexistence of several transplant-related comorbidities (e.g., cardiovascular disease, diabetes) and chronic immunosuppression. As a consequence, a large part of SARS-CoV-2 infected patients have been managed with a reduction of immunosuppression. The mTOR-I, together with antimetabolites, have been often discontinued in order to minimize the risk of pulmonary toxicity and to antagonize pharmacological interaction with antiviral/anti-inflammatory drugs. However, at our opinion, this therapeutic strategy, although justified in kidney transplant recipients with severe COVID-19, should be carefully evaluated in asymptomatic/paucisymptomatic patients in order to avoid the onset of acute allograft rejections, to potentially exploit the mTOR-I antiviral properties, to reduce proliferation of conventional T lymphocytes (which could mitigate the cytokine storm) and to preserve Treg growth/activity which could reduce the risk of progression to severe disease. In this review, we discuss the current literature regarding the therapeutic potential of mTOR-Is in kidney transplant recipients with COVID-19 with a focus on pulmonary fibrosis.
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Affiliation(s)
- Simona Granata
- Renal Unit, Department of Medicine, University-Hospital of Verona, Verona, Italy
| | - Pierluigi Carratù
- Division of Internal Medicine, Clinica Medica "A. Murri", Department of Biomedical Sciences and Human Oncology, "Aldo Moro" University of Bari, Bari, Italy
| | - Giovanni Stallone
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Science, University of Foggia, Foggia, Italy
| | - Gianluigi Zaza
- Renal Unit, Department of Medicine, University-Hospital of Verona, Verona, Italy
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18
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Thet Z, Lam AK, Ranganathan D, Aung SY, Han T, Khoo TK. Reducing non-melanoma skin cancer risk in renal transplant recipients. Nephrology (Carlton) 2021; 26:907-919. [PMID: 34240786 DOI: 10.1111/nep.13939] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 06/11/2021] [Accepted: 07/05/2021] [Indexed: 12/19/2022]
Abstract
With an increasing number of renal transplant recipients (RTRs) and improving patient survival, a higher incidence of non-melanoma skin cancer (NMSC) has been observed. NMSC in RTRs are often more numerous and biologically more aggressive than the general population, thus contributing towards an increase in morbidity and to a lesser degree, mortality. The resultant cumulative health and financial burden is a recognized concern. Proposed strategies in mitigating risks of developing NMSC and early therapeutic options thereof include tailored modification of immunosuppressants in conjunction with sun protection in all transplant patients. This review highlights the clinical and financial burden of transplant-associated skin cancers, carcinogenic mechanisms in association with immunosuppression, importance of skin cancer awareness campaign and integrated transplant skin clinic, and the potential role of chemoprotective agents. A scheme is proposed for primary and secondary prevention of NMSC based on the available evidence.
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Affiliation(s)
- Zaw Thet
- School of Medicine & Dentistry, Griffith University, Gold Coast, Queensland, Australia.,Department of Nephrology, Central Queensland Hospital and Health Service, Rockhampton, Queensland, Australia
| | - Alfred K Lam
- School of Medicine & Dentistry, Griffith University, Gold Coast, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Pathology Queensland, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Dwarakanathan Ranganathan
- School of Medicine & Dentistry, Griffith University, Gold Coast, Queensland, Australia.,Department of Nephrology, Metro North Hospital and Health Service, Herston, Queensland, Australia
| | - Soe Yu Aung
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Department of Oncology, Central Queensland Hospital and Health Service, Rockhampton, Queensland, Australia
| | - Thin Han
- Department of Nephrology, Central Queensland Hospital and Health Service, Rockhampton, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Tien K Khoo
- School of Medicine & Dentistry, Griffith University, Gold Coast, Queensland, Australia.,School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia
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19
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Watarai Y, Danguilan R, Casasola C, Chang SS, Ruangkanchanasetr P, Kee T, Wong HS, Kenmochi T, Amante AJ, Shu KH, Ingsathit A, Bernhardt P, Hernandez-Gutierrez MP, Han DJ, Kim MS. Everolimus-facilitated calcineurin inhibitor reduction in Asian de novo kidney transplant recipients: Two-year results from the subgroup analysis of the TRANSFORM study. Clin Transplant 2021; 35:e14415. [PMID: 34216395 PMCID: PMC9255374 DOI: 10.1111/ctr.14415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 06/23/2021] [Accepted: 06/25/2021] [Indexed: 11/28/2022]
Abstract
Objective We analyzed the efficacy and safety of an everolimus with reduced‐exposure calcineurin inhibitor (EVR+rCNI) versus mycophenolic acid with standard‐exposure CNI (MPA+sCNI) regimen in Asian patients from the TRANSFORM study. Methods In this 24‐month, open‐label study, de novo kidney transplant recipients (KTxRs) were randomized (1:1) to receive EVR+rCNI or MPA+sCNI, along with induction therapy and corticosteroids. Results Of the 2037 patients randomized in the TRANSFORM study, 293 were Asian (EVR+rCNI, N = 136; MPA+sCNI, N = 157). At month 24, EVR+rCNI was noninferior to MPA+sCNI for the binary endpoint of estimated glomerular filtration rate (eGFR) < 50 ml/min/1.73 m2 or treated biopsy‐proven acute rejection (27.0% vs. 29.2%, P = .011 for a noninferiority margin of 10%). Graft loss and death were reported for one patient each in both arms. Mean eGFR was higher in EVR+rCNI versus MPA+sCNI (72.2 vs. 66.3 ml/min/1.73 m2, P = .0414) even after adjusting for donor type and donor age (64.3 vs. 59.3 ml/min/1.73 m2, P = .0582). Overall incidence of adverse events was comparable. BK virus (4.4% vs. 12.1%) and cytomegalovirus (4.4% vs. 13.4%) infections were significantly lower in the EVR+rCNI arm. Conclusion This subgroup analysis in Asian de novo KTxRs demonstrated that the EVR+rCNI versus MPA+sCNI regimen provides comparable antirejection efficacy, better renal function, and reduced viral infections (NCT01950819).
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Affiliation(s)
- Yoshihiko Watarai
- Department of Transplant Surgery, Kidney Disease Center, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Romina Danguilan
- National Kidney and Transplant Institute, Quezon City, Philippines
| | - Concesa Casasola
- National Kidney and Transplant Institute, Quezon City, Philippines
| | - Shen-Shin Chang
- National Cheng Kung University College of Medicine and Hospital, Tainan, Taiwan
| | | | - Terence Kee
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
| | - Hin Seng Wong
- Department of Nephrology & Clinical Research Centre Hospital Selayang, Selangor Darul Ehsan, Batu Caves, Malaysia
| | | | | | | | - Atiporn Ingsathit
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | | | | | - Myoung Soo Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
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20
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Abstract
Tacrolimus was discovered in 1984 and entered clinical use shortly thereafter, contributing to successful solid organ transplantation across the globe. In this review, we cover development of tacrolimus, its evolving clinical utility, and issues affecting its current usage. Since earliest use of this class of immunosuppressant, concerns for calcineurin-inhibitor toxicity have led to efforts to minimize or eliminate these agents in clinical regimens but with limited success. Current understanding of the role of tacrolimus focuses more on its efficacy in preventing graft rejection and graft loss. As we enter the fourth decade of tacrolimus use, newer studies utilizing novel combinations (as with the mammalian target of rapamycin inhibitor, everolimus, and T-cell costimulation blockade with belatacept) offer potential for enhanced benefits.
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Affiliation(s)
- Song C Ong
- Department of Medicine, Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL
| | - Robert S Gaston
- Department of Medicine, Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL
- CTI Clinical Trial and Consulting, Inc., Covington, KT
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21
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Grabowska M, Michałek K, Kędzierska-Kapuza K, Kram A, Gill K, Piasecka M. The long-term effects of rapamycin-based immunosuppressive protocols on the expression of renal aquaporins 1, 2, 3 and 4 water channels in rats. Histol Histopathol 2021; 36:459-474. [PMID: 33634832 DOI: 10.14670/hh-18-321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND To this day, the effect of multi-drug immunosuppressive protocols on renal expression of AQPs is unknown. This study aimed to determine the influence of rapamycin-based multi-drug immunosuppressive regimens on the expression of aquaporins (AQPs) 1, 2, 3, and 4 in the rat kidney. METHODS For 6 months, 24 male Wistar rats were administered immunosuppressants, according to the three-drug protocols used in patients after organ transplantation. The rats were divided into four groups: the control group, the TRP group (tacrolimus, rapamycin, prednisone), the CRP group (cyclosporine A, rapamycin, prednisone), and the MRP group (mycophenolate mofetil, rapamycin, prednisone). Selected red cell indices and total calcium were measured in the blood of rats and quantitative analysis of AQP1, AQP2, AQP3 and AQP4 immunoexpression in the kidneys were performed. RESULTS In the TRP and CRP groups, a mild increase of mean corpuscular hemoglobin concentration, hematocrit and total calcium were observed. Moreover, decreased expression of AQP1-4 was found in all experimental groups, with the highest decrease in the CRP group. CONCLUSIONS The long-term immunosuppressive treatment using multi-drug protocols decreased AQP1-4 expressions in renal tubules, possibly leading to impaired urine-concentrating ability in rat.
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Affiliation(s)
- Marta Grabowska
- Department of Histology and Developmental Biology, Pomeranian Medical University, Szczecin, Poland
| | - Katarzyna Michałek
- Department of Physiology, Cytobiology and Proteomics, West Pomeranian University of Technology, Szczecin, Poland
| | - Karolina Kędzierska-Kapuza
- Department of Gastroenterological Surgery and Transplantation, Central Hospital of Ministry of Internal Affairs and Administration in Warsaw, Medical Center for Postgraduate Education, Warsaw, Poland
| | - Andrzej Kram
- Department of Pathology, West Pomeranian Oncology Center, Szczecin, Poland
| | - Kamil Gill
- Department of Histology and Developmental Biology, Pomeranian Medical University, Szczecin, Poland
| | - Małgorzata Piasecka
- Department of Histology and Developmental Biology, Pomeranian Medical University, Szczecin, Poland.
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22
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Préterre J, Visentin J, Saint Cricq M, Kaminski H, Del Bello A, Prezelin-Reydit M, Merville P, Kamar N, Couzi L. Comparison of two strategies based on mammalian target of rapamycin inhibitors in secondary prevention of non-melanoma skin cancer after kidney transplantation, a pilot study. Clin Transplant 2021; 35:e14207. [PMID: 33369772 DOI: 10.1111/ctr.14207] [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: 06/26/2020] [Revised: 12/10/2020] [Accepted: 12/16/2020] [Indexed: 01/05/2023]
Abstract
After kidney transplantation, withdrawal of calcineurin inhibitors (CNI) and conversion to sirolimus (SRL) may reduce the occurrence of new non-melanoma skin cancer (NMSC). Conversely, a reduced CNI exposure with everolimus (EVR) is an alternative strategy that has not been thoroughly evaluated. We retrospectively compared the occurrence of newly diagnosed NMSCs in two cohorts of kidney transplant recipients (KTR) with at least one NMSC: 35 patients were converted to EVR with reduced CNI exposure (CNI/EVR group), whereas 46 patients were converted to SRL in association with mycophenolic acid (MPA) (SRL/MPA group). Two years after conversion, survival free of new NMSC was similar between the two cohorts (p = .37), with 19 KTR (54.3%) in the CNI/EVR group and 22 (47.8%) in the SRL/MPA group being diagnosed of at least one new NMSC. Half of the KTR from both groups showed adverse events, leading to mTORi discontinuation for 37.1% of KTR in the CNI/EVR group and 21.7% in the SRL/MPA group (p = .09). The incidence of rejections was similar between the two groups. In a retrospective cohort of KTR with at least one post-transplant NMSC, the outcome of the patients converted to a CNI/EVR regimen was not different from those converted to a SRL/MPA regimen.
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Affiliation(s)
- Julie Préterre
- CHU de Bordeaux, Service de Néphrologie-Transplantation-Dialyse-Aphérèse, Hôpital Pellegrin, Bordeaux, France
| | - Jonathan Visentin
- CHU de Bordeaux, Service d'Immunologie et Immunogénétique, Hôpital Pellegrin, Bordeaux, France.,Université de Bordeaux, CNRS "ImmunoConcEpT" UMR 5164, Bordeaux, France
| | - Morgane Saint Cricq
- Department of Nephrology, Dialysis and Organ Transplantation, Hôpital Rangueil, CHU de Toulouse, Toulouse, France
| | - Hannah Kaminski
- CHU de Bordeaux, Service de Néphrologie-Transplantation-Dialyse-Aphérèse, Hôpital Pellegrin, Bordeaux, France.,Université de Bordeaux, CNRS "ImmunoConcEpT" UMR 5164, Bordeaux, France
| | - Arnaud Del Bello
- Department of Nephrology, Dialysis and Organ Transplantation, Hôpital Rangueil, CHU de Toulouse, Toulouse, France.,Centre de Physiopathologie Toulouse Purpan, University Paul Sabatier, INSERM U1043, Toulouse, France
| | - Mathilde Prezelin-Reydit
- CHU de Bordeaux, Service de Néphrologie-Transplantation-Dialyse-Aphérèse, Hôpital Pellegrin, Bordeaux, France
| | - Pierre Merville
- CHU de Bordeaux, Service de Néphrologie-Transplantation-Dialyse-Aphérèse, Hôpital Pellegrin, Bordeaux, France.,Université de Bordeaux, CNRS "ImmunoConcEpT" UMR 5164, Bordeaux, France
| | - Nassim Kamar
- Department of Nephrology, Dialysis and Organ Transplantation, Hôpital Rangueil, CHU de Toulouse, Toulouse, France.,Centre de Physiopathologie Toulouse Purpan, University Paul Sabatier, INSERM U1043, Toulouse, France
| | - Lionel Couzi
- CHU de Bordeaux, Service de Néphrologie-Transplantation-Dialyse-Aphérèse, Hôpital Pellegrin, Bordeaux, France.,Université de Bordeaux, CNRS "ImmunoConcEpT" UMR 5164, Bordeaux, France
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Tönshoff B, Tedesco-Silva H, Ettenger R, Christian M, Bjerre A, Dello Strologo L, Marks SD, Pape L, Veldandi U, Lopez P, Cousin M, Pandey P, Meier M. Three-year outcomes from the CRADLE study in de novo pediatric kidney transplant recipients receiving everolimus with reduced tacrolimus and early steroid withdrawal. Am J Transplant 2021; 21:123-137. [PMID: 32406111 DOI: 10.1111/ajt.16005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 04/27/2020] [Accepted: 04/30/2020] [Indexed: 01/25/2023]
Abstract
CRADLE was a 36-month multicenter study in pediatric (≥1 to <18 years) kidney transplant recipients randomized at 4 to 6 weeks posttransplant to receive everolimus + reduced-exposure tacrolimus (EVR + rTAC; n = 52) with corticosteroid withdrawal at 6-month posttransplant or continue mycophenolate mofetil + standard-exposure TAC (MMF + sTAC; n = 54) with corticosteroids. The incidence of composite efficacy failure (biopsy-proven acute rejection [BPAR], graft loss, or death) at month 36 was 9.8% vs 9.6% (difference: 0.2%; 80% confidence interval: -7.3 to 7.7) for EVR + rTAC and MMF + sTAC, respectively, which was driven by BPARs. Graft loss was low (2.1% vs 3.8%) with no deaths. Mean estimated glomerular filtration rate at month 36 was comparable between groups (68.1 vs 67.3 mL/min/1.73 m2 ). Mean changes (z-score) in height (0.72 vs 0.39; P = .158) and weight (0.61 vs 0.82; P = .453) from randomization to month 36 were comparable, whereas growth in prepubertal patients on EVR + rTAC was better (P = .050) vs MMF + sTAC. The overall incidence of adverse events (AEs) and serious AEs was comparable between groups. Rejection was the leading AE for study drug discontinuation in the EVR + rTAC group. In conclusion, though AE-related study drug discontinuation was higher, an EVR + rTAC regimen represents an alternative treatment option that enables withdrawal of steroids as well as reduction of CNIs for pediatric kidney transplant recipients. ClinicalTrials.gov: NCT01544491.
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Affiliation(s)
- Burkhard Tönshoff
- Department of Pediatrics I, University Children's Hospital Heidelberg, Heidelberg, Germany
| | | | - Robert Ettenger
- Division of Pediatric Nephrology, UCLA Mattel Children's Hospital, Los Angeles, California, USA
| | - Martin Christian
- Department of Pediatric Nephrology, Nottingham Children's Hospital, Nottingham, UK
| | - Anna Bjerre
- Division of Pediatric and Adolescent Medicine, Department of Pediatrics, Oslo University Hospital, Oslo, Norway
| | - Luca Dello Strologo
- Nephrology Unit, Department of Pediatrics, Institute for Scientific Research, Bambino Gesù Children's Hospital, Rome, Italy
| | - Stephen D Marks
- Department of Pediatric Nephrology, Great Ormond Street Hospital for Children, NHS Foundation Trust and University College London Great Ormond Street Institute of Child Health, NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
| | - Lars Pape
- Department of Pediatric Nephrology, Hannover Medical School, Hannover, Germany
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Hauser IA, Marx S, Sommerer C, Suwelack B, Dragun D, Witzke O, Lehner F, Schiedel C, Porstner M, Thaiss F, Neudörfl C, Falk CS, Nashan B, Sester M. Effect of everolimus-based drug regimens on CMV-specific T-cell functionality after renal transplantation: 12-month ATHENA subcohort-study results. Eur J Immunol 2020; 51:943-955. [PMID: 33306229 DOI: 10.1002/eji.202048855] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 10/15/2020] [Accepted: 12/07/2020] [Indexed: 02/06/2023]
Abstract
Post-transplant cytomegalovirus (CMV) infections and increased viral replication are associated with CMV-specific T-cell anergy. In the ATHENA-study, de-novo everolimus (EVR) with reduced-exposure tacrolimus (TAC) or cyclosporine (CyA) showed significant benefit in preventing CMV infections in renal transplant recipients as compared to standard TAC + mycophenolic acid (MPA). However, immunomodulatory mechanisms for this effect remain largely unknown. Ninety patients from the ATHENA-study completing the 12-month visit on-treatment (EVR + TAC n = 28; EVR + CyA n = 19; MPA + TAC n = 43) were included in a posthoc analysis. Total lymphocyte subpopulations were quantified. CMV-specific CD4 T cells were determined after stimulation with CMV-antigen, and cytokine-profiles and various T-cell anergy markers were analyzed using flow cytometry. While 25.6% of MPA + TAC-treated patients had CMV-infections, no such events were reported in EVR-treated patients. Absolute numbers of lymphocyte subpopulations were comparable between arms, whereas the percentage of regulatory T cells was significantly higher with EVR + CyA versus MPA + TAC (p = 0.019). Despite similar percentages of CMV-specific T cells, their median expression of CTLA-4 and PD-1 was lower with EVR + TAC (p < 0.05 for both) or EVR + CyA (p = 0.045 for CTLA-4) compared with MPA + TAC. Moreover, mean percentages of multifunctional CMV-specific T cells were higher with EVR + TAC (27.2%) and EVR + CyA (29.4%) than with MPA + TAC (19.0%). In conclusion, EVR-treated patients retained CMV-specific T-cell functionality, which may contribute to enhanced protection against CMV infections.
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Affiliation(s)
- Ingeborg A Hauser
- Department of Nephrology, Goethe-University Frankfurt, Frankfurt, Germany
| | - Stefanie Marx
- Department of Transplant and Infection Immunology, Saarland University, Homburg, Germany
| | - Claudia Sommerer
- Nephrology Unit, University Hospital Heidelberg, Heidelberg, Germany
| | - Barbara Suwelack
- Department of Internal Medicine, Transplant Nephrology, University Hospital of Münster, Münster, Germany
| | - Duska Dragun
- Department of Nephrology and Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Oliver Witzke
- Department of Infectious Diseases, West German Centre of Infectious Diseases, Universitätsmedizin Essen, University Duisburg-Essen, Duisburg-Essen, Germany
| | - Frank Lehner
- Clinic for General, Abdominal and Transplant Surgery, Hannover Medical School, Hannover, Germany.,Helios Hospital Hildesheim, Department of General- and Visceral Surgery, Academic Teaching Hospital of the Hannover Medical School, Hildesheim, Germany
| | | | | | - Friedrich Thaiss
- Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christine Neudörfl
- Institute of Transplant Immunology, Hannover Medical School MHH, Hannover, Germany
| | - Christine S Falk
- Institute of Transplant Immunology, Hannover Medical School MHH, Hannover, Germany.,German Center for Infection Research DZIF, Hannover, Germany
| | - Björn Nashan
- Department of Hepatobiliary Surgery and Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Organ Transplantation Center, The First Affiliated Hospital of University of Science and Technology of China, Anhui Provincial Hospital, Hefei, China
| | - Martina Sester
- Department of Transplant and Infection Immunology, Saarland University, Homburg, Germany
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Naik MG, Arns W, Budde K, Diekmann F, Eitner F, Gwinner W, Heyne N, Jürgensen JS, Morath C, Riester U, Heller KM, Fischereder M. Sirolimus in renal transplant recipients with malignancies in Germany. Clin Kidney J 2020; 14:2047-2058. [PMID: 34476091 PMCID: PMC8406058 DOI: 10.1093/ckj/sfaa262] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 11/23/2020] [Indexed: 12/29/2022] Open
Abstract
Background Renal transplant recipients have an increased cancer risk. The mammalian target of rapamycin inhibitor sirolimus (SRL) has immunosuppressive and antitumour activities but knowledge about its use in recipients with cancer is limited. Methods We retrospectively analysed 726 renal allograft recipients converted to SRL from 10 German transplant centres. Patient and graft survival were analysed depending on malignancy status prior to conversion and tumour entity. Results Malignancy before conversion to SRL was reported in 230 patients, with 137 patients having skin cancers and 101 having solid cancers. Cancer occurred 4.6 ± 9.4 (median 3.0) years after transplantation. Basal cell carcinoma, squamous cell carcinoma and Bowen’s disease were the most prevalent skin cancers, while carcinomas of the kidney, colon and breast were the most prevalent solid cancers before conversion. Patients with prior malignancy were older and had better renal function at conversion compared with patients without a history of cancer. After conversion to SRL, cancer incidence rates (IRs) of all tumours were lower compared with rates before conversion. Cancer IRs after conversion were higher in patients with malignancy before conversion compared with those without. Patient survival was worse in patients with solid cancers compared with patients with skin cancers or without malignancies. Biopsy-proven acute rejections in the first year after conversion were less frequent in patients with malignancy compared with those without. Graft survival and renal function in all cancer types were better than in patients converted to SRL without cancers. Conclusions Conversion to SRL in patients with a history of cancer is safe regarding renal function and graft survival, while patient survival is largely dependent on tumour entity.
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Affiliation(s)
- Marcel G Naik
- Division of Nephrology, Charité University-Mitte, Berlin, Germany.,Berliner Institut für Gesundheitsforschung/Berlin Institute of Health (BIH) Körperschaft des öffentlichen Rechts Anna-Louisa-Karsch-Str. 2 10178 Berlinn, Germany
| | - Wolfgang Arns
- Transplant Centre Cologne, Cologne General Hospital, Cologne, Germany
| | - Klemens Budde
- Division of Nephrology, Charité University-Mitte, Berlin, Germany
| | - Fritz Diekmann
- Department of Nephrology and Kidney Transplantation, Hospital Clinic, Barcelona, Spain
| | - Frank Eitner
- Division of Nephrology and Immunology, Kidney Diseases Research, RWTH Aachen University Hospital, Bayer AG, Wuppertal, Germany
| | - Wilfried Gwinner
- Division of Nephrology, Hannover Medical School, Hannover, Germany
| | - Nils Heyne
- Division of Nephrology, University of Tübingen, Tübingen, Germany
| | | | - Christian Morath
- Division of Nephrology, University of Heidelberg, Heidelberg, Germany
| | | | - Katharina M Heller
- Department of Medicine, Division of Nephrology, University of Erlangen, Erlangen, Germany
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Cohen-Bucay A, Ramirez-Andrade SE, Gordon CE, Francis JM, Chitalia VC. Advances in BK Virus Complications in Organ Transplantation and Beyond. Kidney Med 2020; 2:771-786. [PMID: 33319201 PMCID: PMC7729234 DOI: 10.1016/j.xkme.2020.06.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Reactivation of BK virus (BKV) remains a dreaded complication in immunosuppressed states. Conventionally, BKV is known as a cause for BKV-associated nephropathy and allograft dysfunction in kidney transplant recipients. However, emerging studies have shown its negative impact on native kidney function and patient survival in other transplants and its potential role in diseases such as cancer. Because BKV-associated nephropathy is driven by immunosuppression, reduction in the latter is a convenient standard of care. However, this strategy is risk prone due to the development of donor-specific antibodies affecting long-term allograft survival. Despite its pathogenic role, there is a distinct lack of effective anti-BKV therapeutics. This limitation combined with increased morbidity and health care cost of BKV-associated diseases add to the complexity of BKV management. While summarizing recent advances in the pathogenesis of BKV-associated nephropathy and its reactivation in other organ transplants, this review illustrates the limitations of current and emerging therapeutic options and provides a compelling argument for an effective targeted anti-BKV drug.
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Affiliation(s)
- Abraham Cohen-Bucay
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico
- Nephrology Department, American British Cowdray Medical Center, Mexico City, Mexico
| | - Silvia E. Ramirez-Andrade
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico
| | | | - Jean M. Francis
- Section of Nephrology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
- Renal Section, Boston University Medical Center, Boston, MA
| | - Vipul C. Chitalia
- Renal Section, Boston University Medical Center, Boston, MA
- Institute of Medical Engineering and Sciences, Massachusetts Institute of Technology, Cambridge, MA
- Veteran Affairs Boston Healthcare System, Boston, MA
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27
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Gierczak V, Jouve T, Malvezzi P, Terrec F, Naciri-Bennani H, Janbon B, Rostaing L, Noble J. Impact of Immunosuppressive Strategies on Post-Kidney Transplantation Thrombocytopenia. Transplant Proc 2020; 53:941-949. [PMID: 33121819 DOI: 10.1016/j.transproceed.2020.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 08/11/2020] [Accepted: 09/18/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Thrombocytopenia after kidney transplantation is a common complication, partly induced by immunosuppressive therapies. Peritransplant thrombocytopenia may cause serious hemorrhages. We assessed the incidence of early posttransplantation thrombocytopenia (defined as a platelet count of <150,000 mm3 or <150 G/L) in de novo kidney transplant recipients (KTRs) across 4 immunosuppressive regimens. METHODS This was a single-center observational study that included all consecutive KTRs who received either Thymoglobulin (THY) or Grafalon (GRA) and maintenance therapy of either mycophenolate-mofetil (MMF) or everolimus (EVR), associated with tacrolimus/corticosteroids. RESULTS Between July 27, 2016, and September 7, 2018, 237 KTRs were included; 64.6% experienced thrombocytopenia within the first week. Thrombocytopenia was significantly more frequent (P = .004) among GRA-treated patients (73.4%) compared to THY-treated patients (61.3%). These patients also had lower nadir platelet count (120 ± 52 vs 142 ± 48 G/L; P = .002) and lower platelet count at discharge (227 ± 94 vs 243 ± 92 G/L; P = .25). More of the GRA-EVR group had thrombocytopenia (81.0% vs 61.4% in THY-MMF, 60.9% in THY-EVR, and 69.8% in GRA-MMF; P = .081) and a worse nadir platelet count (109 ± 41 in GRA-EVR vs 141 ± 47G/L in THY-MMF, 145 ± 52 G/L in THY-EVR, and 125 ± 56 G/L in GRA-MMF; P = .011) but GRA was the only risk factor for thrombocytopenia in multivariate analyses (P = .002). Rates of hemorrhage, red blood cell transfusions, reoperations needed within the first week, delayed graft function, acute rejection, graft loss, and death did not differ between the groups after a mean follow-up of 25 ± 8 months. CONCLUSIONS GRA associated with EVR led to more frequent and severe thrombocytopenia, although we found no significant clinical consequences.
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Affiliation(s)
- Valentine Gierczak
- Nephrology Department, Hémodialyse, Apheresis and Renal Transplantation, CHU Grenoble-Alpes, Grenoble, France; Grenoble Alpes University, Grenoble, France
| | - Thomas Jouve
- Nephrology Department, Hémodialyse, Apheresis and Renal Transplantation, CHU Grenoble-Alpes, Grenoble, France; Grenoble Alpes University, Grenoble, France
| | - Paolo Malvezzi
- Nephrology Department, Hémodialyse, Apheresis and Renal Transplantation, CHU Grenoble-Alpes, Grenoble, France
| | - Florian Terrec
- Nephrology Department, Hémodialyse, Apheresis and Renal Transplantation, CHU Grenoble-Alpes, Grenoble, France
| | - Hamza Naciri-Bennani
- Nephrology Department, Hémodialyse, Apheresis and Renal Transplantation, CHU Grenoble-Alpes, Grenoble, France
| | - Benedicte Janbon
- Nephrology Department, Hémodialyse, Apheresis and Renal Transplantation, CHU Grenoble-Alpes, Grenoble, France
| | - Lionel Rostaing
- Nephrology Department, Hémodialyse, Apheresis and Renal Transplantation, CHU Grenoble-Alpes, Grenoble, France; Grenoble Alpes University, Grenoble, France.
| | - Johan Noble
- Nephrology Department, Hémodialyse, Apheresis and Renal Transplantation, CHU Grenoble-Alpes, Grenoble, France
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Cytomegalovirus disease in de novo kidney-transplant recipients: comparison of everolimus-based immunosuppression without prophylaxis with mycophenolic acid-based immunosuppression with prophylaxis. Int Urol Nephrol 2020; 53:591-600. [PMID: 33058036 DOI: 10.1007/s11255-020-02676-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 10/03/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To compare everolimus (EVR) plus low-dose tacrolimus (TAC) with mycophenolic acid (MPA) plus standard-dose TAC with regards to rates of cytomegalovirus (CMV) disease in de novo kidney-transplant recipients (KTRs). METHODS This single-center retrospective study included 187 de novo KTRs; 59 patients (31.6%) received EVR/low-dose TAC (group 1); 128 patients (68.4%) received MPA with standard-dose TAC (group 2). All received anti-thymocyte globulins as the induction therapy, and steroid-sparing strategy. Valganciclovir prophylaxis was mandatory for CMV D+/R- KTRs (seronegative recipients of a seropositive donor) in both groups and for R+ seropositive recipients (only in group 2). RESULTS The 2-year incidence of CMV disease was low and comparable between groups: 6.8% and 7.0% in groups 1 and 2, respectively (p = 0.94). There was no statistical difference in CMV serostatus (p = 1). However, CMV disease tended to be less frequent, though not statistically different, in R+ KTRs receiving EVR without prophylaxis (3.7% vs. 8.5% in groups 1 and 2, respectively) and in patients without EVR discontinuation (2.6% vs. 6.9% in patients who did not discontinue MPA (p = 0.29). Two-year graft function was good and comparable between groups (median eGFR of 54.2 and 53.0 mL/min in groups 1 and 2, respectively; p = 0.47); incidence of immunological events was low. Significantly more patients in group 1 discontinued EVR because of adverse events than patients that discontinued MPA in group 2 (35.6% in group 1 vs. 10.2% in group 2; p < 0.001). CONCLUSIONS Everolimus plus low-dose TAC given to de novo KTRs was associated with low rates of CMV disease, especially in R+ patients with no CMV prophylaxis.
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Early conversion to a CNI-free immunosuppression with SRL after renal transplantation-Long-term follow-up of a multicenter trial. PLoS One 2020; 15:e0234396. [PMID: 32756556 PMCID: PMC7406080 DOI: 10.1371/journal.pone.0234396] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 05/22/2020] [Indexed: 12/21/2022] Open
Abstract
Introduction Early conversion to a CNI-free immunosuppression with SRL was associated with an improved 1- and 3- yr renal function as compared with a CsA-based regimen in the SMART-Trial. Mixed results were reported on the occurrence of donor specific antibodies under mTOR-Is. Here, we present long-term results of the SMART-Trial. Methods and materials N = 71 from 6 centers (n = 38 SRL and n = 33 CsA) of the original SMART-Trial (ITT n = 140) were enrolled in this observational, non-interventional extension study to collect retrospectively and prospectively follow-up data for the interval since baseline. Primary objective was the development of dnDSA. Blood samples were collected on average 8.7 years after transplantation. Results Development of dnDSA was not different (SRL 5/38, 13.2% vs. CsA 9/33, 27.3%; P = 0.097). GFR remained improved under SRL with 64.37 ml/min/1.73m2 vs. 53.19 ml/min/1.73m2 (p = 0.044). Patient survival did not differ between groups at 10 years. There was a trend towards a reduced graft failure rate (11.6% SRL vs. 23.9% CsA, p = 0.064) and less tumors under SRL (2.6% SRL vs. 15.2% CsA, p = 0.09). Conclusions An early conversion to SRL did not result in an increased incidence of dnDSA nor increased long-term risk for the recipient. Transplant function remains improved with benefits for the graft survival.
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Immunosuppressive Drug-Associated Adverse Event Profiles in De Novo Kidney Transplant Recipients Receiving Everolimus and Reduced Tacrolimus Doses. Ther Drug Monit 2020; 42:811-820. [PMID: 32657909 DOI: 10.1097/ftd.0000000000000790] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The safety of immunosuppressive regimens is influenced by the induction agent, maintenance drug combination, and prophylactic strategy for cytomegalovirus (CMV) infection. Herein, this safety analysis compares rabbit antithymocyte globulin (r-ATG) or basiliximab (BAS) combined with everolimus (EVR) versus BAS combined with mycophenolate sodium (MPS) in kidney transplant recipients receiving tacrolimus, prednisone, and preemptive CMV therapy. METHODS In this single-center, prospective, randomized study, adverse events (AEs), serious AEs (SAEs), viral infections, laboratory abnormalities, dose reductions, and temporary or permanent discontinuation of the immunosuppressant were compared among patients receiving r-ATG/EVR (n = 85), BAS/EVR (n = 102), and BAS/MPS (n = 101). RESULTS A total of 2741 AEs and 344 SAEs were observed. There were no differences in the proportion of patients with at least one AE (96% versus 98% versus 96%, respectively; P > 0.05). The proportion of patients with at least one SAE was highest in the BAS/MPS group (33% versus 48% versus 69%, respectively; P < 0.05). This difference was due primarily to a high incidence of CMV infection in the BAS/MPS group (4.7% versus 10.8% versus 37.6%, respectively). The incidence of mild/moderate abnormalities in creatinine, cholesterol, and triglyceride levels was higher in both EVR groups. The cumulative freedom from dose reduction or treatment discontinuation due to an AE was higher in both EVR groups than in the BAS/MPS group (89.2% versus 92.8% versus 76.3%, respectively, P = 0.003). There was no difference in the incidence of biopsy-confirmed acute rejection (9.4% versus 18.6 versus 15.8%, respectively; P = 0.403). CONCLUSIONS This analysis suggests that r-ATG induction combined with EVR is associated with a comparable incidence of acute rejection, lower incidence of CMV infection, and fewer changes in initial immunosuppressive regimen due to AEs in kidney transplant recipients receiving tacrolimus, prednisone, and preemptive CMV therapy.
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Citterio F, Henry M, Kim DY, Kim MS, Han DJ, Kenmochi T, Mor E, Tisone G, Bernhardt P, Hernandez Gutierrez MP, Watarai Y. Wound healing adverse events in kidney transplant recipients receiving everolimus with reduced calcineurin inhibitor exposure or current standard-of-care: insights from the 24-month TRANSFORM study. Expert Opin Drug Saf 2020; 19:1339-1348. [PMID: 32633157 DOI: 10.1080/14740338.2020.1792441] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES In TRANSFORM, de novo kidney transplant recipients received either everolimus in combination with reduced-exposure calcineurin inhibitor (EVR+rCNI) at standard EVR pre-dose concentrations of 3-8 ng/mL or mycophenolic acid plus standard-exposure CNI (MPA+sCNI). The authors analyzed the incidence of wound healing adverse events (WHAEs) over the 2-year study period 15. METHODS Patients were randomized to either EVR+rCNI or MPA+sCNI, both combined with induction therapy and steroids 19. RESULTS The safety population consisted of 2,026 patients (EVR+rCNI: 1,014, MPA+sCNI: 1,012). The proportion of patients with at least 1 WHAE was comparable between EVR+rCNI and MPA+sCNI treatment groups [20.6% vs. 17.3%; risk ratio (RR): 1.19; 95% confidence interval (CI): 0.99, 1.43] at month 24. The numerical difference between EVR+rCNI and MPA+sCNI was mainly caused by an increased proportion of EVR patients with lymphocele and wound dehiscence [7.5% vs. 5.1% (RR: 1.46; 95% CI: 1.04, 2.05) and 3.9% vs. 1.8% (RR: 2.22; 95%CI: 1.28, 3.84), respectively] 20. CONCLUSION The immediate introduction of EVR+rCNI after kidney transplantation was associated with an overall comparable incidence of WHAEs versus current standard-of-care over the 24-month study period. There was an increased relative risk of experiencing lymphocele and wound dehiscence but the absolute risks were rather low in both groups 21. CT.GOV IDENTIFIER NCT01950819.
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Affiliation(s)
- Franco Citterio
- Department of Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS , Rome, Italy
| | - Mitchell Henry
- Department of Surgery, The Comprehensive Transplant Center, The Ohio State University, Wexner Medical Center , Columbus, OH, USA
| | - Dean Y Kim
- Department of Transplant and Hepatobiliary Surgery, Henry Ford Hospital , Detroit, USA
| | - Myoung Soo Kim
- Department of Surgery, Yonsei University College of Medicine , Seoul, Republic of Korea
| | - Duck-Jong Han
- Department of Surgery, Asan Medical Center , Seoul, Republic of South Korea
| | - Takashi Kenmochi
- Department of Transplant Surgery, Fujita Health University , Toyoake, Japan
| | - Eytan Mor
- Department of Surgery, Transplant Center at Sheba Medical Center , Ramat-Gan, Israel
| | - Giuseppe Tisone
- Department of Surgery HPB and Transplant Unit, University of Tor Vergata , Rome, Italy
| | - Peter Bernhardt
- Department of Research and Development, Novartis Pharma AG , Basel, Switzerland
| | | | - Yoshihiko Watarai
- Department of Transplant Surgery and Nephrology, Nagoya Daini Red Cross Hospital , Nagoya-City, Japan
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32
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Ahlenstiel-Grunow T, Pape L. Immunosuppression, BK polyomavirus infections, and BK polyomavirus-specific T cells after pediatric kidney transplantation. Pediatr Nephrol 2020; 35:625-631. [PMID: 31858227 DOI: 10.1007/s00467-019-04408-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 10/02/2019] [Accepted: 10/29/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND After kidney transplantation, immunosuppressive therapy increases risk of BK polyomavirus-associated nephropathy (BKPyVAN). Outcomes of BKPyV viremia are various and prognostic markers are missing. The impact of different immunosuppressive regimens on BKPyV infections is currently under discussion. METHODS We analyzed immunosuppressive therapy and BKPyV-specific cellular immunity to distinguish patients at risk of BKPyVAN from those with self-limiting viremia for purposes of risk-stratified BKPyV management. In a retrospective analysis, 46 pediatric kidney recipients with BKPyV viremia were analyzed with regard to duration of BKPyV viremia and immunosuppressive therapy; in addition, in 37/46 patients, BKPyV-specific CD4 and CD8 T cells were measured. RESULTS Nine patients showed persistent BKPyV viremia and BKPyVAN, and required therapeutic intervention, while 37 patients had asymptomatic, self-limiting viremia. At onset of viremia, 78% of patients with persistent viremia and BKPyVAN were treated with tacrolimus, whereas tacrolimus therapy was significantly less frequent in patients with self-limiting viremia (14%). The majority of patients with transient, self-limiting viremia received cyclosporine A (81%) and/or mTOR inhibitors (81%). Patients with persistent BKPyV viremia and BKPyVAN showed lack of BKPyV-specific CD4 and CD8 T cells (6/6), whereas the majority of patients with self-limiting viremia (27/31) had detectable BKPyV-specific CD4 and/or CD8 T cells ≥ 0.5 cells/μl (p < 0.001). CONCLUSIONS These results indicate that tacrolimus enhances risk of BKPyVAN with need of therapeutic intervention, whereas under cyclosporine A and mTOR inhibitors, the majority of pediatric kidney recipients showed self-limiting viremia. In patients at risk of BKPyV infections, combination of cyclosporine A and mTOR inhibitor may be advantageous.
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Affiliation(s)
- Thurid Ahlenstiel-Grunow
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany.
| | - Lars Pape
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
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Ahlenstiel-Grunow T, Pape L. Diagnostics, treatment, and immune response in BK polyomavirus infection after pediatric kidney transplantation. Pediatr Nephrol 2020; 35:375-382. [PMID: 30539254 DOI: 10.1007/s00467-018-4164-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 11/26/2018] [Accepted: 11/29/2018] [Indexed: 12/27/2022]
Abstract
After pediatric kidney transplantation BK polyomavirus (BKPyV) infections are associated with an increased risk of graft loss by BKPyV-associated nephropathy (BkPyVAN). However, suitable prognostic markers for the individual outcome of BKPyV infections are missing and the management of therapeutic interventions remains a challenge to the success of pediatric kidney transplantation. This review gives an overview on current diagnostic and therapeutic strategies in the field of BKPyV infections after pediatric kidney transplantation. Methods determining the individual immune response to BKPyV are described and their usability is discussed. There is growing evidence that BKPyV-specific T cells (BKPyV-Tvis) may serve as prognostic markers in order to steer immunosuppressive therapy in pediatric kidney recipients with BKPyV viremia in future. Prospective randomized trials in viremic kidney recipients comparing Tvis-steered therapeutic intervention with standard reduction of immunosuppression are needed before implementation of BKPyV-Tvis monitoring in routine care of BKPyV infections.
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Affiliation(s)
- Thurid Ahlenstiel-Grunow
- Department of Pediatric Kidney, Liver and Metabolic Disease, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany.
| | - Lars Pape
- Department of Pediatric Kidney, Liver and Metabolic Disease, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
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One-year Outcome of Everolimus With Standard-dose Tacrolimus Immunosuppression in De Novo ABO-incompatible Living Donor Kidney Transplantation: A Retrospective, Single-center, Propensity Score Matching Comparison With Mycophenolate in 42 Transplants. Transplant Direct 2020; 6:e514. [PMID: 32047842 PMCID: PMC6964930 DOI: 10.1097/txd.0000000000000962] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 10/09/2019] [Accepted: 11/01/2019] [Indexed: 12/18/2022] Open
Abstract
Background. Despite improvement in immunosuppressive therapy, long-term kidney allograft survival remains a major challenge. The outcomes of therapy with everolimus (EVR) and standard-dose tacrolimus (Tac) have not been compared with those of mycophenolate mofetil (MMF) and standard-dose Tac in recipients of de novo ABO-incompatible (ABOi) living donor kidney transplantation (LDKT). Methods. This retrospective, observational, single-center, propensity score matching (PSM) study compared the outcomes of EVR and standard-dose Tac with those of MMF and standard-dose Tac following de novo ABOi LDKT. In total, 153 recipients of ABOi LDKT between January 2008 and March 2018 were screened for inclusion in the study. The variables considered for PSM were: recipient age/sex, duration of dialysis, cytomegalovirus mismatch (seronegative recipient and seropositive donor), cause of kidney disease, donor age/sex, and numbers of mismatches (HLA-A, HLA-B, and HLA-DR). After PSM, there were 21 patients in each group (n = 42 overall). Results. Four patients in the EVR group and 1 patient in the MMF group were withdrawn because of adverse effects. There were no significant differences between the 2 groups in 1-year outcomes regarding patient death, graft loss, delayed graft function, biopsy-proven acute rejection, infection requiring hospital admission, or estimated glomerular filtration rate. The 1-year protocol biopsy showed that the severity of interstitial fibrosis/tubular atrophy was significantly milder in the EVR group than in the MMF group. Conclusions. The findings suggest that the renal efficacy and safety of EVR and standard-dose Tac in recipients of de novo ABOi LDKT are comparable with those of MMF and standard-dose Tac.
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Mühlbacher T, Beck R, Nadalin S, Heyne N, Guthoff M. Low-dose cidofovir and conversion to mTOR-based immunosuppression in polyomavirus-associated nephropathy. Transpl Infect Dis 2019; 22:e13228. [PMID: 31797495 DOI: 10.1111/tid.13228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 11/08/2019] [Accepted: 12/01/2019] [Indexed: 01/05/2023]
Abstract
BACKGROUND Polyomavirus-associated nephropathy (PVAN) remains a relevant complication following kidney transplantation with allograft loss rates of up to 50%. Reduction in overall immunosuppression is a cornerstone of therapy, whereas no specific antiviral regimen has shown conclusive benefit to date. The present case series demonstrates the efficacy of a dual therapeutic approach with low-dose cidofovir and conversion to mTOR-based immunosuppression in PVAN. METHODS Patients with biopsy-proven PVAN having received low-dose cidofovir (0.25 mg/kg) according to the Tübingen Cidofovir Protocol and been converted to mTOR-based immunosuppression were analyzed retrospectively. RESULTS Twenty-three patients with a median follow-up of 2.24 [IQR 1.55-5.01] years were included in the analysis. Median time to PVAN diagnosis was 268 [IQR 153-869] days after transplantation. Polyomavirus clearance from plasma was achieved in 78% of patients after a median of 118 [IQR 76-293] days. Of the 23 patients, nine patients (39%) lost their allograft function during follow-up, but only three of these (13%) due to PVAN. Fourteen patients (61%) stabilized or improved allograft function. The cidofovir protocol allowed for specific antiviral therapy without adverse nephrotoxicity, even in patients with low allograft function. CONCLUSIONS Low-dose cidofovir and conversion to mTOR-based immunosuppression allow for effective virus clearance and preservation of allograft function in a high proportion of patients with PVAN and progressive allograft dysfunction and may prolong allograft survival in these patients.
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Affiliation(s)
- Thomas Mühlbacher
- Section of Nephrology and Hypertension, Dept. of Diabetology, Endocrinology, Nephrology, University of Tübingen, Tübingen, Germany.,Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center Munich at the University of Tübingen, Tübingen, Germany.,German Center for Diabetes Research (DZD e.V.), Neuherberg, Germany
| | - Robert Beck
- Institute of Medical Virology and Epidemiology of Viral Diseases, University of Tübingen, Tübingen, Germany
| | - Silvio Nadalin
- Dept. of General-, Visceral- and Transplant Surgery, University of Tübingen, Tübingen, Germany
| | - Nils Heyne
- Section of Nephrology and Hypertension, Dept. of Diabetology, Endocrinology, Nephrology, University of Tübingen, Tübingen, Germany.,Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center Munich at the University of Tübingen, Tübingen, Germany.,German Center for Diabetes Research (DZD e.V.), Neuherberg, Germany
| | - Martina Guthoff
- Section of Nephrology and Hypertension, Dept. of Diabetology, Endocrinology, Nephrology, University of Tübingen, Tübingen, Germany.,Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center Munich at the University of Tübingen, Tübingen, Germany.,German Center for Diabetes Research (DZD e.V.), Neuherberg, Germany
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Hahn D, Hodson EM, Hamiwka LA, Lee VWS, Chapman JR, Craig JC, Webster AC. Target of rapamycin inhibitors (TOR-I; sirolimus and everolimus) for primary immunosuppression in kidney transplant recipients. Cochrane Database Syst Rev 2019; 12:CD004290. [PMID: 31840244 PMCID: PMC6953317 DOI: 10.1002/14651858.cd004290.pub3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Kidney transplantation is the therapy of choice for many patients with end-stage kidney disease (ESKD) with an improvement in survival rates and satisfactory short term graft survival. However, there has been little improvement in long-term survival. The place of target of rapamycin inhibitors (TOR-I) (sirolimus, everolimus), which have different modes of action from other commonly used immunosuppressive agents, in kidney transplantation remains uncertain. This is an update of a review first published in 2006. OBJECTIVES To evaluate the short and long-term benefits and harms of TOR-I (sirolimus and everolimus) when used in primary immunosuppressive regimens for kidney transplant recipients. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 20 September 2019 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register were identified through searches of CENTRAL, MEDLINE and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA All randomised controlled trials (RCTs) and quasi-RCTs in which drug regimens, containing TOR-I commenced within seven days of transplant, were compared to alternative drug regimens, were included without age restriction, dosage or language of report. DATA COLLECTION AND ANALYSIS Three authors independently assessed study eligibility, risk of bias, and extracted data. Results were reported as risk ratios (RR) with 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) with 95% CI for continuous outcomes. Statistical analyses were performed using the random-effects model. The certainty of the evidence was assessed using GRADE MAIN RESULTS: Seventy studies (17,462 randomised participants) were included; eight studies included two comparisons to provide 78 comparisons. Outcomes were reported at six months to three years post transplant. Risk of bias was judged to be low for sequence generation in 25 studies, for allocation concealment in 23 studies, performance bias in four studies, detection bias in 65 studies, attrition bias in 45 studies, selective reporting bias in 48 studies, and for other potential bias in three studies. Risk of bias was judged to be at high risk of bias for sequence generation in two studies, allocation concealment in two studies, performance bias in 61 studies, detection bias in one study, attrition bias in four studies, for selective reporting bias in 11 studies and for other potential risk of bias in 46 studies. Compared with CNI and antimetabolite, TOR-I with antimetabolite probably makes little or no difference to death (RR 1.31, 95% CI 0.87 to 1.98; 19 studies) or malignancies (RR 0.86, 95% CI 0.50 to 1.48; 10 studies); probably increases graft loss censored for death (RR 1.32, 95% CI 0.96 to 1.81; 15 studies), biopsy-proven acute rejection (RR 1.60, 95% CI 1.25 to 2.04; 15 studies), need to change treatment (RR 2.42, 95% CI 1.88 to 3.11; 14 studies) and wound complications (RR 2.56, 95% CI 1.94 to 3.36; 12 studies) (moderate certainty evidence); but reduces CMV infection (RR 0.43, 95% CI 0.29 to 0.63; 13 studies) (high certainty evidence). Compared with antimetabolites and CNI, TOR-I with CNI probably makes little or no difference to death (RR 1.06, 95% CI 0.84 to 1.33; 31 studies), graft loss censored for death (RR 1.09, 95% CI 0.82 to 1.45; 26 studies), biopsy-proven acute rejection (RR 0.95, 95% CI 0.81 to 1.12; 24 studies); and malignancies (RR 0.83, 95% CI 0.64 to 1.07; 17 studies); probably increases the need to change treatment (RR 1.56, 95% CI 1.28 to 1.90; 25 studies), and wound complications (RR 1.56, 95% CI 1.28 to 1.91; 17 studies); but probably reduces CMV infection (RR 0.44, 95% CI 0.34 to 0.58; 25 studies) (moderate certainty evidence). Lower dose TOR-I and standard dose CNI compared with higher dose TOR-I and reduced dose CNI probably makes little or no difference to death (RR 1.07, 95% CI 0.64 to 1.78; 9 studies), graft loss censored for death (RR 1.09, 95% CI 0.54 to 2.20; 8 studies), biopsy-proven acute rejection (RR 0.87, 95% CI 0.67 to 1.13; 8 studies), and CMV infection (RR 1.42, 95% CI 0.78 to 2.60; 5 studies) (moderate certainty evidence); and may make little or no difference to wound complications (RR 0.95, 95% CI 0.53 to 1.71; 3 studies), malignancies (RR 1.04, 95% CI 0.36 to 3.04; 7 studies), and the need to change treatments (RR 1.18, 95% CI 0.58 to 2.42; 5 studies) (low certainty evidence). Lower dose of TOR-I compared with higher doses probably makes little or no difference to death (RR 0.84, 95% CI 0.67 to 1.06; 13 studies), graft loss censored for death (RR 0.92, 95% CI 0.71 to 1.19; 12 studies), biopsy-proven acute rejection (RR 1.26, 95% CI 1.10 to 1.43; 11 studies), CMV infection (RR 0.87, 95% CI 0.63 to 1.21; 9 studies), wound complications (RR 0.92, 95% CI 0.66 to 1.29; 7 studies), and malignancy (RR 0.84, 95% CI 0.54 to 1.32; 10 studies) (moderate certainty evidence); and may make little or no difference to the need to change treatments (RR 0.91, 95% CI 0.78 to 1.05; 10 studies) (low certainty evidence). It is uncertain whether sirolimus and everolimus differ in their effects on kidney function and lipid levels because the certainty of the evidence is very low based on a single small study with only three months of follow-up. AUTHORS' CONCLUSIONS In studies with follow-up to three years, TOR-I with an antimetabolite increases the risk of graft loss and acute rejection compared with CNI and an antimetabolite. TOR-I with CNI potentially offers an alternative to an antimetabolite with CNI as rates of graft loss and acute rejection are similar between interventions and TOR-I regimens are associated with a reduced risk of CMV infections. Wound complications and the need to change immunosuppressive medications are higher with TOR-I regimens. While further new studies are not required, longer-term follow-up data from participants in existing methodologically robust RCTs are needed to determine how useful immunosuppressive regimens, which include TOR-I, are in maintaining kidney transplant function and survival beyond three years.
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Affiliation(s)
- Deirdre Hahn
- The Children's Hospital at WestmeadDepartment of NephrologyLocked Bag 4001WestmeadNSWAustralia2145
| | - Elisabeth M Hodson
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchLocked Bag 4001WestmeadNSWAustralia2145
| | - Lorraine A Hamiwka
- University of Calgary/Alberta Children's HospitalDepartment of Medicine/Pediatrics2888 Shaganappi Trail NW Children's HospitalCalgaryAlbertaCanadaT3B 6A8
| | - Vincent WS Lee
- Westmead & Blacktown HospitalsDepartment of Renal MedicineDarcy RdWestmeadNSWAustralia2145
- The University of Sydney at WestmeadCentre for Transplant and Renal Research, Westmead Millennium InstituteWestmeadAustralia
| | - Jeremy R Chapman
- Westmead Millennium Institute, The University of Sydney at WestmeadCentre for Transplant and Renal ResearchDarcy RdWestmeadNSWAustralia2145
| | - Jonathan C Craig
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchLocked Bag 4001WestmeadNSWAustralia2145
- Flinders UniversityCollege of Medicine and Public HealthAdelaideSAAustralia5001
| | - Angela C Webster
- The University of Sydney at WestmeadCentre for Transplant and Renal Research, Westmead Millennium InstituteWestmeadAustralia
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
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Preventive effect of early introduction of everolimus and reduced-exposure tacrolimus on renal interstitial fibrosis in de novo living-donor renal transplant recipients. Clin Exp Nephrol 2019; 24:268-276. [PMID: 31792639 DOI: 10.1007/s10157-019-01822-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 11/14/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND To improve the long-term outcomes following renal transplantation, prevention of renal-allograft interstitial fibrosis (IF), mainly due to calcineurin inhibitors, is an important therapeutic target. Everolimus (EVR) was reported to have antifibrotic effects. We aimed to investigate the safety, efficacy, and IF of our modified immunosuppressive regimen, which includes early introduction of EVR and reduced-exposure tacrolimus (Tac) (EVR group), and compare it with the standard-exposure tacrolimus-based regimen (Tac group) in de novo living-donor renal recipients. METHODS In this retrospective, single-center cohort study, we compared the 2-year clinical courses between the two groups according to intention to treat. Additionally, in patients in whom biopsies were obtained at 1 h, 3 months, and 12 months post-transplant, we compared IF between the groups using imaging analysis. RESULTS Overall, 47 patients were included (EVR group, n = 22; Tac group, n = 25). There were no significant differences in renal function and incidences of rejection and viral infections between the groups at the 2-year post-transplant follow-up. However, pathologic imaging analysis (n = 34) revealed chronological progression of IF in the Tac group during the first year post-transplant and no changes in the EVR group (fibrosis rate at 3 months: 20.8 vs. 13.6%, p < 0.001; at 12 months: 24.7 vs. 14.7%, p < 0.001, respectively). CONCLUSION Our modified immunosuppressive regimen may have an antifibrotic effect on transplanted kidneys without loss of safety and efficacy.
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Berger SP, Sommerer C, Witzke O, Tedesco H, Chadban S, Mulgaonkar S, Qazi Y, de Fijter JW, Oppenheimer F, Cruzado JM, Watarai Y, Massari P, Legendre C, Citterio F, Henry M, Srinivas TR, Vincenti F, Gutierrez MPH, Marti AM, Bernhardt P, Pascual J. Two-year outcomes in de novo renal transplant recipients receiving everolimus-facilitated calcineurin inhibitor reduction regimen from the TRANSFORM study. Am J Transplant 2019; 19:3018-3034. [PMID: 31152476 DOI: 10.1111/ajt.15480] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 04/11/2019] [Accepted: 05/04/2019] [Indexed: 01/25/2023]
Abstract
TRANSFORM (TRANSplant eFficacy and safety Outcomes with an eveRolimus-based regiMen) was a 24-month, prospective, open-label trial in 2037 de novo renal transplant recipients randomized (1:1) within 24 hours of transplantation to receive everolimus (EVR) with reduced-exposure calcineurin inhibitor (EVR + rCNI) or mycophenolate with standard-exposure CNI. Consistent with previously reported 12-month findings, noninferiority of the EVR + rCNI regimen for the primary endpoint of treated biopsy-proven acute rejection (tBPAR) or estimated glomerular filtration rate (eGFR) <50 mL/min per 1.73 m2 was achieved at month 24 (47.9% vs 43.7%; difference = 4.2%; 95% confidence interval = -0.3, 8.7; P = .006). Mean eGFR was stable up to month 24 (52.6 vs 54.9 mL/min per 1.73 m2 ) in both arms. The incidence of de novo donor-specific antibodies (dnDSA) was lower in the EVR + rCNI arm (12.3% vs 17.6%) among on-treatment patients. Although discontinuation rates due to adverse events were higher with EVR + rCNI (27.2% vs 15.0%), rates of cytomegalovirus (2.8% vs 13.5%) and BK virus (5.8% vs 10.3%) infections were lower. Cytomegalovirus infection rates were significantly lower with EVR + rCNI even in the D+/R- high-risk group (P < .0001). In conclusion, the EVR + rCNI regimen offers comparable efficacy and graft function with low tBPAR and dnDSA rates and significantly lower incidence of viral infections relative to standard-of-care up to 24 months. Clinicaltrials.gov number: NCT01950819.
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Affiliation(s)
- Stefan P Berger
- Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Claudia Sommerer
- Department of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Oliver Witzke
- Department of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Essen, Germany.,Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Helio Tedesco
- Nephrology Division, Hospital do Rim, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Steve Chadban
- Department of Renal Medicine and Transplantation, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Shamkant Mulgaonkar
- Renal and Pancreas Division, Saint Barnabas Medical Center, Livingston, New Jersey
| | - Yasir Qazi
- Division of Nephrology, Keck School of Medicine Renal Transplant Program, University of Southern California, Los Angeles, California
| | | | - Federico Oppenheimer
- Department of Nephrology and Renal Transplantation, Renal Transplant Unit, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Josep M Cruzado
- Hospital Universitari De Bellvitge, IDIBELL, Hospitalet de Llobregat, Barcelona, Spain
| | - Yoshihiko Watarai
- Department of Transplant Surgery, Nagoya Daini Red Cross Hospital, Nagoya-City, Aichi, Japan
| | - Pablo Massari
- Hospital Privado Centro Medico de Cordoba, Cordoba, Argentina
| | - Christophe Legendre
- Department of Kidney Transplantation, Adult Transplantation Service, Paris Descartes University and Necker Hospital, Paris, France
| | - Franco Citterio
- Agostino Gemelli University Polyclinic Foundation, Catholic University of the Sacred Heart, Rome, Italy
| | - Mitchell Henry
- Department of Surgery, The Comprehensive Transplant Center, The Ohio State University, Wexner Medical Center, Columbus, Ohio
| | - Titte R Srinivas
- Division of Nephrology, Medical University of South Carolina, Mount Pleasant, South Carolina
| | - Flavio Vincenti
- Department of Surgery, Kidney Transplant Service, University of California, San Francisco, California
| | | | - Ana Maria Marti
- Department of Research and Development, Novartis Pharma AG, Basel, Switzerland
| | - Peter Bernhardt
- Department of Research and Development, Novartis Pharma AG, Basel, Switzerland
| | - Julio Pascual
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
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Mammalian Target of Rapamycin Inhibitors Combined With Calcineurin Inhibitors as Initial Immunosuppression in Renal Transplantation: A Meta-analysis. Transplantation 2019; 103:2031-2056. [DOI: 10.1097/tp.0000000000002769] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Tedesco-Silva H, Pascual J, Viklicky O, Basic-Jukic N, Cassuto E, Kim DY, Cruzado JM, Sommerer C, Adel Bakr M, Garcia VD, Uyen HD, Russ G, Soo Kim M, Kuypers D, Buchler M, Citterio F, Hernandez Gutierrez MP, Bernhardt P, Chadban S. Safety of Everolimus With Reduced Calcineurin Inhibitor Exposure in De Novo Kidney Transplants: An Analysis From the Randomized TRANSFORM Study. Transplantation 2019; 103:1953-1963. [PMID: 30801548 DOI: 10.1097/tp.0000000000002626] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The safety profiles of standard therapy versus everolimus with reduced-exposure calcineurin inhibitor (CNI) therapy using contemporary protocols in de novo kidney transplant recipients have not been compared in detail. METHODS TRANSFORM was a randomized, international trial in which de novo kidney transplant patients were randomized to everolimus with reduced-exposure CNI (N = 1014) or mycophenolic acid (MPA) with standard-exposure CNI (N = 1012), both with induction and corticosteroids. RESULTS Within the safety population (everolimus 1014, MPA 1012), adverse events with a suspected relation to study drug occurred in 62.9% versus 59.2% of patients given everolimus or MPA, respectively (P = 0.085). Hyperlipidemia, interstitial lung disease, peripheral edema, proteinuria, stomatitis/mouth ulceration, thrombocytopenia, and wound healing complications were more frequent with everolimus, whereas diarrhea, nausea, vomiting, leukopenia, tremor, and insomnia were more frequent in the MPA group. The incidence of viral infections (17.2% versus 29.2%; P < 0.001), cytomegalovirus (CMV) infections (8.1% versus 20.1%; P < 0.001), CMV syndrome (13.6% versus 23.0%, P = 0.044), and BK virus (BKV) infections (4.3% versus 8.0%, P < 0.001) were less frequent with everolimus. CMV infection was less common with everolimus versus MPA after adjusting for prophylaxis therapy in the D+/R- subgroup (P < 0.001). Study drug was discontinued more frequently due to rejection or impaired healing with everolimus, and more often due to BKV infection or BKV nephropathy with MPA. CONCLUSIONS De novo everolimus with reduced-exposure CNI yielded a comparable incidence, though a distinctly different pattern, of adverse events versus current standard of care. Both regimens are safe and effective, yet their distinct profiles may enable tailoring for individual kidney transplant recipients.
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Affiliation(s)
- Helio Tedesco-Silva
- Division of Nephrology, Hospital do Rim, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Julio Pascual
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
| | - Ondrej Viklicky
- Department of Nephrology, Transplant Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Nikolina Basic-Jukic
- Department of Nephrology, Arterial Hypertension, Dialysis and Transplantation, University Hospital Centre Zagreb, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Elisabeth Cassuto
- Department of Nephrology and Renal Transplantation, Hôpital Pasteur, Nice, France
| | - Dean Y Kim
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI
| | - Josep M Cruzado
- Department of Nephrology, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Claudia Sommerer
- Department of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Valter D Garcia
- Department of Renal Transplantation, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Brazil
| | - Huynh-Do Uyen
- Department of Nephrology and Hypertension, Inselspital Bern, Bern, Switzerland
| | - Graeme Russ
- Central and Northern Adelaide Renal and Transplantation Services, Royal Adelaide Hospital, Adelaide, Australia
| | - Myoung Soo Kim
- Department of Transplantation Surgery, Severance Hospital Yonsei University Health System, Seoul, Republic of Korea
| | - Dirk Kuypers
- Department of Nephrology and Renal Transplantation, Gasthuisberg University Hospital, University of Leuven, Leuven, Belgium
- Department of Microbiology and Immunology, University of Leuven, Leuven, Belgium
| | - Matthias Buchler
- Department of Nephrology and Renal Transplantation, CHRU de Tours, Hôpital Bretonneau, Tours, France
| | - Franco Citterio
- Policlinico Foundation, A Gemelli University, IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | | | - Peter Bernhardt
- Research and Development, Novartis Pharma AG, Basel, Switzerland
| | - Steve Chadban
- Department of Renal Medicine, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia
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Pape L. BK polyomavirus and cytomegalovirus - a closer link than expected? Am J Transplant 2019; 19:2401-2402. [PMID: 31306544 DOI: 10.1111/ajt.15531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 06/23/2019] [Accepted: 06/25/2019] [Indexed: 01/25/2023]
Affiliation(s)
- Lars Pape
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
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Everolimus and Long-term Clinical Outcomes in Kidney Transplant Recipients: A Registry-based 10-year Follow-up of 5 Randomized Trials. Transplantation 2019; 103:1705-1713. [DOI: 10.1097/tp.0000000000002499] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Pascual J, Berger SP, Chadban SJ, Citterio F, Kamar N, Hesselink DA, Legendre C, Eisenberger U, Oppenheimer F, Russ GR, Sommerer C, Rigotti P, Srinivas TR, Watarai Y, Henry ML, Vincenti F, Tedesco-Silva H. Evidence-based practice: Guidance for using everolimus in combination with low-exposure calcineurin inhibitors as initial immunosuppression in kidney transplant patients. Transplant Rev (Orlando) 2019; 33:191-199. [PMID: 31377099 DOI: 10.1016/j.trre.2019.07.001] [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] [Received: 04/05/2019] [Revised: 07/11/2019] [Accepted: 07/18/2019] [Indexed: 12/28/2022]
Abstract
The mammalian target of rapamycin (mTOR) inhibitor, everolimus, in combination with reduced-exposure calcineurin inhibitor (CNI), has been demonstrated in clinical trials to have comparable efficacy in low-to-moderate immunological risk kidney transplant recipients to the Standard of Care, mycophenolic acid (MPA) in combination with standard-exposure CNI. Current treatment guidelines consider mTOR inhibitors to be a second-line therapy in the majority of cases; however, given that everolimus-based regimens are associated with a reduced rate of viral infections after transplantation, their wider use could have great benefits for kidney transplant patients. In this evidence-based practice guideline, we consider the de novo use of everolimus in kidney transplant recipients. The main outcomes of our consideration of the available evidence are that: 1. Everolimus, in combination with reduced-exposure CNI and low dose steroids, is a suitable regimen for the prophylaxis of kidney transplant rejection in the majority of low-to-moderate immunological risk adult patients, with individualized management; 2. Induction with either basiliximab or rabbit anti-thymocyte globulin is an effective therapy for kidney transplant recipients when initiating an everolimus-based, reduced-exposure CNI regimen; and 3. An individualized approach should be adopted when managing kidney transplant recipients on everolimus-based therapy.
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Affiliation(s)
- Julio Pascual
- Department of Nephrology, Hospital del Mar, Barcelona, Spain.
| | - Stefan P Berger
- Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Steven J Chadban
- Renal Medicine, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia
| | - Franco Citterio
- Department of Surgery, Renal Transplantation, Catholic University, Rome 00168, Italy
| | - Nassim Kamar
- Department of Nephrology, Dialysis and Organ Transplantation, CHU Rangueil, INSERM U1043, IFR-BMT, University Paul Sabatier, Toulouse, France
| | - Dennis A Hesselink
- Erasmus MC, University Medical Center Rotterdam, Department of Internal Medicine, Division of Nephrology and Transplantation, Rotterdam, the Netherlands
| | - Christophe Legendre
- Paris Translational Research Center for Organ Transplantation, INSERM U970, Necker Hospital University Paris Descartes, Paris, France
| | - Ute Eisenberger
- Department of Nephrology, University Duisburg-Essen, University Hospital Essen, Essen, Germany
| | | | - Graeme R Russ
- Central and Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, Australia
| | - Claudia Sommerer
- Department of Nephrology, University Hospital Heidelberg, Heidelberg, Germany
| | - Paolo Rigotti
- Kidney and Pancreas Transplant Unit, Padua University Hospital, Padua, Italy
| | - Titte R Srinivas
- Division of Nephrology, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Yoshihiko Watarai
- Department of Transplant Nephrology and Surgery, Kidney Disease Center, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Mitchell L Henry
- Department of Surgery, The Comprehensive Transplant Center, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Flavio Vincenti
- Department of Surgery, Kidney Transplant Service, University of California, San Francisco, CA, USA
| | - Helio Tedesco-Silva
- Division of Nephrology, Hospital do Rim, Universidade Federal de São Paulo, São Paulo 04038-002, Brazil.
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Chadban S, Tedesco-Silva H. ATHENA: wisdom and warfare in defining the role of de novo mTOR inhibition in kidney transplantation. Kidney Int 2019; 96:27-30. [DOI: 10.1016/j.kint.2019.04.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Accepted: 04/23/2019] [Indexed: 01/05/2023]
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Gottlieb J, Neurohr C, Müller‐Quernheim J, Wirtz H, Sill B, Wilkens H, Bessa V, Knosalla C, Porstner M, Capusan C, Strüber M. A randomized trial of everolimus-based quadruple therapy vs standard triple therapy early after lung transplantation. Am J Transplant 2019; 19:1759-1769. [PMID: 30615259 PMCID: PMC6590654 DOI: 10.1111/ajt.15251] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 12/04/2018] [Accepted: 12/27/2018] [Indexed: 01/25/2023]
Abstract
Calcineurin inhibitor (CNI) therapy after lung transplantation increases risk of kidney failure. Early everolimus-based quadruple low CNI immunosuppression may improve renal function without compromising efficacy or safety. A prospective, randomized, open-label, 12-month multicenter trial was conducted at 8 German sites. Patients 3-18 months after lung transplantation were randomized (1:1), stratified by baseline estimated glomerular filtration rate (eGFR). In the quadruple low CNI regimen, patients received everolimus (target trough level 3-5 ng/mL) with reduced CNI (tacrolimus 3-5 ng/mL or cyclosporine 25-75 ng/mL) and a cell cycle inhibitor plus prednisone. In the standard triple CNI regimen, patients received tacrolimus (target trough level >5 ng/mL) or cyclosporine (>100 ng/mL) and a cell cycle inhibitor plus prednisone. Of the 180 patients screened, 130 were randomized: 67 in the quadruple low CNI group and 63 in the standard triple CNI group. The primary endpoint (eGFR after 12 months) demonstrated superiority of the quadruple low CNI regimen: 64.5 mL/min vs 54.6 mL/min for the standard triple group (least squares mean, analysis of covariance; P < .001). Key efficacy parameters (biopsy-proven acute rejection, chronic lung allograft dysfunction, and death) and safety endpoints were similar between both groups. Quadruple low CNI immunosuppression early after lung transplantation was demonstrated to be efficacious and safe. Clinical trials registry: ClinicalTrials.gov NCT01404325.
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Affiliation(s)
- Jens Gottlieb
- Department of Respiratory MedicineHannover Medical SchoolHannoverGermany,Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH)Member of the German Center for Lung Research (DZL)HannoverGermany
| | - Claus Neurohr
- Grosshadern Medical Clinic and Policlinic VLMU Munich University HospitalMunichGermany
| | | | - Hubert Wirtz
- Internal Medicine/Department of PneumologyLeipzig University HospitalLeipzigGermany
| | - Bjoern Sill
- Department of Cardiovascular SurgeryHamburg‐Eppendorf University HospitalHamburgGermany
| | - Heinrike Wilkens
- Internal Medicine VUniversity Hospital of SaarlandHomburg SaarGermany
| | - Vasiliki Bessa
- Department of PneumologyRuhrlandklinikWest German Center for Lung TransplantationUniversity Hospital EssenUniversity Duisburg‐EssenEssenGermany
| | - Christoph Knosalla
- Department of Cardiothoracic and Vascular SurgeryGerman Heart Institute BerlinDZHK (German Center for Cardiovascular Research)BerlinGermany
| | | | | | - Martin Strüber
- Department of Cardiothoracic SurgeryNewark Beth Israel Medical CenterChildren's Hospital of New JerseyNewarkNew Jersey
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mTOR Inhibitor in Combination with Cyclosporine as Primary Maintenance Immunosuppression in Combined Kidney/Pancreas Transplant Recipients. CURRENT TRANSPLANTATION REPORTS 2019. [DOI: 10.1007/s40472-019-00246-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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47
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Paoletti E, Citterio F, Corsini A, Potena L, Rigotti P, Sandrini S, Bussalino E, Stallone G. Everolimus in kidney transplant recipients at high cardiovascular risk: a narrative review. J Nephrol 2019; 33:69-82. [DOI: 10.1007/s40620-019-00609-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 04/05/2019] [Indexed: 12/20/2022]
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48
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Chong S, Antoni M, Macdonald A, Reeves M, Harber M, Magee CN. BK virus: Current understanding of pathogenicity and clinical disease in transplantation. Rev Med Virol 2019; 29:e2044. [PMID: 30958614 DOI: 10.1002/rmv.2044] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 02/28/2019] [Accepted: 03/01/2019] [Indexed: 12/19/2022]
Abstract
BK polyomavirus (BKV) is an important cause of graft loss in renal transplant recipients that continues to pose a significant challenge to clinicians due to its frequently unpredictable onset, persistence, and the lack of effective antiviral agents or prevention strategies. This review covers our current understanding of epidemiology, viral transmission and disease progression, and treatment and prevention strategies that have been used to manage this disease.
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Affiliation(s)
- Stephanie Chong
- Department of Renal Medicine, Royal Free Hospital, University College London, London, UK
| | - Michelle Antoni
- School of Molecular and Cellular Biology, Faculty of Biological Sciences, University of Leeds, London, UK
| | - Andrew Macdonald
- School of Molecular and Cellular Biology, Faculty of Biological Sciences, University of Leeds, London, UK
| | - Matthew Reeves
- Institute of Immunity and Transplantation, Royal Free Hospital, University College London, London, UK
| | - Mark Harber
- Department of Renal Medicine, Royal Free Hospital, University College London, London, UK
| | - Ciara N Magee
- Department of Renal Medicine, Royal Free Hospital, University College London, London, UK
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Takasaki S, Yamaguchi H, Kawasaki Y, Kikuchi M, Tanaka M, Ito A, Mano N. Long-term relationship between everolimus blood concentration and clinical outcomes in Japanese patients with metastatic renal cell carcinoma: a prospective study. J Pharm Health Care Sci 2019; 5:6. [PMID: 30906563 PMCID: PMC6413453 DOI: 10.1186/s40780-019-0135-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 02/21/2019] [Indexed: 01/05/2023] Open
Abstract
Background Everolimus is an oral inhibitor of mammalian target of rapamycin, approved for metastatic renal cell carcinoma (mRCC). Recently, personalized medicine through therapeutic drug monitoring (TDM) is recommended in cancer therapy. In this study, the relationship between everolimus blood concentration and clinical outcomes on a long-term were evaluated in Japanese patients with mRCC. Methods Patients with mRCC were enrolled following treatment with everolimus at Tohoku University Hospital between April 2012 and December 2016. The relationship between everolimus trough blood concentration on day 8 of everolimus therapy and just before discontinuation or dose reduction, and their adverse events were evaluated. Patients were divided into two groups based on the median of everolimus blood concentration on day 8 of treatment, and the profiles of adverse events, and efficacy [time to treatment failure (TTF) and progression-free survival (PFS)] were evaluated. Results The median (range) everolimus blood concentrations on day 8 after starting everolimus administration and just before discontinuation or dose reduction were 15.3 (8.1-28.0) ng/mL and 14.8 (6.4-58.4) ng/mL, respectively, with no significant difference between these values (P = 0.3594). Patients (n = 6) with discontinuation or dose reduction following adverse events in everolimus therapy had significantly higher blood concentrations than patients (n = 4) with dose maintenance on both day 8 (median, 18.0 vs 8.2 ng/mL; P = 0.0139) and just before discontinuation or dose reduction (median, 22.9 vs 9.7 ng/mL; P = 0.0142). Median TTF and PFS of the total patients (n = 10) were 96 days (95% confidence interval [CI], 26-288) and 235 days (95% CI, 28-291), respectively. Subgroup analysis showed that TTF of the patients with > 15.3 ng/mL (n = 5) was not significantly different from that of the patients with ≤15.3 ng/mL (n = 5; P = 0.5622). Similarly, PFS of the patients with > 15.3 ng/mL was not significantly different from that of the patients with ≤15.3 ng/mL (P = 0.3436). Conclusions This study demonstrated the long-term relationship between everolimus blood level and clinical outcomes and adverse events in Japanese patients with mRCC. Thus, TDM in everolimus therapy could be a useful tool for the early prediction of adverse events for Japanese patients with mRCC.
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Affiliation(s)
- Shinya Takasaki
- 1Department of Pharmaceutical Sciences, Tohoku University Hospital, 1-1 Seiryo-machi, Aobaku, Sendai, Miyagi 980-8574 Japan
| | - Hiroaki Yamaguchi
- 1Department of Pharmaceutical Sciences, Tohoku University Hospital, 1-1 Seiryo-machi, Aobaku, Sendai, Miyagi 980-8574 Japan
| | - Yoshihide Kawasaki
- 2Department of Urology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aobaku, Sendai, Miyagi 980-8574 Japan
| | - Masafumi Kikuchi
- 1Department of Pharmaceutical Sciences, Tohoku University Hospital, 1-1 Seiryo-machi, Aobaku, Sendai, Miyagi 980-8574 Japan
| | - Masaki Tanaka
- 1Department of Pharmaceutical Sciences, Tohoku University Hospital, 1-1 Seiryo-machi, Aobaku, Sendai, Miyagi 980-8574 Japan
| | - Akihiro Ito
- 2Department of Urology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aobaku, Sendai, Miyagi 980-8574 Japan
| | - Nariyasu Mano
- 1Department of Pharmaceutical Sciences, Tohoku University Hospital, 1-1 Seiryo-machi, Aobaku, Sendai, Miyagi 980-8574 Japan
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Tönshoff B, Ettenger R, Dello Strologo L, Marks SD, Pape L, Tedesco-Silva H, Bjerre A, Christian M, Meier M, Martzloff ED, Rauer B, Ng J, Lopez P. Early conversion of pediatric kidney transplant patients to everolimus with reduced tacrolimus and steroid elimination: Results of a randomized trial. Am J Transplant 2019; 19:811-822. [PMID: 30125462 DOI: 10.1111/ajt.15081] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 07/25/2018] [Accepted: 08/12/2018] [Indexed: 01/25/2023]
Abstract
In a 12-month, multicenter, open-label study, 106 children were randomized at 4 to 6 weeks after kidney transplantation to switch to everolimus with reduced TAC (EVR/rTAC) and steroid elimination from month 5 posttransplant or to continue standard tacrolimus with mycophenolate mofetil (sTAC/MMF) and steroids. The cumulative incidence of a co-primary efficacy end point (biopsy-proven acute rejection [BPAR], graft loss, or death from randomization to month 12) was 10.3% with EVR/rTAC and 5.8% with sTAC/MMF (difference 4.4%; P = .417). BPAR occurred in 9.6% and 5.6% of patients, respectively. Patient and renal allograft survival were 100%. The co-primary end point of mean estimated glomerular filtration rate at month 12 was 76.2 mL/min/1.73 m2 with EVR/rTAC and 72.5 mL/min/1.73 m2 for sTAC/MMF (difference 3.8 mL/min/1.73m2 ; P = .49). One EVR/rTAC patient developed posttransplant lymphoproliferative disease. Longitudinal growth and sexual maturation were equivalent between groups. The randomized drug regimen was discontinued in 34.6% and 13% of patients in the EVR/rTAC and sTAC/MMF groups, respectively (P = .024), and discontinued due to adverse events/infections in 25.0% and 11.1% of patients (P = .062). In conclusion, early conversion of pediatric kidney transplant patients from TAC, MMF, and steroids to EVR/rTAC and steroid withdrawal maintains immunosuppressive efficacy and preserves renal function.
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Affiliation(s)
- Burkhard Tönshoff
- Department of Pediatrics I, University Children's Hospital Heidelberg, Heidelberg, Germany
| | - Robert Ettenger
- Division of Pediatric Nephrology, UCLA Mattel Children's Hospital, Los Angeles, CA, USA
| | - Luca Dello Strologo
- Nephrology Unit, Department of Pediatrics, Institute for Scientific Research, Bambino Gesù Children's Hospital, Rome, Italy
| | - Stephen D Marks
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Lars Pape
- Department of Pediatric Nephrology, Hannover Medical School, Hannover, Germany
| | | | - Anna Bjerre
- Division of Paediatric and Adolescent Medicine, Department of Pediatrics, Oslo University Hospital, Oslo, Norway
| | - Martin Christian
- Department of Paediatric Nephrology, Nottingham Children's Hospital, Nottingham, UK
| | | | | | | | - Jennifer Ng
- Biometrics and Statistical Science, Novartis Pharmaceuticals, East Hanover, NJ, USA
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