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Hoff U, Markmann D, Nieminen-Kelhä M, Budde K, Hegner B. Low-dose rapamycin does not impair vascular integrity and tubular regeneration after kidney transplantation in rats. Sci Rep 2021; 11:16270. [PMID: 34381142 PMCID: PMC8358014 DOI: 10.1038/s41598-021-95790-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 07/16/2021] [Indexed: 11/23/2022] Open
Abstract
mTOR inhibitors offer advantages after kidney transplantation including antiviral and antitumor activity besides facilitating low calcineurin inhibitor exposure to reduce nephrotoxicity. Concerns about adverse effects due to antiproliferative and antiangiogenic properties have limited their clinical use particularly early after transplantation. Interference with vascular endothelial growth factor (VEGF)-A, important for physiologic functioning of renal endothelial cells and tubular epithelium, has been implicated in detrimental renal effects of mTOR inhibitors. Low doses of Rapamycin (loading dose 3 mg/kg bodyweight, daily doses 1.5 mg/kg bodyweight) were administered in an allogenic rat kidney transplantation model resulting in a mean through concentration of 4.30 ng/mL. Glomerular and peritubular capillaries, tubular cell proliferation, or functional recovery from preservation/reperfusion injury were not compromised in comparison to vehicle treated animals. VEGF-A, VEGF receptor 2, and the co-receptor Neuropilin-1 were upregulated by Rapamycin within 7 days. Rat proximal tubular cells (RPTC) responded in vitro to hypoxia with increased VEGF-A and VEGF-R1 expression that was not suppressed by Rapamycin at therapeutic concentrations. Rapamycin did not impair proliferation of RPTC under hypoxic conditions. Low-dose Rapamycin early posttransplant does not negatively influence the VEGF network crucial for recovery from preservation/reperfusion injury. Enhancement of VEGF signaling peritransplant holds potential to further improve outcomes.
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Affiliation(s)
- Uwe Hoff
- Department of Nephrology and Critical Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Denise Markmann
- Nieren- und Dialysezentrum Schöneberg-Tempelhof, Berlin, Germany
| | - Melina Nieminen-Kelhä
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Klemens Budde
- Department of Nephrology and Critical Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Björn Hegner
- Department of Nephrology and Critical Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.
- Vitanas Hospital for Geriatric Medicine, Berlin, Germany.
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2
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Li X, Zhu G, Gou X, He W, Yin H, Yang X, Li J. Negative feedback loop of autophagy and endoplasmic reticulum stress in rapamycin protection against renal ischemia-reperfusion injury during initial reperfusion phase. FASEB J 2018; 32:fj201800299R. [PMID: 29771603 DOI: 10.1096/fj.201800299r] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
Rapamycin, an immunosuppressant, is widely used in patients with kidney transplant. However, the therapeutic effects of rapamycin remain controversial. Additionally, previous studies have revealed deleterious effects of rapamycin predominantly when administered for ≥24 h. Few studies, however, have focused on the short-term effects of rapamycin administered only during the initial reperfusion phase. As such, we designed this study to explore the potential effects and mechanisms of rapamycin under a specific therapeutic regimen in which rapamycin is mixed in the perfusate during the initial reperfusion phase (within 24 h). Interestingly, we found that rapamycin maintained renal function and attenuated ischemia-reperfusion (I/R)-induced apoptosis in vivo and in vitro during the initial reperfusion phase, especially at 8 h after reperfusion. Simultaneously, rapamycin activated autophagy and inhibited endoplasmic reticulum (ER) stress and 3 pathways of unfolding protein response: ATF6, PERK, and IRE1α. Interestingly, we further found that the protective effects of rapamycin were suppressed when autophagy was inhibited by chloroquine and 3-methyladenine or when ER stress was induced by thapsigargin. Moreover, in terms of the regulatory effects of rapamycin, a negative-feedback loop between autophagy and ER stress occurred, with autophagy inhibiting ER stress and increased ER stress promoting autophagy during the initial reperfusion phase of renal I/R injury. Our study provides evidence that immediate reperfusion with rapamycin during the initial reperfusion phase repairs renal function and reduces apoptosis via activating autophagy, which could further inhibit ER stress. These results suggest a novel treatment modality for application during the initial reperfusion phase of renal I/R injury caused by kidney transplantation.-Li, X., Zhu, G., Gou, X., He, W., Yin, H., Yang, X., Li, J. Negative feedback loop of autophagy and endoplasmic reticulum stress in rapamycin protection against renal ischemia-reperfusion injury during initial reperfusion phase.
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Affiliation(s)
- Xinyuan Li
- Department of Urology, First Affiliated Hospital, Chongqing Medical University, Chongqing, China; and
- Chongqing Key Laboratory of Molecular Oncology and Epigenetics, Chongqing, China
| | - Gongmin Zhu
- Department of Urology, First Affiliated Hospital, Chongqing Medical University, Chongqing, China; and
- Chongqing Key Laboratory of Molecular Oncology and Epigenetics, Chongqing, China
| | - Xin Gou
- Department of Urology, First Affiliated Hospital, Chongqing Medical University, Chongqing, China; and
| | - Weiyang He
- Department of Urology, First Affiliated Hospital, Chongqing Medical University, Chongqing, China; and
| | - Hubin Yin
- Department of Urology, First Affiliated Hospital, Chongqing Medical University, Chongqing, China; and
- Chongqing Key Laboratory of Molecular Oncology and Epigenetics, Chongqing, China
| | - Xiaoyu Yang
- Department of Urology, First Affiliated Hospital, Chongqing Medical University, Chongqing, China; and
- Chongqing Key Laboratory of Molecular Oncology and Epigenetics, Chongqing, China
| | - Jie Li
- Department of Urology, First Affiliated Hospital, Chongqing Medical University, Chongqing, China; and
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3
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Malat GE, Boyle SM, Jindal RM, Guy S, Xiao G, Harhay MN, Lee DH, Ranganna KM, Anil Kumar MS, Doyle AM. Kidney Transplantation in HIV-Positive Patients: A Single-Center, 16-Year Experience. Am J Kidney Dis 2018; 73:112-118. [PMID: 29705074 DOI: 10.1053/j.ajkd.2018.02.352] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 02/14/2018] [Indexed: 11/11/2022]
Abstract
Hahnemann University Hospital has performed 120 kidney transplantations in human immunodeficiency virus (HIV)-positive individuals during the last 16 years. Our patient population represents ∼10% of the entire US population of HIV-positive kidney recipients. In our earlier years of HIV transplantation, we noted increased rejection rates, often leading to graft failure. We have established a multidisciplinary team and over the years have made substantial protocol modifications based on lessons learned. These modifications affected our approach to candidate evaluation, donor selection, perioperative immunosuppression, and posttransplantation monitoring and resulted in excellent posttransplantation outcomes, including 100% patient and graft survival at 1 year and patient and graft survival at 3 years of 100% and 96%, respectively. We present key clinical data, including a granular patient-level analysis of the associations of antiretroviral therapy regimens with long-term survival, cellular and antibody-mediated rejection rates, and the causes of allograft failures. In summary, we provide details on the evolution of our approach to HIV transplantation during the last 16 years, including strategies that may improve outcomes among HIV-positive kidney transplantation candidates throughout the United States.
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Affiliation(s)
| | | | - Rahul M Jindal
- USU-Walter Reed Department of Surgery, Uniformed Services University, Bethesda, MD.
| | - Stephen Guy
- Department of Surgery, Drexel University, Philadelphia, PA
| | - Gary Xiao
- Department of Surgery, Drexel University, Philadelphia, PA
| | - Meera N Harhay
- Department of Medicine, Drexel University, Philadelphia, PA
| | - Dong H Lee
- Department of Medicine, Drexel University, Philadelphia, PA
| | | | | | - Alden M Doyle
- Department of Medicine, Drexel University, Philadelphia, PA.
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4
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Does Delayed Graft Function Still Herald a Poorer Outcome in Kidney Transplantation? CURRENT TRANSPLANTATION REPORTS 2016. [DOI: 10.1007/s40472-016-0110-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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5
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Mazuecos A, Fernandez A, Zarraga S, Andres A, Rodriguez-Benot A, Jimenez C, Gomez E, Paul J, Jimeno L, Fernandez C, Burgos D, Sanchez-Fructuoso A, Guirado L. High incidence of delayed graft function in HIV-infected kidney transplant recipients. Transpl Int 2013; 26:893-902. [DOI: 10.1111/tri.12147] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Revised: 05/08/2013] [Accepted: 06/14/2013] [Indexed: 11/30/2022]
Affiliation(s)
| | - Ana Fernandez
- Renal Transplant Unit; Hospital Ramon y Cajal; Madrid; Spain
| | - Sofia Zarraga
- Renal Transplant Unit; Hospital de Cruces; Barakaldo; Spain
| | - Amado Andres
- Renal Transplant Unit; Hospital Doce de Octubre; Madrid; Spain
| | | | | | - Ernesto Gomez
- Renal Transplant Unit; Hospital Central de Asturias; Oviedo; Spain
| | - Javier Paul
- Renal Transplant Unit; Hospital Miguel Servet; Zaragoza; Spain
| | - Luisa Jimeno
- Renal Transplant Unit; Hospital Virgen de la Arrixaca; Murcia; Spain
| | | | - Dolores Burgos
- Renal Transplant Unit; Hospital Carlos Haya; Malaga; Spain
| | | | - Lluis Guirado
- Renal Transplant Unit; Fundacion Puigvert; Barcelona; Spain
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6
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A Randomized, Open-Label Study of Sirolimus Versus Cyclosporine in Primary De Novo Renal Allograft Recipients. Transplantation 2013; 95:1233-41. [DOI: 10.1097/tp.0b013e318291a269] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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7
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Patel SJ, Dawson KL, Knight RJ, Abdellatif A, Achkar K, Gaber LW, Gaber AO. The role of mTOR inhibition in renal transplant immune suppression. ACTA ACUST UNITED AC 2011. [DOI: 10.1002/dat.20530] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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8
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Sucher R, Gehwolf P, Oberhuber R, Hermann M, Margreiter C, Werner ER, Obrist P, Schneeberger S, Ollinger R, Margreiter R, Brandacher G. Tetrahydrobiopterin protects the kidney from ischemia-reperfusion injury. Kidney Int 2010; 77:681-9. [PMID: 20164829 DOI: 10.1038/ki.2010.7] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Tetrahydrobiopterin (BH4) is an essential cofactor for the nitric oxide (NO) synthases and represents a critical determinant of NO production. BH4 depletion during ischemia leads to the uncoupling of the synthases, thus contributing to reperfusion injury due to increased superoxide formation. To examine whether BH4 supplementation attenuates ischemia-reperfusion injury, we clamped the left renal arteries of male Lewis rats immediately following right-side nephrectomy. BH4 tissue levels significantly decreased after 45 min of warm ischemia compared with levels in non-ischemic controls. Histopathology demonstrated significant tubular damage and increased peroxynitrite formation. Intravital fluorescent microscopy found perfusion deficits in the microvasculature and leakage of the capillary mesh. Supplemental BH4 treatment before ischemia significantly reduced ischemia-induced renal dysfunction, and decreased tubular histologic injury scores and peroxynitrite generation. BH4 also significantly improved microcirculatory parameters such as functional capillary density and diameter. These protective effects of BH4 on microvasculature were significantly correlated with its ability to abolish peroxynitrite formation. We suggest that BH4 significantly protects against acute renal failure following ischemia reperfusion. Whether BH4 has a therapeutic potential will require more direct testing in humans.
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Affiliation(s)
- Robert Sucher
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Innsbruck Medical University, Innsbruck, Austria
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9
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Therapeutic role of sirolimus in non-transplant kidney disease. Pharmacol Ther 2009; 123:187-206. [DOI: 10.1016/j.pharmthera.2009.03.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2009] [Accepted: 03/24/2009] [Indexed: 12/20/2022]
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10
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Campistol JM, Cockwell P, Diekmann F, Donati D, Guirado L, Herlenius G, Mousa D, Pratschke J, Millán JCRS. Practical recommendations for the early use of m-TOR inhibitors (sirolimus) in renal transplantation. Transpl Int 2009; 22:681-7. [DOI: 10.1111/j.1432-2277.2009.00858.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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11
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Patel SJ, Elliott EN, Knight RJ, Gaber LW, Gaber AO. Considerations in sirolimus use in the early and late post-transplant periods. Expert Opin Drug Saf 2009; 8:421-34. [DOI: 10.1517/14740330903037156] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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12
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Risk factors and consequences of delayed graft function in deceased donor renal transplant patients receiving antithymocyte globulin induction. Transplantation 2008; 86:313-20. [PMID: 18645496 DOI: 10.1097/tp.0b013e31817ef190] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Induction rabbit antithymocyte globulin (rATG) is largely used in renal allograft recipients at risk for delayed graft function (DGF) and immunologic rejection. The purpose of our study was to characterize risk factors and outcomes associated with DGF when it occurs in recipients undergoing routine rATG induction. METHODS We retrospectively reviewed our experience in a predominantly high-risk population receiving modern immunosuppressive regimens. RESULTS Of 231 deceased-donor transplants, high-risk characteristics included African American race (68%), retransplants (12%), peak panel reactive antibody of atleast 20% (19%), expanded criteria donor kidney (15%), and cold ischemia time exceeding 24 hr (27%). DGF occurred in 29% of patients. rATG was continued to a dose of 7.3 mg/kg in DGF patients and 5 mg/kg in non-DGF patients (P<0.0001). Risk factors for DGF were recipient body mass index greater than 30 kg/m(2) (odds ratio [OR]=1.5, P=0.02), female donor/male recipient pairings (OR=1.5, P=0.033), sirolimus use (OR=1.7, P=0.003), and donor creatinine more than 1.5 mg/dL (OR=1.6, P=0.016). One-year patient survival (99% non-DGF, 91% DGF; P=0.001) and acute rejection incidence through 36 months (11% non-DGF, 22.4% DGF; P=0.025) differed between groups. DGF patients experienced a higher rejection rate during the second and third years posttransplant. Death-censored graft survival was similar throughout 36 months. CONCLUSION In kidney transplantation with routine rATG induction, DGF was related to size and gender, donor creatinine, and immunosuppressive protocol. Despite low first-year rejection rates, DGF was associated with inferior patient survival. Importantly, patients with DGF continued to be at risk for rejection beyond the first year. Donor and recipient selection impacts short-term outcomes, and induction alone may not confer a long-term advantage without further modification of baseline therapy.
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13
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Laugharne M, Cross S, Richards S, Dawson C, Ilchyshyn L, Saleem M, Mathieson P, Smith R. Sirolimus toxicity and vascular endothelial growth factor release from islet and renal cell lines. Transplantation 2007; 83:1635-8. [PMID: 17589348 DOI: 10.1097/01.tp.0000266555.06635.bf] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Presently, sirolimus (rapamycin) is used as both induction and maintenance immunosuppression in solid organ transplants, including whole pancreas and kidney, and islet transplantation. Sirolimus has been suggested to have deleterious effects on islet beta-cell and renal function. We investigated the effect of sirolimus on the viability of islets, podocytes, and renal tubular cells. Sirolimus reduced the viability of islets and HK-2 human proximal renal tubular cells in vitro. This toxic effect was associated with a reduction of vascular endothelial growth factor (VEGF) release by islets but not the proximal tubular cells. Sirolimus reduced both viability and VEGF production by murine beta-cells, and blockade of VEGF-164 was associated with a reduction in viability. Transfection of murine islets with adenoviral VEGF-165 improved islet viability. These data are consistent with the hypothesis that sirolimus is toxic to islets and beta-cells by blockade of VEGF-mediated survival pathways.
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Affiliation(s)
- Matthew Laugharne
- Academic Renal Unit, Paul O'Gorman Lifeline Centre, Clinical Science at North Bristol, Southmead Hospital, Westbury-on-Trym, Bristol, UK
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14
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Gonçalves GM, Cenedeze MA, Feitoza CQ, de Paula CB, Marques GD, Pinheiro HS, de Paula Antunes Teixeira V, Antônia dos Reis M, Pacheco-Silva A, Câmara NOS. The Role of Immunosuppressive Drugs in Aggravating Renal Ischemia and Reperfusion Injury. Transplant Proc 2007; 39:417-20. [PMID: 17362745 DOI: 10.1016/j.transproceed.2007.01.027] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
UNLABELLED Renal ischemia followed by reperfusion leads to acute renal failure in both native kidneys and renal allografts. Cyclosporine has known nephrotoxic effects. Thus, cyclosporine therapy subsequent to ischemia/reperfusion (I/R) injury may further exacerbate graft dysfunction. Rapamycin is a newer agent that suppresses the immune system by a different mechanism. In the present study, the effects of Cyclosporine and rapamycin at low and higher concentrations were investigated in an I/R-induced injury model. METHODS Cyclosporine (100 mg/kg or 50 mg/kg), rapamycin (3 mg/kg per day or 1.5 mg/kg), or both were administered to mice before being subjected to 45 minutes of ischemia. Blood and kidney samples were collected at 24, 48, and 120 hours after surgery. We quantified acute tubular necrosis and tubular regeneration. RESULTS Animals subjected to I/R showed impaired renal function that peaked at 24 hours (2.05 +/- 0.23 mg/dL), decreasing thereafter. Treatment with higher concentrations of cyclosporine or rapamycin caused even more renal dysfunction at 48 hours, which was sustained up to 120 hours after reperfusion (1.53 +/- 0.6 mg/dL), when compared to the low concentrations of cyclosporine or rapamycin (1.08 +/- 0.19 mg/dL; 0.99 +/- 0.14 mg/dL, P < .05, respectively). Cyclosporine delayed tubular regeneration, which was higher in controls at day 5 (67.0% vs 37.6%, P < .05). CONCLUSIONS These results demonstrated that cyclosporine or rapamycin might further aggravate ischemically injured organs, negatively affecting posttransplantation recovery in a concentration-dependent fashion.
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Affiliation(s)
- G M Gonçalves
- Laboratório de Imunologia Clínica e Experimental, Division of Nephrology, Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, Brazil
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15
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Gonçalves GM, Cenedeze MA, Feitoza CQ, Wang PMH, Bertocchi APF, Damião MJ, Pinheiro HS, Antunes Teixeira VP, dos Reis MA, Pacheco-Silva A, Câmara NOS. The role of heme oxygenase 1 in rapamycin-induced renal dysfunction after ischemia and reperfusion injury. Kidney Int 2006; 70:1742-9. [PMID: 17003813 DOI: 10.1038/sj.ki.5001893] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Ischemia and reperfusion injury (IRI) is the main etiology of acute renal failure in native and transplanted kidneys. In the transplantation field, immunosuppressive drugs may play an additional role in acute graft dysfunction. Rapamycin may impair renal regeneration post IRI. Heme oxygenase 1 (HO-1) is a protective gene with anti-inflammatory and anti-apoptotic actions. We investigated whether HO-1 played a role in rapamycin-induced renal dysfunction in an established model of IRI. Rapamycin (3 mg/kg) was administered to mice before being subjected to 45 min of ischemia. Animals subjected to IRI presented with impaired renal function that peaked at 24 h (2.05+/-0.23 mg/dl), decreasing thereafter. Treatment with rapamycin caused even more renal dysfunctions (2.30+/-0.33 mg/dl), sustained up to 120 h after reperfusion (1.54+/-0.4 mg/dl), when compared to the control (0.63+/-0.09 mg/dl, P<0.05). Rapamycin delayed tubular regeneration that was normally higher in the control group at day 5 (68.53+/-2.30 vs 43.63+/-3.11%, P<0.05). HO-1 was markedly upregulated after IRI and its expression was even enhanced by rapamycin (1.32-fold). However, prior induction of HO-1 by cobalt protoporphyrin improved the renal dysfunction imposed by rapamycin, mostly at later time points. These results demonstrated that rapamycin used in ischemic-injured organs could also negatively affect post-transplantation recovery. Modulation of HO-1 expression may represent a feasible approach to limit rapamycin acute toxicity.
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Affiliation(s)
- G M Gonçalves
- Laboratório de Imunologia Clínica e Experimental, Division of Nephrology, Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, Brazil
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16
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Pelletier R, Nadasdy T, Nadasdy G, Satoskar A, Tewari AK, Cotrill J, Henry M, Rajab A, Ferguson R. Acute Renal Failure Following Kidney Transplantation Associated with Myoglobinuria in Patients Treated with Rapamycin. Transplantation 2006; 82:645-50. [PMID: 16969287 DOI: 10.1097/01.tp.0000230310.27913.01] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Since using an immunosuppression regimen that includes rapamycin, we have occasionally encountered renal transplant patients who develop unexpected severe acute renal dysfunction. Biopsies obtained in these recipients demonstrate acute tubular necrosis (ATN) occasionally associated with tubular casts giving the classic appearance of myoglobin casts. METHODS We retrospectively reviewed all biopsies from consecutively transplanted kidneys engrafted between April 9, 2002 and June 29, 2004 to determine the incidence of ATN, ATN with intratubular casts, and casts with the classic myoglobin appearance. The clinical setting, treatment, and outcomes of those patients with classic myoglobin-appearing casts are reviewed. RESULTS Histological ATN as the principal finding in at least one biopsy occurred in 10.5% (57/543) of patients. About half of these patients (30/57) had tubular casts present in at least one biopsy and in 14 of these the casts had a classic appearance of myoglobin casts. These myoglobin-appearing casts were only noted in patients receiving rapamycin. A review of 28 ATN biopsies from an earlier prerapamycin era did not demonstrate similar myoglobin-appearing casts. Immunostaining for myoglobin was positive in all 14 recipient biopsies. This was confirmed by western blot analyses in three of five patient biopsies tested. Three of three recipients tested had elevated serum creatine phosphokinase levels and detectable serum myoglobin. All 14 patients slowly resolved their acute renal dysfunction and no grafts were lost. CONCLUSION We conclude that myoglobinuria with myoglobin cast formation can occur following rapamycin administration, and may be a causative factor in the development of unexpected severe acute renal dysfunction.
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Affiliation(s)
- Ronald Pelletier
- Division of Transplantation, Department of General Surgery, The Ohio State University College of Medicine, Columbus, OH, USA.
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17
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Pallet N, Thervet E, Legendre C, Anglicheau D. Néphrotoxicité du sirolimus : données cliniques et expérimentales. Nephrol Ther 2006; 2:183-90. [PMID: 16966063 DOI: 10.1016/j.nephro.2006.04.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2005] [Revised: 03/14/2006] [Accepted: 04/12/2006] [Indexed: 01/29/2023]
Abstract
Sirolimus (SRL, rapamycin) is a potent immunosuppressive drug that binds to and inhibits mammalian Target Of Rapamycine (mTOR) kinase activity, a central controller of cell growth. In response to amino acids, hormones and growth factors, mTOR activates the translational machinery. By inhibiting mTOR, SRL reduces the translational process and T-cell proliferation in the mid-to-late G1 phase of the cell cycle. The antiproliferative effects of SRL are not limited to activated T cells. SRL has also been shown to block the cell cycle in various cell types such as epithelial renal cells, and many types of tumor cell lines. Since the approval by the US Food and Drug Administration and by the European agency, SRL has provoked great interest, as evidenced by the exponential increase in clinical studies. However, whereas preclinical studies failed to show any nephrotoxic effect on animal models, many clinical trials raised the possibility that SRL might be associated with renal adverse events. The evidence for SRL-associated early graft nephrotoxicity emerged from these results, and subsequent experimental data gave some explanations about the involved mechanisms. The aim of this review is to summarize the various renal adverse events reported in clinical studies and to present the experimental evidence for putative mechanisms of action for this SRL-induced nephrotoxicity.
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Affiliation(s)
- Nicolas Pallet
- Service de transplantation rénale et de soins intensifs, hôpital Necker-Enfants-Malades, APHP et université Paris-V, René-Descartes, 149, rue de Sèvres, 75743 cedex 15 Paris, France
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18
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Abstract
Sirolimus is a novel immunosuppressant with potent antiproliferative actions through its ability to inhibit the raptor-containing mammalian target of rapamycin protein kinase. Sirolimus represents a major therapeutic advance in the prevention of acute renal allograft rejection and chronic allograft nephropathy. Its role in the therapy of glomerulonephritis, autoimmunity, cystic renal diseases and renal cancer is under investigation. Because sirolimus does not share the vasomotor renal adverse effects exhibited by calcineurin inhibitors, it has been designated a 'non-nephrotoxic drug'. However, clinical reports suggest that, under some circumstances, sirolimus is associated with proteinuria and acute renal dysfunction. A common risk factor appears to be presence of pre-existing chronic renal damage. The mechanisms of sirolimus-associated proteinuria are multifactorial and may be due to an increase in glomerular capillary pressure following calcineurin inhibitor withdrawal. It has also been suggested that sirolimus directly causes increased glomerular permeability/injury, but evidence for this mechanism is currently inconclusive. The acute renal dysfunction associated with sirolimus (such as in delayed graft function) may be due to suppression of compensatory renal cell proliferation and survival/repair processes. Although these adverse effects occur in some patients, their occurrence could be minimised by knowledge of the molecular effects of sirolimus on the kidney, the use of sirolimus in appropriate patient populations, close monitoring of proteinuria and renal function, use of angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers if proteinuria occurs and withdrawal if needed. Further long-term analysis of renal allograft studies using sirolimus as de novo immunosuppression along with clinical and laboratory studies will refine these issues in the future.
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Affiliation(s)
- Gopala K Rangan
- Centre for Transplant and Renal Research, Westmead Millennium Institute, The University of Sydney at Westmead Hospital, Sydney, New South Wales, Australia.
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Abstract
Sirolimus (Rapamycin, Wyeth Pharmaceuticals Australia Pty Ltd, Baulkham Hills, NSW, Australia) (SRL) has received increasing attention as an immunosuppressant in renal and other solid organ transplantation. Sirolimus is the first marketed agent in a new class of drugs with a novel mechanism of action. Sirolimus binds, like tacrolimus, to a member of the FK binding protein (FKBP) family. The SRL/FKBP complex binds to the protein kinase mTOR. Binding to mTOR blocks activation of signal transduction pathways causing arrest of the cell cycle in the G1 phase. It is now known that mTOR is a central regulator of cell growth and proliferation. The immunosuppressive properties of SRL are due primarily to blockade of interleukin-2 (IL-2)-induced proliferation of T cells. There is still much to be learnt about how best to use the drug. The key advantage over the current choice of immunosuppressive agents is the ability to preserve renal function and pathology while producing excellent rejection-free, graft survival rates. Thus, SRL may find its pivotal role as a calcineurin inhibitors replacement in patients whose grafts are affected by chronic allograft nephropathy. A second major driver for use may prove to be the impact of SRL on cancer incidence and prognosis. Studies still need to be performed to evaluate the best timing for commencement of SRL and the optimal dosage to minimize side-effects.
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Affiliation(s)
- Vincent Ws Lee
- Department of Renal Medicine, Westmead Hospital, New South Wales, Australia.
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Boratyńska M, Banasik M, Patrzalek D, Szyber P, Klinger M. Sirolimus Delays Recovery From Posttransplant Renal Failure in Kidney Graft Recipients. Transplant Proc 2005; 37:839-42. [PMID: 15848550 DOI: 10.1016/j.transproceed.2004.12.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The aim of this study was to evaluate the impact of sirolimus and cyclosporine (CsA) combined therapy on the incidence and duration of delayed graft function (DGF), and the impact of the latter on 1-year graft function. The study entailed 23 cadaveric renal recipients treated with sirolimus-CsA-prednisone regimen (sirolimus group). The reference group entailed 23 patients treated with CsA-azathioprine-prednisone. In the sirolimus group the frequency of DGF was 39% and was essentially the same as in reference group (34.8%). The duration of DGF was significantly longer in SRL group and lasted 21.2 +/- 12.2 days versus 6.8 +/- 2.5 in reference group (P = .004). Serum creatinine level decreased below 3.0 mg/dL after 36 +/- 22 days in sirolimus group versus 16.8 +/- 6 days in reference group (P < .04). Cold ischemia was slightly longer and donors were older in DGF patients in both groups. Sirolimus dose during first month was higher in DGF patients (3.5 versus 2.6 mg), whereas level of CsA was lower (230 versus 310 ng/mL). Biopsy-proven acute rejection (AR) occurred in most of DGF patients and during the DGF period. Serum creatinine level at the 12th month posttransplant was higher in DGF versus non-DGF patients (2.0 +/- 0.5 versus 1.5 +/- 0.4 mg/dL). One-year patient and graft survival was 100% in sirolimus group and 100% and 95% in reference group. In conclusion, sirolimus significantly retards the recovery from posttransplant renal failure; however, it does not increase the incidence of DGF. Patients who suffered from posttransplant acute renal failure had worse renal function at 1 year after transplantation, independent of the treatment protocol.
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Affiliation(s)
- M Boratyńska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland.
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