1
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Stoumpos S, Van Rhijn P, Mangion K, Thomson PC, Mark PB. Arteriovenous fistula for haemodialysis as a predictor of de novo heart failure in kidney transplant recipients. Clin Kidney J 2024; 17:sfae105. [PMID: 38737344 PMCID: PMC11087827 DOI: 10.1093/ckj/sfae105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Indexed: 05/14/2024] Open
Abstract
Background The haemodynamic effects of a functioning haemodialysis arteriovenous fistula (AVF) can cause or exacerbate heart failure (HF). We investigated whether the presence of an AVF at the time of kidney transplant (KT) is associated with de novo HF. Methods This was an observational cohort study including adult patients who received a KT in the West of Scotland between 2010 and 2020. We evaluated the risk and associations of pretransplant factors with de novo HF, alone and as a composite cardiovascular (CV) outcome (including non-fatal myocardial infarction, non-fatal stroke, de novo HF and CV death). Multivariable proportional hazards regression and sensitivity analyses were used to identify independent correlates of the outcomes. Results Among 1330 included patients, the incident rate of de novo HF after transplantation was 58/1000 person-years [95% confidence interval (CI) 50-67] in AVF patients (n = 716) compared with 33/1000 person-years (95% CI 27-41) in non-AVF patients (n = 614). De novo HF was associated with the presence of an AVF [adjusted hazard ratio (aHR) 2.14 (95% CI 1.40-3.26)], duration of dialysis [aHR 1.03/year increase (95% CI 1.01-1.04)], age at transplant [aHR 1.03/year increase (95% CI 1.02-1.05)], female sex [aHR 1.93 (95% CI 1.40-2.65)] and pretransplant diabetes [aHR 2.43 (95% CI 1.48-4.01)]. The presence of an AVF was also associated with the composite CV outcome [aHR 1.91 (95% CI 1.31-2.78)]. Conclusions The presence of an AVF may be an underrecognized modifiable predictor of de novo HF posttransplantation.
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Affiliation(s)
- Sokratis Stoumpos
- Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Peter Van Rhijn
- Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Kenneth Mangion
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Peter C Thomson
- Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Patrick B Mark
- Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
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2
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Zangla E, Mahajan R, Jiang Z, Kizilbash SJ. Lipid abnormalities in pediatric kidney transplant recipients on steroid withdrawal maintenance immunosuppression. Pediatr Nephrol 2024; 39:261-268. [PMID: 37535124 DOI: 10.1007/s00467-023-06110-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 07/06/2023] [Accepted: 07/24/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND Dyslipidemia is a modifiable risk factor for cardiovascular disease. The prevalence of dyslipidemia in pKTR (pediatric kidney transplant recipients) under modern immunosuppression remains unknown. We determined the prevalence, risk factors, co-morbidities, and treatment patterns of lipid abnormalities in pediatric kidney transplant recipients on steroid withdrawal immunosuppression. METHODS pKTR (age ≤ 21 years) at a single center on steroid withdrawal immunosuppression underwent lipid screening between January 1, 2020, and September 30, 2022. Continuous and categorical variables were compared using the Wilcoxon rank-sum and chi-square or Fisher's exact tests, respectively. The correlation between total cholesterol and BMI (body mass index) was assessed using Pearson's product-moment correlation, and predictors of lipid abnormalities were evaluated using the multivariable logistic regression. RESULTS A total of 96 patients were included, with a median post-transplant time of 2.5 years (IQR: 1.3-5.4). Of the total, 64.6% (n = 62) of patients had a fasting lipid abnormality. We found a significant linear correlation between total cholesterol and BMI (r = 0.38, p = 0.0022). After multivariable adjustment, every 1 ml/min/1.73 m2 increase in eGFR was associated with a 2% lower odds of a lipid abnormality (OR 0.979, p = 0.026). Obesity, hypertension, and left ventricular hypertrophy were similar between those with and without lipid abnormalities, while insulin-treated diabetes was more prevalent in recipients with lipid abnormalities (12.9% vs. 0%, p = 0.047). Only 36.5% of patients (n = 19) were referred to a dietician and/or lipid specialist; one received statin therapy. CONCLUSIONS Lipid abnormalities are highly prevalent in pKTR, but therapeutic intervention is infrequent. Calcineurin inhibition without corticosteroids may not be protective; however, higher eGFR is associated with a lower prevalence of lipid abnormalities. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Emily Zangla
- Department of Pediatrics, Division of Nephrology, University of Minnesota, Academic Office Building, 2450 Riverside Ave S AO-201, Minneapolis, MN, 55454, USA.
| | - Ruchi Mahajan
- Department of Pediatrics, Division of Nephrology, University of Minnesota, Academic Office Building, 2450 Riverside Ave S AO-201, Minneapolis, MN, 55454, USA
| | - Ziou Jiang
- Clinical and Translational Science Institute, University of Minnesota, Minneapolis, MN, USA
| | - Sarah J Kizilbash
- Department of Pediatrics, Division of Nephrology, University of Minnesota, Academic Office Building, 2450 Riverside Ave S AO-201, Minneapolis, MN, 55454, USA
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3
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Kim CS, Oh TR, Suh SH, Choi HS, Bae EH, Ma SK, Jung JH, Kim B, Han KD, Kim SW. Uncontrolled hypertension is associated with increased risk of graft failure in kidney transplant recipients: a nationwide population-based study. Front Cardiovasc Med 2023; 10:1185001. [PMID: 37522087 PMCID: PMC10379652 DOI: 10.3389/fcvm.2023.1185001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 07/04/2023] [Indexed: 08/01/2023] Open
Abstract
Backgroud Hypertension is highly prevalent in patients with kidney transplantation caused by transplantation-related immunologic or non-immunologic risk factors. However, whether a strict definition of hypertension (≥130/80 mmHg) and subdivided blood pressure (BP) groups are associated with an increased risk of graft failure after kidney transplantation using a nationwide large cohort study are still unknown. Methods Using Korean National Health Insurance Service data, we included 14,249 patients who underwent kidney transplantation from 2002 to 2016. Patients were categorized into five BP groups according to the 2021 Kidney Disease: Improving Global Outcomes practice guidelines for BP management: normal BP (<120/80 mmHg), elevated BP (120-129/ < 80 mmHg), incident hypertension (≥130/80 mmHg), and controlled or uncontrolled hypertension with anti-hypertensive medications. Results The primary outcome was graft failure, which occurred in 1934 (13.6%) participants during the 6-year follow-up. After adjusting for covariates, hypertension was associated with a higher risk of graft failure [Adjusted hazard ratio (AHR), 1.70; 95% confidence interval (CI), 1.48-1.96)] than no-hypertension. The AHR for graft failure was the highest in patients with uncontrolled hypertension (AHR, 2.13; 95% CI, 1.80-2.52). The risk of graft failure had a linear relationship with systolic and diastolic BP, and pulse pressure. Conclusions In this nationwide population-based study, hypertension ≥130/80 mmHg based on the 2021 KDIGO BP guidelines in kidney transplantion recipients, and elevated systolic and diastolic BP, and pulse pressure were associated with the risk of developing graft failure in kidney transplant recipients.
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Affiliation(s)
- Chang Seong Kim
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Tae Ryom Oh
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Sang Heon Suh
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Hong Sang Choi
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Eun Hui Bae
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Seong Kwon Ma
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Jin Hyung Jung
- Department of Biostatistics, College of Medicine, Catholic University of Korea, Seoul, Republic of Korea
| | - Bongseong Kim
- Department of Statistics and Actuarial Science, Soongsil University, Seoul, Republic of Korea
| | - Kyung-Do Han
- Department of Statistics and Actuarial Science, Soongsil University, Seoul, Republic of Korea
| | - Soo Wan Kim
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
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4
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Anderson JLC, van der Giet M, Gomes Neto AW, Bakker SJL, Tietge UJF. Statin use and incident cardiovascular events in renal transplant recipients. Eur J Clin Invest 2021; 51:e13594. [PMID: 34042174 PMCID: PMC8596424 DOI: 10.1111/eci.13594] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 04/24/2021] [Accepted: 05/03/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Statins achieve potent LDL lowering in the general population leading to a significant cardiovascular (CV) risk reduction. In renal transplant recipients (RTR) statins are included in treatment guidelines, however, conclusive evidence of improved cardiovascular outcomes has not been uniformly provided and concerns have been raised about simultaneous use of statins and the immunosuppressant cyclosporine. This study aimed to elucidate the effect of statins on a compound CV endpoint, comprised of ischaemic CV events and CV mortality in RTR, with subgroup analysis focussing on cyclosporine users. METHOD 622 included RTR (follow-up 5.4 years) were matched based on propensity scores and dichotomized by statin use. Survival analysis was conducted. RESULTS Cox regression showed that statin use was not significantly associated with the compound CV endpoint in a fully adjusted model (HR = 0.81, 95% CI = 0.53-1.24, P = .33). Subgroup analyses in RTR using cyclosporine revealed a strong positive association of statin use with the CV compound outcome in a fully adjusted model (HR = 6.60, 95% CI 1.75-24.9, P = .005). Furthermore, statin use was positively correlated with cyclosporine trough levels (correlation coefficient 0.11, P = .04). CONCLUSION In conclusion, statin use does not significantly decrease incident CV events in an overall RTR cohort, but is independently associated with CV-specific mortality and events in cyclosporine using RTR, possibly due to a bilateral pharmacological interaction.
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Affiliation(s)
- Josephine L C Anderson
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Markus van der Giet
- Medizinische Klinik für Nephrologie und Internistische Intensivtherapie, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Antonio W Gomes Neto
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Stephan J L Bakker
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Uwe J F Tietge
- Division of Clinical Chemistry, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden.,Clinical Chemistry, Karolinska University Laboratory, Karolinska University Hospital, Stockholm, Sweden
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5
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Lim JH, Hwang I, Cho JH, Kwon E, Jung HY, Choi JY, Park SH, Kim YL, Kim HK, Huh S, Won DI, Kim CD. Impact of Conversion From Cyclosporine to Tacrolimus on Glucose Metabolism and Cardiovascular Risk Profiles in Long-Term Stable Kidney Transplant Recipients. Transplant Proc 2019; 51:2697-2703. [PMID: 31439330 DOI: 10.1016/j.transproceed.2019.04.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 03/29/2019] [Accepted: 04/11/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Compared to tacrolimus, cyclosporine increases cardiovascular risk. Furthermore, tacrolimus has a negative effect on glucose metabolism compared to cyclosporine. This study investigated the effect of the conversion from cyclosporine to tacrolimus for immunosuppressive therapy on glucose metabolism and cardiovascular risk profiles in long-term stable kidney transplant recipients (KTRs). METHODS In this prospective, open-label, single-arm study, 36 KTRs were enrolled; 3 were excluded. Patients were evaluated for glucose metabolism and cardiovascular risk factors at baseline, 3, and 6 months after conversion of medication. Serial changes were analyzed by repeated analysis of variance. RESULTS The mean duration from transplantation was 12.6 ± 4.0 years and baseline serum creatinine levels were 1.10 ± .23 mg/dL. After conversion, fasting plasma glucose levels increased sequentially from 101.7 ± 18.5 to 107.4 ± 21.3 mg/dL (P = .007), and glycated hemoglobin levels increased from 5.7 ± .8 to 6.0 ± 1.2% (P = .016). Among cardiovascular risk factors, fibrinogen levels were decreased (P = .015), but other factors, including blood pressure and lipid profile, did not change (all P > .05). There was no change in renal function, including serum creatinine (P = .611) and urine protein-to-creatinine ratio (P = .092). Body mass index levels were decreased (P = .037) and body weight tended to decrease (P = .063). CONCLUSIONS Switching immunosuppressant therapy to tacrolimus has an apparent negative effect on glucose metabolism and imparts an unclear advantage on cardiovascular risk profiles for long-term stable KTRs.
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Affiliation(s)
- Jeong-Hoon Lim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Inryang Hwang
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Jang-Hee Cho
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Eugene Kwon
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Hee-Yeon Jung
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Ji-Young Choi
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Sun-Hee Park
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Yong-Lim Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Hyung-Kee Kim
- Department of Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Seung Huh
- Department of Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Dong-Il Won
- Department of Clinical Pathology, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Chan-Duck Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea.
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6
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Warden BA, Duell PB. Management of dyslipidemia in adult solid organ transplant recipients. J Clin Lipidol 2019; 13:231-245. [PMID: 30928441 DOI: 10.1016/j.jacl.2019.01.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 01/21/2019] [Accepted: 01/22/2019] [Indexed: 02/07/2023]
Abstract
Solid organ transplantation (SOT) has revolutionized treatment of end-stage disease. Improvements in the SOT continuum of care have unmasked a significant burden of cardiovascular disease, manifesting as a leading cause of morbidity and mortality. Although several risk factors for development of post-transplant cardiovascular disease exist, dyslipidemia remains one of the most frequent and modifiable risks. An important contributor to dyslipidemia in SOT recipients is the off-target metabolic effects of immunosuppressive medications, which may alter lipoproteins and their metabolism. Dyslipidemia management is paramount as lipid-lowering therapy with statins has demonstrated reductions in graft vasculopathy, decreased rejection rates, and improved survival. Several nonstatin medication options are available, but data supporting their benefit in the SOT population are minimal, typically extrapolated from studies in the general population. Further compounding dyslipidemia management is the complex interplay of drug interactions between lipid-lowering and immunosuppressant medications, which can result in serious toxicity and/or therapeutic failure.
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Affiliation(s)
- Bruce A Warden
- Center for Preventive Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - P Barton Duell
- Center for Preventive Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA.
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7
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Lenihan CR, Liu S, Deswal A, Montez-Rath ME, Winkelmayer WC. De Novo Heart Failure After Kidney Transplantation: Trends in Incidence and Outcomes. Am J Kidney Dis 2018; 72:223-233. [DOI: 10.1053/j.ajkd.2018.01.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 01/14/2018] [Indexed: 02/08/2023]
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8
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Wissing KM, Abramowicz D, Weekers L, Budde K, Rath T, Witzke O, Broeders N, Kianda M, Kuypers DRJ. Prospective randomized study of conversion from tacrolimus to cyclosporine A to improve glucose metabolism in patients with posttransplant diabetes mellitus after renal transplantation. Am J Transplant 2018; 18:1726-1734. [PMID: 29337426 DOI: 10.1111/ajt.14665] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 12/22/2017] [Accepted: 01/07/2018] [Indexed: 02/06/2023]
Abstract
Tacrolimus (TAC) increases the risk of posttransplant diabetes (PTDM) compared with cyclosporine A (CYC). The present 12-month, multicenter, investigator-driven, prospective, randomized study was designed to assess whether conversion from tacrolimus to CYC can reverse PTDM after renal transplantation. Predominantly white patients with PTDM according to the 2005 American Diabetes Association criteria were randomized to either replacement of TAC with CYC or continuation of their TAC-based regimen after stratification for type of glucose-lowering therapy, steroid therapy, and hepatitis C status. At 12 months, 14 of 41 patients with complete data in the CYC arm (34%; 95%CI 19%-49%) were free of diabetes, whereas this was the case in only 4 of 39 patients (10%; 95%CI 3%-20%) in the TAC arm (P = .01). At 12 months, 39% of patients in the CYC arm were off glucose-lowering medication vs 13% of patients in the TAC arm (P = .01). The CYC group decreased glycated hemoglobin level during the 12-month follow-up, resulting in significantly lower levels compared with the TAC group (6.0 ± 0.9% vs 7.1 ± 1.7% at 12 months; P = .002). In conclusion, replacement of TAC with CYC significantly improves glucose metabolism and has the potential to reverse diabetes during the first year after conversion. (EU Clinical Trials Register No. 2006-001765-42).
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Affiliation(s)
- Karl M Wissing
- Department of Nephrology, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Daniel Abramowicz
- Department of Nephrology, Universitair Ziekenhuis Antwerpen, Antwerpen, Belgium
| | - Laurent Weekers
- Department of Nephrology, Centre Hospitalier Universitaire Liège, Liège, Belgium
| | - Klemens Budde
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Thomas Rath
- Department of Nephrology, Westpfalz Klinikum Kaiserslautern, Kaiserslautern, Germany
| | - Oliver Witzke
- Department of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Nilufer Broeders
- Department of Nephrology, Centre Universitaire de Bruxelles - Hôpital Erasme, Brussels, Belgium
| | - Mireille Kianda
- Department of Nephrology, Centre Hospitalier Universitaire Brugmann, Brussels, Belgium
| | - Dirk R J Kuypers
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
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9
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Al-Lawati H, Aliabadi HM, Makhmalzadeh BS, Lavasanifar A. Nanomedicine for immunosuppressive therapy: achievements in pre-clinical and clinical research. Expert Opin Drug Deliv 2018; 15:397-418. [DOI: 10.1080/17425247.2018.1420053] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Hanan Al-Lawati
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada
| | | | | | - Afsaneh Lavasanifar
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada
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10
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Vincenti F, Blancho G, Durrbach A, Grannas G, Grinyó J, Meier‐Kriesche H, Polinsky M, Yang L, Larsen CP. Ten-year outcomes in a randomized phase II study of kidney transplant recipients administered belatacept 4-weekly or 8-weekly. Am J Transplant 2017; 17:3219-3227. [PMID: 28758341 PMCID: PMC5724691 DOI: 10.1111/ajt.14452] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 06/30/2017] [Accepted: 07/20/2017] [Indexed: 01/25/2023]
Abstract
In the phase II IM103-100 study, kidney transplant recipients were first randomized to belatacept more-intensive-based (n = 74), belatacept less-intensive-based (n = 71), or cyclosporine-based (n = 73) immunosuppression. At 3-6 months posttransplant, belatacept-treated patients were re-randomized to receive belatacept every 4 weeks (4-weekly, n = 62) or every 8 weeks (8-weekly, n = 60). Patients initially randomized to cyclosporine continued to receive cyclosporine-based immunosuppression. Cumulative rates of biopsy-proven acute rejection (BPAR) from first randomization to year 10 were 22.8%, 37.0%, and 25.8% for belatacept more-intensive, belatacept less-intensive, and cyclosporine, respectively (belatacept more-intensive vs cyclosporine: hazard ratio [HR] = 0.95; 95% confidence interval [CI] 0.47-1.92; P = .89; belatacept less-intensive vs cyclosporine: HR = 1.61; 95% CI 0.85-3.05; P = .15). Cumulative BPAR rates from second randomization to year 10 for belatacept 4-weekly, belatacept 8-weekly, and cyclosporine were 11.1%, 21.9%, and 13.9%, respectively (belatacept 4-weekly vs cyclosporine: HR = 1.06, 95% CI 0.35-3.17, P = .92; belatacept 8-weekly vs cyclosporine: HR = 2.00, 95% CI 0.75-5.35, P = .17). Renal function trends were estimated using a repeated-measures model. Estimated mean GFR values at year 10 for belatacept 4-weekly, belatacept 8-weekly, and cyclosporine were 67.0, 68.7, and 42.7 mL/min per 1.73 m2 , respectively (P<.001 for overall treatment effect). Although not statistically significant, rates of BPAR were 2-fold higher in patients administered belatacept every 8 weeks vs every 4 weeks.
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Affiliation(s)
- F. Vincenti
- University of California, San FranciscoSan FranciscoCAUSA
| | - G. Blancho
- University Hospital of NantesNantesFrance
| | - A. Durrbach
- University Hôpital of BicêtreLe Kremlin‐BicêtreFrance
| | - G. Grannas
- Medizinische Hochschule HannoverHannoverGermany
| | - J. Grinyó
- University Hospital of BellvitgeBarcelonaSpain
| | | | | | - L. Yang
- Bristol‐Myers SquibbLawrencevilleNJUSA
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11
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Islam F, Westcott M, Rees A, Robson AG, Kapoor B, Holder G, Pavesio C. Safety profile and efficacy of tacrolimus in the treatment of birdshot retinochoroiditis: a retrospective case series review. Br J Ophthalmol 2017; 102:983-990. [PMID: 29051329 DOI: 10.1136/bjophthalmol-2017-310436] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 09/24/2017] [Accepted: 09/27/2017] [Indexed: 11/04/2022]
Abstract
AIM Evaluation of the use of tacrolimus in the treatment of birdshot retinochoroiditis (BRC) at a tertiary referral centre with the aim to describe its safety and efficacy. METHODS The medical records of 25 patients diagnosed with BRC at uveitis service, Moorfields Eye Hospital, and who had received tacrolimus treatment were retrospectively reviewed. The main outcome measures of the study were (1) safety of tacrolimus in terms of side effects and (2) efficacy, as measured both by control of inflammation and visual function assessed by Humphrey visual fields and electrophysiological testing over at least 6 months and then 1 year. RESULTS Tacrolimus was commenced in 25 patients (mean age 50.4±10.8 years) and was well tolerated in 21 patients (84%). It was necessary to stop the tacrolimus in four patients. No patient showed major changes in renal function: 3/21 patients (14.28%) showed slightly abnormal (less than 30%) function at the end of the first month of treatment; 1/21 (4.76%) patients at 3 months, but at the end of a 6-month treatment period only 1/21 patients (4.76%) showed minor abnormality in renal function. The mean daily prednisolone dose was 19.7 mg at the beginning of the study, which had fallen to 6.9 mg at the end (t=5.071, p=0.001). Visual acuity mostly remained stable. Visual fields improved over time (mean improvement in Humphrey mean deviation, right eye=1.8±2.4 dB, t=3.821, p=0.004; left eye=1.9±2.7, dB, t=3.06, p=0.007). Electrophysiological function showed improvement in 10 patients, and in four patients an initial deterioration in function improved following tacrolimus dose adjustment. CONCLUSION Tacrolimus has a good safety profile for long-term use in patients with BRC as a second-line agent enabling steroid sparing and visual function stabilisation or improvement.
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Affiliation(s)
- Farrah Islam
- Department of Medical Retina, Moorfields Eye Hospital, London, UK.,Vitreoretinal department, Al-ShifaTrust Eye Hospital, Rawalpindi, Pakistan
| | - Mark Westcott
- Department of Medical Retina, Moorfields Eye Hospital, London, UK.,Medical retina, Institute of Ophthalmology, University College London, London, UK
| | - Angela Rees
- Department of Medical Retina, Moorfields Eye Hospital, London, UK
| | - Anthony George Robson
- Department of Medical Retina, Moorfields Eye Hospital, London, UK.,Medical retina, Institute of Ophthalmology, University College London, London, UK
| | - Bharat Kapoor
- Department of Medical Retina, Moorfields Eye Hospital, London, UK
| | - Graham Holder
- Department of Medical Retina, Moorfields Eye Hospital, London, UK.,Medical retina, Institute of Ophthalmology, University College London, London, UK
| | - Carlos Pavesio
- Department of Medical Retina, Moorfields Eye Hospital, London, UK.,Medical retina, Institute of Ophthalmology, University College London, London, UK
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Tutakhel OAZ, Moes AD, Valdez-Flores MA, Kortenoeven MLA, Vrie MVD, Jeleń S, Fenton RA, Zietse R, Hoenderop JGJ, Hoorn EJ, Hilbrands L, Bindels RJM. NaCl cotransporter abundance in urinary vesicles is increased by calcineurin inhibitors and predicts thiazide sensitivity. PLoS One 2017; 12:e0176220. [PMID: 28430812 PMCID: PMC5400280 DOI: 10.1371/journal.pone.0176220] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 04/08/2017] [Indexed: 11/30/2022] Open
Abstract
Animal studies have shown that the calcineurin inhibitors (CNIs) cyclosporine and tacrolimus can activate the thiazide-sensitive NaCl cotransporter (NCC). A common side effect of CNIs is hypertension. Renal salt transporters such as NCC are excreted in urinary extracellular vesicles (uEVs) after internalization into multivesicular bodies. Human studies indicate that CNIs also increase NCC abundance in uEVs, but results are conflicting and no relationship with NCC function has been shown. Therefore, we investigated the effects of CsA and Tac on the abundance of both total NCC (tNCC) and phosphorylated NCC at Thr60 phosphorylation site (pNCC) in uEVs, and assessed whether NCC abundance in uEVs predicts the blood pressure response to thiazide diuretics. Our results show that in kidney transplant recipients treated with cyclosporine (n = 9) or tacrolimus (n = 23), the abundance of both tNCC and pNCC in uEVs is 4–5 fold higher than in CNI-free kidney transplant recipients (n = 13) or healthy volunteers (n = 6). In hypertensive kidney transplant recipients, higher abundances of tNCC and pNCC prior to treatment with thiazides predicted the blood pressure response to thiazides. During thiazide treatment, the abundance of pNCC in uEVs increased in responders (n = 10), but markedly decreased in non-responders (n = 8). Thus, our results show that CNIs increase the abundance of both tNCC and pNCC in uEVs, and these increases correlate with the blood pressure response to thiazides. This implies that assessment of NCC in uEVs could represent an alternate method to guide anti-hypertensive therapy in kidney transplant recipients.
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Affiliation(s)
- Omar A. Z. Tutakhel
- Department of Physiology, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Arthur D. Moes
- Department of Internal Medicine, Nephrology and Transplantation, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Marco A. Valdez-Flores
- Department of Physiology, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
- Programa Regional en Doctorado en Biotecnología, Universidad Autónoma de Sinaloa, Sinaloa, Mexico
| | - Marleen L. A. Kortenoeven
- Department of Biomedicine, Center for Interaction of Proteins in Epithelial Transport, Aarhus University, Aarhus, Denmark
| | - Mathijs v. D. Vrie
- Department of Nephrology, Radboud university medical center, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Sabina Jeleń
- Department of Physiology, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Robert A. Fenton
- Department of Biomedicine, Center for Interaction of Proteins in Epithelial Transport, Aarhus University, Aarhus, Denmark
| | - Robert Zietse
- Department of Internal Medicine, Nephrology and Transplantation, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Joost G. J. Hoenderop
- Department of Physiology, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Ewout J. Hoorn
- Department of Internal Medicine, Nephrology and Transplantation, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Luuk Hilbrands
- Department of Nephrology, Radboud university medical center, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - René J. M. Bindels
- Department of Physiology, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
- * E-mail:
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Han E, Kim MS, Kim YS, Kang ES. Risk assessment and management of post-transplant diabetes mellitus. Metabolism 2016; 65:1559-69. [PMID: 27621191 DOI: 10.1016/j.metabol.2016.07.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 07/13/2016] [Accepted: 07/21/2016] [Indexed: 02/06/2023]
Abstract
The success rate of organ transplantation has been increasing with advances in surgical and pharmacological techniques. However, the number of solid organ transplant recipients who require metabolic disease management is also growing. Post-transplant diabetes mellitus (PTDM) is a common complication after solid organ transplantation and is associated with risks of graft loss, cardiovascular morbidity, and mortality. Other risk factors for PTDM include older age, genetic background, obesity, hepatitis C virus infection, hypomagnesemia, and use of immunosuppressant agents (corticosteroids, calcineurin inhibitors, and mammalian target of rapamycin inhibitor). Management of PTDM should be started before the transplantation plan to properly screen high-risk patients. Even though PTDM management is similar to that of general type 2 diabetes, therapeutic approaches must be made with consideration of drug interactions between immunosuppressive agents, glucose-lowering medications, and graft rejection and function.
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Affiliation(s)
- Eugene Han
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea; Severance Hospital Diabetes Center
| | - Myoung Soo Kim
- Department of Transplantation Surgery, Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea
| | - Yu Seun Kim
- Department of Transplantation Surgery, Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea
| | - Eun Seok Kang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea; Severance Hospital Diabetes Center; Institute of Endocrine Research, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Yu H, Kim H, Baek C, Shin E, Cho H, Han D, Park S. Risk Factors for Hypertension After Living Donor Kidney Transplantation in Korea: A Multivariate Analysis. Transplant Proc 2016; 48:88-91. [DOI: 10.1016/j.transproceed.2015.12.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Revised: 11/26/2015] [Accepted: 12/22/2015] [Indexed: 12/31/2022]
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Houri I, Tzukert K, Levi IMY, Aharon M, Bloch A, Gotsman O, Backenroth R, Levi R, Dov IB, Rubinger D, Elhalel MD. Implementation of guidelines for metabolic syndrome control in kidney transplant recipients: results at a single center. Diabetol Metab Syndr 2015; 7:90. [PMID: 26478748 PMCID: PMC4609158 DOI: 10.1186/s13098-015-0083-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 10/01/2015] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Cardiovascular disease is a leading cause of death among kidney transplant recipients. Metabolic syndrome increases the risk for cardiovascular events and decreases graft survival. Lately, guidelines for management of the metabolic syndrome, primarily hypertension, diabetes mellitus (DM) and hypercholesterolemia have dramatically changed in an attempt to decrease cardiovascular risks among kidney transplant recipients. In the present study we examined whether these guideline changes had impact on our management of post-transplantation patients and the subsequent treatment outcomes for these diseases. METHODS Data were obtained from kidney transplant clinic files from two follow-up (FU) periods-between 1994-1997 and between 2008-2011. Demographic data, monitoring and screening frequency for cardiovascular risk factors, immunosuppression regimen, treatment for hypertension, diabetes and hyperlipidemia, treatment outcomes and graft function changes were compared between the two follow-up periods. RESULTS There was a significant increase in the percentage of patients undergoing transplantation due to renal failure secondary to diabetes and/or hypertension. Patient monitoring and screening during the second FU period were less frequent, but more targeted, reflecting changes in clinic routines. Blood pressure was better controlled in the second FU period (p < 0.01), as was hypercholesterolemia (p < 0.001). High fasting glucose levels were more prevalent among patients in the second group (p < 0.005), although more patients received treatment for DM (p < 0.001). Significantly, fewer patients experienced deterioration of kidney functions during the second FU period (p < 0.001). CONCLUSIONS We found that guideline changes had impact on clinical practice, which translated to better control of the metabolic syndrome. DM control is challenging. Overall, stability of kidney function improved.
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Affiliation(s)
- Inbal Houri
- Nephrology and Hypertension Services, Hadassah-Hebrew University Medical Center, 91120 Jerusalem, Israel
| | - Keren Tzukert
- Nephrology and Hypertension Services, Hadassah-Hebrew University Medical Center, 91120 Jerusalem, Israel
| | - Irit Mor-Yosef Levi
- Nephrology and Hypertension Services, Hadassah-Hebrew University Medical Center, 91120 Jerusalem, Israel
| | - Michal Aharon
- Nephrology and Hypertension Services, Hadassah-Hebrew University Medical Center, 91120 Jerusalem, Israel
| | - Aharon Bloch
- Nephrology and Hypertension Services, Hadassah-Hebrew University Medical Center, 91120 Jerusalem, Israel
| | - Olga Gotsman
- Nephrology and Hypertension Services, Hadassah-Hebrew University Medical Center, 91120 Jerusalem, Israel
| | - Rebecca Backenroth
- Nephrology and Hypertension Services, Hadassah-Hebrew University Medical Center, 91120 Jerusalem, Israel
| | - Ronen Levi
- Nephrology and Hypertension Services, Hadassah-Hebrew University Medical Center, 91120 Jerusalem, Israel
| | - Iddo Ben Dov
- Nephrology and Hypertension Services, Hadassah-Hebrew University Medical Center, 91120 Jerusalem, Israel
| | - Dvora Rubinger
- Nephrology and Hypertension Services, Hadassah-Hebrew University Medical Center, 91120 Jerusalem, Israel
| | - Michal Dranitzki Elhalel
- Nephrology and Hypertension Services, Hadassah-Hebrew University Medical Center, 91120 Jerusalem, Israel
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Klawitter J, Klawitter J, Schmitz V, Shokati T, Epshtein E, Thurman JM, Christians U. Mycophenolate mofetil enhances the negative effects of sirolimus and tacrolimus on rat kidney cell metabolism. PLoS One 2014; 9:e86202. [PMID: 24497939 PMCID: PMC3907404 DOI: 10.1371/journal.pone.0086202] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Accepted: 12/08/2013] [Indexed: 12/12/2022] Open
Abstract
Background and Purpose Mycophenolate mofetil (MMF) per se is not known to have negative effects on the kidney. MMF alone or in combination with sirolimus, can be the basis of calcineurin inhibitor (CNI)-free, kidney sparing drug protocols. However, long-term outcomes in patients on MMF/SRL seem to be inferior to those treated with regimens that include the CNI tacrolimus (TAC) due to an increased risk of allo-immune reactions. Interestingly, potential enhancement of the negative effects of SRL and TAC on the kidney by MMF has never been considered. Experimental Approach It was our aim to study the effects of TAC, SRL and MMF alone and evaluate their interactions when combined on the rat kidney. For this purpose we used a comprehensive molecular marker approach including measurements of urinary 8-isoprostane concentrations (oxidative stress marker) and changes of urinary metabolite patterns (1H-NMR spectroscopy) and comparing these markers to renal function (glomerular filtration rate (GFR)) and morphologic alterations (histology). Key Results While MMF alone did not impact GFR, its interaction with SRL and TAC led to a significant decrease of rats’ renal function. The decline went in parallel with a significant increase in urinary isoprostane concentrations and an enhancement of negative effects on urinary metabolite patterns. Conclusions In broad summary, the present study showed that MMF may enhance the negative effects of TAC on kidney function and may even display nephrotoxic properties when combined with SRL.
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Affiliation(s)
- Jelena Klawitter
- Department of Anesthesiology, University of Colorado, Aurora, Colorado, United States of America
- Division of Renal Diseases and Hypertension, University of Colorado, Aurora, Colorado, United States of America
- * E-mail:
| | - Jost Klawitter
- Department of Anesthesiology, University of Colorado, Aurora, Colorado, United States of America
| | - Volker Schmitz
- Department of Anesthesiology, University of Colorado, Aurora, Colorado, United States of America
- Department of General-, Visceral- and Transplantation Surgery, Charité, Campus Virchow, Berlin, Germany
| | - Touraj Shokati
- Department of Anesthesiology, University of Colorado, Aurora, Colorado, United States of America
| | - Ekaterina Epshtein
- Department of Anesthesiology, University of Colorado, Aurora, Colorado, United States of America
| | - Joshua M. Thurman
- Division of Renal Diseases and Hypertension, University of Colorado, Aurora, Colorado, United States of America
| | - Uwe Christians
- Department of Anesthesiology, University of Colorado, Aurora, Colorado, United States of America
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Affiliation(s)
- Yujung Yun
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Severance Hospital Diabetes Center, Seoul, Korea
- Institute of Endocrine Research, Yonsei University College of Medicine, Seoul, Korea
| | - Eun Seok Kang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Severance Hospital Diabetes Center, Seoul, Korea
- Institute of Endocrine Research, Yonsei University College of Medicine, Seoul, Korea
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Wissing KM, Pipeleers L. Obesity, metabolic syndrome and diabetes mellitus after renal transplantation: prevention and treatment. Transplant Rev (Orlando) 2013; 28:37-46. [PMID: 24507957 DOI: 10.1016/j.trre.2013.12.004] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Accepted: 12/18/2013] [Indexed: 02/06/2023]
Abstract
The prevalence of the metabolic syndrome in dialysis patients is high and further increases after transplantation due to weight gain and the detrimental metabolic effects of immunosuppressive drugs. Corticosteroids cause insulin resistance, hyperlipidemia, abnormal glucose metabolism and arterial hypertension. The calcineurin inhibitor tacrolimus is diabetogenic by inhibiting insulin secretion, whereas cyclosporine causes hypertension and increases cholesterol levels. Mtor antagonists are responsible for hyperlipidemia and abnormal glucose metabolism by mechanisms that also implicate insulin resistance. The metabolic syndrome in transplant recipients has numerous detrimental effects such as increasing the risk of new onset diabetes, cardiovascular disease events and patient death. In addition, it has also been linked with accelerated loss of graft function, proteinuria and ultimately graft loss. Prevention and management of the metabolic syndrome are based on increasing physical activity, promotion of weight loss and control of cardiovascular risk factors. Bariatric surgery before or after renal transplantation in patients with body mass index >35 kg/m(2) is an option but its long term effects on graft and patient survival have not been investigated. Steroid withdrawal and replacement of tacrolimus with cyclosporine facilitate control of diabetes, whereas replacement of cyclosporine and mtor antagonists can improve hyperlipidemia. The new costimulation inhibitor belatacept has potent immunosuppressive properties without metabolic adverse effects and will be an important component of immunosuppressive regimens with better metabolic risk profile. Medical treatment of cardiovascular risk factors has to take potential drug interactions with immunosuppressive medication and drug accumulation due to renal insufficiency into account.
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Affiliation(s)
- Karl Martin Wissing
- Nephrology Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium; Nephrology and Dialysis Clinic, Centre Hospitalier Universitaire Brugmann, Brussels, Belgium.
| | - Lissa Pipeleers
- Nephrology Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
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Ciftci HS, Ayna TK, Calıskan YK, Turkmen A, Gurtekin M. Lipid parameters, doses and blood levels of calcineurin inhibitors in renal transplant patients. Indian J Clin Biochem 2013; 28:164-8. [PMID: 24426203 PMCID: PMC3613508 DOI: 10.1007/s12291-012-0251-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Accepted: 08/13/2012] [Indexed: 11/26/2022]
Abstract
The calcineurin inhibitors (CNIs) [cyclosporin A (CsA) and tacrolimus (Tac)] are currently the most widely prescribed drugs for maintenance of immunosuppression after renal transplantation. These immunosuppressants are associated with side effects such as hyperlipidemia. We evaluated the differential effects of different CNIs on serum lipid parameters in renal transplant patients. Moreover, the aim of this study is to investigate the relationships between doses and blood levels of CNIs, and blood levels of CNIs and lipid parameters retrospectively. Two groups of 98 non-diabetic renal transplant patients, each treated with different CNIs, were studied: group A (n = 50, mean age: 31 ± 10 years), CsA, mycophenolate mofetil/azathioprin, steroid; group B (I = 48, mean age: 34 ± 12 years), Tac, mycophenolate mofetil/azathioprin, steroid. In renal transplant patients, CNIs blood levels and doses were examined at 1, 3, 6, 9, and 12 months after transplantation. Biochemical laboratory parameters including plasma lipids [total-cholesterol (CHOL), low-density lipoprotein (LDL)-CHOL, high-density lipoprotein (HDL)-CHOL, and triglycerides (TG)], CNI levels and doses were examined at 1, 3, 6, 9, and 12 months after transplantation. None of the patients received anti-lipidemic drugs during the study period. Blood levels of CNIs were detectable in all whole-blood samples by Cloned- Enzyme-Donor Immunoassay (CEDIA). The relationship between CNIs blood levels and CHOL, (LDL)-CHOL, HDL-CHOL, TG were evaluated. The mean serum CHOL levels and LDL-CHOL levels of patients in group A were found significantly higher than the patients in group B during the 12 month of follow up (p < 0.05). There was no significant difference in TG and HDL-CHOL plasma levels between group A and group B (p > 0.005). In group A the daily dose of CsA was significantly correlated with the mean blood levels of CsA at the 1st and 3rd months (r = 0.387, p = 0.005; r = 0.386, p = 0.006), respectively. In group A, the daily dose of CsA was significantly correlated with the mean serum TG levels during the 12 month of follow up (r = 0.420, p = 0.003). In group B, the daily dose of Tac was significantly correlated with the mean blood level of Tac (r = 0.335, p = 0.020) at the 1st month. No correlation was found between mean Tac blood levels and lipid parameters during the 12-month of follow up (p > 0.05). Significant positive correlation was observed between the CsA blood levels and LDL-CHOL levels (r = 0.338, p = 0.027) at the 3rd month. In the renal transplant patients with well functioning grafts, CsA therapy is associated with increased CHOL and LDL-CHOL ratio which represents an increased atherogenic risk tended to be associated with CsA. Serum LDL-CHOL levels may be effected by blood CsA levels.
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Affiliation(s)
- Hayriye Senturk Ciftci
- />Medical Biology Department, Istanbul Medicine Faculty, Istanbul University, Capa, Fatih, Istanbul, Turkey
| | - Tulay Kilicaslan Ayna
- />Medical Biology Department, Medicine Faculty, Katip Celebi University, Cigli, Izmir, Turkey
| | - Yasar Kerem Calıskan
- />Nephrology Department, Istanbul Medicine Faculty, Istanbul University, Capa, Fatih, Istanbul, Turkey
| | - Aydin Turkmen
- />Nephrology Department, Istanbul Medicine Faculty, Istanbul University, Capa, Fatih, Istanbul, Turkey
| | - Mehmet Gurtekin
- />Medical Biology Department, Istanbul Medicine Faculty, Istanbul University, Capa, Fatih, Istanbul, Turkey
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Lima BR, Nussenblatt RB, Sen HN. Pharmacogenetics of drugs used in the treatment of ocular inflammatory diseases. Expert Opin Drug Metab Toxicol 2013; 9:875-82. [PMID: 23521173 DOI: 10.1517/17425255.2013.783818] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Ocular inflammatory diseases comprise uveitis, scleritis, and inflammation of adjacent structures of the eye. Therapy may be challenging and often involves corticosteroids and immunomodulatory agents. AREAS COVERED This review describes the genes involved in noninfectious ocular inflammatory diseases and focuses on pharmacogenetic studies regarding different classes of anti-inflammatory drugs used in the management of uveitis, including corticosteroids, antimetabolites, calcineurin inhibitors, alkylating agents, and biological agents. EXPERT OPINION Pharmacogenetics holds the promise of a personalized medicine with potential to customize treatment that can achieve the best clinical response and avoid toxicity. Several polymorphisms in various genes involved in the metabolism of drugs commonly utilized in the treatment of ocular inflammatory diseases have been described. Most promising is the polymorphism in thiopurinemethyltransferase gene for which a genotype analysis can reveal slow metabolizers of azathioprine and help avoid serious drug toxicity. Although pharmacogenetic studies with specific focus on ocular inflammatory diseases are lacking, knowledge from studies in rheumatologic diseases and transplant medicine can provide a platform for future research. Prospective clinical studies are needed to determine the clinical significance of such polymorphisms and their true effect on drug metabolism and side effects.
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Affiliation(s)
- Breno R Lima
- National Eye Institute, National Institutes of Health, Laboratory of Immunology, Bethesda, MD 20892, USA
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Heo J, Sepah YJ, Yohannan J, Renner M, Akhtar A, Gregory A, Shulman M, Do DV, Nguyen QD. The role of biologic agents in the management of non-infectious uveitis. Expert Opin Biol Ther 2012; 12:995-1008. [PMID: 22780091 DOI: 10.1517/14712598.2012.688021] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Uveitis is an intriguing group of disorders characterized by inflammation of the uveal tract. Due to the potential grave consequences of the disease process, it is important to assess the various therapeutic options available for treating uveitis, and their outcomes. AREAS COVERED This review discusses the use of conventional agents in the management of uveitis, including discussion of the molecular and clinical properties of corticosteroids, antimetabolites, calcineurin inhibitors and alkylating agents and their side effects. In addition, it also discusses the molecular and clinical properties of novel biologic agents and their side effects. Moreover, recommendations as to when biologic agents should be employed are also discussed. EXPERT OPINION We recommend that in general (except in selected cases of Adamantiades-Behçet's disease) biologics should not be used as a first-line therapy for uveitis due to inconvenience, high cost, and potential immunosuppressive effects. However, many biologics are potent in inducing drug-free remission of uveitis and may be employed to manage recurrent diseases or diseases not responsive to conventional agents.
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Affiliation(s)
- Jangwon Heo
- Johns Hopkins University School of Medicine, Wilmer Eye Institute, Johns Hopkins Hospital, Retinal Imaging Research and Reading Center, 600 North Wolfe Street, Maumenee 745, Baltimore, MD 21287, USA
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A randomized trial of tacrolimus versus tacrolimus and prednisone for the maintenance of disease remission in noninfectious uveitis. Ophthalmology 2012; 119:1223-30. [PMID: 22381809 DOI: 10.1016/j.ophtha.2011.12.030] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2011] [Revised: 12/17/2011] [Accepted: 12/19/2011] [Indexed: 11/24/2022] Open
Abstract
PURPOSE To compare tacrolimus monotherapy with tacrolimus and prednisone therapy for the maintenance of disease remission in subjects with noninfectious posterior segment intraocular inflammation (PSII). DESIGN Randomized, controlled, phase 2b, open-label, dual-center noninferiority trial. PARTICIPANTS Fifty-eight patients with sight-threatening PSII. METHODS Patients requiring a second-line systemic immunosuppressive agent to control their PSII were treated with therapeutic doses of oral tacrolimus. Those subjects who subsequently were able to taper their prednisone dose to 10 mg daily without disease reactivation were assigned randomly either to stop prednisone or to continue 7.5 to 10 mg prednisone daily for 9 months. MAIN OUTCOME MEASURES Change in logarithm of the minimum angle of resolution (logMAR) visual acuity (VA) and rate of patient withdrawal resulting from treatment inefficacy or intolerance. RESULTS Thirty-five patients successfully tapered their prednisone to 10 mg daily. Of these, 16 were allocated randomly to receive tacrolimus monotherapy and 19 to continue taking prednisone and tacrolimus dual therapy. The difference in the mean change in VA for monotherapy compared with the dual therapy group was less than 1 logMAR letter (logMAR, -0.008; 95% confidence interval, -0.108 to 0.092; P = 0.870). The proportion of patients who tolerated treatment and maintained disease remission for 9 months after randomization also was similar in both groups (monotherapy, 62.5%; dual therapy, 68.4%; P = 0.694). All monotherapy treatment failures were the result of disease reactivation, whereas 50% of dual-therapy failures were the result of drug intolerance. CONCLUSIONS This study provides preliminary evidence that corticosteroids can be withdrawn in tacrolimus-treated patients who are able to achieve control of PSII with 10 mg prednisone daily, and any advantage of dual therapy in the prevention of disease reactivation was offset by its greater treatment intolerance. These findings support the further evaluation of corticosteroid-free treatment in future phase 3 trials (International Standard Randomised Controlled Trial Number Register identification, ISRCTN46576063). FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found after the references.
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Rostaing L, Sánchez-Fructuoso A, Franco A, Glyda M, Kuypers DR, Jaray J. Conversion to tacrolimus once-daily from ciclosporin in stable kidney transplant recipients: a multicenter study. Transpl Int 2011; 25:391-400. [DOI: 10.1111/j.1432-2277.2011.01409.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Yuan J, Zhai JJ, Huang X, Zhou SY, Chen JQ. Ocular safety and pharmacokinetics study of FK506 suspension eye drops after corneal transplantation. J Ocul Pharmacol Ther 2011; 28:153-8. [PMID: 22136074 DOI: 10.1089/jop.2011.0108] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE The aim of this study was to investigate the sensitization, pharmacokinetics, and absorption of FK506 after corneal transplantation. METHODS New Zealand albino rabbits were divided into normal and corneal transplantation groups. Each group was divided into 5 subgroups--saline, blank matrix, high-dose, medium-dose, and low-dose, respectively. There were 10 rabbits in each subgroup. One drop (25 μL) of FK506 was administered topically to both eyes of the rabbits 4 times daily for 30 days. Thirty days later, 5 rabbits of each subgroup were sacrificed after the administration of the last dose. Both eyes were enucleated; the left eye was used for pathologic examination and the right eye for the determination of FK506 distribution. The other 5 rabbits in each subgroup were sacrificed 14 days after the former 5 rabbits were sacrificed, and their eyes were enucleated for pathologic examination and tissue distribution determination as the former 5 rabbits in each subgroup (the second batch). RESULTS Fluorescein staining and local ocular reaction provided evidence that there were no significant differences between control and FK506-instilled eyes in the rabbit model at any of the tested doses. Histologic examination revealed no ocular abnormality in the rabbits instilled with any doses of FK506 eyedrop. The peak serum concentration (C(max)) of systemic absorption ranged from 4.31±0.79 ng/mL to 14.89±6.85 ng/mL. CONCLUSION Our study suggests that up to 0.1% FK506 administered 4 times a day (q.i.d.) topically is safe for the rabbit eye. However, further safety studies are required in view of systemic adverse effects.
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Affiliation(s)
- Jin Yuan
- Zhongshan Ophthalmic Center at Sun Yat-sen University, The State Key Laboratory of Ophthalmology, Guangzhou, China
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Hwang H, Ghee JY, Song JH, Piao S, Yang CW. Comparison of adverse drug reaction profiles of two tacrolimus formulations in rats. Immunopharmacol Immunotoxicol 2011; 34:434-42. [PMID: 21970589 DOI: 10.3109/08923973.2011.618135] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Tacrobell(®) (TB) is a generic tacrolimus which showed the comparable efficacy to original product, Prograf(®) (PG) in renal transplantation, but toxicity between two drugs is unclear. The aim of this study was to compare the toxicity between these two formulations. TB and PG (0.5, 1 and 2 mg/kg/day) was administered to rats for 4 weeks. The rat survival rate, kidney, liver and pancreas injury was investigated. The survival rate was similar between TB- and PG-treated rats. TB and PG induced renal dysfunction in a dose-dependent manner. Compared to PG treatment in equal dose, TB treatment reduced urinary creatinine clearance in a less degree and renal interstitial fibrosis was comparable between two regimens. The r-glutamyl transpeptidase was aggravated by tacrolimus treatment, and this was not different between TB and PG treatment. In the intraperitoneal glucose tolerance test, a significant diabetogenic effect was observed in all tacrolimus treated-rats. The glucose tolerance of TB-treated rats was similar to those of PG-treated rats in each dose. The decrement in pancreatic β-cell mass by tacrolimus showed the dose-dependent response and it was comparable between TB and PG treatment. In conclusion, TB is similar to PG in terms of nephrotoxicity, hepatoxicity and diabetogenic effect.
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Affiliation(s)
- HyeonSeok Hwang
- Division of Nephrology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Management of hypertension in the transplant patient. ACTA ACUST UNITED AC 2011; 5:425-32. [DOI: 10.1016/j.jash.2011.07.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2011] [Indexed: 11/19/2022]
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Claes K, Meier-Kriesche HU, Schold JD, Vanrenterghem Y, Halloran PF, Ekberg H. Effect of different immunosuppressive regimens on the evolution of distinct metabolic parameters: evidence from the Symphony study. Nephrol Dial Transplant 2011; 27:850-7. [PMID: 21617197 DOI: 10.1093/ndt/gfr238] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The metabolic syndrome (MS) is an important risk factor for graft dysfunction and patient death after renal transplantation. The aim of this sub-analysis of the Symphony study was to assess the progression of the laboratory parameters associated with MS in the first year after transplantation. METHODS Data collected from the Symphony study were used; 1645 patients were randomized to receive standard-dose cyclosporine (Stand-CsA), low-dose cyclosporine (Low-CsA), tacrolimus (Low-Tac) or sirolimus (Low-SRL), in addition to mycophenolate mofetil (MMF) and corticosteroids. Data were collected for levels and progression over the first year post-transplantation of systolic and diastolic blood pressure, uric acid, triglycerides, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol and fasting glucose levels by treatment arm. RESULTS The low-SRL group had significantly higher levels of triglycerides and LDL. The two CsA arms were associated with the highest uric acid levels at each time point. There were no significant differences in overall levels or changes in glucose or HDL. Patients in the standard-CsA arm had significantly higher diastolic blood pressure than those in the Low-SRL and Low-Tac arms. Systolic blood pressure was higher in the Low-CsA arm than in the Low-Tac arm. The use of antihypertensive and antidiabetic agents was similar between the treatment arms. In the Low-SRL arm, more patients were treated with lipid-lowering therapy. Mean daily steroid doses were the highest in the Low-SRL arm. CONCLUSIONS This sub-analysis demonstrates that there is a difference in metabolic parameters between immunosuppressive groups. CsA therapy was associated with the highest values of uric acid and systolic and diastolic blood pressure. Patients on SRL therapy had the worst lipaemic control. A possible effect of Tac on new-onset diabetes could not be excluded.
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Affiliation(s)
- Kathleen Claes
- Department of Nephrology and Renal Transplantation, University Hospital Gasthuisberg, Leuven, Belgium
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Rubin MF. Hypertension following kidney transplantation. Adv Chronic Kidney Dis 2011; 18:17-22. [PMID: 21224026 DOI: 10.1053/j.ackd.2010.10.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2010] [Revised: 10/11/2010] [Accepted: 10/19/2010] [Indexed: 12/31/2022]
Abstract
The majority of patients become hypertensive following kidney transplantation. Its occurrence is associated not only with increased fatal and nonfatal cardiovascular events but also with decreased allograft survival. This review summarizes the current knowledge of the epidemiology, etiology, pathophysiology, and management of post-transplant hypertension.
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Differential effects of acute and sustained cyclosporine and tacrolimus on sympathetic nerve activity. J Hypertens 2010; 28:1928-34. [PMID: 20577127 DOI: 10.1097/hjh.0b013e32833c20eb] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND We studied the effect of acute and sustained cyclosporine and tacrolimus on muscle sympathetic nerve activity (MSNA) in groups of healthy male volunteers. METHODS AND RESULTS Acute cyclosporine in normal dose (2.5 mg/kg) increased MSNA from 11 +/- 6 to 19 +/- 8 bursts/min (P < 0.05). Acute cyclosporine in high dose (10 mg/kg) increased MSNA from 13 +/- 6 to 25 +/- 4 bursts/min (P < 0.05) and increased heart rate and mean arterial pressure (heart rate from 64 +/- 8 to 74 +/- 6 b.p.m., MAP from 92 +/- 10 to 105 +/- 8 mmHg; both P < 0.05). Sustained cyclosporine (2.5 mg/kg b.i.d. for 2 weeks) suppressed MSNA from 14 +/- 6 to 8 +/- 7 bursts/min (P < 0.05). Blood pressure increased from 89 +/- 6 to 98 +/- 6 mmHg (P < 0.05). Body weight increased and plasma renin activity was suppressed. Acute tacrolimus in regular dose (0.05 mg/kg) and high dose (0.20 mg/kg) had no effect on MSNA and blood pressure. Sustained tacrolimus (0.05 mg/kg b.i.d. for 2 weeks) had no effect on blood pressure, body weight and plasma renin activity, but decreased MSNA from 14 +/- 6 to 8 +/- 5 bursts/min (P < 0.05). CONCLUSION Sympathetic overactivity plays a role in the acute hypertensive action of cyclosporine. Cyclosporine given during 2 weeks increases blood pressure and suppresses MSNA, possibly by volume retention. Tacrolimus, in the presently applied dosages, does not cause hypertension or sympathetic overactivity. However, sustained tacrolimus also suppresses sympathetic activity, the reason of which is unclear.
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Jeong JC, Ro H, Hwang YH, Lee HK, Ha J, Ahn C, Yang J. Cardiovascular diseases after kidney transplantation in Korea. J Korean Med Sci 2010; 25:1589-94. [PMID: 21060747 PMCID: PMC2966995 DOI: 10.3346/jkms.2010.25.11.1589] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2010] [Accepted: 05/24/2010] [Indexed: 12/31/2022] Open
Abstract
Cardiovascular disease (CVD) is the leading cause of death in renal allograft recipients with functioning graft. Our study aimed to determine the incidence and the risk factors of cardiovascular disease after renal transplantation in Korea. We retrospectively analyzed 430 adult recipients who underwent kidney transplantation between January 1997 and February 2007. CVD was defined as a composite outcome of ischemic heart disease, cerebrovascular accident and peripheral vascular disease. Mean age of recipients was 40.0±11.8 yr. Mean duration of follow-up was 72±39 months. The cumulative incidence of CVD after renal transplantation was 2.4% at 5 yr, 5.4% at 10 yr and 11.4% at 12 yr. Multivariate analysis revealed that recipient's age, diabetes mellitus and duration of dialysis before transplantation were associated with post-transplant CVD (hazard ratio 1.843 [95% CI, 1.005-3.381], 3.846 [95% CI, 1.025-14.432] and 3.394 [95% CI, 1.728-6.665] respectively). In conclusion, old age, duration of dialysis and diabetes mellitus are important risk factors for post-transplant CVD, although the incidence of post-renal transplant CVD is lower in Korea than that in western countries.
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Affiliation(s)
- Jong Cheol Jeong
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Han Ro
- Transplantation Research Institute, Seoul National University, Seoul, Korea
| | - Young-Hwan Hwang
- Department of Internal Medicine, Eulji General Hospital, Eulji University College of Medicine, Seoul, Korea
| | - Han Kyu Lee
- Transplantation Center, Seoul National University Hospital, Seoul, Korea
| | - Jongwon Ha
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Curie Ahn
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Transplantation Research Institute, Seoul National University, Seoul, Korea
- Transplantation Center, Seoul National University Hospital, Seoul, Korea
| | - Jaeseok Yang
- Transplantation Research Institute, Seoul National University, Seoul, Korea
- Transplantation Center, Seoul National University Hospital, Seoul, Korea
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Metabonomic Analysis of Serum Metabolites in Kidney Transplant Recipients With Cyclosporine A- or Tacrolimus-Based Immunosuppression. Transplantation 2010; 90:748-56. [DOI: 10.1097/tp.0b013e3181edd69a] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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35
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Hypertension in the kidney transplant recipient. Transplant Rev (Orlando) 2010; 24:105-20. [DOI: 10.1016/j.trre.2010.02.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2010] [Accepted: 02/02/2010] [Indexed: 12/31/2022]
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36
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Choquette M, Goebel JW, Campbell KM. Nonimmune complications after transplantation. Pediatr Clin North Am 2010; 57:505-21, table of contents. [PMID: 20371049 DOI: 10.1016/j.pcl.2010.01.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
As posttransplant longevity has increased, nonimmune complications related to the transplant and posttransplant course have emerged as important factors in defining long-term outcomes. The incidence of, and risk factors for these complications may vary by transplanted organ based on immunosuppressive protocols and preexisting risk factors. This article discusses the relevant nonimmune complications associated with posttransplant care, with a focus on risk factors and management strategies.
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Affiliation(s)
- Monique Choquette
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Research Foundation, Cincinnati, OH 45229, USA
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37
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Lee YJ, Kim B, Lee JE, Kim YG, Kim DJ, Kim SJ, Joh JW, Oh HY, Huh W. Randomized trial of cyclosporine and tacrolimus therapy with steroid withdrawal in living-donor renal transplantation: 5-year follow-up. Transpl Int 2010; 23:147-54. [DOI: 10.1111/j.1432-2277.2009.00955.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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38
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Calcineurin inhibitor sparing with mycophenolate in kidney transplantation: a systematic review and meta-analysis. Transplantation 2009; 87:591-605. [PMID: 19307799 DOI: 10.1097/tp.0b013e318195a421] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Limiting the exposure of kidney transplant recipients to calcineurin inhibitors (CNIs) has potential merit, but there is no clear consensus on the utility of current strategies. In an attempt to aid clarification, we conducted a systematic review and meta-analysis of randomized trials that assessed CNI sparing (minimization or elimination) with mycophenolate as sole adjunctive immunosuppression. METHODS The search strategy identified trials where CNI sparing was accompanied by the continuation of, or conversion to, mycophenolate and compared with standard or higher dose CNI therapy. Two investigators independently examined each trial for eligibility, quality, and outcome measures. Additional subgroup analyses were assessed: (1) de novo CNI sparing; (2) elective CNI sparing beyond 2 months posttransplantation; and (3) CNI sparing for transplant dysfunction. RESULTS Nineteen randomized controlled trials met the inclusion criteria permitting analysis of 3312 renal transplant recipients with median follow-up of 12 months. CNI sparing significantly improved glomerular filtration rate (weighted mean difference 4.4 mL/min, 95% confidence interval [CI] 2.9-5.9, P<0.001); with some evidence, albeit weak, of improved graft survival (odds ratio 0.72, 95% CI 0.52-1.01, P=0.06). Acute rejection rates were only increased after elective CNI elimination (odds ratio 2.23, 95% CI 1.57-3.17, P<0.001). There were no significant differences in mortality, malignancy or incidence of infections. CONCLUSIONS CNI sparing strategies with adjunctive mycophenolate may play an important role in kidney transplant recipients. Improvements in short-term graft function, and possibly graft survival, are achievable. Longer term studies are needed to substantiate the short-term benefits, and refining elective CNI elimination protocols may help to reduce the risk of rejection.
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Civilibal M, Caliskan S, Kurugoglu S, Candan C, Canpolat N, Sever L, Kasapcopur O, Arisoy N. Progression of coronary calcification in pediatric chronic kidney disease stage 5. Pediatr Nephrol 2009; 24:555-63. [PMID: 18982357 DOI: 10.1007/s00467-008-1038-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2008] [Revised: 09/30/2008] [Accepted: 10/06/2008] [Indexed: 02/06/2023]
Abstract
Coronary artery calcification (CAC) is common in adults with chronic kidney disease (CKD) and progresses with time. However, data are limited for younger patients. We have previously reported CAC in eight of 53 children with CKD. After 2 years, CAC evaluation was repeated in 48 patients. The median CAC score (CACS) increased from 101.3 (1473.6 +/- 1978.6, range 8.5-4332) to 1759.2 (2236.4 +/- 2463.3, range 0-5858) Agatston units (AU). When the individual changes in CACS were evaluated one by one, we showed a mild decrease in two patients on hemodialysis (HD) and in one transplant (Tx) recipient, a moderate increase in one patient on HD, one on peritoneal dialysis (PD) and one Tx recipient, and a large increase in one HD patient. Also, CAC disappeared in one HD patient. All patients with no calcification at baseline remained calcification-free at follow-up. To obtain the individual cumulative exposure, we calculated time-averaged mean values, using the laboratory values from the beginning of dialysis to the first and second multidetector spiral computed tomography (MDCT) scans (baseline and final values, respectively). Final CACS was positively related to final calcium-phosphorus (CaxP) product, while CAC progression was inversely associated with final serum albumin level. This report is the first study with the largest number and the youngest cohort to document the natural history of coronary calcification.
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Affiliation(s)
- Mahmut Civilibal
- Department of Pediatric Nephrology, Istanbul University Cerrahpasa Medical Faculty, Istanbul, Turkey.
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40
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Zadrazil J, Horak P, Zahalkova J, Strebl P, Horcicka V, Krejci K, Bachleda P, Dedochova J, Valkovsky I. IMPROVEMENT OF CARDIOVASCULAR RISK FACTORS AND COSMETIC SIDE EFFECTS IN KIDNEY TRANSPLANT RECIPIENTS AFTER CONVERSION TO TACROLIMUS. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2009; 153:67-73. [DOI: 10.5507/bp.2009.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Luan FL, Zhang H, Schaubel DE, Miles CD, Cibrik D, Norman S, Ojo AO. Comparative risk of impaired glucose metabolism associated with cyclosporine versus tacrolimus in the late posttransplant period. Am J Transplant 2008; 8:1871-7. [PMID: 18786231 DOI: 10.1111/j.1600-6143.2008.02328.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
New onset diabetes after transplantation (NODAT) and impaired fasting glucose (IFG) are common in kidney transplant recipients (KTRs). Calcinuerin inhibitor (CNI) therapy is a causal risk factor. NODAT is associated with increased mortality and diminished graft survival. We studied the incidence of NODAT and IFG in KTRs before and after a medically indicated switch of CNI therapy from cyclosporine (CsA) to tacrolimus (Tac). The study population consisted of 704 nondiabetic KTRs. Of them, 171 underwent conversion from CsA to Tac (group I) and 533 remained on the CsA since transplantation (Group II). Time-dependent Cox regression and generalized estimating equations were used to account for sequential CNI exposure. NODAT and IFG occurred in 15.2% and 22.1% of group I subjects and 15.6% and 25.8% of group II subjects, respectively (p = 0.90 for NODAT and p = 0.38 for IFG). Accounting for equal follow-up time since conversion from CsA to Tac, the adjusted 5-year NODAT-free survival was 87.4% and 91.4% in group I and group II, respectively (p = 0.90). In conclusion, conversion to Tac, compared to continuous exposure to CsA, carries quantitatively similar risk of impaired glucose metabolism in KTRs in the late posttransplant period.
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Affiliation(s)
- F L Luan
- Internal Medicine, Division of Nephrology, University of Michigan, Ann Arbor, MI, USA.
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42
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Marcard T, Ivens K, Grabensee B, Willers R, Helmchen U, Rump LC, Blume C. Early conversion from cyclosporine to tacrolimus increases renal graft function in chronic allograft nephropathy at BANFF stages I and II. Transpl Int 2008; 21:1153-62. [PMID: 18684111 DOI: 10.1111/j.1432-2277.2008.00731.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Switching from cyclosporine to tacrolimus without steroid pulse was suggested as a therapeutic option in chronic allograft nephropathy (CAN). Thirty-one renal transplant recipients with CAN were prospectively converted from cyclosporine to tacrolimus (group A), in parallel 31 matched cyclosporin A (CsA) patients (group B) without CAN were followed up for 30 months. In six matching patients of groups A and B inulin and para-aminohippurate (PAH)-clearances and mycophenolate were measured over a span of 3 months. Transplant biopsies of group A were scored according to BANFF. While group A presented with transplant dysfunction compared with group B before switching (2.7 +/- 0.16 mg/dl vs. 1.7 +/- 0.09 mg/dl; P < 0.001), transplant function was equal 30 months later: it ameliorated in group A (2.0 +/- 0.18 mg/dl vs. 2.7 +/- 0.16 mg/dl; P < 0.001) and decreased in group B (1.9 +/- 0.13 mg/dl vs. 1.7 +/- 0.09 mg/dl, P < 0.05). Especially, patients with biopsy scores I and II according to BANFF benefited from tacrolimus. Within 3 months, mycophenolate acid (MPA) levels increased under tacrolimus (P < 0.05) whereas inulin and PAH-clearances remained unchanged. At switching, antihypertensive treatment was more intense in group B, but this difference evened out. Adverse side effects were more frequent under tacrolimus. Patients with mild to moderate CAN significantly benefited from switching to tacrolimus. Increased MPA-levels under tacrolimus might have contributed to this effect.
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Affiliation(s)
- Thorsten Marcard
- Department for Nephrology, Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany
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Pozzetto U, Citterio F, Fioravanti G, Navarra P, Boccalini F, Castagneto M. Dyslipidemia can reduce the immunosuppressive effects of cyclosporine. Transpl Immunol 2007; 18:349-51. [PMID: 18158122 DOI: 10.1016/j.trim.2007.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2007] [Accepted: 10/04/2007] [Indexed: 11/19/2022]
Abstract
AIMS Dyslipidemia is a significant risk factor for the development of atherosclerotic disease and of chronic allograft rejection. Few data are available on the effects of dyslipidemia on the immunosuppressive action of immunosuppressive agents. We investigate the in vitro effects of lipids solution on the immunosuppressive action of cyclosporine (CsA). METHODS Peripheral blood mononuclear cells (PBMC) were PHA or OKT3 activated in vitro with/without different concentrations of Intralipid solution (INT, range 0.5% to 15%). CsA inhibition of activation was measured after a 3 day incubation, by adding H3-thimidine. The intracellular concentration of CsA was measured by radioimmunoassay and related to the CsA inhibitory effects. RESULTS Increasing INT concentration in the medium, CsA inhibition of PBMC activation by PHA or OKT3 was reduced from 72+/-13% to 8+/-2% and from 80+/-10% to 18+/-3%, respectively. A significant reduction of the intracellular CsA concentration was also evident with increasing INT concentrations and was related to the inhibitory activity of CsA. CONCLUSIONS These results suggest that dyslipidemia may reduce the availability of intracellular CsA concentration to inhibit the immune activation process and may explain the relationship between dyslipidemia and chronic allograft loss.
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Morales JM, Domínguez-Gil B. Impact of tacrolimus and mycophenolate mofetil combination on cardiovascular risk profile after kidney transplantation. J Am Soc Nephrol 2007; 17:S296-303. [PMID: 17130278 DOI: 10.1681/asn.2006080930] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Cardiovascular risk factors after kidney transplantation are enhanced as a result of the chronic use of immunosuppressants. Tacrolimus with mycophenolate mofetil has become the most commonly used combination after kidney transplantation. Cardiovascular risk factors that are related to the use of this combined therapy have been analyzed in various clinical trials in comparison with other immunosuppressive therapies. This review summarizes the main results of these studies regarding arterial hypertension, lipid profile, posttransplantation diabetes, renal function, and even acute rejection rate. The aim is to characterize the cardiovascular risk profile of tacrolimus and mycophenolate mofetil association when compared with older and newer immunosuppressive associations.
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Affiliation(s)
- Jose María Morales
- Renal Transplant Unit, Nephrology Department, Doce de Octubre Hospital, Madrid, Spain.
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Vasilic D, Alloway RR, Barker JH, Furr A, Ashcroft R, Banis JC, Kon M, Woodle ES. Risk Assessment of Immunosuppressive Therapy in Facial Transplantation. Plast Reconstr Surg 2007; 120:657-668. [PMID: 17700117 DOI: 10.1097/01.prs.0000270316.33293.ec] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Immunosuppression-related risks are foremost among ethical concerns regarding facial transplantation. However, previous risk estimates are inaccurate and misleading, because they are based on data from studies using different immunosuppression regimens, health status of the transplant recipients, tissue composition, and antigenicity. This review provides a comprehensive risk assessment for facial transplantation based on comparable data of immunosuppression, recipient health status, and composition and antigenicity of the transplanted tissue. METHODS The risk estimates for face transplantation presented here are based on data reported in clinical kidney (10-year experience) and hand transplantation (5-year experience) studies using tacrolimus/mycophenolate mofetil/corticosteroid therapy. Mitigating factors including ease of rejection diagnosis, rejection reversibility, infection prophylaxis, patient selection, and viral serologic status are taken into account. RESULTS Estimated risks include acute rejection (10 to 70 percent incidence), acute rejection reversibility (approximating 100 percent with corticosteroid therapy alone), chronic rejection (<10 percent over 5 years), cytomegalovirus disease (1 to 15 percent), diabetes (5 to 15 percent), hypertension (5 to 10 percent), and renal failure (<5 percent). CONCLUSIONS A review of these data indicates that previously reported estimates of immunosuppression-related risks are outdated and therefore should no longer be used. These updated risk estimates should be used by facial transplant teams, institutional review boards, and potential recipients when considering the immunologic risks associated with facial transplantation.
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Affiliation(s)
- Dalibor Vasilic
- Louisville, Ky.; Cincinnati, Ohio; and Utrecht, The Netherlands From the Departments of Surgery and Sociology, University of Louisville; Division of Nephrology, Department of Internal Medicine, and Division of Transplantation, Department of Surgery, University of Cincinnati; and Department of Plastic, Reconstructive, and Hand Surgery, University of Utrecht
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Schneeberger S, Ninkovic M, Gabl M, Ninkovic M, Hussl H, Rieger M, Loescher W, Zelger B, Brandacher G, Bonatti H, Hautz T, Boesmueller C, Piza-Katzer H, Margreiter R. First forearm transplantation: outcome at 3 years. Am J Transplant 2007; 7:1753-62. [PMID: 17511764 DOI: 10.1111/j.1600-6143.2007.01837.x] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We here report on the surgical procedure, postoperative course and functional results at 3 years following the first bilateral forearm transplantation. A 41-year-old male underwent bilateral forearm transplantation on February 17, 2003. After ATG induction therapy, tacrolimus, prednisone and MMF were given for maintenance immunosuppression. At 16 months, MMF was switched to everolimus. Hand function, histology, immunohistochemistry, radiomorphology, motor and nerve conduction and somatosensory-evoked potentials were investigated at frequent intervals. A total of six rejection episodes required treatment with either steroids, basiliximab, ATG, alemtuzumab or tacrolimus dose augmentation. At 3 years, the patient is free of clinical signs of rejection despite a persisting minimal perivascular lymphocytic dermal infiltrate. No signs of myointimal proliferation in graft vessels were seen. Motor function continuously improved, resulting in satisfactory hand function. Intrinsic hand muscle function was first observed at 16 months and continues to improve. Although discrimination of hot and cold recovered, overall sensitivity remains poor. The patient is satisfied with the outcome. Bilateral forearm transplantation represents a novel therapeutic option after loss of forearms.
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Affiliation(s)
- S Schneeberger
- Department of General and Transplant Surgery, Innsbruck Medical University, Innsbruck, Austria.
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Ozdemir FN, Akgul A, Altunoglu A, Bilgic A, Arat Z, Haberal M. The Association Between Cytomegalovirus Infection and Atherosclerotic Events in Renal Transplant Recipients. Transplant Proc 2007; 39:990-2. [PMID: 17524871 DOI: 10.1016/j.transproceed.2007.02.026] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Cytomegalovirus (CMV) infection is a risk factor for arteriosclerosis in renal transplant recipients. We sought to investigate the effects of CMV infection on atherosclerotic events (AE) in renal transplant recipients. This retrospective analysis included 200 patients: 52 women and 148 men of overall mean age of 36.18 +/- 10.23 years who were transplanted at our center between 1998 and 2001. We analyzed demographic features, dialysis duration, diabetes, blood pressure level, body mass index (BMI), medications, and lipid parameters. CMV infection was diagnosed in 23.5% of patients in the first 2 years after transplantation; these patients were followed for 4 years. All patients had been assessed for AE, including previous myocardial infarction, angina, revascularization procedures, intermittent claudication, stroke, or transient ischemic attack. AE occurred in 13% during the follow-up period. CMV infection was more frequent among these patients compared to those without AE, namely 42.3% versus 20.6%, respectively. Although the gender, dialysis duration, serum cholesterol level, presence of acute rejection, and BMI were not associated with AE, age, hypertension, and CMV infection did show a relation. A multivariate analysis by logistic regression revealed mean age and CMV infection to be independent risk factors for AE: odds ratio (OR)=5.6, 95% confidence interval (CI)=1.3 to 24.6 (P=0.02) and OR=4, 95% CI = 1.3 to 12.3 (P=.01). This study suggested that the presence of CMV infection may be a triggering factor for AE in renal transplant recipients.
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Affiliation(s)
- F N Ozdemir
- Department of Nephrology, Baskent University Hospital, Ankara, Turkey
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Hogan AC, McAvoy CE, Dick AD, Lee RWJ. Long-term Efficacy and Tolerance of Tacrolimus for the Treatment of Uveitis. Ophthalmology 2007; 114:1000-6. [PMID: 17467532 DOI: 10.1016/j.ophtha.2007.01.026] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2006] [Revised: 01/30/2007] [Accepted: 01/31/2007] [Indexed: 10/23/2022] Open
Abstract
PURPOSE To evaluate the long-term efficacy and tolerance of tacrolimus for the treatment of uveitis. DESIGN Retrospective case series. PARTICIPANTS Sixty-two consecutive patients with noninfectious uveitis treated with tacrolimus at a single academic referral center between April 2000 and April 2004. METHODS A standard data set was obtained from patients' medical records and analyzed according to the recommendations of the Standardization of Uveitis Nomenclature Working Group. MAIN OUTCOME MEASURES (1) Rate of tapering oral prednisone to 10 mg daily, (2) requirement for alternative second-line immunosuppressive therapy, and (3) rate of tacrolimus dose reduction or discontinuation due to side effects. RESULTS In this cohort with well-established ocular inflammation, patients successfully tapered their oral prednisone to 10 mg daily at an average rate of 1.62 per patient-year (PY), with an 85% probability of achieving < or =10 mg after 1 year 2 months of treatment. Tacrolimus was discontinued due to intolerance at a rate of 0.13/PY. This was predominantly due to noncardiovascular adverse events, and rates of introducing or increasing concomitant treatment for hypertension, hypercholesterolemia, and diabetes mellitus were all below 0.05/PY. Creatinine rises of > or =30% were also notably uncommon (0.05/PY). CONCLUSION Tacrolimus's efficacy for the treatment of uveitis is maintained long-term, and its cardiovascular risk profile is excellent.
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Moon JW, Song SJ, Koo BK, Cho YM, Yu HG. Short-term Effects and Side Effects of Tacrolimus for Behçet's Uveitis. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2007. [DOI: 10.3341/jkos.2007.48.12.1654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Jun Woong Moon
- Department of Ophthalmology, College of Medicine and Medical Research Center, Seoul National University, Seoul, Korea
| | - Su Jeong Song
- Department of Ophthalmology, College of Medicine and Medical Research Center, Seoul National University, Seoul, Korea
| | - Bo Kyung Koo
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Young Min Cho
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Hyeong Gon Yu
- Department of Ophthalmology, College of Medicine and Medical Research Center, Seoul National University, Seoul, Korea
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Deleuze S, Garrigue V, Delmas S, Chong G, Swarcz I, Cristol JP, Mourad G. New onset dyslipidemia after renal transplantation: is there a difference between tacrolimus and cyclosporine? Transplant Proc 2006; 38:2311-3. [PMID: 16980075 DOI: 10.1016/j.transproceed.2006.06.125] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
UNLABELLED Lipid abnormalities including increased total cholesterol (TC), triglycerides (TG) and low density lipoprotein cholesterol (LDL-C) have been frequently reported in renal transplantation and could be involved in the high frequency of cardiovascular diseases in this population. PATIENTS AND METHODS Two hundred ninety-five patients were transplanted between January 1995 and October 2000 in our center. Two hundred two patients were included in this study. Seventy-six patients received tacrolimus (Tac), and 126 patients cyclosporine (CsA). Lipid parameters were assessed the day of transplantation and 1 year posttransplantation. RESULTS Serum lipids were similar between the two groups at D0. At M12, TC and LDL-C were significantly higher in the CsA group (6.14 +/- 1.37 vs 5.28 +/- 1.32 mmol/L; P < .05 and 3.98 +/- 1.05 vs 3.26 +/- 1.03 mmol/L; P < .05 CsA vs Tac, respectively). TG were comparable in both groups (1.86 +/- 1.07 vs 1.62 +/- 0.92 mmol/L; P = .55; CsA vs Tac). Incidence of de novo hypercholesterolemia was significantly higher in the CsA group (28 vs 8%) whereas incidence of hyperTG was similar in both groups. Prevalence of LDL-C was significantly higher in the CsA group (65% vs 31%; P < .001), whereas there was no difference in high density lipoprotein (HDL)-C levels. DISCUSSION Mean serum lipid levels and incidence and prevalence of hyperTC, especially LDL-C, was significantly higher in patients receiving CsA when compared with Tac. TG and HDL-C levels were similar. Although the study was retrospective, our results confirm that CsA increases lipid levels, whereas Tac does not. CONCLUSION Lipid disorders are frequently observed in renal transplant recipients. CsA, but not Tac, significantly increases incidence and prevalence of high TC and LDL-C.
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Affiliation(s)
- S Deleuze
- Department of Nephrology and Transplantation, Lapeyronie University Hospital, University of Montpellier Medical School, 34295 Montpellier 05, France
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