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Piburn KH, Sigurjonsdottir VK, Indridason OS, Maestretti L, Patton MV, McGrath A, Palsson R, Gallo A, Chaudhuri A, Grimm PC. Patterns in Tacrolimus Variability and Association with De Novo Donor-Specific Antibody Formation in Pediatric Kidney Transplant Recipients. Clin J Am Soc Nephrol 2022; 17:1194-1203. [PMID: 35882506 PMCID: PMC9435976 DOI: 10.2215/cjn.16421221] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 05/11/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND OBJECTIVES High tacrolimus intrapatient variability has been associated with inferior graft outcomes in patients with kidney transplants. We studied baseline patterns of tacrolimus intrapatient variability in pediatric patients with kidney transplants and examined these patterns in relation to C1q-binding de novo donor-specific antibodies. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS All tacrolimus levels in participants who underwent kidney-only transplantation at a single pediatric center from 2004 to 2018 (with at least 12-month follow-up, followed until 2019) were analyzed to determine baseline variability. Intrapatient variability was defined using the coefficient of variation (SD/mean ×100%) of all samples in a 6-month moving window. Routine de novo donor-specific antibody measurements were available for a subgroup of patients transplanted in 2010-2018. Cox proportional hazards models using tacrolimus intrapatient variability as a time-varying variable were used to examine the association between intrapatient variability and graft outcomes. The primary outcome of interest was C1q-binding de novo donor-specific antibody formation. RESULTS Tacrolimus intrapatient variability developed a steady-state baseline of 30% at 10 months post-transplant in 426 patients with a combined 31,125 tacrolimus levels. Included in the outcomes study were 220 patients, of whom 51 developed C1q-binding de novo donor-specific antibodies. De novo donor-specific antibody formers had higher intrapatient variability, with a median of 38% (interquartile range, 28%-48%) compared with 28% (interquartile range, 20%-38%) for nondonor-specific antibody formers (P<0.001). Patients with high tacrolimus intrapatient variability (coefficient of variation >30%) had higher risk of de novo donor-specific antibody formation (hazard ratio, 5.35; 95% confidence interval, 2.45 to 11.68). Patients in the top quartile of tacrolimus intrapatient variability (coefficient of variation >41%) had the strongest association with C1q-binding de novo donor-specific antibody formation (hazard ratio, 11.81; 95% confidence interval, 4.76 to 29.27). CONCLUSIONS High tacrolimus intrapatient variability was strongly associated with de novo donor-specific antibody formation.
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Affiliation(s)
- Kim H. Piburn
- Division of Nephrology, Department of Pediatrics, Stanford University, Palo Alto, California
| | - Vaka K. Sigurjonsdottir
- Division of Nephrology, Department of Pediatrics, Stanford University, Palo Alto, California,Division of Nephrology, Internal Medicine and Emergency Services, Landspitali–The National University Hospital of Iceland, Reykjavik, Iceland,Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland
| | - Olafur S. Indridason
- Division of Nephrology, Internal Medicine and Emergency Services, Landspitali–The National University Hospital of Iceland, Reykjavik, Iceland
| | - Lynn Maestretti
- Pediatric Kidney Transplant Program, Division of Nephrology, Department of Pediatrics, Lucile Packard Children’s Hospital Stanford, Palo Alto, California
| | - Mary Victoria Patton
- Pediatric Kidney Transplant Program, Division of Nephrology, Department of Pediatrics, Lucile Packard Children’s Hospital Stanford, Palo Alto, California
| | - Anne McGrath
- Pediatric Kidney Transplant Program, Division of Nephrology, Department of Pediatrics, Lucile Packard Children’s Hospital Stanford, Palo Alto, California
| | - Runolfur Palsson
- Division of Nephrology, Internal Medicine and Emergency Services, Landspitali–The National University Hospital of Iceland, Reykjavik, Iceland,Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland
| | - Amy Gallo
- Division of Abdominal Transplantation, Department of Surgery, Stanford University, Palo Alto, California
| | - Abanti Chaudhuri
- Division of Nephrology, Department of Pediatrics, Stanford University, Palo Alto, California
| | - Paul C. Grimm
- Division of Nephrology, Department of Pediatrics, Stanford University, Palo Alto, California
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Yin S, Wang X, Huang Z, Fan Y, Song T, Lin T. Tacrolimus variability score outperforms coefficient of variation in predicting clinical outcomes of living kidney transplantation. Br J Clin Pharmacol 2021; 88:75-83. [PMID: 33899267 DOI: 10.1111/bcp.14876] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 04/04/2021] [Accepted: 04/06/2021] [Indexed: 02/05/2023] Open
Abstract
AIMS Intrapatient variability (IPV) was previously defined as coefficient of variation (CV) or standard deviation of tacrolimus (Tac) exposure while none of them was easily being interpreted and translated into clinical practice after kidney transplantation. METHODS We developed a novel Tac variability score (TVS) to evaluate IPV by calculating the frequency of clinically significant changes of Tac trough levels after kidney transplantation. Multivariate Cox proportional analyses were conducted to compare the impact of TVS and CV on transplant outcomes. RESULTS A total of 1343 patients were divided into high TVS (>0.30) and low TVS (<0.30) groups, and low CV (<0.30) and high CV (>0.30) groups. Univariate analyses showed that high TVS (hazard ratio [HR]: 2.323, 95% confidence interval [CI]: 1.455-3.709) and high CV (HR: 1.606, 95%CI: 1.044-2.471) were associated with inferior graft survival. However, only TVS was an independent predictor for graft failure in multivariate analyses (HR: 1.972, 95%CI: 1.2-3.24), and the correlation maintained in high CV (P = .020) and low CV (P = .037) subgroups, while CV failed to predict graft loss in neither low (P = .387) nor high TVS (P = .600) subgroups. In addition, TVS had a higher correlation with graft survival in patients with Tac exposure within the therapeutic range and the correlation was less influenced by mean Tac trough levels. CONCLUSION TVS is a novel measure of Tac IPV with higher correlation with graft survival and more convenience in clinical use than CV after kidney transplantation.
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Affiliation(s)
- Saifu Yin
- Urology Department/Urology research institute/Organ transplantation center, West China Hospital, Sichuan University, Chengdu City, Sichuan Province, China.,West China Medical School, Sichuan University, Chengdu City, Sichuan Province, China
| | - Xianding Wang
- Urology Department/Urology research institute/Organ transplantation center, West China Hospital, Sichuan University, Chengdu City, Sichuan Province, China.,West China Medical School, Sichuan University, Chengdu City, Sichuan Province, China
| | - Zhongli Huang
- Urology Department/Urology research institute/Organ transplantation center, West China Hospital, Sichuan University, Chengdu City, Sichuan Province, China.,West China Medical School, Sichuan University, Chengdu City, Sichuan Province, China
| | - Yu Fan
- Urology Department/Urology research institute/Organ transplantation center, West China Hospital, Sichuan University, Chengdu City, Sichuan Province, China.,West China Medical School, Sichuan University, Chengdu City, Sichuan Province, China
| | - Turun Song
- Urology Department/Urology research institute/Organ transplantation center, West China Hospital, Sichuan University, Chengdu City, Sichuan Province, China.,West China Medical School, Sichuan University, Chengdu City, Sichuan Province, China
| | - Tao Lin
- Urology Department/Urology research institute/Organ transplantation center, West China Hospital, Sichuan University, Chengdu City, Sichuan Province, China.,West China Medical School, Sichuan University, Chengdu City, Sichuan Province, China
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Zhu J, Pasternak AL, Crona DJ. The future of research into genetics and the precision dosing of tacrolimus: what do we need to know? Pharmacogenomics 2020; 21:1061-1064. [PMID: 32896220 DOI: 10.2217/pgs-2020-0093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Jing Zhu
- Division of Pharmacotherapy & Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Amy L Pasternak
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI 48109, USA.,Department of Pharmacy, Michigan Medicine, Ann Arbor, MI 48109, USA
| | - Daniel J Crona
- Division of Pharmacotherapy & Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC 27599, USA.,UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC 27599, USA.,Department of Pharmacy, UNC Hospitals & Clinics, Chapel Hill, NC 27514, USA
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Leino AD, Pai MP. Maintenance Immunosuppression in Solid Organ Transplantation: Integrating Novel Pharmacodynamic Biomarkers to Inform Calcineurin Inhibitor Dose Selection. Clin Pharmacokinet 2020; 59:1317-1334. [PMID: 32720300 DOI: 10.1007/s40262-020-00923-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Calcineurin inhibitors, the primary immunosuppressive therapy used to prevent alloreactivity of transplanted organs, have a narrow therapeutic index. Currently, treatment is individualized based on clinical assessment of the risk of rejection or toxicity guided by trough concentration monitoring. Advances in immune monitoring have identified potential markers that may have value in understanding calcineurin inhibitor pharmacodynamics. Integration of these markers has the potential to complement therapeutic drug monitoring. Existing pharmacokinetic-pharmacodynamic (PK-PD) data is largely limited to correlation between the biomarker and trough concentrations at single time points. Immune related gene expression currently has the most evidence supporting PK-PD integration. Novel biomarker-based approaches to pharmacodynamic monitoring including development of enhanced PK-PD models are proposed to realize the full clinical benefit.
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Affiliation(s)
- Abbie D Leino
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, 428 Church Street, Rm 3569, Ann Arbor, MI, 48109, USA
| | - Manjunath P Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, 428 Church Street, Rm 3569, Ann Arbor, MI, 48109, USA.
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Prado-Velasco M, Borobia A, Carcas-Sansuan A. Predictive engines based on pharmacokinetics modelling for tacrolimus personalized dosage in paediatric renal transplant patients. Sci Rep 2020; 10:7542. [PMID: 32371893 DOI: 10.1038/s41598-020-64189-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 04/10/2020] [Indexed: 01/18/2023] Open
Abstract
The development of predictive engines based on pharmacokinetic-physiological mathematical models for personalised dosage recommendations is an immature field. Nevertheless, these models are extensively applied during the design of new drugs. This study presents new advances in this subject, through a stable population of patients who underwent kidney transplantation and were prescribed tacrolimus. We developed 2 new population pharmacokinetic models based on a compartmental approach, with one following the physiologically based pharmacokinetic approach and both including circadian modulation of absorption and clearance variables. One of the major findings was an improved predictive capability for both models thanks to the consideration of circadian rhythms, both in estimating the population and in Bayesian individual customisation. This outcome confirms a plausible mechanism suggested by other authors to explain circadian patterns of tacrolimus concentrations. We also discovered significant intrapatient variability in tacrolimus levels a week after the conversion from a fast-release (Prograf) to a sustained-release formulation (Advagraf) using adaptive optimisation techniques, despite high adherence and controlled conditions. We calculated the intrapatient variability through parametric intrapatient variations, which provides a method for quantifying the mechanisms involved. We present a first application for the analysis of bioavailability changes in formulation conversion. The 2 pharmacokinetic models have demonstrated their capability as predictive engines for personalised dosage recommendations, although the physiologically based pharmacokinetic model showed better predictive behaviour.
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