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Pottebaum AA, January SE, Liu C, Lavine S, Schilling JD, Lavine KJ. Feasibility of Interleukin-6 Receptor Blockade in Cardiac Antibody-mediated Rejection. Transplantation 2024; 108:539-544. [PMID: 37638881 PMCID: PMC10798586 DOI: 10.1097/tp.0000000000004784] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 06/15/2023] [Accepted: 06/28/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Antibody-mediated rejection (AMR) remains a significant cause of heart transplant mortality with few effective therapies. METHODS This study aimed to describe initial experience of using interleukin-6 receptor blockade with tocilizumab in the treatment of acute cardiac AMR at Barnes-Jewish Hospital/Washington University Transplant Center from July 2017 to May 2021 (n = 7). Clinical, echocardiographic, and serum alloantibody data were analyzed before and after treatment. RESULTS All participants demonstrated marked improvement in functional status. Echocardiographic data following 4-6 mo of tocilizumab revealed significant improvements in biventricular systolic function for all participants. Consistent reductions in donor-specific HLA or angiotensin type I receptor antibodies were not observed, suggesting that tocilizumab may act downstream of antibody production. No patient experienced drug-related complications that necessitated discontinuation of therapy. CONCLUSIONS These findings provide initial insights into the safety and efficacy of interleukin-6 receptor blockade in the treatment of cardiac AMR and support the design of larger prospective studies.
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Affiliation(s)
| | | | - Chang Liu
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO
| | - Steven Lavine
- Division of Cardiology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Joel D Schilling
- Center for Cardiovascular Research, Division of Cardiology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Kory J Lavine
- Center for Cardiovascular Research, Division of Cardiology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
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January SE, Hubbard J, Fester KA, Dubrawka CA, Vazquez Guillamet R, Kulkarni HS, Hachem RR. Impact of Angiotensin Blockade on Development of Chronic Lung Allograft Dysfunction. J Pharm Pract 2023:8971900231213699. [PMID: 37923307 DOI: 10.1177/08971900231213699] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Indexed: 11/07/2023]
Abstract
Background: The renin-angiotensin-aldosterone system (RAAS) is responsible for a multitude of physiological functions, including immunological effects such as promotion of TGF-β and upregulation of IL-6 and IL-8 which are also implicated in the development of chronic lung allograft dysfunction (CLAD). Blockade of the RAAS pathway in pre-clinical models has demonstrated a decrease in these cytokines and pulmonary neutrophil recruitment. Objective: This study sought to evaluate whether use of RAAS inhibitor (RAASi) in lung transplant recipients impacted CLAD-free survival. Methods: In this retrospective, single-center study, 35 lung transplant recipients who received a RAASi post-transplant were compared to 70 lung transplant recipients not exposed to a RAASi and were followed for up to 5 years post-transplant. Results: The incidence of CLAD did not differ based on RAASi treatment (34.3% in RAASi vs 38.6%, P-value .668). This was confirmed with a multivariable Cox proportional hazards model with RAASi initiation as a time-varying covariate (RAASi hazard ratio of 1.01, P-value .986). Incidence of hyperkalemia and acute kidney injury were low in the RAASi group. Conclusions: This study demonstrated no association between post-transplant RAASi use and decreased risk of CLAD development. RAASi were also well tolerated in this patient population.
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Affiliation(s)
- Spenser E January
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, MO, USA
| | - Julie Hubbard
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, MO, USA
| | - Keith A Fester
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, MO, USA
| | - Casey A Dubrawka
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, MO, USA
| | - Rodrigo Vazquez Guillamet
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, Saint Louis, MO, USA
| | - Hrishikesh S Kulkarni
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, Saint Louis, MO, USA
| | - Ramsey R Hachem
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, Saint Louis, MO, USA
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3
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January SE, Fester KA, Halverson LP, Witt CA, Byers DE, Vazquez-Guillamet R, Alexander-Brett J, Tague LK, Kreisel D, Gelman A, Puri V, Bahena RN, Takahashi T, Hachem RR, Kulkarni HS. Tocilizumab for antibody-mediated rejection treatment in lung transplantation. J Heart Lung Transplant 2023; 42:1353-1357. [PMID: 37268051 PMCID: PMC10529998 DOI: 10.1016/j.healun.2023.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 03/08/2023] [Accepted: 05/20/2023] [Indexed: 06/04/2023] Open
Abstract
Tocilizumab (TCZ), an IL-6 inhibitor, has shown promise in the treatment of donor-specific antibodies (DSA) and chronic antibody-mediated rejection (AMR) in renal transplant recipients. However, its use in lung transplantation has not been described. This retrospective case-control study compared AMR treatments containing TCZ in 9 bilateral lung transplant recipients to 18 patients treated for AMR without TCZ. Treatment with TCZ resulted in more clearance of DSA, lower recurrence of DSA, lower incidence of new DSA, and lower rates of graft failure when compared to those treated for AMR without TCZ. The incidence of infusion reactions, elevation in transaminases, and infections were similar between the 2 groups. These data support a role for TCZ in pulmonary AMR and establish preliminary evidence to design a randomized controlled trial of IL-6 inhibition for the management of AMR.
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Affiliation(s)
- Spenser E January
- Department of Pharmacy, Barnes-Jewish Hospital , Saint Louis, Missouri.
| | - Keith A Fester
- Department of Pharmacy, Barnes-Jewish Hospital , Saint Louis, Missouri
| | - Laura P Halverson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri
| | - Chad A Witt
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri
| | - Derek E Byers
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri
| | - Rodrigo Vazquez-Guillamet
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri
| | - Jennifer Alexander-Brett
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri
| | - Laneshia K Tague
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Andrew Gelman
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Ruben Nava Bahena
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Tsuyoshi Takahashi
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Ramsey R Hachem
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri
| | - Hrishikesh S Kulkarni
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri
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4
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Escamilla JE, January SE, Vazquez Guillamet R. Diagnosis and Treatment of Fungal Infections in Lung Transplant Recipients. Pathogens 2023; 12:pathogens12050694. [PMID: 37242364 DOI: 10.3390/pathogens12050694] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 03/25/2023] [Revised: 04/27/2023] [Accepted: 05/05/2023] [Indexed: 05/28/2023] Open
Abstract
Fungal infections are a significant source of morbidity in the lung transplant population via direct allograft damage and predisposing patients to the development of chronic lung allograft dysfunction. Prompt diagnosis and treatment are imperative to limit allograft damage. This review article discusses incidence, risk factors, and symptoms with a specific focus on diagnostic and treatment strategies in the lung transplant population for fungal infections caused by Aspergillus, Candida, Coccidioides, Histoplasma, Blastomyces, Scedosporium/Lomentospora, Fusarium, and Pneumocystis jirovecii. Evidence for the use of newer triazole and inhaled antifungals to treat isolated pulmonary fungal infections in lung transplant recipients is also discussed.
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Affiliation(s)
- Jesus E Escamilla
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, MO 63110, USA
| | - Spenser E January
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, MO 63110, USA
| | - Rodrigo Vazquez Guillamet
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, Saint Louis, MO 63110, USA
- Rodrigo Vazquez Guillamet, 4921 Parkview Place, Saint Louis, MO 63110, USA
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5
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Dubrawka CA, Progar KJ, January SE, Hagopian JC, Nesselhauf NM, Malone AF. Impact of antimetabolite discontinuation following cytomegalovirus or BK polyoma virus infection in kidney transplant recipients. Transpl Infect Dis 2022; 24:e13931. [PMID: 35980197 DOI: 10.1111/tid.13931] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 04/20/2022] [Revised: 07/15/2022] [Accepted: 07/19/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) and BK polyoma virus (BKV) infection following kidney transplantation have been associated with allograft dysfunction and allograft loss. Reduction in immunosuppression is a mainstay of management yet has been associated with increased risk of rejection. According to international consensus guidelines, one approach to management of these viral infections is to discontinue the antimetabolite. Little is known surrounding long-term outcomes in these patients, and it remains unclear if consideration should be given to resuming the antimetabolite as variable re-escalation strategies have been reported. The objective was to describe episodes of rejection and identify risk factors for rejection following antimetabolite withdrawal after CMV or BKV DNAemia in kidney transplant recipients. METHODS This single-center, retrospective review evaluated adult kidney transplant recipients with a serum CMV or BKV DNA PCR ≥500 copies/ml who underwent antimetabolite discontinuation. The primary outcome assessed was the incidence of biopsy-proven acute rejection (BPAR). RESULTS One hundred fifty-nine patients were included. Overall, 14 patients (8.8%) experienced BPAR at a median of 1.6 years after antimetabolite discontinuation. Compared to CMV, discontinuation after BKV DNAemia was associated with a higher incidence of BPAR. Characteristics observed more frequently in patients with BPAR included younger age, female sex, higher initial viral load, and development of de novo donor-specific antibody (DSA). CONCLUSION These findings suggest that antimetabolite discontinuation after CMV or BKV DNAemia in kidney transplant recipients is a reasonable and safe approach. Further prospective studies investigating optimal immunosuppression management following CMV or BKV DNAemia in kidney transplant recipients are warranted.
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Affiliation(s)
- Casey A Dubrawka
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, Missouri, USA
| | - Kristin J Progar
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, Missouri, USA
| | - Spenser E January
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, Missouri, USA
| | | | | | - Andrew F Malone
- Division of Nephrology, Washington University School of Medicine in St. Louis, Saint Louis, Missouri, USA
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6
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Robinson AC, January SE, Botkin KW, Vader JM, Hartupee JC, Tellor Pennington BR. Association of bleeding with serotonergic antidepressants in patients receiving left ventricular assist device support. Pharmacotherapy 2021; 42:4-13. [PMID: 34655495 DOI: 10.1002/phar.2632] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 07/27/2021] [Revised: 09/21/2021] [Accepted: 09/25/2021] [Indexed: 11/06/2022]
Abstract
STUDY OBJECTIVE This study sought to determine whether SA use is associated with bleeding in patients receiving CF-LVAD support. DESIGN A retrospective cohort analysis was conducted of all adult patients who received CF-LVAD implantation at our institution. SETTING Barnes-Jewish Hospital between July 1, 2009, and October 1, 2018. PATIENTS Patients at least 18 years of age who received a HVAD™ (HeartWare Corp.), HeartMate II™ (St. Jude Medical), or HeartMate 3™ (St. Jude Medical) CF-LVAD and survived for at least 30 days postoperatively were included. INTERVENTION Patients who received SAs (n = 203) were compared to those who did not (n = 391) from 30 days to 18 months following implantation. The primary outcome was the incidence of first bleeding events including gastrointestinal bleed (GIB), epistaxis, or intracerebral hemorrhage (ICH). MEASUREMENTS AND MAIN RESULTS During follow-up, 219 patients had bleeding events: 93 of 203 (45.8%) in the SA group versus 126 of 391 (32.2%) in the control group (p = 0.001). After adjustment for age, angiotensin-converting enzyme (ACE) inhibitor and angiotensin receptor blocker (ARB) use, history of bleeding events, history of smoking, and CF-LVAD type, SA use remained associated with bleeding (adjusted odds ratio: 1.75, 95% confidence interval: 1.22-2.51, p = 0.002). HeartMate 3™ patients experienced less bleeding than HeartMate II™ patients (adjusted odds ratio 0.46, 95% confidence interval: 0.23-0.90, p = 0.024). CONCLUSIONS In this single-center, retrospective cohort of patients supported with CF-LVADs, SA use was associated with the incidence of first bleeding events, primarily driven by GIB. Further studies are needed to assess any differential risk of bleeding among SA agents and to assess the utility of altering antithrombotic strategies.
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Affiliation(s)
- Adam C Robinson
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - Spenser E January
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - Kent W Botkin
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - Justin M Vader
- Division of Cardiovascular Diseases, Washington University School of Medicine in Saint Louis, St. Louis, Missouri, USA
| | - Justin C Hartupee
- Division of Cardiovascular Diseases, Washington University School of Medicine in Saint Louis, St. Louis, Missouri, USA
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7
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January SE, Hagopian JC, Nesselhauf NM, Progar K, Horwedel TA, Santos RD. Clinical Experience with Extended-Release Tacrolimus in Older Adult Kidney Transplant Recipients: A Retrospective Cohort Study. Drugs Aging 2021; 38:397-406. [PMID: 33755934 DOI: 10.1007/s40266-021-00842-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Extended-release tacrolimus (LCP-Tac) prescribing information states that there is insufficient data in older adult patients from which to make recommendations on use in this population. This study sought to provide information on de novo use of LCP-Tac in the older adult kidney transplant population. METHODS This single-center retrospective study had two distinct objectives; to determine if weight-based doses of LCP-Tac differ based on recipient age and to compare safety and efficacy between LCP-Tac and immediate-release tacrolimus (IR-Tac) in older adult transplant recipients. Data was obtained through electronic chart review up to 2 years after transplant with censoring for graft loss and death. RESULTS Weight-based doses were compared between patients aged ≥ 65 years (n = 84), 36-64 years (n = 64), and ≤35 years (n = 44). LCP-Tac weight-based doses were lower at all time points in patients ≥ 65 years of age. Both age and race significantly impacted required dose on linear regression. The doses required to achieve therapeutic tacrolimus troughs were significantly lower in all age groups compared with the current FDA de novo dosing recommendation. In the older adult population, graft outcomes and infectious and metabolic complications were compared between recipients of LCP-Tac (n = 84) and IR-Tac (n = 42). Within this cohort, there were no differences between LCP-Tac and IR-Tac on graft function, rejection, graft loss, death, cytomegalovirus viremia, BK viremia, hypertension, diabetes, alopecia, or tremor up to 2 years after transplant. CONCLUSIONS Older adult recipients required significantly lower LCP-Tac doses compared with younger recipients and with the FDA-labeled starting dose. There were no differences in graft outcomes or adverse effects in older adult patients who received LCP-Tac versus IR-Tac.
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Affiliation(s)
- Spenser E January
- Department of Pharmacy, Barnes-Jewish Hospital, 1 Barnes-Jewish Hospital Plaza, Mailstop 90-52-411, Saint Louis, MO, 63130, USA.
| | - Jennifer C Hagopian
- Department of Pharmacy, Barnes-Jewish Hospital, 1 Barnes-Jewish Hospital Plaza, Mailstop 90-52-411, Saint Louis, MO, 63130, USA
| | - Nicole M Nesselhauf
- Department of Pharmacy, Barnes-Jewish Hospital, 1 Barnes-Jewish Hospital Plaza, Mailstop 90-52-411, Saint Louis, MO, 63130, USA
| | - Kristin Progar
- Department of Pharmacy, Barnes-Jewish Hospital, 1 Barnes-Jewish Hospital Plaza, Mailstop 90-52-411, Saint Louis, MO, 63130, USA
| | | | - Rowena Delos Santos
- Division of Nephrology, Washington University in Saint Louis, Saint Louis, MO, USA
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8
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January SE, Progar K, Nesselhauf NM, Hagopian JC, Malone AF. Choice of Acid Suppressant Therapy and Long-Term Graft Outcomes After Kidney Transplantation. Pharmacotherapy 2020; 40:1082-1088. [PMID: 33037663 DOI: 10.1002/phar.2470] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
STUDY OBJECTIVE The purpose of this study was to comprehensively evaluate the long-term adverse effects of proton pump inhibitors (PPIs) compared with histamine-2 receptor antagonists (H2RAs) in kidney transplant recipients. METHODS This retrospective cohort compared 582 patients treated with PPI with 705 patients treated with H2RA and evaluated adverse effects throughout their course of acid suppressant therapy to a maximum of nine years posttransplant. The primary outcome of interest was renal function at 1 year posttransplant; secondary outcomes included renal function at 30 days, 3, 5, and 9 years posttransplant as well as rejection, electrolyte and laboratory abnormalities, osteoporosis, pneumonia, and Clostridium difficile infections. RESULTS Renal function did not significantly differ at any timepoint posttransplant. Rejection rates and Clostridium difficile infections were similar between groups; osteoporosis and pneumonia rates were numerically higher in the PPI treated arm but did not reach statistical significance. Proton pump inhibitor (PPI) treated patients were more likely to experience hypomagnesemia requiring supplementation. High dose PPI treated patients had significantly higher rates of pneumonia and osteoporosis compared with H2RA treated patients. Patients were maintained on PPI therapy for an average of 5 years and H2RA therapy for 3 years posttransplant, the majority without a clear indication for therapy. CONCLUSIONS There was no difference in renal function, rejection, or graft loss between PPI and H2RA treated patients. The majority of patients were maintained on PPI therapy for several years posttransplant without a clear indication; critical evaluation of ongoing need for acid suppressant therapy in the posttransplant course should be an area of future focus.
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Affiliation(s)
- Spenser E January
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, Missouri, USA
| | - Kristin Progar
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, Missouri, USA
| | | | | | - Andrew F Malone
- Division of Nephrology, Washington University Physicians, Saint Louis, Missouri, USA
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9
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January SE, Fester KA, Bain KB, Kulkarni HS, Witt CA, Byers DE, Alexander-Brett J, Trulock EP, Hachem RR. Rabbit antithymocyte globulin for the treatment of chronic lung allograft dysfunction. Clin Transplant 2019; 33:e13708. [PMID: 31494969 DOI: 10.1111/ctr.13708] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [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: 07/02/2019] [Revised: 08/01/2019] [Accepted: 09/03/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Chronic lung allograft dysfunction (CLAD) is the leading cause of death beyond the first year after lung transplantation. Several treatments have been used to prevent the progression or reverse the effects of CLAD. Cytolytic therapy with rabbit antithymocyte globulin (rATG) has previously shown to be a potential option. However, the effect on patients with restrictive allograft syndrome (RAS) versus bronchiolitis obliterans syndrome (BOS) and the effect of cumulative dosing are unknown. METHODS The charts of lung transplant patients treated with rATG at Barnes-Jewish Hospital from 2009 to 2016 were retrospectively reviewed. The primary outcome was response to rATG; patients were deemed responders if their FEV1 improved in the 6 months after rATG treatment. Safety endpoints included incidence of serum sickness, cytokine release syndrome, malignancy, and infectious complications. RESULTS 108 patients were included in this study; 43 (40%) patients were responders who experienced an increase in FEV1 after rATG therapy. No predictors of response to rATG therapy were identified. Serum sickness occurred in 22% of patients, 15% experienced cytokine release syndrome, and 19% developed an infection after therapy. CONCLUSION 40% of patients with CLAD have an improvement in lung function after treatment with rATG although the improvement was typically minimal.
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Affiliation(s)
- Spenser E January
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, Missouri
| | - Keith A Fester
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, Missouri
| | | | - Hrishikesh S Kulkarni
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, Missouri.,Division of Pulmonary and Critical Care, Washington University Physicians, Saint Louis, Missouri
| | - Chad A Witt
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, Missouri.,Division of Pulmonary and Critical Care, Washington University Physicians, Saint Louis, Missouri
| | - Derek E Byers
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, Missouri.,Division of Pulmonary and Critical Care, Washington University Physicians, Saint Louis, Missouri
| | - Jennifer Alexander-Brett
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, Missouri.,Division of Pulmonary and Critical Care, Washington University Physicians, Saint Louis, Missouri
| | - Elbert P Trulock
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, Missouri.,Division of Pulmonary and Critical Care, Washington University Physicians, Saint Louis, Missouri
| | - Ramsey R Hachem
- Department of Pharmacy, Barnes-Jewish Hospital, Saint Louis, Missouri.,Division of Pulmonary and Critical Care, Washington University Physicians, Saint Louis, Missouri
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10
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Bartlett FE, Carthon CE, Hagopian JC, Horwedel TA, January SE, Malone A. Tacrolimus Concentration-to-Dose Ratios in Kidney Transplant Recipients and Relationship to Clinical Outcomes. Pharmacotherapy 2019; 39:827-836. [PMID: 31230376 DOI: 10.1002/phar.2300] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION One factor impacting tacrolimus interpatient variability is the presence of CYP3A5 polymorphisms. Low tacrolimus concentration-to-dose ratios (CDRs), or rapid metabolizers (RMs), have been associated with poor graft function outcomes and higher biopsy-proven acute rejection (BPAR) rates in a predominantly white population. Pretransplant CYP genotyping is not routinely conducted, and therefore only a small number of studies have assessed the use of tacrolimus CDRs as a surrogate for metabolism. We explored differences in outcomes between patients with low tacrolimus CDRs and high tacrolimus CDRs (i.e., nonrapid metabolizers [NRMs]) in a diverse patient population. OBJECTIVE To determine the relationship between tacrolimus CDRs and graft and patient outcomes in kidney transplant recipients at a large transplant center between 2006 and 2016. METHODS Inclusion criteria consisted of adult kidney transplant recipients who received rabbit antithymocyte globulin induction followed by a maintenance regimen of tacrolimus, mycophenolate, and prednisone. The primary end point was BPAR at 1 year. Secondary end points included graft survival, patient survival, and toxicities. Determination of clusters was conducted using the two-step cluster analysis with a defined two-cluster distribution. Kaplan-Meier survival curves were created using the log-rank test. RESULTS The NRM cluster consisted of 322 patients with a mean CDR of 2.91 ng/ml/mg. The RM cluster consisted of 932 patients with a mean CDR of 1.14 ng/ml/mg. The BPAR at 1 year posttransplant was 3.7% in the NRM cluster and 3.6% in the RM cluster (p=0.95). Death at 5 years was higher in the NRM group compared with the RM group for unknown reasons (p=0.03). Differences in the incidence of posttransplant toxicities were not statistically significant at any time point, except for increased rates of cutaneous cancer at 5 years and cardiovascular disease overall in the NRM group. CONCLUSION Tailoring tacrolimus therapy early posttransplant based on CDR is not supported by the findings in this study.
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Affiliation(s)
| | | | | | | | | | - Andrew Malone
- Division of Nephrology, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri
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11
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Veve MP, January SE, Kenney RM, Zoratti EM, Zervos MJ, Davis SL. Impact of Reported β-Lactam Allergy on Management of Methicillin-Sensitive Staphylococcus aureus Bloodstream Infections. J Pharm Pract 2019; 33:809-814. [PMID: 30991876 DOI: 10.1177/0897190019841737] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Antistaphylococcal β-lactams antibiotics are the preferred treatment for methicillin-sensitive Staphylococcus aureus (MSSA) infections. Patient-reported β-lactam allergies may complicate antibiotic decision-making and delay optimal therapy, with potential implications on patient outcomes. OBJECTIVE To determine the impact of reported β-lactam allergies on the receipt of optimal therapy and outcomes for MSSA bloodstream infections (BSI). METHODS Retrospective, matched cohort of MSSA BSI patients with and without a reported β-lactam allergy. The primary end point was receipt of optimal therapy, defined as an antistaphylococcal β-lactam. RESULTS Two hundred twelve patients were included: 53 with reported β-lactam allergy and 159 without β-lactam allergy. Commonly reported β-lactam allergies were 26 (49%) immune-mediated reaction and 8 (15%) intolerance, with 19 (36%) having no documented reaction. Optimal antibiotics were given to 135 patients without a β-lactam allergy and 37 patients with a reported β-lactam allergy (85% vs 70%, P = .015). Among reported β-lactam allergy patients, those without a documented reaction were less likely to receive optimal therapy (47% vs 79%, P = .042). Reported β-lactam allergy was not associated with clinical response (P = .61) or MSSA-related mortality (P = .83). When adjusting for immunosuppression, variables independently associated with optimal therapy were β-lactam allergy (adjusted odds ratio [adjOR], 0.3; 95% confidence interval [CI], 0.1-0.6) and infectious diseases consultation (adjOR, 6.1; 95%CI, 2.7-13.9). Optimal antibiotic use was associated with decreased all-cause 90-day mortality (adjOR, 0.23; 95%CI, 0.09-0.54). CONCLUSIONS Patients with reported β-lactam allergies, particularly those without a documented reaction, were less likely to receive optimal antibiotics for MSSA BSI. Patient outcomes may be improved with enhanced quality of allergy history and routine infectious disease consultation.
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Affiliation(s)
- Michael P Veve
- 2971Henry Ford Hospital, Detroit, MI, USA.,Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI, USA.,The author is now with the Department of Clinical Pharmacy and Translational Science, 4285University of Tennessee Health Science Center, Knoxville, TN, USA
| | - Spenser E January
- 2971Henry Ford Hospital, Detroit, MI, USA.,The author is now with 21737Barnes-Jewish Hospital, St Louis, MO, USA
| | | | | | | | - Susan L Davis
- 2971Henry Ford Hospital, Detroit, MI, USA.,Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI, USA
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Pathuri G, Hedrick AF, January SE, Galbraith WK, Awasthi V, Arnold CD, Cowley BD, Gali H. Synthesis andin vivoevaluation of gallium-68-labeled glycine and hippurate conjugates for positron emission tomography renography. J Labelled Comp Radiopharm 2014; 58:14-9. [DOI: 10.1002/jlcr.3255] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Revised: 12/01/2014] [Accepted: 12/02/2014] [Indexed: 01/14/2023]
Affiliation(s)
- Gopal Pathuri
- Department of Pharmaceutical Sciences, College of Pharmacy; The University of Oklahoma Health Sciences Center; Oklahoma City OK USA
| | - Andria F. Hedrick
- Department of Pharmaceutical Sciences, College of Pharmacy; The University of Oklahoma Health Sciences Center; Oklahoma City OK USA
| | - Spenser E. January
- Department of Pharmaceutical Sciences, College of Pharmacy; The University of Oklahoma Health Sciences Center; Oklahoma City OK USA
| | - Wendy K. Galbraith
- Department of Pharmaceutical Sciences, College of Pharmacy; The University of Oklahoma Health Sciences Center; Oklahoma City OK USA
| | - Vibhudutta Awasthi
- Department of Pharmaceutical Sciences, College of Pharmacy; The University of Oklahoma Health Sciences Center; Oklahoma City OK USA
| | - Charles D. Arnold
- Department of Radiological Sciences; The University of Oklahoma Health Sciences Center; Oklahoma City OK USA
| | - Benjamin D. Cowley
- Nephrology Section, Department of Internal Medicine, College of Medicine; The University of Oklahoma Health Sciences Center; Oklahoma City OK USA
| | - Hariprasad Gali
- Department of Pharmaceutical Sciences, College of Pharmacy; The University of Oklahoma Health Sciences Center; Oklahoma City OK USA
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