Hylke de Jonge

Donor Age and Renal P-Glycoprotein Expression Associate with Chronic Histological Damage in Renal Allografts

The contributions of donor kidney quality (partially determined by donor age), allograft rejection, and calcineurin inhibitor nephrotoxicity on the progression of histologic damage of renal allografts are not completely defined. Moreover, the determinants of individual susceptibility to calcineurin inhibitor nephrotoxicity are not known but may include variability in drug transport and metabolism. In a prospective cohort of 252 adult renal allograft recipients treated with a combination of tacrolimus, mycophenolate mofetil, and corticosteroids, we studied 744 renal allograft biopsies obtained regularly from time of transplantation for 3 yr. We assessed determinants of histologic evolution, including tacrolimus exposure, renal P-glycoprotein (ABCB1) expression, and polymorphisms in the CYP3A4, CYP3A5, and ABCB1 genes. Within the first 3 yr after transplantation, we noted a progressive increase in interstitial fibrosis, tubular atrophy, glomerulosclerosis, and vascular intimal thickening. Older donor age, absence of P-glycoprotein expression at the apical membrane of tubular epithelial cells, and combined donor-recipient homozygosity for the C3435T variant in ABCB1 significantly associated with increased susceptibility to chronic allograft damage independent of graft quality at implantation. Changes in graft function over time reflected these associations with donor age and ABCB1 polymorphisms, but it was acute T cell-mediated and antibody-mediated rejection that determined early graft survival. In conclusion, the effects of older donor age reach beyond the quality of the allograft at implantation and continue to be important for histologic evolution in the posttransplantation period. In addition, ABCB1 genotype and expression of P-glycoprotein in renal tubular epithelial cells determine susceptibility to chronic tubulointerstitial damage of transplanted kidneys.

New insights into the pharmacokinetics and pharmacodynamics of the calcineurin inhibitors and mycophenolic acid: possible consequences for therapeutic drug monitoring in solid organ transplantation

Although therapeutic drug monitoring (TDM) of immunosuppressive drugs has been an integral part of routine clinical practice in solid organ transplantation for many years, ongoing research in the field of immunosuppressive drug metabolism, pharmacokinetics, pharmacogenetics, pharmacodynamics, and clinical TDM keeps yielding new insights that might have future clinical implications. In this review, the authors will highlight some of these new insights for the calcineurin inhibitors (CNIs) cyclosporine and tacrolimus and the antimetabolite mycophenolic acid (MPA) and will discuss the possible consequences. For CNIs, important relevant lessons for TDM can be learned from the results of 2 recently published large CNI minimization trials. Furthermore, because acute rejection and drug-related adverse events do occur despite routine application of CNI TDM, alternative approaches to better predict the dose-concentration-response relationship in the individual patient are being explored. Monitoring of CNI concentrations in lymphocytes and other tissues, determination of CNI metabolites, and CNI pharmacogenetics and pharmacodynamics are in their infancy but have the potential to become useful additions to conventional CNI TDM. Although MPA is usually administered at a fixed dose, there is a rationale for MPA TDM, and this is substantiated by the increasing knowledge of the many nongenetic and genetic factors contributing to the interindividual and intraindividual variability in MPA pharmacokinetics. However, recent, large, randomized clinical trials investigating the clinical utility of MPA TDM have reported conflicting data. Therefore, alternative pharmacokinetic (ie, MPA free fraction and metabolites) and pharmacodynamic approaches to better predict drug efficacy and toxicity are being explored. Finally, for MPA and tacrolimus, novel formulations have become available. For MPA, the differences in pharmacokinetic behavior between the old and the novel formulation will have implications for TDM, whereas for tacrolimus, this probably will not to be the case.

Recovery of Hyperphosphatoninism and Renal Phosphorus Wasting One Year after Successful Renal Transplantation

BACKGROUND AND OBJECTIVES In the first months after successful kidney transplantation, hypophosphatemia and renal phosphorus wasting are common and related to inappropriately high parathyroid hormone (PTH) and fibroblast growth factor-23 (FGF-23) levels. Little is known about the long-term natural history of renal phosphorus homeostasis in renal transplant recipients. DESIGN, SETTING, PARTICIPANTS We prospectively followed parameters of mineral metabolism (including full-length PTH and FGF-23) in 50 renal transplant recipients at the time of transplantation (Tx), at month 3 (M3) and at month 12 (M12). Transplant recipients were (1:1) matched for estimated GFR with chronic kidney disease (CKD) patients. RESULTS FGF-23 levels (Tx: 2816 [641 to 10665] versus M3: 73 [43 to 111] versus M12: 56 [34 to 78] ng/L, median [interquartile range]) and fractional phosphorus excretion (FE(phos); M3: 45 +/- 19% versus M12: 37 +/- 13%) significantly declined over time after renal transplantation. Levels 1 yr after transplantation were similar to those in CKD patients (FGF-23: 47 [34 to 77] ng/L; FE(phos) 35 +/- 16%). Calcium (9.1 +/- 0.5 versus 8.9 +/- 0.3 mg/dl) and PTH (27.2 [17.0 to 46.0] versus 17.5 [11.7 to 24.4] ng/L) levels were significantly higher, whereas phosphorus (3.0 +/- 0.6 versus 3.3 +/- 0.6 mg/dl) levels were significantly lower 1 yr after renal transplantation as compared with CKD patients. CONCLUSIONS Data indicate that hyperphosphatoninism and renal phosphorus wasting regress by 1 yr after successful renal transplantation.

The P450 oxidoreductase *28 SNP is associated with low initial tacrolimus exposure and increased dose requirements in CYP3A5-expressing renal recipients.

AIM Recently a SNP of the gene encoding P450 oxidoreductase (POR*28; rs1057868C>T) has been associated with increased in vivo CYP3A activity using midazolam as a drug probe. Because tacrolimus is metabolized by CYP3A isoenzymes, this SNP might affect tacrolimus pharmacokinetics. MATERIALS & METHODS To test this hypothesis we performed a study in a cohort of 298 de novo renal allograft recipients stratified according to CYP3A5 genotype, which has a known impact on tacrolimus pharmacokinetics. RESULTS We found that in CYP3A5 expressers (CYP3A5*1 allele carriers) receiving a standard loading dose of 0.2 mg/kg, POR*28T allele carriers had lower tacrolimus C₀ levels in the first days post-transplantation and reached target C₀ levels significantly later as compared with POR*28CC homozygous patients. The POR*28T allele carriers had significantly higher tacrolimus dose requirements throughout the first year. In CYP3A5 nonexpressers (CYP3A5*3/*3) the POR*28 SNP did not affect tacrolimus pharmacokinetics. CONCLUSION These data indicate that the POR*28 SNP is associated with additional increases in early tacrolimus dose-requirements in patients carrying a CYP3A5*1 allele.

Intrarenal Resistive Index after Renal Transplantation

BACKGROUND The intrarenal resistive index is routinely measured in many renal-transplantation centers for assessment of renal-allograft status, although the value of the resistive index remains unclear. METHODS In a single-center, prospective study involving 321 renal-allograft recipients, we measured the resistive index at baseline, at the time of protocol-specified renal-allograft biopsies (3, 12, and 24 months after transplantation), and at the time of biopsies performed because of graft dysfunction. A total of 1124 renal-allograft resistive-index measurements were included in the analysis. All patients were followed for at least 4.5 years after transplantation. RESULTS Allograft recipients with a resistive index of at least 0.80 had higher mortality than those with a resistive index of less than 0.80 at 3, 12, and 24 months after transplantation (hazard ratio, 5.20 [95% confidence interval {CI}, 2.14 to 12.64; P<0.001]; 3.46 [95% CI, 1.39 to 8.56; P=0.007]; and 4.12 [95% CI, 1.26 to 13.45; P=0.02], respectively). The need for dialysis did not differ significantly between patients with a resistive index of at least 0.80 and those with a resistive index of less than 0.80 at 3, 12, and 24 months after transplantation (hazard ratio, 1.95 [95% CI, 0.39 to 9.82; P=0.42]; 0.44 [95% CI, 0.05 to 3.72; P=0.45]; and 1.34 [95% CI, 0.20 to 8.82; P=0.76], respectively). At protocol-specified biopsy time points, the resistive index was not associated with renal-allograft histologic features. Older recipient age was the strongest determinant of a higher resistive index (P<0.001). At the time of biopsies performed because of graft dysfunction, antibody-mediated rejection or acute tubular necrosis, as compared with normal biopsy results, was associated with a higher resistive index (0.87 ± 0.12 vs. 0.78 ± 0.14 [P=0.05], and 0.86 ± 0.09 vs. 0.78 ± 0.14 [P=0.007], respectively). CONCLUSIONS The resistive index, routinely measured at predefined time points after transplantation, reflects characteristics of the recipient but not those of the graft. (ClinicalTrials.gov number, NCT01879124 .).

Reduced C0 concentrations and increased dose requirements in renal allograft recipients converted to the novel once-daily tacrolimus formulation.

Background. Recently, a once-daily prolonged release formulation of tacrolimus (TacOD) has been approved for the prevention of renal allograft rejection. Studies reported equivalent area under the concentration-time curve0–24 and predose trough (C0) concentrations when compared with the standard twice-daily tacrolimus (Tac) formulation. Hence, the package insert advices a 1:1 mg conversion. Here, we report our independent experience with conversion to TacOD according to the manufacturers instructions. Methods. Retrospective single-center study evaluating the evolution of C0 concentrations and dose requirements after conversion to TacOD in 284 renal allograft recipients. Potential clinical, biochemical, and genetic determinants of changes in C0 concentrations and dose requirements after conversion were explored in univariate and multivariate analyses. Results. After conversion, C0 concentrations decreased significantly (−1.36±2.51 &mgr;g/L or −12.66%±24.36%, P<0.0001). In 38.3% of patients, this decrease exceeded 20%. TacOD dose was increased in 52.5% of patients. Average dose requirements increased to 0.71±1.78 mg/day or 14.68%±28.87% (P<0.0001). In 28.0% of patients, dose requirements increased more than 20%. Dose changes were more profound in patients converted within 1 year after transplantation, and in this subgroup (n=78), higher creatinine and lower hemoglobin levels were associated with a larger increase in dose requirements in multivariate analysis (r2=0.35, P<0.0001). Despite dose adjustments, average C0 concentrations remained 9.09%±28.85% lower after conversion (P<0.0001). Conclusions. Conversion from standard twice-daily tacrolimus formulation to TacOD on a 1:1 mg basis results in reduced Tac C0 concentrations and increased dose requirements. Thus, conversion is not as straightforward as suggested by the manufacturer, and converted patients should be monitored strictly until stable C0 concentrations are achieved.

Tacrolimus Dose Requirements and cyp3a5 Genotype and the Development of Calcineurin Inhibitor-associated Nephrotoxicity in Renal Allograft Recipients

Objectives: Prolonged calcineurin inhibitor maintenance therapy in kidney allograft recipients is complicated by the development of chronic irreversible drug-induced nephrotoxicity (CNIT). Methods: In 304 de novo renal graft recipients, the association among tacrolimus exposure indices (dose, C0, AUC0-12h), CYP3A5, CYP3A4 and ABCB1 polymorphisms, clinical covariables and de novo arteriolar hyalinization as a histologic sign of CNIT was examined. Results: Tacrolimus C0 and AUC0-12h at 3 and 12 months posttransplantation did not differ between patients with and without CNIT. Patients who developed CNIT more often carried the CYP3A5*1 allele (32.4% versus 15.2%, P = 0.01). Twenty-five percent of recipients with tacrolimus dose requirements exceeding 0.2 mg/kg per day at 3 months posttransplantation developed CNIT, whereas 16.2% of patients with dose requirements between 0.10 and 0.20 mg/kg per day and 4.5% of patients who needed less than 0.10 mg/kg per day developed CNIT (P < 0.0001). These early differences in tacrolimus dose requirements between recipients with and without CNIT persisted during subsequent follow-up. In a Cox proportional hazards analysis, the CYP3A5*1 allele (hazard ratio: 2.38; 95% confidence interval: 1.15-4.92) or tacrolimus dose range (hazard ratio: 2.06; 95% confidence interval: 1.30-3.27) and continued corticosteroid therapy (hazard ratio: 4.75; 95% confidence interval: 1.13-19.98) were independently associated with CNIT. A Kaplan-Meier survival curve demonstrated a significant difference in CNIT-free survival (93.5% versus 81.8% versus 66.9%; log-rank test: P = 0.0006) between patients with, respectively, tacrolimus dose requirements less than 0.1, 0.1 or greater, less than 0.2, and 0.2 mg/kg per day or greater. More patients with CNIT sustained graft loss during follow-up (32.3% versus13.7%, P = 0.004). Conclusions: High early tacrolimus dose requirements, predominantly but not exclusively encountered in CYP3A5*1 expressers, are associated with the development of calcineurin inhibitor-related nephrotoxicity, especially in recipients who continue corticosteroid therapy.

Effects of CYP3A5 and MDR1 single nucleotide polymorphisms on drug interactions between tacrolimus and fluconazole in renal allograft recipients

Objective Drug interactions between tacrolimus and azole antifungals are characterized by a large clinical variability. The aim of this study was to examine the influence of the CYP3A4, CYP3A5, and MDR1 single nucleotide polymorphisms on changes in tacrolimus exposure and dosing in renal allograft recipients treated with fluconazole. Methods Twenty-nine patients who had received documented fluconazole treatment were identified out of a total of 753 renal recipients on maintenance tacrolimus therapy. These 29 patients were genotyped for CYP3A4*1/*1B, CYP3A5*1/*3, MDR1 C3435T, and G2677T/A, and the influence of the latter polymorphisms on tacrolimus exposure and dose before, during, and after fluconazole administration was examined. Results Dose-corrected trough blood tacrolimus concentration did not change significantly from baseline (1.26±1.23-fold) in heterozygous CYP3A5*1 carriers during exposure to fluconazole, in contrast to homozygous CYP3A5*3 carriers (3.28±2.34-fold; P=0.04 between CYP3A5*3/*3 and CYP3A5*3/*1 genotypes). Homozygous CYP3A5*3 carriers experienced a significant decrease of weight-corrected tacrolimus dose requirements during fluconazole administration (54.7±23.7% from baseline, P<0.05) in contrast to heterozygous carriers of CYP3A5*1 (25.1±29.9%; P=0.07 between CYP3A5*3/*3 and CYP3A5*3/*1 genotypes). These findings were not influenced by fluconazole dose or duration of administration. Significantly more CYP3A5*3/*3 carriers were exposed to tacrolimus dose-uncorrected trough blood tacrolimus concentration value greater than or equal to 15 ng/ml during administration of fluconazole compared with CYP3A5*3/*1 carriers (73.9 vs. 16.7%, P=0.01). Conclusion In renal allograft recipients the CYP3A5*3/*1 genotype is associated with a reduced susceptibility for the inhibitory effects of fluconazole on tacrolimus metabolism, thereby identifying a genetic determinant of the clinical variability of CYP3A-mediated drug interactions.

Pharmacogenetics in solid organ transplantation: current status and future directions.

Tailoring of immunosuppressive drug therapy to the specific requirements of the individual patient to optimize efficacy and minimize toxicity remains one of the biggest challenges in solid organ transplantation. Pharmacogenetic and pharmacogenomic research, studying the effects of genetic polymorphisms on drug disposition and action, holds promise to produce useful clinical tools for individualizing immunosuppressive therapy. In the past years, many interesting studies have been reported, assessing the impact of single nucleotide polymorphisms of genes encoding drug metabolizing enzymes, drug transporters and-to lesser extent-pharmacological target molecules, on pharmacokinetics and pharmacodynamics of immunosuppressive drugs like tacrolimus, cyclosporine, sirolimus, mycophenolic acid, and corticosteroids. Currently, we still are in the early phases of this exciting research, and the question whether pharmacogenetic profiling will eventually become a useful clinical tool remains to be answered.

Calcium Metabolism in the Early Posttransplantation Period

BACKGROUND AND OBJECTIVES Information on the time course of serum calcium levels after renal transplantation is scanty, especially in the early posttransplantation period. Both the abrupt cessation of calcium-containing phosphorus binders and vitamin D (analogs) at the time of surgery and the recovery of renal function may be hypothesized to affect serum calcium levels in this period. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In this prospective observational study, biointact parathyroid hormone, calcidiol, calcitriol, calcium, and phosphorus levels were monitored in 201 renal transplant recipients at the time of transplantation and 3 mo thereafter. In addition, the serum calcium nadir and peak in each individual patient within this time frame were identified and the urinary fractional calcium excretion was determined at month 3. RESULTS Serum calcium levels followed a biphasic pattern with a significant decline during the first postoperative week, followed by a significant increase. High pretransplantation parathyroid hormone levels protect against hypocalcemia within the first postoperative week but put patients at risk for hypercalcemia later. These complications, occurring in 41 and 14% of the patients, respectively, most probably reflect inappropriate calcium release from the skeleton, rather than inappropriate renal calcium handling. CONCLUSIONS Our data indicate that both hypo- and hypercalcemia are prevalent in the early posttransplantation period. Pretransplantation parathyroid function is an important predictor of posttransplantation calcium levels.