Journal List > J Korean Soc Transplant > v.29(1) > 1034461

Yo, Sang, Ha, Ha, Hae, and Hee: Pharmacodynamic Monitoring of Calcineurin Inhibitor in Pediatric Kidney Transplantation

Abstract

Background

Introduction of calcineurin inhibitor (CNI) has markedly improved the outcome of kidney transplantation. While therapeutic drug monitoring is used to adjust the dosage of CNI, some patients, particularly children, still suffer from rejection, infection, and CNI toxicity. This study was conducted in order to assess the adequacy of immunosuppression using pharmacodynamic monitoring.

Methods

Pharmacodynamic monitoring was performed for 64 pediatric kidney allograft recipients. Expression of nuclear factor of activated T lymphocytes (NFAT)-regulated genes in patients' mononuclear cells was measured by quantitative polymerase chain reaction of interleukin-2, interferon-gamma (IFN-), and granulocyte-macrophage colony stimulating-factor before (trough) and 1.5 hour (peak) after ingestion of tacrolimus and the residual gene expression (RGE) was calculated. Global immune response was assessed by Cylex-ImmuKnow assay. Trough and peak levels of tacrolimus were measured and clinical findings of rejection episodes and infectious complications were reviewed retrospectively.

Results

Global immune response measured byImmuKnow did not show correlation with trough and peak levels of tacrolimus. Adenosine triphosphate level of ImmuKnow was higher in patients with Epstein-Barr virus (EBV) infection than in those without infectious complications (515.4±149.0 ng/mL vs. 342.7±155.3 ng/mL, P=0.006). Mean RGE of the three NFAT-regulated genes showed negative correlation with tacrolimus peak levels. RGE of IFN- was lower in patients with other infections except EBV than in those without infectious complications (34.0%±7.5% vs. 56.0%±30.2%, P<0.001).

Conclusions

RGE of NFAT-regulated genes and ImmuKnow did not show significant correlation with clinical manifestation of under- or over-suppression of immune function in pediatric kidney allograft recipients. Further studies are required for development of optimal pharmacodynamic monitoring for pediatric kidney transplantation recipients.

References

1). Nankivell BJ, Borrows RJ, Fung CL, O'Connell PJ, Allen RD, Chapman JR. The natural history of chronic allograft nephropathy. N Engl J Med. 2003; 349:2326–33.
crossref
2). Opelz G, Dohler B. Lymphomas after solid organ transplantation: a collaborative transplant study report. Am J Transplant. 2004; 4:222–30.
crossref
3). Farrugia D, Cheshire J, Mahboob S, Begaj I, Khosla S, Ray D, et al. Mortality after pediatric kidney transplantation in England: a population-based cohort study. Pediatr Transplant. 2014; 18:16–22.
4). Smith JM, Martz K, Blydt-Hansen TD. Pediatric kidney transplant practice patterns and outcome benchmarks, 1987–2010: a report of the North American Pediatric Renal Trials and Collaborative Studies. Pediatr Transplant. 2013; 17:149–57.
crossref
5). Harambat J, Ranchin B, Bertholet-Thomas A, Mestrallet G, Bacchetta J, Badet L, et al. Long-term critical issues in pediatric renal transplant recipients: a singlecenter experience. Transpl Int. 2013; 26:154–61.
crossref
6). Comoli P, Ginevri F. Monitoring and managing viral infections in pediatric renal transplant recipients. Pediatr Nephrol. 2012; 27:705–17.
crossref
7). Karuthu S, Blumberg EA. Common infections in kidney transplant recipients. Clin J Am Soc Nephrol. 2012; 7:2058–70.
crossref
8). Press RR, de Fijter JW, Guchelaar HJ. Individualizing calcineurin inhibitor therapy in renal transplantation: current limitations and perspectives. Curr Pharm Des. 2010; 16:176–86.
9). Wallemacq PE, Verbeeck RK. Comparative clinical pharmacokinetics of tacrolimus in paediatric and adult patients. Clin Pharmacokinet. 2001; 40:283–95.
crossref
10). Mancinelli LM, Frassetto L, Floren LC, Dressler D, Carrier S, Bekersky I, et al. The pharmacokinetics and metabolic disposition of tacrolimus: a comparison across ethnic groups. Clin Pharmacol Ther. 2001; 69:24–31.
crossref
11). Koefoed-Nielsen PB, Gesualdo MB, Poulsen JH, Jorgensen KA. Blood tacrolimus levels and calcineurin phosphatase activity early after renal transplantation. Am J Transplant. 2002; 2:173–8.
crossref
12). Kowalski RJ, Post DR, Mannon RB, Sebastian A, Wright HI, Sigle G, et al. Assessing relative risks of infection and rejection: a metaanalysis using an immune function assay. Transplantation. 2006; 82:663–8.
crossref
13). Israeli M, Klein T, Sredni B, Avitzur Y, Mor E, Bar-Nathen N, et al. ImmuKnow: a new parameter in immune monitoring of pediatric liver transplantation recipients. Liver Transpl. 2008; 14:893–8.
crossref
14). Huskey J, Gralla J, Wiseman AC. Single time point immune function assay (ImmuKnow) testing does not aid in the prediction of future opportunistic infections or acute rejection. Clin J Am Soc Nephrol. 2011; 6:423–9.
15). Billing H, Breil T, Schmidt J, Tonshoff B, Schmitt CP, Giese T, et al. Pharmacodynamic monitoring by residual NFAT-regulated gene expression in stable pediatric liver transplant recipients. Pediatr Transplant. 2012; 16:187–94.
crossref
16). Billing H, Giese T, Sommerer C, Zeier M, Feneberg R, Meuer S, et al. Pharmacodynamic monitoring of cyclosporine A by NFAT-regulated gene expression and the relationship with infectious complications in pediatric renal transplant recipients. Pediatr Transplant. 2010; 14:844–51.
crossref
17). Giese T, Sommerer C, Zeier M, Meuer S. Monitoring immunosuppression with measures of NFAT decreases cancer incidence. Clin Immunol. 2009; 132:305–11.
crossref
18). Sommerer C, Konstandin M, Dengler T, Schmidt J, Meuer S, Zeier M, et al. Pharmacodynamic monitoring of cyclosporine a in renal allograft recipients shows a quantitative relationship between immunosuppression and the occurrence of recurrent infections and malignancies. Transplantation. 2006; 82:1280–5.
crossref
19). Giese T, Zeier M, Meuer S. Analysis of NFAT-regulated gene expression in vivo: a novel perspective for optimal individualized doses of calcineurin inhibitors. Nephrol Dial Transplant. 2004; 19(Suppl 4):iv55–60.
crossref
20). Schulz-Juergensen S, Burdelski MM, Oellerich M, Brandhorst G. Intracellular ATP production in CD4+ T cells as a predictor for infection and allograft rejection in trough-level guided pediatric liver transplant recipients under calcineurin-inhibitor therapy. Ther Drug Monit. 2012; 34:4–10.
crossref
21). Ling X, Xiong J, Liang W, Schroder PM, Wu L, Ju W, et al. Can immune cell function assay identify patients at risk of infection or rejection? A metaanalysis. Transplantation. 2012; 93:737–43.
crossref
22). Vyas S, Roberti I. Lymphocyte ATP immune cell function assay in pediatric renal transplants: is it useful? Transplant Proc. 2011; 43:3675–8.
crossref
23). Ben-Youssef R, Baron PW, Sahney S, Weissman J, Baqai W, Franco E, et al. The impact of intercurrent EBV infection on ATP levels in CD4+ T cells of pediatric kidney transplant recipients. Pediatr Transplant. 2009; 13:851–5.
crossref
24). Sommerer C, Giese T, Schmidt J, Meuer S, Zeier M. Ciclosporin A tapering monitored by NFAT-regulated gene expression: a new concept of individual immunosuppression. Transplantation. 2008; 85:15–21.
crossref
25). Sommerer C, Hartschuh W, Enk A, Meuer S, Zeier M, Giese T. Pharmacodynamic immune monitoring of NFAT-regu-lated genes predicts skin cancer in elderly longterm renal transplant recipients. Clin Transplant. 2008; 22:549–54.
crossref
26). Zahn A, Schott N, Hinz U, Stremmel W, Schmidt J, Ganten T, et al. Immunomonitoring of nuclear factor of activated T cells-regulated gene expression: the first clinical trial in liver allograft recipients. Liver Transpl. 2011; 17:466–73.
crossref
27). Hooper E, Hawkins DM, Kowalski RJ, Post DR, Britz JA, Brooks KC, et al. Establishing pediatric immune response zones using the Cylex ImmuKnow assay. Clin Transplant. 2005; 19:834–9.
crossref

Table 1.
Characteristics of patients (n=62)
Characteristic Value
Gender (male:female) 35:27
Age (yr) 12.9 (4.1∼19.2)
Time after kidney transplantation (yr) 2.9 (0.2∼10.9)
Cause of ESRD  
NPHP/MCKD 15 (24.2)
Focal segmental glomerular sclerosis 11 (17.7)
Reflux nephropathy 11 (17.7)
Renal hypoplasia/dysplasia 7 (11.3)
Unknown 5 (8.1)
Others 13 (21.0)
No. of drug monitoring 128
Age at drug monitoring (yr) 12.9 (4.1∼19.2)
Immunosuppressant regimen  
CNI+MMF 78 (60.9)
CNI+MMF+steroid 31 (24.2)
CNI+steroid 11 (8.6)
CNI only 6 (4.7)
CNI+azathioprine 2 (1.6)
Infectious complications at drug monitoring  
EBV infection 8 (6.1)
CMV infection 2 (1.5)
Viral gastroenteritis 3 (2.3)
Upper respiratory infection 3 (2.3)
Rejections at drug monitoring  
Acute T cell-mediated type 4 (3.1)
Acute antibody-mediated type or mixed 4 (3.1)
Data are presented as median (range) or number (%).

Abbreviations: ESRD, end stage renal disease; NPHP, nephrono-phthisis; MCKD, medullary cystic kidney disease; CNI, calcineurin inhibitor; MMF, mycophenolate mofetil; EBV, Epstein-Barr virus; CMV, cytomegalovirus.

Table 2.
Correlation between pharmacokinetic and pharmacodynamic monitoring of calcineurin inhibitor
  Tacrolimus through level Tacrolimus 1.5 hr level
r2 P-value r2 P-value
ImmuKnow 0.001 0.757 0.021 0.167
IL-2 RGE 0.001 0.764 0.021 0.174
IFN- RGE 0.003 0.620 0.041 0.055
GM-CSF RGE 0.046 0.037 0.066 0.015
Mean RGE 0.011 0.312 0.060 0.019

Abbreviations: IL-2, interleukin-2; RGE, residual gene expression; IFN-, interferon-gamma; GM-CSF, granulocyte-macrophage colony stimulating-factor.

Table 3.
Results of pharmacokinetic and pharmacodynamic monitoring according to the clinical status
Variable Stable (n=104) Infection (n=16) Rejection (n=8)
Age (yr) 12.4±2.9 10.8±4.0 14.5±2.3 a
Duration after TPL (yr) 3.6±2.4 3.0±2.3 3.8±2.3
Gender (male:female) 56:48 11:5 6:2
ImmuKnow (ng/mL) 344.5±152.9 412.1±168.0 320.2±211.0
IL-2 RGE (%) 50.9±62.1 23.8±28.0 46.4±22.5
IFN- RGE (%) 56.5±29.4 50.9±29.7 52.9±45.1
GM-CSF RGE (%) 54.7±64.4 41.5±37.8 32.2±27.1
Mean RGE (%) 54.0±42.2 38.7±27.0 43.8±28.7
Tac trough level (ng/mL) 4.27±1.60 4.29±1.62 4.34±1.60
Tac 1.5 hr level (ng/mL) 12.35±4.3 14.08±6.69 10.99±6.66
Tac dose (mg/BSA) 3.12±1.42 2.84±1.50 2.90±0.94
Tac 1.5 hr level/dose 4.62±2.52 5.86±3.18 3.93±2.11
Data are presented as mean±SD.

Abbreviations: TPL, transplantation; IL-2, interleukin-2; RGE, residual gene expression; IFN-, interferon-gamma; GM-CSF, granu-locyte-macrophage colony stimulating-factor; Tac, Tacrolimus; BSA, body surface area.

a P<0.05 compared with stable group.

Table 4.
Results of pharmacokinetic and pharmacodynamic monitoring according to the causes of infection
Variable Other infection (n=7) No infection (n=113) EBV infection (n=8)
Age (yr) 13.3±3.9 12.6±2.9 8.2±2.6 b
Duration after TPL (yr) 2.3±1.7 3.7±2.5 2.7±1.2
Gender (male:female) 5:2 63:50 5:3
ImmuKnow (ng/mL) 283.0±101.7 342.7±155.3 515.4±149.0 a
IL-2 RGE (%) 13.1±18.0 50.2±59.7 34.4±36.7
IFN- RGE (%) 34.0±7.5 b 56.0±30.2 69.3±36.7
GM-CSF RGE (%) 33.7±33.0 52.5±62.5 57.3±41.1
Mean RGE (%) 26.9±16.6 52.9±41.2 53.7±32.0
Tac trough level (ng/mL) 4.73±2.35 4.27±1.59 3.94±0.76
Tac 1.5 hr level (ng/mL) 15.23±7.05 12.20±4.51 13.93±6.75
Tac dose (mg/BSA) 3.41±1.73 3.09±1.40 2.55±1.20
Tac 1.5 hr level/dose 4.92±1.87 4.58±2.48 6.67±4.13 a
Data are presented as mean±SD.

Abbreviations: EBV, Epstein-Barr virus; TPL, transplantation; IL-2, interleukin-2; RGE, residual gene expression; IFN-, interferon-gamma; GM-CSF, granulocyte-macrophage colony stimulating-factor; Tac, tacrolimus; BSA, body surface area.

a P<0.05 compared with no infection group;

b P<0.001 compared with no infection group.

TOOLS
Similar articles