Low-dose CsA Research Articles

Outcomes of Cyclosporine Ophthalmic Emulsion 0.05% Use in Pediatric Blepharokeratoconjunctivitis

Purpose: Pediatric blepharokeratoconjunctivitis (BKC) is a chronic ocular surface inflammatory disease. In this article, we report our experience using low-dose topical cyclosporine (CsA) 0.05% for the treatment of pediatric BKC. Methods: A retrospective review was conducted on pediatric patients treated with topical CsA 0.05% for BKC between 2018 and 2022 at a single academic institution. Patients with less than 6 weeks of follow-up, a history of ocular infectious disease, or previous usage of topical/systemic immunomodulators (except corticosteroids) were excluded. The primary outcome was the change in the number of episodes of disease reactivation (flare) before and after the use of CsA 0.05%. Secondary outcomes included the number of clinic visits per year, success rate in corticosteroid tapering, and usage of rescue topical corticosteroid. Results: A total of 21 patients (13 male patients and 8 female patients) treated with CsA 0.05% twice daily were included in this study. The mean age of patients was 9.7 ± 4.2 years, and the mean follow-up period was 62.2 ± 62.5 weeks. The median number of flares per year was 5.6 (95% CI, 3.9–7.3) before treatment with CsA 0.05%, which reduced to 0.0 (95% CI, 0.0–0.9) while on CsA 0.05% (P = 0.01). The median number of clinic visits significantly reduced from 9.5 (95% CI, 7.3–11.7) to 4.5 (95% CI, 3.7–6.8) visits per year (P < 0.0001). After 3.5 ± 2.7 weeks, 90.4% of patients using topical CSs concomitantly with topical CsA 0.05% could be successfully tapered off their topical CSs. Of the patients who tapered off their topical CSs, 3 patients (15%) later required rescue topical CSs despite ongoing CsA 0.05% treatment because of acute flare episodes. No adverse effects were reported with CsA use. Conclusions: This study demonstrates the efficacy of low-dose topical CsA 0.05% in reducing the frequency of acute flares and clinic visits per year in pediatric BKC.

Comparative Inhibitory Effects of Tacrolimus, Cyclosporine, and Rapamycin on Human Anti-Pig Xenogeneic Mixed Lymphocyte Reactions.

Long-term immunosuppressive maintenance therapy is necessary to prevent the rejection of xenografts. However, it is still unclear which oral immunosuppressant is most suitable for pig-to-human xenotransplantation . A xenogeneic mixed lymphocyte reaction (MLR) system was established using peripheral blood mononuclear cells (PBMCs) isolated from wildtype (WT) or GTKO/CMAHKO/β4GalNT2KO (TKO) pigs as stimulator cells and human PBMCs as responder cells. Various concentrations of tacrolimus (Tac), cyclosporine (CsA), or rapamycin (Rapa) were added to the MLR system as interventions. The inhibitory effects of the three immunosuppressants on the proliferation and cytokine production of human T cells were studied and compared. The inhibitory effect of anti-CD154 mAb alone or in combination with Tac/CsA/Rapa on xenoreactive MLR was also investigated. PBMCs from both WT and TKO pigs stimulated significant proliferation of human T cells. Tac had a strong inhibitory effect on human T-cell proliferation stimulated by pig PBMCs. CsA inhibited human T-cell proliferation in a typical dose-dependent manner. When Tac and CsA concentrations reached 5 and 200ng/mL, respectively, the proliferation rates of CD3+/CD4+/CD8+ T cells were reduced almost to a negative level. Even at high concentrations, Rapa had only a moderate inhibitory effect on xenogeneic MLR. The inhibitory effects of these three immunosuppressants on xenogeneic T-cell responses were further confirmed by the detection of CD25 expression and supernatant cytokines (IL-2, IL-6, IFN-γ, TNF-α, IL-4, IL-10, and IL-17). Although anti-CD154 mAb monotherapy showed only moderate inhibitory effects on xenoreactive T-cell proliferation, low-dose anti-CD154 mAb combined with low-dose Tac, CSA, or Rapa could produce significant synergistic inhibitory effects. Tac is more efficient than CsA or Rapa in inhibiting xenogeneic T-cell responses in vitro. If used in combination with anti-CD154 mAb, all the three immunosuppressants can achieve satisfactory synergistic inhibitory effects.

Abstract 10121: Hypoimmunogenic Human Induced Pluripotent Stem Cells Derived Cardiomyocytes for Cardiac Regeneration

Introduction: Post-transplant rejection resulting from human leukocyte antigen (HLA) mismatch is a challenge in allogeneic cell therapy. Human amniotic fluid stem cell-derived iPSCs (hAFSC-iPSCs) are proved to have immune privilege. Hypothesis: hAFSC-iPSC derived cardiomyocytes (hAFSC-iPSC-CMs) are less immunogenic. Methods and Results: hAFSC-iPSCs and hAFSC-iPSC-CMs expressed classical HLA-Ia (HLA-A, -B and -C) and non-classical HLA-Ib but did not have HLA-II expression, indicating that these cells may not be highly immunogenic. We did T Cell Assays to confirm low immunogenicity of hAFSC-iPSC-CMs. We did ischemia-reperfusion surgery of left anterior descending coronary artery to create large transmural myocardial infarction in rats. At post-infarct 4 days, we injected human pluripotent stem cell-derived cardiomyocytes (1.0х10 7 cells/kg), including human embryonic stem cell-derived cardiomyocytes (hESC-CMs), hiPSC-CMs and hAFSC-iPSC-CMs, into the infarcted myocardium. Using very low dose of cyclosporine A (CsA, 2.5 mg/kg/day), only hAFSC-iPSC-CMs transplantation could improve post-infarct cardiac function (left ventricular ejection fraction improvement in hAFSC-iPSC-CMs, hESC-CMs and hiPSC-CMs: 13.1 ± 1.8%, 0.6 ± 1.7% and -1.9 ± 1.6%, respectively). Compared with hESC-CMs and hiPSC-CMs, hAFSC-iPSC-CM transplantation remuscularized the infarcted myocardium with infarct size reduction. Using very low dose CsA, these engrafted hAFSC-iPSC-CMs resulted in a 3-month survival in vivo. hAFSC-iPSC-CMs expressing non-classical HLA-Ib evaded detection and attack by natural killer (NK) cells and cytotoxic T cells because these hAFSC-iPSC-CMs activated the protein tyrosine phosphatase SHP-1/SHP-2 signalling pathway of NK cells and cytotoxic T cells which downregulated signal transducer and activator of transcription 1 (STAT-1) and nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) expression. Conclusions: We demonstrated the immune privilege of hAFSC-iPSC-CM for cardiac regeneration. HLA-Ib-expressing hiPSCs with reduced HLA-II expression are less immunogenic and may serve as platforms for regenerative medicine.

Association between the cumulative dose of cyclosporine and liver enzyme abnormalities in dermatology patients managed with a low‐dose regimen

Cyclosporine (CsA) is an immunosuppressive agent that specifically inhibits T cell-related immune responses. There is little evidence regarding the association between low-dose CsA administration and abnormal hepatic function in dermatology patients. This study aimed to examine the association between the cumulative dose of CsA and liver enzyme abnormalities obtained from peripheral blood tests in patients with skin diseases. A retrospective single-center study of 697 patients who were prescribed CsA for skin disease in the outpatient dermatology clinic between 2015 and 2019 were performed. Multiple logistic regression with confounder adjustment was performed to assess the association between the cumulative dose of CsA and liver enzyme abnormalities. Compared to patients with the lowest cumulative dose of CsA (˂7.0 g), patients with the highest cumulative dose of CsA (≥30.6 g) were significantly associated with an increased likelihood of developing liver enzyme abnormalities (odds ratio [OR]=1.96; 95% confidence interval [CI]=1.02-3.79). In the stratified analysis, patients with the highest cumulative dose of CsA (≥30.6 g) were significantly associated with a 1.5-or higher alanine aminotransferase elevation from baseline (OR=2.26, CI=1.08-4.73). Patients prescribed long-term, low-dose CsA up to a high cumulative dose (≥30.6 g) may be associated with an increased risk of developing liver enzyme abnormalities. However, these liver enzyme elevations were not severe in magnitude and were reversible.

Post-transplant Diabetes Mellitus: What Physicians Need to Know.

Post-transplant diabetes mellitus (PTDM) is a common problem among solid organ transplant recipients contributing to morbidity and affecting patient as well as graft survival adversely. It can occur at any period following transplantation, but maximum incidence is observed in the first few months, with a second peak after a few years after transplantation. The pathogenesis is complex and poorly understood, however, it is associated with both dysfunctional beta-cells and insulin resistance. Both nonpharmacologic and antidiabetic therapies are important for adequate glycemic control. This point of view article provides a short review on PTDM in solid organ transplantation (SOT) recipients from a general physician's perspective.

Topical Cyclosporine in Oral Lichen Planus-A Series of 21 Open-Label, Biphasic, Single-Patient Observations.

Topical cyclosporine (CSA) has been reported as an alternative treatment in steroid-refractory oral lichen planus (OLP), but evidence is limited and conflicting. An N-of-1 trial setting could be appropriate to evaluate interindividual differences in treatment response. We studied a series of 21 open-label, biphasic single-patient observations. Patients (15 women, 6 men) with OLP recalcitrant to topical steroids received four weeks of CSA mouth rinse (200 mg/twice daily) followed by four weeks of drug withdrawal. Pain (visual analogue scale (VAS) score), disease extent (physicians’ global assessment (PGA) score) and quality of life (Dermatology Life Quality Index (DLQI) score,) were assessed at baseline (T0), after four weeks of treatment (T1) and after another four weeks without treatment (T2). Median age was 58 years (interquartile range/IQR = 52–67) and median disease duration was 18 months (IQR = 12–44). Median baseline VAS score decreased significantly at T1 (p = 0.0003) and increased at T2 (p = 0.032) (T0 = 5 (IQR = 3–6.5); T1 = 2 (IQR = 0.5–3.4); T2 = 3 (IQR = 2–4.8)). Similarly, median baseline PGA score decreased significantly at T1 (p = 0.001) and increased at T2 (p = 0.007) (T0 = 2 (IQR = 1.3–2.5); T1 = 1 (IQR = 1–2); T2 = 2 (IQR = 1–2)). Median baseline DLQI score also decreased significantly at T1 (p =.027) but did not change at T2 (p = 0.5) (T0 = 2.5 (IQR = 1–5.8); T1 = 1 (IQR = 0–3); T2 = 1 (IQR = 1–4)). CSA responders (n = 16) had significantly higher median baseline VAS scores (5.2 (IQR = 5–6.5)) than nonresponders (n =5) (2 (IQR = 2–3.5) (p = 0.02). In our study, pain, disease extent and quality of life of patients with OLP improved significantly during therapy with low-dose CSA mouth rinse and exacerbated after drug withdrawal. Remarkably, patients with high initial VAS scores seemed to profit most.

Epigenetic Loss of the HLA-DR15 Expression on Hematopoietic Stem Progenitor Cells in Patients with Acquired Aplastic Anemia Characterized By Cyclosporine Dependency: A Novel Mechanism Underlying the Immune Escape of Hematopoietic Stem Progenitor Cells

[Background] HLA-DR15 (DR15) has been implicated in the susceptibility to immune-mediated bone marrow (BM) failure, such as acquired aplastic anemia (AA), wherein the hematopoietic function depends on cyclosporine (CsA), paroxysmal nocturnal hemoglobinuria (PNH) with BM failure, and low-risk myelodysplastic syndrome responsive to immunosuppressive therapy. However, how DR15 contributes to the development of such immune-mediated BM failure remains unclear. Although the copy-number neutral loss of heterozygosity in chromosome 6p (6pLOH) of hematopoietic stem progenitor cells (HSPCs) in AA patients sometimes involves the HLA-DRB1 region, the frequency of the resultant DR15 loss is low, suggesting little involvement of this DR allele in the escape of HSPCs from cytotoxic T-cell attack. Several studies have recently reported that acute myeloid leukemia cells that relapse after allogeneic hematopoietic stem cell transplantation often lack HLA class II expression through an epigenetic mechanism and thereby escape the graft-versus-leukemia effect. The epigenetic loss of HLA class II expression may also occur in HSPCs that survive the immune attack in AA patients in remission. [Objectives/Methods] To test this hypothesis, we determined the HLA-DR expression on HSPCs defined by lineage-CD45dimCD34+CD38+ cells as well as their subpopulations, including common myeloid progenitors (CMPs), megakaryocyte-erythroid progenitors (MEPs), and granulocyte-monocyte progenitors (GMPs), in the peripheral blood of 52 AA patients (34 with DR15 and 18 without DR15) and 20 healthy individuals using flow cytometry (FCM) with anti-pan-HLA-DR antibodies. All patients were in remission after ATG-based therapy (ATG+CsA±thrombopoietin receptor agonists [TPO-RA] or anabolic steroids [AS], n=19), CsA-based therapy (CsA±TPO-RA or AS, n=27), and others (n=6), and 18 required low-dose CsA to maintain remission. Eighteen (35%) had HLA-class I allele-lacking (HLA-class I[-]) leukocytes due to 6pLOH and/or allelic mutations while 33 (63%) had 0.003-83.8% (median 0.194%) GPI-anchored protein-deficient (GPI[-]) granulocytes. HLA-DR(-) HSPCs detected in some patients were sorted together with their HLA-DR(+) counterparts and subjected to incubation in the presence of interferon gamma (IFN-γ) to see whether or not the DR expression was restored; in addition, they were subjected to RNA sequencing to compare the gene expression profiles between DR(-) and DR(+) HSPCs. [Results] Five (9.6%) of the 52 AA patients had 28.6% to 42.3% (median 34.0%) DR(-) cell populations in HSPCs, which were not detected in either monocytes or B lymphocytes of the same patients or in HSPCs of any healthy individuals (Figure 1a). All 5 patients possessed either HLA-DRB1*15:01 (n=3), DRB1*15:02 (n=1), or DRB1*15:01/15:02 (n=1), with the other DRB1 alleles differing among individuals, and their hematopoietic function depended on CsA, except for 1 patient (Case 5) whose HSPCs consisted of 69% GPI(+) and 31% GPI(-) cells. Of particular interest, Case 5's DR(-) cells were detected in GPI(+) HSPCs but not in GPI(-) HSPCs (Figure 1b). None of the 5 patients possessed HLA-class I(-) leukocytes, which were detected in 18 (38%) of 47 patients not possessing DR(-) HSPCs. In contrast to the patients possessing DR(-) HSPCs, CsA dependency was only observed in 13 (28%) of the 47 AA patients without DR(-) HSPCs. Incubation of sorted DR(-) HSPCs in the presence of IFN-γ for 72 h resulted in full restoration of the DR expression in all HSPC subpopulations (Figure 2). A comparison of the transcriptome profile between DR(-) and DR(+) HSPCs revealed that the signature of differentially expressed genes was enriched in immune response-related genes. [Conclusions] HSPCs that lacked DR due to an epigenetic mechanism were frequently detected in AA patients with DR15 characterized by CsA dependency. Although the loss of expression occurred in both DR alleles, the fact that only DRB1*15:01 or 15:02 was an allele shared by the five patients indicates that the DR loss phenomenon targeted DR15. The DR15(-) HSPCs may escape from antigen-specific CD4+ T-cell attack, which cannot be completely abolished by CsA. As demonstrated by findings of Case 5 showing the presence of a DR(-) cell population only in GPI(+) HSPCs, the lack of GPI may be a mechanism underlying substitution for the DR15 loss. Disclosures Takamatsu: Ono pharmaceutical: Honoraria, Research Funding; SRL: Consultancy, Research Funding; Janssen Pharmaceutical: Consultancy, Honoraria, Research Funding; Bristol-Myers Squibb: Honoraria, Research Funding; Adaptive Biotechnologies: Honoraria. Ishiyama:Alexion: Research Funding; Novartis: Honoraria. Yamazaki:Kyowa Kirin: Honoraria, Research Funding; Novartis: Honoraria. Nakao:Alexion: Research Funding; Novartis: Honoraria; Kyowa Kirin: Honoraria; Symbio: Consultancy.

Dual T-Cell Depletion with a Very Low Dose of ATG and Ptcy Provides an Effective Control of Acute Gvhd in PBSC RIC Allo-HSCT

Introduction As has been described by Dr. Viswabandya et al, the combination of anti-thymoglobulin (ATG), post-transplant cyclophosphamide (PTCy) and cyclosporine (CsA) provides an effective control of graft-versus host disease (GVHD) in peripheral blood (PB) allo-HSCT. We aim to report our experience in reduced intensity conditioning (RIC) allo-HSCT using a novel GVHD prophylaxis composed by a very low dose of ATG, PTCy and CsA for GVHD prophylaxis. Patients and methods Between May 2018 and April 2019, 106 adult patients underwent RIC allo-HSCT with the present GVHD prophylaxis. All these recipients were included in the study. RIC regimen was composed by fludarabine, busulfan, and 200cGy of total body irradiation. For GVHD prophylaxis all recipients received a total dose of 2mg/kg of rabbit-ATG on day -3 (0.5mg/kg) and -2 (1.5mg/kg), PTCy 50mg/m2/day on day +3 and +4, and CsA since day +5. Data was collected retrospectively and updated on July 2019. The median follow-up was 7.6 months (range: 0.4-14.6) and survival percentages were calculated at 6 months. The cum.Inc of GVHD was assessed accounting relapse and death as competing events. Results The main baseline and post-transplant information is summarized in the Table 1 and 2. The cum.Inc of grade II-IV and III-IV acute GVHD at day +100 was 19% and 7.7%. The cum.Inc of grade II- IV was not significantly affected by donor type (P=0.787). However, the cum.Inc of grade III-IV was significantly higher in those recipients who received haploidentical or 9/10 matched unrelated donor (MUD) grafts (p=0.048). Rates of CMV and EBV reactivation were respectively 62.3% and 68.9%. No patients were diagnosed with CMV disease. Biopsy proven post-transplant lymphoproliferative disorder was diagnosed in only 1 recipient and successfully resolved after rituximab. Thirty-two (30.2%) recipients died and 16 (15.1%) relapsed during the follow-up. Main causes of death were relapse 13 (12.3%) and infection 6 (5.7%). The main outcome information is reported in the Table 2 and Plot 1 and 2. Those recipients who received grafts from matched related and unrelated donors had a significant better non-relapse mortality (NRM) (P=0.001), overall survival (OS) (P=0.02), relapse-free survival (RFS) (P=0.03) and GVHD-free/RFS (P=0.006). Table 3 shows the impact of risk factors in transplant outcomes. Those recipients with an HCT-CI score ≥3 had a significant worse OS (HR 2.5; P=0.024) and RFS (HR 2.5; P=0034). Those recipients who received grafts from 9/10 MUD and haploidentical donors had a significant worse RFS (HR 2.1; P=0.049). Disease risk index was not a significant risk factor for OS or RFS. Lastly, those recipients who received grafts from haploidentical donors had a significant worse GRFRS (HR 2.9; P=0.04). Conclusion The dose of ATG for GVHD prophylaxis is not well established. The combination of ATG (2mg/kg), PTCy, and CsA is safe and provides an effective acute GVHD prophylaxis in PB RIC allo-HSCT. Further investigations are required to analyze the effect of this prophylaxis in chronic GVHD to better state long-term outcome conclusions and to improve post-transplant outcomes in those recipients who received grafts from mismatched donor sources (haploidentical and 9/10 matched unrelated donors). Disclosures Michelis: CSL Behring: Other: Financial Support. Mattsson:Celgene: Honoraria; Therakos: Honoraria; Gilead: Honoraria.

15-PGDH Inhibition Mitigates Aplastic Anemia Severity

Acquired aplastic anemia (AA) is a primary bone marrow (BM) failure syndrome in which hematopoietic stem cells (HSC) are depleted in an immune-mediated fashion. AA is rare, with an estimated 900 new cases per year in the U.S., and onset is typically in childhood or adolescence. AA is fatal if untreated and poses a high burden of frequent, long-term transfusions and associated complications. The current standard of care for severe AA is allogeneic stem cell transplantation for young patients who have a matched related donor or immunosuppressive therapy (IST) for those who do not. Among other toxicities, prolonged neutropenia, immune suppression and the resulting risk of severe infections remain challenges in managing even AA patients responding to standard therapies. These challenges are more critical in severe AA patients refractory to front line therapy. Importantly, this disorder is also associated with clonal evolution of myeloid progenitor cells, and the development of myelodysplastic syndrome and acute myeloid leukemia in 10-20% of cases (Yoshizato, N Engl J Med, 2015). Therefore, additional therapies to either block immune-mediated BM destruction, or to accelerate hematologic recovery in patients receiving IST, are needed. Inhibiting 15-hydroxyprostaglandin dehydrogenase (15-PGDH) using the small molecule SW033291 (PGDHi) in mice was recently shown by Zhang et al. to increase BM prostaglandin E2 (PGE2) levels, expand HSC numbers, accelerate hematologic reconstitution following BM transplantation, and synergize with G-CSF for neutrophil recovery (Zhang, Science, 2015). To determine whether PGDHi is capable of improving hematopoiesis in acquired AA, we induced immune-mediated BM failure in mice (Chen, Blood, 2004) and treated with SW033291 starting at day 4 post-induction. PGDHi mitigated both neutropenia and thrombocytopenia, increased phenotypic and functional BM HSC and progenitor cells, and significantly extended survival compared to vehicle-treated mice in the same cohort. Analysis of peripheral blood serum revealed no impact of PGDHi on circulating IFNγ levels, however. These data suggest that PGDHi protects hematopoietic stem cell function in acquired AA. There was an observed trend for lower CD8+ FasL+ T cells in the BM of PGDHi treated mice. Experiments are underway to determine if PGDHi reproducibly impairs T cell activation and modulates the inflammatory cytokine milieu in the BM. A comparison of PGDHi and Cyclosporine (CsA), the backbone of IST in AA, is also underway to examine if PGDHi can augment IST efficacy using lower, better tolerated cyclosporine dosing. In this murine model, low dose (10mg/kg) CsA, unlike standard dose (50mg/kg) CsA, did not cause kidney or liver toxicity as assessed in peripheral blood serum, but failed to protect against neutropenia and thrombocytopenia. Preliminary results demonstrate that dual PGDHi and low dose Cyclosporine administration significantly enhances neutrophil and platelet recovery, achieving responses similar to that of standard dose IST, thus suggesting that PGDHi can complement IST to accelerate hematologic recovery and reduce morbidity in severe AA. Disclosures Markowitz: Rodeo Therapeutics: Equity Ownership, Membership on an entity's Board of Directors or advisory committees, Patents & Royalties, Research Funding. Desai:Rodeo Therapeutics: Consultancy.

Low-dose cyclosporine for active lupus nephritis: a dose titration approach.

Achievement of complete renal remission (CR) is an important goal in lupus nephritis (LN) treatment. The use of cyclosporine (CsA) for active LN has been challenged because of variations in CsA doses and reports of adverse reactions (AR). A cohort of 62 patients with active LN (induction-resistant LN and flared LN) who were treated with CsA was evaluated. CsA was started at 50 mg/day and titrated up 25 mg/day every 2-4 weeks until CR was achieved or until treatment termination because of AR. The range of CsA dosage was 50-200 mg/day, and mean CsA dose was 102.8 ± 50.43 mg/day (1.73 ± 0.91 mg/kg/day). CsA plus mycophenolate mofetil and prednisolone was administered to 35.5% of patients, while the other 64.5% were treated with CsA and prednisolone. 90.32% had achieved CR and 4.84% had partial remission after 12 months of treatment. UPCR (urinary protein:creatinine ratio) decreased significantly in both groups (2.58 ± 3.37 to 0.36 ± 0.71 and 2.32 ± 1.45 to 0.29 ± 0.24 respectively) (P < 0.001). Non-renal activity including arthritis, alopecia, hematologic and cutaneous conditions improved in all patients. Patients whose prednisolone dose were increase received higher doses of prednisolone at baseline than patients who had stable prednisolone dose, but after 12 months the difference in dosage was insignificant (p = 0.58). Patients with active LN can be effectively treated with low dose CsA, and the dose titration approach can lead to 90.32% CR with low AR rates. No difference in clinical response was observed among patients who received CsA plus prednisolone or CsA plus MMF and prednisolone.

Addition of cyclosporine/tacrolimus for pediatric relapsed lupus nephritis during mycophenolate mofetil maintenance therapy.

ObjectiveWe aimed to evaluate the efficacy of low-dose cyclosporine (CsA) or tacrolimus (Tac) in children with proliferative lupus nephritis (PLN) during maintenance therapy.MethodsA low dose of CsA or Tac was added to 11 children who relapsed during mycophenolate mofetil (MMF) maintenance therapy. Renal remission was analyzed at 3 and 6 months, and at 1, 2, and 3 years after CsA/Tac addition. Adverse effects were recorded.ResultsThe clinical response rates were 81.9%, 100%, 90.0%, 100%, and 100% at 3 months, 6 months, 1 year, 2 years, and 3 years after CsA/Tac addition, respectively. Complete renal remission rates were 45.5%, 45.5%, 40.0%, 44.4%, and 71.4% at 3 months, 6 months, 1 year, 2 years, and 3 years after CsA/Tac addition, respectively. None of the patients had severe adverse events.ConclusionLow-dose CsA/Tac combined with MMF shows a promising effect in renal remission with acceptable safety in children with PLN. Therefore, this combination would be a good choice for children with lupus nephritis who relapse or have suboptimal MMF maintenance therapy.

The Effect of Mycophenolate Mofetil versus Cyclosporine as Combination Therapy with Low Dose Corticosteroids in High-risk Patients with Idiopathic Membranous Nephropathy: a Multicenter Randomized Trial.

BackgroundAppropriate immunosuppressive therapy for patients with idiopathic membranous nephropathy (MN) remains controversial. The effect of mycophenolate mofetil (MMF) versus cyclosporine (CsA) combined with low-dose corticosteroids was evaluated in patients with idiopathic MN in a multi-center randomized trial (NCT01282073).MethodsA total of 39 biopsy-proven idiopathic MN patients with severe proteinuria were randomly assigned to receive MMF combined with low-dose corticosteroids (MMF group) versus CsA combined with low-dose corticosteroids (CsA group), respectively, and followed up for 48 weeks. Complete or partial remission rate of proteinuria and estimated glomerular filtration rate (eGFR) at 48 weeks were compared.ResultsThe level of proteinuria at baseline and at 48 weeks was 8.9 ± 5.9 and 2.1 ± 3.1 g/day, respectively, in the MMF group compared to 8.4 ± 3.5 and 3.2 ± 5.7 g/day, respectively, in the CsA group. In total, 76.1% of the MMF group and 66.7% of the CsA group achieved remission at 48 weeks (95% confidence interval, −0.18 to 0.38). There was no difference in eGFR between the two groups. Anti-phospholipase A2 receptor Ab levels at baseline decreased at 48 weeks in the complete or partial remission group (P = 0.001), but were unchanged in the no-response group. There were no significant differences between the two groups in changes in the Gastrointestinal Symptom Rating Scale and Gastrointestinal Quality of Life Index scores from baseline to 48 weeks.ConclusionIn combination with low-dose corticosteroids, the effect of MMF may not be inferior to that of CsA in patients with idiopathic MN, with similar adverse effects including gastrointestinal symptoms.Trial RegistrationClinicalTrials.gov Identifier: NCT01282073

Influence of cyclosporine and everolimus on the main mycophenolate mofetil pharmacokinetic parameters: Cross-sectional study.

The objective of the present study was to assess the effect of cyclosporine (CsA) on the pharmacokinetic parameters of mycophenolic acid (MPA), an active mycophenolate mofetil (MMF) metabolite, and to compare with the effect of everolimus (EVR).Anonymized medical records of 404 kidney recipients were reviewed. The main MPA pharmacokinetic parameters (AUC(0–12) and Cmax) were evaluated.The patients treated with a higher mean dose of CsA displayed higher MPA AUC(0–12) exposure in the low-dose MMF group (1000 mg/day) (40.50 ± 10.97 vs 28.08 ± 11.03 h mg/L; rs = 0.497, P < 0.05), medium-dose MMF group (2000 mg/day) (43.00 ± 6.27 vs 28.85 ± 11.08 h mg/L; rs = 0.437, P < 0.01), and high-dose MMF group (3000 mg/day) (56.75 ± 16.78 vs 36.20 ± 3.70 h mg/L; rs = 0.608, P < 0.05).A positive correlation was also observed between the mean CsA dose and the MPA Cmax in the low-dose MMF group (Cmax 22.83 ± 10.82 vs 12.08 ± 5.59 mg/L; rs = 0.507, P < 0.05) and in the medium-dose MMF group (22.77 ± 8.86 vs 13.00 ± 6.82 mg/L; rs = 0.414, P < 0.01).The comparative analysis between 2 treatment arms (MMF + CsA and MMF + EVR) showed that MPA AUC(0–12) exposure was by 43% higher in the patients treated with a medium dose of MMF and EVR than in the patients treated with a medium dose of MMF and CsA.The data of the present study suggest a possible CsA versus EVR influence on MMF pharmacokinetics. Study results show that CsA has an impact on the main MPA pharmacokinetic parameters (AUC(0–12) and Cmax) in a CsA dose-related manner, while EVR mildly influence or does not affect MPA pharmacokinetic parameters. Low-dose CsA (lower than 180 mg/day) reduces MPA AUC(0–12) exposure under the therapeutic window and may lead to ineffective therapy, while a high-dose CsA (>240 mg/day) is related to greater than 10 mg/L MPA Cmax and increases the likelihood of adverse events.

Cyclosporine Sparing Effect of Enteric-Coated Mycophenolate Sodium in De Novo Kidney Transplantation.

PurposeThe increased tolerability of enteric-coated mycophenolate sodium (EC-MPS), compared to mycophenolate mofetil, among kidney transplant recipients has the potential to facilitate cyclosporine (CsA) minimization. Therefore, a prospective trial to determine the optimum EC-MPS dose in CsA-based immunosuppression regimens is necessary.Materials and MethodsA comparative, parallel, randomized, open-label study was performed for 140 patients from four centers to compare the efficacy and tolerability of low dose CsA with standard dose EC-MPS (the investigational group) versus standard dose CsA with low dose EC-MPS (the control group) for six months in de novo kidney transplant recipients. Graft function, the incidence of efficacy failure [biopsy-confirmed acute rejection (BCAR), death, graft loss, loss to follow-up], and adverse events were compared.ResultsThe mean estimated glomerular filtration rate (eGFR) of the investigational group at six months post-transplantation was non-inferior to that of the control group (confidence interval between 57.3 mL/min/1.73m2 and 67.4 mL/min/1.73 m2, p<0.001). One graft loss was reported in the control group, and no patient deaths were reported in either group. The incidence of BCAR of the investigational group was 8.7%, compared to 18.8% in the control group (p=0.137), during the study period. There were no significant differences (p>0.05) in the incidence of discontinuations and serious adverse events (SAE) between the groups.ConclusionCsA minimization using a standard dose of EC-MPS kept the incidence of acute rejection and additional risks as low as conventional immunosuppression and provided therapeutic equivalence in terms of renal graft function and safety issues.

Effectiveness and safety of conversion therapy with the combination of sirolimus with low dose cyclosporine in renal transplantation recipients: a five-year clinical observation

To assess the effectiveness and safety of the conversion therapy from traditional cyclosporine (CsA) triple immunosuppression therapy to sirolimus (SRL) combined with low dose CsA and prednisone (Pred) in renal transplantation recipients in a five-year follow-up period. A prospective, open-label non-randomized study was performed with 46 renal allograft recipients who visited Tongji Hospital regularly for follow-up visits between January 2007 and May 2011 and were taking CsA+ mycophenolate mofetil (MMF)+ Pred. Conversion therapy to SRL+ low dose CsA+ Pred was initiated after renal transplantation. The recipients were allocated to 2 groups according to their renal function and proteinuria before the conversion: active conversion group [n=27, serum creatinine (SCr) ≤ 140 μmol/L with no or minimal proteinuria] and passive conversion group [n=19, SCr>140 μmol/L with less than moderate proteinuria]. After conversion, dosages of SRL and CsA were adjusted for trough levels of 5-7 μg/L and 20-60 μg/L, respectively. SCr and urine protein were compared before and after the conversion in five-year follow-up. Incidence of acute rejection, renal graft survival and SRL-related adverse effects of the immunosuppressive regimen were also observed. After conversion, an average 63% dose reduction of CsA was achieved in all the patients. In the active conversion group, the mean SCr level was (110±19) μmol/L at the time of conversion. Eight patients in this group withdrew from the study during the follow-up period for the following reasons: arthralgia (1 case), deteriorated proteinuria (2 cases), chronic diarrhea (2 cases), mild or suspicious acute rejection (2 cases), and recurrent fever (1 case). The rest patients (19/27) with a mean follow-up time of 5 years had a stable SCr level [(103±12) μmol/L] and a 100% 5-year graft survival. In the passive conversion group, the mean SCr level was (205±45) μmol/L at the time of conversion. There were 4 patients quitting the study, 2 for deteriorated proteinuria and 2 for lost to follow-up. Chronic allograft failure developed in 10 patients in this group 1-50 months after conversion, while the remaining 5 patients had a stable SCr during the 5-year follow-up period [(218 ±46) μmol/L before conversion vs (205±73) μmol/L 5 years after conversion]. The overall 5-year graft survival after the conversion therapy in the passive conversion group was 33.3%, significantly lower than that of the active conversion group (P<0.001). Acute rejection was observed in 2 cases in the active conversion group, while not observed in the passive conversion group. None of the patients developed leukopenia, thrombocytopenia, oral ulcer, or pneumonia in the follow-up. The combination therapy of SRL and low dose of CsA is overall a safe and effective maintenance immunosuppressive regimen, but it is important to initiate at an appropriate stage. More favourable long-term benefits may be obtained from the conversion therapy in patients with normal or only slightly impaired renal graft function. It may offer an option of individualized immunosuppressive therapy after renal transplantation.

Immunosuppressive therapy in patients with aplastic anemia: a single-center retrospective study.

BackgroundAplastic anemia (AA) is a rare disease in which hematopoietic stem cells are severely diminished resulting in hypocellular bone marrow and pancytopenia. Etiology of AA includes auto immunity, toxins, infection, ionizing radiation, drugs and rare genetic disorders, but in the majority of cases no cause can be identified. In the present study we assessed response rate, survival, relapse and clonal evolution in patients with AA treated with immunosuppressive therapy.MethodsPatients with AA who received immunosuppressive therapy between May 1998 and September 2013 were included in this study. Patients with non-severe AA (NSAA) were treated with cyclosporine (CsA) and danazol while patients with severe AA (SAA) as well as patients with NSAA who progressed to SAA after beginning of the treatment, were candidates for receiving antithymocyte globulin in addition to CsA and danazol.ResultsAmong the 63 studied patients, 29 (46%) had NSAA and 34 (54%) had SAA. Three months after treatment, overall response was 58.6% in NSAA and 12.9% in patients with SAA. Survival of all patients at 5, 10 and 15 years were 73%, 55% and 49%, respectively. Survival rates were significantly higher in patients with NSAA compared to patients with SAA as well as in patients who responded at 6 months compared to non-responders. The relapse risk was 39.7% at 10 years. Relapse occurred in patients who discontinued the therapy more than those who continued taking CsA (p value<0.01). The risk of clonal evolution was 9.9% at 10 years and 22.8% at 15 years after treatment.ConclusionThis long-term retrospective study indicated that immunosuppressive therapy should be recommended to patients with AA. Also, our experience indicated that immunosuppressive therapy should not be discontinued after response to therapy in patients with both NSAA and SAA due to high risk of relapse. Low dose of CsA should be continued indefinitely.

Adverse effects of low-dose systemic cyclosporine therapy in high-risk penetrating keratoplasty.

The purpose of this study was to investigate the adverse effects of low-dose oral cyclosporine (CsA) therapy following high-risk corneal transplantation. The medical records from 88 subjects who had undergone high-risk penetrating keratoplasties and had been administered oral CsA were retrospectively analyzed. High risk was defined as a history of graft rejection, three or more quadrants of vascularization, or the presence or history of intraocular inflammation. An initial CsA dose of 3-5 mg/kg per day was given for 3-7 days, followed by 2.5-3.5 mg/kg per day for approximately 1 month. The concentration of CsA was maintained at the target trough level of 120-150 ng/ml for at least 6 months or until serious complications developed. The relationship between the cumulative dose and duration of CsA administration and the adverse systemic effects, including the frequency of herpes keratitis, was evaluated. The incidence of herpes keratitis in the study subjects was compared with the incidence in 185 patients who had not received CsA therapy following penetrating keratoplasty. The mean survival time of the grafts was 33.6 months. Adverse effects occurred in 81.8 % of subjects. Hypertension, elevated liver enzyme levels, elevated serum creatinine level, and decreased absolute neutrophil count (ANC) were observed in 14.8, 6.8, 5.7, and 5.7 % of subjects, respectively. Simvastatin-induced rhabdomyolysis also developed in one case. Some patients exhibited minor complications, with gastrointestinal problems and hypertrichosis recorded in 5.7 and 3.4 % of subjects, respectively. Hypertension and hepatotoxicity most frequently occurred after 4 to 8 weeks of medication, while ANC decrease and nephrotoxicity generally developed after 24 weeks of treatment, with incidence related to the cumulative dose. Herpes keratitis occurred more frequently (31.8 %) in the CsA-treated subjects than in subjects that did not receive CsA therapy (p = 0.005). Most of the adverse effects were reversed after discontinuation of CsA therapy. The results of this study suggest that low-dose oral CsA therapy may induce various adverse effects, the most common of which are herpes keratitis and hypertension.

Immunosuppressive Treatment Combined with Nucleoside Analogues Is Superior to Nucleoside Analogues Alone in the Treatment of Severe Thrombocytopenia in Patients with Cirrhosis-Associated with Hepatitis B in China: A Multicenter, Observational Study

Introduction: Thrombocytopenia is a frequent manifestation of liver cirrhosis (LC) related to the hepatitis B virus (HBV). Severe thrombocytopenia is associated with bleeding events that increase morbidity and mortality in patients with LC. No effective treatment has been identified for patients with composited liver cirrhosis associated with HBV and severe thrombocytopenia. The pathogenesis of thrombocytopenia in liver diseases has not been well established. It has been suggested that autoantibody-mediated platelet destruction might contribute, at least in part, to hepatitis B cirrhotic thrombocytopenia. We aimed to explore the effectiveness and safety of low dose prednisone or low dose cyclosporine combined with a nucleoside analogue in patients with severe thrombocytopenia associated with HBV-related LC.Methods: In this observational cohort study, we included 145 consecutive compensated HBV-associated LC patients with severe thrombocytopenia (PLT<30,000 per cubic millimeter, accompanied by a tendency towards bleeding) between January 1, 2006 and December 31, 2013. We divided the patients into three groups by treatment strategy, including NA alone (n=57), NA plus prednisone (n=46), and NA plus cyclosporine (CsA) (n=42). Prednisone was given at a dosage of 0.5 mg/kg/d for 4 weeks until a response was observed or until the side effects became intolerable. The cyclosporine regimen consisted of oral CsA at a dosage of 1 mg/kg/d given in two divided doses. The dose of prednisone or CsA was then slowly tapered in the patients who responded to the drugs. We analyzed the platelet counts, bleeding events, liver function, replication of HBV, and outcomes in each group. The platelet counts following the treatments were estimated using mixed-effects linear models that included all available platelet counts after treatment. These models were adjusted by age, sex, the Child-Pugh score, other systemic complications, platelet transfusion, and research center. Cox proportional hazards analyses were performed to examine the factors related to bleeding events. Data was analyzed using IBM SPSS Statistics version 19.0 (SPSS Inc., an IBM company). P values less than 0.05 were considered significant. This study is registered with ClinicalTrials.gov under number NCT01987791.Results: At all time points during this observation, platelet counts in the prednisone plus NA and CsA plus NA groups were higher than those in the NA group. In the group receiving prednisone plus NA, 35 of the 46 patients (76.1%) had platelet counts of 50,000 per cubic millimeter or greater during this observation. As in the CsA plus NA group, 30 of the 42 patients (71.4%) had platelet counts of 50,000 per cubic millimeter or greater. Only 4 of the 57 patients (7.0%) in the NA treatment group had platelet counts that were higher than 50,000 per cubic millimeter. The cumulative bleeding events in the three treatment groups were 67.0% in the NA only group, 56.9% in the prednisone group and 62.2% in the CsA group. The cumulative rates of bleeding events were significantly different among the three groups (p=0.001). The platelet counts, treatment with prednisone plus NA and treatment with CsA plus NA were factors associated with bleeding events in the multivariate analysis. After treatment, serum alanine transaminase levels were significantly lower than those before treatment in all groups. The differences in the HBV-DNA negative rates, HBV-DNA elevated rates, normal serum alanine transaminase rates, serum alanine transaminase rates that elevated more than two times the baseline rate, and HBeAg seropositive conversion ratios among the groups did not reach statistical significance. Levels of the platelet-associated anti-GPIIb-IIIa antibodies after the 4-week treatment were lower than those at baseline in the prednisone group and CsA group; no difference was observed in the NA alone group. The adverse events in our study were mild in general and balanced among the three treatment groups.Conclusions: Treatment with low dose prednisone or low dose CsA plus NA could elevate the platelet count and reduce the risk of bleeding events in HBV LC patients with severe thrombocytopenia; the treatment had no obvious adverse effects on liver function and HBV DNA replication. DisclosuresNo relevant conflicts of interest to declare.

5 year Comparison of Very Low-dose Cyclosporine and High-dose Everolimus vs Standard Cyclosporine and Enteric-coated Mycophenolate in Renal Transplantation Patients

In this retrospective study, we compared the outcome of renal transplanted patients who received everolimus (EVR) (C0: 8–12 ng/mL) + cyclosporine (CsA) (C2: 150–300 ng/mL) + steroids, vs those who received enteric-coated mycophenolate sodium (EC-MPS) (1,440 mg/d) + CsA (C2: 500–700 ng/mL) + steroids. Efficacy was evaluated at 5 years. We found a nonsignificant trend toward a better 5-year graft survival (81.2% vs 68.6%) and better graft function (estimated glomerular filtration rate 71.8 ± 35.7 vs 60.0 ± 26.2 mL/min, P = .114) in favor of the EVR group. In our experience, EVR with a very low dose of CsA was associated with a nonstatistical trend toward better renal function and graft survival compared to a standard regimen of CsA and EC-MPS.

Ixazomib Citrate (MLN9708) Inhibits Kidney Allograft Infiltrating Macrophages in a CNI Minimizing Strategy.

Macrophages (MΦ) play an important role in acute rejection after kidney transplantation (Tx). Calcineurin inhibitor minimizing strategies may be associated with improved outcome after Tx. We sought to determine the role of a new protease inhibitor (PI, Ixazomib citrate, MLN9708) on MΦand MΦ associated genes in a CNI minimization strategy. Lewis (RT1l) recipients were transplanted with a full MHC mismatch Brown Norway (RT1n) rat kidney. Recipients were randomized into four groups: Control Brown Norway (C), Transplant with no treatment (Tx), transplant with full dose CsA (Tx, 10 mg/kg/d) or transplant with MLN9708 + half dose CsA (TxMLNCsA, 5 mg/kg/d). One week post-transplant, RNA was isolated from kidney for gene microarray analysis on Affymetrix Rat ST 2.0 chips. Differentially expressed gene (DEG) and pathway analyses were performed using iReport. Cellular analyses were performed using immunohistochemistry. Tx alone animals had a strong influx of MΦ into the kidney. Treatment with full dose CsA or low dose CsA + MLN9708 greatly reduced MΦ infiltration. The molecular signature associated with MΦ activation pathways was downregulated in animals treated with MLN9708 + ½ CsA, similar to full dose CsA.Table: No Caption available.These genes included IL-10, heme oxygenase 1 and biomarkers of M1 (iNOS) and M2 (arg1, CD163) MΦ phenotypes. These preclinical studies suggest that CNI minimization strategies with novel proteasome inhibitors may be effective in preventing macrophage-induced allograft injury. Further studies are needed to better characterize the significance and regulation of macrophage associated genes by proteasome inhibitors.