Tacrolimus Monotherapy Research Articles

Differential inflammatory networks distinguish responses to bone marrow-derived versus adipose-derived mesenchymal stem cell therapies in vascularized composite allotransplantation.

Vascularized composite allotransplantation (VCA) is aimed at enabling injured individuals to return to their previous lifestyles. Unfortunately, VCA induces an immune/inflammatory response, which mandates lifelong, systemic immunosuppression, with attendant detrimental effects. Mesenchymal stem cells (MSC)-both adipose-derived (AD-MSC) and bone marrow-derived (BM-MSC)-can reprogram inflammation and have been suggested as an alternative to immunosuppression, but their mechanism of action is as yet not fully elucidated. We sought to gain insights into these mechanisms using a systems biology approach. PKH26 (red) dye-labeled AD-MSC or BM-MSC were administered intravenously to Lewis rat recipients of mismatched Brown-Norway hindlimb transplants. Short course tacrolimus (FK-506) monotherapy was withdrawn at postoperative day 21. Sera were collected at 4 weeks, 6 weeks, and 18 weeks; assayed for 29 inflammatory/immune mediators; and the resultant data were analyzed using Dynamic Network Analysis (DyNA), Dynamic Bayesian Network (DyBN) inference, and Principal Component Analysis. DyNA network complexity decreased with time in AD-MSC rats, but increased in BM-MSC rats. DyBN and Principal Component Analysis suggested mostly different central nodes and principal characteristics, respectively, in AD-MSC versus BM-MSC rats. AD-MSC and BM-MSC are associated with both overlapping and distinct dynamic networks and principal characteristics of inflammatory/immune mediators in VCA grafts with short-course tacrolimus induction therapy. The decreasing inflammatory complexity of dynamic networks in the presence of AD-MSC supports the previously suggested role for T regulatory cells induced by AD-MSC. The finding of some overlapping and some distinct central nodes and principal characteristics suggests the role of key mediators in the response to VCA in general, as well as potentially differential roles for other mediators ascribed to the actions of the different MSC populations. Thus, combined in vivo/in silico strategies may yield novel means of optimizing MSC therapy for VCA.

Surgical Challenges in the Long Term Follow-up after Intestinal and Multivisceral Transplantation

Background: Intestinal and multivisceral transplant recipients have often undergone mulitple operations prior to and early after transplantation. In addition, they receive high amounts of immunosupression. Thus abdominal surgery at a later stage posttransplant is very challenging and may increase the morbidity and mortality of these fragile patients. Methods: We retrospectively studied 69 patients (27 female, 42 male, 37±9 years) with isolated intestinal (ITX, n=48), modified (mMVTX, n=7) or typical multivisceral transplantation (MVTX, n=15) in 2 large european transplant centres. 4 grafts included a kidney and 17 included the abdominal wall. Maintenance immunosuppression consisted of either Tacrolimus Monotherapy in 31 patients or a double combination of Tacrolimus/MMF, Tacrolimus/Sirolimus, Tacrolimus/Everolimus. We recorded all intraabdominal interventions, which were performed after the first year posttransplant, and subdivided them into 2 groups depending on whether or not they were related to the intestinal graft. Results: The median follow-up time posttransplant was 8 years [1;15]. 20 intraabdominal operations were reported in 15 patients after a median of 5 years [1;13] posttransplant. 81% were emergency operations: Graft-related surgery was required due to graft ischeamia (n=2), adhesive ileus (n=3) and encapsulating ileus (n=2). Surgery for these patients included partial graft resection (n=5), graft explantation (n=4) and intestinal retransplantation (n=1). Non graft-related operations did not affect the graft or graft function and were: native colon resection due to Volvulus (n=1), native nephrectomy due to outflow obstruction (n=1), kidney transplantation due to CNI-toxicity (n=1), cholecystectomy due to necrotic cholecystitis (n=1), caesarian (n=1), post-mortem kidney/liver donation (n=1). There were no deaths related to surgery. 19% was elective surgery: Incisional herniotomy at the previous stoma-site (n=3) and a bilateral inguinal herniotomy without incarceration(n=1). A conservative treatment was attempted in 4 patients with: rectovaginal fistula in a stapled rectum stump (n=1), neutropenic colitis (n=1) and upper GI-haemorrhage (n=2). The latter 2 patients died. The median hospital stay following surgery was 27 days [7;210]. Six patients had to undergo repeated surgery (median number of operations 3 [2;13]). Conclusion: Abdominal surgery in ITX and (m)MVTX-recipients is challenging but feasible. Especially graft-related surgery was accompanied with a high risk of graft-loss but not with mortality. Non graft-related surgery did not affect graft function or longterm survival.

Safety and Outcomes in 100 Consecutive Donation After Circulatory Death Liver Transplants Using a Protocol That Includes Thrombolytic Therapy.

Donation after circulatory death (DCD) liver transplantation (LT) reportedly yields inferior survival and increased complication rates compared with donation after brain death (DBD). We compare 100 consecutive DCD LT using a protocol that includes thrombolytic therapy (late DCD group) to an historical DCD group (early DCD group n = 38) and a cohort of DBD LT recipients (DBD group n = 435). Late DCD LT recipients had better 1- and 3-year graft survival rates than early DCD LT recipients (92% vs. 76.3%, p = 0.03 and 91.4% vs. 73.7%, p = 0.01). Late DCD graft survival rates were comparable to those of the DBD group (92% vs. 93.3%, p = 0.24 and 91.4% vs. 88.2%, p = 0.62). Re-transplantation occurred in 18.4% versus 1% for the early and late DCD groups, respectively (p = 0.001). Patient survival was similar in all three groups. Ischemic-type biliary lesions (ITBL) occurred in 5%, 3%, and 0.2% for early DCD, late DCD, and DBD groups, respectively, but unlike in the early DCD group, in the late DCD group ITBL was endoscopically managed and resolved in each case. Using a protocol that includes a thrombolytic therapy, DCD LT yielded patient and graft survival rates comparable to DBD LT.

Abstract 47: Delayed Tolerance Induction Protocol for Vascularized Composite Allografts in Non-Human Primates: The Immunomodulatory Effect of Donor Bone Marrow Transplantation Does Not Prevent the Development of Chronic Rejection in the Absence of Durable Mixed Chimerism

PURPOSE: Our laboratory is currently developing a delayed tolerance induction protocol for vascularized composite allografts (VCAs) in a clinically relevant non-human primate (NHP) model using donor bone marrow transplantation (DBMT) after VCA to induce durable mixed chimerism and tolerance. DBMT has a demonstrated immunomodulatory effect in our previous experimental work and in clinical VCA, enabling some patients to be maintained on low-dose tacrolimus monotherapy. With longer-term follow-up of clinical VCA, recent reports of chronic rejection have emerged. We sought to investigate in further detail the immunomodulatory effect of DBMT on acute and chronic rejection of VCAs in NHPs. METHODS: Following VCA transplantation and maintenance on standard triple immunosuppression (IS) for 2 months, donor bone marrow cells that were previously harvested from the vertebrae, minimally processed and cryopreserved were thawed and infused into MHC-mismatched recipient NHPs (n=6) conditioned with irradiation (total body and thymic), T cell depletion, co-stimulatory blockade and anti-inflammation (with anti-IL-6 receptor monoclonal antibody). A bridging course of calcineurin inhibition (CNI) was given for 4 weeks before IS withdrawal and assessment of the VCA for tolerance. Observed rejection episodes of the VCA were biopsied and treated with CNI and a tapering course of steroids before IS withdrawal after 2 weeks. Systemic immune function was assessed by CFSE-based mixed lymphocyte reaction (MLR) proliferation assays and allo-sensitization was evaluated by the detection of serum allo-antibody formation. Evidence for mixed chimerism was assayed in peripheral blood. RESULTS: Durable mixed chimerism (only detected transiently at 6 weeks post-DBMT) did not develop but recipients managed to come off all IS for 4–5 weeks before acute rejection (Banff II) developed between POD115-POD126. Rejection could be treated and reversed both clinically and histologically. However, following subsequent re-withdrawal of IS, Banff II rejection developed again within 2 weeks (on POD172), could not be reversed despite treatment (Banff II on POD195) and ultimately culminated in necrosis of the VCA (on POD224). Final histology showed severe acute cell-mediated and antibody-mediated rejection with C4d deposition in subcutaneous arteries and arterioles as well as chronic allograft vasculopathy. Despite these findings, corresponding serial MLR assays demonstrate unresponsiveness after DBMT and no allo-antibody formation was detected. CONCLUSION: While DBMT demonstrated systemic immunomodulation based on MLR, in the absence of durable mixed chimerism, this effect was not enough to prevent acute projection episodes and the development of chronic rejection in this cohort of animals. These rejection episodes may be related to the subsequent development of chronic rejection. The presence of vascular lesions (based on C4d deposition) throughout all time points following DBMT may predate clinical progression to eventual chronic allograft vasculopathy and rejection, and may represent a potential prognostic factor in clinical VCA.

The efficacy and safety of tacrolimus monotherapy in adult-onset nephrotic syndrome caused by idiopathic membranous nephropathy

Introduction: The purpose of the study is to evaluate the efficiency and safety of tacrolimus (TAC) monotherapy in the treatment of nephrotic idiopathic membranous nephropathy (IMN) compared with the protocol of cyclophosphamide (CTX) combined with corticosteroids.Methods: In total, 58 patients with nephrotic syndrome and biopsy-proven IMN were included in this study. 30 patients received TAC monotherapy with an initial dose of 0.05–0.1 mg/kg/day. 28 patients received transvenous CTX at a dose of 0.5–0.75 g/m2 once in every month initially for 6 months and once in every 2 or 3 months for the later period, and the regimen was combined with corticosteroids (prednisone 1 mg/kg/d). All patients were observed for the treatment effects, recurrence and side effects.Results: Twelve months after the initial treatment, a total of 24 (80%) patients in the TAC group and 23 (82.1%) patients in the CTX group achieved remission (either partial or complete remission). The survival curve of the probability of remission and complete remission were similar between the two groups (p > .05). Proteinuria (based on 24 h urinary protein excretion) was significantly decreased, and serum albumin was significantly increased after immunosuppressive treatment in both the groups. Estimated glomerular filtration rate (eGFR) was comparable between before and after treatment. The main adverse effects in TAC treatment were glucose intolerance, diabetes and abnormal aminotransferase.Conclusions: TAC monotherapy is an alternative therapeutic regimen for patients with nephrotic IMN. Its short-term efficiency and patient tolerance are both acceptable.

Successful Rescue of Late-onset Antibody-mediated Rejection 12 Years After Living-donor Intestinal Transplantation: A Case Report

BackgroundAntibody-mediated rejection (ABMR) has recently surfaced as a potential form of graft dysfunction after intestinal transplantation. MethodsWe present a case of an intestinal transplant recipient who developed late-onset ABMR 12 years after living-donor transplantation. An 18-year-old male recipient with a history of extensive intestinal resection secondary to acute bowel volvulus exhibited an excellent baseline immune profile for transplantation, including ABO-identical and HLA-haploidentical to the donor; a negative cross-match with a panel reactive antibody of 3.0%. ResultsPost-transplantation immunosuppression consisted of tacrolimus, mycophenolate mofetil (MMF), and prednisone within the first year, followed by tacrolimus and MMF in the second year, and maintenance with tacrolimus monotherapy thereafter. The recipient experienced a single episode of indetermined acute cellular rejection 3 months after transplantation. Since then, he did not require any parenteral nutrition and had completely reintegrated with society. Twelve years later, the patient developed persistent diarrhea associated with transplant biopsy diffuse C4d deposition and circulating donor-specific antibodies. After the use of rituximab and intravenous immunoglobulin, the recipient stabilized 17 years after transplantation with complete recovery of intestinal mucosal damage. ConclusionLate-onset ABMR can emerge after transplantation and must be considered a possible cause of graft dysfunction in long-term intestinal transplantation survivors.

Tacrolimus Monotherapy after Intravenous Methylprednisolone in Adults with Minimal Change Nephrotic Syndrome.

Glucocorticoid treatment is the first choice therapy for adults with minimal change nephrotic syndrome; however, this therapy associates with many adverse effects. Tacrolimus may be an alternative to conventional glucocorticoid therapy. To investigate this possibility, we conducted a prospective, randomized, controlled trial (WHO International Clinical Trials Registry Platform: ChiCTR-TRC-11001454) in eight renal units across China. We randomized enrolled patients with adult-onset minimal change nephrotic syndrome (n=119) to receive glucocorticoid therapy or tacrolimus after intravenous methylprednisolone (0.8 mg/kg per day) for 10 days. Patients received a conventional glucocorticoid regimen or tacrolimus monotherapy, starting with 0.05 mg/kg per day (target trough whole-blood level of 4-8 ng/ml) for 16-20 weeks and subsequently tapering over approximately 18 weeks. Remission occurred in 51 of 53 (96.2%; all complete remission) glucocorticoid-treated patients and 55 of 56 (98.3%; 52 complete and three partial remission) tacrolimus-treated patients (P=0.61 for remission; P=0.68 for complete remission). The groups had similar mean time to remission (P=0.55). Relapse occurred in 49.0% and 45.5% of the glucocorticoid- and tacrolimus-treated patients, respectively (P=0.71), with similar time to relapse (P=0.86). Seven (13.7%) glucocorticoid-treated and four (7.3%) tacrolimus-treated patients suffered frequent relapse (P=0.28); five glucocorticoid-treated and two tacrolimus-treated patients became drug dependent (P=0.26). Adverse events occurred more frequently in the glucocorticoid group (128 versus 81 in the tacrolimus group). Seven adverse events in the glucocorticoid group and two adverse events in the tacrolimus group were serious. Consequently, tacrolimus monotherapy after short-term intravenous methylprednisolone is noninferior to conventional glucocorticoid treatment for adult-onset minimal change nephrotic syndrome in this cohort.

Failure of Calcineurin Inhibitor (Tacrolimus) Weaning Randomized Trial in Long-Term Stable Kidney Transplant Recipients.

Long-term renal transplant outcome is limited by side effects of immunosuppressive drugs, particularly calcineurin inhibitor (CNI). We assumed that some patients selected for a "low immunological risk of rejection" could be eligible and benefit from a CNI weaning strategy. We designed a prospective, randomized, multicenter, double-blind placebo-controlled clinical study (Eudract: 2010-019574-33) to analyze the benefit-risk ratio of tacrolimus weaning on highly selected patients (≥4 years of transplantation, normal histology, stable graft function, no anti-HLA immunization). The primary endpoint was improvement of renal function. Fifty-two patients were scheduled in each treatment arm, placebo compared to the CNI maintenance arm. Only 10 patients were eligible and randomized. Five patients were assigned to the placebo arm and five were assigned to the tacrolimus maintenance arm. In the tacrolimus maintenance arm, all patients maintained stable graft function and no immunological events occurred. Contrastingly, in the placebo arm, all five patients had to reintroduce a full dose of tacrolimus since three of them presented an acute rejection episode (one humoral, one mixed, and one borderline) and two displayed anti-HLA antibodies without histological lesion (one donor-specific antibodies [DSA] and one non-DSA). Clearly, tacrolimus withdrawal must be avoided even in long-term highly selective stable kidney recipients.

(764) - Lower Dose Tacrolimus Monotherapy in Heart Transplant Patients: Is It Safe

Monotherapy with CNI alone has been found to be efficacious as seen in the previous published TICTAC trial. In this trial, patients were maintained on a higher tacrolimus level in the range of 8-12 ng/ml which resulted in a higher serum creatinine level. It has not been established as to whether lower blood levels of tacrolimus (5-8 ng/ml) in monotherapy leaves these patients adequately immunosuppressed. The Cylex test allows us to assess how immunosuppressed are heart transplant patients. The Cylex test measures ATP production in stimulated CD4 T-cells. Adequate immunosuppression should result in a targeted ATP level between 200-550 ATP ng/ml. Lower scores correlate to increased immunosuppressed state. We sought to assess whether patients on lower dose tacrolimus monotherapy using the Cylex score are indeed adequately immunosuppressed. Between 2008 - 2013 we identified 8 patients on tacrolimus therapy for at least 1 month. The average time from transplant to initiation on monotherapy was 25±22 months. Cylex scores within 2 months after transition to monotherapy were assessed. The reasons for monotherapy included leukopenia, severe diabetes, recurrent infection. In this cohort, Cylex scores averaged 234 ± 94 ATP ng/ml with concomitant average tacrolimus trough level of 5.2 ± 1.5 ng/ml. For these patients on monotherapy there was complete freedom from subsequent treated rejection and infection within 1 year. Patients on monotherapy appear to be adequately immunosuppressed (by Cylex score) on a relatively low level of tacrolimus without clinical events. The Cylex score appears to be helpful in this unique population where minimal immunosuppression is required.

Effectiveness and safety of topical tacrolimus monotherapy for repigmentation in vitiligo: a comprehensive literature review.

Thus far, several small studies and case reports on the use of topical immunomodulators in vitiligo have been published. We undertook a comprehensive literature review, searching for studies evaluating clinical response to tacrolimus topical therapy for vitiligo. A search was performed on PubMed/Medline using the term “vitiligo”, combined with “topical” and “ointment”. Our inclusion criteria were: use of tacrolimus ointment as monotherapy to treat vitiligo. We found 29 studies from 2002 to 2014. Overall, 709 patients were treated in 29 studies. Pooling the lesions, 50% repigmentation of vitiligo patches was never achieved before 2 months of treatment, with a peak after 6 months of therapy. The best results were obtained on lesions of the cephalic region, especially the face, with tacrolimus 0.1% ointment two times daily. The percentage of non-responsive patients ranged from 0% to 14%. Treatment was generally well-tolerated; only localized adverse effects were reported. Our objective was to verify the effectiveness and safety of tacrolimus ointment monotherapy. It has good efficacy and tolerability. At present, only small trials and case series are available in the literature. Further, standardized investigations on a larger number of patients are needed.

Ten-Year Experience With Bowel Transplantation at Seoul St. Mary's Hospital

A retrospective review of intestinal transplantation (ITx) at Seoul St. Mary's Hospital was made by collecting clinical data over the past 10 years. Fifteen consecutive cases from 2004 were analyzed. Five children and 10 adults (6 months to 69 years of age) were included. Primary diseases in adults included 4 mesenteric vessel thromboses, 2 strangulations, and 1 each of visceral myopathy, malignant gastrointestinal stromal tumor (GIST), mesenteric lymphangiectasis, and injury. Pediatric cases involved 2 Hirschsprung disease, 2 visceral myopathy, and 1 necrotizing enterocolitis. Three of 7 stomas were closed using a serial transverse enteroplasty procedure before transplantation. The ITx were performed using 3 living-donor Itx, 12 deceased-donor ITx, 14 isolated Itx, and 1 modified multivisceral transplantation. Daclizumab, basiliximab, alemtusumab, or basiliximab with rabbit antithymocyte globulin (rATG) was used for the induction; tacrolimus monotherapy was used as the basic maintenance immunosuppressant; and m-TOR inhibitor was used for renal dysfunction patients. Seven cases of acute cellular rejection were treated with rATG. Three cases of antibody-mediated rejection were treated with rituximab alone or with rituximab and bortezomib combination. There were 4 cases of early mortality within 6 months after Itx. Causes of death were declamping shock, cardiac tamponade with acute cellular rejection, dysmotility, and sepsis. Surgical complications consisted of 1 feeding jejunostomy displacement, and a minor leakage at a colo-colostomy site. One-year survival of the patient and graft was 73.33% (Kaplan–Meier survival curve). Although the total number of ITx is small, its social impact has been remarkable in changing the related laws and reimbursement policy in Korea.

Tacrolimus for Remission Induction and Maintenance Therapy in Patients with Ulcerative Colitis: A Retrospective Evaluation Study.

Background. In this retrospective study, we compared the efficacy of tacrolimus (TAC) or prednisolone (PSL) for maintenance therapy in patients with ulcerative colitis (UC) at remission. Methods. The study patients were followed up for at least one year after induction of remission with either PSL (n = 55, between April 2004 and March 2014) or TAC (n = 40, between April 2009 and March 2014). The clinical features and relapse rates were compared in the two groups. Maintenance therapy in the TAC group included TAC alone, AZA alone, and TAC plus AZA. Results. The recurrence rates at 1500 days after remission were 61% and 46% for the PSL and TAC groups, respectively (P < 0.05). The recurrence rates at 600 days for TAC, AZA, and TAC + AZA maintenance groups were 24%, 49%, and 55%, respectively. Nephrotoxicity developed in 16 patients on TAC maintenance therapy. Conclusions. TAC monotherapy is a potential alternative especially for PSL nonresponders or those intolerant to AZA. However, patients on TAC therapy should be regularly monitored for adverse effects including nephrotoxicity.

Asymptomatic De Novo Inflammatory Bowel Disease Late After Liver Transplantation for Primary Sclerosing Cholangitis: A Case Report

Guidelines recommend colonoscopy screening for possible asymptomatic inflammatory bowel disease (IBD) in all patients diagnosed with primary sclerosing cholangitis (PSC). PSC-IBD warrants regular dysplasia-surveillance colonoscopy. However, no consensus exists regarding follow-up colonoscopy in PSC patients without IBD who remain asymptomatic. We describe a 43-year-old female who had undergone liver transplantation (LT) due to advanced PSC. Previous colonoscopies had been normal. The post-transplantation course was uneventful, with no rejections and signs of PSC recurrence. Immunosuppression was by tacrolimus monotherapy. She was asymptomatic with normal inflammation markers. A protocol colonoscopy, performed as general dysplasia surveillance 8 years post-transplantation, revealed mucopurulent-covered small superficial ulcerations and erythema diffusely distributed from the cecal to sigmoid colon with intervening normal mucosa and rectal sparing. Histologic examination showed patchy chronic colitis with crypt architectural distortion and mild-moderate inflammation activity. Infection samples were negative. Findings complied with de novo IBD, type unclassified. In conclusion, the link between PSC and clinically silent IBD may manifest after the PSC diagnosis and even several years after LT. Given the increased colorectal cancer risk associated with PSC, IBD, and LT, repeat colonoscopy might be warranted in PSC patients without IBD at initial assessment, and also after LT.

Liver Transplant Patient Carriers of Polymorphism Cyp3a5*1 Donors May Need More Doses of Tacrolimus From the First Month After Transplantation

BackgroundThe aim of this work was to evaluate the CYP3A5:CYP3A5*1/CYP3A5*3 (6986A>G) polymorphism related to the pharmacokinetic characteristics of tacrolimus during the first 3 months after transplantation, analyzing both donor and recipient genotype, in liver transplant patients. MethodsThis retrospective, single-center, cohort study included patients who had been treated with tacrolimus monotherapy with or without corticoids (n = 67). Donors and recipients were genotyped for the CYP3A5*3 allele polymorphism (6986A>G) by use of a TaqMan polymerase chain reaction technique. The presence or absence of the *1 allele (“minor-allele”) was analyzed for correlation with the tacrolimus dose-normalized ratio during the 3 months after transplantation. ResultsThe following observations were obtained in the population studied: (1) Frequency of the minor allele*1 was much lower both in recipients (11.9% versus 88.1%) and donors (19.4% versus 80.6%), with no statistically significant differences between both distributions. (2) Recipient genotype for CYP3A5*1/*3-polymorphism had no influence in tacrolimus pharmacokinetics, with no differences between carriers and non-carriers of the minor-allele*1. (3) However, from the first month after transplantation, patients with grafts from donor carriers of minor allele*1 had lower concentration-dose ratios compared with patients with grafts from donor non-carriers of that allele (71.1 versus 119.3 and 90.5 versus 126.3, for 30 and 90 days after transplantation, respectively; P < .05). ConclusionsThe presence of the CYP3A5-6986A>G-polymorphism in the donor affects tacrolimus pharmacokinetics in the recipient, although the difference was statistically significant only for the first month after transplantation. This means that in liver transplant patients receiving grafts from donors carrying the CYP3A5*1-polymorphism, a larger dose of tacrolimus from the first month after transplantation would be needed. The evidence provided in this study showed no effect of the recipient genotype.

Adipose- and Bone Marrow-Derived Mesenchymal Stem Cells Prolong Graft Survival in Vascularized Composite Allotransplantation.

Strategies aiming at minimization or elimination of systemic immunosuppression are key immediate goals for clinical expansion of vascularized composite allotransplantation (VCA). We compared the in vitro and in vivo immunomodulatory efficacy of adipose-derived mesenchymal stem cells (AD-MSCs) and bone marrow (BM)-derived MSCs in a rat VCA model. Both cell types were tested in vitro for suppressor function using mixed lymphocyte reactivity assays. AD-MSCs or BM-MSCs were administered intravenously (1 × 10 or 5 × 10 cells/animal) to Lewis rat recipients of mismatched Brown Norway hindlimb transplants. Short course tacrolimus (FK-506) monotherapy was withdrawn at postoperative day 21. In vivo regulatory T-cell induction, peripheral blood chimerism, and microchimerism in lymphatic organs were analyzed. AD-MSCs and BM-MSCs exhibited strong dose-dependent suppressor function in vitro, which was significantly more pronounced for AD cells. In vivo, all animals revealed peripheral multi-lineage chimerism at four weeks (P < 0.01) independent of cell type and dosage. Regulatory T-cell levels were increased with both cell types, the most in AD-MSC groups. These immunomodulatory effects were only transient. MSC treatment resulted in long-term (>120 day) allograft survival in 47% of the animals, which correlated with durable microchimerism in BM and spleen. AD-MSCs and BM-MSCs exert immunomodulatory effects that prolong survival of immunogenic skin-bearing VCA grafts with short course (21 day) tacrolimus induction therapy. The in vivo findings in terms of allograft survival did not reflect superior immunomodulatory characteristics of AD-MSCs found in vitro.

New Onset Bloody Diarrhea in a Liver Transplant Recipient

A 54-year-old Caucasian male presented with new onset abdominal pain and diarrhea over the past 2 weeks. Two years ago, he underwent an uncomplicated liver transplant (LT) for hepatocellular carcinoma and HCV cirrhosis. He had received standard oral valganciclovir prophylaxis against opportunistic viral infections for 90 days postLT while on tacrolimus, prednisone and mycophenolate and was tapered to tacrolimus monotherapy by month 6 postLT. He completed a 12 week course of sofosbuvir, daclatasvir, and ribavirin for his recurrent hepatitis C genotype 1 infection without any adverse effects. Two days after completing treatment, he developed diffuse abdominal cramping and 10-12 watery bowel movements daily with occasional streaks of bright red blood and fecal urgency. His medications included tacrolimus, metoprolol, omeprazole, and aspirin. There was no family history of gastrointestinal or autoimmune diseases nor recent travel or sick contacts. The patient was afebrile with mild diffuse tenderness on abdominal palpation. His liver biochemistries and electrolytes were normal, HCV RNA was undetectable and his hemoglobin had decreased from 13.0 to 11.2 g/ dL with a normal WBC and differential. Stool culture, ova and parasites, and C difficile antigen and toxin EIA were negative. His cytomegalovirus (CMV) IgG serology was positive but CMV-DNA by PCR was negative. A flexible sigmoidoscopy revealed patchy erythema, and ulcerated, friable mucosae (Figure A); mucosal biopsies showed active, chronic colitis (Figure B). New Onset Bloody Diarrhea in a Liver Transplant Recipient

Steroid-free Liver Transplantation Using Rabbit Antithymocyte Globulin Induction in 500 Consecutive Patients.

We have previously documented the efficacy of a steroid-free immunosuppression protocol using rabbit antithymocyte globulin (RATG) induction in orthotopic liver transplantation (OLT) with tacrolimus minimization. The purpose of this report is to demonstrate the benefits of this protocol in a large cohort of patients. We evaluated outcomes of 500 consecutive OLT recipients who received RATG induction and a single dose of solumedrol given before the first dose of RATG. Mycophenolate mofetil was initiated postoperatively with delayed initiation of tacrolimus. Sirolimus replaced tacrolimus if serum creatinine remained above 2.0 mg/dL by day 7. Patients were weaned to tacrolimus or sirolimus monotherapy at 3 months. Mean model for end-stage liver disease (MELD) at transplantation was 22 ± 6. Forty-four percent of patients had hepatitis C. Posttransplant creatinine was highest at 1 month (1.43 ± 0.95 mg/dL) and improved to 1.26 ± 0.60 mg/dL (P < 0.05) at 2.5 years. Glomerular filtration rate was lowest at 1 month (65.6 ± 30.0) and improved by 1 year (72.7 ± 28.2, P < 0.01). Tacrolimus was initiated at 4.79 ± 13.3 days with a level of 4.95 ± 2.45 ng/mL at 1 year. One-year patient and graft survival were 92.8% and 89.6%, respectively, with a 3-year patient survival of 82.9%. Rejection occurred in 114 (22.8%) patients, 33 (6.6%) patients requiring steroids. Univariate and multivariate Cox proportional hazard analyses were performed to evaluate the effects of donor and recipient characteristics on patient and graft survivals. Pretransplant creatinine was consistently a statistically significant predictor for patient and graft survival. This is the largest reported series of OLT recipients using a steroid-free protocol with RATG induction demonstrating excellent outcomes, low complication rates, and preservation of renal function.

(855) - Tacrolimus Monotherapy After Pediatric Heart Transplantation

Routine long-term immunosuppression (IS) after pediatric heart transplantation is based on the combination of tacrolimus (TAC) and mycophenolate mofetil (MMF) or everolimus (EVE). Gastrointestinal side-effects of the MMF and/or recurrent infections related to EVE can indicate the use of TAC monotherapy. The safety of TAC monotherapy was analized. Between 2007-2014 September, 26 pediatric heart transplantations were performed in our institute (age: 3 months-16 years; male/female: 12/14; weight: 4.4-61.5 kg). Tacrolimus monotherapy was indicated in 4 cases due to recurrent side effects (age: 11-23 months; male/female: 3/1; weight: 7.6-11.4 kg). Target level of tacrolimus was determined 2 ng/ml higher than used by combined therapy. Surveillance biopsies and echocardiography were performed to detect rejections. Rejections and incidence of infections were studied retrospectively. In every case the first line therapy was the combination of TAC+MMF. In 3 of them MMF/EVE conversion was indicated due to severe enteral side-effects in spite of MMF dose reduction. TAC target level was reduced on TAC+EVE combination depending on posttransplant time. After the conversion the gastrointesinal symptoms were eliminated, but in all of 3 patients recurrent infections were occured (in 2 patients upper-airway infections, in 1 patient permanent high replication of Ebstein Barr virus developed). In 1 patient on TAC+MMF therapy CMV disease and recurrent CMV activations were detected, indicating the reduction of IS. The main follow-up were 14 months. No side-effects was documented related to higher tacrolimus-level. No rejections were detected on biopsies. Infection rate was significantly reduced in every patients. Reduced immunosuppression could be necessary in small children (<2 yrs of age) due to recurrent side effects of TAC+MMF/EVE therapy. Tacrolimus monotherapy can be a good and safe alternative with higher target level. Long-term follow-up is needed to evaluate chronic rejection.

Sustained linear growth and preserved renal function in 10-year survivors of pediatric liver transplantation.

The aim of this study was to characterize the clinical outcomes of children and adolescents who achieved survival of more than 10 years following liver transplantation (LT) in a single center in Korea. From June 1996 to October 2003, 57 pediatric LTs were performed. The medical records of 44 patients who had survived more than 10 years were reviewed retrospectively. Median age of patients at LT was 0.8 years. Forty-one patients received living donor LT, and three patients received deceased donor LT. Biliary atresia was the most common indication (65.9%). Thirty-five patients were on tacrolimus monotherapy at 10 years post-LT with a mean trough level of 2.73 ng/ml, and five patients were maintaining stable graft function without any immunosuppression. There were no patients receiving antihypertensive medication and one case of diabetes mellitus. Renal dysfunction was seen in two patients (4.5%), while none required renal replacement therapy. Mean height z-score prior to LT was -1.35 and at 10 years post-transplant was 0.05. Good linear growth was sustained in this cohort throughout the 10 years, approaching the 50th percentile. Also, there were remarkably low incidences of renal dysfunction and patients requiring medications for glycemic or hypertensive control, all hallmarks of continued use of immunosuppressive agents.

Everolimus in liver transplantation.

In this review, we discuss the mechanism of action, side-effects, and role of everolimus (EVR) in liver transplant, specifically the most recent de-novo (within 1 month of transplant) and conversion (months to years after transplant) trials in the literature. Everolimus was recently approved by the Food and Drug Administration for use in liver transplantation. Its primary benefit over other immunosuppressive agents is the absence of renal toxicity. De-novo liver recipients receiving EVR with reduced-dose tacrolimus had similar rates of death, graft loss, and rejection compared with tacrolimus monotherapy, but significantly better renal function. The most common side effects are manageable and include stomatitis, hyperlipidemia, and cytopenias. Compared with the other mammalian target of rapamycin inhibitor, sirolimus, EVR is not associated with impaired wound healing or hepatic artery thrombosis. In addition, EVR may provide some benefit as an antineoplastic agent that may be particularly applicable to liver recipients with hepatocellular carcinoma. Everolimus is the only Food and Drug Administration-approved mammalian target of rapamycin inhibitor for liver transplantation. It offers noninferior immunosuppression (compared with standard therapy) with the absence of renal toxicity. Its use will likely increase over time as clinicians become more familiar with this drug.