Tacrolimus Treatment Research Articles

A multicenter prospective observational study on the safety and efficacy of tacrolimus in patients with myasthenia gravis

IntroductionSeveral clinical studies using tacrolimus revealed reasonable therapeutic mechanisms and efficacy in patients with myasthenia gravis (MG). However, long-period studies in a large number of patients with MG are limited; therefore, the aim of this study was to investigate the therapeutic efficacies and safety of tacrolimus in patients with MG during a 12-month follow-up period. MethodsTacrolimus was administered to 150 patients with MG who were recruited based on the inclusion criteria. Fifteen medical centers in Korea participated in this study. The efficacy of tacrolimus was assessed using MG composite scales (MGCS) and the prednisolone-sparing effect. And the adverse drug reactions (ADRs) of tacrolimus were monitored in each patient from the beginning of tacrolimus treatment to the end of the follow-up period. ResultsAfter starting tacrolimus, the 32 patients were affected by ADRs, and consequentially 134 patients of the enrolled patients were followed up for 12months. They showed that the mean prednisolone dosage significantly decreased (6.1±7.6mg/day), compared to that in the baseline (11.3±9.5mg/day), and MGCS significantly improved after 12months of tacrolimus treatment, compared to that at the baseline. ConclusionsOur study showed that tacrolimus would be an effective immunosuppressant as an initial therapeutic agent in patients with MG; in addition, it showed tolerable safety profiles during the 12-month follow-up evaluation.

Immunosuppressive treatment using tacrolimus promotes pregnancy outcome in infertile women with repeated implantation failures.

We aim to investigate whether the peripheral blood T helper (Th) 1 cell level could predict pregnancy outcome in patients who have experienced repeated implantation failure (RIF, three or more) after ART cycles. This is a prospective cohort study of total 124 women with RIF who showed elevated Th1/Th2 (CD4+ IFN-γ+ /CD4+ IL-4+ ) cell ratios (≥10.3) and received tacrolimus at Sugiyama Clinic between November 2011 and July 2016. Patients were divided into three groups as per Th1 cell levels: Th1 level of <22.8 as Low; 22.8 to <28.8 as Middle, and 28.8 or greater as High group. The study patients received daily dose of tacrolimus 1-3mg based on initial Th1/Th2 cell ratio. The clinical pregnancy rates of Low, Middle, and High groups were 48.8%, 43.9%, and 33.3%, respectively (P=NS), with tacrolimus treatment. The ongoing pregnancy/delivery rate of Low group (46.3%) was significantly higher than that of High group (21.4%, P<.05). Middle group (34.3%) had higher success rate than High group, albeit without statistical significant. We confirm our previous report that Th1/Th2 ratio can predict ART outcomes in patients with RIF and immunosuppressant treatment with tacrolimus, and peripheral blood Th1 cell levels were negatively correlated with pregnancy outcome.

One More Step Toward a Clinically Applicable Tolerance Induction Protocol in Solid Organ Transplantation?

In Brief The authors discuss the feasibility and safety of the tolerance induction protocol regarding of standard tacrolimus treatment with delayed T cell depletion and T cell-depleted donor bone marrow infusion for liver transplantation.

Intragraft and Systemic Immune Parameters Discriminating Between Rejection and Long-Term Graft Function in a Preclinical Model of Intestinal Transplantation.

The pathology and diagnosis of acute and chronic rejection in intestinal transplantation (ITX) are far from being completely understood. We established models of acute and chronic intestinal graft rejection and analyzed peripheral and intragraft immune responses. We performed ITX from Dark Agouti into Lewis rats applying single-dose tacrolimus (TAC) at varying concentrations. Graft histology and immunohistology were assessed on postoperative day (POD)7, 14, and 45. Intragraft and peripheral gene expressions of inflammatory and anti-inflammatory markers and lipopolysaccharide binding protein (LBP) plasma as well as alloantibodies were measured simultaneously. A 1-mg TAC resulted in acute rejection and recipient death; 3 mg and 5 mg prolonged survival and led to severe or moderate chronic rejection, respectively, with 50% of the 5-mg TAC recipients surviving the observation period. Consequently, we observed severe infiltration on POD7 in untreated and 1-mg TAC recipients compared with minor histological alterations in 3 and 5 mg TAC groups. Only 5-mg TAC treatment prevented accumulation of CD4+ T cells and ED1+ macrophages over the entire observation period. Peripheral and intragraft expressions of T cell activation inhibitor-mitochondrial were stable in long-term surviving 5-mg TAC recipients but declined before acute or chronic rejection in 1 and 3 mg TAC recipients. In contrast, LBP levels increased during acute and chronic rejections. We studied acute and chronic rejections in a preclinical model of ITX, which recapitulates clinical findings and highlights the importance of monitoring peripheral T cell activation inhibitor-mitochondrial expression, LBP levels, and antidonor antibodies for revealing rejection.

Efficacy and safety of tacrolimus treatment for neuromyelitis optica spectrum disorder

Neuromyelitis optica spectrum disorder (NMOSD) is a severe inflammatory autoimmune disease that mainly involves the optic nerves and spinal cord, causing blindness and paralysis. Although some immunosuppressants such as rituximab and azathioprine have proven to be effective in relapse prevention, the high costs or intolerable adverse events preclude their wide application. Thus, we have conducted a retrospective study in 25 NMOSD patients who were treated with tacrolimus, an immunosuppressant with high efficacy and good tolerance in other autoimmune diseases, to assess its efficacy and safety in NMOSD treatment during the last five years (2011–2016). The results revealed that tacrolimus could reduce the relapse rate by 86.2% and improve the Expanded Disability Status Scale (EDSS) scores (4.5 vs 2.3; P < 0.001) significantly. Relapses in tacrolimus treatment were associated with serum titers of aquaporin 4 antibody (AQP4-IgG) (P = 0.028). Further Cox proportional analysis demonstrated that patients with high titers of AQP4-IgG (≥1:64) had a significantly higher risk of relapse than those with low titers after tacrolimus therapy (HR:5.665; CI95: 1.012–31.705; P = 0.048). Tacrolimus tended to be superior to azathioprine (29 patients) in terms of efficacy and safety during the same period. Our study suggests that tacrolimus may be another promising immunosuppressant for NMOSD.

Abstract 1: Topical Tacrolimus for the Treatment of Lymphedema

PURPOSE: Lymphedema is a common, life-long complication of cancer treatment that currently has no cure. Patients with lymphedema have decreased quality of life and suffer recurrent infections, while current treatments are merely palliative and designed to prevent disease progression. Accumulating evidence indicates that T cells play a key role in the pathology of lymphedema by inhibiting lymphangiogenesis and promoting tissue fibrosis. Because the pathophysiology of lymphedema involves primarily the skin and subcutaneous tissues, it may be possible to target T cells locally using topical medications such as tacrolimus without inducing systemic immunosuppression. The purpose of this study was therefore to study the efficacy of topical tacrolimus for prevention and treatment of lymphedema using preclinical mouse models. METHODS: Topical tacrolimus (0.1%) was used to treat mice that underwent tail superficial/deep lymphatic ablation or popliteal lymph node dissection (PLND). To test the hypothesis that this therapy prevents development of lymphedema, mice were treated after a short delay following surgery (2 weeks). Other animals were treated once lymphedema was established (6 weeks postop) to test the hypothesis that topical tacrolimus can be used to treat established lymphedema. Outcomes including fibroadipose tissue deposition, limb volumes, inflammation, lymphangiogenesis, lymphatic transport and pumping capacity were then measured. RESULTS: Treatment with topical tacrolimus did not result in significant systemic absorption or immunosuppression. However, this treatment markedly decreased swelling, soft tissue thickness, and fibrosis in the tail model of lymphedema. In addition, topical tacrolimus treatment significantly decreased T cell infiltration. Preventative treatment eliminated more than 95% of lymphedema-associated swelling while late treatment reduced swelling by more than 70%. Technetium99 lymphoscintigraphy showed that preventative treatment resulted in a 5-fold increase in interstitial fluid transport to regional lymph nodes. This increased transport capacity corresponded to a more than 2 fold increase in collecting lymphatic pumping capacity as measured by near infra-red lymphangiography. Interestingly, tacrolimus application significantly increased formation of collateral superficial lymphatics and increased inflammatory lymphangiogenesis in 2 other in vivo lymphangiogenesis assays. We observed more collateral lymphatic vessels in both the tail and the PLND models. CONCLUSION: Treatment with topical tacrolimus markedly decreased chronic T cell inflammation, significantly improved formation of lymphatic collaterals, and decreased tissue fibrosis. These changes were associated with significant decreases in lymphedema and improved lymphatic function. These results have significant implications for the treatment of lymphedema because there is currently no effective pharmacologic treatment for this chronic disease.

Cynomolgus monkeys are successfully and persistently infected with hepatitis E virus genotype 3 (HEV-3) after long-term immunosuppressive therapy.

Epidemiological studies found that hepatitis E virus genotype 3 (HEV-3) infection was associated with chronic hepatitis and cirrhosis in immunocompromised patients. Our study aimed to investigate the relationship between the host immunosuppressive status and the occurrence of HEV-related chronic hepatitis. Here we describe a successful experimental study, using cynomolgus monkeys previously treated with tacrolimus, a potent calcineurin inhibitor immunosuppressant, and infected with a Brazilian HEV-3 strain isolated from naturally infected pigs. HEV infected monkeys were followed up during 160 days post infection (dpi) by clinical signs; virological, biochemical and haematological parameters; and liver histopathology. The tacrolimus blood levels were monitored throughout the experiment. Immunosuppression was confirmed by clinical and laboratorial findings, such as: moderate weight loss, alopecia, and herpes virus opportunistic infection. In this study, chronic HEV infection was characterized by the mild increase of liver enzymes serum levels; persistent RNA viremia and viral faecal shedding; and liver histopathology. Three out of four immunosuppressed monkeys showed recurrent HEV RNA detection in liver samples, evident hepatocellular ballooning degeneration, mild to severe macro and microvesicular steatosis (zone 1), scattered hepatocellular apoptosis, and lobular focal inflammation. At 69 dpi, liver biopsies of all infected monkeys revealed evident ballooning degeneration (zone 3), discrete hepatocellular apoptosis, and at most mild portal and intra-acinar focal inflammation. At 160 dpi, the three chronically HEV infected monkeys showed microscopic features (piecemeal necrosis) corresponding to chronic hepatitis in absence of fibrosis and cirrhosis in liver parenchyma. Within 4-months follow up, the tacrolimus-immunosuppressed cynomolgus monkeys infected with a Brazilian swine HEV-3 strain exhibited more severe hepatic lesions progressing to chronic hepatitis without liver fibrosis, similarly as shown in tacrolimus-immunosuppressed solid organ transplant (SOT) recipients. The cause-effect relationship between HEV infection and tacrolimus treatment was confirmed in this experiment.

Protective effects of tacrolimus on podocytes in early diabetic nephropathy in rats.

The aim of the present study was to investigate the protective effect of tacrolimus on early podocyte damage in rats with diabetic nephropathy (DN). A total of 38 normal male Sprague‑Dawley rats were randomly divided into four groups: Normal control group (group N; n=8), DN group (n=10), tacrolimus (FK506) treatment group (group F; n=10), benazepril (Lotensin) treatment group (group L; n=10). The rats in groups DN, F and L were administered with streptozotocin (STZ; 60mg/kg) by intraperitoneal injection to establish the diabetic rat model. After 4weeks, the diabetic rat model was established, and rats in the different groups were administered intragrastically with the respective drugs. Blood glucose (BS), body weight (BW) and 24‑h urine protein were detected every 4weeks, serum creatinine (SCr), blood urea nitrogen (BUN) and kidney weight/body weight (KW/BW) were measured at the end of the 8weeks of drug treatment. Renal pathological changes were observed under a light microscope and electron microscope. Expression of nephrin, which is a podocyte‑specific marker, was detected using western blot analysis. The results showed that the levels of SCr, BUN, KW/BW and 24‑h urine protein in groups D, F and L were significantly higher, compared with those in group N (P<0.05). No significant differences were found between groups F and L for the above indicators, with the exception of BS. However, all indices were significantly lower, compared with those in group DN (P<0.05). Renal pathological expression was normal in group N under light microscopy. There were significant increases in the glomerular volume, proliferative mesangial cells, width of the mesangial area and thickness of the basement membrane in group DN, however, all the above pathological characteristics were reduced in groups F and L, compared with group DN (P<0.05). No significant difference was found between groups F and L. A widened glomerular basement membrane, and disorder, widening and fusion of podocyte processes were observed under the electron microscope in group DN, however, these were reduced in groups F and L, compared with group DN (P<0.05). The results of the western blot analysis showed that the expression of nephrin decreased by 60.1% in group DN, compared with group N, and significant recovery in the expression of nephrin was observed in groups F and L (P<0.05). Tacrolimus reduced urinary protein and slowed the progression of DN, partially by recovering the protein expression of nephrin in the renal tissue of diabetic rats, and maintaining the integrity of the structure and function of podocytes.

Study progress of Tacrolimus treatment on steroid-resistant nephrotic syndrome in children

Steroid-resistant nephrotic syndrome (SRNS) is a relatively difficult clinical type of treatment.The major therapy measures in present include steroid and immunosuppressant.Commonly used immunosuppressant include tacrolimus, cyclosporin, cyclophosphamide, mycophenolate mofetil, ect.Tacrolimus-induced clinical remission rate is superior to other immunosuppressive agents, has been the first-line agent of SRNS.Because of the individual difference in metabolism, the drug concentration of tacrolimus should be determined periodically.In order to obtain optimal efficacy of tacrolimus and reduce renal toxicity, the treatment protocols of small doses with long courses for children with SRNS were recommended. Key words: Tacrolimus; Child; Steroid-resistant; Idiopathic nephrotic syndrome

Positioning of Tacrolimus for the Treatment of Diabetic Nephropathy Based on Computational Network Analysis.

ObjectiveTo evaluate tacrolimus as therapeutic option for diabetic nephropathy (DN) based on molecular profile and network-based molecular model comparisons.Materials and MethodsWe generated molecular models representing pathophysiological mechanisms of DN and tacrolimus mechanism of action (MoA) based on literature derived data and transcriptomics datasets. Shared enriched molecular pathways were identified based on both model datasets. A newly generated transcriptomics dataset studying the effect of tacrolimus on mesangial cells in vitro was added to identify mechanisms in DN pathophysiology. We searched for features in interference between the DN molecular model and the tacrolimus MoA molecular model already holding annotation evidence as diagnostic or prognostic biomarker in the context of DN.ResultsThirty nine molecular features were shared between the DN molecular model, holding 252 molecular features and the tacrolimus MoA molecular model, holding 209 molecular features, with six additional molecular features affected by tacrolimus in mesangial cells. Significantly affected molecular pathways by both molecular model sets included cytokine-cytokine receptor interactions, adherens junctions, TGF-beta signaling, MAPK signaling, and calcium signaling. Molecular features involved in inflammation and immune response contributing to DN progression were significantly downregulated by tacrolimus (e.g. the tumor necrosis factor alpha (TNF), interleukin 4, or interleukin 10). On the other hand, pro-fibrotic stimuli being detrimental to renal function were induced by tacrolimus like the transforming growth factor beta 1 (TGFB1), endothelin 1 (EDN1), or type IV collagen alpha 1 (COL4A1).ConclusionPatients with DN and elevated TNF levels might benefit from tacrolimus treatment regarding maintaining GFR and reducing inflammation. TGFB1 and EDN1 are proposed as monitoring markers to assess degree of renal damage. Next to this stratification approach, the use of drug combinations consisting of tacrolimus in addition to ACE inhibitors, angiotensin receptor blockers, TGFB1- or EDN1-receptor antagonists might warrant further studies.

Evaluating tacrolimus treatment in idiopathic membranous nephropathy in a cohort of 408 patients

BackgroundThe KDIGO Clinical Practice Guidelines for Glomerulonephritis recommended tacrolimus as an alternative regimen for the initial therapy for Idiopathic membranous nephropathy (IMN), however, large observational studies evaluating tacrolimus treatment in IMN remains rare.MethodsA total of 408 consecutive IMN patients with nephrotic syndrome who were treated with tacrolimus in Jinling Hospital were included. The effectiveness and safety of tacrolimus treatment in IMN were analyzed in this study.ResultsThe cumulative partial or complete remission after tacrolimus therapy were 50%, 63% and 67% at 6, 12 and 24 months, respectively, and the cumulative complete remission rates were 4%, 13% and 23%, respectively. Multivariate logistic analysis showed that higher tacrolimus exposure during induction treatment, female gender, higher eGFR and no history of previous immunosuppressive therapy were independently associated with higher probability of remission. A relapse occurred in 101 of the 271 (37.3%) patients with partial or complete remission, and 18 of the 95 (18.9%) patients with complete remission. Tapering duration of tacrolimus and complete remission versus partial remission status were independent factors associated with risk of relapse. A decline in eGFR was the most frequent adverse event during tacrolimus treatment. During tacrolimus treatment, a ≥40% decrease in eGFR was observed in 43 (10.5%) patients.ConclusionsLow dose tacrolimus is effective for IMN, with a total remission rate of 66% whereas with a rather high rate of relapse. However, the safety of tacrolimus treatment needs to be further validated in large randomized clinical trials.

Calcineurin inhibitors improve memory loss and neuropathological changes in mouse model of dementia

AimThe present study was designed to investigate the potential of Cyclosporine (CsA) and Tacrolimus, the inhibitors of calcineurin (CaN) in cognitive deficits of mice. MethodsStreptozotocin [STZ, 3mg/kg, injected intracerebroventricular (i.c.v.)] was used to induce memory deficits in NIH mice, while aged mice separately taken served as a natural model of dementia. Morris water maze (MWM) test was employed to evaluate learning and memory of the animals. A battery of biochemical and histopathological studies was also performed. Extent of oxidative stress was measured by estimating the levels of brain glutathione (GSH) and thiobarbituric acid reactive species (TBARS). Brain acetylcholinestrase (AChE) activity was estimated to assess cholinergic activity. The brain level of myeloperoxidase (MPO) was measured as a marker of inflammation. ResultsSTZ i.c.v. and aging results in marked decline in MWM performance of the animals, reflecting impairment of learning and memory. STZ i.c.v. treated mice and aged mice exhibited a marked accentuation of AChE activity, TBARS and MPO levels along with a fall in GSH level. Further the stained micrographs of STZ treated mice and aged mice indicate pathological changes, severe neutrophilic infiltration and amyloid deposition. Cyclosporine and Tacrolimus treatment significantly attenuated STZ induced and age related memory deficits, biochemical and histopathological alterations. ConclusionThe findings demonstrate the potential of CaN inhibitors Cyclosporine and Tacrolimus in memory dysfunctions which may probably be attributed to anti-cholinesterase, anti-amyloid, anti-oxidative and anti-inflammatory effects. It is concluded that CaN can be explored as a potential therapeutic target in dementia.

Effectiveness and safety of topical tacrolimus in treatment of vitiligo

Vitiligo is one of the most primitive well-known dermatoid disorders with different suggested therapies. Therefore, this study investigated the efficiency and safety of topical tacrolimus in treatment of patients with vitiligo. This study was a clinical randomized designed study pre- post-test method, has been conducted on thirty cases with vitiligo who have referred to polyclinic and dermatology clinic. Participant's evaluated and demographic information recorded in designed checklist. In the next stage, the disease activity scored by vitiligo index disease activity system. Photography and depigmentation percent has recorded before treatment and further in 4th, 8th, 12th, 16th, 20th, and 24th weeks. Finally, gathered data compared through SPSS-20 software. The final sample comprised 30 persons including: 12 men (40%) and 18 women (60%). The average of patient's age in this study was 26/13 ± 18/20 (2-76-year-old). Eleven persons was ≤15 years old and rest was older than 15. Sixty-six lesions have funded in patients that maximum has accrued on face and neck (37/87%) and trunk (21/21%). In addition, minimum of lesions is related to genitalia (9/09%). In the in 4th, 8th, 12th, 16th weeks, improvement in face and neck had increased significantly, into the past weeks. In the 20th and 24th weeks, the improvement has increased although it was not significant enhancement. Also about trunk, in the 4th week the improvement does not have significant increasing in compare to the past week. In the eighth, 12th, 16th, 20th, and 24th weeks the improvement has been increased significantly in compare to the past weeks. Although in the case of limbs and genitalia, the improvement was lower. There was no significant difference between male and females and age. Although the improvement was, slow in older persons. Study results, has presented applying topical tacrolimus in vitiligo, particularly in face and neck, could be effective and does not seen any specified adverse effects during consumption of tacrolimus, it could be effective in decreasing effects in use of corticosteroid.

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.

Brain injury in combination with tacrolimus promotes the regeneration of injured peripheral nerves.

Both brain injury and tacrolimus have been reported to promote the regeneration of injured peripheral nerves. In this study, before transection of rat sciatic nerve, moderate brain contusion was (or was not) induced. After sciatic nerve injury, tacrolimus, an immunosuppressant, was (or was not) intraperitoneally administered. At 4, 8 and 12 weeks after surgery, Masson's trichrome, hematoxylin-eosin, and toluidine blue staining results revealed that brain injury or tacrolimus alone or their combination alleviated gastrocnemius muscle atrophy and sciatic nerve fiber impairment on the experimental side, simultaneously improved sciatic nerve function, and increased gastrocnemius muscle wet weight on the experimental side. At 8 and 12 weeks after surgery, brain injury induction and/or tacrolimus treatment increased action potential amplitude in the sciatic nerve trunk. Horseradish peroxidase retrograde tracing revealed that the number of horseradish peroxidase-positive neurons in the anterior horn of the spinal cord was greatly increased. Brain injury in combination with tacrolimus exhibited better effects on repair of injured peripheral nerves than brain injury or tacrolimus alone. This result suggests that brain injury in combination with tacrolimus promotes repair of peripheral nerve injury.

English

Tacrolimus is a powerful immunosuppressive agent with hepatotoxic and nephrotoxic effects. It has a protective role against many toxicants. This study was conducted to evaluate the possible protective role of spirulina against tacrolimus induced hepatotoxicity and nephrotoxicity. Forty adult male albino rats divided into 4 groups. Group I, control group, Group II, spirulina group (received spirulina 500 mg/Kg body weight (bw)/day orally), Group III, tacrolimus group (received tacrolimus 12 mg/kg bw/day orally); and Group VI, prophylactic group (orally administered spirulina for 3 days before and 28 days concurrently with tacrolimus in the same previous doses). Tacrolimus induced adverse effects on both liver and kidney functions and structure that was manifested by elevated hepatic transaminases, total and direct bilirubin, albumin, blood urea nitrogen, serum creatinine and creatinine clearance. There was a significant decrease in serum total antioxidant capacity (TAC) and hepatic and renal total thiol molecules (TTM), with a significant increase in serum malondialdehyde in tacrolimus group. Histopathologically, tacrolimus induced swelling and granulation of hepatocytes, congestion of blood sinusoids and degeneration of bile ductiles, glomerular hypertrophy and segmentation, swelling, degeneration and hyalinosis of renal tubules. Spirulina pre- and co-treatment significantly improved these deleterious effects. This was accompanied by partial restoration of the expression of PCNA near to the normal level observed in control rats. Moreover, spirulina treatment did not alter the trough blood tacrolimus levels or tacrolimus-induced immunosuppression. Further studies are warranted to evaluate whether transplant patients on tacrolimus treatment may benefit from the protective effects of spirulina. Key words: Antioxidant, malondialdehyde (MDA), total antioxidant capacity (TAC), tacrolimus, total thiol molecules (TTM), proliferating cell nuclear antigen (PCNA), spirulina.

Effect of ABCB1 (3435C>T) and CYP3A5 (6986A>G) genes polymorphism on tacrolimus concentrations and dosage requirements in liver transplant patients

BackgroundTacrolimus (TAC) is an immunosuppressant used in organtransplant recipients. It is a substrate of drug transporter ABCB1 as well as of cytochrome P4503A (CYP3A). AimTo assess the influence of ABCB1 (3435 C>T) and CYP3A5 (6986 A>G) genes polymorphism of liver transplant donors and recipients on blood level and dose requirements of oral tacrolimus, to help in designing an individualized tacrolimus regimen for liver transplant recipients. Subjects and methodsForty-eight adult liver transplant recipients and their matching living donors were prospectively enrolled in this study. TAC doses and blood concentration were recorded on 1st, 2nd and 3rd days, after 1 and 2weeks, and at 1, 3 and 6months postoperatively using ultra performance liquid chromatography Tandem mass spectrometry. Genotyping of ABCB1 (3435C>T) and CYP450 3A5 (6986A>G) genes were determined by Polymerase chain reaction followed by restriction fragment length polymorphism and by TaqMan allelic discrimination assay techniques, respectively. ResultsOf the enrolled 48 recipients, CYP3A5∗3/∗3 and CYP3A5∗1/∗3 genotypes were detected in 18 (37.5%) and in 20 (41.7%) recipients respectively, while ABCB1 CT and TT genotypes were detected in16 (33.3%) and 10 (20.8%) recipients respectively. TAC daily dose was significantly increased among recipients carrying ABCB1 CC genotype compared to recipients carrying CT and TT genotypes during and after the first month postoperatively. During 1st, 2nd days and 2weeks post-transplant, a significant increase of TAC concentration / dose ratio was observed among recipients carrying CYP3A5∗3∗3 genotype than recipients carrying 1∗1∗ and 1∗3∗ genotypes, and among recipients carrying ABCB1 CT and TT genotypes compared to those carrying CC genotype on 1st, 3rd days and at 3months postoperatively. ConclusionsABCB1 and CYP3A5 genetic polymorphism is one of the factors influencing TAC pharmacokinetics, screening for these SNPs prior to liver transplantation might be helpful for individualization of tacrolimus treatment.

Adequate tacrolimus concentration for myasthenia gravis treatment.

A single, oral dose of 3 mg/day tacrolimus, approved for myasthenia gravis (MG) treatment in Japan, was shown to reduce steroid dose and anti-acetylcholine receptor (AChR) antibody titers as well as to improve MG symptoms. However, no studies have investigated the association between tacrolimus concentration and its clinical efficacy in MG. In this study, we aimed to determine the optimal tacrolimus concentration for MG treatment. The trough tacrolimus concentration in 51 patients with MG (positive for anti-AChR antibody, n = 48; negative for anti-AChR and anti-muscle-specific tyrosine kinase antibodies, n = 3) who received 3 mg/day tacrolimus for more than 1 year was measured using a chemiluminescent enzyme immunoassay. The clinical characteristics of patients with MG as well as the dose of prednisolone used before and after tacrolimus treatment were evaluated retrospectively. The median trough tacrolimus concentration was 5.4 (range, 2.9-7.6) ng/mL, which was correlated with 'minimal manifestation or better status' (P = 0.0190, r = 0.3273) and the reduction in anti-AChR antibody 1 year after tacrolimus initiation (P = 0.0170, r = 0.3465). When the cut-off value for tacrolimus was defined as 4.8 ng/mL using a receiver operating characteristic curve, patients with adequate tacrolimus concentration (≥4.8 ng/mL) showed more reduction in anti-AChR antibody titers and more improvement in MG-related activities in daily life scores. More patients with adequate tacrolimus concentration achieved 'minimal manifestation or better status' compared with those with low tacrolimus concentration. An adequate tacrolimus concentration is required for better MG prognosis.

Calcineurin inhibitors block sodium-chloride cotransporter dephosphorylation in response to high potassium intake

Dietary potassium intake is inversely related to blood pressure and mortality. Moreover, the sodium-chloride cotransporter (NCC) plays an important role in blood pressure regulation and urinary potassium excretion in response to potassium intake. Previously, it was shown that NCC is activated by the WNK4-SPAK cascade and dephosphorylated by protein phosphatase. However, the mechanism of NCC regulation with acute potassium intake is still unclear. To identify the molecular mechanism of NCC regulation in response to potassium intake, we used adult C57BL/6 mice fed a 1.7% potassium solution by oral gavage. We confirmed that acute potassium load rapidly dephosphorylated NCC, which was not dependent on the accompanying anions. Mice were treated with tacrolimus (calcineurin inhibitor) and W7 (calmodulin inhibitor) before the oral potassium loads. Dephosphorylation of NCC induced by potassium was significantly inhibited by both tacrolimus and W7 treatment. There was no significant difference in WNK4, OSR1, and SPAK expression after high potassium intake, even after tacrolimus and W7 treatment. Another phosphatase, protein phosphatase 1, and its endogenous inhibitor I-1 did not show a significant change after potassium intake. Hyperkaliuria, induced by high potassium intake, was significantly suppressed by tacrolimus treatment. Thus, calcineurin is activated by an acute potassium load, which rapidly dephosphorylates NCC, leading to increased urinary potassium excretion.

The Use of Tacrolimus in Refractory Autoimmune Hepatitis in Children and Adults: A Single-Center Experience

Introduction: Despite the progress in diagnosing and treating patients with autoimmune hepatitis (AIH), there is limited data on using alternative agents in patients who do not achieve remission to standard therapy. Corticosteroids, in conjunction with azathioprine, are the mainstay of treatment for AIH in children and adults. Tacrolimus, a calcineurin inhibitor, has been proposed as a promising salvage agent in both age groups. The aim of this study was to determine the efficacy and safety of tacrolimus in treating refractory AIH in both children and adults. Methods: The diagnosis of AIH was made based on the criteria that was established by the International Autoimmune Hepatitis Group. We identified all adult and pediatric patients with AIH who were treated with tacrolimus between 2008 and 2013. A total of 23 patients (17 adults and 6 children) were included in the study. Median age at time of AIH diagnosis was 20 years and median disease duration at time of prograf start was 18 months. Results: Biochemical response was noted in 68% of subjects; 41% had a partial response (ALT decreased by >50%, but not completely normalized) and 27% had complete response (normalization of ALT< 50 U/L), Figure. Paired comparison of pre and post tacrolimus treatment labs showed a substantial reduction in ALT levels 155.0 [61.0,318.0] vs 61.0 [22.0,163.0] p-value = 0.009. Concomitantly, serum creatinine significantly increased after treatment with tacrolimus 0.67 [0.50,0.70] vs 0.75 [0.70,1.1] p-value of 0.026. Treatment with tacrolimus was discontinued prematurely in two adults because of significant adverse events (n=1), and lack of efficacy (n=1) and one child because of adverse effects. Conclusion: Tacrolimus was relatively safe and effective in treating refractory AIH in both adults and children who did not respond to standard therapy.Figure 1