Adenovirus-mediated antisense ERK2 gene therapy ameliorates chronic allograft nephropathy in a rat model

To investigate the effect and underlying mechanism of adenovirus-mediated antisense ERK2 (Adanti-ERK2) gene therapy upon chronic allograft nephropathy (CAN) of rats, male Lewis (LEW, RT11) rats received male Fisher (F344, RT11v1) renal allografts. The recipients were divided into three groups: (1) empty control group; (2) vector control group; (3) gene therapy group. All recipients were sacrificed for the grafts and serum analysis at the 24th week after transplantation. Morphometric analysis was used to determine the fibrosis of grafts. Immunohistochemistry was used to detect the expression of E-Cadherin, Vimentin, TβR I and the infiltration of CD4⁺ T lymphocyte, CD8⁺ T lymphocyte and ED-1⁺ monocytes. Enzyme linked immunosorbent assay (ELISA) was used to detect TGF-β1 in serum. The grafts in the empty control group and vector control group showed CAN. There was less E-Cadherin in renal tubular epithelial cells in the empty control group but more Vimentin and TβR I. In the gene therapy group, the fibrosis was ameliorated and fewer T lymphocytes and ED-1⁺ monocytes infiltrated in the interstitium. There was no significant difference in the expression of E-Cadherin between the gene therapy group and normal rats. Compared with the empty control group, the expression of TGF-β1 in the gene therapy group was down-regulated. Adanti-ERK2 gene therapy protects the renal allograft and attenuates graft fibrosis, which may be correlated with a decreased renal tubular epithelial mesenchymal transition, a decreased infiltration of CD4⁺ T lymphocyte, CD8⁺ T lymphocytes and ED-1⁺ monocytes in renal interstitium, and the down-regulated TGF-β1 expression.     

复方丹参滴丸在慢性移植肾肾病中的应用研究

目的:探讨复方丹参滴丸能否改善慢性移植肾肾病(chronic allograft nephropathy,CAN)患者的肾功能。方法:选择我院2005年1月-2008年12月的肾移植术后、经活检明确诊断为CAN(Ⅰ～Ⅱ级)患者66例为研究对象,随机分为治疗组(A组,n=34),对照组(B组,n=32),A组患者常规抗慢性排斥治疗基础上加用复方丹参滴丸(剂量27 mg/丸,10丸/次,tid);B组维持原常规抗慢性排斥治疗方案不变。对患者的SCr,BUN,CCr,24 h尿总蛋白(24 h Upro)进行动态观察,入组时上述指标连查3次(间隔3 d),取平均值,以后每2周查1次,实验结束时再对上述指标连查3次(间隔3 d),取平均值,共观察6个月。结果:治疗前两组各指标无显著差异(P>0.05);服用复方丹参滴丸治疗6个月后,A组的SCr,BUN,CCr,24 h尿总蛋白(24 h Upro)均有显著改善(P<0.05),而B组各指标与治疗前比较无显著差异(P>0.05)。治疗6个月后,A组中肾功能好转19例,稳定11例,恶化4例;B组中肾功能好转8例,稳定12例,恶化12例,两组比较差异有显著性(P<0.05...     

HPLC法检测肾移植病人全血中西罗莫司的药物浓度

目的 :建立测定全血中西罗莫司含量的方法。 方法 :采用HPLC法 ,色谱柱为 :YMC PackODS A(15 0mm× 4 .6mm ,5 μm) ,预柱为AlltimaC18(7.5mm× 4 .6mm ,5 μm)。流动相为乙腈∶四氢呋喃∶水 =5 5∶5∶4 0 ;检测波长为 2 78nm ,流速为 1.5ml/min ,柱温 :5 0℃。 32 去甲氧基西罗莫司为内标。 结果 :西罗莫司及内标 32 去甲氧基西罗莫司的保留时间分别为 10 .1、12 .1min ,全血定量线性范围 :2 .4 9～ 76 .36ng/ml,最低检测浓度为 1.98ng/ml,方法回收率为 99.93%～ 10 5 .90 % ,日内、日间RSD <7.4 0 %。 结论 :本方法准确、可靠 ,适用于临床对西罗莫司的血药浓度监测。     

Population pharmacokinetics of sirolimus in de novo Chinese adult renal transplant patients

AIMS

This study was aimed at determining the population pharmacokinetics of sirolimus and identifying factors that explain pharmacokinetic variability in de novo Chinese adult renal transplant patients.

METHODS

Data were retrospectively extracted from a formal multicentre clinical trial, which was originally designed to evaluate the safety and efficacy of ciclosporin dose reduction and ciclosporin elimination in patients receiving sirolimus. All patients received 12-month treatment, i.e. induction therapy with ciclosporin, sirolimus and corticosteroids during the first 3 months followed by either ciclosporin dose reduction or ciclosporin discontinuation thereafter. Eight-hundred and four sirolimus trough blood concentrations (C₀) from 112 patients were used to develop a population pharmacokinetic model using the nonmem program. A one-compartment model with first-order absorption and elimination was selected as the base model. The influence of demographic characteristics, biochemical and haematological indices, ciclosporin daily dose, ciclosporin C₀ as well as other commonly used co-medications were explored.

RESULTS

The typical values with interindividual variability for apparent clearance (CL/F) and apparent volume of distribution (V/F) were 10.1 l h⁻¹ (23.8%) and 3670 l (56.7%), respectively. The residual variability was 29.9%. CL/F decreased significantly with silymarin or glycyrrhizin co-therapy in hepatically impaired patients, and with increasing total cholesterol levels or ciclosporin C₀. Moreover, CL/F increased nonlinearly with increasing sirolimus daily dose. The median parameter estimates from a nonparametric bootstrap procedure were comparable and within 5% of the estimates from nonmem.

CONCLUSIONS

These results provide important information for clinicians to optimize sirolimus regimens in Chinese renal transplant patients.     

A comparison of the effect of ciclosporin and sirolimus on the pharmokinetics of mycophenolate in renal transplant patients

AIM: To compare the pharmacokinetics of mycophenolic acid when given with either ciclosporin or sirolimus, and investigate in vitro the potential effect of ciclosporin, sirolimus, tacrolimus and everolimus on mycophenolic acid metabolism. METHODS: In renal transplant patients given mycophenolate mofetil in combination with ciclosporin (n = 19) or sirolimus (n = 12), concentration-time profiles of mycophenolic acid, mycophenolic-acid-phenyl-glucuronide, mycophenolic-acid-acyl-glucuronide and mycophenolic-acid-phenyl-glucoside were determined at one month post-transplant. The effect of immunosuppressive drugs on mycophenolic acid glucuronidation and glycosylation was investigated in vitro using human liver microsomes. RESULTS: The mean mycophenolic acid AUC(0-9 h) in the sirolimus group was 44.9 mg h(-1) L(-1) (95% CI: 34.7-55.1), vs. 30.5 mg h(-1) L(-1) (95% CI: 25.4-35.6) in the ciclosporin group, corresponding to 1.5-fold dose-normalized difference (95% CI: 1.1-1.9; P < 0.05). In addition, the metabolite/mycophenolic acid AUC(0-9 h) ratios were significantly higher in patients cotreated with ciclosporin than with sirolimus, giving values of 1.8-fold (95% CI: 1.3-2.3; P = 0.0009), 2.6-fold (95% CI: 2.0-3.3; P < 0.0001) and 4.3-fold (95% CI: 2.6-6.0; P = 0.0016) for mycophenolic-acid-phenyl-glucuronide, mycophenolic-acid-acyl-glucuronide and mycophenolic-acid-phenyl-glucoside, respectively. In vitro, none of the immunosuppressive drugs tested inhibited mycophenolic acid metabolism. CONCLUSION: Patients taking mycophenolate mofetil and sirolimus experience a higher exposure to mycophenolic acid and a lower exposure to mycophenolic acid metabolites than those being treated with mycophenolate mofetil and ciclosporin. This interaction is probably not caused by inhibition of mycophenolic acid glucuronidation or glycosylation, but is more likely to be due to the influence of ciclosporin on the excretion of mycophenolic acid metabolites into bile.     

中药肾康注射液治疗慢性移植肾肾病的临床研究

目的：观察中药肾康注射液治疗肾移植术后慢性移植肾肾病（CAN）的有效性和安全性。方法：将48例确诊为CAN的患者随机分为肾康治疗组，静脉滴注肾康注射液，丹参治疗组予丹参注射液治疗，维持原免疫抑制方案不变，治疗4周后总结观察疗效。结果：肾康组与丹参组在临床生化指标（SCr，BUN）改善方面存在着显著的统计学差异（P〈0．05），前者优于后者。结论：肾康注射液可以治疗CAN，延缓其临床进展，是CAN多种治疗方案的有益补充。     

肾移植受者应用西罗莫司治疗窗的临床研究

目的:探讨西罗莫司应用于国内肾移植受者的治疗窗范围。方法:采用多中心、开放性临床研究,来自国内4家移植中心的首次肾移植病人共100例。免疫抑制方案为西罗莫司联合环孢素和皮质激素的三联疗法。移植后48h内开始服用西罗莫司,首次负荷剂量为6mg·d-1,维持剂量为2mg·d-1,采用高效液相色谱法测定西罗莫司浓度。结果:100例病人西罗莫司总的全血谷浓度为(6.6±s2.8)μg·L-1,10及90百分位数浓度分别为3.2μg·L-1和10.26μg·L-1。肾移植后6mo内急性排斥发生率为10%(8/84),此8例病人急性排斥时的西罗莫司浓度明显低于非排斥时浓度(P<0.01)。主要不良反应为肝功能损害和高脂血症,三酰甘油浓度与西罗莫司浓度相关(r=0.276,P<0.01)。结论:西罗莫司浓度维持在4～8μg·L-1范围内较为合适,定期监测血药浓度,合理调整用量,可增加西罗莫司应用的有效性及安全性。     

ABCB1 haplotype influences the sirolimus dose requirements in Chinese renal transplant recipients

Sirolimus, an immunosuppressive drug used to prevent organ rejection after renal transplantation, has a narrow therapeutic index and a large inter‐individual variability of pharmacokinetics. The aim of this study was to analyse the dose‐normalized trough blood concentrations (C₀/D ratio) of sirolimus in patients with different genotypes and attempt to investigate the possible associations between ABCB1/CYP3A5 genotypes and sirolimus dose requirements in Chinese renal transplant recipients. Blood samples were collected from 85 Chinese renal transplant recipients who were treated with sirolimus for at least 3 months and polymorphisms of the ABCB1 and CYP3A5 were determined by the SNaPShot multiplex assay. The blood concentrations of sirolimus were determined with HPLC. A significant allele‐dependent effect was observed between the CYP3A5*3 polymorphism and the C₀/D ratio of sirolimus. The patients bearing at least one CYP3A5*1 allele had a lower sirolimus C₀/D ratio compared with those with a homozygous CYP3A5*3 genotype (p < 0.05). No significant differences of sirolimus C₀/D ratios were observed among various ABCB1 1236C>T, 2677G>T/A and 3435C>T genotype groups. However, haplotype analysis including ABCB1 1236C>T, 2677G>T/A and 3435C>T SNPs showed that the mean sirolimus C₀/D of subjects carrying the CGC/CGC diplotype was about 30% lower compared with those carrying the CGC/TTT or TTT/TTT diplotype, whether or not they expressed the CYP3A5 (p < 0.05). These results demonstrated that the haplotype of ABCB1 might be a better index for the prediction of sirolimus blood concentration than single SNPs. Genotyping of ABCB1 and CYP3A5 might help to optimize individualized sirolimus treatments for Chinese renal transplant recipients. Copyright © 2013 John Wiley & Sons, Ltd.     

Pharmacokinetics, safety, and efficacy of mycophenolate mofetil in combination with sirolimus or ciclosporin in renal transplant patients

Aims

To compare the pharmacokinetics of mycophenolic acid (MPA) and its metabolite (MPAG) when mycophenolate mofetil (MMF) is administered in combination with sirolimus or ciclosporin (CsA) in renal allograft recipients. Safety and efficacy (biopsy-proven acute rejection (BPAR)) were also assessed.

Methods

Patients (n = 45) were randomized 2 : 1 to receive treatment with sirolimus (n = 30; dosed to maintain trough concentrations of 10–25 ng ml⁻¹ until week 8, and then 8–15 ng ml⁻¹ thereafter) or CsA (n = 15; administered as per centre practice) both in combination with daclizumab, oral MMF and corticosteroids. Pharmacokinetic assessments were performed at day 7, week 4, and months 3 and 6 post-transplant. The primary endpoint was the AUC(0,12 h) for MPA and MPAG. The pharmacokinetics of sirolimus were also assessed.

Results

MPA exposure was 39–50% lower (month 6 mean AUC(0,12 h) (95%CI): 40.4 (33.8, 47.0) vs. 68.5 (54.9, 82.0) µg ml⁻¹ h) and MPAG exposure was 25–52% higher (722 (607, 838) vs. 485 (402, 569) µg ml⁻¹ h at month 6) in the presence of CsA compared with sirolimus across visits. BPAR was 40.0% with sirolimus and 13.3% with CsA. The incidence of hypertension, tremors and hirsutism was higher with CsA than with sirolimus, while the incidence of diarrhoea, hyperlipidaemia and impaired wound closure was higher with sirolimus. No deaths, malignancies or graft losses were reported.

Conclusions

Co-administration of sirolimus with MMF led to greater MPA exposure, but lower MPAG exposure, than co-administration with CsA. As rejection rates were higher in the absence of CsA, further study of calcineurin inhibitor-free regimens is required before general recommendations can be made.     

Sirolimus steady-state trough concentrations are not affected by bolus methylprednisolone therapy in renal allograft recipients

AIMS: To determine whether bolus doses of methylprednisolone affect the steady-state trough concentrations of sirolimus. METHODS: Fourteen renal transplant recipients received concentration-controlled sirolimus therapy in combination with azathioprine and steroids (n=8) or mycophenolate mofetil and steroids (n=6). Bolus doses of methylprednisolone (mean total dose over 1-5 days, 1694 mg; range, 500-3000 mg) were given for the treatment of acute rejection. For each patient, the sirolimus dose (mean, 24.1 mg; range, 3.3-52.5 mg) was the same before and during methylprednisolone therapy. RESULTS: Mean sirolimus whole blood trough concentrations before and after treatment with methylprednisolone were 28.8 ng ml-1 (range, 13.9-45.3 ng ml-1), and 28.5 ng ml-1 (range, 13.0-47.9 ng ml-1), respectively (P=0.85; 95% confidence interval on the difference -3.3, 4.0 ng ml-1). CONCLUSIONS: Bolus methylprednisolone treatment does not affect steady-state sirolimus trough concentrations.     

Role of altered prednisolone-specific lymphocyte sensitivity in chronic renal failure as a pharmacodynamic marker of acute allograft rejection after kidney transplantation

Summary The effects of four immunosuppressive agents on the in vitro blastogenesis of peripheral blood lymphocytes activated by concanavalin A have been studied using cells from 26 healthy subjects, 34 patients with chronic renal failure (CRF) and 30 kidney transplant recipients.Differences in lymphocyte sensitivity to prednisolone between the healthy subjects and the CRF patients were statistically significant (P<0.0002), with impaired sensitivity in CRF. Impaired lymphocyte sensitivity occurred in 3.8% and 52.9% of the healthy and CRF subjects, respectively. Lymphocyte sensitivity to prednisolone, both preoperatively and 3 months post-operatively, was strongly correlated with early allograft rejection during co-administration of prednisolone with cyclosporin or azathioprine. Lymphocyte sensitivity to cyclosporin, azathioprine, and mizoribine in CRF was not significantly less than that in healthy subjects.Since the pharmacokinetics of prednisolone are little altered in renal transplantation, it is concluded that lymphocyte sensitivity specific to prednisolone may be a pharmacodynamic marker characteristic of successful graft survival in patients with histo-incompatibility and/or drug resistance.     

西罗莫司高产菌株与野生菌株中FKBP25的初步比较

目的　对比西罗莫司高产突变菌株———吸水链霉菌R2 7、R388、R4 4 1和野生菌株———吸水链霉菌ATCC 36 7817的蛋白质电泳图谱及FKBP2 5含量的差异 ,探讨FKBP2 5与西罗莫司产量的可能关系。方法　制备、分离高产突变株与野生菌株的菌体蛋白质并进行PPIase活性测定 ,比较 3株西罗莫司高产突变株与野生菌株的蛋白质电泳图谱及PPI ase酶活性。结果　西罗莫司低产的野生菌株的FKBP2 5含量比西罗莫司高产突变菌株高。结论　初步认为在吸水链霉菌中西罗莫司的产量与FKBP2 5量的多寡呈现一定的相关性     

Integrin CD11a/CD18, CD11b/CD18 and CD69 expression in patients after renal transplantation

Chronic renal failure (CRF) is a complex clinical entity caused by progressive destruction of functional renal parenchyma in the course of various pathological processes resulting in complete failure of renal function and subsequent metabolic, acid base and electrolyte as well as immune disorders. Renal transplantation (RT) is one of the renal replacement therapy options in the terminal stage of chronic renal failure. The replacement of the failing organ with one from a healthy donor may be complicated with immune host response. This study was designed to investigate the changes in serum concentration of integrins CD11a/CD18, CD11b/CD18, CD69 on the surface of human polymorphonuclear leukocytes (PMNL) after the RT within two six-month periods. The study included 25 RT patients (mean 5.4±2.7 yrs after the transplantation, 10 females and 15 males) treated with immune suppressive therapy including cyclosporine A, azathioprine and prednisolone. The expression was assessed with monoclonal antibodies by means of flow cytometry. Also, the expression of CD69 was determined before and after phytohemaglutinine (PHA) stimulation. There was no significant alternation in serum concentration of CD11a/CD18, CD11b/CD18 and CD69 at baseline, six months and twelve months later. The expression of integrins was not altered in renal transplantation patients in the current study setting.     

Association study of ABCB1 and CYP3A5 gene polymorphisms with sirolimus trough concentration and dose requirements in Chinese renal transplant recipients

The objective of this study was to investigate the possible association of the ABCB1 gene C3435 T polymorphism and the CYP3A5 gene A6986G polymorphism with sirolimus (SRL) trough concentration and dose requirements in Chinese stable renal transplant recipients. Blood samples were collected from 105 healthy volunteers and 50 renal transplant patients, whose polymorphisms of the ABCB1 and CYP3A5 genes were determined by polymerase chain reaction (PCR)-restriction fragment length polymorphism (RFLP). Plasma concentrations of SRL were determined with HPLC. The allele frequencies of the ABCB1 mutation in Chinese healthy volunteers and renal transplant recipients were 51.0% and 44.0% (p>0.05), while the allele frequencies of the CYP3A5 mutation were 72.9% and 71.0% (p>0.05). The SRL concentration/dose ratio (C/D) in patients with CYP3A5 (*)3/(*)3 were significantly higher than that of those with (*)1 allele (p<0.05). However, no significant differences were observed between C/D and ABCB1 SNPs (p>0.05). These results confirm that when treated with a SRL-based therapy and low-dose steroids, patients carrying the CYP3A5(*)1 allele required significantly more SRL to achieve adequate blood trough concentrations. In patients with SRL-based therapy, genotyping of the CYP3A5 genes may help to optimize the SRL management in renal transplant recipients.     

Relationships between sirolimus dosing, concentration and outcomes in renal transplant recipients

AIM: To explore relationships between sirolimus dosing, concentration and clinical outcomes. METHODS: Data were collected from 25 kidney transplant recipients (14 M/11 F), median 278 days after transplantation. Outcomes of interest were white blood cell (WBC) count, platelet (PLT) count, and haematocrit (HCT). A naive pooled data analysis was performed with outcomes dichotomized (Mann-Whitney U-tests). RESULTS: Several patients experienced at least one episode when WBC (n = 9), PLT (n = 12), or HCT (n = 21) fell below the lower limits of the normal range. WBC and HCT were significantly lower (P < 0.05) when sirolimus dose was greater than 10 mg day(-1), and sirolimus concentration greater than 12 microg l(-1). No relationship was shown for PLT and dichotomized sirolimus dose or concentration. CONCLUSIONS: Given this relationship between sirolimus concentration and effect, linked population pharmacokinetic-pharmacodynamic modelling using data from more renal transplant recipients should now be used to quantify the time course of these relationships to optimize dosing and minimize risk of these adverse outcomes.     

Trimethoprim-sulphamethoxazole does not affect the pharmacokinetics of sirolimus in renal transplant recipients

AIMS: The influence of the trimethoprim-sulphamethoxazole combination on the steady-state pharmacokinetics of sirolimus, a potent macrocyclic immunosuppressant, was studied in renal transplant recipients. METHODS: Fifteen kidney transplant recipients were treated with sirolimus 8-23 mg m(-2) in combination with azathioprine and prednisolone from the day of transplantation. Whole blood sirolimus AUC and C(max) were determined on days 6 and 7 after transplantation. On day 7, sirolimus was coadministered with the first dose of trimethoprim (80 mg) and sulphamethoxazole (400 mg). RESULTS: On day 6, the mean (95% confidence interval) whole blood sirolimus AUC((0-24 h)) was 1040 (846, 1234) ng ml(-1) and mean C(max) was 109 (88, 129) ng ml(-1). Corresponding values on day 7 were AUC((0-24 h)) 1060 (826, 1293) ng ml(-1) and C(max) mean 107 (87, 127) ng ml(-1). The mean difference in the dose-corrected AUC((0-24 h)) was 0.40% (-9.4, +10). CONCLUSIONS: A single dose of trimethoprim-sulphamethoxazole does not affect the pharmacokinetics of sirolimus in renal transplant patients.     

西罗莫司同分异构体Rap-D1的分离与鉴定

从西罗莫司产生菌的突变株FC904-25的发酵产物中分离获得化合物Rap-D1的晶体。对其理化性质包括UV、IR、LC-MS、NMR谱等进行分析，结果表明Rap-D-与西罗莫司为同分异构体，具有相同的平面结构。通过单晶X-衍射确定了构型，它与文献报道经化学半合成获得的28-epirapamyein同质。     

Microvascular resistance in response to iodinated contrast media in normal and functionally impaired kidneys

Contrast‐induced nephropathy (CIN) is considered to result from intrarenal vasoconstriction, and occurs more frequently in impaired than in normal kidneys. It was hypothesized that iodinated contrast media would markedly change renal blood flow and vascular resistance in functionally impaired kidneys. Thirty‐six patients were enrolled (32 men; mean age, 75.3 ± 7.6 years) undergoing diagnostic coronary angiography and were divided into two groups based on the presence of chronic kidney disease (CKD), defined as an estimated glomerular filtration rate (eGFR) of < 60 mL/min per 1.73 m² (CKD and non‐CKD groups, n = 18 in both). Average peak velocity (APV) and renal artery resistance index (RI) were measured by Doppler flow wire before and after administration of the iodinated contrast media. The APV and the RI were positively and inversely correlated with the eGFR at baseline, respectively (APV, R = 0.545, P = 0.001; RI, R = ?0.627, P < 0.001). Mean RI was significantly higher (P = 0.015) and APV was significantly lower (P = 0.026) in the CKD than in the non‐CKD group. Both APV (P < 0.001) and RI (P = 0.002) were significantly changed following contrast media administration in the non‐CKD group, but not in the CKD group (APV, P = 0.258; RI, P = 0.707). Although renal arterial resistance was higher in patients with CKD, it was not affected by contrast media administration, suggesting that patients with CKD could have an attenuated response to contrast media.     

Basic requirements for the use of terms for reporting adverse drug reactions (VIII): renal and urinary system disorders

This paper is the report of a meeting held in Geneva under the auspices of the Council for International Organizations of Medical Sciences (CIOMS) on 4-5 June 1996. It contains definitions of terms used in reporting adverse drug reactions of the system/organ class renal and urinary system disorders and basic requirements for their use.     

益肾泄浊方治疗痛风性肾病并慢性肾衰竭32例

目的 观察益肾泄浊方治疗痛风性肾病并慢性肾衰竭的疗效。方法 将64例痛风性肾病并慢性肾衰竭患者随机分为研究组和对照组,各32例。研究组患者采用益肾泄浊方治疗,对照组采用常规西药治疗,比较两组患者的临床疗效及不良反应。结果 研究组的总有效率为84.37%,明显高于对照组的68.75%（χ^2=4.11,P〈0.05）;治疗后,研究组的血尿酸、血尿素氮、血肌酐、肌酐清除率等指标与对照组比较,有明显差异（t=4.65,3.25,5.01,3.97,P〈0.05）;两组患者不良反应发生率比较无明显差异。结论 益肾泄浊方治疗痛风性肾病并慢性肾衰竭的疗效确切,不良反应发生率低,值得临床推广。