tacrolimus and Nephrosis

Until 1985, glucocorticoids and cytotoxic drugs were the only treatments available for idiopathic nephrotic syndrome (nephrosis), that is, minimal change disease (MCD) and focal segmental glomerulosclerosis (FSGS). Trials of cyclosporine (CsA) treatment of nephrosis, the rationale of which was based on pathophysiologic considerations, have shown that this immunophillin modulator is effective in inducing and maintaining remission in patients suffering from idiopathic nephrotic syndrome. It appears that the best results, in the order of 80% remission rate, are obtained in steroid-sensitive cases, essentially MCD, and that in steroid-resistant FSGS the drug obtains remission in no more than 20% of the cases. Addition of glucocorticoids increases the success rate to approximately 30% of cases. Renal toxicity is proportional to previous impairment of renal function, primary renal disease (FSGS vs MCD) dosage >5.5 mg/kg/day and duration of treatment. The better bioavailability of the new formulation of CsA (Neoral), implies that the former dosage recommendations be reconsidered for distinctly lower figures. Repeat renal biopsy after 1 year of continuous CsA treatment is advisable, as stable serum creatinine levels may be falsely reassuring. CsA dependency is the rule during the first year of treatment. However, in some 25% of cases stable remission may be maintained after slow tapering off following 3-4 years of treatment. Other immunophillin modulators have been tried in the treatment of idiopathic nephrotic syndrome. Despite few preliminary reports indicating some success of tacrolimus the effects of this drug do not seem convincingly superior to CsA in terms of remission rate, toxicity and dependency. Rapamycin has not been tried in the treatment of nephrosis. Anecdotal cases of de novo FSGS induced by rapamycin in transplanted patients might indicate that this drug is in fact contraindicated in the treatment of nephrosis.

Topics: Cyclosporine; Humans; Immunophilins; Immunosuppressive Agents; Nephrosis; Sirolimus; Tacrolimus

The purpose of this study was to investigate the potential impact of CYP3A4, CYP3A5, and CYP3A7 polymorphisms on the concentration and efficacy of tacrolimus in a cohort of pediatric patients with nephrotic range proteinuria.. Genetic variants including CYP3A5*3 (rs776746), CYP3A4*1G (rs2242480), rs4646437, and CYP3A7 rs2257401 and rs10211 were detected in 70 pediatric patients with nephrotic range proteinuria. The relationships of dose-adjusted trough concentration (C. Our study demonstrated the associations between CYP3A5*3, CYP3A7 rs2257401 and rs10211, and tacrolimus concentration in pediatric patients with nephrotic range proteinuria. Children with CYP3A5*3 A, CYP3A7 rs2257401 C, and rs10211 G alleles might need a higher dose of tacrolimus.

Topics: Adolescent; Child; Child, Preschool; Cytochrome P-450 CYP3A; Female; Genotype; Humans; Immunosuppressive Agents; Male; Nephrosis; Polymorphism, Single Nucleotide; Proteinuria; Tacrolimus

Successful immunosuppressive therapy is critical for the treatment of patients with anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis and nephrosis. However, a considerable number of patients have shown clinical resistance to therapy. Bacterial infection might influence the clinical response of patients to immunosuppressive drugs, but few studies have been carried out to investigate the effect of bacterial superantigens on the efficacy of the drugs in these patients. We evaluated the suppressive efficacy of prednisolone, methylprednisolone, cyclosporine, and tacrolimus on the blastogenesis of PBMCs obtained from 12 ANCA-associated vasculitis patients (ANCA patients), eight patients with nephrotic syndrome, and eight healthy subjects. PBMC-stimulation index was calculated from the formula: [3H]thymidine incorporated in the presence of stimulant (dpm)/[3H]thymidine incorporated in the absence of stimulant (dpm). In vitro drug concentrations giving 50% inhibition (IC50s) of PBMC blastogenesis stimulated with concanavalin A (con A) or toxic shock syndrome toxin 1 (TSST-1) derived from Staphylococcus aureus (S. aureus) were calculated. The IC50 values for the four drugs evaluated in TSST-1-stimulated PBMCs were significantly higher than those evaluated in con A-stimulated PBMCs in both ANCA patients and nephrosis patients (p<0.012-0.044). Whereas, the IC50 values for these immunosuppressive drugs, except methylprednisolone, were not significantly different between con A- and TSST-1-stimulated PBMCs in healthy subjects. The stimulation index was not significantly different between the con A- and TSST-1-stimulated PBMCs in either of the subject groups. These observations raise the possibility that TSST-1 induced by S. aureus infection attenuates the clinical efficacy of glucocorticoids and calcineurin inhibitors in ANCA patients and nephrosis patients.

Topics: Adult; Aged; Aged, 80 and over; Antibodies, Antineutrophil Cytoplasmic; Bacterial Toxins; Calcineurin Inhibitors; Cell Proliferation; Concanavalin A; Cyclosporine; Enterotoxins; Female; Glucocorticoids; Humans; Immunosuppressive Agents; Inhibitory Concentration 50; Leukocytes, Mononuclear; Lymphocyte Activation; Male; Methylprednisolone; Middle Aged; Nephrosis; Prednisolone; Superantigens; Tacrolimus; Vasculitis

We examined the effect of immunosuppressive agent, FK506 (Fujisawa, Co.), on puromycin aminonucleoside (PAN)-induced nephrosis. Single i.p. injection of PAN in a dose of 100 mg/kg was introduced into Munich-Wistar rats weighing about 200 g. Those rats were divided into four groups. PAN-induced nephrosis rats in group 1 (PAN-FK0.1, n = 5), group 2 (PAN-FK0.3, n = 5), group 3 (PAN-FK1.0, n = 5) were treated with i.m. injection of FK506 for 10 days in a dose of 0.1 mg/kg, 0.3 mg/kg, 1.0 mg/kg, respectively, and rats in group 4 were treated with FK-placebo (PAN-PL, n = 5). The rats in group 5 with Saline+placebo were served as a control (NS-PL, n = 5). Among 5 groups, urinary protein, anionic sites (AS) in GBM, and subsets of peripheral lymphocytes through FACS were compared. After 9 days of PAN injection, the rats in PAN-FK0.1 (160.0 +/- 38.4), PAN-FK0.3 (118.0 +/- 34.4) & PAN-FK1.0 (89.2 +/- 40.0) given FK-506 had significantly less proteinuria in a PAN dose dependent manner, compared to those in NS-PL (349 +/- 86.8 mg/day). The numbers of AS/1000 mmGBM were more attenuated in FK506-treated PAN rats (PAN-FK1.0; 16.2 +/- 3.9) than those in PAN-PL (11.7 +/- 4.4). In related to subset of lymphocytes, increased W3/25 in PAN-PL was regressed in PAN-FK0.1, PAN-FK0.3 & PAN-1.0 after 10 days of PAN-injection. W3/25/OX-8 was significantly higher in PAN-PL (3.6) than those in NS-PL (2.4), but not between PAN-1.0 & NS-PL. These data indicate that the mechanism for therapeutic effect of FK506 on PAN-induced nephrosis includes a revision of abnormal cellular immunity, which attenuates the decrease of AS structure and as a result decrease proteinuria.

Topics: Animals; Male; Nephrosis; Puromycin Aminonucleoside; Rats; Rats, Inbred Strains; Tacrolimus