Mycophenolic acid trough level monitoring: relevance in acute and chronic graft versus host disease and its relation with albumin.

Mycophenolate mofetil (MMF) is used to treat acute and chronic graft versus host disease (GvHD). There is scant evidence in the literature about mycophenolic acid (MPA) trough level monitoring in GvHD. We therefore reviewed 32 patients treated with MMF for acute (n = 19) or chronic GvHD (n = 13). Twelve (63%) of 19 patients with acute GvHD and nine (69%) of 13 with chronic GvHD showed a good response. In all 21 patients who responded to MMF, their mean total MPA levels were therapeutic (1-3.5 mg/L), whereas five of 11 patients who did not respond had sub-therapeutic mean MPA levels (p = 0.002). Sixteen (66%) of 24 steroid refractory or dependent patients responded to MMF. Associations between the mean total MPA level for each patient and the corresponding mean serum albumin concentration showed therapeutic mean total MPA levels for all 23 patients with mean albumin ≥ 31 g/L but sub-therapeutic mean total MPA levels in five of nine patients with mean albumin <31 g/L (p = 0.0006). In conclusion, MMF is efficacious in steroid refractory and dependent acute or chronic GvHD with statistically significant correlation between therapeutic plasma total MPA trough levels and clinical response. Serum albumin levels should be taken into account when considering MMF dose adjustments.

Inhibition of zaleplon metabolism by cimetidine in the human liver: in vitro studies with subcellular fractions and precision-cut liver slices.

1. The effect of cimetidine on the metabolism of zaleplon (ZAL) in human liver subcellular fractions and precision-cut liver slices was investigated. 2. ZAL was metabolized to a number of products including 5-oxo-ZAL (M2), which is known to be formed by aldehyde oxidase, N-desethyl-ZAL (DZAL), which is known to be formed by CYP3A forms, and N-desethyl-5-oxo-ZAL (M1). 3. Human liver microsomes catalysed the NADPH-dependent metabolism of ZAL to DZAL. Kinetic analysis of three microsomal preparations revealed mean (+/-SEM) S(50) and V(max) of 310 +/- 24 micro M and 920 +/- 274 pmol/min/mg protein, respectively. 4. Human liver cytosol preparations catalysed the metabolism of ZAL to M2. Kinetic analysis of three cytosol preparations revealed mean (+/-SEM), K(m) and V(max) of 124 +/- 14 micro M and 564 +/- 143 pmol/min/mg protein, respectively. 5. Cimetidine inhibited ZAL metabolism to DZAL in liver microsomes and to M2 in the liver cytosol. With a ZAL substrate concentration of 62 micro M, the calculated mean (+/-SEM, n = 3) IC50 were 596 +/- 103 and 231 +/- 23 micro M for DZAL and M2 formation, respectively. Kinetic analysis revealed that cimetidine was a competitive inhibitor of M2 formation in liver cytosol with a mean (+/-SEM, n = 3) K(i) of 155 +/- 16 micro M. 6. Freshly cut human liver slices metabolized ZAL to a number of products including 1, M2 and DZAL. 7. Cimetidine inhibited ZAL metabolism in liver slices to M1 and M2, but not to DZAL. Kinetic analysis revealed that cimetidine was a competitive inhibitor of M2 formation in liver slices with an average (n = 2 preparations) K(i) of 506 micro M. 8. The results demonstrate that cimetidine can inhibit both the CYP3A and aldehyde oxidase pathways of ZAL metabolism in the human liver. Cimetidine appears to be a more potent inhibitor of aldehyde oxidase than of CYP3A forms and hence in vivo is likely to have a more marked effect on ZAL metabolism to M2 than on DZAL formation. 9. The results also demonstrate that precision-cut liver slices may be a useful model system for in vitro drug-interaction studies.

Differential maintenance of cytochrome P450 enzymes in cultured precision-cut human liver slices.

The maintenance of the major hepatic cytochrome P450 (CYP) enzymes has been studied in precision-cut human liver slices cultured for up to 72 h in supplemented RPMI 1640 medium. The relative apoprotein levels of 11 CYP enzymes were determined using a panel of antipeptide antibodies. In addition, 7-ethoxyresorufin O-deethylase, tolbutamide methylhydroxylase, debrisoquine 4-hydroxylase, and testosterone 6beta-hydroxylase activities were determined as enzymatic markers for CYP1A2, CYP2C9, CYP2D6, and CYP3A4, respectively. There was a large variation in the rate of decline of different CYP levels with time in culture. Based on the rate of decrease, CYP enzymes could be separated into two groups, with CYP2C9, CYP2D6, CYP3A4, and CYP4A11 being relatively stable (half-lives between 70 and 104 h), compared with CYP1A2, CYP2A6, CYP2B6, CYP2C8, CYP2C19, CYP2E1, and CYP3A5, which were relatively unstable (half-lives between 23 and 36 h). Enzyme activities decreased at rates similar to those of their corresponding apoproteins. There was also a large difference in the stability of individual CYP enzymes from different liver donors, particularly for the most rapidly declining CYP enzymes. Similar losses of CYP enzymes were found when human liver slices were cultured in supplemented Williams' medium E for 72 h, except that CYP2E1 apoprotein levels were better maintained. Because of the variable decreases of CYP enzymes, xenobiotic metabolism studies are best performed with freshly cut rather than cultured human liver slices.

Comparison of five cyclosporin immunoassays with HPLC.

High performance liquid chromatography (HPLC) is the reference method for cyclosporin (CyA) measurements but therapeutic monitoring of the drug is frequently made using the more practical immunoassays. Cross-reactivity with CyA metabolites may compromise the specificity of immunoassays, particularly in liver graft recipients where metabolites may accumulate. The aim of this study was to compare with HPLC the performance of two recently introduced CyA immunoassays (the AxSYM fluorescent polarisation immunoassay (FPIA) and non-extraction CEDIA assay). The comparison was extended to the well-established TDx monoclonal FPIA (TDx mono) and the enzyme multiplied (EMIT)-specific assays and to the polyclonal FPIA (TDx poly), in which metabolite cross-reactivity is extensive. Assays were performed on 106 blood samples (taken 6 days to 118 months post-liver transplant) and results were compared by non-parametric regression analysis and difference plots. AxSYM and CEDIA showed both constant and proportional bias against HPLC (unlike EMIT) but the mean difference from HPLC was least for AxSYM (2.7 microg/l vs. 11.7, 9.4 and 54 microg/l for CEDIA, EMIT and TDx mono, respectively. (TDx poly - HPLC) values were proportional to all immunoassay results, with slopes of 0.33, 0.38 and 0.45 for EMIT, AxSYM and CEDIA, respectively. Our data suggest close agreement between AxSYM, CEDIA and EMIT results.

In vitro pentamer formation as a biomarker of tacrolimus-related immunosuppressive activity after liver transplantation.

Therapeutic drug monitoring of tacrolimus (FK) is widely performed to assist adjustments of drug dosage but may be an inadequate surrogate of the immunosuppression induced. The aim of this investigation was to develop an alternative method for measuring FK-related immunosuppressive activity in blood samples from liver transplant recipients. A pentamer formation assay (PFA) was devised based on the attachment of the 12 kDa FK-binding protein (FKBP12) to microtitre plates in the presence of calcineurin, calmodulin, Ca++ and FK. Pentamer formation could be detected at FK concentrations > or = 0.2 microg/l by optimising assay conditions, particularly by including Ca++ (0.5 mM) only during the formation of the pentameric complex. Three methods (blood lysis, proteolytic digestion and use of commercial solutions used in a microparticle enzyme immunoassay (MEIA) technique) were incompatible with PFA measurements after extracting immunosuppressive FK-related material from patients' blood samples. However, therapeutic amounts of FK-related material could be quantified by the PFA assay after extraction of blood samples with methanol. There was a moderate correlation (r = 0.689) of FK equivalents assayed by PFA with results using MEIA in 56 blood samples from 14 liver graft recipients, but no obvious relationship of results to variables reflecting their clinical status.

Inhibition of xenobiotic-induced genotoxicity in cultured precision-cut human and rat liver slices.

In this study precision-cut liver slices have been used to evaluate the effects of the flavone tangeretin, the flavonoid glycoside naringin and the flavanone naringenin (the aglycone derived from naringin) on xenobiotic-induced genotoxicity. Liver slices were cultured for 24 h in medium containing [3H]thymidine and the test compounds and then processed for autoradiographic determination of unscheduled DNA synthesis (UDS). The cooked food mutagen 2-amino-1-methyl-6-phenylimidazo[4,5-b]pyridine (PhIP) markedly induced UDS in cultured human liver slices and both 2-acetylaminofluorene (2-AAF) and aflatoxin B1 (AFB1) induced UDS in cultured rat liver slices. Tangeretin (20 and 50 microM) was found to be a potent inhibitor of 5 and 50 microM PhIP-induced UDS in human liver slices, whereas 20 and 50 microM naringenin was ineffective and naringin only inhibited genotoxicity at a concentration of 1000 microM. In rat liver slices 50 microM tangeretin inhibited 10 and 50 microM 2-AAF-induced UDS, whereas 50 microM naringenin and 100 and 1000 microM naringin were ineffective. None of the three flavonoids examined inhibited 5 microM AFB1-induced UDS in rat liver slices. The inhibition of PhIP- and 2-AAF-induced UDS by tangeretin is probably attributable to the inhibition of the human and rat cytochrome P-450 isoforms which are responsible for the bioactivation of these two genotoxins. Although flavonoids can modulate xenobiotic-induced genotoxicity in human and rat liver slices, any protective effect is dependent on the particular combination of genotoxin and flavonoid examined. These results demonstrate that cultured precision-cut liver slices may be utilised as an in vitro model system to examine the modulation of xenobiotic-induced genotoxicity by flavonoids and other dietary components.

Evidence that S-adenosyl-L-methionine diastereoisomers may reduce ischaemia-reperfusion injury by interacting with purinoceptors in isolated rat liver.

1. Mechanisms underlying the haemodynamic activity of diastereoisomers of S-adenosyl-L-methionine (SAM) were investigated using inhibitors of purinoceptors and nitric oxide (NO) synthase in perfused rat livers damaged by sequential 24 h cold and 20 min rewarming ischaemia + reperfusion. 2. Stored livers were flushed with 10 ml saline alone (control) or with added (R,S) or (S,S) SAM (100 microM) and reperfused in the absence (control) or presence of 10 microM 8-phenyltheophylline (8-PT) or 100 microM L-N-monomethylarginine (L-NMMA). 3. Both SAM diastereoisomers rapidly increased blood flow and bile production versus controls (P<0.001) but the (R,S) isomer induced greater increases in blood flow and the (S,S) isomer greater increases in bile production: 625 versus 596 versus 518 ml blood flow and 100 versus 119 versus 56 mg bile production per g liver over 3 h in (R,S), (S,S) and control, respectively. 4. 8-PT prevented the enhancement of blood flow by (S,S) SAM (529 versus 596 ml g(-1) liver over 3 h for (S,S) SAM alone, P<0.001), but was without effect in control livers. 8-PT also reduced SAM-enhanced bile production: 51 versus 119 mg g(-1) liver over 3 h, P<0.001. L-NMMA reduced blood flow and bile production similarly in the absence or presence of (S,S) SAM. 5. Thus, SAM may improve liver perfusion after ischaemia-reperfusion injury via stimulation of P, (A2) purinoceptors at which SAM shows activity. The choleretic activity of (S,S) SAM is disproportionately greater than enhanced blood flow and may occur independently of a NO-dependent component of bile production.

3,3'-Diindolylmethane induces CYP1A2 in cultured precision-cut human liver slices.

1. The effect of 3,3'-diindolylmethane (DIM), an indole derivative derived from cruciferous vegetables, on cytochrome P450 (CYP) isoforms in the CYP1A and CYP3A subfamilies has been studied in 72-h cultured human liver slices. 2. In cultured human liver slices 50 microM DIM induced 7-ethoxyresorufin O-deethylase and to a lesser extent 7-methoxyresorufin O-demethylase activities. 3. Western immunoblotting of liver slice microsomes was performed with antibodies to rat CYP1A2 and human CYP3A4. Compared with control liver slice microsomes (dimethyl sulphoxide-only treated), DIM induced levels of CYP1A2 but had little effect on levels of CYP3A4. The treatment of human liver slices with 2 microg/ml of the polycholorinated biphenyl mixture Aroclor 1254 also resulted in an induction of levels of CYP1A2, but had no effect on CYP3A4. 4. These results demonstrate that DIM induces CYP1A isoforms in cultured human liver slices. Some variability in the magnitude of induction of enzyme activities by DIM was observed in four human liver samples examined. For 7-ethoxyresorufin O-deethylase, the magnitude of induction by 50 microM DIM ranged from 2.3- to 19.3-fold. 5. These results demonstrate that cultured human liver slices can be used to evaluate the effect of chemicals derived from cruciferous and other vegetables on CYP isoforms.

Ischaemia-reperfusion injury of the liver: treatment in theory and in practice.

Cold ischaemia-reperfusion injuries are an unavoidable feature of current liver transplantation procedures. Damage to liver grafts accures mainly from hypothermic storage under hypoxic conditions (cold ischaemia), from sustained ischaemia during implantation into the recipient (rewarming ischaemia) and from restoration of blood and oxygen to the graft (reperfusion injury). These three stages are characterized by progressive deteriorations in hepatic function, with sinusoidal endothelial cells most affected during cold ischaemia. Activation of Kupffer cells (hepatic macrophages) at reperfusion augments damage to both endothelial and parenchymal cells by the release of numerous compounds which initiate and perpetrate injury and impair the hepatic microcirculation. The key events in the expression of ischaemia-reperfusion injury are detailed and therapeutic interventions are described which target these steps. The treatments discussed include University of Wisconsin (UW) preservation solution, calcium channel blockade, inhibitors of Kupffer cell activation, promoters of microvascular vasodilation, hepatoprotectants and the use of anti-oxidants.

The effect of tacrolimus (FK506) on intestinal barrier function and cellular energy production in humans.

BACKGROUND & AIMS: The maintenance of the intestinal mucosal barrier may be energy dependent. Tacrolimus is a potent immunosuppressive drug that decreases mitochondrial adenosine triphosphate production and increases intestinal permeability in animals. METHODS: Twelve liver graft recipients receiving tacrolimus, 9 healthy volunteers, and 5 liver graft recipients not receiving immunosuppression underwent a combined absorption-permeability-mitochondrial function test using 5 g lactulose, 1 g L-rhamnose, 0.5 g D-xylose, 0.2 g 3-O-methyl-D-glucose, 1 mg/kg 2-keto[1-13C]isocaproic acid ([13C]KICA), and 20 mg/kg L-leucine. The respiratory quotient and resting energy expenditure were measured by indirect calorimetry. Tacrolimus pharmacokinetic profiles and levels of endotoxin and IgM and IgG endotoxin core antibodies were determined. RESULTS: Tacrolimus inhibited the decarboxylation of [13C]KICA, the resting energy expenditure, and the respiratory quotient in an exposure-dependent manner, suggesting an inhibition of mitochondrial respiration. Tacrolimus inhibited intestinal absorptive capacity in an exposure-dependent manner. Tacrolimus-treated patients had an increased intestinal permeability and significantly higher endotoxin levels compared with healthy volunteers. CONCLUSIONS: Tacrolimus inhibits cellular energy production in humans at clinically relevant doses. This is associated with an increased intestinal permeability, endotoxemia, and an impaired intestinal absorptive capacity.

Effect of some cooked food mutagens on unscheduled DNA synthesis in cultured precision-cut rat, mouse and human liver slices.

Precision-cut liver slices were prepared from male Fischer 344 rats, female CDF1 mice and humans (both male and female subjects). Liver slices were cultured for 24 hr in medium containing [3H]thymidine and either PhIP, IQ, MeIQ, MeIQx, Glu-P-1 or Trp-P-1, and then processed for auto-radiographic evaluation of unscheduled DNA synthesis (UDS). All six cooked food mutagens examined produced concentration-dependent increases in UDS in human liver slices. PhIP was the most potent compound examined, followed by MeIQx, IQ and then MeIQ, Glu-P-1 and Trp-P-1. Significant increases in UDS were observed with PhIP, IQ and MeIQx at concentrations as low as 5 microM in the culture medium. The same rank order of potency was not apparent in either rat or mouse liver slices. In rat liver slices only MeIQ significantly induced UDS, although positive results were obtained with two other genotoxins, namely 2-acetylaminofluorene and aflatoxin B1. Apart from MeIQx, all the cooked food mutagens produced significant increases in UDS in mouse liver slices. This study demonstrates the usefulness of precision-cut liver slices to evaluate species differences in xenobiotic-induced genotoxicity. Both marked compound and species differences in induction of UDS were observed. The data provide further evidence that dietary cooked food mutagens are potential human carcinogens.

Therapeutic monitoring of tacrolimus (FK506) with the first- and second-generation microparticle enzyme immunoassays: performance and results in four patient populations.

The performance of the first- and second-generation microparticle enzyme immunoassays for tacrolimus (Tacrolimus I and Tacrolimus II, respectively) was compared during 8 months routine drug monitoring. The minimum detection limit of the Tacrolimus II assay was lower: 1.4 versus 4.0 microg tacrolimus/l. There was also no overlap between results using 10 samples containing 0 and 1 microg tacrolimus/l in the Tacrolimus II assay (p < 0.001), with a corresponding significant difference achieved for the Tacrolimus I assay only at 0 and 4 microg/l. For control specimens, within-assay precision was superior for Tacrolimus II at 5 microg/l (7.3% vs. 31.5%), similar at 10 and 15 microg/l (6.3% versus 6.6% and 4.4% vs. 4.6%, respectively) but worse than Tacrolimus I at 25 microg/l (8.0% vs. 4.0%). Using three pools of blood samples from recipients of liver transplants (containing approximately 4, 10, and 20 microg tacrolimus/l) interassay precision (n > 20) was 14.2%, 10.4%, and 8.0% for Tacrolimus II and 42.4%, 13.8%, and 7.1%, for Tacrolimus I. The analytical times and stability of the calibration curves were similar for the two assays. Tacrolimus I and Tacrolimus II results were closely correlated using patients' blood samples (r approximately equal to 0.8 in 249 adult and 168 pediatric liver transplant samples, 161 renal transplant samples, and 61 samples from patients with autoimmune diseases). However, Tacrolimus II assay results were consistently lower (by a mean of 1.02 to 2.05 microg/l). The authors conclude that the Tacrolimus II assay retains the speed, accuracy, and precision of its predecessor and demonstrates an improved sensitivity, which should facilitate monitoring at less than 5 microg tacrolimus/l.

Induction of CYP3A isoforms in cultured precision-cut human liver slices.

1. The effect of rifampicin on cytochrome P450 isoforms in the CYP1A and CYP3A subfamilies has been studied in 72-h cultured precision-cut human liver slices. 2. In cultured human liver slices 50 microM rifampicin induced testosterone 6 beta-hydroxylase activity, but had no effect on 7-ethoxyresorufin O-deethylase and 7-methoxyresorufin O-demethylase activities. 3. Western immunoblotting of liver slice microsomes was performed with antibodies to rat CYP1A2 and human CYP3A4. Compared with control (dimethyl sulphoxide only treated) liver slice microsomes, rifampicin increased levels of CYP3A4 but had no effect on CYP1A2. 4. These results demonstrate that rifampicin induces CYP3A isoforms, but not CYP1A2, in cultured human liver slices. Some variability in the magnitude of induction by rifampicin was observed in the six human liver samples examined. 5. These results demonstrate that cultured human liver slices may be used to evaluate the effects of xenobiotics on CYP3A isoforms.

Treatment of experimental ischemia/reperfusion injury with S-adenyosylmethionine: evidence that donor pretreatment complements other regimens.

Triple therapy with S-adenosylmethionine (SAM) (given to the donor animal, included in University of Wisconsin solution [UW], and added to the reperfusing medium) has been shown to reduce the sequential cold and warm ischemia/reperfusion injuries characteristic of the liver transplantation procedure. To clarify the actions of SAM during different stages of ischemia/ reperfusion, we have compared its benefit in five dosage regimens, using perfused rat livers after sequential periods of 24 hr cold and 20 min rewarming ischemia. When added only to UW, the presence of SAM throughout ischemia improved hepatic blood flow by 26% after 15 min of reperfusion versus no treatment (2.32+/-0.18 vs. 1.84+/-0.11 ml/min/g liver, P<0.05). SAM also improved blood flow by 23% during the 3-hr perfusion overall (P<0.05). Oxygen consumption and the release of purine nucleoside phosphorylase (PNP) were decreased (both P<0.05). When added to both UW and the perfusate, SAM additionally increased bile production at 15 min (7.14+/-1.21 vs. 2.31+/-0.74 mg/h/g liver, P<0.01). By pretreating the liver donor with SAM in vivo, and including it in the preservation and reperfusing media, it was possible to prolong and amplify the benefits on blood flow (P<0.001) and bile production (P<0.05) and to sustain glucose uptake (P<0.01). An acute exposure to SAM, when used in saline to flush UW from the graft before reperfusion, increased blood flow at 15 min (by 68%) and over a 3-hr period (both P<0.001), but no indices of metabolic activity were improved. Oxygen consumption and PNP release were both decreased (P<0.05). When added to the perfusate (present throughout reperfusion), SAM increased blood flow at 15 min (58%) and over a 3-hr period (P<0.01 in both cases). Net glucose uptake was increased (P<0.05), whereas oxygen consumption (P<0.001) and PNP release fell (P<0.05). Actions of SAM achieved acutely and over the intermediate- and long-term all seem to underlie its benefits in reducing ischemia/reperfusion injuries.

Tacrolimus (FK506) malabsorption: management with fluconazole coadministration.

We report the use of fluconazole to control primary immunosuppressive management with tacrolimus in a 9-year-old liver transplant recipient. Progressive increases in the doses of both cyclosporin (up to 20 mg/kg/day) and, subsequently, tacrolimus (up to 60 mg/day) failed to maintain immunosuppressive levels of both agents. After excluding poor compliance, drug interactions and analytical problems and identifying poor bioavailability (< 2.6%) and rapid clearance (4.2 l/h), fluconazole (100 mg/day) was initiated to inhibit tacrolimus metabolism and consistent therapeutic blood levels of tacrolimus were achieved. However, graft function had deteriorated irrevocably and retransplantation was performed. Simultaneous use of tacrolimus (5 mg/day) and fluconazole (100 mg/day) maintained immunosuppression after transplantation. Three weeks later, obstruction of the Roux loop caused deteriorating liver function and tacrolimus blood levels fell. After correction at laparotomy, stabilisation was achieved and discharge was possible on 5 mg tacrolimus b.i.d. plus fluconazole (100 mg).

Antioxidant properties of S-adenosyl-L-methionine: a proposed addition to organ storage fluids.

Glutathione (GSH) depletion adversely affects the survival of organ grafts. Supplementation of commercial organ preservation solutions with GSH is complicated by the ease of oxidation of its thiol group and its ability to act as a pro-oxidant under certain conditions. Alternative sulphur-containing compounds such as S-adenosyl-L-methionine (SAM) can reduce ischaemia-reperfusion injury, possibly by acting as glutathione precursors, and are effective when added to preservation solutions. Although the antioxidant properties of GSH are known in some detail, there is little information on the ability of SAM to interact directly with reactive oxygen species (ROS) produced during ischaemia-reperfusion injury. This work compares the interaction of SAM and GSH with several ROS which may be formed during ischaemia-reperfusion. In a variety of lipid peroxidation systems, SAM and GSH had little effect except at high concentrations (5 mM) where they became pro-oxidant. Scavenging of O2.- by both species was slow. SAM was less effective than GSH at preventing damage by peroxynitrite or HOCl. In contrast, SAM was more effective than GSH in scavenging hydroxyl radicals (.OH) and in chelating iron ions to inhibit .OH generation. Unlike GSH, SAM did not stimulate .OH formation at low concentrations. The beneficial effects of SAM in preservation solutions could therefore include direct radical scavenging as well as acting as a precursor for intracellular GSH.

Catalytic metal ions and the loss of reduced glutathione from University of Wisconsin preservation solution.

The University of Wisconsin solution is widely used for organ preservation. We show that this fluid is often contaminated by traces of iron catalytic for free radical reactions, as demonstrated by the bleomycin assay and the ability of the iron to stimulate lipid peroxidation. Reduced glutathione (GSH) added to University of Wisconsin solution during its commercial preparation had oxidized to the disulfide in all samples examined. Addition of GSH to UW solution showed its half-life to be about one day. The metal ion chelators desferrioxamine and phenanthroline did not substantially delay the loss of GSH, although desferrioxamine was able to suppress iron-mediated lipid peroxidation induced by the contaminant iron in the preservation solution. Additional iron was released from rat liver after a period of cold storage/rewarming.