The pharmacokinetic advantage of local 6-mercaptopurine infusion in a canine renal transplant model.

In light of recent technologic advances, we developed a canine renal allograft model utilizing implantable, programmable infusion pumps and biocompatible catheters to reexplore the concept of local immunosuppression. Thirteen mongrel dogs underwent bilateral nephrectomy and autotransplantation of 1 kidney via end-to-end renal-iliac artery and end-to-side renal-iliac vein anastomoses. The proximal end of an infusion catheter directed into the iliac artery was tunneled to a subcutaneously placed programmable pump. A second, sampling catheter was placed with its tip in the iliac vein just proximal to the venous anastomosis. During a period of i.a. infusion of heparinized saline ranging from 19 to 63 days, serum creatinine remained normal in all but 1 animal, which developed pyelonephritis and catheter-tip perforation of the iliac artery. No cases of arterial thrombosis or catheter migration were observed at necropsy. In 7 additional autotransplanted dogs, simultaneous iliac vein and systemic (jugular vein) concentrations of 6-mercaptopurine (6-MP), the major immunosuppressive metabolite of azathioprine, were determined during a continuous 24-hr i.a. infusion (10 mg/kg/24 hr). Following termination of the infusion, 10 mg/kg 6-MP was administered to the same 7 dogs as an i.v. bolus, and systemic drug concentrations were determined over a 4-hr period. Mean +/- SE total-body clearance and elimination half-life were 887 +/- 159 ml/min and 1.4 +/- 0.2 hr, respectively, in the i.v. bolus study, indicating that 6-MP is rapidly cleared from the systemic circulation. Unexpectedly, the kidney removed as much as 60-95% of locally infused 6-MP, reducing the amount of active drug entering the systemic circulation to 5-40% of that which would be present during an i.v. infusion of the same dose. According to the principles governing the advantages of i.a. infusions, these data demonstrate that 6-MP can be infused intrarenally to produce both a 4-fold increase in drug concentration within the kidney and an 80% decrease in systemic drug delivery when compared to same-dose i.v. administration. The overall result is the presence of a 30-fold gradient between local and systemic drug concentrations during intrarenal 6-MP infusion. We conclude that i.a. infusion of an immunosuppressive agent is technically feasible with preservation of renal function, and that 6-MP can be delivered locally in a canine model with great pharmacokinetic and potential therapeutic advantage.

Liposomal formulation eliminates acute toxicity and pump incompatibility of parenteral cyclosporine.

The currently available intravenous dosage form of cyclosporine (CSA), Sandimmune I.V., contains the vehicle, Cremophor EL, which has been implicated in producing anaphylactic reactions in man and animals. This formulation also leaches through silicone tubing, an important component of some automatic drug delivery devices, causing pump dysfunction. In an attempt to develop a less toxic and pump-compatible formulation of CSA, suitable for intrarenal infusion in a canine transplant model, we compared the acute toxicity, pharmacokinetics, and pump compatibility of emulsified (CSA/emulsion) and liposomal (CSA/liposomes) CSA preparations with those of Sandimmune I.V. and CSA dissolved in ethanol vehicle (CSA/alcohol) in healthy, unoperated dogs. Animals receiving Sandimmune I.V. demonstrated marked acute toxicity despite progressive 10-fold dose reduction and greater than 50-fold prolongation of infusion duration. One of two animals receiving CSA/emulsion and both dogs receiving emulsion vehicle alone exhibited a moderately severe reaction, while five of seven dogs receiving CSA/alcohol demonstrated immediate, mild reactions. No discernible adverse reactions occurred in any animal receiving CSA/liposomes. Systemic disposition of CSA/alcohol and CSA/liposomes was similar. In contrast to the liposomal vehicle, the emulsion vehicle produced a marked, early weight gain and substantial decrease in tensile strength of the pump tubing, both of which would adversely affect pump function. These results provide the first description of liposomal CSA toxicology and pharmacokinetics in a large animal model and may lead to the successful development of a less toxic parenteral CSA formulation for systemic and local pump-based administration.

An implantable pump for intrarenal infusion of immunosuppressants in a canine autotransplant model.

We developed a canine renal allograft model utilizing implantable infusion pumps and biocompatible catheters to investigate the pharmacokinetics of local immunosuppressive drug administration. Seven mongrel dogs underwent bilateral nephrectomy and autotransplantation of one kidney to the iliac vessels. The proximal end of an infusion catheter directed into the iliac artery was tunneled to a subcutaneously placed programmable pump. A second, sampling catheter was placed with its tip in the iliac vein. Simultaneous regional (iliac vein) and systemic (jugular vein) venous concentrations of 6-mercaptopurine (6-MP), the immunosuppressive metabolite of azathioprine, were determined during a continuous 24-h intraarterial infusion (10 mg/kg/24 hr). The gradient between regional and systemic 6-MP concentrations was maximal initially when the pump was turned on, continuously decreased until steady state was reached, and disappeared immediately after the pump was turned off. The mean ratio of steady-state iliac vein to systemic 6-MP concentrations was 5.0 +/- 1.4, demonstrating a pharmacokinetic advantage of continuous intraarterial 6-MP infusion to the autotransplanted kidney. The novel canine renal allograft model described herein overcomes the technical limitations of earlier models and represents a foundational step in the design of intrarenal infusion patterns of immunosuppressive agents which we expect to prolong survival of the allotransplanted kidney with minimal systemic drug exposure and side effects.