title: Mycophenolate pharmacokinetics and pharmacodynamics in belatacept treated renal allograft recipients - a pilot study.
abstract: BACKGROUND
  Mycophenolic acid (MPA) is widely used as part of immunosuppressive regimens following allograft transplantation. The large pharmacokinetic (PK) and pharmacodynamic (PD) variability and narrow therapeutic range of MPA provide a potential for therapeutic drug monitoring. The objective of this pilot study was to investigate the MPA PK and PD relation in combination with belatacept (2nd generation CTLA4-Ig) or cyclosporine (CsA).
  
  
  METHODS
  Seven renal allograft recipients were randomized to either belatacept (n = 4) or cyclosporine (n = 3) based immunosuppression. Samples for MPA PK and PD evaluations were collected predose and at 1, 2 and 13 weeks posttransplant. Plasma concentrations of MPA were determined by HPLC-UV. Activity of inosine monophosphate dehydrogenase (IMPDH) and the expressions of two IMPDH isoforms were measured in CD4+ cells by HPLC-UV and real-time reverse-transcription PCR, respectively. Subsets of T cells were characterized by flow cytometry.
  
  
  RESULTS
  The MPA exposure tended to be higher among belatacept patients than in CsA patients at week 1 (P = 0.057). Further, MPA concentrations (AUC0-9 h and C0) increased with time in both groups and were higher at week 13 than at week 2 (P = 0.031, n = 6). In contrast to the postdose reductions of IMPDH activity observed early posttransplant, IMPDH activity within both treatment groups was elevated throughout the dosing interval at week 13. Transient postdose increments were also observed for IMPDH1 expression, starting at week 1. Higher MPA exposure was associated with larger elevations of IMPDH1 (r = 0.81, P = 0.023, n = 7 for MPA and IMPDH1 AUC0-9 h at week 1). The maximum IMPDH1 expression was 52 (13-177)% higher at week 13 compared to week 1 (P = 0.031, n = 6). One patient showed lower MPA exposure with time and did neither display elevations of IMPDH activity nor IMPDH1 expression. No difference was observed in T cell subsets between treatment groups.
  
  
  CONCLUSIONS
  The significant influence of MPA on IMPDH1 expression, possibly mediated through reduced guanine nucleotide levels, could explain the elevations of IMPDH activity within dosing intervals at week 13. The present regulation of IMPDH in CD4+ cells should be considered when interpreting measurements of IMPDH inhibition.
authors.affiliation: Department of Medical Biochemistry, Rikshospitalet University Hospital, Oslo, Norway. sara.bremer@rikshospitalet.no
authors.forename: Sara
authors.initials: S
authors.lastname: Bremer
authors.forename: Nils T
authors.initials: NT
authors.lastname: Vethe
authors.forename: Helge
authors.initials: H
authors.lastname: Rootwelt
authors.forename: Pål F
authors.initials: PF
authors.lastname: Jørgensen
authors.forename: Jean
authors.initials: J
authors.lastname: Stenstrøm
authors.forename: Hallvard
authors.initials: H
authors.lastname: Holdaas
authors.forename: Karsten
authors.initials: K
authors.lastname: Midtvedt
authors.forename: Stein
authors.initials: S
authors.lastname: Bergan
mesh_terms: D000069594:Abatacept; D000305:Adrenal Cortex Hormones / Q000627:therapeutic use; D000368:Aged; D000911:Antibodies, Monoclonal / Q000627:therapeutic use; D019540:Area Under Curve; D000077552:Basiliximab; D015496:CD4-Positive T-Lymphocytes / Q000201:enzymology; D016572:Cyclosporine / Q000627:therapeutic use; D004305:Dose-Response Relationship, Drug; D004359:Drug Therapy, Combination; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007168:IMP Dehydrogenase / Q000097:blood; D018796:Immunoconjugates / Q000627:therapeutic use*; D007166:Immunosuppressive Agents / Q000097:blood / Q000627:therapeutic use*; D007262:Infusions, Intravenous; D016030:Kidney Transplantation / Q000276:immunology*; D008297:Male; D008657:Metabolic Clearance Rate; D008775:Methylprednisolone / Q000627:therapeutic use; D009173:Mycophenolic Acid / Q000097:blood / Q000493:pharmacokinetics* / Q000494:pharmacology*; D010865:Pilot Projects; D011239:Prednisolone / Q000627:therapeutic use; D020033:Protein Isoforms / Q000097:blood; D011993:Recombinant Fusion Proteins / Q000627:therapeutic use; D013997:Time Factors; D014184:Transplantation, Homologous
chemical_list: D000305:Adrenal Cortex Hormones; D000911:Antibodies, Monoclonal; D018796:Immunoconjugates; D007166:Immunosuppressive Agents; D020033:Protein Isoforms; D011993:Recombinant Fusion Proteins; D000069594:Abatacept; D016572:Cyclosporine; D000077552:Basiliximab; D011239:Prednisolone; D007168:IMP Dehydrogenase; C488211:IMPDH1 protein, human; D009173:Mycophenolic Acid; D008775:Methylprednisolone