Este estudo teve como objetivo avaliar longitudinalmente a incidência e severidade do crescimento gengival (CG) induzido por agentes imunossupressores, tacrolimus (Tcr) e ciclosporina-A (CsA), na ausência de bloqueadores de canal cálcio, em indivíduos transplantados renais. Foram avaliados 49 sujeitos transplantados renais, divididos em: grupo CsA (n=25) e grupo Tcr (n=24). Os indivíduos foram avaliados em quatro momentos: prétransplante, 30, 90 e 180 dias após o transplante renal. Os dados demográficos, parâmetros clínicos (IP, JEC-MG, PCS, NCI, SS e ICG) foram coletados em todos os momentos. A média do índice de crescimento gengival (ICG) foi significativamente menor no grupo Tcr comparado com grupo CsA após 30 dias (p=0,03), 90 dias (p=0,004) e 180 dias (p=0,01) de terapia imunossupressora. Decorridos 180 dias após o transplante renal, o crescimento gengival clinicamente significante foi observado em 20% dos sujeitos do grupo CsA e 8,3% dos sujeitos grupo Tcr. Porém, essa diferença não foi estatisticamente significante (p = 0,41). Para os parâmetros clínicos periodontais houve uma redução, em relação ao tempo de terapia imunossupressora, para o IP e SS (p<0,001) em ambos os grupos. Apesar de não apresentar diferença estatística na incidência do crescimento gengival clinicamente significante após 180 dias de terapia imunossupressora, observou-se que para o grupo Tcr o crescimento gengival ocorreu de forma mais tardia e a severidade do crescimento gengival nos pacientes que faziam uso do Tcr foi menor que nos pacientes que faziam uso da CsA. / The aim of this study was to make a longitudinal evaluation of the incidence and severity of gingival overgrowth (GO) induced by immunosuppressive agents, such as tacrolimus (Tcr) and cyclosporin A (CsA), in the absence of calcium channel blockers, in renal transplant patients. This longitudinal study was conducted with 49 renal transplant patients, who were divided into: CsA group (n=25) and Tcr group (n=24). The individuals were assessed at four time intervals: before transplant, 30, 90 and 180 days after the renal transplant. The demographic data, clinical parameters (PI, CEJ-GM, PD, CAL, BOP and GOI) were collected at all times intervals. The gingival overgrowth index mean was significantly lower in Tcr group compared with CsA group after 30 days (p=0.03), 90 days (p=0.004) and 180 days (p=0.01) of immunosuppressive therapy. One hundred and eighty days after the renal transplant, clinically significant gingival overgrowth was observed in 20.0% of the individuals in CsA group and 8.3% of the individuals in Tcr group. However, this difference was not statistically significant (p = 0.41). There was a reduction of the periodontal clinical parameters as regards the time of immunosuppressive therapy for PI and BOP (p <0.001) in both groups. Although there was no statistical difference in the incidence of clinically significant gingival overgrowth after 180 days of immunosuppressive therapy, it was observed that for the Tcr group gingival overgrowth occurred later and the severity of gingival overgrowth in this group was lower than in patients who used CsA.

Este estudo teve como objetivo avaliar longitudinalmente a incidência e severidade do crescimento gengival (CG) induzido por agentes imunossupressores, tacrolimus (Tcr) e ciclosporina-A (CsA), na ausência de bloqueadores de canal cálcio, em indivíduos transplantados renais. Foram avaliados 49 sujeitos transplantados renais, divididos em: grupo CsA (n=25) e grupo Tcr (n=24). Os indivíduos foram avaliados em quatro momentos: prétransplante, 30, 90 e 180 dias após o transplante renal. Os dados demográficos, parâmetros clínicos (IP, JEC-MG, PCS, NCI, SS e ICG) foram coletados em todos os momentos. A média do índice de crescimento gengival (ICG) foi significativamente menor no grupo Tcr comparado com grupo CsA após 30 dias (p=0,03), 90 dias (p=0,004) e 180 dias (p=0,01) de terapia imunossupressora. Decorridos 180 dias após o transplante renal, o crescimento gengival clinicamente significante foi observado em 20% dos sujeitos do grupo CsA e 8,3% dos sujeitos grupo Tcr. Porém, essa diferença não foi estatisticamente significante (p = 0,41). Para os parâmetros clínicos periodontais houve uma redução, em relação ao tempo de terapia imunossupressora, para o IP e SS (p<0,001) em ambos os grupos. Apesar de não apresentar diferença estatística na incidência do crescimento gengival clinicamente significante após 180 dias de terapia imunossupressora, observou-se que para o grupo Tcr o crescimento gengival ocorreu de forma mais tardia e a severidade do crescimento gengival nos pacientes que faziam uso do Tcr foi menor que nos pacientes que faziam uso da CsA. / The aim of this study was to make a longitudinal evaluation of the incidence and severity of gingival overgrowth (GO) induced by immunosuppressive agents, such as tacrolimus (Tcr) and cyclosporin A (CsA), in the absence of calcium channel blockers, in renal transplant patients. This longitudinal study was conducted with 49 renal transplant patients, who were divided into: CsA group (n=25) and Tcr group (n=24). The individuals were assessed at four time intervals: before transplant, 30, 90 and 180 days after the renal transplant. The demographic data, clinical parameters (PI, CEJ-GM, PD, CAL, BOP and GOI) were collected at all times intervals. The gingival overgrowth index mean was significantly lower in Tcr group compared with CsA group after 30 days (p=0.03), 90 days (p=0.004) and 180 days (p=0.01) of immunosuppressive therapy. One hundred and eighty days after the renal transplant, clinically significant gingival overgrowth was observed in 20.0% of the individuals in CsA group and 8.3% of the individuals in Tcr group. However, this difference was not statistically significant (p = 0.41). There was a reduction of the periodontal clinical parameters as regards the time of immunosuppressive therapy for PI and BOP (p <0.001) in both groups. Although there was no statistical difference in the incidence of clinically significant gingival overgrowth after 180 days of immunosuppressive therapy, it was observed that for the Tcr group gingival overgrowth occurred later and the severity of gingival overgrowth in this group was lower than in patients who used CsA.

Este estudo teve como objetivos avaliar a ocorrência de crescimento gengival derivado da administração de duas drogas imunossupressoras ciclosporina-A (CsA) e tacrolimus, em indivíduos transplantados renais, e verificar as possíveis alterações dos parâmetros clínicos periodontais (IP, JEC-MG, PCS, NCI e SS) após o início da terapia imunossupressora. Foram avaliados dois grupos: grupo CsA que consistiu de 20 indivíduos que receberam o protocolo de imunossupressão composto por ciclosporina-A e o grupo tacrolimus que consistiu de 20 indivíduos que receberam tacrolimus. Ambos os grupos foram avaliados em três momentos: momento prétransplante , 30 dias após o transplante renal (momento 30 dias) e 90 dias após o transplante renal (momento 90 dias). Em todas as avaliações foram registrados os seguintes parâmetros clínicos: distância da junção esmalte-cemento à margem gengival (JEC-MG), profundidade clínica de sondagem (PCS), nível clínico de inserção (NCI), sangramento à sondagem (SS), índice de placa (IP) e índice de crescimento gengival (ICG). Foi observada redução significante do IP, em ambos os grupos, entre o momento pré-transplante e o momento 90 dias, mas não houve diferença significante entre os grupos nos três momentos avaliados. Com relação ao SS, foi observado no grupo tacrolimus uma redução significante entre o momento pré-transplante e o momento 30 dias (p=0,001) e entre o momento pré-transplante e o momento 90 dias (p<0,001). Também não houve diferença significante entre os grupos nos momentos avaliados. Não foi encontrada diferença significante entre os grupos com relação à JEC-MG e PCS nos três momentos. Quanto ao NCI, houve diferença significante entre os momentos pré-transplante e 30 dias (p=0,015), e entre os momentos pré-transplante e 90 dias (p=0,03), independentemente do grupo. Com relação ao ICG, foi observado no grupo CsA diferença significante entre os momentos pré-transplante e 30 dias (p<0,001), pré-transplante e 90 dias (p<0,001) e entre 30 dias e 90 dias. No grupo tacrolimus, foi observada diferença significativa no ICG entre os momentos pré-transplante e 90 dias (p=0,007) e entre 30 dias e 90 dias (p=0,007). Ainda com relação ao ICG, o grupo ciclosporina-A sempre apresentou médias superiores ao grupo tacrolimus e essa diferença foi significativa nos momentos 30 dias (p=0,03) e 90 dias (p=0,014). Os autores concluíram que ambos os grupos apresentaram crescimento gengival após 90 dias de terapia imunossupressora. Entretanto, a média do índice de crescimento gengival do grupo CsA foi significantemente maior que a média do grupo tacrolimus após 30 dias e 90 dias. Além disso, os parâmetros clínicos periodontais IP, SS, JEC-MG, PCS e NCI não apresentaram diferenças significativas entre os grupos durante o estudo. / The purpose of this study was to evaluate the occurrence of gingival overgrowth induced by cyclosporin-A (CyA) and tacrolimus, in kidney transplant patients, and to verify the possible changes of the periodontal parameters (plaque index, bleeding on probing, distance of the enamel-cement junction to gingival margin, probing depth and clinical attachment level) after the beginning of the immunosuppressant therapy. Two groups were evaluated: group CyA that consisted of 20 individuals who received CyA and the group tacrolimus that consisted of 20 individuals who received tacrolimus. Both groups were evaluated at three moments: pre-transplant moment, 30 days after the kidney transplant (30 days moment) and 90 days after the kidney transplant (90 days moment). In all these evaluations we registered the following parameters: plaque index (PI), bleeding on probing (SS), distance of enamel-cement junction to gingival margin (JEC-MG), probing depth (PD), clinical attachment level (CAL) and gingival overgrowth index (GO). It was observed a significant reduction of the PI in both groups, between the pre-transplant moment and the 90 days moment, but it was not observed any significant difference between the groups in the three evaluated moments. A significant reduction was found in the SS between the pretransplant moment and the 30 days moment (p=0,001), and between the pretransplant moment and the 90 days moment (p<0,001) for the group tacrolimus. Again it was not found any significant difference between the groups in the evaluated moments. It was not found any significant difference between the groups in the three moments of the study when the JEC-MG and PD were compared. About the CAL, it was found a significant difference between the pre-transplant moment and the 30 days moment, and between the pre-transplant moment and the 90 days moment, independently of the group compared. When we evaluated the GO in the CyA group we found a significant difference between the pre-transplant moment and 30 days moment (p<0,001), the pre-transplant moment and the 90 days moment (p<0,001) and between the 30 days moment and the 90 days moment. In the group tacrolimus, it was observed a significant difference in the GO between the pre-transplant moment and the 90 days moment (p=0,007) and between the 30 days moment and the 90 days moment (p=0,007). The group CyA always presented superior GO mean scores when compared to the group tacrolimus and this difference was significant at the 30 days moment (p=0,03) and 90 days moment (p=0,014). The authors concluded that both groups presented gingival overgrowth after 90 days of immunosuppressant therapy. However, the mean GO scores of the group CyA was significantly higher than the mean of the group tacrolimus after 30 days and 90 days. Moreover, periodontal clinical parameters PI, SS, JEC-MG, PD and CAL did not present significant differences between the groups during the study.

Introdução: No contexto do transplante de órgãos, a adesão à imunossupressão é imprescindível para evitar episódios de rejeição celular, perda do enxerto e óbito do paciente. No transplante hepático infantil, as taxas de não adesão aos imunossupressores variam de 10 a 70,4%, são aparentemente mais frequentes em pacientes adolescentes e raramente estudada em crianças abaixo de 12 anos de idade. Objetivos: determinar a prevalência de não adesão ao tacrolimo em crianças (idade no transplante < 12 anos), acompanhadas no Programa de Transplante Hepático Infantil do Hospital de Clínicas de Porto Alegre, transplantados por no mínimo 1 ano, traçar o perfil dos pacientes classificados como sem adesão e identificar as possíveis repercussões desta sobre o enxerto. Material e métodos: Trata-se de uma coorte histórica de um único centro, onde os pacientes foram recrutados do banco de dados da Unidade de Gastroenterologia Pediátrica do Hospital de Clínicas de Porto Alegre. Foram revisados os registros médicos de todos os pacientes pediátricos que receberam um enxerto hepático. Critérios de inclusão: procedimento realizado entre os períodos de 1999-2011, por qualquer indicação, em uso de tacrolimo como imunossupressão de manutenção e com no mínimo cinco níveis séricos do imunossupressor em intervalos de aproximadamente três meses. Excluídos pacientes em uso de medicamentos que pudessem interferir no nível sérico do imunossupressor. Não adesão ao tacrolimo foi definida como valores de desvio-padrão do medicamento ≥ 2, considerando-se no mínimo cinco medidas consecutivas do nível sérico (índice de variabilidade do nível do tacrolimo). As características clínicas, sociais, e demográficas dos pacientes, idade e nível educacional maternos definiram a variável perfil do paciente. ALT > 60 IU / l (excluídas infecção e hepatotoxicidade), rejeição celular histologicamente comprovada, perda do enxerto e morte do paciente definiram repercussão da não adesão sobre o enxerto. Análise Estatística: foram utilizados os testes T de Student para as variáveis descritivas e o qui-quadrado para as variáveis categóricas. Valores de p < 0,05 foram considerados significativos. Resultados: Oitenta e seis pacientes menores de 12 anos foram submetidos ao transplante hepático nos períodos entre 1999 e 2011. Destes, sessenta e cinco preencheram os critérios de inclusão. Quinze foram excluídos, resultando em uma amostra final de cinquenta pacientes. Vinte e oito eram do sexo masculino (56%) sendo a média de idade de 4,0 ± 3,5 anos. A atresia biliar representou 62% das indicações de transplante, 87,7% eram lactentes e escolares. Não adesão medicamentosa foi observada em 22 (44%) dos pacientes e nas famílias com maior renda (p=0,045). Houve uma tendência da não adesão ser mais frequente nas famílias cujas mães tinham maior escolaridade (p=0,051). A média de idade materna foi de 31 anos e esta variável não esteve associada aos desfechos. ALT > 60 UI/l foi mais frequente nos pacientes sem adesão medicamentosa (p=0,035) e prontamente resolvida após ajuste da imunossupressão. A rejeição celular aguda foi semelhante entre os grupos (p=0,90). Óbito ou perda do enxerto não foram observados. Conclusão: Houve alta variabilidade do nível de tacrolimo na amostra estudada. Esta foi mais prevalente nas famílias com maior renda. Elevação transitória da ALT foi a principal repercussão dessa variabilidade sobre o enxerto. O índice de variabilidade do nível sérico de tacrolimo ≥2DP pode sugerir alguma falha da adesão medicamentosa. / Introduction: In the context of organ transplantation, the adherence to immunosuppression is important to avoid cell rejection episodes, graft loss and patient death. In pediatric liver transplantation, the rates of non-adherence to immunossupressors vary from 10 to 70,4%. This is more frequent in teenage patients and it is rarely studied in children younger than twelve years old. Objectives: Determining the prevalence of non-adherence to tacrolimus in children (age at transplant below 12 years) followed in the Pediatric Liver Transplantation Program of Clinical Hospital of Porto Alegre (HCPA) for at least 1 year in order to establish these patients’ profile and identify possible repercussions of non-adherence of the graft. Materials and methods: This is a matter of a single center historical cohort in which patients were recruited from the Pediatric Gastroenterology Unit at HCPA. We verified medical records of all pediatric patients who received a liver graft. Inclusion criteria are: procedure carried out from 1999 to 2011 under any recommendation, using tacrolimus as a maintenance immunosupressor, and with at least five serum levels of tacrolimus in approximately every three months. Patients in treatment with medication that could interfere in the suppressor's serum level were excluded. Non-adherence to tacrolimus was defined when the medication standard deviation was greater than or equal to 2, considering at least five consecutive measurements of serum level (variability rates of the tacrolimus level). Each patient profile was defined by their clinical, social and demographic characteristics, as well as their mother's age and educational level. Alanine transaminase (ALT) higher than 60 UI/l (infection and hepatotoxity were excluded), histologically proved cell rejection, graft loss and patient death defined the repercussions on non-graft adherence. Statistical Analysis: We used T tests for the descriptive variables and chi-squared for the categorical variables. Values of p lower than 0.05 were considered as significant. Findings: Eighty-six patients younger than 12 years old were subject to liver transplantation between 1999 and 2011. From these, sixty-five patients fulfilled the inclusion criteria. Fifteen patients were excluded, resulting in a sample of fifty patients. Twenty-eight were male (56%) and the average age was 4.0 ± 3.5 years. Biliary atresia represented 62% of the transplant indications. 87.7% were infants and students. Nonadherence to medication was observed in 22 (44%) patients and it more prevalent it families with greater income (p = 0.045). Non-adherence tended to be more frequent in families in which mothers had a better level of education (p = 0.051). The average age of the mothers was 31 years old and this variable was not associated with the outcomes. ALT> 60 IU/l was more frequent in patients without adherence to medication (p = 0.035) and immediately solved after an adjustment of the immunosuppression. Acute cell rejection was similar among groups (p = 0.90). Death and graft loss were not observed. Conclusion: There was a high variability in tacrolimus levels in the sample studied. This was more prevalent in families with higher income. Temporary elevation of ALT was the main effect of this variability on the graft. The variability rates of the serum level of tacrolimus, which was greater or equal to 2 SD (Standard deviation), may suggest failure of the medication adherence.

Background: Abdominal solid organ transplantation has evolved from an experimental procedure to a well-established therapy within a few decades. This success is largely due to the introduction of calcineurin inhibitor immunosuppression. Tacrolimus is the most widely used calcineurin inhibitor but has a narrow therapeutic range which requires close drug monitoring to prevent both toxicity and inadequate immunosuppression. Previous studies in renal transplantation have shown that genetic polymorphisms, CYP3A5, CYP3A4*22 and ABCB1 can influence the bioavailability and pharmacokinetics of tacrolimus. These polymorphisms are closely linked to ethnicity and have never been studied in a Scottish population before. Additionally, increasing evidence suggests that high variability of tacrolimus is linked to increased graft loss in kidney transplant patients. Methods: 5889 subjects were genotyped for the genetic polymorphisms CYP3A5 A > G allele transition, CYP3A4*22 C > T and ABCB1 C > T transition. This included 4899 healthy individuals from Generation Scotland bio-resource and 990 patients who underwent renal, liver, or simultaneous pancreas kidney transplants or were organ donors. Tacrolimus dose, trough level and renal function were measured at 11 time points from date of transplant up to and including 12 months post-transplant. Clinical data including episodes of acute rejection, graft and patient survival were compared between the different genotypes. Separate analyses were undertaken for kidney, SPK transplants, as well as liver transplants, the latter looking at recipient and liver donor genotype. A separate cohort of 103 renal transplant patients converted from twice-daily to once-daily tacrolimus had their tacrolimus variability calculated and compared with graft survival. Results: The distribution of the 3 different genotypes of CYP3A5, CYP3A4*22 and ABCB1 were comparable with other Caucasian populations studied previously. In renal transplant recipient expression of the A allele (GA/AA) led to significantly increased dose requirements of tacrolimus and initially lower tacrolimus trough levels. The different genotypes of ABCB1 had no effect. Expression of a CYP3A4*22 T allele trended towards a lower tacrolimus dose requirement but this was not significant. There was no difference in renal function, graft survival or patient survival with any of the polymorphisms. SPK patients had comparable results. In the liver transplant patients, the donor genotype had a greater influence than the recipient one. The donors with CYP3A5 A allele expression had significantly higher tacrolimus dose requirements and lower initial tacrolimus levels. This was apparent to a lesser extent with the recipient expression of CYP3A5 and did not reach statistical significance at all time points. There was no significant difference in tacrolimus dose requirements or level with either donor or recipient expression of ABCB1 or CYP3A4*22. There was a significantly higher incidence of acute rejection in donor CYP3A5 A allele expressers of liver transplant patients in univariate and multivariate analysis. There was no significant different in acute rejection with ABCB1 or CYP3A4*22 genotype. No differences in graft or patient survival with either donor or recipient genotype of any of the 3 polymorphisms were noted. Conversion from twice-daily to once-daily tacrolimus in the first 12 months post-transplant reduced tacrolimus variability. Patients with high tacrolimus variability pre and post conversion had significantly greater graft loss than patients with low tacrolimus variability. Conclusion: CYP3A5 expression results in increased tacrolimus requirements to achieve adequate immunosuppression in renal transplant and SPK patients. Donor rather than recipient CYP3A5 expression is relevant for liver transplantation and dose requirements. There may be an association with donor CYP3A5 expression in liver transplant patients and acute rejection which needs further evaluation. ABCB1 and CYP3A4*22 do not appear to have a significant impact in any of the organ transplants. High tacrolimus variability is associated increased graft loss in renal transplant patients.

Made available in DSpace on 2016-01-26T12:51:41Z (GMT). No. of bitstreams: 1 pauloeduardofbotturafilho_dissert.pdf: 8951270 bytes, checksum: e8c0f107001a21241dfc8719ec74d296 (MD5) Previous issue date: 2012-04-13 / Background: Periodontal disease is often associated with systemic diseases and is characterized by destruction of the tissues supporting the teeth. Patients using immunosuppressive drugs such as tacrolimus are among those who suffer from tissue destruction. Objective: To evaluate the effects of laser and photodynamic therapies (PDT) (nonsurgical) as an adjunct to scaling and root planing in the treatment of corona-induced periodontitis in rats immunosuppressed with tacrolimus (Prograf ®). Materials and methods: The animals were divided into five groups. Each groups had 6 rats. Group 1, the control group, received only saline solution throughout the study period of 42 days and did not receive periodontal treatment; Group 2, received saline solution and scaling and root planning (SRP); Group 3, received tacrolimus (1 mg/kg/day) and was treated with SRP; Group 4, animals were treated identically to group 3 and then administered laser treatment; and in Group 5, the animals were treated identically to group 3 and then administered photodynamic therapy. Results: Statistical analysis indicated decreased bone loss with the progression of time (p<0.005). There was no significant difference between the bone loss associated with the types of treatment administered to groups 1, 2 and 3 (p>0.9) and groups 4 and 5 (p>0.6). The analysis also indicated that immunosuppression was not a bone loss determining factor. Conclusion: Laser and PDT therapies were effective as an adjunctive treatment to SRP in reducing bone loss caused by experimental periodontitis induced in animals being treated systemically with tacrolimus. / Introdução: A doença periodontal está frequentemente associada a doenças sistêmicas e caracteriza-se pela destruição dos tecidos de suporte dos dentes. Pacientes que usam medicamentos imunossupressores como o tacrolimo, estão entre os que sofrem com esse problema. Objetivo: Avaliar os efeitos do laser e da Terapia Fotodinâmica (PDT) (tratamentos não cirúrgicos) como tratamento adjunto a raspagem e alisamento corono-radicular (RAR) sobre a periodontite induzida em ratos imunodeprimidos com tacrolimo. Materiais e métodos: Cada grupo continha 6 ratos. Grupo 1, grupo controle, recebeu apenas solução salina através do período estudado de 42 dias e não recebeu tratamento periodontal; Grupo 2, recebeu solução salina e RAR; Grupo 3, recebeu tacrolimo (1 mg/kg/d) e foi tratado com RAR; Grupo 4, os animais foram tratados identicamente ao grupo 3 e então administrado tratamento com laser; e o Grupo 5, os animais foram tratados identicamente ao grupo 3 e então foi administrado a PDT. Resultados: A análise estatística indicou decréscimo da perda óssea com a progressão do tempo (p<0,005). Não há diferenças significativas na perda óssea associada conforme o tipo de tratamento entre os grupos 1, 2 e 3 (p>0,9) e também entre os grupos 4 e 5 (p>0,6). As análises também demonstraram que a imunossupressão não foi um fator determinante para a perda óssea. Conclusão: O laser e a PDT foram efetivos como tratamento adjunto a RAR na redução da perda óssea causada pela periodontite experimental induzida em animais tratados com tacrolimo.

Made available in DSpace on 2016-01-26T12:51:42Z (GMT). No. of bitstreams: 1 rosasoubhia_tese.pdf: 792706 bytes, checksum: bba71696e22270729d09c3130cc047eb (MD5) Previous issue date: 2005-05-25 / Introduction: Tacrolimus (FK 506) is a potent immunosuppressive drug that may cause nephrotoxicity decreasing the renal blood flow (RBF) and glomerular filtration rate (GFR). Conventional non-steroidal anti-inflammatory drugs (NSAIDs) may cause nephrotoxicity, interfering with renal hemodynamics and fluid and eletrolyte homeostasis. Recently, new selective COX-2 inhibitors have been developed producing less side effects (gastric, cardiac and renal) related to COX-1 inhibition. The increasing use of FK 506 and the intensive use of NSAIDs with analgesic or ani-inflammatory purposes, increases the possibility of a drug combination, potentiating the nephrotoxic risk of the two drugs. Objective : Compare the renal function of rats receiving combination therapy with FK and a non-selective COX inhibitor, sodium diclofenac (SD) with those receiving FK and a selective COX-2 inhibitor, rofecoxib (RO). Material and Methods : Male Munich-Wistar rats receiving a low sodium diet (0.06%) for 7 days and gavage treatment for 7 days with FK (2 mg/kg/day), SD (10 mg/kg/day), RO (3 mg/kg/day), FK+SD, FK+RO and vehicle (control) were used. Glomerular filtration rate (GFR, inulin clearance, ml/min/100g); renal blood flow (RBF, Doppler ultrasound, ml/min); mean blood pressure (MBP, intracarotid probe, mmHg); renal vascular resistence ( RVR, mmHg/ml/min); hematocrit (Htc); urinary volume ( UV, &#956;l/min); solute clearance; renal histology; animal weight (g) and FK serum concentration (SCFK, ng/ml) were assessed. Results are presented as a mean±standart deviation and compared by ANOVA followed by Student-Neuman-Keuls test. Results : The GRF of the SD group was 0.98±0.03, RO 1.06±0.04 and FK 0.99±0.06 similar to control values (1.10±0.05). GRF values decreased in the FK+RO (0.86±0.06;p<0.05 vs RO and Control) and FK+SD (0.63±0.06;p<0.001 vs control, FK and SD groups and p<0.01 vs FK+RO) groups. RBF, MBP, RVR and Htc values were similar in all groups. Diuresis was lower in the groups with drug combination, but there was a statistically significant difference only between FK+SD and RO groups (8.38±0.46 vs 12.99±1.22;p<0.05). There were no significant histological chan ges in the treatment groups. The FK+SD group showed statistically significant weigth changes (-18±5) when compared to the Control and RO groups (6±2 and 5±2, respectively; p<0.001) and to the SD an FK+RO groups (0.2±4 and 1±2, respectively; p<0.01). SCFK was significantly decreased (p<0.05) for FK+SD and FK+RO (1.7±0.3 and 1.8±0.4) groups when compared to the FK group (3.2±0.4. Conclusions: The combination of FK and a non-selective COX inhibitor significantly decreased GFR regardless of a RBF decrease or RVR increase, and is probably a result of Kf decrease. The trend to antidiuresis was similar for the combination of FK with both classes of NSAIDs. FK combined to a non-selective COX inhibitor caused a mild systemic toxicity when compared with the COX-2 selective inhibitor. Serum FK concentrations were significantly lower in NSAIDs treated animals. / Introdução: O tacrolimus (FK 506) é uma potente droga imunossupressora, pode causar nefrotoxicidade aguda com diminuição do fluxo sanguíneo renal (FSR) e ritmo de filtração glomerular (RFG). Os antiinflamatórios não-hormonais (AINHs) convencionais podem causar nefrotoxicidade, interferindo na hemodinâmica renal e na homeostase de fluidos e eletrólitos. Recentemente surgiram novas drogas do grupo coxib que são inibidores seletivos da COX-2, e portanto teriam menos efeitos colaterais relacionados à inibição da COX-1 (gástricos, cardíacos e renais). O crescente uso do FK 506 e o intenso uso de AINHs com finalidade analgésica e ou antiinflamatória aumenta a possibilidade de utilização em conjunto, potencializando o risco de nefrotoxicidade das duas drogas. Objetivo: Comparar a função renal de ratos sob os efeitos do uso simultâneo do FK e de um inibidor não-seletivo da COX, o diclofenaco sódico (DS) e do FK e de um inibidor seletivo da COX-2, o rofecoxib (RO). Materiais e Método: Utilizaram-se ratos Munich-Wistar machos em dieta hipossódica (0,06%) por 7 dias e tratamento por gavagem por 7 dias com FK (2 mg/kg/dia), DS (l0mg/kg/dia), RO (3mg/kg/dia), FK+DS, FK+RO e veículo (Contr). Aferidos ritmo de filtração glomerular (RFG, depuração de inulina, ml/min/l00g); o fluxo sanguíneo renal (FSR, ultrasom Doppler, ml/min); a pressão arterial média (PAM, probe intracarotídeo, mmHg); a resistência vascular renal (RVR, mmHg/ml/min); hematócríto (Ht); o volume urinário (VU, pl/min); a depuração de solutos; a histologia renal; o peso dos animais (g) e a concentração sanguínea de FK CSFK, ng/ml). Os resultados são apresentados com médiaserro padrão da média e comparados por ANOVA seguido do teste Student-Neuman-Keuls. Resultados: O RFG do grupo DS foi 0,980,03, do RO foi 1,060,04 e do FK 0,990,06 similares ao controle (1,100,05). Houve queda do RFG nos grupos FK+RO (0,860,06;p<0,Os vs RO e Contr) e FK+DS (0,630,06;p<0,001 vs Contr,DS, RO e FK; p<0,01 vs FK+RO) Nota de Resumo O FSR, a PAM, a RVR e o Ht foram semelhantes em todos os grupos. A diurese foi menor nos grupos com associação de drogas, mas houve diferença estatisticamente significante apenas entre os grupos FK+DS e RO (8,380,46 vs l299l,22;p<0,05). Não ocorreram modificações histológicas significativas nos grupos estudados. O grupo FK+DS apresentou variação de peso (-185) estatisticamente significante em relação aos grupos Contr 62 e RO 52 (p<0,001) e DS 0,24 e FK+RO -12 (p<0,01). A CSFK diminuiu significativamente (p<0,05) para os grupos FK+DS e FK+RO (1,70,3 e 1,80,4) em relação ao grupo FK (3,20,4). Conclusões: A associação do FK com um inibidor não-seletivo da COX causou diminuição mais acentuada do RFG independentemente da diminuição do FSR ou aumento da RVR, sendo provavelmente decorrente da diminuição do Kf. A tendência à antidiurese foi similar para a associação do FK com as duas classes de AINHs. O FK associado com um inibidor não-seletivo da COX causou discreta toxicidade sistêmica quando comparado com inibidor seletivo da COX-2. Nos animais tratados com AINHs, as concentrações sanguíneas do FK foram significativamente menores.

INTRODUÇÃO: O tratamento cirúrgico da endometriose profunda tem se mostrado benéfico para os resultados de Reprodução Assistida. O motivo que leva aos melhores resultados ainda é desconhecido, mas remete à etiologia multifatorial dessa doença. Observa-se, então, a oportunidade de investigar mecanismos moleculares que possam justificar este fato. Nesse contexto, os microRNAs podem desempenhar papel fundamental na medida em que alteram a expressão de diferentes genes por meio da inibição póstranscricional. OBJETIVO: Analisar o efeito da remoção cirúrgica das lesões de endometriose profunda na expressão dos microRNAs -21, -451 e -29c, além da expressão da proteína FKBP52. MÉTODOS: Trata-se de estudo clínico, prospectivo, longitudinal e comparativo no qual foram incluídas 26 pacientes que foram divididas em dois grupos, segundo o resultado da ultrassonografia transvaginal com preparo intestinal. As pacientes que não apresentaram alterações sugestivas de endometriose compuseram o grupo controle (n = 11) e foram submetidas à coleta de amostra de endométrio. As pacientes do grupo de estudo (n = 15) foram submetidas à amostragem endometrial antes e após o tratamento cirúrgico da endometriose, além de ter sido realizada a coleta de amostra da lesão profunda durante o ato operatório. Foi realizada a extração total de RNA dessas amostras e, posteriormente, PCR em tempo real para análise de expressão dos microRNAs -21, -451 e -29c, além da proteína FKBP52. RESULTADOS: A comparação da expressão relativa dos microRNAs -21 e -451 entre as amostras, de forma geral, não mostrou diferença estatisticamente significante. A expressão relativa do microRNA-29c foi maior no endométrio de pacientes com endometriose em relação ao grupo controle e ainda maior nas lesões de endometriose profunda. Após a cirurgia, a expressão do microRNA-29c no endométrio, foi equivalente à do grupo controle. A expressão da FKBP52 foi menor no endométrio das mulheres com endometriose e nas lesões da doença em comparação ao grupo controle. Após o tratamento cirúrgico houve aumento da expressão de FKBP52 nas amostras de endométrio nas pacientes com endometriose que passou a ser semelhante à do grupo controle. CONCLUSÕES: Os resultados sugerem que a presença das lesões de endometriose pode aumentar a expressão do microRNA-29c no endométrio e, por conseguinte, diminuir a expressão de um dos seus RNA mensageiros alvos que codifica a proteína FKBP52. Após o tratamento cirúrgico, com remoção das lesões de endometriose, a expressão do microRNA-29c e da FKBP52 se assemelhou à do grupo controle / INTRODUCTION: Surgical treatment of deeply infiltrating endometriosis appears to yield benefits to the affected women and also to the assisted reproduction treatments. Although the mechanisms involved on the improvement of the outcomes are still unknown; yet, they are similar to the multifactorial origin of the endometriosis. Considering that the microRNAs can modify different genes expression, it was investigated their role concerning the molecular pathways leading to endometriosis and the clinical betterment of the assisted reproductive procedures after the surgical treatment. OBJECTIVE: The aim of this study was to evaluate the effect of surgical treatment in women with endometriosis focusing the microRNAs -21, -451 and -29c expression, as well as the protein FKBP52 expression. METHODS: This is a clinical, prospective, longitudinal and comparative study which included 26 patients that were divided into two groups according to the findings of the transvaginal ultrasound with bowel preparation. Eleven women without evidence of DIE composed the control group and were submitted to eutopic endometrium sampling. Fifiteen women presented with evidence for DIE detected by pelvic ultrasound were also submitted to eutopic endometrium sampling before and after surgical treatment. Surgical procedures revealed the presence of relevant DIE. Total RNA extraction of all samples was performed and followed by real time PCR to evaluate microRNAs -21, -451, -29c and protein FKBP52 expression. RESULTS: MicroRNAs -21 and -451 expression analysis did not show statistically significant difference among samples. Nonetheless, expression of microRNA-29c was elevated in eutopic endometrium of women suffering from DIE in comparison to the control group. After surgery, the microRNA- 29c expression in eutopic endometrium became equivalent to the control group. The expression for FKBP52 was lower in women having DIE than those without endometriosis. The surgical treatment increased the expression of the protein FKBP52 in eutopic endometrial samples, turning it similar to the control group. CONCLUSIONS: The results of this study suggest that the presence of DIE might increase the expression of microRNA-29c in eutopic endometrium and consequently decrease the expression of one of its target messenger RNA that codifies the protein FKBP52. After surgical removal of endometriosis lesions, the microRNA-29c and the FKBP52 expression returned to a level similar to the control group

Reproduction de : Mémoire du DES : Pharmacie hospitalière : Nantes : 2008. Reproduction de : Thèse d'exercice : Pharmacie : Nantes : 2008. / Bibliogr.

Το tacrolimus παραμένει ο ακρογωνιαίος λίθος στην ανοσοκατασταλτική αγωγή που λαμβάνουν οι ασθενείς με μεταμόσχευση νεφρού. Το στενό θεραπευτικό παράθυρο και η σημαντική ενδοϋποκειμενική και διϋποκειμενική διακύμανση της κινητικής του εκθέτει τον ασθενή στον κίνδυνο υπερδοσολογίας και πιθανής εμφάνισης τοξικότητας ή υποδοσολογίας και κινδύνου απόρριψης του μοσχεύματος. Σκοπός της παρούσας διδακτορικής διατριβής ήταν η φαρμακοκινητική και η φαρμακογενετική προσέγγιση με στόχο την εξατομίκευση της χρήσης του tacrolimus σε ασθενείς με μεταμόσχευση νεφρού. Τον πληθυσμό μελέτης αποτέλεσαν 40 ασθενείς με μεταμόσχευση νεφρού της Νεφρολογικής Κλινικής του Πανεπιστημιακού Γενικού Νοσοκομείου Πατρών. Η γονοτύπιση αφορούσε στην ανεύρεση του CYP3A5*1 και *3 αλληλομόρφου και πραγματοποιήθηκε με τη μεθοδολογία της απόμονωσης DNA από λευκά αιμοσφαίρια περιφερικού αίματος των ασθενών, την αλυσιδωτή αντίδραση πολυμεράσης για τον πολλαπλασιασμό του τμήματος ενδιαφέροντος και την ανάλυση πολυμορφισμού περιοριστικών θραυσμάτων. Για τη στατιστική ανάλυση, χρησιμοποιήθηκαν το Student’s t-test ή τo Mann-Whitney test, ανάλογα με το εάν οι μεταβλητές ακολουθούσαν κανονική ή όχι κατανομή, η μέθοδος της γραμμικής παλινδρόμησης και η μεθόδος των γενικευμένων γραμμικών μοντέλων-ανάλυση επαναλαμβανόμενων μετρήσεων. Η συχνότητα του CYP3A5*3/*3 και CYP3A5*1/*3 γονοτύπου ήταν 87,5% (35/40) και 12,5% (5/40), αντίστοιχα. Δεν ανευρέθησαν ομοζυγώτες για το CYP3A5*1 αλληλόμορφο. Ανεδείχθη συσχέτιση του CYP3A5*1 με χαμηλότερες προβλεπόμενες τιμές της προσαρμοσμένης στη δόση συγκέντρωσης και υψηλότερες προβλεπόμενες τιμές του όγκου κατανομής του υπό μελέτη φαρμάκου. Οι ασθενείς που έφεραν το CYP3A5*1 αλληλόμορφο απαιτούσαν υψηλότερες δόσεις tacrolimus για την επίτευξη της επιθυμητής συγκέντρωσης στο αίμα σε σχέση με τους ομοζυγώτες για το CYP3A5*3 νωρίς αλλά και στην απώτερη φάση μετά τη μεταμόσχευση. Η επίδραση της χρονικής στιγμής, δηλαδή του χρόνου μετά τη μεταμόσχευση, στην κινητική του tacrolimus ήταν σημαντική ενώ δεν ανεδείχθη σημαντική επίδραση του φύλου. Δεν ανευρέθη ανάγκη για πιο τακτικό έλεγχο από το σύνηθες της συγκέντρωσης του tacrolimus σε μεταμοσχευμένους νεφρού που δεν εκφράζουν το CYP3A5 και λαμβάνουν ομεπραζόλη ή στατίνη (ατορβαστατίνη, σιμβαστατίνη, πραβαστατίνη ή φλουβαστατίνη). Η ασφάλεια και η αποτελεσματικότητα των στατινών διατηρήθηκε κατά τη συγχορήγηση με tacrolimus. Η φαρμακοκινητική και η φαρμακογενετική προσέγγιση αναδεικνύουν τις γενετικές και επιγενετικές εκείνες παραμέτρους που επηρεάζουν την κινητική του tacrolimus και συμβάλλουν στην εξατομίκευση της χορήγησής του. / Tacrolimus remains the centerpiece of the maintenance treatment scheme in renal transplant recipients. Both its narrow therapeutic window and its highly pharmacokinetic variance may lead to overtreatment and toxicity or insufficient treatment and transplant rejection, conditions that are usually seen in clinical practice. Our aim was to determine the impact of patient characteristics, drug-to-drug interactions and genotype (presence of CYP3A5*1 and CYP3A5*3) on the kinetics of tacrolimus in renal transplant recipients. Our patient population consisted of 40 renal transplant recipients. CYP3A5 genotyping was performed based on the following procedures: DNA extraction from blood, polymerase chain reaction and accordingly, restriction fragment length polymorphism. Statistical analysis was performed with Student’s t-test or Mann-Whitney test, according to the presence of normality of the studied parameters, linear regression analysis and general linear model-repeated measures. The frequency of CYP3A5*3/*3 genotype was 87.5% (35/40) whereas the frequency of the CYP3A5*1/*3 genotype was 12.5% (5/40). No individual homozygote for CYP3A5*1 was detected. CYP3A5*1 variant was associated with significant lower tacrolimus dose adjusted concentration. Carriers of CYP3A5*1 allele had lower predicted measures for tacrolimus dose adjusted concentration and higher predicted measures for volume of distribution. Timepoint, in contast with gender, had a statistically significant impact on tacrolimus kinetics. No statistically significant difference was observed in tacrolimus kinetics during the coadministration of omeprazole or statin. Statistically significant decrease in serum cholesterol was observed after the initiation of statin whilst renal and hepatic function remained unchanged. No skeletal muscle abnormalities were reported during the coadministration of statin. Pharmacokinetic and pharmacogenetic approach can be used to elucidate genetic and epigenetic factors that influence tacrolimus kinetics and thus, they can contribute to dose individualization.