1. Paediatric Renal Transplantation
Angela Lamb
Paediatric Renal Pharmacist
Yorkhill Hospital
Glasgow

2. Summary History of kidney transplants Kidney transplantation
History Immunosuppression
Immunosuppressive
NICE guidelines on immunosuppression therapy
Renal unit guidelines for Kidney Transplant
Role of pharmacist
Future

3. History of Kidney Transplant
1954
First successful kidney transplantation took place in Brigham hospital in Boston in identical twins
1959
First successful kidney transplantation non-identical individuals
1960
First UK living donor kidney Tx took place in Edinburgh
1965
First recorded cadaver kidney Tx in UK

4. Paediatric Transplantation
1950
RHSC Glasgow was the first regional referral unit for children with renal disease in the UK
1960s
Peritoneal Dialysis was pioneered in RHSC Glasgow for acute renal failure
1971
New purpose built Renal Unit which led to the use of PD for ESRF

5. Paediatric Transplantation
1970s(early)
Guys in London & Royal Manchester Children's Hospital first Paediatric Haemodialysis units in the UK
Dr Anna Murphy
HD unit at RHSC Glasgow
1977 (March)
First paediatric renal Tx took place in RHSC Glasgow
1990s
One specialist paediatric renal unit in Scotland

6. Transplants saves lives:
Information from UK Transplant website :
1,933 kidney Tx of which 676 (35%) were given their kidney by a friend or relative (living related donor LRD)
Most recent figures on 15/4/07
6,359 patients were listed as actively waiting for a transplant of which 99 are children <18years

7. Kidney Transplant Renal replacement therapy
Cadaver - last for years
Living related donor – last for years
First choice for children
Planned
Better donor match
Require 2-3 kidneys in a lifetime
Kidney Tx is preferred renal rt for anyone with ESRF

8. Kidney Transplant Leave the native kidneys Remove if primary
disease cause
long-term problem
Tx kidney located low
in the abdomen

9. Problems post transplant
Rejection
Infection
Dehydration
Drug toxicity
Obstruction
Graft vascular thrombosis

10. Transplant Rejection Three types: Hyperacute Acute Chronic
this occurs within hours of transplant and is mediated by preformed allo-antibodies
Acute
usually seen within a few months of transplant. Cellular or vascular.
Chronic
a progressive decline in graft function over months or years.
Acute- cellular acute rejection charecterised by cytotoxic T cell infiltration into the graft.
Chronic – complex processs influenced by both immunological and non-immunological factors.

11. Immune Response
Immune system goes into a “search out and destroy” mode when it recognises a foreign antigen
Antigen is an enormous range of substances that can be bound by an antibody and induce some kind of immune response

12. Cells in the immune system

13. Immune Response
Donor molecules are expressed on the surface of graft cells (eg Human Leucocyte Antigen HLA) are presented on “antigen presenting cells”, to resting CD4+, T-helper cells .
This process activates T helper cells causing them to produce and secrete chemical messenger cytokines (IL2- considered the main cytokine) they also express cell surface receptors to the cytokines (eg IL2-R).
The T cells then differentaite and proliferates under the influence of IL2
This process activates cytotoxic CD8+ T cells, these cytotoxic T cells lyse the donor cells.
B lymphocytes are activated by other cytokines leading to antibody formation.

14. History of Immunosuppression
Organ Tx first attempted at the turn of the last century- failure
1944 Sir Peter Medawar – graft loss was a result of host vs graft immune response
Skin graft model – discovered that the immune system recognised the Tx as non-self

15. History of Immunosuppression
1956 Billingham & colleagues
skin grafts were co-Tx with allogenic bone marrow cells into irradiated mice
Hume
extended these observation in kidney & BMTx in irradiated dogs
Extended
to humans giving sub-lethal doses of total body irradiation before kidney Tx
Humans study in Paris in patients irradiated to ablate immune cells. They were isolated for 1 month 2/6 infected. 4/6 graft survival 2 days to 2 and a half years. Carefully selected blood group typing & leucocyte antigen activity

16. History of Immunosuppression
Goodwin & colleagues used myeloablative agents such as nitrogen mustard and also chlorambucil & prednisolone
Technical difficulties
High rate of infection
100% mortality
This early work established
Organ cooling
Minimal ischaemic time
Matching of donor & recipient

17. History of Immunosuppression
Over the next 30 years three types of drugs were developed:
Aim of limiting B-cell & T-cell proliferation mediating rejection
Inhibitors of DNA synthesis
Lymphocyte depleting agents
Cytokine modulators

18. Immunosuppressants 1962 Azathioprine 1963 Prednisolone
1967 Anti-human polyclonal antibodies:
equine ATGAM
rabbit Thymoglobulin (ATG)
1978 Ciclosporin
1980s Muromonab (OKT3)
1990 Tacrolimus
1995 Mycophenolate mofetil
2000 Monoclonal antibodies
2000 Sirolimus
Ciclosporin general use in 1983

19. Azathioprine First drug to be used to prevent graft rejection
Mechanism of action
Well absorbed and quickly metabolised to 6-mercaptopurine (6-MP)
6-MP is further metabolised to thioguanine nucleotides which disrupt the cellular synthesis of RNA & DNA
Preventing mitosis and thus proliferation of B & T cells

20. Azathioprine Dosage: Side effects: Advice
Started pre-Tx just before TH
Once daily dose 2mg/kg (max 100mg daily)
Side effects:
Reversible, dose dependent BMS
GI upset give with meals
Advice
Not to crush or split tablets
Tablet will disperse in water

21. Prednisolone Mechanism of Action
Mechanism of action not fully understood
Inhibit production of a number of T cells and macrophage cytokines (IL, IF, TNF-ɑ)
This results in a non-specific effect in disrupting the response of the immune system
High doses act as immunosuppressant and anti-inflammatory

22. Prednisolone Dosage: Side effects: Advice:
Given at anastomosis 600mg/m² as IV methylprednisolone
Changed to oral prednisolone asap starting at 60mg/m² in two divided doses (max 60mg),then on a reducing dose
Side effects:
 BP
electrolyte balance
 appetite GI
fat distribution
Advice:
Do not use EC tablets

23. Mycophenolate Mofetil (MMF)
Alternative anti-purine agent
Mechanism of action:
MMF is a prodrug of mycophenolate acid which was produced by the mould penicillium glaucum
MMF is a non-competitive, reversible inhibitor of purine synthesis which leads to inhibition of both B & T cell proliferation
No effect on the production or release of cytokines
GI upset is main reason for withdrawal of MMF lessen by splitting the dose 3-4 times a day
Only used MFS in one patient

24. Mycophenolate Mofetil (MMF)
Dosage:
Dose 600mg/m² bd (max 1g bd) with ciclosporin
Dose 600mg/m² bd (max 1g bd) for 1 week then 300mg/m² bd (max 1g bd) with tacrolimus
Side effects
Cause BMS
Main problem GI upset – diarrhoea
Advice
Liquid is available
Other information
Mycophenolate sodium
No effect on the production or release of cytokines
GI upset is main reason for withdrawal of MMF lessen by splitting the dose 3-4 times a day
Only used MFS in one patient

25. Ciclosporin First inhibitor of cytokine synthesis Mechanism of action
Originally isolated from the fungus tolypocldium inflatum
Ciclopsorin forms a complex with cycophyllin which binds to the enzyme calcineurin – Calcineurin inhibitor
This complex inhibits newly activated T cells from transcribing the genes that code for IL-2
Halting cytokine production inhibits the T cell driven immune response
Metabolism
Cytochrome P450 3A4
Ciclosporin first cytokine inhibitor to be introduced into clinical practice.
Borel & Kiss at Sandoz in 1976
Cyclophyllin is a cellular isomerase

26. Ciclosporin Dosage: Side effects Other information
Can be started pre-Tx
Dose oral 5mg/kg bd then adjust according to 12 hour trough level
0-3months nmol/l
1-3months nmol/l
3-12months nmol/l
>12months nmol/l
Side effects
Renal dysfunction
 BP
Hypertrichosis
Gingival hyperplasia,
Hyperlipidaemia
Other information
Liquid available
Ciclosporin first cytokine inhibitor to be introduced into clinical practice.
Borel & Kiss at Sandoz in 1976
Cyclophyllin is a cellular isomerase

27. Tacrolimus Calcineurin inhibitor
It is a macrolide discovered in 1984 from the fermentation broth of a Japanese soil sample that contained the bacteria Streptomyces tsukubaensis.
Mechanism of action
Tacrolimus binds to the intracellular protein FK506 binding protein-12 (FKBP12) this forms a complex with Ca²+ and calmodulin. This complex inhibits calcineurin
This complex inhibits newly activated T cells from transcribing the genes that code for IL-2
Halting cytokine production inhibits the T cell driven immune response
Metabolism
Cytochrome P450 3A4
Tacrolimus was discovered in 1987 by a Japanese team headed by T. Goto, T. Kino and H. Hatanaka; it was the first macrolide immunosuppressant discovered.[1] Like ciclosporin, it was found in a soil fungus, although it is produced by a type of bacteria, Streptomyces tsukubaensis,
Tacrolimus is chemically known as a macrolide. It reduces peptidyl-prolyl isomerase activity by binding to the immunophilin FKBP-12 (FK506 binding protein) creating a new complex. This FKBP12-FK506 complex interacts with and inhibits calcineurin thus inhibiting both T-lymphocyte signal transduction and IL-2 transcription.[3] Although this activity is similar to ciclosporin, studies have shown that the incidence of acute rejection is reduced by tacrolimus use over ciclosporin.

28. Tacrolimus Dosage: Side effects Can be started pre-Tx
Dose oral 0.15mg/kg bd then adjust according to 12 hour trough level
0-2months 10-15ng/ml
2-12months 5-10ng/ml
>12months 3-7ng/ml
Side effects
Renal dysfunction
 BP
Glucose intolerance
Neurotoxicity
Tremor
Alopecia

29. Sirolimus Latest immunosuppressant to be licensed for kidney Tx
Sirolimus is a macrolide antibiotic first discovered as a product of the bacterium Streptomyces hygroscopicus in a soil sample from an island called Rapa Nui
Mechanism of action
binds to the intracellular protein FKBP12 in a similar way to tacrolimus
sirolimus-FKBP12 complex inhibits the mammalian target of rapamycin (mTOR)
This blocks the proliferation of lymphocytes by blocking the cells response to IL-2
Metabolism
Cytochrome P450 3A4
Sirolimus (INN) is a relatively new immunosuppressant drug used to prevent rejection in organ transplantation, and is especially useful in kidney transplants. It is also known as rapamycin. Sirolimus is a macrolide antibiotic ("-mycin") first discovered as a product of the bacterium Streptomyces hygroscopicus in a soil sample from an island called Rapa Nui, better known as Easter Island.[1] It is marketed under the trade name Rapamune by Wyeth.
Interestingly, sirolimus was originally developed as an antifungal agent. However, this was abandoned when it was discovered that it had potent immunosuppressive and antiproliferative properties.
The mode of action of sirolimus is that it binds to the cytosolic protein FK-binding protein 12 (FKBP12) in a similar way to tacrolimus. However, unlike the tacrolimus-FKBP12 complex which inhibits calcineurin (PP2B), the sirolimus-FKBP12 complex inhibits the mammalian target of rapamycin (mTOR) pathway through direct binding to the mTOR Complex1 (mTORC1). mTOR is also called FRAP (FKBP-rapamycin associated protein) or RAFT (rapamycin and FKBP target). FRAP and RAFT are actually more accurate names since they reflect the fact that rapamycin must bind to FKBP12 first, and only the FKBP12-rapamycin complex can bind FRAP/RAFT/mTOR

30. Sirolimus Dosage: Side effects Other information
Dose oral 1-4mg then adjust according to 24 hour trough level 4-12ng/ml
Dosage & timing depends on co-administration with ciclosporin
Side effects
Hyperlipidaemia
Delayed wound healing
 LDH
Thrombocytopenia
Hypokalaemia
Lymphocoele formation
Other information
Liquid available
LDH Lactate dehydrogenase measure of tissue damage

31. Monoclonal antibodies (mAbs)
CD25 mAbs
Basiliximab & Daclizumab
Mechanism of action
Block IL-2 from binding to the IL-2Rɑ(CD25)
Reduce proliferation of T-cells by IL-2 cytokine pathway
IL2 is probably the most impotant cytokine for t cell growth in the early stages of the immune respone and it needs to bind to IL2R to induce proliferation of T cells by the IL2 cytokine pathway
CD25 is a surface glycoprotein on the surface of the T cell

32. Monoclonal antibodies (mAbs)
Dosage - Basiliximab
Only 2 doses given
Day 0 (2 hours before Th)
Day 4 IV
35kg 20mg each dose
<35kg 10mg each dose
Side effects
Hypersensitivity reactions (same CD25)
Other Information
IL-2R (CD25) blockade for 4-6weeks
Reduce Acute Cellular Rejection (ACR)
IL2 is probably the most impotant cytokine for t cell growth in the early stages of the immune respone and it needs to bind to IL2R to induce proliferation of T cells by the IL2 cytokine pathway
CD25 is a surface glycoprotein on the surface of the T cell

33. Prednisolone mAbs Azathioprine MMF Ciclosporin Tacrolimus Sirolimus
Prednisolone-Mechanism of action not fully understood Inhibit production of a number of T cells and macrophage cytokines (IL, IF, TNF-ɑ)
This results in a non-specific effect in disrupting the response of the immune system
Aza-6-MP is further metobolised to thioguanine nucleotides which disrupt the cellular synthesis of RNA & DNA
Preventing mitosis and thus proliferation of B & T cells
MMF -is a non-competitive, reversible inhibitor of purine synthesis which leads to inhibition of both B & T cell proliferation
Cic-Halting cytokine production inhibits the T cell driven immune response
Tac-Halting cytokine production inhibits the T cell driven immune response
Sir-This blocks the proliferation of lymphocytes by blocking the cells response to IL-2
mArbs-Block IL-2 from binding to the IL-2Rɑ(CD25) Reduce proliferation of T-cells by IL-2 cytokine pathway

34. Prophylactic Medication
PCP
Co-trimoxazole
Anti-coagulation
Dalteparin (anti Xa levels ) then aspirin
GI cover
Ranitidine
Infection
Cefotoxime
CMV
Ganciclovir/ valganciclovir

35. Supplements Magnesium Phosphate Magasorb magnesium citrate
Phosphate sandoz 

36. NICE guidelines: Immunosuppressive therapy for renal transplantation in children and adolescents April 2006
Basiliximab or Daclizumab
used as part of ciclosporin-based immunosuppressive regimen
Tacrolimus
alternative to ciclosporin (side effect profile)

37. NICE guidelines: MMF -option ONLY when:
Proven intolerance to CNI especially nephrotoxicity
There is a very high risk of nephrotoxicity requiring the min or avoidance of CNI until risk has passed
MMF- RCT for steroid reduction/ withdrawal regimen
MPS- not recommended
Sirolimus- not recommended unless:
Proven intolerance to CNI (complete withdrawal)

38. RHSC Renal Unit Transplant Guidelines
Azathioprine/ Prednisolone & Tacrolimus
+/- Basiliximab
MMF/ Prednisolone(rapid reduction) & Ciclosporin

39. Role of Paediatric Renal Pharmacist
Transplant work-up
See everyone in the multidisciplinary team
Discuss medication
Complete change of medicines pre & post Tx
Meet once or twice pre Tx
Carefully monitor dosage post Tx
Meet as part of discharge plan from ward update RMB

40. Twist Study Steroid sparing regimen Arm one Arm two
see the effect on growth
Arm one
Daclizumab/ Tacrolimus/ MMF & 4 days of prednisolone post Tx
Arm two
Tacrolimus/ MMF & normal prednisolone regimen post Tx

41. Future Aim of immunosuppression over the next 30 years
The addition of new immunosuppressive agents in routine use
mArbs will becomes routine practice in paediatric transplantation
Steroid use will change