1. Isepamicin and nephrotoxicity
Paul M. Tulkens
Unité de pharmacologie cellulaire et moléculaire
Université catholique de Louvain
Brussels, Belgium
isepamicin nephtotoxicity
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2. Isepamicin and nephrotoxicity
Lets do a Medline Search …
isepamicin
isepamicin and nephrotox*
amikacin
amikacin and nephrotox* 245
gentamicin
gentamicin and nephrotox* 908
isepamicin nephtotoxicity
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3. The birth of isepamicin…1
Diaminocyclitol derivatives. Wright, John J.; Daniels, Peter John L. (Scherico Ltd., Switz.).
Ger. Offen. (1975), pp. CODEN: GWXXBX DE
Patent written in German. Application: DE Priority: US
Bactericides, 1-N-(S-4-amino-2-hydroxybutyryl) sisomicin,
-gentamicin B,-verdamicin, and -gentamicin C1a, effective at
1-15 mg/kg doses, were prepd. by treatment of sisomicin,
gentamicin, or verdamicin derivs. with N-(S-4-phthalimido-
or -trifluoroacetamido-2-hydroxybutyryloxy) succinimide.
1-N-(S-3-amino-2-hydroxypropionyl)gentamicin C1 was similarly
prepd.
isepamicin nephtotoxicity
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4. The birth of isepamicin…2
Nagabhushan, T. L.; Cooper, A. B.; Tsai, H.; Daniels, P. J. L.;
Miller, G. H. Schering Corp., Bloomfield, N. J., USA.
J. Antibiot. (1978), 31(7),
The syntheses and biological properties of
1-N-(S-4-amino-2-hydroxybutyryl)gentamicin B
and 1-N-(S-3-amino-2-hydroxypropionyl)gentamicin B.
isepamicin nephtotoxicity
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5. isepamicin nephtotoxicity
Why isepamicin ? (1) OH OH O HO H N OH 2 HO HO O OH NH O 2 O
2HN NH 2
kanamycin A
isepamicin nephtotoxicity
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6. isepamicin nephtotoxicity
Why isepamicin ? (2) 3’ OH OH O HO H N OH 2 HO HO O OH NH O 2 O 2”
2HN NH 2 6’ 3
resistance to kanamycin A
isepamicin nephtotoxicity
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7. isepamicin nephtotoxicity
Why isepamicin ? (3) 2” 3 3’ O HO NH 2 H N OH HN
HOHC 6’
amikacin A
isepamicin nephtotoxicity
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8. isepamicin nephtotoxicity
Why isepamicin ? (4) OH O H C 3 HN H N HO O CH 2 2 OH CH 3 O NH H N O NH 2 2 2
gentamicin C1a
isepamicin nephtotoxicity
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9. isepamicin nephtotoxicity
Why isepamicin ? (5)
garosamine
= gentamicin c
= netillmicin
= sisomicin
2’, 3’, 4’ hydroxy
= kanamycin A
= amikacin OH OH O H C 3 HN OH HO HO O CH 2 OH CH 3 O NH 2 H N O NH 2 2
gentamicin B
isepamicin nephtotoxicity
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10. isepamicin nephtotoxicity
Why isepamicin ? (5) 3’ OH OH O H C 3 HN OH HO HO O CH 2 OH CH 3 O NH H N O NH 2 2” 2 2 6’ 3
resistance to gentamicin B
isepamicin nephtotoxicity
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11. isepamicin nephtotoxicity
Why isepamicin ? (6) O CH 2 HO NH OH HN H 3 C
HOHC 6’ 3’
making an ”amikacin-like” gentamicin B...
isepamicin nephtotoxicity
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12. The nearly (but not entirely) twins...HO NH 2 H N OH HN
HOHC O CH 2 HO NH OH HN H 3 C
HOHC
Quizz ...
which is amikacin, which is isepamicin…
???
isepamicin nephtotoxicity
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13. Aminoglycoside nephrotoxicity
Incidence: 0-50%
- patient factors
- drug factors
gentamicin
netilmicin
amikacin
isepamicin
- schedule of administration
- concomitant drugs
isepamicin nephtotoxicity
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14. Proximal tubular cells of rats (10 mg/kg.day gentamicin for 7 days)
Kosek et al [1974] Lab. Invest 30: 48-57
isepamicin nephtotoxicity
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15. Aminoglycoside nephrotoxicity sequence ...
AG uptake (adsorbtive pinocytosis) by proximal tubular cells
AG transport, accumulation to lysosomes, and development of a lysosomal phospholipidosis
Rupture (?) of lysosomes, cell necrosis, phospholipiduria
Tubular necrosis / tubular regeneration
Acute tubular necrosis
Non-oliguric renal failure
isepamicin nephtotoxicity
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16. isepamicin nephtotoxicity
Protection against aminoglycoside nephrotoxicity (see more in AAC 43:1008, 1999)
reduce uptake (adsorbtive pinocytosis)
reduce phospholipidosis
stabilize lysosomes and / or prevent the damaging effects of lysosomal rupture
promote cellular regeneration and tissue repair
protect againts glomerular effects
once-a-day schedule
polyaspartic
acid
desferrioxamine
and oxydant scavengers
growth factors
corticoids, saline
isepamicin nephtotoxicity
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17. isepamicin nephtotoxicity
Can better aminoglycosides exist ? (see also more in AAC 43:1008, 1999)
tobramycin
amikacin
isepamicin
reduce uptake (adsorbtive pinocytosis)
reduce phospholipidosis
stabilize lysosomes and / or prevent the damaging effects of lysosomal rupture
promote cellular regeneration and tissue repair
protect againts glomerular effects
amikacin isepamicin
netilmicin ?? ? ?
isepamicin nephtotoxicity
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18. Lower uptake, lesser phospholipidosis ...
C = saline
G = gentamicin
N = netilmicin
A = amikacin
I = isepamicin
SD rats
10 mg/kg
10 days
isepamicin nephtotoxicity
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19. isepamicin nephtotoxicity
Aminoglycoside-phospholipid interactions leading to inhibition of lysosomal phospholipase activity
isepamicin nephtotoxicity
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20. Experimental (belgian) studies on isepamicin toxicity …1...
Schanck A, Mingeot-Leclercq MP, Tulkens PM, Carrier D, Smith IC, Jarrell HC. Interactions of aminoglycoside antibiotics with phospholipids. A deuterium nuclear magnetic resonance study.
Chem Phys Lipids Sep;62(2):
Mingeot-Leclercq MP, Tulkens PM, Brasseur R. Accessibility of aminoglycosides, isolated and in interaction with posphatidylinositol, to water. A conformational analysis using the concept of molecular hydrophobicity potential. Biochem Pharmacol Nov 17;44(10):
isepamicin nephtotoxicity
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21. isepamicin nephtotoxicity
Isepamicin interacts less with phospolipids N NMR Studies (interactions of amines with phospholipids) O H 2 N NH OH 3 C HO HN CH R
AG alone
AG + PI 3
isepa 3” 6’ 5 3
amika 3” 5 6’ 1 6’
kana A 3 3” 1 3 3”
kana B 6’ 2’
isepamicin nephtotoxicity
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22. isepamicin nephtotoxicity
Isepamicin interacts less with phospolipids ... deuteriumNMR Studies (segregation of PI in membrane plane)
DPPC d control
DPPCd62:PI 1:1 control
+ Kanamycin B
+ Kanamycin A
+ Amikacin
+ Isepamicin
isepamicin nephtotoxicity
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23. isepamicin nephtotoxicity
Aminoglycoside-phospholipid interactions: correlation between the theoretical and experimental studies
Aminoglycoside
isepamicin
amikacin
kanamycin A
kanamycin B
Interaction
detected by
equilibrium dialysis
Kd (µM) 47 30 7 6
Interaction
detected by
15N NMR
weak
medium
strong
Calculated
interaction
(KJ / mol)
- 23.4
- 35.7
- 46.8
- 48.5
isepamicin nephtotoxicity
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24. Isepamicin inhibits less the lysosomal phospholipases A1
100
200
300
400
Drug concentration (µM) 20 40 60 80
lysophosphatidylcholine
Release of
(% control)
Gentamicin
Isepamicin
IC50 =
220 µM
100 µM
IC50
for amikacin
= 205 µM
isepamicin nephtotoxicity
17/01/2001

25. The Japanese trip of isepamicin…
everything you’d like to know, the japanese way, on
microbiology,
pharmacology,
toxicology,
etc...
Jpn J Antibiot Dec;39(12)
Jpn J Antibiot Jan;40(1)
isepamicin nephtotoxicity
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26. Experimental (belgian) studies on isepamicin toxicity …2...
Van Bambeke F, Mingeot-Leclercq MP, Schanck A, Brasseur R, Tulkens PM. Alterations in membrane permeability induced by aminoglycoside antibiotics: studies on liposomes and cultured cells.
Eur J Pharmacol Oct 15;247(2):
Van Bambeke F, Mingeot-Leclercq MP, Brasseur R, Tulkens PM, Schanck A. Aminoglycoside antibiotics prevent the formation of non-bilayer structures in negatively-charged membranes. Comparative studies using fusogenic (bis(beta-diethylaminoethylether)hexestrol) and aggregating (spermine) agents.
Chem Phys Lipids Mar 29;79(2):
isepamicin nephtotoxicity
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27. Experimental (belgian) studies on isepamicin toxicity …3...
reviewed in Mingeot-Leclercq and Tulkens, 1999, AAC 43:
isepamicin nephtotoxicity
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28. Amikacin / Isepamicin animal and clinical studies at UCL
rat studies (0-100 mg/kg):
low cortical accumulation
low phospholipid accumulation
low incidence of necrosis/regeneration
human studies (young female subjects; 15 mg/kg)
minimal phospholipiduria
no sign of renal dysfunction
isepamicin nephtotoxicity
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29. isepamicin nephtotoxicity
Conclusions of the modelling, in vitro, animal and human studies of isepamicin at UCL / ULB / Gembloux
Isepamicin is systematically either similar or better than amikacin ...
tip...
Accepted toxicity ranking *
gentamicin > tobramycin > amikacin
gentamicin > netilmicin
* at equal level of risk factors
isepamicin nephtotoxicity
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30. The European clinical scene… 1 ...
Carbon, C. Overview of the efficacy of isepamicin in the adult core clinical trial program. J. Chemother. (Florence) (1995), 7(Suppl. 2),
Beaucaire, G. Evaluation of the efficacy and safety of isepamicin compared with amikacin in the treatment of nosocomial pneumonia and septicemia.
J. Chemother. (Florence) (1995), 7(Suppl. 2),
Sturm-W
Isepamicin versus amikacin in the treatment of urinary tract infection.
J-Chemother Jun; 7 Suppl 2:
isepamicin nephtotoxicity
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31. The European clinical scene… 2….
Vigano-A; Principi-N
A randomised comparison of isepamicin and amikacin in the treatment of bacterial infections in paediatric patients.
J-Chemother Jun; 7 Suppl 2:
Covi-M; Velluti-G
Comparison of the efficacy and safety of isepamicin and amikacin in the treatment of acute lower respiratory tract infections caused by gram-negative organisms.
J-Chemother Jun; 7 Suppl 2:
Colardyn-F
The efficacy and safety of isepamicin and ceftazidime compared with amikacin and ceftazidime in acute lower respiratory tract infection.
J-Chemother Jun; 7 Suppl 2:
isepamicin nephtotoxicity
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32. The European clinical scene… 3….
Tod-M; Minozzi-C; Beaucaire-G; Ponsonnet-D; Cougnard-J; Petitjean-O
Isepamicin in intensive care unit patients with nosocomial pneumonia: population pharmacokinetic-pharmacodynamic study.
J-Antimicrob-Chemother Jul; 44(1):
isepamicin nephtotoxicity
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33. Conclusions of the (limited) european clinical evaluation
Isepamicin is systematically similar or
better than amikacin ...
Accepted toxicity ranking:
gentamicin > tobramycin > amikacin
gentamicin > netilmicin
* at equal level of risk factors
tip...
isepamicin nephtotoxicity
17/01/2001

34. Very recent experimental (Belgian) data ...
El Mouedden M, Laurent G, Mingeot-Leclercq MP, Taper HS, Cumps J, Tulkens PM. Apoptosis in renal proximal tubules of rats treated with low doses of aminoglycosides.
Antimicrob Agents Chemother Mar;44(3):
isepamicin nephtotoxicity
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35. Evidence of apoptosis in proximal tubular cells
Laurent et al., AAC, 1983
Gentamicin 10 mg/kg 10 days; HE staining
isepamicin nephtotoxicity
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36. Evidence of apoptosis in proximal tubular cells: histology
HE staining
methyl green-pyronin
El Mouedden et al., 2000
gentamicin 10 mg/kg, 10 days
isepamicin nephtotoxicity
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37. Evidence of apoptosis in proximal tubular cells: TUNEL staining
El Mouedden et al., 2000
gentamicin 10 mg/kg, 10 days
isepamicin nephtotoxicity
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38. Aminoglycoside-induced apoptosis occurs at low doses ...* †
250
200
150
TUNEL (+) nuclei
(no. / sq mm)
100 * 50
El Mouedden et al., 2000 10 20
Gentamicin daily dosage (mg/kg)
isepamicin nephtotoxicity
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39. AG-induced apoptosis severity varies among derivatives ...
150 b
100
b,d
gm = gentamicin
nt = netilmicin
is = isepamicin
am = amikacin
a,d
a,d 50 a
TUNEL (+) nuclei DNA specific
(no./sq mm) radioactivity b 80 60 40 c d d a 20
El Mouedden et al., 2000
ct gm nt is am
isepamicin nephtotoxicity
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40. Aminoglycosides also induce apoptosis in cultured cells ...
LLC-PK1
fibroblasts cells (R = 0.943)
MDCK cell lines (R = 0.954)
LLC-PK1 cell lines (R = 0.945) 30
Apoptosis (% of TUNEL (+) nuclei) 20
MDCK 10 20 40 60
gentamicin accumulation (µg/mg prot.)
Fibroblasts
El Mouedden, 2000
isepamicin nephtotoxicity
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41. Conclusions of the apoptosis studies (kidney and cultured cells)
Isepamicin is systematically similar or better than amikacin ...
apoptosis ranking:
gentamicin > tobramycin > amikacin
gentamicin > netilmicin
tip...
isepamicin nephtotoxicity
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42. The isepamicin UCL / ULB / Gembloux team ...
P. Maldague
P. Lambricht
K. Matsumoto
M. El Mouedden
M.P. Mingeot
B.K. Kishore
M. Dellale
F. Van Bambeke
B. Carlier
R. Brasseur
G. Laurent
J.M. Ruysschaert
...
isepamicin nephtotoxicity
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