sp

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ted in

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Ever

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dinal study charted the course of CAN in 120 renalinhibitors), sirolimus (Rapamune, Wyeth Pharmaceuticals,

Madison, NJ), and everolimus (Certican, Novartis Pharma

AG, Basel, Switzerland) has potential in this respect. This

Transplantation Reviewsdyslipidemia, impaired wound healing, and proteinuria. A low incidence of malignancy has been observed with everolimus, and studies are

ongoing to examine its antitumor effects in the treatment of certain malignancies. It seems likely that everolimus will continue to play a role

in the development of reduced-exposure calcineurin inhibitor regimens and has considerable potential to improve outcomes for transplant

recipients, focused perhaps on bold-for-oldQ transplant recipients and patients at high risk of poor graft function or malignancy. This reviewconsiders the available data on the clinical application of everolimus and identifies current and future strategies for improving outcomes after

renal transplantation.

D 2006 Elsevier Inc. All rights reserved.

1. Introduction

Survival of renal organ transplant recipients has

improved greatly over the years, particularly since the

introduction of calcineurin inhibitors (CNIs), such as

cyclosporine (CsA), and purine biosynthesis inhibitors

(eg, mycophenolic acids [MPAs]). Renal graft survival

rates are now in the order of 90% at 1-year posttransplant

[1], but ensuring very long-term graft survival (ie, up to

10 years) remains a challenge. Chronic allograft nephrop-

athy (CAN), characterized by interstitial fibrosis and

tubular atrophy [2], is the main cause of renal graft loss,

although patient death is also an important cause of loss of

otherwise functioning grafts. Risk factors for the develop-

ment of CAN include acute rejection, use of CNIs,

cytomegalovirus (CMV) infection, and comorbidities such

as hypertension and hyperlipidemia [3]. A recent longitu-

transplant recipients [4]. Chronic allograft nephropathy

was shown to be a progressive, time-dependent process,

with much tubulointerstitial damage occurring within 1 to

2 years of transplantation. Later damage was characterized

by progressive arteriolar hyalinosis, ischemic glomerulo-

sclerosis, and further interstitial fibrosis associated with

CNI toxicity [4], highlighting the difficult balance that

physicians must achieve with CNIs, the mainstay of

immunosuppressive therapy. Despite their efficacy, these

agents were almost universally associated with nephrotoxic

effects at 10-year follow-up. Further improvements in renal

graft survival will depend on the development of immu-

nosuppressive regimens that can prevent CAN and do so

without inducing nephrotoxic effects. A new class of

immunosuppressant agents, proliferation signal inhibitors

(PSIs; also known as mammalian target of rapamycinEverolimus (Certican) in renal tran

data, current usage,

Julio Pascuala,4, Ioannis N.aServicio de Nefrologia, Hospital

bDepartment of Nephrology and TransplacServei de Nefrologia i Trasplantament Renal, Hospital Clnic

Abstract

The efficacy and tolerability of everolimus have been demonstra

clinical experience. The efficacy of everolimus after renal transpla

combining everolimus with full- or reduced-dose cyclosporine (CsA

the risk of acute rejection, particularly when combined with thera

elimination of calcineurin inhibitors is currently being investigated.

enhance CsA-related nephrotoxicity. Adverse events seen in trials o0955-470X/$ see front matter D 2006 Elsevier Inc. All rights reserved.

doi:10.1016/j.trre.2005.10.005

E-mail address: jpascual.hrc@salud.madrid.org (J. Pascual).lantation: a review of clinical trial

d future directions

letisb, Josep M. Campistolc

n y Cajal, 28034 Madrid, Spain

n, Laiko Hospital, 15562 Athens, Greece

arcelona, Universitat de Barcelona, 08036 Barcelona, Spain

a number of clinical trials, and there is also an increasing body of

n is at least equivalent to that of mycophenolate mofetil. Studies

ve shown that CsA exposure can be minimized, without increasing

ic drug monitoring. A role for everolimus in regimens involving

olimus with significantly reduced-dose CsA has not been shown to

rolimus are generally class-specific and include edema, arthralgia,

20 (2006) 118

www.elsevier.com/locate/trrereview will concentrate on the clinical trial data for4 Corresponding author. Tel.: +34 913368018.

everolimus and its use in clinical practice.

2. Everolimusclinical development and efficacy in de

novo renal transplantation

2.1. Mechanism of action

Everolimus has a mode of action that is distinct from

CNIs, which inhibit the transcription of early T-cellspecific

genes, thus reducing the production of T-cell growth factors

such as interleukin (IL) 2 [5]. Everolimus acts at a later

stage of the cell cycle, blocking the proliferation signal

provided by these growth factors and preventing cells from

entering the S phase [5]. The antiproliferative actions of

everolimus are not limited to the immune system; it also

inhibits growth factordriven cell proliferation in general

(eg, reducing vascular smooth muscle cell proliferation) [5].

The antiproliferative effects of everolimus also prevent

vascular remodeling [6], a key component of progressive

(44% and 50%, respectively), with the most frequent

adverse events being headache in the everolimus groups

and dizziness among those receiving placebo. Mean

changes in laboratory parameters did not differ significantly

between everolimus and placebo groups. Importantly,

administration of everolimus in single doses did not appear

to affect the steady-state pharmacokinetics of CsA in these

individuals [14]. A further study in healthy individuals

evaluated coadministration of everolimus with 2 different

CsA formulationsa microemulsion (Neoral, Novartis

Pharma AG) and an oral solution (Sandimmune, Novartis

Pharma AG) [15]. Both CsA formulations were observed to

increase systemic exposure (area under the concentration-

time curve [AUC]) to everolimus, but the percentage or

increase was significantly greater for the microemulsion

formulation (P = .008). A 2- to 3-fold decrease in

raft dy

ermis

J. Pascual et al. / Transplantation Reviews 20 (2006) 1182allograft dysfunction (Fig. 1) [7].

Preclinical studies have demonstrated the immunosup-

pressive actions of everolimus in animal models of renal

transplantation [8-11]. Moreover, such models provide

evidence for synergistic activity between everolimus and

CsA, with the 2 combined agents offering more potent

immunosuppression than either one alone [8,12]. Animal

models have also been used to demonstrate the anti-

proliferative effect of everolimus on nonimmune cells.

For example, everolimus was associated with delayed

progression of CAN in a rat model of renal transplan-

tation because of antiproliferative or apoptosis-enhancing

effects [13].

2.2. Early clinical development

In the first study of everolimus in humans, 54 stable renal

transplant recipients split into 6 groups received either a

single dose of everolimus, ranging from 0.25 to 25 mg or

placebo in addition to CsA [14]. The safety of each dose

was monitored for 11 days before the next group of

individuals received a higher dose. All doses of everolimus

were well tolerated. Similar proportions of patients receiv-

ing everolimus and placebo had at least 1 adverse event

Fig. 1. Vascular remodeling in transplanted organs, a key component of allog

to cytokine release and up-regulation of growth factors. Reproduced with peverolimus exposure can therefore be expected after

withdrawal of CsA from immunosuppressant regimens.

This pharmacokinetic interaction may be due to direct

competition between everolimus and CsA because both

agents undergo metabolism by CYP3A4 and are substrates

of P-glycoprotein. Conversely, if CsA is added to an

everolimus-containing regimen, an average 3-fold increase

in systemic exposure to everolimus is observed [16].

After administration of single doses of everolimus

(0.2515 mg) to 7 renal transplant recipients also receiving

standard CsA immunosuppression, the pharmacokinetics of

CsA were again unaffected by everolimus administration

[17]. The mean maximal plasma concentration (Cmax) of

everolimus (dose normalized to 1 mg everolimus) was 7.9F2.7 lg/L, whereas the mean time to maximum plasmaconcentration (Tmax) was 1.5F 0.9 hours. In a larger phase Istudy, 24 renal transplant recipients were given everolimus

0.75, 2.5, or 7.5 mg/d, or placebo for 4 weeks [18]. Mean

initial Tmax varied from 1.3 F 0.3 to 1.8 F 0.5 hours forthe 3 everolimus groups, and steady state was reached

within 4 days. The mean elimination half-life was 19.2 F3.4, 18.1 F 7.6, and 16.0 F 5.6 hours for the 0.75, 2.5,and 7.5-mg groups, respectively. The pharmacokinetics of

sfunction. Continued immune and endothelial activation posttransplant lead

sion from Neumayer [7].

everolimus showed dose-exposure proportionality and a

good correlation between trough and AUC concentrations.

The most frequently occurring adverse event was an

increased incidence of infection. Thrombocytopenia and

hyperlipidemia occurred in a dose-dependent manner.

In a phase II trial, 101 de novo renal transplant

recipients receiving everolimus 1.0, 2.0, or 4.0 mg/d were

monitored for 1 year posttransplant [19]. Steady-state

pharmacokinetics was achieved on or before day 7. Cmaxand systemic exposure (AUC) were proportional to ever-

olimus dose, with AUC being stable throughout follow-up.

Pharmacokinetic parameters associated with CsA treatment

did not differ with administration of everolimus at any

dose. The incidence of acute rejection was analyzed in 103

de novo renal transplant recipients who were randomized

to receive everolimus 1.0, 2.0, or 4.0 mg/d in addition to

CsA and corticosteroids [20]. Over the first 6 months of

treatment, 32.4%, 14.7%, and 25.7% of patients in the

respective treatment groups experienced biopsy-proven

acute rejection (BPAR). Compared with the everolimus

1.0 mg/d group, the incidence of moderate and severe

BPAR was significantly lower in the 2.0 and 4.0 mg/d

groups (P = .002 and .006, respectively). Everolimus was

generally well tolerated, although viral and fungal infec-

tions were more common in patients receiving the highest

dose. As in previous studies, blood lipid levels were

elevated during everolimus treatment, requiring lipid-

2.3. Clinical efficacy studies

Clinical development of everolimus in de novo renal

transplantation was supported by a long-term phase II study

and 4 major phase III clinical trials (Table 1). A 3-year

phase II trial (study B156) compared the efficacy and

tolerability of everolimus in combination with full- and

reduced-dose CsA [21]. Two 3-year phase III trials (studies

B201 and B251) were conducted to establish whether

everolimus was similar in efficacy to mycophenolate mofetil

(MMF) in renal transplantation when both agents were

combined with full-dose CsA and corticosteroids [22-24].

Subsequently, the efficacy of everolimus in combination

with reduced-dose CsA was investigated with the aim of

establishing immunosuppressive regimens with lower CNI-

induced nephrotoxicity (studies A2306 and A2307) [25].

2.3.1. Everolimus vs MMF with full-dose CsA

The large-scale trials, studies B201 [22,23] and B251

[24], were of a similar design, with de novo renal transplant

recipients being randomized to receive fixed doses of

everolimus 1.5 mg/d, everolimus 3.0 mg/d, or MMF

2.0 g/d in a blinded fashion for 1 year, followed by 2 years

of open-label treatment. In addition, all patients received

full-dose CsA microemulsion (Neoral) and corticosteroids.

The primary objective in both cases was to compare the

incidence of an efficacy composite end pointefficacy

le)

le)

re CsA

J. Pascual et al. / Transplantation Reviews 20 (2006) 118 3lowering agents.

Table 1

Clinical trials for the development of everolimus in renal transplantation

Study Study design Study duration

B156 Phase IIrandomized,

open-label, parallel-group

3 y

B201 Fixed-dose everolimus 3 y

Phase IIIrandomized,

double-blind, double-dummy,

parallel-group

Open study years 23

B251 Fixed-dose everolimus 3 y

Phase IIIrandomized,

double-blind,

double-dummy,

parallel-group

Open study years 23

A2306 Concentration-controlled

everolimus

1 y (6-mo data availab

Phase IIIrandomized,

open-label, parallel-group

A2307 Concentration-controlled

everolimus

1 y (6-mo data availab

Phase IIIrandomized,

open-label, parallel-group

a In combination with basiliximab and corticosteroids.b In combination with standard-dose CsA and corticosteroids.c In combination with standard-dose CsA and prednisone.d In combination with corticosteroids and reduced-exposure CsA.e In combination with basiliximab, corticosteroids, and reduced-exposufailurein each treatment group at 12 or 36 months

Treatment Patients (n) References

Everolimus 3.0 mg/d +

full-dose CsAa53 Nashan et al [21]

Everolimus 3.0 mg/d +

reduced-dose CsAa58

Everolimus 1.5 mg/db 194 Vtko et al [22,23]

Everolimus 3.0 mg/db

MMF 2.0 g/db198

196

Everolimus 1.5 mg/dc 193 Lorber et al [24]

Everolimus 3.0 mg/dc

MMF 2.0 g/dc194

196

Everolimus 1.5 mg/dd

Everolimus 3.0 mg/dd112

125

Vtko et al [25]

Everolimus 1.5 mg/de

Everolimus 3.0 mg/de117

139

Vtko et al [25]

.

posttransplant. Efficacy failure was defined as the incidence

of BPAR, graft loss, death, or loss to follow-up. Secondary

end points included allograft and patient survival, as well as

the incidence of acute rejection and safety parameters.

The incidences of efficacy failure, BPAR, graft loss, and

death at 12 and 36 months of follow-up in studies B201 and

B251 are shown in Fig. 2 and were similar among patients

randomized to MMF and everolimus 1.5 or 3.0 mg/d.

Furthermore, the therapeutic equivalence of everolimus and

MMF was maintained in the long term, as there were no

significant differences between efficacy end points in either

trial at 36 months of follow-up [23,24]. A significant

difference between the treatment arms was noted in study

B251 [24], in which the incidence of antibody-treated acute

rejection was significantly lower among patients receiving

everolimus 1.5 mg/d than among those receiving MMF at

12 months (7.8% vs 16.3%; P = .01) and 36 months of

follow-up (9.8% vs 18.4%, respectively; P = .014). In both

studies, most graft loss occurred within the first 12 months

of treatment. In study B251, reasons for graft loss included

infection, acute and chronic rejection, kidney infarction, and

recurrence of original disease [24].

The interactions noted in studies B201 and B251

highlighted that therapeutic drug monitoring (TDM) could

be beneficial for patients receiving everolimus and CsA.

Analysis of data from 779 patients in the 2 trials showed that

everolimus trough blood levels of 3 ng/mL or more were

necessary to gain most clinical benefit from the agent [26].

Risk of BPAR was 3.4-fold higher for patients with

everolimus trough blood levels less than 3 ng/mL compared

B201

J. Pascual et al. / Transplantation Reviews 20 (2006) 1184Fig. 2. Efficacy analyses at 12 and 36 months of follow-up in clinical trials

graft loss, death, loss to follow-up [22-24].and B251 (intent-to-treat population). Primary efficacy is defined as BPAR,

J. Pascual et al. / Transplantation Reviews 20 (2006) 118 5with patients whose trough blood levels were in the range 3

to 8 ng/mL (P b .0001) (Fig. 3) [26]. There was a trendtoward even lower rates of BPAR in patients with ever-

olimus trough blood levels greater than 8 ng/mL, but this

finding should be interpreted cautiously given the small

number of patients in this group. It was estimated that after

initiation of everolimus at a dose of 1.5 mg/d, 2 TDM-led

dose adjustments would be sufficient for 84% of patients to

achieve everolimus trough blood levels in excess of

3 ng/mL. With respect to renal function, the TDM analysis

showed that risk of serum creatinine levels of 200 lmol/L ormore increased greatly with increasing CsA trough levels,

but was affected only slightly by everolimus trough blood

levels [26].

Monitoring of serum creatinine levels in studies B201

and B251 showed that patients receiving everolimus

Fig. 3. Kaplan-Meier plots over the first 6 months of treatment showing the

percentage of patients free from BPAR at different everolimus trough blood

levels (n = 779). Reproduced with permission from Lorber et al [26].exhibited higher mean serum creatinine levels than those

receiving MMF [22-24]. At 12 months of follow-up, a

protocol amendment was introduced in both trials allowing

for lower CsA trough blood levels (5075 ng/mL) to be

targeted in the everolimus groups, provided everolimus

trough blood levels were at least 3 ng/mL. Mean serum

creatinine levels subsequently decreased slightly or

remained stable in everolimus-treated patients, and CsA

reduction was not accompanied by an increase in BPAR.

Everolimus itself does not induce renal dysfunction, but

these findings appeared to indicate that it can potentiate

CsA-related nephrotoxicity. A similar effect has been noted

in patients receiving sirolimus [27].

In addition to efficacy and safety analyses, an economic

evaluation of treatment was also carried out during study

B201 [28]. At 12 months of follow-up, mean overall

treatment costs were US$33 715, US$38 519, and US$36

509 for the everolimus 1.5 mg, everolimus 3.0 mg, and

MMF groups, respectively. Differences in cost between the

treatment groups were not significant.2.3.2. Everolimus combined with full- or reduced-dose CsA

After protocol amendment, data from studies B201 and

B251 indicated that everolimus plus reduced-exposure CsA

could result in improved renal function without increased

risk of rejection. This is supported by the findings of a

3-year phase II trial (study 156) in which patients received

everolimus 3.0 mg/d in combination with basiliximab,

corticosteroids, and either full- (n = 53) or reduced-dose

(n = 58) CsA microemulsion [21]. From 3 to 36 months of

follow-up, target CsA trough blood levels were 125 to

250 ng/mL in the full-dose CsA group, compared with 50

to 100 ng/mL in the reduced-dose CsA group. The

incidence of efficacy failure (BPAR, graft loss, death, or

loss to follow-up) was significantly lower in the reduced-

dose CsA group compared with the full-dose CsA group at

6 (P = .046), 12 (P = .012), and 36 (P = .032) months

of follow-up [21]. More specifically, BPAR was less

frequent in the reduced-dose CsA group than in the full-

dose CsA group at each follow-up time point: 6 months,

3.4% vs 15.1%; 12 months, 6.9% vs 17.0%; and

36 months, 12.1% vs 18.9%, respectively.

Importantly, at 6 and 12 months of follow-up, mean

serum creatinine levels were numerically lower in patients

randomized to reduced CsA dosing than in those receiving

full-dose CsA [21]. The advantage of reduced-dose CsAwas

more evident in relation to mean creatinine clearance values,

which were significantly higher in the reduced-dose group

at 6 (P = .009) and 12 (P = .007) months of follow-up.

Patients remaining on treatment at 12 months were treated

according to an amended protocol to optimize their renal

function: CsA dosing was adjusted to achieve trough blood

levels of 50 to 75 ng/mL, whereas everolimus dose was

adjusted to ensure trough blood levels of at least 3 ng/mL

(in accordance with TDM study findings). After transition to

the amended protocol, mean serum creatinine levels in the

full-dose CsA group fell. In patients randomized to reduced-

dose CsA, mean serum creatinine and creatinine clearance

values remained stable, reflecting the smaller reduction in

CsA dose for this group [21].

Overall, study B156 demonstrated how synergy between

everolimus and CsA permitted reduced-dose CsA, resulting

in lower rates of efficacy failure and improved renal

function compared with everolimus and full-dose CsA [21].

2.3.3. Concentration-controlled everolimus plus

reduced-exposure CsA

Therapeutic use of everolimus in combination with CsA

was further refined in 2 similarly designed phase III clinical

trials in which TDM was used to optimize everolimus

dosing, and the CsA blood levels 2 hours after administra-

tion (C2 monitoring) was used to guide reduction in CsA

exposure [25]. In study A2306, concentration-controlled

everolimus 1.5 or 3.0 mg/d was combined with reduced-

exposure CsA (given as CsA microemulsion) and cortico-

steroids; the same approach was used in study A2307

with the exception that patients also received doses of

and A2307) examining the use concentration-controlled everolimus with reduced-

out basiliximab) Study A2307 (with basiliximab)

/d Everolimus 3.0 mg/d Everolimus 1.5 mg/d Everolimus 3.0 mg/d

2) 62 (62) (n = 111) 66 (66) (n = 107) 67 (65) (n = 123)

2) 62 (65) (n = 125) 64 (68) (n = 117) 65 (65) (n = 139)

2) 61 (63) (n = 125) 63 (60) (n = 117) 61 (60) (n = 139)

5) 132 (140) (n = 112) 130 (137) (n = 113) 130 (136) (n = 127)

2) 126 (134) (n = 125) 128 (132) (n = 117) 126 (132) (n = 139)

2) 128 (141) (n = 125) 142 (136) (n = 117) 142 (136) (n = 139)

24/125 (19.2%) 18/117 (15.4%) 27/139 (19.4%)

32/125 (26%) 23/117 (20%) 34/139 (25%)

34/125 (27%) 23/117 (20%) 34/139 (25%)

19/125 (15.2%) 16/117 (13.7%) 21/139 (15.1%)

24/125 (19%) 16/117 (13.7%) 22/139 (15.8%)

26/125 (21%) 19/117 (16%) 25/139 (18%)

J. Pascual et al. / Transplantation Reviews 20 (2006) 1186basiliximab on the day of transplantation and 4 days later.

Everolimus dose was adjusted to ensure trough blood levels

of at least 3 ng/mL. In study A2306, CsA C2 level target

ranges were 1000 to 1400 ng/mL during weeks 0 to 4, 700

to 900 ng/mL during weeks 5 to 8, 550 to 650 ng/mL during

weeks 9 to 12, and 350 to 450 ng/mL thereafter. Because of

the use of induction therapy, target CsA C2 ranges were set

lower in study A2307: 500 to 700 ng/mL during weeks 0 to

8 and 350 to 450 ng/mL from week 9 onward.

The primary end point of the trials was renal function as

assessed by glomerular filtration rate (GFR) and creatinine

clearance or serum creatinine [25]. Table 2 shows values for

GFR and serum creatinine at 6, 12, and 24 months of

follow-up in both trials [25,29-33]. Serum creatinine values

were substantially lower than those observed among

patients receiving everolimus with full-dose CsA in study

Table 2

Renal function and efficacy parameters in 2 similarly designed trials (A2306

exposure CsA in renal transplantation [25,29-33]

Follow-up period (mo) Study A2306 (with

Everolimus 1.5 mg

Renal function

Median (mean)

calculated GFR

(creatinine clearance;

mL/min)

6 65 (63) (n = 10

12 69 (69) (n = 11

24 68 (66) (n = 11

Median (mean) serum

creatinine (lmol/L)6 133 (147) (n = 10

12 122 (126) (n = 11

24 129 (133) (n = 11

Efficacy

Efficacy failure, n (%) 6 31/112 (27.7%)

12 31/112 (28%)

24 34/112 (30%)

BPAR, n (%) 6 28/112 (25%)

12 29/112 (26%)

24 30/112 (27%)B251 [24].

Efficacy end points are also listed in Table 2. The

incidence of efficacy failure in both studies was equivalent

to, or lower than, that in earlier studies in which full doses

of CsA were used. Efficacy failure occurred more

frequently in study A2306 compared with study A2307,

mainly because of higher rates of BPAR in the first

6 months posttransplant [25]. These data confirm the added

benefit of IL-2 receptor antagonist induction therapy to

reduce risk of early BPAR in combination with a lower

dose of everolimus.

Infection was the most common adverse event, occurring

in 61.6% and 56.8% of patients randomized to everolimus

1.5 or 3.0 mg/d in study A2306 within the first 6 months of

treatment [25]. Interestingly, CMV disease was not com-

mon; in study A2306, it occurred in just 0.9% of patients

receiving everolimus 1.5 mg/d and in 3.2% of patients

receiving everolimus 3.0 mg/d. In the same trial, thrombo-

cytopenia occurred in 3.6% of the everolimus 1.5 mg/d

group and in 8.0% of the everolimus 3.0 mg/d group. Otheradverse events included anemia, which occurred in 18.8%

and 23.9% of the everolimus 1.5 mg/d groups of studies

A2306 and A2307, respectively, and lymphocele, the

incidence of which varied from 6.4% to 15.2% in the

4 treatment groups. In study A2306, mean total serum

cholesterol rose from 4.2 and 3.9 mmol/L at baseline to

6.6 and 6.5 mmol/L at 6 months in the everolimus 1.5 and

3.0 mg/d groups, respectively [25]. Similar elevations were

noted in study A2307 with hyperlipidemia generally

manifesting early in treatment and lipid levels stabilizing

after 2 to 3 months.

No upper limit for everolimus trough blood levels was

defined in either trial. A post hoc analysis of data from study

A2306 showed that everolimus trough blood levels up to

12 ng/mL were tolerated during 12 months of follow-up

[34]. In line with findings from studies B201 and B251,however, in which full-dose CsA was used [26], everolimus

Fig. 4. A significant reduction in CsA trough blood levels can be achieved

when used in combination with everolimus. Reproduced with permission

from Pascual [35].

trough blood levels between 3 and 8 ng/mL were found to

be optimal in efficacy and safety for patients receiving

reduced-exposure CsA.

An unanswered question remains: how low can CNI

blood levels be reduced in conjunction with everolimus

without adversely influencing efficacy and safety? Compar-

ison of the mean CsA trough blood levels of patients in

studies B201 and A2306 showed that CsA blood levels can

be reduced by at least 57% at 12 months when used in

combination with everolimus (Fig. 4) [35]. Further trials

will be needed to further study this potential for synergy.

2.4. Calcineurin inhibitor elimination

Calcineurin inhibitor withdrawal in everolimus-based

regimens is currently being validated in large clinical trials.

Studies have been conducted however with sirolimus.

Sirolimus has been used to eliminate CsA 3 months

posttransplant, with significantly improved graft function

20 patients, conversion to sirolimus led to a significant

decrease in serum creatinine from 233 F 34 to 210 F56 lmol/L after 6 months (P b .05) in 12 patients withchronic nephrotoxicity [45]. When the factors predictive of

success in patients converted from a CNI to sirolimus were

investigated, 27 (46%) of 59 patients were classed as

nonresponders based on deteriorating renal function [46].

Several baseline factors were observed that differed

significantly between responders and nonresponders, in-

cluding proteinuria, histological grade of allograft nephrop-

athy, grade of vascular intimal thickening, and number of

acute rejections before conversion. In a multivariate

analysis, only proteinuria lower than 800 mg/d before

conversion was a significant predictor of response [46]. This

finding has recently been confirmed in a study of 43 patients

converted from a CNI to sirolimus, which also identified

baseline antihypertensive therapy and serum lactate dehy-

drogenase level 1 month after conversion as independent

us hav

J. Pascual et al. / Transplantation Reviews 20 (2006) 118 7after 6, 12, 36, and 48 months in the Rapamune

Maintenance Regimen Trial [36-41] and in other studies

[42,43]. A meta-analysis of 6 sirolimus/CNI withdrawal

studies, enrolling a total of 1047 patients, showed that CNI

elimination was associated with a significant improvement

in creatinine clearance (P b .00001) at 1 year, with asignificant reduction in hypertension (P = .0006) [44].

There was, however, an 8% increased risk of acute rejection

(P = .002), although the incidences of graft loss and death

were similar in both groups. Overall, early CNI elimination

(ie, within 23 months posttransplant) is accompanied by a

reduction in the progression of chronic pathologic allograft

lesions and a lower incidence of new cases and severity of

CAN during the first year after transplantation [41]. Such

regimens may not, however, be appropriate for patients with

severe acute rejection episodes or persistent suboptimal

graft function [27].

Maintenance renal transplant patients have been con-

verted from CsA to sirolimus. In an initial study in

Fig. 5. Everolimus and sirolimpredictive factors [47].

Triple therapy with sirolimus as de novo therapy has

been compared with CsA both in combination with

azathioprine and corticosteroids in 83 patients [48], but

there was a high incidence of acute rejection (41% with

sirolimus vs 38% with CsA; NS). In a trial of similar design,

with MMF instead of azathioprine, there was a lower

incidence of acute rejection (28% with sirolimus vs 18%

with CsA) [49]. Two-year pooled data from these studies

demonstrated an improvement in graft function with

sirolimus compared with CsA (GFR, 69.3 vs 56.8 mL/min;

P b .004) [50].Sirolimus, MMF, and corticosteroids have been used

with basiliximab induction therapy to reduce the incidence

of acute rejection. When this regimen was compared with

CsA in a prospective study in 61 renal transplant recipients

there was a numerically lower incidence of acute rejection

(6% vs 17%) combined with significantly improved graft

function in the sirolimus group compared with the CsA

e similar chemical structures.

tic toxicity when used in combination with the CNIs or the

3.3.1. Dyslipidemia

Sirolimus induces dose-dependent hyperlipidemia in

30% to 50% of patients who may require concomitant

lipid-lowering medication [81,82]. A similar incidence of

hypercholesterolemia and hypertriglyceridemia has been

observed in studies of everolimus [22,25]. The alterations in

lipid metabolism appear to be related mainly to variation in

lipoprotein lipase activity and reduced catabolism of very

low-density lipoprotein apolipoprotein B100 [83]. It has

with severe refractory hyperlipidemia [33]

Lymphocele

! Treat with povidone iodine and surgical intervention as required[63-65]

Wound healing

! Surgical techniques to manage delayed fibrosis of wounds, for example,nonabsorbable sutures for muscle layers and delayed removal of skin

clips [66]

! Avoid PSIs during wound healing in patients with diabetes orobesity [67]

Maintenance patients

CAN

! Consider reducing CsA dose to counter increased creatininelevels [33,68]

! Consider withdrawing CsA (if not managed by CsA reduction)[39,41,69]

! If CsA is reduced or withdrawn, patients may require increasedeverolimus trough blood levels [33]a

! If proteinuria is N800 mg/d, do not convert to PSI therapy [46]b

Proteinuria

! Treat with ACE inhibitors and/or angiotensin receptor blockers [70,71]! Maintain everolimus blood trough levels at 38 ng/mL [33]! Minimization of CsA dose may be sufficient [72]Hypertension

! Treat with ACE inhibitors, angiotensin receptor blockers, orb-blockers [73,74]

! Consider withdrawal of CsA [36,43]! Use of calcium channel blockers may increase everolimus plasmaconcentrations [33]

Anemia

! Treat severe anemia with erythropoietin [75]! Avoid ACE inhibitors in patients who develop anemia [70]! Reduce dose of MPA agent [76]Malignancy

! Use of a PSI is recommended in patients who develop a malignancyposttransplant [77,78]

! Consider withdrawal of CsA [38,79]a Cyclosporine withdrawal from everolimus-based regimens has not

been validated in large clinical trials. There is limited experience of the use of

everolimus above trough levels of 12 ng/mL [33]. A single case study reports

everolimus trough levels above 12 ng/mL after CsAwithdrawal [80].b A phase IV study assessing 1500 mg/d proteinuria as the cutoff value

for conversion to PSI therapy is currently enrolling patients.

J. Pascual et al. / Transplantation Reviews 20 (2006) 1188mycophenolates, and those related to nonspecific immuno-

suppressive actions. Management strategies for key adverse

events are summarized in Table 3.group (creatinine clearance, 77.8 vs 64.1 mL/min at

6 months; P = .004) [51].

3. Proliferation signal inhibitors/mammalian targets of

rapamycineverolimus and sirolimus

To date, only one small head-to-head study has been

published comparing everolimus and sirolimus in 28 patients

[52]. In this study, renal function, measured by GFR, was

improved using CsA in combination with everolimus rather

than sirolimus [52]. Because of the limited analysis, a direct

comparison of the efficacy and tolerability of the 2 agents is

not possible. Based on review of the literature, an overview

of these compounds is provided below.

3.1. Pharmacology and pharmacokinetics

Everolimus and sirolimus are macrolide derivatives

with similar chemical structures, everolimus having a

2-hydroxyethyl group at position 40 of the molecule

(Fig. 5). Despite the similarities in structure, there are

important differences in the pharmacokinetic and pharma-

codynamic properties of the 2 molecules. Everolimus has a

considerably shorter half-life than sirolimus (28 vs 62 hours)

and, because of differences in regimen, everolimus reaches

steady state in 4 days, compared with 6 days for sirolimus

[33,53,54]. More detailed reviews of everolimus and

sirolimus pharmacology and pharmacokinetics can be found

in Kirchner et al [55] and Mahalati and Kahan [56].

3.2. Interaction with CsA

Although the modes of action of everolimus and sirolimus

are broadly similar, there is evidence of a difference between

these agents in their interaction with CsA. In vitro, sirolimus

has been shown to enhance CsA activity by increasing the

brain concentration of CsA, which in turn inhibits mito-

chondrial glucose metabolism and high-energy phosphate

metabolism [57,58]. Although there is no direct evidence to

link such an effect to increased neuropathologic symptoms,

drugs that inhibit glycolysis have the potential to enhance

toxicity of other agents that inhibit mitochondrial oxidation

[57]. Conversely, coadministration of everolimus and CsA

leads to a reduction in brain CsA concentration and

antagonizes the effect of CsA on glucose and high-energy

phosphate metabolism [57,59]. The clinical impact of these

different effects is not yet understood.

3.3. Adverse events

It has become evident, through extensive clinical studies,

that there are specific adverse events associated with dose-

related class actions of PSIs everolimus and sirolimus.

Additional adverse events include those related to synergis-Table 3

Guidelines for the management of adverse events in renal transplant

recipients receiving everolimus as part of their immunosuppressive regimen

De novo patients

Hyperlipidemia

! Reeducate patient regarding lifestyle changes [60,61]! Treat hypercholesterolemia with statins atorvastatin, pravastatin, orfluvastatin, as preferred [25,33,61]

! Treat hypertriglyceridemia with fibrates [60,62]! Reevaluate the risk/benefit of continued everolimus therapy in patients

J. Pascual et al. / Transplantation Reviews 20 (2006) 118 9been proposed that sirolimus indirectly up-regulates expres-

sion of the gene apo CIII, an important inhibitor of

lipoprotein lipase [27,84]. Sirolimus has also been shown

to lead to a 42% increase in free fatty acid concentrations,

thus stimulating hepatic triglyceride synthesis [85].

Hyperlipidemia should be managed in accordance with

guidelines (eg, National Kidney Foundation Kidney Disease

Outcomes Quality Initiative), focusing on both lifestyle

changes and drug treatment [60,61]. Statins and fibrates are

used to treat elevated low-density lipoprotein cholesterol

and hypertriglyceridemia, respectively [60]. Lipid-lowering

agents (mainly statins) were used in 58.9% and 66.4% of

patients receiving everolimus 1.5 and 3.0 mg/d in study

A2306, whereas in study A2307, 66.7% and 72.7% of

patients received such therapy [25]. In addition, statins were

taken by 90% of patients after heart transplantation;

although low-density lipoprotein and high-density lipopro-

tein levels were increased at 12 months, there was no

difference between the azathioprine and everolimus groups

[86]. In a study of healthy individuals given single doses of

everolimus in addition to atorvastatin or pravastatin, no

clinically significant effects on the pharmacokinetics of any

drug were noted [87], although fluvastatin has recently been

shown to improve cardiovascular outcomes in renal

transplant recipients in a large-scale clinical trial [88].

3.3.2. Myelosuppression

A higher incidence of microcytic anemia, perhaps related

to antiproliferative effects in bone marrow and reduced

incorporation of iron, has been observed with sirolimus than

with CsA or MMF in a number of studies [81,89,90]. In a

12-month study comparing everolimus and MMF (study

B201), the incidence of anemia was similar with both

agents: 34.3% in patients receiving everolimus 3.0 mg/d vs

32.1% in those receiving MMF [22].

Thrombocytopenia is common with PSIs, but seldom

clinically significant. In phase III trials with everolimus and

low-dose CsA, the incidence was 3.6% and 8.0% for

everolimus 1.5 and 3.0 mg/d, respectively, in the absence of

IL-2 receptor agonist therapy, and 3.4% and 5.8% with IL-2

receptor therapy [25]. Thrombocytopenia occurred in 37%

to 45% of sirolimus and 9% to 23% of sirolimus/CsA-

treated recipients [48,49,81,82]. The incidence, but not the

severity, of thrombocytopenia correlated with sirolimus

trough blood levels; however, this is self-limiting and the

adverse event disappears over time [27]. The incidence of

leukopenia in everolimus studies is similar to that of

thrombocytopenia, occurring in around 4% of patients in

the absence of IL-2 receptor agonist therapy, and in 3.4%

(1.5 mg/d dose) and 5.8% (3.0 mg/d) with IL-2 receptor

therapy [25].

Two hypotheses have been suggested to explain the

myelosuppression observed with PSIs. First, in vitro studies

have shown enhanced, dose-dependent, agonist-induced

platelet aggregation and granule secretion after sirolimus

exposure. Second, sirolimus inhibits signal transduction viathe gp130b chain, which is shared by cytokine receptors for

IL-11, granulocyte colony-stimulating factor, and erythro-

poietin. These molecules are all necessary for the production

of platelets and leukocytes, and sirolimus may therefore

inhibit their production [27].

Dose reduction of PSIs may be an appropriate response

to myelosuppression, but evidence for this is limited, and

active treatment with erythropoietin may become necessary

in severe anemia [90].

3.3.3. Edema

Edema of the lower and upper limbs is commonly

observed during treatment with sirolimus or everolimus

[27,91]. Prostacyclin release from endothelial cells, stimu-

lated by sirolimus, leads to vasodilatation [92], suggesting

that edema may be related to capillary leakage, as has been

observed in sirolimus-treated lung transplant recipients and

patients with psoriasis [93,94]. In addition to limb edema,

bilateral eyelid edema has been observed both in de novo

and maintenance transplant recipients receiving sirolimus

and everolimus [91,95,96].

3.3.4. Arthralgia

Arthralgia is a common adverse event occurring with

both drugs. In a study comparing sirolimus and CsA,

arthralgia was reported in 20% of patients in the sirolimus

group at 12 months, but was not reported in the CsA group

[48]. In a separate study comparing sirolimus and azathio-

prine, arthralgia was listed as a cause of study discontinu-

ation in the sirolimus group [81]. Arthralgia has also been

reported in patients in the everolimus A2306 study [91]. The

cause of this phenomenon is, however, not clear.

3.3.5. Impaired wound healing

The antiproliferative effects of PSIs have been associated

with a high incidence of wound healing problems. Delayed

healing of lymphatic channels divided during surgery and

a reduced fibrotic reaction contribute to an increased

incidence of lymphocele [97]. Compared with azathioprine,

sirolimus 5 mg/d is associated with an increased incidence

of postoperative lymphoceles [81], and similar results have

been seen with sirolimus in combination with CsA or

tacrolimus [98]. In studies A2306 and A2307, the incidence

of lymphocele at 6 months posttransplant was 15.2% and

10.3% with everolimus 1.5 mg/d, and 6.4% and 7.2% with

everolimus 3.0 mg/d, respectively [25] (Table 4). Potential

risk factors for delayed healing include recipient age,

presence of diabetes, and living vs cadaveric donor

[66,67]. In addition, thymoglobulin induction, body mass

index greater than 32 kg/m2, and a cumulative sirolimus

dose greater than 35 mg over the first 5 days of treatment

were all significantly associated with impaired wound

healing [98]. When the loading dose of sirolimus was

eliminated from a study of steroid-free maintenance

regimens in 239 patients, the incidence of wound healing

problems decreased [99]. Excellent surgical technique, such

hibiting renal tubular cell regeneration and by increasing

enal tubular cell loss by apoptosis [103].

.3.7. Proteinuria

In chronic glomerular diseases, proteinuria is an impor-

nt marker of the risk of a progressive, irreversible decline

GFR [104], and proteinuria levels greater than 800 mg/d

ave a negative correlation with outcome if treatment of

atients is converted from CNI to sirolimus [46]. Minimi-

ation of proteinuria is, therefore, a key goal in the treatment

f chronic kidney disease [70]. In 50 renal transplant

ecipients with CAN who were switched from CNIs to

irolimus, 64% developed marked proteinuria, with ne-

hrotic syndrome in around half of these patients [105],

atients with preexisting proteinuria having a higher

ecurrence rate. In 1 study of patients with existing CAN,

2% had no proteinuria (b150 mg/d) at the time ofonversion from CNI to sirolimus [47]. However, 19.4%

f patients had proteinuria greater than 1000 mg/d at 1-year

inhibitor regimens are safe and effective in the long-term

treatment of hypertension in renal transplant recipients

[73,74]. The long-term benefits of using calcium channel

blockers are not well defined in renal transplant recipients,

and there may be a possible interaction between agents

such as verapamil or diltiazem with everolimus, resulting in

an increase in everolimus levels [33]. Studies with

sirolimus have shown a significant reduction in blood

pressure after CNI elimination, demonstrating another

possible approach [36,43].

4. Proliferation signal inhibitors in current

clinical practice

4.1. Patient selection

In combination with CsA and corticosteroids, everolimus

is currently approved for the prophylaxis of organ rejection

in adult patients at low-to-moderate immunologic risk

s and

/d)a

/d)a

/d)b

/d)b

.0 mg

.0 mg/d) 154

mus

blood

blood

/d)

/d)

J. Pascual et al. / Transplantation Reviews 20 (2006) 11810r

in

r

3

ta

in

h

p

z

o

r

s

p

p

r

8

c

oas meticulous ligation of transected lymphatic channels,

delayed removal of skin clips, and the use of nonabsorbable

sutures, may reduce wound complications. Management of

posttransplant lymphocele remains the subject of debate.

Milder cases may be self-limiting or respond to instillation

of povidone iodine [63], although laparoscopic drainage

may be required [64,65].

3.3.6. Renal dysfunction

Experimental data demonstrate that the PSI class of

drugs has limited direct toxic effects on the kidney;

however, sirolimus and everolimus clearly augment CNI

toxicity partly through the effect shown with sirolimus,

which increases tissue CsA concentrations [100,101]

and may also be related to its effects on glucose meta-

bolism [102].

There has been concern that PSIs delay the recovery of

enal function after acute tubular necrosis (ATN) possibly by

Table 4

Incidence of wound healing problems and lymphoceles in trials of sirolimu

Study Duration (mo) Agent

Study A2306 [25] 6 Everolimus (1.5 mg

Everolimus (3.0 mg

Study A2307 [25] 6 Everolimus (1.5 mg

Everolimus (3.0 mg

Kahan [81] 12 CsA + sirolimus (2

CsA + sirolimus (5

CsA + azathioprine

Ciancio et al [98] 12 Tacrolimus + siroli

Tacrolimus + MMF

CsA + sirolimus

Studies B201 and B251 12 Everolimus (trough

Everolimus (trough

Study B201 [23] 36 Everolimus (1.5 mg

Everolimus (3.0 mg

MMF (2.0 g/d)

a In combination with reduced-dose CsA.b In combination with reduced-dose CsA and basiliximab induction.

4 P b .001 vs azathioprine.postconversion and this increased to 20.6% at 2 years [47].

Experimental laboratory evidence suggests that sirolimus

may lead to an increase in proteinuria through interference

with normal tubular epithelial cell compensatory mecha-

nisms [106]. It is of interest that there was no excess de novo

proteinuria reported in any of the randomized phase II and

III studies of sirolimus [27]. There is no evidence available

for everolimus in phase III studies as data on proteinuria

were not routinely collected. However, the incidence,

mechanism, and management of proteinuria in patients

receiving everolimus are currently being investigated.

Angiotensin-converting enzyme (ACE) inhibitors and

angiotensin II receptor blockers may have potential clinical

utility for the management of both hypertension and

proteinuria in patients receiving everolimus [71,104]. This

is an area that requires further investigation especially in

relation to exacerbating anemia [107].

Nevertheless, clinical trial data suggest that ACE

3

16 6

6 4

14 4

level, 3 ng/mL) 20 20

level, 8 ng/mL) 12 16

9

12

4 everolimus

Lymphocele (%) Wound dehiscence (%)

15.2

6.4

10.3

7.2

/d) 12

J. Pascual et al. / Transplantation Reviews 20 (2006) 118 11receiving an allogeneic renal or cardiac transplant. Ever-

olimus should not be used with full doses of CsA beyond

1 month posttransplantation.

4.1.1. bOld-for-oldQ transplantationIn recent years, the age of patients receiving renal

transplants has increased, with around one third being older

than 55 years [108,109]. Similarly, the proportion of donors

aged older than 55 years has increased. There has therefore

been a trend toward age matching of donor and recipient to

ensure appropriate use of donated organs [80,108,110,111].

This means that the current estimated potential for bold-for-old Q transplantation is approximately 30% of all trans-plants. Older organs are at greater risk of delayed graft

functioning, CAN and CNI toxicity, and it has been

suggested that they should be targeted for CNI minimization

[80,110,112].

4.1.2. Patients younger than 15 years

Everolimus is not currently indicated in pediatric

patients, but dosing, efficacy, and safety data in this patient

group are beginning to emerge [113,114].

4.1.3. Malignancy

Everolimus and sirolimus interrupt the PI3K/Akt signal-

ing pathway, which plays a critical role in regulating cell

proliferation, survival, mobility, and angiogenesis [115].

Tumors that rely on overactivity of the PI3K/Akt pathway

for growth may therefore be susceptible to this class of

agent. In vitro and in vivo studies have shown that growth

of a number of tumor cell lines can be slowed or prevented

with sirolimus, including those derived from liver [116,117],

breast [118], pancreas [119], and ovary [120], as well as

myeloid and lymphocytic leukemia cell lines [121,122]. In a

breast cancer cell line, sirolimus has also been shown to

restore sensitivity to tamoxifen [123].

Use of everolimus in vitro and in vivo has yielded

similar results to those with sirolimus. A combination of

everolimus and epidermal growth factor receptor/vascular

endothelial growth factor receptor 2 leads to inhibition

of glioblastoma growth [124], and everolimus has also

been shown to reverse Akt-dependent prostate intra-

epithelial neoplasia [125]. In a primary cell culture derived

from patients with acute myeloid leukemia, everolimus

enhanced the activity of the PI3 kinase inhibitor,

LY294002 [126]. Everolimus has also been shown to

inhibit the growth of transformed B lymphocytes [127] and

a cell line derived from a patient with posttransplant

lymphoproliferative disorder [128]. In a rat pancreatic

tumor model, everolimus demonstrated significant, dose-

dependent antitumor activity that was similar to that

observed with the cytotoxic agent 5-fluorouracil [129]. In

a study combining everolimus with the DNA-damaging

agent cisplatin, everolimus was shown to inhibit expres-

sion of p21, thus increasing the susceptibility of tumor

cells to apoptosis [130].In phase III studies of sirolimus, no increased incidence

of malignancies has been observed compared with either

placebo or azathioprine when combined with CsA and

corticosteroids [81,82]. During a 3-year study of CNI

elimination in sirolimus-treated patients, those in whom

CNI therapy was stopped had a numerically lower incidence

of malignancies compared with those remaining on CNI

(5.6% vs 11.2%) [37]. When results were pooled from

5 phase II and III studies, the overall incidence of

malignancies in patients receiving a combination of CsA

and sirolimus was found to be similar to that in patients

receiving CsA or azathioprine, whereas early elimination of

CsA was associated with a reduced risk of malignancies

[79]. In a multicenter, open-label study of 167 patients

enrolled from previous sirolimus studies (mean exposure to

sirolimus, 1526 days), malignancies were reported in 11

patients receiving CsA and sirolimus; none of the patients in

whom CsA had been eliminated experienced malignancies

[38]. In a study of 430 patients randomized at 3 months after

renal transplantation to continue sirolimus and CsA or have

CsA withdrawn, CNI-free therapy significantly reduced the

incidence of nonskin cancer at 5 years posttransplant [131].

In studies of everolimus, the incidence of malignancies was

lowafter 36 months of treatment, the incidence of

malignancies was 5.2%, 4.5%, and 4.6% in the 1.5 mg/d

everolimus, 3.0 mg/d everolimus, and MMF group, respec-

tively (study B201) [23], and 4.7%, 5.2%, and 6.1%,

respectively (study B251) [24]. After 24 months of

treatment with reduced CsA doses, the proportion of

patients experiencing malignancies was even lower [30].

Conversion from CsA to sirolimus has recently been

suggested as a potential method of treating malignancies in

transplant recipients without increasing the risk of graft

rejection. For example, 2 renal transplant recipients with

Kaposi sarcoma underwent conversion from CsA to siroli-

mus, with complete regression of their Kaposi sarcoma

lesions [77]. These beneficial effects on Kaposi sarcoma

were further explored in a prospective study in 15 renal

transplant recipients who were switched from CsA to

sirolimus [78]. Three months after conversion, all Kaposi

sarcoma lesions had disappeared, and remission was con-

firmed by histopathology at 6 months. There were no

acute episodes of rejection or changes in graft function.

Beneficial effects of sirolimus in liver transplant recipients

with hepatocellular carcinoma have also been reported,

in both decreased tumor recurrence and remission of

metastases [132,133].

4.2. Everolimus dosing and administration

As has been demonstrated in clinical trials, everolimus is

an effective immunosuppressant when given immediately

after renal transplantation in combination with CsA,

corticosteroids and, possibly, IL-2 receptor antagonist

induction therapy [21,25]. Suggested algorithms for ever-

olimus treatment are provided for de novo (Fig. 6) and

maintenance (Fig. 7) renal transplant recipients.

J. Pascual et al. / Transplantation Reviews 20 (2006) 118124.2.1. De novo patients

In de novo renal transplant recipients, everolimus should

be initiated at a dose of 0.75 mg BID dose adjustment to

ensure trough blood levels of 3 to 8 ng/mL [26,34] (Fig. 6).

Straightforward TDM can now be achieved using an

immunoassay (Innofluor Certican, Seradyn Inc, Indian-

apolis, Ind). Lower CsA C2 levels can be targeted in the

weeks after transplantation with IL-2 receptor antibody

Fig. 6. Treatment guidelines for the use of everolimus in de novo renal transplan

stable at with down-titration of CsA concentrations, with CsA C0 levels in t

therapy, CsA exposure may be minimized further: CsA C2 levels 500 to 700

[25,33]. yCsA withdrawal from everolimus-based regimens is currently being veverolimus above trough levels of 12 ng/mL [33]. A single case study reports e

indicates twice daily.induction [25]. Table 5 provides insights from a single

center experience on the practical use of low-dose CsA and

everolimus in renal transplantation.

4.2.2. Maintenance patients

Based on studies with sirolimus, everolimus could allow

CsA minimization or elimination [38,44,46] (Fig. 7).

Cyclosporine has been reduced or withdrawn in progres-

t recipients. Everolimus trough blood levels have been reported to remain

he range of 25 to 50 ng/mL [26,134,135]. *With basiliximab induction

ng/mL in weeks 0 to 8 and 350 to 450 ng/mL in week 9 to month 12

alidated in large clinical trials. zThere is limited experience of the use ofverolimus trough levels above 12 ng/mL after CsA withdrawal [80]. b.i.d.

Fig. 7. Treatment guidelines for the use of everolimus in maintenance renal transplant recipients receiving CNIs. CNI can be reduced in a stepwise progression

of approximately 25% each step; however, abrupt cessation of CNI is also used in clinical practice. zRange 800 to 1500 mg/d; published data from 1 study [46]recommends 800 mg/d as the cutoff point for proteinuria; however, an ongoing phase IV study is assessing 1500 mg/d proteinuria as the cutoff value for

conversion to PSI therapy. yThere is limited experience of the use of everolimus above trough levels of 12 ng/mL [33]. Clinical opinion (see Table 5) suggeststhat lower everolimus exposure may allow for increased tolerability. Everolimus levels of 6 to 12 ng/mL are currently being evaluated in ongoing phase IV

studies. *CsA withdrawal from everolimus-based regimens is currently being validated in large clinical trials.

J. Pascual et al. / Transplantation Reviews 20 (2006) 118 13

insig

[80] p

eg, y

of thi

toxic

lder p

e to CNI-related nephrotoxicity, not least because older organs tend to have worse

renal

re to

case

to 40

sA. G

splant

ld-for

from

us an

l tran

receiv

J. Pascual et al. / Transplantation Reviews 20 (2006) 11814Table 5

Low-dose CsA and everolimus strategies in de novo renal transplantation

Q: Which renal transplant patients should be considered for PSI therapy?

A: Everolimus offers potential for both CsA minimization and withdrawal

! De novo patients at high risk of suboptimal renal function! Patients for whom very long-term immunosuppression will be required (! Patients at risk for CMV infection (it is associated with a low incidence! In the maintenance setting, patients at risk for or exhibiting CNI-related

Q: Can one define patients at high risk of suboptimal graft function?

A: In an effort to expand the donor pool, it is becoming common for o

transplantation [80,137]. However, these patients may be more susceptibl

function than younger organs [112,136].

Q: How may everolimus be used to reduce CNI exposure and to optimize

A: Two recent clinical trials show that everolimus allows CsA exposu

immunosuppressive efficacy and good renal function [25]. Two long-term

recently published [80].

! Case 1: Everolimus 0.75 mg BID allowed a reduction in CsA C2 levelsstabilized at around 1.7 mg/dL [80].

! Case 2: Everolimus 1.5 mg BID was combined with reduced-exposure Cpeaking at 3.8 mg/dL before CsAwas withdrawn [80]. By 2 years posttran

everolimus and low-dose steroids [80].

Q: What is an acceptable posttransplant mean serum creatinine level for boA: Previous experience from Spain shows that patients receiving a kidney

2.06 mg/dL [112]. Case 1 above, in which a patient treated with everolim

2 years posttransplant represents a good outcome for an old-for-old rena

Q: What CsA C2 levels optimize long-term renal graft function in patientssive steps of approximately 25% over 4 weeks; how-

ever, immediate cessation of CNIs has also been used in

clinical practice.

In the maintenance phase of treatment, there are currently

few data in patients with CsAC2 levels lower than 350 ng/mL

(trough blood (C0) 50 ng/mL). Initial experience suggests

that CsA can be discontinued in selected patients receiving

everolimus [80], although the dose of everolimus then needs

to be increased to compensate for the pharmacokinetic

interaction that leads to a 2- to 3-fold decrease in everolimus

blood levels when CsA is withdrawn [15]. After CsA

withdrawal, initial clinical experience suggests that ever-

olimus trough blood levels of 10 to 15 ng/mL may be needed

when using everolimus and corticosteroids only [80], but that

lower trough blood levels may be required if also using an

MPA agent.

4.1.3. Future study of everolimus

There is an ongoing phase IV clinical trial program for

everolimus to refine the use of everolimus in clinical

practice [7], including a delayed start to permit wound

healing, prospective use in maintenance renal transplant

patients, and the ability to facilitate CNI minimization and

withdrawal. Everolimus is currently licensed for use in

combination with low-dose CsA, but tacrolimus is also

widely used in renal transplant recipients. At least 1

pharmacokinetic phase II and 2 large phase III trials are

exploring the combination of tacrolimus and everolimus in

de novo kidney transplantation. Everolimus has also been

shown to reduce the severity and incidence of cardiac

allograft vasculopathy posttransplantation in heart transplan

recipients, perhaps by inhibiting proliferation of smooth

muscle cells [86]. This is an additional area for future

investigation in the renal transplant population.

5. Conclusions

There is good clinical trial evidence to support the

efficacy and tolerability of everolimus in renal transplanta-

tion. Clinical trial data indicate that everolimus can facilitate

minimization of CsA exposure, but ongoing clinical trials

and clinical practice will help to further refine its therapeutic

role. Everolimus is associated with several class-specific

adverse events (eg, hyperlipidemia), but experience to date

A: Minimization of CsA exposure to ensure C2 levels less than 400 ng/mL by 6 months posttransplant is desirable [80]. Cyclosporine C2 exposure levels o

350450 ng/mL from week 13 posttransplantation, or week 9 posttransplantation if using basiliximab (Simulect) induction therapy, are recommended

[25,33].

Q: When is complete withdrawal of CNIs appropriate?

A: CNI withdrawal is generally only necessary if the patient is experiencing nephrotoxicity or other serious adverse events that do not respond to CNI dose

minimization [80]. In our experience, if CNIs are withdrawn, everolimus dose should be increased to achieve blood trough levels of 812 ng/mL, but there

are no clinical trials to support this strategy.

Q: Which specific adverse events associated with use of everolimus are most troublesome?

A: Patients may experience hyperlipidemia during everolimus therapy, which can generally be controlledwith statins [33,80]. Early after transplantation, lymphocele

or wound dehiscence can occur, but they are usually not severe [33]. Lymphocele may be self-limiting or responsive to povidone iodine treatment [91].

Q: How should everolimus be used in combination with mycophenolate therapy in maintenance renal transplant recipients?

A: It is advisable to closely monitor patients receiving everolimus, MPA, and steroids to ensure that they do not become over-immunosuppressed or anemic

[138]. The use of low levels of everolimus (38 ng/mL) and MMF (1 g) should be considered. Formal study in clinical trials is needed to explore this strategyt

f

.function?

be reduced in de novo renal transplant recipients, while maintaining

studies of bold-for-oldQ renal transplants from one of these trials have been

0 ng/mL after 4 months posttransplant [80]. Serum creatinine subsequently

raft function deteriorated despite CsA minimization, with serum creatinine

, serum creatinine had stabilized at 2.5 mg/dL with the patient maintained on

-oldQ transplant patients?an elderly donor have mean 12-month serum creatinine levels around

d reduced-dose CsA has a stable serum creatinine level of 1.7 mg/dL up to

splant [80].

ing everolimus?hts from Hospital Ramon y Cajal, Madrid, Spain

articularly in:

oung patients) [136]

s infection [22])

ities or CAN.

atients (ie, N55 years) to receive older kidneysso-called bold-for-oldQ

microemulsion in cynomolgus monkey kidney allotransplantation.

the novel rapamycin analog, SDZ RAD, to rat lung allograft

recipients: potentiation of immunosuppressive efficacy and improve-

J. Pascual et al. / Transplantation Reviews 20 (2006) 118 15ment of tolerability of staggered versus simultaneous treatment.

Transplantation 1999;67:956 -62.

[13] Lutz J, Zou H, Liu S, Antus B, et al. Apoptosis and treatment of

chronic allograft nephropathy with everolimus. Transplantation

2003;76:508 -15.

[14] Neumayer HH, Paradis K, Korn A, et al. Entry-into-human study

with the novel immunosuppressant SDZ RAD in stable renal

transplant recipients. Br J Clin Pharmacol 1999;48:694 -703.

[15] Kovarik JM, Kalbag J, Figueiredo J, et al. Differential influence of

two cyclosporine formulations on everolimus pharmacokinetics: a

clinically relevant pharmacokinetic interaction. J Clin Pharmacol

2002;42:95 -9.Transplantation 2000;69:737 -42.

[11] Viklicky O, Zou H, Muller V, et al. SDZ-RAD prevents manifes-

tation of chronic rejection in rat renal allografts. Transplantation

2000;69:497-502.

[12] Hausen B, Boeke K, Berry GJ, et al. Coadministration of Neoral andsuggests that these can be managed. Investigation of

the antineoplastic activity of everolimus is anticipated given

the positive effects that have been documented for sirolimus

especially in patients with Kaposi sarcoma. This class

of agent has yet to find its true role, but the potential

to maintain immunosuppression without the twin penalties

of nephrotoxicity and malignancy will provide the

incentive to refine our clinical use of both sirolimus

and everolimus.

Acknowledgement

The authors thank Dr J Chapman for review of the

manuscript.

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