African-American race modifies the influence of tacrolimus concentrations on acute rejection and toxicity in kidney transplant recipients.

Publisher: Wiley-Blackwell Country of Publication: United States NLM ID: 8111305 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 1875-9114 (Electronic) Linking ISSN: 02770008 NLM ISO Abbreviation: Pharmacotherapy Subsets: MEDLINE

Publication: 2012- : Malden, MA : Wiley-Blackwell
Original Publication: [Carlisle, MA : Pharmacotherapy Publications, c1981-

Black or African American* ; Kidney Transplantation*; Graft Rejection/*ethnology ; Immunosuppressive Agents/*administration & dosage ; Kidney Tubules/*pathology ; Tacrolimus/*administration & dosage; Adult ; Atrophy/chemically induced ; Dose-Response Relationship, Drug ; Female ; Fibrosis/chemically induced ; Humans ; Immunosuppressive Agents/adverse effects ; Immunosuppressive Agents/pharmacokinetics ; Longitudinal Studies ; Male ; Middle Aged ; Tacrolimus/adverse effects ; Tacrolimus/pharmacokinetics

Study Objective: To determine the effect of tacrolimus trough concentrations on clinical outcomes in kidney transplantation, while assessing if African-American (AA) race modifies these associations.
Design: Retrospective longitudinal cohort study of solitary adult kidney transplants.
Setting: Large tertiary care transplant center.
Patients: Adult solitary kidney transplant recipients (n=1078) who were AA (n=567) or non-AA (n=511).
Exposure: Mean and regressed slope of tacrolimus trough concentrations. Subtherapeutic concentrations were lower than 8 ng/ml.
Measurements and Main Results: AA patients were 1.7 times less likely than non-AA patients to achieve therapeutic tacrolimus concentrations (8 ng/ml or higher) during the first year after kidney transplant (35% vs 21%, respectively, p<0.001). AAs not achieving therapeutic concentrations were 2.4 times more likely to have acute cellular rejection (ACR) as compared with AAs achieving therapeutic concentrations (20.8% vs 8.5%, respectively, p<0.01) and 2.5 times more likely to have antibody-mediated rejection (AMR; 8.9% vs 3.6%, respectively, p<0.01). Rates of ACR (8.3% vs 6.7%) and AMR (2.0% vs 0.9% p=0.131) were similar in non-AAs compared across tacrolimus concentration groups. Multivariate modeling confirmed these findings and demonstrated that AAs with low tacrolimus exposure experienced a mild protective effect for the development of interstitial fibrosis/tubular atrophy (IF/TA; hazard ratio [HR] 0.78, 95% confidence interval [CI] 0.47-1.32) with the opposite demonstrated in non-AAs (HR 2.2, 95% CI 0.90-5.1).
Conclusion: In contradistinction to non-AAs, AAs who achieve therapeutic tacrolimus concentrations have substantially lower acute rejection rates but are at risk of developing IF/TA. These findings may reflect modifiable time-dependent racial differences in the concentration-effect relationship of tacrolimus. Achievement of therapeutic tacrolimus trough concentrations, potentially through genotyping and more aggressive dosing and monitoring, is essential to minimize the risk of acute rejection in AA kidney transplant recipients.
(© 2015 Pharmacotherapy Publications, Inc.)

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K23 DK099440 United States DK NIDDK NIH HHS; T35 DK007431 United States DK NIDDK NIH HHS; K23DK099440 United States DK NIDDK NIH HHS

Keywords: African-American; acute rejection; kidney transplantation; tacrolimus; therapeutic drug monitoring

0 (Immunosuppressive Agents)
WM0HAQ4WNM (Tacrolimus)

Date Created: 20150527 Date Completed: 20160104 Latest Revision: 20221207

20231215

PMC4534305

10.1002/phar.1591

26011276