supplementary materials for€¦ · supplementary materials for individualizing liver transplant...
TRANSCRIPT
Supplementary Materials for
Individualizing liver transplant immunosuppression using a phenotypic
personalized medicine platform
Ali Zarrinpar,* Dong-Keun Lee, Aleidy Silva, Nakul Datta, Theodore Kee,
Calvin Eriksen, Keri Weigle, Vatche Agopian, Fady Kaldas, Douglas Farmer,
Sean E. Wang, Ronald Busuttil, Chih-Ming Ho,* Dean Ho*
*Corresponding author. E-mail: [email protected] (A.Z.); [email protected] (C.-M.H.);
[email protected] (D.H.)
Published 6 April 2016, Sci. Transl. Med. 8, 333ra49 (2016)
DOI: 10.1126/scitranslmed.aac5954
This PDF file includes:
Subject clinical details
Methods
Fig. S1. The effect of cotrimoxazole and fluconazole dosing on patients’ trough
levels.
Fig. S2. PPD tacrolimus-prednisone interaction plots for patients PPD1, PPD2,
and C1.
Fig. S3. PPD tacrolimus-cotrimoxazole interaction plots for patient PPD4.
Fig. S4. Retrospective PPD-guided tacrolimus and prednisone dosing
optimization for patients C1 and C2.
Table S1. Clinical summaries of control patients (C1 to C4) and PPD-guided
patients (PPD1 to PPD4).
Table S2. Data used for statistical comparisons in Fig. 5.
Table S3. Patient-specific antibiotic and antifungal dosing changes and
corresponding tacrolimus trough levels.
Table S4. Patient-specific anti-inflammatory and immunosuppressant dosing
changes and corresponding trough levels.
Other Supplementary Material for this manuscript includes the following:
(available at www.sciencetranslationalmedicine.org/cgi/content/full/8/333/333ra49/DC1)
Movie S1 (.mov format). Introduction to PPD and patient recalibration.
Movie S2 (.mov format). Patient PPD2 recalibration tutorial.
www.sciencetranslationalmedicine.org/cgi/content/full/8/333/333ra49/DC1
Movie S3 (.mov format). Patient PPD3 recalibration tutorial.
SUBJECT CLINICAL DETAILS
We enrolled 8 consecutive adult liver transplant patients and randomized to two groups:
physician-guided standard of care dosing (Control Patients: C1-C4) and PPD-guided dosing
(PPD1-PPD4) (table S1). Physician-guided standard of care dosing was used for the first 10 days
of tacrolimus dosing after liver transplant, during which all patients were transitioned from
methylprednisolone to prednisone based on an established clinical protocol. To avoid
confounding effects from this protocol and to allow the establishment of steady-state drug
concentrations, personalized tacrolimus dosing via PPD started after this period (after post-
transplant tacrolimus dosing day 10) for the four PPD-assisted patients, whereas the four control
patients stayed on the standard of care. Additional drugs were given to each patient during the
course of treatment due to their diverse range of pre- and post-operative conditions.
Control patients. C1 was a 50-year-old woman with nonalcoholic steatohepatitis (NASH)
cirrhosis. Prior to transplantation, she was in the hospital ICU for a few days because of acute
decompensation. Her MELD (model of end-stage liver disease) score at transplantation was 36.
The MELD score predicts patient mortality within three months without transplantation, and
MELD values range from 6 (lowest acuity) to 40 (highest acuity). Her peri- and post-operative
course was uncomplicated. She was discharged on post-operative day 22.
C2 was a 39-year-old man with alcoholic cirrhosis. He was in the hospital ICU for
approximately one month prior to receiving an organ offer. During that time he was
intermittently on the ventilator. He was on vasopressors and continuous dialysis before
transplantation and his MELD score was 40. His operative course was unremarkable, except for
the fact that his biliary anastomosis was stented with a T-tube. Post-operatively he required
prolonged ventilator support and the attendant inability to swallow. He was on dialysis after liver
transplantation until his discharge on post-operative day 46.
C3 was a 73-year-old man with a physiologic MELD score of 13 who came from home to
be transplanted for alcoholic cirrhosis and hepatocellular carcinoma. His operative course was
complicated by severe ischemia reperfusion injury and cardiac instability. He was temporarily
closed and biliary anastomosis was deferred until postoperative day 3. His post-operative course
was very complex. He initially had poor graft function with liver function tests that were
persistently elevated. Multiple explorations and biopsies led to equivocal results, with the poor
graft function being ascribed to persistent infection, antibody-mediated rejection [for which he
underwent plasmapheresis, intravenous immunoglobulin (IVIg) injection, and treatment with
bortezomib]. Ultimately, interventional radiology embolized a splenorenal shunt, and the patient
underwent endoscopic stenting of his biliary anastomosis resulting in improved hepatic function.
Fortunately, his renal function was unaffected during this time. He was discharged on post-
operative day 98.
C4 was a 61-year-old man with a physiologic MELD score of 19 who came from home to
be transplanted for hepatitis C cirrhosis and hepatocellular carcinoma. His operative course was
complicated by coagulopathy requiring deferment of the biliary anastomosis until post-operative
day 2. He suffered some acute kidney injury from the operation but did not require hemodialysis.
He was discharged on post-operative day 29.
PPD patients. PPD1 was a 53 year-old-man with alcoholic cirrhosis. He had been in the
hospital ICU on a ventilator and requiring vasopressors and continuous dialysis for months prior
to receiving an organ offer. His MELD score was 40 at the time of transplantation. His intra- and
post-operative course was mostly unremarkable. Because of his debility, he was unable to
swallow for weeks after his operation. His renal function has not yet recovered. He was
discharged on post-operative day 33.
PPD2 was a 56-year-old man with hepatitis C who came from home to be transplanted
with a MELD score of 25. His operative course was unremarkable. He had some acute kidney
injury after transplantation but that gradually recovered. His post-operative course was
complicated by a biliary leak that required drain placement and endoscopic biliary stent
placement. He was discharged on post-operative day 30.
PPD3 was a 65-year-old man with hepatitis C cirrhosis and hepatocellular carcinoma. He
came from home for an organ offer with a physiologic MELD score of 9. Intraoperatively he
suffered from stress-induced cardiomyopathy and needed to have his biliary anastomosis
deferred until post-operative day 3. His cardiac function improved slowly, and his perioperative
acute kidney injury recovered. He was discharged on postoperative day 22.
PPD4 was a 54-year-old morbidly obese woman with a MELD score of 40 who was
transplanted for NASH cirrhosis. She had been in the ICU for days because of encephalopathy
and need for continuous dialysis. Her operation was notable for the need to have a Roux-en-Y
biliary anastomosis due to scarring from previous operations. She had some persistent infections
requiring antibiotics. Her renal function recovered slowly after liver transplantation and she no
longer needs dialysis. She was discharged on post-operative day 33.
SUPPLEMENTARY METHODS
Prospective clinical treatment protocol
Following liver transplant, patients were started on a regimen of tacrolimus, MMF, and
methylprednisolone. According to the protocol, daily methylprednisolone dosing was tapered
using a 1000-150-210-120-80-40-20 mg regimen. Methylprednisolone was subsequently
changed to prednisone given at 20 mg daily which was subsequently tapered per protocol. MMF
dosing was performed according to the protocols determined by the clinical team based on the
recipient’s individual circumstances. Trough levels were taken between 4:00 and 6:00 AM daily,
and a first dose of tacrolimus was administered between 5:00 and 6:00 AM daily, following the
whole blood trough recording. The clinical team obtained the daily treatment regimen details
including drugs already administered, drugs to be administered, hemodialysis to be performed,
co-infections, and planned prophylaxis and sent an updated clinical chart for each patient to the
PPD team. Following PPD analysis, we sent the suggested total daily tacrolimus administration
information to the clinicians prior to the administration of the evening dose.
Dosing days, D(X), were defined based on specific parameters immediately following
transplantation. Commencing from the first day of tacrolimus dosing following transplantation,
the target range and immunosuppressant dosing levels were changed frequently according to
protocol. For example, methylprednisolone dosing would be introduced with tacrolimus dosing
and was tapered from 1000 to 0 mg within the first 5 days following transplantation, at which
time it was replaced with a prednisone taper beginning at 20 mg. PPD-assisted treatment
commenced after the transition from methylprednisolone to prednisone. D(1) of the control
group was defined as the average value of the starting day of the PPD-treated patients which was
10 days after tacrolimus was introduced into patient’s regimen.
Retrospective parabolic personalized dosing process
Two anonymized liver transplantation patients’ (C1 and C2) clinical data, such as trough level
and drug regimen dosages, were obtained for analyses for the retrospective study. In order to
recommend optimal dosages, a 2nd order polynomial fit for each patient was made from linear
regression with covariates: tacrolimus and prednisone. The original PPD calibration required a
minimum of 6 different dosage combinations. In this process, the inclusion of the two drugs
allowed for better representation of each patient’s data and examination of the effects of drug-
drug interaction within each patient’s regimen. The importance of the retrospective PPD is based
on its ability to simultaneously identify optimal drug dose combinations for tacrolimus and
prednisone at specific time points that enabled the trough levels to remain within the prescribed
target ranges. Prednisone was administered according to the Dumont-UCLA Liver Transplant
Center’s clinical guidelines, which depend on each patient’s risk for rejection, recurrent disease,
or complication from steroids. The center’s guidelines are provided for reference.
If the patient is diagnosed with autoimmune hepatitis (AIH), primary sclerosing
cholangitis (PSC), or primary biliary cholangitis (PBC), a standard steroid taper is provided (7
days). Patients are to receive 1000mg hydrocortisone on the way to or in the operating room
(OR) with the following schedule: Day 1: 50 mg every 6 hours (q6h) x 4 methylprednisolone;
Day 2: 40 mg q6h x 4 methylprednisolone; Day 3: 30 mg q6h x 4 methylprednisolone; Day 4: 20
mg q6h x 4 methylprednisolone; Day 5: 20 mg every 12 hours (q12h) x 2 methylprednisolone;
Day 6: 10 mg q12h x 2 methylprednisolone; Day 7: 20 mg prednisone and wean over 3 months.
If the patient is diagnosed with hepatitis B, hepatitis C, alcoholic liver disease or non-
alcoholic steatohepatitis (NASH), a rapid steroid taper is provided (5 days). Patients are to
receive 1000mg hydrocortisone on the way to or in the OR with the following schedule: Day 1:
50 mg q6h x 4 methylprednisolone; Day 2: 25 mg q6h x 4 methylprednisolone; Day 3: 25 mg
q12h x 2 methylprednisolone; Day 4: 10 mg q12h x 2 methylprednisolone; Day 5: 20 mg
prednisone and wean over 1 month.
If the patient is at high risk of steroid complications, a steroid-free immune suppression
protocol is implemented: Rabbit Anti-Thymocyte Globulin (RATG) 1.5 mg/kg over 6 hours
starting during anhepatic phase; 500 mg methylprednisolone iv premedication before first dose
of RATG to minimize cytokine release; RATG 1.5 mg/kg on post-transplant day 2;
Mycophenolate Mofetil (MMF) starting postoperative day (POD) 1: 1,000 mg twice a day (bid)
x 3 months. If the patient is diagnosed with PBC, PSC, or AIH, then MMF is administered
indefinitely. Tacrolimus is administered starting POD 3-7; goal 6-8 until week 12; goal 3-5 until
week 24; goal ~3 until week 52; goal 1-3 thereafter.
.
Fig. S1. The effect of cotrimoxazole and fluconazole dosing on patients’ trough levels. These
patients were given cotrimoxazole and fluconazole, and had pure correlations between the
dosage changes in these drugs and changes in tacrolimus trough levels. These pure correlations
were used to pre-emptively dose tacrolimus for days with anticipated regimen changes. (A)
Cotrimoxazole dosing (blue) and the trough levels (red) were plotted against the dates of
administration for C4, PPD1, and PPD4. (B) Fluconazole dosing (purple) and the trough levels
(red) were plotted against the dates of administration for C2, C4, and PPD4.
Fig. S2. PPD tacrolimus-prednisone interaction plots for patients PPD1, PPD2, and C1. 3D
drug interaction maps of tacrolimus and prednisone dosing were correlated with the trough levels
for: PPD1, PPD2, and C1. The tacrolimus-prednisone surfaces indicate synergistic or
antagonistic interactions based upon the respective shape (convex or concave) and the trend
(upward or downward). The color within the plot represents the trough level (ng/ml) according to
the color bar (blue to red).
Fig. S3. PPD tacrolimus-cotrimoxazole interaction plots for patient PPD4. Two-
dimensional (2D) drug interaction maps of tacrolimus and cotrimoxazole dosing correlated with
the trough level for: treatment days 6-12, treatment days 6-15, treatment days 14-23, and
treatment days 14-26. The color within the plot represents the trough level (ng/ml) according to
the color bar (blue to red).
Fig. S4. Retrospective PPD-guided tacrolimus and prednisone dosing optimization for
patients C1 and C2. (A and B) Control patients C1 (A) and C2 (B) PPD-optimized (red) and the
clinically observed (blue) tacrolimus whole blood trough concentration levels (trough levels),
tacrolimus doses, and prednisone doses plotted against dosing days. (C and D) PPD (red) and
clinically observed control (blue) ratios of AUC inside and AUC outside the target range to total
AUC for C1 (C) and C2 (D).
Table S1. Clinical summaries of control patients (C1 to C4) and PPD-guided patients
(PPD1 to PPD4). All patients’ summaries show anonymized demographic information and
treatment parameters.
Rej
ecti
on
None
None
Poss
ible
anti
body
med
iate
d
None
None
Poss
ible
low
gra
de.
No b
iopsy
per
form
ed
None
None
Infe
ctio
n
None
Pneu
mon
ia b
ut
reco
ver
ed
Poss
ible
intr
abdo
min
al
infe
ctio
n,
pre
sum
ed
chola
ngit
is
Bri
ef i
ntr
aven
ous
(IV
) an
tibio
tics
(abx)
for
intr
aabdo
min
al
infe
ctio
n
None
Bil
iary
lea
k -
zosy
n
None
Posi
tive
blo
od
cult
ure
- l
inez
oli
d
Ren
al f
unct
ion
AK
I re
solv
ed
Pre
-ort
ho
topic
liver
tra
nsp
lan
t
(Pre
OL
T)
HD
.
HD
at
dis
char
ge
AK
I re
solv
ed
Acu
te K
idney
Inju
ry (
AK
I)
reso
lved
Pre
OL
T H
D.
HD
at d
isch
arge
AK
I re
solv
ed
AK
I re
solv
ed
Pre
OL
T H
D t
hen
reco
ver
ed
Po
st-o
pera
tiv
e is
sues
No
ne
Res
pir
ato
ry f
ailu
re,
pro
lon
ged
intu
bat
ion
po
st o
per
atio
n,
swal
low
ing
dif
ficu
ltie
s
Per
sist
ent
infe
ctio
n,
po
or
gra
ft
fun
ctio
n,
pla
smap
har
esis
fo
r an
ti-
do
no
r an
tib
od
ies,
bo
rtez
om
ib,
intr
aven
ou
s im
mu
no
glo
bu
lin
(IV
IG),
mu
ltip
le e
xp
lora
tory
lap
rosc
op
ies,
bio
psi
es,
Ttu
be
wit
h
hig
h o
utp
ut
des
pit
e el
evat
ion
,
nee
ded
em
bo
liza
tio
n o
f sp
len
ore
nal
shu
nt,
nee
ded
en
do
sco
pic
ret
rog
rad
e
cho
lan
gio
pan
cre
ato
gra
m a
nd
sten
tin
g o
f d
uct
an
asto
mo
sis/
sten
t
pla
cem
ent
Per
sist
ent
asci
tes
Pro
lon
ged
in
abil
ity
to
sw
allo
w d
ue
to p
rolo
ng
ed
IC
U s
tay
pre
OL
T.
Nee
ded
tu
be
feed
s u
nti
l v
ery
clo
se
to t
ime
of
dis
char
ge
Bil
iary
lea
k
So
me
pro
lon
ged
sw
allo
win
g
dif
ficu
ltie
s b
ut
reco
ver
ed
Per
sist
ent
po
siti
ve
blo
od
cu
ltu
res.
Ev
entu
ally
cam
e o
ff
HD
an
d H
D
lin
e w
as r
emo
ved
Op
erat
ive
issu
es
No
ne
T-t
ub
e p
lace
d.
Sev
ere
isch
emia
rep
erfu
sio
n i
nju
ry,
card
iac
inst
abil
ity
Co
agu
lop
ath
ic,
pac
ked
Ttu
be
pla
ced
.
No
ne
Car
dio
my
op
ath
y,
coag
ulo
pat
hy
,
tem
po
rari
ly c
lose
d.
Tak
en b
ack
fo
r
com
ple
tio
n a
fter
tw
o
day
s
Ro
ux
-en-Y
anas
tom
osi
s.
Mo
rbid
ly o
bes
e
Pre
trea
tmen
t lo
cati
on
ICU
, o
n r
oo
m a
ir,
no
vas
op
ress
ors
,
ence
ph
alo
pat
hic
Inte
nsi
ve
Car
e U
nit
(IC
U),
in
tub
ate
d,
on
hem
od
ialy
sis
(HD
), a
nd
vas
op
ress
ors
Ho
me
Ho
me
ICU
, in
tub
ated
, o
n H
D,
and
vas
op
ress
ors
Ho
me
Ho
me
ICU
, o
n r
oo
m a
ir,
no
vas
op
ress
ors
,
ence
ph
alo
pat
hic
Physi
olo
gic
ME
LD
36
40
13
19
40
25
9
40
Dis
ease
Nonal
coholi
c
Ste
atohep
atit
is
(NA
SH
)
Alc
ohol-
Induce
d
Liv
er D
isea
se
Alc
ohol-
Induce
d
Liv
er D
isea
se,
Hep
atoce
llula
r
Car
cinom
a
Hep
atit
is C
,
Hep
atoce
llula
r
Car
cinom
a
Alc
ohol-
Induce
d
Liv
er D
isea
se
Hep
atit
is C
Hep
atit
is C
,
Hep
atoce
llula
r
Car
cinom
a
NA
SH
Gen
der
F
M
M
M
M
M
M
F
Age
50
39
73
61
53
56
65
54
ID
C1
C2
C3
C4
PP
D1
PP
D2
PP
D3
PP
D4
Table S2. Data used for statistical comparisons in Fig. 5.
Patient
Days post-op in
hospital until
discharge
Days >2 ng/ml
outside of
target range
Ratio of days
>2 ng/ml
outside of
target range
AUC inside
of target
ratio
AUC outside
of target ratio
C1 22 7 0.7 0.058725972 0.941274028
C2 46 2 0.060606061 0.61717296 0.38282704
C3 98 5 0.357142857 0.209903033 0.790096967
C4 29 2 0.111111111 0.589330974 0.410669026
PPD1 33 2 0.095238095 0.629840254 0.370159746
PPD2 30 1 0.090909091 0.671332525 0.328667475
PPD3 22 2 0.2 0.430475768 0.569524232
PPD4 33 1 0.045454545 0.707260047 0.292739953
Table S3. Patient-specific antibiotic and antifungal dosing changes and corresponding
tacrolimus trough levels. A summary is shown of patient-specific correlations between the
trough levels (ng/ml) and the therapeutic co-administration of amikacin, ganciclovir, linezolid,
piperacillin-tazobactam (taz), ciprofloxacin, cotrimoxazole, and fluconazole. (+) are increments
and (-) are decrements of the dosages or the trough levels between treatment period dates (date
vs. date).
Drug Patient Date vs date Change (mg) Trough level ch
ange (ng/ml)
Amikacin (A) and
Ganciclovir (G) PPD1 1/31 vs 2/1 -400 (A)
-110 (G) +1.4
Amikacin (A) and
Linezolid (L) C2 2/7 vs 2/8 -575 (A)
-1200 (L) +3.4
Amikacin (A) and
Piperacillin-Taz (P) C2 2/2 vs 2/3 -150 (A)
-6750 (P) +1.7
Ciprofloxacin C2 1/31 vs 2/1 -400 0
Cotrimoxazole C4 2/4 vs 2/5 -160 -1
C4 2/14 vs 2/16 +160 +0.3
PPD1 2/16 vs 2/17 -160 +0.9
PPD1 2/18 vs 2/19 -160 +0.5
PPD4 2/13 vs 2/14 +320 -4.1
PPD4 2/15 vs 2/16 -320 +1.7
Fluconazole C2 2/18 vs 2/19 -200 -3.4
C4 1/31 vs 2/1 +400 -0.3
PPD4 2/24 vs 2/25 -200 +4.1
Linezolid PPD4 2/23 vs 2/24 -600 +0.7
Table S4. Patient-specific anti-inflammatory and immunosuppressant dosing changes and
corresponding trough levels. A summary is shown of patient-specific correlations of trough
levels (ng/ml) with therapeutic co-administration of methylprednisolone, mycophenolate,
prednisone, and ganciclovir (mg). (+) are increments and (-) are decrements of the dosages or the
trough levels between treatment period dates (date vs. date).
Drug Patient Date vs date Change (mg) Trough level ch
ange (ng/ml)
Methylprednisolone PPD2 2/11 vs 2/12 -120 -1.3
Mycophenolate C1 2/9 vs 2/13 +1000 -7.4
PPD2 2/18 vs 2/23 +500 +2.7
Prednisone C2 2/5 vs 2/6 -2.5 +6.5
PPD1 2/5 vs 2/11 -2.5 -1.5
PPD1 2/14 vs 2/16 -2.5 -0.4
PPD1 2/14 vs 2/18 -2.5 -1.7
Prednisone (P) and
Ganciclovir (G) PPD1 1/30 vs 2/3 -2.5 (P)
-10 (G) -2.9
PPD4 2/17 vs 2/19 -2.5 (P) +125 (G)
-2.6