4 ~5 o, l; p0 Y4 C8 {: O + |) ]7 x! Z& b ! q* G) c) o4 M: O& M2 N% m! P . K! m g5 v9 B' ]+ G% C, M
" f' Y C6 M$ N& H$ B* c: Z% {$ U1 g
8 z! A/ E/ p* z7 Z2 B
6 p0 @, @: V( ~2 J/ J- q 9 B6 T/ g$ R' ?( l- ~9 q
【摘要】 为了研究抗胸腺细胞球蛋白(antithymocyte globulin, ATG)在HLA配型部分相合造血干细胞移植患者体内的药代动力学,将2003年10月至2004年10月北京大学血液病研究所骨髓移植部15例患者纳入本研究方案并应用ATG,其中AML 5例、CML 6 例、ALL 3例、AA 1例。给15例接受HLA部分配型相合造血干细胞移植术患者静脉滴注ATG,剂量为10 mg/kg,分4天给药,用 ELISA Fc法检测ATG血药浓度,用3P97程序根据房室模型进行数据处理。结果表明: ATG为超长半衰期药物,剂量2.5 mg/d连续应用4天,血药浓度随之升高,移植前5天血药浓度上升到44.8%。根据AIC(Akaike's information criterion),该值符合一级消除动力学的二室模型;主要药代动力学参数: AUC0t 3 415.9 ±216.2 mg/(L·d) ; Cmax 136.0±10.31 mg/L, ATG的达峰时间(Tmax)为4.8±0.7天; t1/2 为29. 7±2.60天; ATG表观分布容积的平均值为 0.12±0.02 L/kg; CL(s) 为0.002927 L/d, ATG体内有效的血药浓度至少维持90天。在给药期间患者未出现严重药物不良反应,耐受性好。结论: 含总剂量10 mg ATG预处理方案,临床有效,患者安全耐受,适宜用于HLA部分相合的造血干细胞移植患者,ATG在机体的药代动力学无种族差异性。 . \7 R( Q4 L4 V7 S( v M
【关键词】抗胸腺细胞球蛋白 药代动力学 HLA配型部分相合造血干细胞移植 x7 ]3 n V# e$ Q6 L Pharmacokinetics of Antithymocyte Globulin in RecipientsUndergoing HLA Partially matched Hematopoietic Stem Cell Transplantation ( c5 l# v( P$ m1 D( S1 J2 M+ y& I/ Y5 o/ V, |8 P
ZHANG XiaoHui,HUANG XiaoJun, LIU KaiYan, XU LanPing, LIU DaiHong, LU DaoPei * l0 d. s- l: K# h# V - d: H( e$ L# [' _, @4 L/ bInstitute of Hematology and People Hospital, Peking University, Beijing 100044, China 2 f( b5 Z. c* Y% v. Y, G 1 h0 ^1 _! i2 B8 bAbstractThe aim of study was to investigate the pharmacokinetics and distribution of antithymocyte globulin(ATG) in recipients of partially HLAmatched hematopoietic stem cell transplantation. Fifteen patients with hematological disorders were received hematopoietic stem cell transplantation from partially HLAmatched related donor between October 2003 and October 2004in the Institute of Hematology and People Hospital, Peking University. All patients including5 cases of AML, 6 cases of CML, 3 cases of ALL, 1 case of AA were consecutively enrolled in the present study after providing written informed consent. Antithymocyte globulin was administered before allogeneichematopoietic stem cell transplantation at a dose of 2.5 mg/kg daily for 4 consecutive days (total dose of 10 mg/kg) in the conditioning regimen. The concentration of rabbit ATG in the serum of 15 patients was measured using a new enzymelinked immunoabsorbent assay (ELISA) for the Fc portion of rabbit IgG. The results showed that the washout phase of ATG elimination was analyzed over 0-120 days, results were wellfitted by a single exponential decay giving a mean elimination halflife (t1/2 beta) of 29.67±2.60 days.A mean value for the apparent volume of distribution of ATG (V)obtained by analysis of datawas0.12±0.02 L/kg body weight.The serum concentration of ATG increasedup to 44.8%at5 day beforetransplantation,peak concentration of ATG was 136.0±10.3 mg/L,its concentration slowly descend at 0 day, fall up to 7.1±0.06 μg/ml at90 day after dosing; tmax 4.8±0.7 days;According to AIC (Akaike's information criterion), two compartment model of ATG was estimated. It is concluded thatthe conditioning regimen containingthe dosage of 10 mg/kg of ATGis effective and safely in recipients of partially HLAmatched hematopoietic stem cell transplantation. There is no racial difference in the pharmocokinetics of ATG.% t+ V" k/ Y3 k
" b) ]* G! _. f" YKey wordsantithymocyte globulin; pharmacokinetics; partiallyHLAunmatched HSCT+ G$ q) }6 C- D6 N
2 }7 q( C. i$ W6 ]3 ]* l4 wJ Exp Hematol 2007; 15(1):152-155 4 {$ T- y" T7 i/ x2 ^2 [* _ 8 M, b7 {, x% F3 `+ F; z" K抗胸腺细胞球蛋白(antithymocyte globulin, ATG )在HLA配型部分相合异基因造血干细胞移植(HSCT)中能防治移植物排斥和移植物抗宿主病(GVHD),并可促进植入[1]。本研究旨在通过酶联免疫吸附(ELISA)法检测ATG药物浓度,进一步研究ATG在我国HLA配型部分相合HSCT患者体内药代动力学特征,为临床HSCT患者更合理应用ATG提供药代动力学参数及理论基础。6 S; P) x* R9 Y$ n+ _" A/ E
% y2 v ~5 [0 k& H3 o$ T2 ^
药品、试剂和仪器* x; q4 E2 ?# g. N1 E; B) H
) b( c( B8 ~1 X根据该方程计算其时间浓度数据作图见图2。结果表明,实验值与计算值两线拟合度较高。 ; @8 u# v- r2 w7 G' P, c5 }) P- Q! O7 k4 G
ATG的耐受性 ! ^( O/ A' k5 L, t' ]* S% X; h$ M2 O2 k8 S# z9 |( }
15例配型部分相合造血干细胞移植患者,在ATG应用前均用非那根及氟美松等药物预防不良反应。不良反应主要为发热93.9%,出现发热的中位时间1.8±0.9(1-120)小时;寒战45.5%,出现寒战的中位时间1.3±0.5(0.5-11)小时,皮疹25.8%,出现皮疹的中位时间2.1±0.3(1-145)小时;头晕9.6%,出现头晕的中位时间6.3±0.3(1.5-72)小时;心悸6.5%,出现心悸的中位时间0.5±0.06(0.2-3)小时;皮肤搔痒16.1%,出现皮肤搔痒的中位时间0.8±0.07(0.3-11)小时;经激素等治疗,当日患者症状缓解,未出现严重不良反应,耐受性好。研究结果表明,上述不良反应均与血药浓度无相关性。 8 M0 d* e( ]7 s( J' u6 m) d! k+ ^8 ^2 f& S) J# k, ~
讨论 3 c- q/ z: p: Y8 z' Z 2 h8 L& |! p9 ?ATG是含有IgG和IgM多克隆免疫球蛋白,它是异基因造血干细胞移植应用的重要的免疫抑制剂之一[2],广泛应用在器官移植及造血干细胞移植等诸多领域,为避免患者过度免疫抑制而发生严重感染和复发,以及ATG药物血浓度过低而疗效欠佳,因此探索造血干细胞移植患者个体化的最佳ATG剂量尤为重要。# B' v b: T5 y. c
' j! j. v3 x O* n. Z
ATG的的免疫抑制疗效及不良反应与其药代动力学密切关联。本研究探讨了ATG在中国人体内药代动力学特点,以期为临床设计给药方案提供试验依据。研究结果表明,试验所得药代动力学参数与国外文献报道基本一致[1],说明ATG在机体的药代动力学无种族差异性。本研究采用ELISA 试验法。此方法具有样本处理简单、用时短、检测费用低等优点。本研究中ATG总剂量为10 mg/kg, 移植前5天开始应用ATG, Cmax为136.0±15.31 μg/L; 0天开始呈缓慢下降,ATG 浓度在移植后90天仍可检测到,代谢缓慢。ATG的血药浓度呈剂量依赖性。药代动力学研究提示,在用药第1天单次给足量,可获得最大ATG血药浓度,而临床上大剂量ATG可引起患者高热、腹痛、甚至过敏性休克而危及生命[3]。研究结果证实分次给药既可维持疗效,又避免药物在体内蓄积。根据AIC等数据,判定ATG的药物代谢为2室模型。- J% E8 @9 p/ W6 V% ~
2 _, \% q a7 H( I半衰期(halflife)是机体内药物浓度(或量)下降一半所需的时间。ELISA检测结果表明,ATG在人体内按单指数幂的方式缓慢消除,消除半衰期(t1/2 β)为29.67天,说明ATG为超长半衰期药物[4,5]。ATG体内有效的血药浓度至少维持90天。由于ATG的消除半衰期很长,因此临床每日应用等量ATG剂量,可造成ATG的体内蓄积。蓄积是很多药物产生临床治疗作用的先决条件,同时也是药物产生不良反应的重要原因。评价药物在连续给药过程中患者体内蓄积,对临床用药的个体化有很重要的作用;表观分布容积(apparent volume of distribution, Vd)是用血药浓度来估计体内药量的一个比例常数,是一个独立参数: Vd=X0/C0 [6]。分布容积大,药物在体内排泄较慢,人体细胞外液体积约0.21 L/kg,人体总液量为0.6 L/kg。Vd值为0.14-0.29L/kg ,表明药物主要分布在细胞外液; Vd值为0.3-0.4L/kg,说明药物主要分布在细胞内; Vd值接近0.6 L/kg,说明药物分布在细胞内、外液;如果Vd值更大,则表明组织摄取多,血浆中的药物浓度较低[7,8]。本研究中ATG Vd值为0.11 L/kg,说明ATG药物体内分布主要在血浆和细胞外液,ATG不分布于疏水组织。研究结果认为,肥胖患者用ATG时应去除脂肪重量,避免由于按患者体重计算ATG量,导致较高的血浆浓度而产生过度免疫抑制[9]。 ( y$ v$ _" m% {* j6 @' W; y 9 Y# `) F" _# D1 g本研究结果表明,ATG为超长半衰期药物且疗效呈剂量依赖,提示应用ATG应防治移植后感染和早期复发;根据表观分布容积提示肥胖患者用ATG要防止其过量而产生过度免疫抑制。本研究中未出现严重不良事件,因此根据ATG安全耐受的结果及药代动力学特点,初步推荐ATG用在HLA配型部分相合的造血干细胞移植患者时,按10 mg/kg分次静脉输注是安全有效的。 ( B& H" U$ ?: w. ~3 J 【参考文献】 ' R2 D4 f' x, V9 K1Eiermann TH, Lambrecht P, Zander AR. Monitoring antithymocyte globulin (ATG) in bone marrow recipients. Bone Marrow Transplant, 1999;23:779-7811 D% m6 w9 |* k+ |- x6 [
: y% r$ h/ W% N' g+ N' z
8 o. R! [& U$ M Q. o. w& F* Z+ V$ m+ J 5 L. _6 v, H' l, s: ]/ F 2Bunn D, Lea CK, Bevan DJ, et al. The pharmacokinetics of antithymocyte globulin (ATG) following intravenous infusion in man. Clin Nephrol, 1996; 45: 29-32- d3 u" L7 ~* J" q1 ~; C
7 h( i( w# O# B {" q$ l6 W
7 a' R+ G7 @* s$ h8 | 3 m- @1 T# s, B1 C, C 3Bock HA, Gallati H, Zurcher RM, et al. A randomized prospective trial of prophylactic immunosuppression with ATGfresenius versus OKT3 after renal transplantation. Transplantation, 1995; 59:830-840/ z' C) l2 ~3 t% z$ L* ~3 m
% G3 R: A: z4 l; v! n
6 @. ]; D2 R3 @/ p1 k7 `
& n$ N7 V( n9 K4 v& F
4Guttmann RD, Caudrelier P, Alberici G, et al. Pharmacokinetics, foreign protein immune response, cytokine release and lymphocyte subsets in patients receiving thymoglobulin and immunosuppression. Transplant Proc, 1997; 29(7A):24S-26S : c1 ~0 ?7 L/ R8 t8 e+ n - V: E: ?+ E$ u* J' ^2 y + J) g# c# X: l) q8 U4 r+ ]0 ^2 n * z: e( X, z3 ~$ y 5Gaber AO, First MR, Tesi RJ, et al. Results of the doubleblind, randomized, multicenter, phase III clinical trial of Thymoglobulin versus Atgam in the treatment of acute rejection episodes after renal transplantation. Transplantation, 1998; 66:29-37 ) M4 s ~+ e" \( u: k3 B; c* o' Z ) ]$ c6 \; v% `- y0 Q# K: n9 _* h5 `
) h7 {2 w+ J5 ]" l* x( A
6Regan J, Campbell K, VanSmith L, et al. Characterization of antithymoglobulin, antiAtgam and antiOKT3 IgG antibodies in human serum with an 11min ELISA, Transpl Immunol,1997; 5:49-56* J& |+ J" T- \( `
* k4 R% ?# e) E& j$ f$ @3 R7 {4 V* @4 n" i2 e
7 w$ s1 f/ h4 Q. o# d 7Regan JF, Campbell K, VanSmith L, et al. Sensitization following Thymoglobulin and Atgam rejection therapy as determined with a ra pid enzymelinked immunosorbent assay. US Thymoglobulin MultiCenter Study Gruop. Transpl Immunol, 1999; 7:115-121# B. w$ y8 J# M& P" w1 X
; y0 b5 X2 s7 c; ~1 k0 Z) J/ p3 r9 P: e7 t
9 Q1 N. ^5 |' k% x 8Smith JM, Nemeth TL, McDonald RA. Current immunosuppressive agents in pediatric renal transplantation: efficacy, sideeffects and utilization. Pediatr Transplant, 2004; 8: 445-453 & F) b$ y% ?! C/ M7 e5 Y9 N 5 _$ S C1 K3 n$ w k; }. {; C: M8 g# d: X J) N
: L- H7 h4 I" U9 U6 h 9Seidel MG, Fritsch G, MatthesMartin S, et al. Antithymocyte glo bulin pharmacokinetics in pediatric patients after hematopoietic stem cell transplantation. J Pediatr Hematol Oncol, 2005; 27:532-536[]μβαγ ±SD作者: 张佳 时间: 2015-5-30 18:50