Review Article

Mammalian Target of Rapamycin Inhibitors and Wound Healing Complications in Kidney Transplantation: Old Myths and New Realities

Table 3

Summaries of randomized control trial performed on SRL.

ReferenceJournal/year/designInduction therapyArms comparedLoading dose used (yes/no)SRL dose and levelFinding

Groth et al. [108]Transplantation/1999/open label studyMethyl prednisolone1-SRL-AZA-Pred
2-CsA-AZA-Pred
Yes (loading dose 16–24 mg/m2/day for day 1, then 8–12 mg/m2/day for day 7–10)Trough level 30 ng/mL for first two months and 15 ng/mL thereafterWound infection in 10% of SRL-aza-Pred as compared to 5% CsA-aza-Pred
Kreis et al. [109]Transplantation/2000/open label study-----------------------------1-SRL-MMF-Pred
2-CsA-MMF-Pred
Yes (loading dose: 24 mg/m2 for three days)Trough levels were kept at 30 ng/mL for 2 months and 15 ng/mL afterwardWound infection in 5% of SRL-MMF-Pred as compared to 8% in CsA-MMF-Pred
Kahan [110]Lancet/2000/1-SRL-CsA-Pred (low dose)
2-srl-CsA-Pred (high dose)
3-aza-CsA-Pred
Yes (6 mg loading dose followed by 2 mg per day in low dose and 6 mg per day followed by 5 mg in high-dose group)-------------------------------------Lymphocele occurred in 12% low-dose SRL, 15% high-dose SRL, and 3% in AZA group
<0.001 for SRL
5 mg/d vs. AZA
Flechner et al. [111]Transplantation/2002/open label studyBasiliximab 2 doses1-SRL-MMF-Pred
2-CsA-MMF-Pred
Yes (loading dose 15 mg)Trough 10–12 ng/mL for 6 months and 5–10 ng/mL afterwardWound infection happened in 6.5% of SRL-MMF-Pred as compared to 3.3% in CsA-MMF-Pred lymphocele was reported in 9.7% of SRL-MMF-Pred and 3.3% of CsA-MMF-Pred
Dean et al. [8]Transplantation/2004/open label studyATG1-SRL-MMF-Pred
2-TAC-MMF-Pred
Yes (loading dose 10 mg/d for 2 days)Trough level 15–20 ng/mL for 4 months and 10–15 ng/mL thereafter; reduced to 10–15 ng/mL
throughout after recruitment of first 77 patients
Wound healing complication was found in 47% in SRL-mm-Pred as compared to 8% in TAC-MMF-Pred
Machado et al. [113]Clin Transplant/2004/open label study---------------------------------1-SRL-reduced CsA-Pred
2-aza-CsA-Pred
Yes (loading 6 mg was given)Maintain at 2 mg/dayWound related complications happened in 40% of SRL-reduced CsA-Pred as compared to 20% of AZA-CsA-Predp = 0.117S
Lo et al. [114]Transplantation/2004ATG and corticosteroids administered in both groups1-TAC sparing regimen: standard SRL + reduced TAC
2-TAC-free regimen: full-dose SRL + MMF
Yes (SRL 10 mg loading dose was given after 48 hours for 2 days)SRL (C0, 10–15 ng/mL) + reduced
SRL full-dose (C0, 12–15 ng/mL)
Wound complication occurred in 17% of the subjects in the TAC sparing group and in 7% of the subjects in the TAC-free group (=NS). The incidence of lymphocele or fluid collections was 20% in the CI-sparing and 10% in the CI-free group (=NS)
Ciancio et al. [115]Transplantation/2004/open label studyDaclizumab and methyl prednisolone1-SRL-TAC-Pred
2-SRL-CsA-Pred
3-TAC-MMF-Pred
Yes (A SRL loading dose of 4 mg was given to both groups on SRL on evening of the surgery followed by maintenance)C0 = 8 ng/mL
C0 = 8 ng/ml
Wound complication 6%, lymphocele 16%
Wound complication 4%, lymphocele 14%
Wound complication 4%, lymphocele 6%
 = 0.27
Kandaswamy et al. [116]Am J transplant/2005/open labelATG is followed by1-CsA-MMF
2-high-dose TAC, low-dose SRLv3-low-dose TAC-high-dose SRL
Loading dose was given before December 1, 2002
No loading dose was given after December 1, 2002
C0 = 7 ng/mlc0 = 8–12 ng/mLWound healing complications were 8%, 18%, and 25% in CsA-MMF, low-dose SRL, and high-dose SRL, P = 0.02
Wound healing complications reduced to 5%, 11%, and 20% in CsA-MMF, low-dose SRL, and high-dose SRL, P = 0.3 after stopping loading dose after December 1, 2002
Hamdy et al. [117]Am J Trans /2005/open label studyBasiliximab1-SRL (standard dose)-TAC-Pred
2-srl (full dose)-MMF-Pred
Yes
Group 1: full dose of 10 mg/day orally (single morning dose) for 3 days and then maintained at 5 mg/day
Group 2: a single oral morning dose of 10 mg/day
SRL (C0, 6–12 ng/mL)
SRL (C0, 10–15 ng/mL)
There were 7 wound complications, 4 lymphoceles, and 1 urinary fistula in TAC sparing regimen. There were 11 wound complications, 7 lymphoceles, and 2 urinary fistulas in TAC-free regimen. Surgical complications between two groups were not significant ( = 0.127)
Larson et al. [118]Am J Transplant/2006/open label studyATG/methyl prednisolone1-SRL-MMF-Pred
2-TaC-MMF-Pred
Yes (SRL was initially dosed at 10 mg daily for 2 d and 5 mg daily thereafter)SRL C0 were kept 15–20 ng/mL in the first 4 months and 10–15 ng/mL thereafter18 patients in SRL group discontinued SRL because of wound healing complications
Vitko et al. [11]Am J Transplant/2006/open label studyNo induction therapy1-SRL-TAC-Pred
2-SRL-TAC-Pred
3-MMF-tacrolmus-Pred
Yes
1-SRL-TAC-Pred: loading dose 1.5 mg, then maintenance 0.5 mg per day
2-SRL-TAC-Pred loading dose 6 mg, then 2 mg per day
Median C0 levels in the TAC‐SRL0.5 mg group were 0.95 ng/mL during week 1, 1.46 ng/mL at month 3, and 1.43 ng/mL from 4 to 6 months
Median C0 level TAC-SRL 2 mg group was 2.71 ng/mL during week 1, 4.57 ng/mL at month 3, and 4.75 ng/mL between months 4 and 6
Low SRL group has lymphocele in 4.3% as compared to 8.6% in high SRL group.
 = 0.022
Martinez-Mier et al. [119]Transplantation/2006/open label RCT studyBasiliximab1-SRL-MMF-Pred
2-CsA-MMF-Pred
Yes (10 mg loading dose followed by 3 mg/m body surface area/day)24 hr trough levels were kept at 10–15 ng/mL for six months and 5–10 ng/mL afterwardWound infection occurred in 15% in SRL-MMF-Pred group as compared to 9.5%
Ekberg et al. [1]N Eng J Med/2007/open label RCT studyDaclizumab1-standard-dose CsA-MMF-Pred
2-low-dose CsA-MMF- Pred
3-low-dose TAC-MMF-Pred
4-low-dose SRL
Yes (oral SRL at a dose of 9 mg per day for 3 days and 3 mg per day to aim for target level C0 = 4 to 8 ng/mLl)C0 = 4 to 8 ng/mLThe incidence of lymphocele was double in low-dose SRL as compared to other groups which was high ( < 0.001).
The incidence of delayed wound healing was also significantly high in low-dose SRL as compared to other  = 0.006
Büchler et al. [15]Am J Transplant/2007/open label RCT studyAntilymphocyte antibodies1-SRL-MMF-Pred
2-CsA-MMF-Pred
Yes (loading dose 15 mg for 2 days, then 10 mg for 1 day)C0 = 10–15 ng/mL-Hernia/evisceration occurred in 9.9% vs. 0% in SRL group and CsA group comparatively (=0.006)
Lymphocele occurred in 11.3 and 5.4%, respectively, between two groups but were not significant
Pescovitz et al. [120]Br J Clin Pharmacol/2007/open label RCT studyDaclizumab1-SRL-MMF-Pred
2-CsA-MMF-Pred
NoC0 = 10–25 ng/m L for first 2 months posttransplant, and 8–15 ng/mL afterwardIncision site complications were 40% and 20%, respectively
Gaber et al. [121]Transplantation/2008/open label RCT study1-SRL-TAC-Pred
2-SRL-CsA-Pred
Yes (SRL 10 mg loading dose for first two days and then 5 mg once daily were given in both groups)C0 = 10–25 ng/m LDelayed wound healing between two groups (SRL-TAC-Pred 13.4% vs. SRL-CsA-Pred 16.5%) was not significant
Lymphocele occurred significantly more in SRL-CsA-Pred (27.2% vs. 18.8%) in SRL-TAC-Pred group (P0.043)
Durrbach et al. [12]Transplantation/2008/open label RCT studyATG1-SRL-MMF-Pred
2-CsA-MMF-Pred
Yes (loading dose of 30 mg for two days)C0 = 10–20 ng/m LLymphocele occurred in 24.2% vs. 2% of the cases between the two groups,  = 0.04%
Sampaio et al. [122]Clin Transplant/2008/open label RCT studyNo induction1-SRL-TAC-Pred
2-MMF-TAC-Pred
Yes (loading dose 15 mg, then 5 mg per day for 7 days and then 2 mg per day continued)-------------------Wound healing complications occurred in 34% in SRL group as compared to 10% in MMF group ( = 0.007)
Franz et al. [7]Am J Kidney Dis/2010/open label RCT study--------------------1-SRL-MMF-Pred
2-CsA-MMF-Pred
Yes (30 mg for 3 doses)C0 = 10–20 ng/mL for 3 months and then 8–15 ng/mL afterwardImpaired wound healing occurred in 3.2% of SRL group as compared to 1.6% in CsA group
Lymphocele occurred in 14.3% of SRL group as compared to 3.1% in CsA group
 = 0.03
Glotz et al. [123]Transplantation/2010/open label RCT studyATG1-SRL-MMF-Pred
2-TAC-MMF-prd
Yes (15 mg for two days and then 10 mg for 5 days)C0 = 10–20 ng/m LImpaired wound healing occurred in 11.3% vs. 0 %
 = 0.006
Ekberg et al. [124]Nephrol Dial Transplant/2010/open label RCT studyDaclizumab1-standard-dose CsA-MMF-Pred
2-low-dose CsA-MMF-Pred
3-low-dose TAC-MMF-Pred
4-low-dose SRL
NoC0 = 4 to 8 ng/mLWound healing complications occurred in 11%, 11%, 9%, and 17%, respectively, in each group and was significantly higher across the group (=0.006)
Lymphocele occurred in 7%, 6.8%, 9%, and 15.8%, respectively and = <0.001 across groups for lymphocele formation
Flechner [16]Am J Transplant/2011/open label RCT studyDaclizumab1-SRL-TAC for 3 months-Pred
2-srl-MMF-Pred
2-MMF-TAC-Pred
Yes (loading dose of 15 mg given to both SRL groups)C0 = 8–15 ng/mL for 3 months and then 10–20 ng/mL afterward in SRL-TAC-MMF group
C0 = 10–15 ng/mL for 3 months, then 8–15 ng/mL for 3–6 months and then 5–15 ng/mL afterward
Delayed wound healing occurred in 16.4% in SRL-TAC-Pred, 23% in SRL-MMF-Pred, and 5.8% in MMF-TAC-Pred.
 < 0.01 for delayed wound healing for SRL-TAC-Pred as compared to MMF-TAC-Pred
Lymphocele occurred in 16.4% in SRL-TAC-Pred, 18.4% in SRL-MMF-Pred, and 8.6% MMF-TAC-Pred
de sandes freitas et al. [125]Int Urol Nephrol/2011/open label RCT studyNo induction1-TAC-SRL
2-SRL-Pred
------------------------------------Higher incidence of lymphocele or lymphorrhea was observed in TAC-SRL group as compared to SRL-Pred (13 vs. 4.1%)
Flechner [126]Transplantation/2013/open label RCT studyIL-2 receptor antagonist1-SRL-MMF-Pred
2-CsA-MMF-Pred
Yes (initially 10 to 15 mg SRL oral loading dose within 2 days, 4 to 8 mg daily)
Amendment was done and SRL group received two 15 mg oral loading doses within for 2 days followed by 10 mg daily to achieve C0 = 10.0 ng/mL or more
C0 = day 1 to week 13, 10–15 ng/mL; weeks 14–26, 8–12 ng/mL; weeks 27–104, 5–12 ng/mL.
After amendment C0 = day 1 to week 26, 10–15 ng/mL; weeks 27–104, 8–15 ng/mL.
15.2% of SRL and 8.2% of CSA had wound healing complication,  = 0.033
Huh et al. [127]Nephrol Dial Transplant/2017/open label RCT studyBasiliximab1-ER-TAC-MMF
2-ER-TAC-SRL
No2 mg of SRL was given within 24 hours of transplant,
C0 = 3–5 ng/mL.
SRL group has 10.5% wound healing complications as compared to 2.7% in MMF group, but P value = 0.10 was not significant
Risk of lymphocele was 0% in SRL group and 1.3% in MMF (P = 0.10)