Mycophenolic Acid and Its Metabolites in Kidney Transplant Recipients: A Semimechanistic Enterohepatic Circulation Model to Improve Estimating Exposure

Malek Okour, Pamala A. Jacobson, Mariam A. Ahmed, Ajay K. Israni, Richard C. Brundage

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Mycophenolic acid (MPA) is an approved immunosuppressive agent widely prescribed to prevent rejection after kidney transplantation. Wide between-subject variability (BSV) in MPA exposure exists which in part may be due to variability in enterohepatic recirculation (EHC). Several modeling strategies were developed to evaluate EHC as part of MPA pharmacokinetics, however mechanistic representation of EHC is limited. These models have not provided a satisfactory representation of the physiology of EHC in their modeling assumptions. The aim of this study was i) to develop an integrated model of MPA (total and unbound) and its metabolites (MPAG and acyl-MPAG) in kidney recipients, where this model provides a more physiological representation of EHC process, and ii) to evaluate the effect of donor and recipient clinical covariates and genotypes on MPA disposition. A five-compartment model with first-order input into an unbound MPA compartment connected to the MPAG, acyl-MPAG, and gallbladder compartment best fit the data. To represent the EHC process, the model was built based on the physiological concepts related to the hepatobiliary system and the gallbladder filling and emptying processes. The effect of cyclosporine versus tacrolimus on clearance of unbound MPA was included in the base model. Covariate analysis showed creatinine clearance to be significant on oral clearance of unbound MPA. The hepatic nuclear factor 1 alpha (HNF1A) genetic single nucleotide polymorphism (SNP) (rs2393791) in the recipient significantly affected the fraction of enterohepatically-circulated drug. Oral clearance of MPAG was affected by recipient IMPDH1 SNP (rs2288553), diabetes at the time of transplant, and donor sex.

Original languageEnglish (US)
Pages (from-to)628-639
Number of pages12
JournalJournal of Clinical Pharmacology
Issue number5
StatePublished - May 2018

Bibliographical note

Funding Information:
The study was supported by grants (U19-AI070119 and U01-AI058013) from the National Institute of Allergy and Infectious Disease (AM, PJ, AI, WO).

Funding Information:
The authors wish to thank the research participants for their participation in this study. We acknowledge the dedication and hard work of our coordinators at each of the pharmacokinetic sites: University of Minnesota, Jill Nagorski and Mandi DeGrote; Hennepin County Medical Center, Lisa Berndt; Mayo Clinic, Tom DeLeeuw; University of Alabama, Jacquelin Vaughn and Tena Hilario. We also acknowledge the dedicated work of research scientist Marcia Brott. This study was supported in part by NIH/NIAID grants 5U19-AI070119 and 5U01-AI058013.

Publisher Copyright:
© 2018, The American College of Clinical Pharmacology


  • enterohepatic circulation
  • kidney transplant
  • mycophenolic acid
  • pharmacokinetics


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