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Effect of protein binding on exposure of unbound and total mycophenolic acid: a population pharmacokinetic analysis in Chinese adult kidney transplant recipients

AIMS A population pharmacokinetic (PK) analysis was performed to: (1) characterise the PK of unbound and total mycophenolic acid (MPA) and its 7-O-mycophenolic acid glucuronide (MPAG) metabolite, and (2) identify the clinically significant covariates that cause variability in the dose-exposure relationship to facilitate dose optimisation. METHODS A total of 740 unbound MPA (uMPA), 741 total MPA (tMPA) and 734 total MPAG (tMPAG) concentration-time data from 58 Chinese kidney transplant patients were analysed using a nonlinear mixed-effect model. The influence of covariates was tested using a stepwise procedure. RESULTS The PK of unbound MPA and MPAG were characterised by a two- and one-compartment model with first-order elimination, respectively. Apparent clearance of uMPA (CLuMPA/F) was estimated to be 852 L/h with a relative standard error (RSE) of 7.1%. The tMPA and uMPA were connected using a linear protein binding model, in which the protein binding rate constant (kB) increased non-linearly with the serum albumin (ALB) concentration. The estimated kB was 53.4 /h (RSE, 2.3%) for patients with ALB of 40 g/L. In addition, model-based simulation showed that changes in ALB substantially affected tMPA but not uMPA exposure. CONCLUSIONS The established model adequately described the population PK characteristics of the uMPA, tMPA, and MPAG. The estimated CLuMPA/F and unbound fraction of MPA (FUMPA) in Chinese kidney transplant recipients were comparable to those published previously in Caucasians. We recommend monitoring uMPA instead of tMPA to optimise mycophenolate mofetil (MMF) dosing for patients with lower ALB levels.