Beneficial Effects of the Bioflavonoids Curcumin and Quercetin on Early Function in Cadaveric Renal Transplantation : A Randomized Placebo Controlled Trial

Beneficial Effects of the Bioflavonoids Curcumin and
Quercetin on Early Function in Cadaveric Renal
Transplantation: A Randomized Placebo
Controlled Trial
Daniel Shoskes, Chantale Lapierre, Marcia Cruz-Corerra, Nicolas Muruve, Reinaldo Rosario,
Beth Fromkin, Mauro Braun, and John Copley
Background. The bioflavonoids quercetin and curcumin are renoprotective natural antioxidants. We wished to exam-
ine their effects on early graft function (EF).
Methods. Between September 2002 and August 2004, 43 dialysis dependent cadaveric kidney recipients were enrolled
into a study using Oxy-Q which contains 480 mg of curcumin and 20 mg of quercetin, started after surgery and taken
for 1 month. They were randomized into three groups: control (placebo), low dose (one capsule, one placebo) and high
dose (two capsules). Delayed graft function (DGF) was defined as first week dialysis need and slow function (SGF) as Cr
?2.5 mg/dl by day 10. Category variables were compared by chi squared and continuous variables by Kruskal-Wallis.
Results. There were four withdrawals: one by patient choice and three for urine leak. The control group had 2/14
patients with DGF vs. none in either treatment group. Incidence of EF was control 43%, low dose 71% and high dose
93% (P?0.013). Serum creatinine was significantly lower at 2 days (control 7.6?2.1, low 5.4?0.6, high 3.96?.35
P?0.0001) and 30 days (control 1.82?.16, low 1.65?.09, high 1.33 ?.1, P?0.03). Acute rejection incidence within 6
months was control 14.3%, low dose 14.3% and high dose 0%. Tremor was detected in 13% of high dose patients vs.
46% of others. Urinary HO-1 was higher in bioflavonoid groups.
Conclusion. Bioflavonoid therapy improved early graft function. Acute rejection and neurotoxicity were lowest in the high
dose group. These bioflavonoids improve early outcomes in cadaveric renal transplantation, possibly through HO-1 induc-
tion.
Keywords: Clinical transplantation, Immunosuppression, Kidney.
(Transplantation 2005;80: 1556–1559)
Delayedgraftfunction(DGF)isacommonoccurrencein vonoidsonIRinjury,DGF,acuterejectionanddrugtoxicities
cadaveric renal transplantation that has been linked to
in the early posttransplant period in a randomized, placebo con-
increased rates of acute rejection and reduced graft survival
trolled study, in patients treated concomitantly with MMF.
(1). The primary mechanism is ischemia-reperfusion (IR) in-
jury; however, other factors such as alloimmunity and brain
death triggered tissue inflammation have also been impli-
MATERIALS AND METHODS
cated (2). Although there have been a succession of agents that
Between September 2002 and August 2004, 43 dialysis
can effectively ameliorate IR injury in rodent models, none has
dependent primary recipients of cadaveric kidneys were en-
yet proven effective in clinical transplantation.
rolled into this randomized placebo controlled study after
The bioflavonoids curcumin and quercetin are natu-
appropriate informed consent for this IRB approved proto-
rally occurring polyphenolic compounds with several docu-
col. During this period, 45 cadaveric transplants were per-
mented effects that might be beneficial in early posttransplant
formed. As in our open label study (5), we used the biofla-
injury. We have shown that quercetin and curcumin reduce
vonoid preparation Oxy-Q (Farr Labs, Santa Monica, CA)
IR injury in the rat (3) and reduce both IR injury and rejection
which contains 480 mg of curcumin and 20 mg of quercetin,
synergistically with mycophenolate mofetil (MMF) (4). Finally,
a ratio similar to what we found most beneficial in our rodent
in a phase I open label study, administration of curcumin and
experiments (3). Patients were randomized in a blinded fash-
quercetin to renal transplant recipients was associated with no
ion to receive either the Oxy-Q or placebo according to the
side effects, improvement in early renal function and a surpris-
following schedule: control: one placebo capsule twice a day;
ing decrease in drug induced tremor (5).
low dose: one Oxy-Q in the morning and one placebo in the
We therefore wished to study the effect of these biofla-
evening; high dose: one Oxy-Q capsule twice a day. Treat-
ment was started within 24 hr of surgery and continued for 1
Department of Kidney Transplantation, Cleveland Clinic Florida, Weston,
month. Immunosuppression included daclizumab (1 mg/kg
FL.
on day 0, 7, and every 2 weeks for five total doses), tacrolimus
Address correspondence to: Daniel Shoskes, M.D., Glickman Urologic Insti-
(adjusted to trough levels), mycophenolate mofetil (1 g twice
tute, Cleveland Clinic, Desk A100, 9500 Euclid Ave., Cleveland, OH
44195.
daily) and steroids on a tapering schedule. High immuno-
E-mail: dshoskes@mac.com
logic risk patients and those who developed DGF received
Received 11 January 2005. Revision requested 2 February 2005.
thymoglobulin (1–1.5 mg/k per day) instead of daclizumab.
Accepted 2 April 2005.
Cause of donor death was not recorded.
Copyright © 2005 by Lippincott Williams & Wilkins
DGF was defined as dialysis need in the first week, slow
ISSN 0041-1337/05/8011-1556
DOI: 10.1097/01.tp.0000183290.64309.21
function (SGF) as failure of creatinine (Cr) to drop within the
1556
Transplantation • Volume 80, Number 11, December 15, 2005

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© 2005 Lippincott Williams & Wilkins
Shoske et al.
1557
first 48 hr and/or Cr?2.5 mg/dl by day 10 and early function
surgical repair. All withdrawals were between postoperative
(EF) as the rest. Standard laboratory work was collected on all
day 2 and 10, therefore data on early function was on an
patients including serum creatinine and tacrolimus trough
intent-to-treat basis and later mean creatinine values were per
levels. Urine was collected from the Foley bag or as a mid-
protocol.
stream urine on days 2, 14 and 30. Patients had a protocol
In terms of early functioning of the grafts, the control
biopsy at 1 month and all presumed acute rejection episodes
group had 2/15 patients with DGF compared with none in
in the first 6 months were biopsy proven. Patients were asked
either treatment group. We then compared EF kidneys
specifically about noticeable tremor and also examined for
against those with DGF or SGF, since SGF has been shown to
tremor in the clinic on days 14 and 30.
have a deleterious impact on graft survival and increased risk
HO-1 was measured using the Stress XPress Human
of acute rejection similar to that seen with DGF (6). EF was
HO-1 ELISA kit from Stressgen (Vancouver, Canada). The
seen in 6 of 14 (43%) of controls, 10 of 14 (71%) of low dose
HO-1 was extracted from the pellet obtained after the centrif-
and 13 of 14 (93%) of the high dose group (P?0.013). As seen
ugation of 3 ml of urine. The extraction and immunoassay
in Figure 1, serum creatinine was lower at every time point in
were performed following the manufacturer’s instructions.
patients treated with the bioflavonoids. Median serum Cr was
Lipoxin A4 and 15-epi-lipoxin A4 was also measured by
significantly lower at 2 days (control 7.65 mg/dl, range 4.7–
ELISA. Prior to performing the immunoassay, 5 ml of centri-
11.4, low dose 5.85, 1.4 –9.3, high dose 4.15, 1.6 –5.7;
fuged recipient urine was acidified with 1N HCl and applied
P?0.0002) and 30 days (control 1.6 mg/dl, 1.2–3.0, low dose
to a preconditioned C18 column (JTBaker, Phillipsburg, NJ).
1.65, 1.0 –2.3, high dose 1.2, 0.9 –2.2; P?0.026). Incidence of
The column was then washed with water and petroleum
acute rejection within 6 months (including protocol biopsy)
ether. The Lipoxin A4 and 15-epi-lipoxin A4 were eluted with
was 2 of 14 control (14.3%), 2 of 14 low dose 14.3% and 0 high
methyl formate. After evaporation of the methyl formate the
dose. Both rejections in the control group were Banff IIb,
samples were resuspended in 250 ?l of Extraction Buffer
while the two rejections in the low dose group were Ia (as well
(supplied with the kit). To measure the concentrations of
as being subclinical) and Ib. Tacrolimus associated tremor
lipoxin A4 and 15-epi-lipoxin A4 we used enzyme immuno-
was detected on physical examination on day 30 in 2 high
assay kits from Neogen Corporation (Lexington, KY), 50 ?l
dose patients (13%) vs. 18 of 40 (45%) of the rest. It was
of extracted samples was assayed in duplicate according to the
mentioned as a problem by patients in 7% of the high dose
manufacturer’s instructions.
group (1 patient) vs. 10.3% of the rest.
Category variables were compared by chi squared and
Because there were more men in the control group, we
continuous variables by the Kruskal-Wallis test. Other possi-
performed a variance weighted least square regression to in-
ble covariates for confounders were sought using the vari-
sure that the lower creatinines in the bioflavonoid groups was
ance-weighted least square regression model. Level of signif-
not due to having lower creatinine in females. For baseline
icance was taken at P?0.05. Sample size calculation was based
characteristics, sex was not a cofounder between the groups
upon primary endpoints of early function and day 30 creati-
(P?0.642). For serum creatinine, use of Oxy-Q was signifi-
nine with an estimated power of 80% to detect a 20% differ-
cantly associated with decrease serum creatinine at 2 days
ence, with a target of 40 patients, given the standard devia-
(both high and low dose vs. placebo, P?0.0001) and at 30
tions calculated in our open label study.
days (high dose vs. placebo, P?0.022) and this effect was
independent of sex, although women were also indepen-
RESULTS
dently associated with lower creatinine levels on 30-days as
As seen in Table 1, the three treatment groups were well
compared to men.
matched by age, cold ischemia time, timing of pulsatile per-
Activity of HO-1 in the urine was measured in the early
fusion, HLA mismatches and proportion of highly sensitized
postoperative period. As seen in Figure 2, there was a stepwise
(PRA?80%) patients. The only difference was the control
dose response progression of increasing HO-1 activity from
group having a higher proportion of men (71%). There were
control to low dose to high dose groups at all days measured
four withdrawals: one by patient choice and three for urine
(P?0.046), with pairwise significance in the control vs. high
leak (data prior to withdrawal was included). One urine leak
dose comparison (P?0.04). Similarly, as seen in Figure 3,
was in the low-dose group and two were in the high-dose
there was lowest HO-1 activity in the 2 patients with DGF,
group, although one of these was due to a technical stent
intermediate activity in the patients with SGF and highest
problem and no ureteral ischemia was seen at the time of
activity in the EF group (P?0.006), with pairwise significance
TABLE 1.
Demographic and Transplant Variables by Treatment Groups
Variable
Control
Low dose
High dose
N
15
14
14
Age, median (range)
44 (19–74)
52.5 (20–74)
46 (33–71)
Male (%)
71
50
50
HLA match
2.9
2.8
2.4
PRA?80% (%)
6.70
7.10
14.3
?12 hours before pulsatile perfusion (%)
27.0
50.0
35.7
Cold ischemia time, median hours (range)
28 (15–38)
33.5 (22–45)
29 (22–45)
Thymoglobulin induction (%)
33.30
28.60
14.30

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Transplantation • Volume 80, Number 11, December 15, 2005
FIGURE 1.
Renal function following renal transplant by
FIGURE 3.
Hemoxygenase 1 levels in urine of renal trans-
treatment group. *P?0.05; **P?0.001.
plant recipients by early function. HO-1, hemoxygenase 1.
unexplained elevation of liver function tests. In the control
group, one patient had a new onset of a seizure disorder and
another patient had a prolonged ileus.
DISCUSSION
The deleterious effects of DGF (7) and SGF (6) on short
and long term graft function, especially when associated with
acute rejection, are well described. Multiple therapeutic inter-
ventions are successful in reversing acute ischemic injury in
rodent models but that success has not yet translated into
clinically effective therapies (8, 9). The failure of therapies
targeted to a specific pathway in the IR cascade likely stems
from the multifactorial nature of DGF including both anti-
gen-dependent and -independent mechanisms as well as the
fact that much of the injury leading to DGF may begin at the
onset of brain death prior to organ procurement (10).
The bioflavonoids quercetin and curcumin have mul-
tiple effects that should theoretically be of benefit in IR and
immune mediated injury. They are antioxidants that inhibit
xanthine oxide (11) and scavenge free radicals (12). They re-
duce pro-inflammatory cytokines through blockade of
NF-kB (13) and induction of the hemoxygenase-1 (HO-1)
enzyme (14). They are renoprotective in several models of
rodent ischemic and toxic injury (15). We have shown that
quercetin and curcumin prevent renal injury in rodent mod-
FIGURE 2.
Hemoxygenase 1 levels in urine of renal trans-
els of IR (3) and ureteral obstruction (16). Furthermore, these
plant recipients by treatment group. HO-1, hemoxygenase 1.
bioflavonoids were synergistic with MMF in reducing isch-
emic injury as well as acute rejection (17). Alloimmune re-
for EF vs. SGF (P?0.05) and EF vs. DGF (P?0.02). Total anti-
sponses may be inhibited by bioflavonoids through blockade
oxidant capacity, lipoxin A4 and 15-epi lipoxin A4 were also
of cell mediated cytotoxicity (14) and T cell activation (13).
measured, however results were statistically and clinically equiv-
These findings led to an open label phase I study of quercetin
alent in all treatment and outcome groups (data not shown).
and curcumin in renal transplant recipients (5). We found
The medication was well tolerated with minimal side
that it was well tolerated, did not effect cyclosporine or ta-
effects. One patient in the high dose group had a transient
crolimus levels, had no deleterious effects in patients with

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© 2005 Lippincott Williams & Wilkins
Shoske et al.
1559
good graft function and showed improvement in graft func-
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