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Avoiding immune destruction
Evading growth suppressors
Sustaining proliferative signaling
The pleiotropic effects of mTor inhibitors.
mTOR is a downstream effector of phosphatidylinositol-3-kinase pathway, which is involved in the regulation of protein synthesis and interacts with cell cycle progression. Sirolimus and everolimus may interfere with mTOR activity after their binding with FK binding protein. These drugs may prevent rejection of organ transplants by inhibiting the proliferation signals provided by interleukins 2 and 15, so causing lymphocyte cycle arrest in the G1 phase. Experimental studies have also shown that some oncoproteins may derive either from an overactivity of phosphatidylinositol-3-kinase or from a loss of the tumor suppressor PTEN. As mTOR is an important mediator of the kinase cascade and may also be antiangiogenic, it has become an attractive target in some malignancies. In organ transplant recipients some retrospective studies have shown that patients treated with mTOR inhibitors for immunosuppression had a reduced incidence of neoplasia in comparison with patients treated with calcineurin inhibitors. mTOR is also involved in the replication of cytomegalovirus in the host cells, as it favors transcription and translation signals necessary for virus replication. Recent studies reported a very low incidence of cytomegalovirus infection in organ transplant patients treated wih either sirolimus or everolimus. Finally, mTOR inhibitors may offer vascular protection, as they mediate vascular endothelial growth factor. In cardiac transplants treated with everolimus, cyclosporine, and steroids the average increase in maximal intimal thickness and the incidence of vasculopathy were significantly lower than in patients treated with azathioprine, cyclosporine, and steroids.