Does Amiodarone Influence Early Mortality in Heart Transplantation?

The use of amiodarone before transplantation has been linked to an increased number of complications, acute graft failures, and early mortality after a heart graft. We undertook a retrospective, descriptive, case-controlled study involving early mortality and acute graft failure. The 396 consecutive patients included 25 subjects who had been prescribed amiodarone for at least 30 days before transplantation. We excluded retransplantations, pediatric transplantations, and combined transplantations. The endpoints were early mortality and acute graft failure. No significant differences were observed in early mortality and acute graft failures. The multivariate analysis did not reveal any variable that correlated with early mortality. Our study did not support the idea that amiodarone constituted a negative predictor of early survival or acute graft failure.

Induction Therapy With Daclizumab in Heart Transplantation—How Many Doses?

Since their introduction onto the market, interleukin-2 antagonists have been increasingly used by a growing number of transplant units. Their benefits versus OKT3 appear evident, although the optimal dose remains to be established. Our objective was to establish possible differences related to the use of two versus five doses of daclizumab.

MATERIALS AND METHODS

This study evaluated 81 consecutive patients treated with two bolus doses of daclizumab (1 mg/kg) on days 1 and 14 posttransplantation. We excluded retransplantations, pediatric transplantations, and combined transplantations. We compared our series to a previous trial involving the administration of a single bolus dose every 14 days (five boluses in total). Study variables included the number of graft rejections, the number of infections, and the mortality. Statistical analysis was performed using the chi square and Student's t tests. Significance was set at P < .05.

RESULTS

There were no differences between groups in the baseline characteristics of the patients. The number of rejection episodes during the first year was significantly lower among the patients in our series treated with two bolus doses of daclizumab than in the series of patients treated with five bolus doses: 24 (30%) vs 17 (61%) episodes (P = .003). No significant differences were observed for mortality: the group receiving two boluses registered 10 deaths (12%) versus two (7%) in the group receiving five boluses (P = .4), or infection rate: 11 patients (40%) in the group receiving five bolus versus 31 patients (38%) in the group given two bolus doses (P = .9).

CONCLUSIONS

Our results suggested that induction therapy with two doses of daclizumab was at least as effective in preventing rejection as five doses, with no negative effects on patient survival.

Influence of Immunosuppression Regimen on Heart Transplantation Survival

OBJECTIVE

To perform an analysis comparing long-term survival in heart transplant (HT) patients depending on the immunosuppressive regimen.

MATERIALS AND METHODS

The study included 317 consecutive HT patients. We excluded pediatric cases, retransplants, combined transplants (lung and kidney), and immunosuppressive regimens with fewer than 10 cases. The six groups analyzed were: (1) OKT3 7 days + cyclosporine (CsA) + mycophenolate mofetil (MMF) + steroids (S); (2) OKT3 7 days + CsA + azathioprine (AZA) + S; (3) OKT3 10 days + CsA + MMF + S; (4) OKT3 10 days + CsA + AZA + S; (5) interleukin-2 (IL-2) antagonists + CsA + MMF + S; and (6) IL-2 antagonists + tacrolimus + MMF + S. Probability of survival was analyzed by Kaplan-Meier and log-rank methods.

RESULTS

The groups were heterogeneous regarding the number of patients and follow-up. The baseline characteristics were similar, although there were differences in surgery times. The survivals by groups at the end of the follow-up period were: group 1: 75.8%; group 2: 51.2%; group 3: 63.6%; group 4: 25.3%; group 5: 91.2%; and group 6: 84.6%. A major reduction in survival was observed in the groups that were given induction with OKT3 monoclonal antibodies (groups 1, 2, 3, and 4), particularly when AZA was combined in the maintenance phase (groups 2 and 4) and when the induction dose was high (10-day therapy in groups 3 and 4).

CONCLUSIONS

Our study suggested an association between the immunosuppressive regimen and the long-term survival of HT patients. The best results were obtained with an induction regimen based on IL-2 antagonists. On the basis of the survivals observed in this study, the maintenance combination we regard as "optimal" at this time is based on a combination of CsA, MMF, and steroids.

Circulating activated protein C is reduced in young survivors of myocardial infarction and inversely correlates with the severity of coronary lesions

BACKGROUND

Cardiovascular risk factors for myocardial infarction (MI) are less frequent in younger than in older MI survivors. Therefore, the thrombotic component of MI may play a more important role at a young age. As activated protein C (APC) provides systemic anticoagulant and anti-inflammatory protection, a low plasma APC level may be an arterial thrombotic risk factor.

AIM

To determine whether there is an association between reduced APC levels and early MI and severe coronary lesions.

METHODS

APC was measured in 231 young MI survivors and 231 controls.

RESULTS

Low APC levels were significantly associated with MI. Compared with the fourth quartile, the odds ratio (OR) for APC values in the first quartile was 3.7 [95% confidence interval (CI) = 2.1-6.4], and 3.2 (1.5-7.0) after adjustment for cardiovascular risk factors. Moreover, each decrease of 0.43 ng mL(-1) (1 SD) in APC increased the OR 1.7 times (1.4-2.2), and 1.5 times (1.2-1.9) after adjustment for cardiovascular risk factors. Low APC levels were also associated with the number of coronary arteries affected and with the severity of coronary lesions (P < 0.001).

CONCLUSIONS

There is a significant association between low circulating APC levels and both early MI and the extent and severity of coronary atherosclerosis, which might be related to the anticoagulant and anti-inflammatory properties of APC.

Aromatase expression in endometriotic tissues and cell cultures of patients with endometriosis

Cytochrome P-450 aromatase is responsible for catalysing the conversion of androstendione into estrone, so its expression in endometriotic tissue could contribute to the development of endometriosis. The aims of this study were, on the one hand, to determine the presence of aromatase in eutopic and ectopic endometrium, healthy peritoneum, myometrium and leiomyomas from patients with (n = 61) and without endometriosis (n = 12) and, on the other hand, to determine the effect of peritoneal fluid (PF), interleukin-6 (IL-6) and tumour necrosis factor-alpha (TNFalpha) on aromatase activity from endometriotic stromal cells and subcutaneous adipocytes. After immunohistochemical analysis, aromatase expression was detected in the endometriotic tissue of 61% of patients, whereas the rest of the tissues, as well as those from disease-free women, were negative. Cell cultures were made to determine aromatase activity in endometriotic stromal cells and adipocytes. The addition of PF, TNFalpha and especially IL-6 (P < 0.05) stimulated the basal enzymatic activity observed in both cell types. Our findings confirm the presence of aromatase in endometriosis and probably the existence of a local estrogen production that may be stimulated by some factors such as cytokines present in the PF of these patients. Therefore, the use of aromatase inhibitors combined with immunomodulator agents could be a novel approach to be investigated in future clinical trials.

Influence of Induction Therapy on Rejection and Survival in Heart Transplantation

BACKGROUND AND AIMS

Immunosuppressive therapy has undergone great changes in recent years as a result of the introduction of new drugs, presumed a prior to be more effective and better tolerated. The greatest advance seems to have been the introduction of interleukin-2 (IL-2) receptor antagonists. The objective of this study was to determine whether the use of IL-2 receptor antagonists in induction therapy has implications for the development of rejection and survival.

MATERIALS AND METHODS

Three hundred sixty-five consecutive cardiac transplant patients who received induction therapy were included. Heart-lung and transplants in children under 10 years were excluded. Three groups were compared according to the induction therapy (OKT3, 10 days; OKT3, 7 days; and IL-2R antagonists). Each treatment corresponded to a time period: OKT3 10 days from June 1989 to April 1994; OKT3 7 days from May 1994 to October 2002; and IL-2R antagonists from November 2002 to May 2004. Baseline characteristics of recipient and donor, surgical times, postsurgical complications, maintenance immunosuppression, number of rejections, time (days) to first rejection, and probability of survival at 1 year were recorded. We used analysis of variance, chi(2) test, Kaplan-Meier curves, and log-rank test as appropriate. A P-value < .05 was considered significant.

RESULTS

There were significant differences in the characteristics of the transplanted patients in the various time periods. Thus, recipients in the OKT3 10 day group had worse status but better donors, whereas recipients in the IL-2R antagonists group had better status but older donors with longer duration of ischemia. The incidence of acute graft failure was similar in the three groups. The number of rejection episodes in the first year was higher among the OKT3 groups (OKT3 10 days, 1.7 +/- 1.3; OKT3 7 days, 1.2 +/- 1.2; IL-2R antagonists, 1.0 +/- 1.2; P = .02) and the probability of survival at 1 year was also lower (OKT3 10 days, 74%; OKT3 7 days, 77%; IL-2R antagonists, 94%; P = .0007).

CONCLUSIONS

Induction therapy with IL-2 antagonists offers important advantages over treatment with OKT3 in terms of survival, with absolute and relative risk reductions of 20% and 27%. Furthermore, it did not increase the number of rejections, although this may have been due to the greater use of MMF versus azathioprine.

Predictive Factors for Development of Diabetes Mellitus Post-Heart Transplant

INTRODUCTION

It is known that there is a high incidence of diabetes mellitus (DM) among heart transplant (HT) patients, which may be up to 30% at 5 years. The presence of DM has been associated with increased morbidity (infections, renal dysfunction, or graft vascular disease), and its development has been related primarily to immunosuppressive therapy. The objective of this study was to determine, in our experience, the presence of predictive variables for the development of DM following HT.

METHODS

We studied 315 consecutive non-DM patients (88.6% men, mean age 51.5 years) who underwent HT in our hospital from November 1987 to May 2003, analyzing all variables that could be related to the development of DM during follow-up. Student t-test and chi(2) test were used for univariate statistical analysis and logistic regression for multivariate analysis.

RESULTS

Of the 315 patients, 64 developed DM (20.3%) during a mean follow-up of 3.3 years. The univariate analysis showed that patients developing DM are older (54.9 +/- 8.7 versus 50.7 +/- 11.8 years, P = .008), have a higher body mass index (BMI) (27.3 +/- 3.8 versus 25.7 +/- 3.7, P = .003), a higher prevalence of HT (37.5% versus 23.5%, P = .023), a lower frequency of urgent HT (9.4% versus 26.2%, P = .004), are more often treated with steroids (85.9% versus 70.1%, P = .011) and tacrolimus (12.5% versus 4.4%, P = .015), and have a higher frequency of rejection episodes (71.2% versus 44.6%, P = .001). Multivariate analysis identified the following as predictive factors for the development of DM: age (OR = 1.04, P = .013), urgent HT (OR = 0.36, P = .031), treatment with tacrolimus (OR = 3.89, P = .012), and number of rejections (OR = 2.34, P = .002).

CONCLUSION

In our population, age, urgent HT (which had a protective effect), treatment with tacrolimus, and number of rejections were independent predictive variables for the development of DM during follow-up.

Influence of HLA Matching on Survival in Heart Transplantation

BACKGROUND

In renal transplantation, the degree of HLA matching has been reported to be negatively correlated with graft loss, with the number of rejections with complications. This association is less clear in heart transplantation, where there are contradictory studies, although most are consistent with those in renal transplantation. The objective of this study was to analyze differences in the probability of survival and the incidence of complications during follow-up according to the degree of HLA-A, -B, and -DR matching.

MATERIALS AND METHODS

Two hundred forty-three consecutive patients transplanted over a 13-year period were analyzed for age, gender, pretransplant factors associated with mortality, number of rejections and infections, incidence of acute graft failure, arterial hypertension, diabetes, and survival time with cause of death with reference to the number of HLA matches (zero to six). Exclusion criteria included retransplants, heart-lung transplants, pediatric transplants, and perioperative mortality. Groups were compared using the chi(2) and ANOVA (Bonferroni posthoc test) tests. Kaplan-Meier survival curves were compared using the log rank test. The significance level was set at P < .05.

RESULTS

The overall probability of survival of our series at 1, 5, and 10 years was 85%, 77%, and 60%, respectively. HLA-A, -B, and -DR compatibility: No significant differences were found when the curves were compared (log-rank: .005). The best survival rates were obtained with lower degrees of matching. No significant differences were found in the number of rejections or infections, although survival rates (P = .007) were higher among those with the lower degrees of matching.

CONCLUSIONS

A higher degree of HLA-A, -B, and -DR matching did not have a positive effect on heart transplant patient survival, rejection episodes or infections.

Risk Factors Affecting Survival in Heart Transplant Patients

BACKGROUND

Certain cardiovascular risk factors have been linked to morbidity and mortality in heart transplant (HT) patients. The sum of various risk factors may have a large cumulative negative effect, leading to a substantially worse prognosis and the need to consider whether HT is contraindicated. The objective of this study was to determine whether the risk factors usually available prior to HT result in an excess mortality in our setting that contraindicates transplantation.

MATERIALS AND METHODS

Consecutive patients who underwent heart transplantation from November 1987 to January 2004 were included. Heart-lung transplants, retransplants, and pediatric transplants were excluded. Of the 384 patients, 89% were men. Mean age was 52 years (range, 12 to 67). Underlying disease included ischemic heart disease (52%), idiopathic dilated cardiomyopathy (36%), valvular disease (8%), and other (4%). Variables considered risk factors were obesity (BMI >25), dyslipidemia, hypertension, prior thoracic surgery, diabetes, and history of ischemic heart disease. Survival curves by number of risk factors using Kaplan-Meier and log-rank for comparison of curves.

RESULTS

Overall patient survival at 1, 5, 10, and 13 years was 76%, 68%, 54%, and 47%, respectively. Survival at 10 years, if fewer than two risk factors were present, was 69%; 59% if two or three factors were present; and 37% if more than three associated risk factors were present (P = .04).

CONCLUSIONS

The presence of certain risk factors in patients undergoing HT resulted in lower survival rates. The combination of various risk factors clearly worsened outcomes. However, we do not believe this should be an absolute contraindication for transplantation.

[Evaluating the effect of quaternary ammonium disinfectants on bacterial strains of animal origin]

The authors evaluate two quaternary ammonium compounds, first and second generation, using three methods: minimum bactericide concentration, the suspension test of the German Society for Hygiene and Microbiology and the agar gel diffusion test. The compounds were tested against Escherichia coli, Pseudomonas aeruginosa, Staphylococcus aureus and Enterococcus faecalis from sheep and pigs. The results show that quaternary ammonia compounds with dodecyl chains have greater efficacy than benzalconium chloride, and that quaternary ammonium compounds are more effective against gram-positive bacteria. No resistance linked to the strains used in the tests was detected. Finally, the authors demonstrate that all three techniques are valid for the evaluation of quaternary ammonium disinfectants.

Utility of cardiac magnetic resonance imaging for the diagnosis of heart transplant rejection

OBJECTIVES

To assess the value of the use of cardiac MRI to detect rejection (necrosis) and its ability to discriminate it from other pathologic alterations (edema and fibrosis).

MATERIALS AND METHODS

A prospective and consecutive study was designed in which cardiac MRI was performed at the same time as the scheduled endomyocardial biopsy. The study period was from 31-10-01 to 01-05-02. Ten patients with claustrophobia were excluded. Sixty-four examinations were performed in the remaining 40 patients. MRI assessment was blinded to the biopsy result. The 17 biopsies performed were insufficient (too small sample). Rejection was defined as the presence of at least 1 focus of myocyte necrosis. Technique. A high-field (1.5 T) GE CV/i magnetic resonance imaging system was used to obtain pre- and postcontrast white and black blood anatomic sequences (breathhold fast spin-echo T1-weighted images), as well as myocardial cine, perfusion and viability sequences. Variables analyzed. Ejection fraction, ventricular volumes, pericardial effusion, hypertrophy, absolute and relative myocardial intensity and uptake. Statistics. Variables were normally distributed. Student's t test was used for quantitative variables and the chi2 test for proportions.

RESULTS

Mean age, 51+/-13 years. Women 5, men 35. Time since HT, 13 to 3725 days. No significant differences were found between rejection and ventricular volumes or the presence of effusion and hypertrophy. Visual estimation of myocardial perfusion and viability sequences did not detect any significant changes. Uptake showed a clear trend to increase in patients with necrosis: 34+/-21 versus 23+/-17 for relative uptake, P<.05. There were also differences in uptake when fibrosis was present: 68+/-47 versus 102+/-48 in the group without fibrosis, P <.05; but not in the presence of edema: 93+/-55 versus 94 +/- 45 for absolute uptake.

CONCLUSIONS

(1) Cardiac MRI is a promising technique for diagnosis of rejection. (2) Patients with myocyte necrosis show a clear trend toward increased myocardial uptake. (3) Interstitial fibrosis is associated with decreased levels of uptake.

Radioimmunometric assay of B-type natriuretic peptide (BNP) in heart transplantation: correlation between BNP determinations and biopsy grading of rejection

The aim of this study was to determine whether elevated brain natriuretic peptide (BNP) levels after heart transplantation are correlated with the severity of rejection by using endomyocardial biopsy (EMB) and echocardiographic parameters indicative of ventricular function of the transplanted heart. This was an observational study of 80 orthotopic heart transplant recipients (11 women and 69 men; mean age 53+/-11 years). BNP determinations were performed within 48 h of endomyocardial biopsy. The echocardiographic study and BNP determination were also performed in a group of healthy volunteers. We found significantly higher BNP mean levels in heart transplant patients than in healthy volunteers (volunteers, 16.7+/-16.2 pg.ml-1; transplant, 213.4+/-268.6 pg.ml-1; P<0.001). Transplant recipients with rejection grades 2, 3 and 4 on EMB had significantly higher BNP levels than those with rejection grades 0 and 1 (higher rejection grade, 162.5+/-168.4 pg.ml-1; lower rejection grade, 292+/-361.8 pg.ml-1; P<0.01). BNP values of patients with good left ventricular function (LVF) were significantly lower than in patients with mildly and moderately impaired LVF and patients with severely impaired LVF (good function, 199.76+/-233.6 pg.ml-1; mildly/moderately impaired LVF, 937+/-644.5 pg.ml-1; severely impaired LVF, 1038+/-491.2 pg.ml-1; P<0.001). It is concluded that BNP plasma levels are elevated in heart transplant patients compared to the normal population. The distribution of BNP levels in heart transplanted patients show a wide range. BNP elevation is greater in patients with higher rejection grades on EMB and greater impairment of left ventricular function.

Role of dopamine in renal dysfunction during laparoscopic surgery

BACKGROUND

Sympathetic vascular insult and hemodynamic changes represent the most reliable explanation of renal impairment resulting from acute intraabdominal pressure. We evaluated the effects of low-dose dopamine administration during a long-lasting surgical laparoscopic procedure.

METHODS

For this study 40, patients submitted to a colorectal laparoscopic procedure with 15 mmHg of intraabdominal pressure were randomly allocated to two groups: 20 receiving 2 mg/kg/min of dopamine and 20 receiving the same perfusion of saline. Hemodynamic parameters, renal function, urinary output, and creatinine clearance, were studied.

RESULTS

The hemodynamic parameters were similar in both groups. The urinary output decreased during the intraoperative period only the saline group (p = 0.4). Then 2 h postoperatively, it increased in both groups, and no statistically significant differences were found between the groups. The creatinine clearance decreased in both groups during the intraoperative time, but it was worse in the saline group (-28 +/- 120 vs -194 +/- 106; p = 0.022). During the postoperative period, both groups showed improvement, but in control group the values remained lower than at baseline (p = 0.04), and significantly lower than in the dopamine group (230 +/- 337 vs 100 +/- 192; p = 0.012).

CONCLUSIONS

An intrabdominal pressure of 15 mmHg induces a time-limited renal dysfunction, and low doses of dopamine could prevent this undesirable effect.

A case of self-inflicted wounding by the introduction of needles through the abdominal wall to induce abortion

The self-inflicted wounding of a 23-year-old woman who introduced needles through the abdominal wall to induce abortion is reported. The woman first came to hospital with metrorrhagia and pain in the right iliac fossa. Initially she refused treatment and went home. Twenty-two hours later she was admitted to hospital after giving birth at home to a male fetus of 610 g. The placenta was expelled in the hospital and a sewing needle was found. Lateral and anteroposterior radiographs revealed 15 such needles in the hypogastric region, most of them at subcutaneous level. The newborn was admitted to the intensive care unit in a generally poor condition, with hypothermia, cyanosis and bradycardia. An X-ray showed a metallic object in the abdominal region which, again, corresponded to a sewing needle. The newborn did not respond to treatment and died 2h after admission.

Structural compatibility between the putative voltage sensor of voltage-gated K+ channels and the prokaryotic KcsA channel

Sequence similarity among and electrophysiological studies of known potassium channels, along with the three-dimensional structure of the Streptomyces lividans K(+) channel (KcsA), support the tenet that voltage-gated K(+) channels (Kv channels) consist of two distinct modules: the "voltage sensor" module comprising the N-terminal portion of the channel up to and including the S4 transmembrane segment and the "pore" module encompassing the C-terminal portion from the S5 transmembrane segment onward. To substantiate this modular design, we investigated whether the pore module of Kv channels may be replaced with the pore module of the prokaryotic KcsA channel. Biochemical and immunocytochemical studies showed that chimeric channels were expressed on the cell surface of Xenopus oocytes, demonstrating that they were properly synthesized, glycosylated, folded, assembled, and delivered to the plasma membrane. Unexpectedly, surface-expressed homomeric chimeras did not exhibit detectable voltage-dependent channel activity upon both hyperpolarization and depolarization regardless of the expression system used. Chimeras were, however, strongly dominant-negative when coexpressed with wild-type Kv channels, as evidenced by the complete suppression of wild-type channel activity. Notably, the dominant-negative phenotype correlated well with the formation of stable, glycosylated, nonfunctional, heteromeric channels. Collectively, these findings imply a structural compatibility between the prokaryotic pore module and the eukaryotic voltage sensor domain that leads to the biogenesis of non-responsive channels. Our results lend support to the notion that voltage-dependent channel gating depends on the precise coupling between both protein domains, probably through a localized interaction surface.

The F-actin cytoskeleton modulates slow secretory components rather than readily releasable vesicle pools in bovine chromaffin cells

Adrenal chromaffin cells were used to test the role of the peripheral cytoskeleton of F-actin in controlling different vesicle pools. Phorbol 12-myristate 13-acetate and calyculin A, two substances affecting phosphorylation-dephosphorylation cycles, produced different degrees of F-actin reorganization, inducing the partial and the almost total disassembly of this structure, respectively, as visualized using rhodamine-phalloidin staining. Consequently, electron microscopy studies revealed the higher efficiency of calyculin-A over phorbol 12-myristate 13-acetate in promoting vesicle access to the plasmalemma boundary. Surprisingly, only the phorbol ester enhanced fast kinetics and the population of rapidly releasable vesicle pools as studied by single-cell amperometry, whereas both agents, as well as the F-actin severing compound, Latrunculin A, promoted an increase in the population of vesicles recruited in response to prolonged or repetitive stimulations. Taken together, our data support the notion that the F-actin peripheral barrier controls primary granule recruitment from reserve vesicle pools, whereas the phorbol ester effect on the rapidly releasable pools might be related to the alteration of late secretory stage through protein kinase C-dependent phosphorylation of an unidentified target.