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Torres JD, Krim SR. Management of hypertension in heart transplant recipients: an ongoing conundrum. Curr Opin Cardiol 2024; 39:273-278. [PMID: 38547158 DOI: 10.1097/hco.0000000000001145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
PURPOSE OF REVIEW Hypertension remains one of the most common clinical problems leading to significant posttransplant complications. This study reviews the pathophysiology of hypertension in the postcardiac transplant phase and provides an update on currently available antihypertensive therapies for heart transplant patients. RECENT FINDINGS The true prevalence of hypertension in the heart transplant population remains unknown. Effective blood pressure (BP) control is key to prevent left ventricular remodeling, diastolic dysfunction and stroke. Calcium channel blockers (CCBs) are the most commonly and preferred agents in the early posttransplant phase and may have renal protective effects. Angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs) can all be used as second line antihypertensive agents and may have a role in preventing other long-term complications such as calcineurin-inhibitor induced nephropathy. Although more data are needed, sodium-glucose co-transporter 2 inhibitors (SGLT2i) appeared to be well tolerated and could be considered especially in the presence of type diabetes and chronic kidney disease. Conversely, angiotensin receptor-neprilysin inhibition (ARNI) have not been studied in the heart transplant population therefore cannot be recommended at this time. SUMMARY Hypertension is very common after heart transplant. Early steroid wean and traditional risk factor modification play an important part in the management of post-heart transplant hypertension. CCB, ACEI, ARB are the preferred antihypertensive agents to improve postcardiac transplant complications. Novel therapies such as SGLT2i appear well tolerated and may have benefits in both BP and glycemic control in heart transplant; however, larger trials are needed.
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Affiliation(s)
| | - Selim R Krim
- Section of Cardiomyopathy & Heart Transplantation, John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, Los Angeles, USA
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Masarone D, Tedford RJ, Melillo E, Petraio A, Pacileo G. Angiotensin-converting enzyme inhibitor therapy after heart transplant: from molecular basis to clinical effects. Clin Transplant 2022; 36:e14696. [PMID: 35523577 DOI: 10.1111/ctr.14696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 04/19/2022] [Accepted: 04/25/2022] [Indexed: 11/29/2022]
Abstract
The use of angiotensin-converting enzyme inhibitors is an important therapy for various cardiovascular diseases, such as hypertension, ischemic heart disease and heart failure. In heart transplant recipients, angiotensin-converting enzyme inhibitors have been demonstrated to be a keystone for the treatment of hypertension with a wide spectrum of pleiotropic molecular effects ranging from improvement of the peripheral vascular system to regulation of the fluid and sodium balance. In addition, angiotensin-converting enzyme inhibitors may be also useful in the prevention of graft failure, cardiac allograft vasculopathy and chronic kidney disease progression. Further tailored multi-center and randomized studies are warranted to confirm the pleiotropic clinical effects of ACEi therapy in HTRs and to support more extended use in daily clinical practice. Finally in the near future, the use of novel pharmacological agents that inhibit the renin-angiotensin-aldosterone system such as the neprylisin inhibitor sacubitril should be investigated in heart transplant recipients. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Daniele Masarone
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, Naples, Italy
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Enrico Melillo
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, Naples, Italy
| | - Andrea Petraio
- Heart Transplant Unit, Department of Cardiac Surgery and Heart Transplant, AORN dei Colli-Monaldi Hospital, Naples, Italy
| | - Giuseppe Pacileo
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, Naples, Italy
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3
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Mejia C, Yadav A. Kidney Disease After Nonkidney Solid Organ Transplant. Adv Chronic Kidney Dis 2021; 28:577-586. [PMID: 35367026 DOI: 10.1053/j.ackd.2021.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 10/26/2021] [Accepted: 10/28/2021] [Indexed: 11/11/2022]
Abstract
Nonkidney solid organ transplants (NKSOTs) are increasing in the United States with improving long-term allograft and patient survival. CKD is prevalent in patients with NKSOT and is associated with increased morbidity and mortality especially in those who progress to end-stage kidney disease. Calcineurin inhibitor nephrotoxicity is a main contributor to CKD after NKSOT, but other factors in the pretransplant, peritransplant, and post-transplant period can predispose to progressive kidney dysfunction. The management of CKD after NKSOT generally follows society guidelines for native kidney disease. Kidney-protective and calcineurin inhibitor-sparing immunosuppression has been explored in this population and warrants a discussion with transplant teams. Kidney transplantation in NKSOT recipients remains the kidney replacement therapy of choice for suitable candidates, as it provides a survival benefit over remaining on dialysis.
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Elevated Heart Rate Following Heart Transplantation Is Associated With Increased Graft Vasculopathy and Mortality. J Card Fail 2019; 25:249-256. [DOI: 10.1016/j.cardfail.2019.01.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 12/14/2018] [Accepted: 01/18/2019] [Indexed: 12/24/2022]
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6
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Fearon WF, Okada K, Kobashigawa JA, Kobayashi Y, Luikart H, Sana S, Daun T, Chmura SA, Sinha S, Cohen G, Honda Y, Pham M, Lewis DB, Bernstein D, Yeung AC, Valantine HA, Khush K. Angiotensin-Converting Enzyme Inhibition Early After Heart Transplantation. J Am Coll Cardiol 2017; 69:2832-2841. [PMID: 28595700 DOI: 10.1016/j.jacc.2017.03.598] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 03/27/2017] [Accepted: 03/31/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Cardiac allograft vasculopathy (CAV) remains a leading cause of mortality after heart transplantation (HT). Angiotensin-converting enzyme inhibitors (ACEIs) may retard the development of CAV but have not been well studied after HT. OBJECTIVES This study tested the safety and efficacy of the ACEI ramipril on the development of CAV early after HT. METHODS In this prospective, multicenter, randomized, double-blind, placebo-controlled trial, 96 HT recipients were randomized to undergo ramipril or placebo therapy. They underwent coronary angiography, endothelial function testing; measurements of fractional flow reserve (FFR) and coronary flow reserve (CFR) and the index of microcirculatory resistance (IMR); and intravascular ultrasonography (IVUS) of the left anterior descending coronary artery, within 8 weeks of HT. At 1 year, the invasive assessment was repeated. Circulating endothelial progenitor cells (EPCs) were quantified at baseline and 1 year. RESULTS Plaque volumes at 1 year were similar between the ramipril and placebo groups (162.1 ± 70.5 mm3 vs. 177.3 ± 94.3 mm3, respectively; p = 0.73). Patients receiving ramipril had improvement in microvascular function as shown by a significant decrease in IMR (21.4 ± 14.7 to 14.4 ± 6.3; p = 0.001) and increase in CFR (3.8 ± 1.7 to 4.8 ± 1.5; p = 0.017), from baseline to 1 year. This did not occur with IMR (17.4 ± 8.4 to 21.5 ± 20.0; p = 0.72) or CFR (4.1 ± 1.8 to 4.1 ± 2.2; p = 0.60) in the placebo-treated patients. EPCs decreased significantly at 1 year in the placebo group but not in the ramipril group. CONCLUSIONS Ramipril does not slow development of epicardial plaque volume but does stabilize levels of endothelial progenitor cells and improve microvascular function, which have been associated with improved long-term survival after HT. (Angiotensin Converting Enzyme [ACE] Inhibition and Cardiac Allograft Vasculopathy; NCT01078363).
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Affiliation(s)
- William F Fearon
- Stanford Cardiovascular Institute and Division of Cardiovascular Medicine, Stanford, California; Cardiology Section, Palo Alto Veterans Affairs Health Care System, Palo Alto, California.
| | - Kozo Okada
- Stanford Cardiovascular Institute and Division of Cardiovascular Medicine, Stanford, California
| | - Jon A Kobashigawa
- Advanced Heart Disease Section, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Yuhei Kobayashi
- Stanford Cardiovascular Institute and Division of Cardiovascular Medicine, Stanford, California
| | - Helen Luikart
- Stanford Cardiovascular Institute and Division of Cardiovascular Medicine, Stanford, California
| | - Sean Sana
- Advanced Heart Disease Section, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Tiffany Daun
- Advanced Heart Disease Section, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Steven A Chmura
- Department of Pediatrics, Division of Allergy, Immunology, and Rheumatology, Stanford University School of Medicine, Stanford, California
| | - Seema Sinha
- Stanford Cardiovascular Institute and Division of Cardiovascular Medicine, Stanford, California
| | - Garett Cohen
- Stanford Cardiovascular Institute and Division of Cardiovascular Medicine, Stanford, California
| | - Yasuhiro Honda
- Stanford Cardiovascular Institute and Division of Cardiovascular Medicine, Stanford, California
| | - Michael Pham
- Cardiology Section, Palo Alto Veterans Affairs Health Care System, Palo Alto, California
| | - David B Lewis
- Department of Pediatrics, Division of Allergy, Immunology, and Rheumatology, Stanford University School of Medicine, Stanford, California
| | - Daniel Bernstein
- Department of Pediatrics, Division of Cardiology, Stanford University School of Medicine, Stanford, California
| | - Alan C Yeung
- Stanford Cardiovascular Institute and Division of Cardiovascular Medicine, Stanford, California
| | - Hannah A Valantine
- Stanford Cardiovascular Institute and Division of Cardiovascular Medicine, Stanford, California
| | - Kiran Khush
- Stanford Cardiovascular Institute and Division of Cardiovascular Medicine, Stanford, California
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Varnado S, Peled-Potashnik Y, Huntsberry A, Lowes BD, Zolty R, Burdorf A, Lyden ER, Moulton MJ, Um JY, Raichlin E. Effect of diltiazem on exercise capacity after heart transplantation. Clin Transplant 2017; 31. [DOI: 10.1111/ctr.12997] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Sara Varnado
- Division of Cardiology; University of Nebraska Medical Center; Omaha NE USA
| | | | - Ashley Huntsberry
- Division of Cardiology; University of Nebraska Medical Center; Omaha NE USA
| | - Brian D. Lowes
- Division of Cardiology; University of Nebraska Medical Center; Omaha NE USA
| | - Ronald Zolty
- Division of Cardiology; University of Nebraska Medical Center; Omaha NE USA
| | - Adam Burdorf
- Division of Cardiology; University of Nebraska Medical Center; Omaha NE USA
| | - Elizabeth R. Lyden
- Department of Biostatistics; College of Public Health; University of Nebraska Medical Center; Omaha NE USA
| | - Michael J. Moulton
- Department of Cardiothoracic Surgery; University of Nebraska Medical Center; Omaha NE USA
| | - John Y. Um
- Department of Cardiothoracic Surgery; University of Nebraska Medical Center; Omaha NE USA
| | - Eugenia Raichlin
- Department of Cardiology; Loyola University Medical Center; Maywood IL USA
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Jurgens PT, Aquilante CL, Page RL, Ambardekar AV. Perioperative Management of Cardiac Transplant Recipients Undergoing Noncardiac Surgery: Unique Challenges Created by Advancements in Care. Semin Cardiothorac Vasc Anesth 2017; 21:235-244. [PMID: 28466755 DOI: 10.1177/1089253217706164] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Advancements in postcardiac transplant care have resulted in significant reductions in morbidity and increased life expectancy for cardiac transplant recipients. Consequently, many cardiac transplant recipients are living long enough to require subsequent noncardiac surgery. The perioperative care of heart transplant recipients presents a unique challenge as many of the common preoperative risk assessments do not apply to a transplanted heart, immunosuppressive medications have side effects and potential for drug-drug interactions, and the denervated heart results in an altered autonomic physiology and response to medications. Further adding to the challenge is that many of these noncardiac surgeries need to be performed urgently at nontransplant centers that may not be familiar with the care of these patients. This review aims to summarize the current data regarding preoperative assessment, perioperative immunosuppression management, intraoperative and anesthetic considerations, and outcomes of cardiac transplant recipients undergoing noncardiac surgery.
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Affiliation(s)
- Paul T Jurgens
- 1 School of Medicine, Department of Medicine, University of Colorado, Aurora Colorado, CO, USA
| | - Christina L Aquilante
- 2 Skaggs School of Pharmacy and Pharmaceutical Sciences, Department of Pharmaceutical Sciences, University of Colorado, Aurora Colorado, CO, USA
| | - Robert L Page
- 3 Skaggs School of Pharmacy and Pharmaceutical Sciences, Department of Clinical Pharmacy, University of Colorado, Aurora Colorado, CO, USA
| | - Amrut V Ambardekar
- 4 School of Medicine, Division of Cardiology, University of Colorado, Aurora Colorado, CO, USA
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Peled Y, Varnado S, Lowes BD, Zolty R, Lyden ER, Moulton MJ, Um JY, Raichlin E. Sinus tachycardia is associated with impaired exercise tolerance following heart transplantation. Clin Transplant 2017; 31. [DOI: 10.1111/ctr.12946] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2017] [Indexed: 12/14/2022]
Affiliation(s)
- Yael Peled
- Heart Center; Sheba Medical Center; Ramat Gan and Sackler School of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Sara Varnado
- Division of Cardiology; University of Nebraska Medical Center; Omaha NE USA
| | - Brian D. Lowes
- Division of Cardiology; University of Nebraska Medical Center; Omaha NE USA
| | - Ronald Zolty
- Division of Cardiology; University of Nebraska Medical Center; Omaha NE USA
| | - Elizabeth R. Lyden
- Department of Biostatistics; College of Public Health; University of Nebraska Medical Center; Omaha NE USA
| | - Michael J. Moulton
- Department of Cardiothoracic Surgery; University of Nebraska Medical Center; Omaha NE USA
| | - John Y. Um
- Department of Cardiothoracic Surgery; University of Nebraska Medical Center; Omaha NE USA
| | - Eugenia Raichlin
- Division of Cardiology; University of Nebraska Medical Center; Omaha NE USA
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10
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Abstract
Hypertension is a common complication among post cardiac transplant recipients affecting more than 95% of patients. Increased blood pressure poses a significant cardiovascular morbidity and mortality in these patients; it should be identified quickly and needs to be managed appropriately. Understanding the pathophysiology and contributing factors to this disease in these complex and unique patients is the key to appropriate treatment selection.
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Affiliation(s)
- Amanda L Bennett
- Department of Internal Medicine, Ochsner Clinic Foundation, 1514 Jefferson Highway, New Orleans, LA 70121, USA.
| | - Hector O Ventura
- Department of Cardiomyopathy & Heart Transplantation, John Ochsner Heart and Vascular Institute, 1514 Jefferson Highway, New Orleans, LA 70121, USA
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11
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Chronic renal insufficiency in heart transplant recipients: risk factors and management options. Drugs 2015; 74:1481-94. [PMID: 25134671 DOI: 10.1007/s40265-014-0274-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Renal dysfunction after heart transplantation is a frequently observed complication, in some cases resulting in significant limitation of quality of life and reduced survival. Since the pathophysiology of renal failure (RF) is multifactorial, the current etiologic paradigm for chronic kidney disease after heart transplantation relies on the concept of calcineurin inhibitor (CNI)-related nephrotoxicity acting on a predisposed recipient. Until recently, the management of RF has been restricted to the minimization of CNI dosage and general avoidance of classic nephrotoxic risk factors, with somewhat limited success. The recent introduction of proliferation signal inhibitors (PSIs) (sirolimus and everolimus), a new class of immunosuppressive drugs lacking intrinsic nephrotoxicity, has provided a completely new alternative in this clinical setting. As clinical experience with these new drugs increases, new renal-sparing strategies are becoming available. PSIs can be used in combination with reduced doses of CNIs and even in complete CNI-free protocols. Different strategies have been devised, including de novo use to avoid acute renal toxicity in high-risk patients immediately after transplantation, or more delayed introduction in those patients developing chronic RF after prolonged CNI exposure. In this review, the main information on the clinical relevance and pathophysiology of RF after heart transplantation, as well as the currently available experience with renal-sparing immunosuppressive regimens, particularly focused on the use of PSIs, is reviewed and summarized, including the key practical points for their appropriate clinical usage.
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12
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13
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D'Alessandro LC, Mital S. Pediatric transplantation: opportunities for pharmacogenomics and genomics. Per Med 2013; 10:397-404. [PMID: 29783417 DOI: 10.2217/pme.13.26] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Heterogeneity is the rule among pediatric heart transplant recipients. Patients vary in age, size, organ maturity, immune system maturity and underlying disease etiology, which can all influence post-transplant outcomes. Overall, the survival of pediatric transplant recipients continues to improve and the goal remains long-term survival of the primary graft and mitigation of long-term complications and adverse events. The evolving fields of pharmacogenomics and genomics have the potential to revolutionize and personalize the care of pediatric transplant recipients, and although clinical validation in a pediatric cohort is lacking, many of these technologies are becoming more readily available. We discuss genotype-guided dosing of immunosuppressant medications and other commonly used medications after transplantation, the influence of donor and recipient genotype on risk of post-transplant complications, genotype-guided selection of therapies to treat complications, and the use of next-generation sequencing for noninvasive detection of graft rejection.
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Affiliation(s)
- Lisa Ca D'Alessandro
- Division of Cardiology, Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.,Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Seema Mital
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada.,Division of Cardiology, Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
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Ambrosi P, Lafforgue P. Le cardiologue et les immunosuppresseurs. Presse Med 2012; 41:655-61. [DOI: 10.1016/j.lpm.2012.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2011] [Revised: 02/22/2012] [Accepted: 03/14/2012] [Indexed: 11/26/2022] Open
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Costanzo MR, Dipchand A, Starling R, Anderson A, Chan M, Desai S, Fedson S, Fisher P, Gonzales-Stawinski G, Martinelli L, McGiffin D, Smith J, Taylor D, Meiser B, Webber S, Baran D, Carboni M, Dengler T, Feldman D, Frigerio M, Kfoury A, Kim D, Kobashigawa J, Shullo M, Stehlik J, Teuteberg J, Uber P, Zuckermann A, Hunt S, Burch M, Bhat G, Canter C, Chinnock R, Crespo-Leiro M, Delgado R, Dobbels F, Grady K, Kao W, Lamour J, Parry G, Patel J, Pini D, Towbin J, Wolfel G, Delgado D, Eisen H, Goldberg L, Hosenpud J, Johnson M, Keogh A, Lewis C, O'Connell J, Rogers J, Ross H, Russell S, Vanhaecke J, Russell S, Vanhaecke J. The International Society of Heart and Lung Transplantation Guidelines for the care of heart transplant recipients. J Heart Lung Transplant 2010; 29:914-56. [PMID: 20643330 DOI: 10.1016/j.healun.2010.05.034] [Citation(s) in RCA: 1172] [Impact Index Per Article: 83.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2010] [Accepted: 05/31/2010] [Indexed: 12/26/2022] Open
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Roche SL, O'Sullivan JJ, Kantor PF. Hypertension after pediatric cardiac transplantation: detection, etiology, implications and management. Pediatr Transplant 2010; 14:159-68. [PMID: 19624603 DOI: 10.1111/j.1399-3046.2009.01205.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
While it may rescue children with end-stage heart failure from impending catastrophe, cardiac transplantation leaves 50-70% of pediatric recipients with new-onset hypertension. Given the unique vulnerability of the heart and kidneys in these children, we can expect long-term uncontrolled hypertension to shorten both graft and patient survival. In this review we discuss the multi-factorial etiology of post-transplant hypertension, highlighting current uncertainties and emphasizing mechanisms specific to cardiac recipients. We consider the optimal means of monitoring BP and in particular, the advantages of 24 h-ABP over intermittent clinic measurements. We also review BP treatment after cardiac transplantation, drawing attention to specific cautions appropriate when prescribing antihypertensive agents in these circumstances.
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Affiliation(s)
- S Lucy Roche
- Department of Pediatric Cardiology, The Hospital for Sick Children, Toronto, ON, Canada
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Hasley PB, Arnold RM. Primary care of the transplant patient. Am J Med 2010; 123:205-12. [PMID: 20193824 DOI: 10.1016/j.amjmed.2009.06.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2009] [Revised: 06/12/2009] [Accepted: 06/18/2009] [Indexed: 01/06/2023]
Abstract
A total of 153,245 patients are living with a solid organ transplant in the US. In addition, patients are experiencing high 5-year survival rates after transplantation. Thus, primary care physicians will be caring for transplanted patients. The aim of this review is to update primary care physicians on chronic diseases, screening for malignancy, immunizations, and contraception in the transplant patient. Several studies on the treatment of hypertension and hyperlipidemia demonstrate that most agents used to treat the general population also can be used to treat transplant recipients. Little information exists on the medical management of diabetes in the transplant population, but experts in the area believe that the treatment of diabetes should be similar. Transplant recipients are at increased risk for all malignancies. Aggressive screening should be employed for all cancers with a proven screening benefit. Killed immunizations are safe for the transplant population, but live virus vaccines should be avoided. Women of childbearing age should be counseled about the impact of immunosuppressants on the efficacy and side effects of contraception.
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Affiliation(s)
- Peggy B Hasley
- University of Pittsburgh School of Medicine, PA 15213, USA.
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19
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Pethig K, Hornig B, Bara C, Schieffer B, Haverich A, Sachse A. Eprosartan in the Primary Prevention of Cardiac Allograft Vascular Disease: A Double-Blind Prospectively Randomized Study using Intravascular Ultrasound. J Int Med Res 2008; 36:1022-31. [DOI: 10.1177/147323000803600520] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The angiotensin blocker (ARB) eprosartan (600 mg once daily) and the calcium antagonist diltiazem (90 mg twice daily) were studied in a 24-month prospective, randomized, double-blind trial involving 53 heart transplant patients. The study compared their effects on the development of post-transplant cardiac allograft vasculopathy, a condition that frequently impairs long-term post-transplantation survival and where angiotensin blockers might be expected to play a preventive role. From baseline to month 12, the mean plaque volume increased by 7.7 mm3 for eprosartan-treated patients and by 34.4 mm3 for diltiazem-treated patients, but the eprosartan-related trend for reduced myointimal hyperplasia was not statistically significant. The trend in favour of eprosartan for secondary parameters (mean intimal index, vessel volume, lumen volume and coronary flow reserve) also failed to reach significance. The lack of effect might be due to a lower than planned sample size and observation periods due to recruitment difficulties. A larger study is required to confirm these preliminary findings.
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Affiliation(s)
- K Pethig
- Department of Cardiology, Evangelisches Krankenhaus, Hamm, Germany
| | - B Hornig
- Department of Cardiology, St Claraspital, Basel, Switzerland
| | - C Bara
- Department of Cardiothoracic Surgery
| | - B Schieffer
- Department of Cardiology, Hannover Medical School, Hannover, Germany
| | | | - A Sachse
- Solvay Arzneimittel GmbH, Hannover, Germany
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Al-Naamani N, Maarouf OH, Wilt JS, Bacchetta M, D'Ovidio F, Sonett JR, Arcasoy SM, Lederer DJ, Nickolas TL, Kawut SM. The modification of diet in renal disease (MDRD) and the prediction of kidney outcomes after lung transplantation. J Heart Lung Transplant 2008; 27:1191-7. [PMID: 18971090 DOI: 10.1016/j.healun.2008.07.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2008] [Revised: 06/20/2008] [Accepted: 07/29/2008] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is prevalent after lung transplantation. This study evaluated the ability of the 24-hour urine creatinine clearance (CrCl) and the Modification of Diet in Renal Disease (MDRD) equation at the time of listing to predict CKD after lung transplantation and to determine risk factors for CKD. METHODS This was a retrospective cohort study of 122 patients who underwent lung transplantation at Columbia Presbyterian Medical Center between May 2002 and August 2006. The primary end point was CKD Stage 3 or higher, defined as glomerular filtration rate (GFR) </= 59 ml/min/1.73 m(2) or renal replacement therapy, for at least 3 months. RESULTS Patients were a mean age of 51 +/- 14 years, 55% women, and 83% non-Hispanic white. CKD developed in 62% by 1 year after lung transplantation. Older age, female gender, a diagnosis of sarcoidosis, and diabetes mellitus independently increased the risk of CKD (all p < 0.05). The MDRD equation was significantly better than CrCl at predicting CKD Stage 3 or higher at 1 year after transplantation, with an area under the receiver operating characteristic curve of 0.71 for MDRD (95% confidence interval [CI], 0.61-0.81) and 0.51 for CrCl (95% CI, 0.40-0.61) (P < 0.001). CONCLUSIONS Older age, female gender, and diabetes mellitus increased the risk of developing CKD after lung transplant. The MDRD estimate of GFR at listing was a better predictor of CKD than CrCl. MDRD estimates should be used during lung transplant evaluation for risk stratification for CKD.
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Affiliation(s)
- Nadine Al-Naamani
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, New York, USA
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22
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Sulemanjee NZ, Merla R, Lick SD, Aunon SM, Taylor M, Manson M, Czer LSC, Schwarz ER. The first year post-heart transplantation: use of immunosuppressive drugs and early complications. J Cardiovasc Pharmacol Ther 2008; 13:13-31. [PMID: 18287587 DOI: 10.1177/1074248407309916] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
A large number of heart transplants are performed annually in different transplant centers in the United States. This is partly because of the improved survival of patients who undergo cardiac transplantation, thus making it a more viable option in the management of end-stage heart failure. The survival benefit after heart transplantation is a result of newer immunosuppressive drug regimens and a better understanding of their effects and interactions. Several studies, mostly involving a small number of patients, describe use and comparison of the many distinct immunosuppressive drugs available to date. Interestingly, many transplant centers perform in-house typical induction treatment regimens because of their own experience and intra-institutional preference. This review summarizes current practices of immunosuppressive drug therapy in the first year post-heart transplant based on the available clinical evidence and discusses future options of heart transplant immunosuppressive drug therapies.
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Affiliation(s)
- Nasir Z Sulemanjee
- Division of Cardiology, Department of Internal Medicine, The University of Texas Medical Branch, Galveston, TX, USA
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Bloom RD, Reese PP. Chronic kidney disease after nonrenal solid-organ transplantation. J Am Soc Nephrol 2008; 18:3031-41. [PMID: 18039925 DOI: 10.1681/asn.2007040394] [Citation(s) in RCA: 144] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Chronic kidney disease (CKD) is a common complication after nonrenal solid-organ transplantation. The risk for CKD is influenced by many factors, some of which have a direct impact on how such patients are treated in the pre-, peri-, and posttransplantation settings. This review describes hazards for acute and chronic kidney injury, with particular emphasis on calcineurin inhibitor-mediated nephrotoxicity. Rather than a detailed description of management issues that are common to the general CKD population, highlighted are aspects that are more specific to nonrenal solid-organ transplant recipients with a focus on liver, heart, and lung recipients. Strategies to minimize nephrotoxic insults and retard progressive renal injury are discussed, as are issues that are pertinent to dialysis and transplantation. Finally, future approaches to prevent and treat CKD without compromising function of the transplanted organ are addressed.
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Affiliation(s)
- Roy D Bloom
- Department of Medicine, Renal-Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.
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Hingorani S. Chronic kidney disease after liver, cardiac, lung, heart-lung, and hematopoietic stem cell transplant. Pediatr Nephrol 2008; 23:879-88. [PMID: 18414901 PMCID: PMC2335288 DOI: 10.1007/s00467-008-0785-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2007] [Revised: 01/30/2008] [Accepted: 01/31/2008] [Indexed: 11/24/2022]
Abstract
Patient survival after cardiac, liver, and hematopoietic stem cell transplant (HSCT) is improving; however, this survival is limited by substantial pretransplant and treatment-related toxicities. A major cause of morbidity and mortality after transplant is chronic kidney disease (CKD). Although the majority of CKD after transplant is attributed to the use of calcineurin inhibitors, various other conditions such as thrombotic microangiopathy, nephrotic syndrome, and focal segmental glomerulosclerosis have been described. Though the immunosuppression used for each of the transplant types, cardiac, liver and HSCT is similar, the risk factors for developing CKD and the CKD severity described in patients after transplant vary. As the indications for transplant and the long-term survival improves for these children, so will the burden of CKD. Nephrologists should be involved early in the pretransplant workup of these patients. Transplant physicians and nephrologists will need to work together to identify those patients at risk of developing CKD early to prevent its development and progression to end-stage renal disease.
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Affiliation(s)
- Sangeeta Hingorani
- Pediatrics-University of Washington, 4800 Sandpoint Way NE M1-5, Seattle, WA 98015, USA.
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Leenen FHH, Coletta E, Davies RA. Prevention of renal dysfunction and hypertension by amlodipine after heart transplant. Am J Cardiol 2007; 100:531-5. [PMID: 17659942 DOI: 10.1016/j.amjcard.2007.03.058] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2006] [Revised: 03/06/2007] [Accepted: 03/06/2007] [Indexed: 10/23/2022]
Abstract
To assess whether treatment with a dihydropyridine calcium antagonist can prevent the development of hypertension and renal dysfunction after heart transplantation, 38 patients receiving cyclosporine for immunosuppression were randomized shortly after cardiac transplantation to placebo or amlodipine 2.5 mg/day using a double-blind design. The dose was gradually increased to 10 mg/day as tolerated. At 1, 3, 6, 9, and 12 months, 24-hour ambulatory blood pressure (BP) monitoring was performed for the assessment of BP load, echocardiography for the assessment of left ventricular function and mass, 24-hour urine collection for creatinine clearance, and blood sampling for cyclosporine levels. In the placebo group, BP showed modest increases during follow-up, whereas creatinine clearance decreased by about 10 ml/min. In contrast, in the amlodipine group, systolic BP decreased by 15 to 20 mm Hg and diastolic BP by 7 to 10 mm Hg, whereas creatinine clearance tended to increase. Between-group differences were significant as well. During follow-up, left ventricular mass and function showed small decreases, similar for the 2 groups. Cyclosporine doses and blood levels did not differ during follow-up. In conclusion, the initiation of treatment with the dihydropyridine amlodipine shortly after cardiac transplantation represents an effective strategy to maintain normal BP and renal function for > or =1 year.
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Affiliation(s)
- Frans H H Leenen
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
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26
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Rockx MA, Haddad H. Use of calcium channel blockers and angiotensin-converting enzyme inhibitors after cardiac transplantation. Curr Opin Cardiol 2007; 22:128-32. [PMID: 17284992 DOI: 10.1097/hco.0b013e3280210681] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Hypertension, dyslipidemia, and diabetes are very common problems following heart transplantation and may contribute to the development and progression of graft coronary artery disease. This article reviews current data on clinical use of angiotensin-converting enzyme inhibitors and calcium channel blockers in patients who have had heart transplants. RECENT FINDINGS Angiotensin-converting enzyme inhibitors and calcium channel blockers are established therapy for patients with cardiovascular disease. Use of these medications correlates with decreasing cardiovascular morbidity and mortality. SUMMARY After heart transplantation, hypertension associated with calcineurin inhibitors can be managed effectively with antihypertensive therapy, but it may require use of more than one antihypertensive agent. Calcium channel blockers and angiotensin-converting enzyme inhibitors have been associated with improved outcome measures in graft coronary artery disease.
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27
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Taler SJ. Transplant Hypertension. Hypertension 2007. [DOI: 10.1016/b978-1-4160-3053-9.50036-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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28
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Mathier MA, Murali S. Cardiac Transplantation and Circulatory Support Devices. Cardiovasc Ther 2007. [DOI: 10.1016/b978-1-4160-3358-5.50024-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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29
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Miller LW. Heart Transplantation: Indications, Outcome, and Long-Term Complications. CARDIOVASCULAR MEDICINE 2007. [DOI: 10.1007/978-1-84628-715-2_67] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
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Abstract
Kidney disease is a commonly recognized complication of heart and lung transplantation and is associated with increased morbidity and mortality. While the spectrum of kidney disease in this population is wide-ranging, studies indicate that between 3% and 10% of these patients will ultimately develop end-stage renal disease (ESRD). This review examines the risk factors for both acute and chronic kidney injury, with a particular emphasis on the role of calcineurin inhibitor-mediated nephrotoxicity in both these settings. Against the background of current National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines, we have further considered and recommended appropriate strategies for long-term management of kidney disease-related manifestations in heart and lung transplant recipients. Specific aspects addressed include retarding progressive renal injury and minimizing nephrotoxicity, as well as treatment of hypertension, hyperlipidemia and anemia. Finally, for patients in this population with advanced kidney disease, renal replacement therapy options are discussed. Based on the impact of chronic kidney disease on outcomes in both heart and lung recipients, we advocate early referral to a nephrologist for patients displaying evidence of significant renal dysfunction.
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Affiliation(s)
- R D Bloom
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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Abstract
In more than 35 years of experience with heart transplantation, improvements in patient selection, surgical techniques, organ preservation, and postoperative management have increased survival rates and reduced complications. However, a number of significant complications continue, limiting the benefit of heart transplantation as the long-term solution for patients. Current survival rates are 83% at 1 year and 72% at 5 years, with 50% of patients surviving 9.4 years or more. Recipient and donor characteristics influence survival outcome. Primary graft dysfunction is the most frequent cause of death during the first 30 days. The function of the transplanted heart allows return to pre-illness activities, though denervation limits peak exercise capacity. Advances in immunosuppressive medications have decreased the incidence and severity of rejection, though only recently have shown promise in attenuating the incidence of cardiac graft vasculopathy, the major complication limiting long-term graft function. This review addresses current outcomes and the short- and long-term complications of heart transplantation.
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Affiliation(s)
- Frances M Hoffman
- Transplant Services, Abbott Northwestern Hospital, 800 E. 28th Street, Minneapolis, MN 55407, USA.
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Lindenfeld J, Page RL, Zolty R, Shakar SF, Levi M, Lowes B, Wolfel EE, Miller GG. Drug Therapy in the Heart Transplant Recipient. Circulation 2005; 111:113-7. [PMID: 15630040 DOI: 10.1161/01.cir.0000151609.60618.3c] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- JoAnn Lindenfeld
- Division of Cardiology, University of Colorado Health Sciences Center, 4200 E Ninth Ave, B-130, Denver, CO 80262, USA.
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33
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Mathier MA, McNamara DM. Management of the Patient After Heart Transplant. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2004; 6:459-469. [PMID: 15496263 DOI: 10.1007/s11936-004-0003-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Cardiac transplantation is a highly effective therapy for selected patients with end-stage cardiac disease. The management of the patient after heart transplant involves three main strategies: optimization of immunosuppressive therapy, prevention of complications resulting from the transplant or the immunosuppressive agents, and treatment of those complications when they arise. For most patients, optimal current immunosuppression in the first year after transplantation consists of combination therapy with a calcineurin inhibitor (eg, cyclosporine or tacrolimus), corticosteroids, and an antimetabolite agent (eg, azathioprine or mycophenolate mofetil). Ideally, the corticosteroid is weaned and discontinued 1 to 2 years following transplantation and the patient is managed chronically with a two-drug immunosuppressive regimen. The major complications that occur following cardiac transplantation include infection, hypertension, diabetes, dyslipidemia, osteoporosis, graft coronary disease, renal insufficiency, and malignancy. Preventive efforts focused on infection, osteoporosis, renal insufficiency, and malignancy include minimization of immunosuppression. Once established, treatment of any of the above conditions generally relies on standard pharmacologic therapies; however, an understanding of potential drug interactions is critical. In addition, although standard nonpharmacologic therapies may be used to treat several of these conditions, one must be cognizant of special issues related to the post-transplant state.
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Shiba N, Chan MCY, Kwok BWK, Valantine HA, Robbins RC, Hunt SA. Analysis of survivors more than 10 years after heart transplantation in the cyclosporine era: Stanford experience. J Heart Lung Transplant 2004; 23:155-64. [PMID: 14761762 DOI: 10.1016/s1053-2498(03)00147-5] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2002] [Revised: 03/08/2003] [Accepted: 03/08/2003] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Truly long term survival post heart transplantation has become increasingly frequent over the past two decades. METHODS We analyzed multiple clinical outcomes in the cohort of 140 patients in the Stanford database who underwent heart transplantation after the introduction of cyclosporine-based immunosuppression in 1980 and survived >10 years after transplantation. RESULTS We found generally excellent functional status in these patients, but a high incidence of hypertension, renal dysfunction, and graft CAD as well as malignancy. CONCLUSION With continued improvement in post-transplant survival rates, providing complex care for such long-term recipients as these will assume increasing clinical importance in the everyday practice of transplant medicine and these data highlight the problems to be anticipated.
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Affiliation(s)
- Nobuyuki Shiba
- Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, California 94305, USA
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35
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Abstract
Cardiovascular disease is one of the major causes of morbidity and mortality following solid organ transplantation. Many of the current immunosuppressive drugs are associated with an increase of one or more risk factors for the development of atherosclerosis. This review compares the mechanism by which individual immunosuppressive agents may impact on these risk factors and the differential contribution of cyclosporine, tacrolimus, mycophenolate, azathioprine, and Rapamycin to these individual risk factors. Attention to the potential cardiovascular toxicities of individual immunosuppressive agents may help design strategies for maintenance of immunosuppression tailored to individual patients.
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Affiliation(s)
- Leslie W Miller
- Cardiovascular Division, University of Minnesota, Minneapolis, USA.
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36
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Hankins S, Mancini D. Drug treatment of clinical problems related to cardiac transplantation. HEART DISEASE (HAGERSTOWN, MD.) 2002; 4:242-51. [PMID: 12147184 DOI: 10.1097/00132580-200207000-00007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
In recent years, several new immunosuppressive agents have become available for the treatment of cardiac transplant recipients. Use of these agents and their potential side effects are reviewed.
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Affiliation(s)
- Shelley Hankins
- Department of Medicine, Division of Circulatory Physiology, Columbia Presbyterian Hospital Center, New York, New York, USA
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37
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Affiliation(s)
- M G Crespo-Leiro
- Programa de Trasplante Cardiaco, Hospital Juan Canalejo, A Coruña, Spain
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38
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Frapier JM, Choby C, Mangoni ME, Nargeot J, Albat B, Richard S. Cyclosporin A increases basal intracellular calcium and calcium responses to endothelin and vasopressin in human coronary myocytes. FEBS Lett 2001; 493:57-62. [PMID: 11278005 DOI: 10.1016/s0014-5793(01)02269-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Cyclosporin A (CsA) is a widely used immunosuppressive agent with severe side effects including hypertension. Here, we investigated the effects of CsA on intracellular free calcium ([Ca(2+)](i)) and the mechanisms involved in vasoconstriction in cultured human coronary myocytes. We used the Fura-2 technique for Ca(2+) imaging. Acute application of CsA at therapeutic concentrations (0.1-10 micromol/l) had no effect. Chronic exposure to CsA (1 micromol/l) for 24 h induced a small (20 nmol/l) but highly significant increase of basal [Ca(2+)](i) and enhanced the occurrence of spontaneous Ca(2+) oscillations. Endothelin- and vasopressin-induced rises of [Ca(2+)](i) were also enhanced. The demonstration that CsA increases basal [Ca(2+)](i) in addition to its impact on agonist receptor stimulation is of major importance for new therapeutic approaches.
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Affiliation(s)
- J M Frapier
- Service de Chirurgie Cardiothoracique, INSERM U-390, Hôpital Arnaud de Villeneuve, Montpellier, France
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Paul LC. Calcium channel blockers and angiotensin-converting enzyme inhibitors in the prevention of graft vasculopathy. J Heart Lung Transplant 2000; 19:409-13. [PMID: 10808146 DOI: 10.1016/s1053-2498(00)00072-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- L C Paul
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands. L.C.Paul@Nephrology@.Medfac.LeidenUniv.nl
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40
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Ventura HO, Mehra MR, Stapleton DD, Smart FW. Cyclosporine-induced hypertension in cardiac transplantation. Med Clin North Am 1997; 81:1347-57. [PMID: 9356603 DOI: 10.1016/s0025-7125(05)70587-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Cyclosporine-induced hypertension occurs in more than 90% of patients following cardiac transplantation. This article underlines the clinical characteristics as well as the mechanisms that can be associated with the development of cyclosporine-induced hypertension. In addition, the clinical trials up to date for the treatment of hypertension following cardiac transplantation are discussed. However, in view of the possible long-term sequelae associated with cyclosporine-induced hypertension, further studies to evaluate the long-term efficacy and safety of antihypertensive agents and finally the long-term effects of hypertension on the cardiac allograft are needed.
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Affiliation(s)
- H O Ventura
- Department of Internal Medicine, Ochsner Medical Institutions, New Orleans, Louisiana, USA
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42
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Wagoner LE. Management of the Cardiac Transplant Recipient: Roles of the Transplant Cardiologist and Primary Care Physician. Am J Med Sci 1997. [DOI: 10.1016/s0002-9629(15)40191-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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43
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Wagoner LE. Management of the cardiac transplant recipient: roles of the transplant cardiologist and primary care physician. Am J Med Sci 1997; 314:173-84. [PMID: 9298043 DOI: 10.1097/00000441-199709000-00006] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Cardiac transplantation has become an accepted treatment for selected patients with end-stage heart failure. Despite a successful transplant, denervated transplanted hearts respond differently to cardiac drugs than nontransplanted hearts. The treatments for bradycardia, tachycardia, and hypotension are different than for nontransplanted hearts. Despite the improvement in long-term survival, a number of complications may occur posttransplantation. These complications include, allograft rejection, infection, allograft coronary artery disease, and malignancy. Additionally, posttransplant patients may have complications from the immunosuppressive agents cyclosporine, prednisione, and azathioprine. Such complications include drug interactions with commonly prescribed medications, hypertension, hyperlipidemia, osteoporosis, and gastrointestinal complications. The purpose of this article is to discuss the management of the cardiac transplant recipient as it relates to the aforementioned complications. Management of the cardiac transplantation patient by the primary care physician will also be discussed, including indications for consultation by the primary care physician with the transplant center.
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Affiliation(s)
- L E Wagoner
- Division of Cardiology, University of Cincinnati Medical Center, OH 45267-0542, USA
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