1
|
Dipchand AI, Webber SA. Pediatric heart transplantation: Looking forward after five decades of learning. Pediatr Transplant 2024; 28:e14675. [PMID: 38062996 DOI: 10.1111/petr.14675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 11/17/2023] [Accepted: 11/24/2023] [Indexed: 02/07/2024]
Abstract
Heart transplantation has become the standard of care for pediatric patients with end-stage heart disease throughout the world. Since the first transplant was performed in 1967, the number of transplants has grown dramatically with 13 449 pediatric heart transplants being reported to The International Society of Heart and Lung Transplant (ISHLT) between January 1992 and June 30, 2018. Outcomes have consistently improved over the last few decades, specifically short-term outcomes. Most recent survival data demonstrate that recipients who survive to 1-year post-transplant have excellent long-term survival with more than 60% of those who were transplanted as infants being alive 25 years later. Nonetheless, the rates of graft loss beyond the first year have remained relatively constant over time; driven primarily by our poor understanding and lack of treatments for chronic allograft vasculopathy (CAV). Acute rejection, CAV, graft failure, and infection continue to be the major causes of death within the first 5 years post-transplant. In addition, renal dysfunction, malignancy, and the need for re-transplantation remain as significant issues that require close follow-up. Looking forward, key challenges include improving donor utilization rates (including donation after cardiac death (DCD) and the use of ex vivo perfusion devices), the development of non-invasive biomarkers for rejection, efforts to mitigate the long-term effects of immunosuppression, and prevention of CAV. It is not possible to cover the entire evolution of pediatric heart transplantation over the last five decades, but in this review, we hope to touch on key observations, lessons learned, and practice changes that have advanced the field, as well as glance ahead to the next decade.
Collapse
Affiliation(s)
- Anne I Dipchand
- Department of Paediatrics, Head, Heart Transplant, Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Steven A Webber
- Department of Pediatrics, Vanderbilt University School of Medicine, Pediatrician-in-Chief, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
| |
Collapse
|
2
|
Fraser M, Page RL, Chow S, Alexy T, Peters L. Pharmacotherapy in the heart transplant recipient: A primer for nurse clinicians and pharmacists. Clin Transplant 2024; 38:e15252. [PMID: 38341767 DOI: 10.1111/ctr.15252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 01/02/2024] [Accepted: 01/17/2024] [Indexed: 02/13/2024]
Abstract
Heart transplantation (HT) is the definitive treatment for eligible patients with end-stage heart disease. A major complication of HT is allograft rejection which can lead to graft dysfunction and death. The guiding principle of chronic immunosuppression therapy is to prevent rejection of the transplanted organ while avoiding oversuppression of the immune system, which can cause opportunistic infections and malignancy. The purpose of this review is to describe immunosuppressive management of the HT recipient-including agent-specific pharmacology and pharmacokinetics, outcomes data, adverse effects, clinical considerations, and recent guideline updates. We will also provide recommendations for medical prophylaxis of immunosuppressed patients based on the most recent clinical guidelines. Additionally, we highlight the importance of medical therapy adherence and the effect of social determinants of health on the long-term management of HT. HT recipients are a complex and high-risk population. The objective of this review is to describe basic pharmacotherapy in HT and implications for nurses and pharmacists.
Collapse
Affiliation(s)
- Meg Fraser
- Division of Cardiology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Robert L Page
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado, USA
| | - Sheryl Chow
- Department of Pharmacy Practice and Administration, Western University of Health Sciences, Pomona, California, USA
- Department of Medicine, University of California, Irvine, USA
| | - Tamas Alexy
- Division of Cardiology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Laura Peters
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA
| |
Collapse
|
3
|
Rosenthal LM, Nordmeyer J, Kramer P, Danne F, Pfitzer C, Berger F, Schmitt KRL, Schubert S. Long-term experience using CNI-free immunosuppression in selected paediatric heart transplant recipients. Pediatr Transplant 2021; 25:e14111. [PMID: 34405495 DOI: 10.1111/petr.14111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 06/19/2021] [Accepted: 07/29/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND CNI-free immunosuppression with conversion to mTORi-based immunosuppression has been demonstrated to reduce CNI-toxicity and to exhibit anti-proliferative properties. However, the experience of CNI-free immunosuppression in paediatric heart transplantation is limited. METHODS A retrospective analysis was conducted of 129 paediatric heart transplants performed between 1997 and 2015. Fifteen patients with clinically indicated conversion from CNI-based to CNI-free immunosuppression were identified. Survival data, rejection episodes, renal function, post-transplantation lymphoproliferative disorder and CAV, including examination with OCT were analysed. RESULTS Immunosuppression conversion was successful in all patients. Fourteen of 15 patients (93%) are currently living with good graft function. Median post-transplant survival was 15 years (range, 5-23 years), and median follow-up since conversion was 6 years (range, 1-11 years). Mild (grade 1R) ACR was present in three patients after discontinuation of CNIs. The recovery of renal function with a significant increase in eGFR was observed at 1 and 3 years after conversion. No patient had angiographic signs of macroscopic CAV according to the current ISHLT classification; however, OCT showed the signs of angiographically silent CAV in all patients. CAV did not progress in any patient, implying CAV was stabilised by mTORi-based CNI-free immunosuppression. CONCLUSIONS CNI-free immunosuppression based on mTORis is a safe and appropriate strategy for maintenance therapy in selected paediatric patients, significantly improves renal function and stabilises CAV. OCT revealed early development of angiographically silent CAV.
Collapse
Affiliation(s)
- Lisa-Maria Rosenthal
- Department for Congenital Heart Disease/Pediatric Cardiology, German Heart Institute, Berlin, Germany.,Department for Pediatric Cardiology, Charité Universitätsmedizin, Berlin, Germany
| | - Johannes Nordmeyer
- Department for Congenital Heart Disease/Pediatric Cardiology, German Heart Institute, Berlin, Germany
| | - Peter Kramer
- Department for Congenital Heart Disease/Pediatric Cardiology, German Heart Institute, Berlin, Germany
| | - Friederike Danne
- Department for Congenital Heart Disease/Pediatric Cardiology, German Heart Institute, Berlin, Germany
| | - Constanze Pfitzer
- Department for Congenital Heart Disease/Pediatric Cardiology, German Heart Institute, Berlin, Germany
| | - Felix Berger
- Department for Congenital Heart Disease/Pediatric Cardiology, German Heart Institute, Berlin, Germany.,Department for Pediatric Cardiology, Charité Universitätsmedizin, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Berlin, Germany
| | - Katharina Rose Luise Schmitt
- Department for Congenital Heart Disease/Pediatric Cardiology, German Heart Institute, Berlin, Germany.,Department for Pediatric Cardiology, Charité Universitätsmedizin, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Berlin, Germany
| | - Stephan Schubert
- Department for Congenital Heart Disease/Pediatric Cardiology, German Heart Institute, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Berlin, Germany.,Center of Congenital Heart Disease, Heart and Diabetes Center North Rhine-Westfalia (HDZ-NRW), Ruhr-University of Bochum, Bad Oeynhausen, Germany
| |
Collapse
|
4
|
Anthony C, Imran M, Pouliopoulos J, Emmanuel S, Iliff JW, Moffat KJ, Ross J, Graham RM, Kotlyar E, Muthiah K, Keogh AM, Hayward CS, Macdonald P, Jabbour A. Everolimus for the Prevention of Calcineurin-Inhibitor-Induced Left Ventricular Hypertrophy After Heart Transplantation (RADTAC Study). JACC-HEART FAILURE 2021; 9:301-313. [PMID: 33795116 DOI: 10.1016/j.jchf.2021.01.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 01/04/2021] [Accepted: 01/24/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVES This study aimed to determine the safety and efficacy of combined low-dose everolimus and low-dose tacrolimus compared with standard-dose tacrolimus in attenuating left ventricular hypertrophy (LVH) after orthotopic heart transplantation (OHT). BACKGROUND Calcineurin inhibitors (CNIs) such as tactrolimus are important in preventing cardiac allograft rejection and reducing mortality after OHT. However CNIs are causatively linked to the development of LVH, and are associated with nephrotoxicity and vasculopathy. CNI-sparing agents such as everolimus have been hypothesized to inhibit adverse effects of CNIs. METHODS In this prospective, randomized, open-label study, OHT recipients were randomized at 12 weeks after OHT to a combination of low-dose everolimus and tacrolimus (the RADTAC group) or standard-dose tacrolimus (the TAC group), with both groups coadministered mycophenolate and prednisolone. The primary endpoint was LVH indexed as the change in left ventricular mass (ΔLVM) by cardiovascular magnetic resonance (CMR) imaging from 12 to 52 weeks. Secondary endpoints included CMR-based myocardial performance, T1 fibrosis mapping, blood pressure, and renal function. Safety endpoints included episodes of allograft rejection and infection. RESULTS Forty stable OHT recipients were randomized. Recipients in the RADTAC group had significantly lower tacrolimus levels compared with the TAC group (6.5 ± 3.5 μg/l vs. 8.6 ± 2.8 μg/l; p = 0.02). The mean everolimus level in the RADTAC group was 4.2 ± 1.7 μg/l. A significant reduction in LVM was observed in the RADTAC group compared with an increase in LVM in the TAC group (ΔLVM = -13.0 ± 16.8 g vs. 2.1 ± 8.4 g; p < 0.001). Significant differences were also noted in secondary endpoints measuring function and fibrosis (Δ circumferential strain = -2.9 ± 2.8 vs. 2.1 ± 2.3; p < 0.001; ΔT1 mapping values = -32.7 ± 51.3 ms vs. 26.3 ± 90.4 ms; p = 0.003). No significant differences were observed in blood pressure (Δ mean arterial pressure = 4.2 ± 18.8 mm Hg vs. 2.8 ± 13.8 mm Hg; p = 0.77), renal function (Δ creatinine = 3.1 ± 19.9 μmol/l vs. 9 ± 21.8 μmol/l; p = 0.31), frequency of rejection episodes (p = 0.69), or frequency of infections (p = 0.67) between groups. CONCLUSIONS The combination of low-dose everolimus and tacrolimus compared with standard-dose tacrolimus safely attenuates LVH in the first year after cardiac transplantation with an observed reduction in CMR-measured fibrosis and an improvement in myocardial strain.
Collapse
Affiliation(s)
- Chris Anthony
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Sydney, Australia
| | - Muhammad Imran
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Sydney, Australia
| | - Jim Pouliopoulos
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Sydney, Australia; Victor Chang Cardiac Research Institute
| | - Sam Emmanuel
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Sydney, Australia
| | - James W Iliff
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Sydney, Australia
| | - Kirsten J Moffat
- Medical Imaging Department, St. Vincent's Hospital, Sydney, Australia
| | - Joanne Ross
- Medical Imaging Department, St. Vincent's Hospital, Sydney, Australia
| | - Robert M Graham
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Sydney, Australia; Victor Chang Cardiac Research Institute; Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Eugene Kotlyar
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Sydney, Australia; Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Kavitha Muthiah
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Sydney, Australia; Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Anne M Keogh
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Sydney, Australia; Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Christopher S Hayward
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Sydney, Australia; Victor Chang Cardiac Research Institute; Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Peter Macdonald
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Sydney, Australia; Victor Chang Cardiac Research Institute; Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Andrew Jabbour
- Heart and Lung Transplant Unit, St. Vincent's Hospital, Sydney, Australia; Victor Chang Cardiac Research Institute; Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.
| |
Collapse
|
5
|
Blood Pressure in De Novo Heart Transplant Recipients Treated With Everolimus Compared With a Cyclosporine-based Regimen: Results From the Randomized SCHEDULE Trial. Transplantation 2019; 103:781-788. [PMID: 30211826 DOI: 10.1097/tp.0000000000002445] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Systemic hypertension is prevalent in heart transplant recipients and has been partially attributed to treatment with calcineurin inhibitors (CNIs). SCandinavian HEart transplant De-novo stUdy with earLy calcineurin inhibitors avoidancE trial was the first randomized trial to study early withdrawal of CNIs in de novo heart transplant recipients, comparing an everolimus-based immunosuppressive regimen with conventional CNI-based treatment. As a prespecified secondary endpoint, blood pressure was repeatedly compared across treatment arms. METHODS The The SCandinavian HEart transplant De-novo stUdy with earLy calcineurin inhibitors avoidancE trial was a prospective, multicenter, randomized, controlled, parallel-group, open-label trial in de novo adult heart transplant recipients, undertaken at transplant centers in Scandinavia. Blood pressure was assessed with 24-hour ambulatory blood pressure monitoring up to 3 years after heart transplantation (HTx) in 83 patients. RESULTS Overall, systolic blood pressure fell with time, from 138 ± 15 mm Hg 2 weeks after HTx to 134 ± 11 mm Hg after 12 months and 132 ± 14 mm Hg after 36 months (P = 0.003). Diastolic blood pressure did not change over time. After 12 months, there was a numerically larger fall in systolic blood pressure in the everolimus arm (between-group difference 8 mm Hg; P = 0.053), and after 36 months, there was a significant between group difference of 13 mm Hg (P = 0.02) in favor of everolimus. CONCLUSIONS In this first, randomized trial with early CNI avoidance in de novo HTx recipients, we observed a modest fall in systolic blood pressure over the first 1 to 3 years after transplantation. The fall in systolic blood pressure was more pronounced in patients allocated to everolimus.
Collapse
|
6
|
Silva HT. The Challenges Associated With a Calcineurin Inhibitor-free Regimen After Heart Transplantation. Transplantation 2018; 103:664-665. [PMID: 30247447 DOI: 10.1097/tp.0000000000002444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
7
|
Granata S, Santoro G, Masola V, Tomei P, Sallustio F, Pontrelli P, Accetturo M, Antonucci N, Carratù P, Lupo A, Zaza G. In Vitro Identification of New Transcriptomic and miRNomic Profiles Associated with Pulmonary Fibrosis Induced by High Doses Everolimus: Looking for New Pathogenetic Markers and Therapeutic Targets. Int J Mol Sci 2018; 19:ijms19041250. [PMID: 29677166 PMCID: PMC5979287 DOI: 10.3390/ijms19041250] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 04/17/2018] [Accepted: 04/17/2018] [Indexed: 12/24/2022] Open
Abstract
The administration of Everolimus (EVE), a mTOR inhibitor used in transplantation and cancer, is often associated with adverse effects including pulmonary fibrosis. Although the underlying mechanism is not fully clarified, this condition could be in part caused by epithelial to mesenchymal transition (EMT) of airway cells. To improve our knowledge, primary bronchial epithelial cells (BE63/3) were treated with EVE (5 and 100 nM) for 24 h. EMT markers (α-SMA, vimentin, fibronectin) were measured by RT-PCR. Transepithelial resistance was measured by Millicell-ERS ohmmeter. mRNA and microRNA profiling were performed by Illumina and Agilent kit, respectively. Only high dose EVE increased EMT markers and reduced the transepithelial resistance of BE63/3. Bioinformatics showed 125 de-regulated genes that, according to enrichment analysis, were implicated in collagen synthesis/metabolism. Connective tissue growth factor (CTGF) was one of the higher up-regulated mRNA. Five nM EVE was ineffective on the pro-fibrotic machinery. Additionally, 3 miRNAs resulted hyper-expressed after 100 nM EVE and able to regulate 31 of the genes selected by the transcriptomic analysis (including CTGF). RT-PCR and western blot for MMP12 and CTGF validated high-throughput results. Our results revealed a complex biological network implicated in EVE-related pulmonary fibrosis and underlined new potential disease biomarkers and therapeutic targets.
Collapse
Affiliation(s)
- Simona Granata
- Renal Unit, Department of Medicine, University of Verona, Piazzale Stefani 1, 37126 Verona, Italy.
| | - Gloria Santoro
- Renal Unit, Department of Medicine, University of Verona, Piazzale Stefani 1, 37126 Verona, Italy.
| | - Valentina Masola
- Renal Unit, Department of Medicine, University of Verona, Piazzale Stefani 1, 37126 Verona, Italy.
| | - Paola Tomei
- Renal Unit, Department of Medicine, University of Verona, Piazzale Stefani 1, 37126 Verona, Italy.
| | - Fabio Sallustio
- Department of Emergency and Organ Transplantation, University of Bari "Aldo Moro", Piazza Giulio Cesare 11, 70124 Bari, Italy.
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari "Aldo Moro", Piazza Giulio Cesare 11, 70124 Bari, Italy.
| | - Paola Pontrelli
- Department of Emergency and Organ Transplantation, University of Bari "Aldo Moro", Piazza Giulio Cesare 11, 70124 Bari, Italy.
| | - Matteo Accetturo
- Department of Emergency and Organ Transplantation, University of Bari "Aldo Moro", Piazza Giulio Cesare 11, 70124 Bari, Italy.
| | - Nadia Antonucci
- Renal Unit, Department of Medicine, University of Verona, Piazzale Stefani 1, 37126 Verona, Italy.
| | - Pierluigi Carratù
- Department of Respiratory Diseases, University of Bari "Aldo Moro", Piazza Giulio Cesare 11, 70124 Bari, Italy.
| | - Antonio Lupo
- Renal Unit, Department of Medicine, University of Verona, Piazzale Stefani 1, 37126 Verona, Italy.
| | - Gianluigi Zaza
- Renal Unit, Department of Medicine, University of Verona, Piazzale Stefani 1, 37126 Verona, Italy.
| |
Collapse
|
8
|
Cardiovascular Parameters to 2 years After Kidney Transplantation Following Early Switch to Everolimus Without Calcineurin Inhibitor Therapy: An Analysis of the Randomized ELEVATE Study. Transplantation 2017; 101:2612-2620. [PMID: 28333860 DOI: 10.1097/tp.0000000000001739] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Mammalian target of rapamycin inhibitors may confer cardioprotective advantages, but clinical data are limited. METHODS In the open-label ELEVATE trial, kidney transplant patients were randomized at 10 to 14 weeks after transplant to convert from calcineurin inhibitor (CNI) to everolimus or remain on standard CNI therapy. Prespecified end points included left ventricular mass index and, in a subpopulation of patients, arterial stiffness as measured by pulse wave velocity. RESULTS The mean change in left ventricular mass index from randomization was similar with everolimus versus CNI (month 24, -4.37 g/m versus -5.26 g/m; mean difference, 0.89 [p = 0.392]). At month 24, left ventricular hypertrophy was present in 41.7% versus 37.7% of everolimus and CNI patients, respectively. Mean pulse wave velocity remained stable with both everolimus (mean change from randomization to month 12, -0.24 m/s; month 24, -0.03 m/s) and CNI (month 12, 0.11 m/s; month 24, 0.16 m/s). The change in mean ambulatory nighttime blood pressure from randomization showed a benefit for diastolic pressure at month 12 (P = 0.039) but not at month 24. Major adverse cardiac events occurred in 1.1% and 4.2% of everolimus-treated and CNI-treated patients, respectively, by month 12 (P = 0.018) and 2.3% (8/353) and 4.5% by month 24 (P = 0.145). CONCLUSIONS Overall, these data do not suggest a clinically relevant effect on cardiac end points after early conversion from CNI to a CNI-free everolimus-based regimen.
Collapse
|
9
|
Asante-Korang A, Carapellucci J, Krasnopero D, Doyle A, Brown B, Amankwah E. Conversion from calcineurin inhibitors to mTOR inhibitors as primary immunosuppressive drugs in pediatric heart transplantation. Clin Transplant 2017; 31. [PMID: 28708333 DOI: 10.1111/ctr.13054] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2017] [Indexed: 11/28/2022]
Abstract
There are only a few reports of successful use of mammalian target of rapamycin (mTORI) as primary immunosuppression in pediatric heart transplantation. Compared to calcineurin inhibitors, mTORI have less side effects, especially nephrotoxicity, infections, and malignancies. A retrospective study was conducted at our institution of all 170 heart transplants from 1995 to 2015. Nineteen patients were switched from tacrolimus (n=15) or cyclosporin (n=4) to everolimus (n=4) or sirolimus (n=15) due to nephrotoxicity (n=5), malignancy (n=8), EBV viremia/reactive plasmacytic changes (n=5), and immune hemolytic anemia (n=1). We monitored for rejection, infection, BUN, creatinine, hyperlipidemia, EBV and CMV copies, CBC, cardiac allograft vasculopathy (CAV), and death. Target trough levels of sirolimus and everolimus were 4-10. Four treatment failures included debilitating rash, bone marrow suppression, recurrent rejection, and renal transplantation. There were no deaths. One patient had recurrent rejection episodes, and tacrolimus was reinitiated. One patient with preexisting CAV underwent heart retransplantation. One patient, who was treated for PTLD, transformed to CD30+ Hodgkins disease, and was treated with brentuximab. There were three acute rejection episodes. Median creatinine preswitch was higher 0.82 than postswitch 0.78 (P=.016). Median eGFR was lower preswitch, 75.6, than postswitch, 91.2 (P=.0004). These results indicate that conversion to mTORI as primary immunosuppression may be safely accomplished in some pediatric heart transplant patients.
Collapse
Affiliation(s)
- Alfred Asante-Korang
- Divisions of Cardiology, Johns Hopkins All Children's Hospital, St Petersburg, FL, USA
| | - Jennifer Carapellucci
- Divisions of Cardiology, Johns Hopkins All Children's Hospital, St Petersburg, FL, USA
| | - Diane Krasnopero
- Divisions of Cardiology, Johns Hopkins All Children's Hospital, St Petersburg, FL, USA
| | - Abigail Doyle
- Divisions of Cardiology, Johns Hopkins All Children's Hospital, St Petersburg, FL, USA
| | - Brian Brown
- Pharmacy, Johns Hopkins All Children's Hospital, St Petersburg, FL, USA
| | - Ernest Amankwah
- Center for Translational Research, Johns Hopkins All Children's Hospital, St Petersburg, FL, USA.,Hematology Oncology, Johns Hopkins All Children's Hospital, St Petersburg, FL, USA
| |
Collapse
|
10
|
Hu YN, Lee NY, Roan JN, Hsu CH, Luo CY. High-dose calcineurin inhibitor-free everolimus as a maintenance regimen for heart transplantation may be a risk factor for Pneumocystis pneumonia. Transpl Infect Dis 2017; 19. [PMID: 28425200 DOI: 10.1111/tid.12709] [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] [Received: 10/26/2016] [Revised: 12/21/2016] [Accepted: 01/15/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Everolimus reduces the incidence of cardiac-allograft vasculopathy (CAV) and is less renally toxic than are calcineurin inhibitors (CNIs). We evaluated the safety of CNI-free everolimus for post-heart transplant (HTx) patients. METHODS We retrospectively reviewed the records of 36 consecutive patients who had undergone an HTx between January 2006 and December 2013 in National Cheng Kung University Hospital. All patients initially had been treated with the standard tacrolimus regimen. The Study group-12 patients with CAV, renal impairment, or a history of malignancy-were switched from tacrolimus to everolimus. The Control group consisted of 19 patients who remained on the standard regimen. The target everolimus trough concentration was 8-14 ng/mL. The primary outcome was survival, and the secondary outcomes were bacterial, viral, fungal, and other infections; Pneumocystis jirovecii pneumonia (PJP); and rejection (≥2R). RESULTS During a 53.3±25.6-month follow-up, the survival rate, rejection rate, and number of infections, except for PJP, were not significantly different between the two groups. In the Study group, 6 patients were diagnosed with PJP 33±18.2 months after switching. None of the Control group patients were diagnosed with PJP during follow-up. CONCLUSIONS A high-dose CNI-free everolimus maintenance regimen might yield a higher incidence of post-transplantation PJP.
Collapse
Affiliation(s)
- Yu-Ning Hu
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Nan-Yao Lee
- Division of Infection, Department of Internal Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Jun-Neng Roan
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Institute of Clinical Medicine, National Cheng Kung University Hospital and College of Medicine, Tainan, Taiwan
| | - Chi-Hsin Hsu
- Institute of Clinical Medicine, National Cheng Kung University Hospital and College of Medicine, Tainan, Taiwan.,Division of Critical Care Medicine, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chwan-Yau Luo
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Cardiovascular Research Center, National Cheng Kung University, Tainan, Taiwan
| |
Collapse
|
11
|
Recent Advances in Mammalian Target of Rapamycin Inhibitor Use in Heart and Lung Transplantation. Transplantation 2016; 100:2558-2568. [DOI: 10.1097/tp.0000000000001432] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
|
12
|
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.
Collapse
|
13
|
Imamura T, Kinugawa K, Doi K, Hatano M, Fujino T, Kinoshita O, Nawata K, Noiri E, Kyo S, Ono M. Plasma neutrophil gelatinase-associated lipocalin and worsening renal function during everolimus therapy after heart transplantation. Int Heart J 2015; 56:73-9. [PMID: 25742944 DOI: 10.1536/ihj.14-179] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Recently, the mammalian target of rapamycin inhibitor everolimus (EVL) has been introduced as a novel immunosuppressant for heart transplant (HTx) recipients, and is expected to preserve renal function compared to conventional calcineurin inhibitors (CNIs). However, a considerable number of recipients treated with EVL were not free from worsening renal function regardless of CNI reduction. Data were collected retrospectively from 27 HTx recipients who had received EVL (trough concentration, 3.1-9.2 ng/mL) along with reduced CNIs (%decreases in trough concentration, 27.3 ± 13.0%) because of switching from mycophenolate mophetil due to digestive symptoms or neutropenia, progressive coronary artery vasculopathy, or persistent renal dysfunction, and had been followed over 1 year between August 2008 and January 2013. Estimated glomerular filtration rate (eGFR) decreased in 5 recipients (18.5%) during the study period. Univariate logistic regression analysis demonstrated that a higher plasma neutrophil gelatinase-associated lipocalin (P-NGAL) level was the only significant predictor for a decrease in eGFR over a 1-year EVL treatment period among all baseline parameters (P = 0.008). eGFR and proteinuria worsened almost exclusively in patients with baseline P-NGAL ≥ 85 ng/mL, which was the cutoff value calculated by an ROC analysis (area under the curve, 0.955; sensitivity, 1.000; specificity, 0.955). In conclusion, higher P-NGAL may be a novel predictor for the worsening of renal function after EVL treatment that is resistant to CNI reduction in HTx recipients.
Collapse
Affiliation(s)
- Teruhiko Imamura
- Department of Therapeutic Strategy for Heart Failure, Graduate School of Medicine, University of Tokyo
| | | | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Fuchs U, Zittermann A, Ensminger SM, Schulz U, Gummert JF. Clinical outcome in heart transplant recipients receiving everolimus in combination with dosage reduction of the calcineurin inhibitor cyclosporine A or tacrolimus. Transpl Immunol 2014; 31:87-91. [DOI: 10.1016/j.trim.2014.06.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 06/05/2014] [Accepted: 06/05/2014] [Indexed: 11/15/2022]
|
15
|
Influence of proliferation signal inhibitors on vascular endothelial growth factor production in heart transplant recipients - preliminary report. POLISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2014; 11:173-7. [PMID: 26336417 PMCID: PMC4283867 DOI: 10.5114/kitp.2014.43846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/18/2014] [Revised: 02/07/2014] [Accepted: 04/02/2014] [Indexed: 11/20/2022]
Abstract
Proliferation signal inhibitors (PSI) are especially beneficial for heart transplant recipients, but are rarely used due to frequent side effects. As they may be caused by vascular endothelial growth factor (VEGF), we performed a prospective cross-sectional pilot study to assess the influence of PSI and/or calcineurin inhibitors (CNI) presence in immunosuppressive protocols of heart transplant recipients on VEGF secretion. All electively screened heart transplant recipients willing to participate were enrolled in the study. The preliminary report was based on the results of the first 89 serum samples. The study group (n = 84) consisted of the PSI group (n = 14) further divided into the PSI + CNI subgroup (n = 10) and PSIw/oCNI subgroup (n = 4) based on concomitant CNI use, and the CNIw/oPSI group (n = 70) receiving CNI without PSI. The control group (n = 5) consisted of patients not requiring immunosuppression. VEGF was present in serum of 70 (83%) study group patients: median (range) 18 (0-316) pg/mL, mean 35 ± 57 pg/mL; in 13 (93%) PSI group patients: 22 (0-110) pg/mL, 28 ± 28 pg/mL, with 19 (8-20) pg/mL, 16 ± 6 pg/mL in the PSI + CNI subgroup, and 29 (0-110) pg/mL, 32 ± 32 pg/mL in the PSIw/oCNI subgroup. In the CNIw/oPSI group VEGF was present in 57 (81%) patients: 16 (0-316) pg/mL, 37 ± 62 pg/mL, and in the control group in 3 (60%) patients: 4 (0-110) pg/mL, 32 ± 48 pg/mL. None of the differences observed between any compared groups and/or subgroups was significant (χ2 and Mann-Whitney U test). In conclusion, differences of VEGF concentration observed among groups imply the influence of PSI and CNI on VEGF production, but further studies involving higher numbers of participants are needed to prove it.
Collapse
|