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Liu X, Shen J, Yan H, Hu J, Liao G, Liu D, Zhou S, Zhang J, Liao J, Guo Z, Li Y, Yang S, Li S, Chen H, Guo Y, Li M, Fan L, Li L, Luo P, Zhao M, Liu Y. Posttransplant complications: molecular mechanisms and therapeutic interventions. MedComm (Beijing) 2024; 5:e669. [PMID: 39224537 PMCID: PMC11366828 DOI: 10.1002/mco2.669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 07/02/2024] [Accepted: 07/08/2024] [Indexed: 09/04/2024] Open
Abstract
Posttransplantation complications pose a major challenge to the long-term survival and quality of life of organ transplant recipients. These complications encompass immune-mediated complications, infectious complications, metabolic complications, and malignancies, with each type influenced by various risk factors and pathological mechanisms. The molecular mechanisms underlying posttransplantation complications involve a complex interplay of immunological, metabolic, and oncogenic processes, including innate and adaptive immune activation, immunosuppressant side effects, and viral reactivation. Here, we provide a comprehensive overview of the clinical features, risk factors, and molecular mechanisms of major posttransplantation complications. We systematically summarize the current understanding of the immunological basis of allograft rejection and graft-versus-host disease, the metabolic dysregulation associated with immunosuppressive agents, and the role of oncogenic viruses in posttransplantation malignancies. Furthermore, we discuss potential prevention and intervention strategies based on these mechanistic insights, highlighting the importance of optimizing immunosuppressive regimens, enhancing infection prophylaxis, and implementing targeted therapies. We also emphasize the need for future research to develop individualized complication control strategies under the guidance of precision medicine, ultimately improving the prognosis and quality of life of transplant recipients.
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Affiliation(s)
- Xiaoyou Liu
- Department of Organ transplantationThe First Affiliated Hospital, Guangzhou Medical UniversityGuangzhouChina
| | - Junyi Shen
- Department of OncologyZhujiang HospitalSouthern Medical UniversityGuangzhouChina
| | - Hongyan Yan
- Department of Organ transplantationThe First Affiliated Hospital, Guangzhou Medical UniversityGuangzhouChina
| | - Jianmin Hu
- Department of Organ transplantationZhujiang HospitalSouthern Medical UniversityGuangzhouChina
| | - Guorong Liao
- Department of Organ transplantationZhujiang HospitalSouthern Medical UniversityGuangzhouChina
| | - Ding Liu
- Department of Organ transplantationZhujiang HospitalSouthern Medical UniversityGuangzhouChina
| | - Song Zhou
- Department of Organ transplantationZhujiang HospitalSouthern Medical UniversityGuangzhouChina
| | - Jie Zhang
- Department of Organ transplantationThe First Affiliated Hospital, Guangzhou Medical UniversityGuangzhouChina
| | - Jun Liao
- Department of Organ transplantationZhujiang HospitalSouthern Medical UniversityGuangzhouChina
| | - Zefeng Guo
- Department of Organ transplantationZhujiang HospitalSouthern Medical UniversityGuangzhouChina
| | - Yuzhu Li
- Department of Organ transplantationZhujiang HospitalSouthern Medical UniversityGuangzhouChina
| | - Siqiang Yang
- Department of Organ transplantationZhujiang HospitalSouthern Medical UniversityGuangzhouChina
| | - Shichao Li
- Department of Organ transplantationZhujiang HospitalSouthern Medical UniversityGuangzhouChina
| | - Hua Chen
- Department of Organ transplantationZhujiang HospitalSouthern Medical UniversityGuangzhouChina
| | - Ying Guo
- Department of Organ transplantationZhujiang HospitalSouthern Medical UniversityGuangzhouChina
| | - Min Li
- Department of Organ transplantationZhujiang HospitalSouthern Medical UniversityGuangzhouChina
| | - Lipei Fan
- Department of Organ transplantationZhujiang HospitalSouthern Medical UniversityGuangzhouChina
| | - Liuyang Li
- Department of Organ transplantationZhujiang HospitalSouthern Medical UniversityGuangzhouChina
| | - Peng Luo
- Department of OncologyZhujiang HospitalSouthern Medical UniversityGuangzhouChina
| | - Ming Zhao
- Department of Organ transplantationZhujiang HospitalSouthern Medical UniversityGuangzhouChina
| | - Yongguang Liu
- Department of Organ transplantationZhujiang HospitalSouthern Medical UniversityGuangzhouChina
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Miura K, Yu R, Entwistle TR, McKenzie SC, Green AC. Long-term changes in body weight and serum cholesterol in heart transplant recipients. Clin Transplant 2022; 36:e14819. [PMID: 36074751 PMCID: PMC10909516 DOI: 10.1111/ctr.14819] [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: 04/14/2022] [Revised: 08/27/2022] [Accepted: 09/05/2022] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Long-term changes in weight and blood lipids beyond 12 months after heart transplantation are largely unknown. We quantified changes in weight, body mass index (BMI), blood cholesterol, and triglycerides in heart transplant recipients (HTRs) during the 36 months after transplantation, and we assessed the influence of statin therapy on these outcomes. METHODS Retrospective cohort study of adult HTRs, transplanted 1990-2017, in Queensland, Australia. From each patient's medical charts, we extracted weight, total cholesterol, triglycerides, and statin therapy at four time-points: time of transplant (baseline), and 12-, 24-, 36-month post-transplant. Changes in weight and blood lipids were assessed according to baseline BMI. RESULTS Among 316 HTRs, 236 (median age 52 years, 83% males) with available information were included. During the 36 months post-transplant, all patients gained weight (83.5-90.5 kg; p < .001), especially those with baseline BMI < 25.0 km/m2 (67.9-76.2 kg; p < .001). Mean blood cholesterol (4.60-4.90 mmol/L; p = .004) and mean blood triglycerides (1.79-2.18 mmol/L; p = .006) also increased significantly in all patients, particularly in those with baseline BMI ≥ 25.0 km/m2 but the differences were not significant (total cholesterol 4.42-5.13 mmol/L; triglycerides 1.76-2.47 mmol/L). Total cholesterol was highest in patients not taking statins, and levels differed significantly (p = .010) according to statin dosing changes during the 36 months post-transplant. CONCLUSION Patients demonstrate significant rises in weight and blood lipids in the 36 months after heart transplantation.
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Affiliation(s)
- Kyoko Miura
- Population Health DepartmentQIMR Berghofer Medical Research InstituteHerstonQLDAustralia
- Faculty of MedicineThe University of QueenslandSt LuciaQueenslandAustralia
| | - Regina Yu
- Population Health DepartmentQIMR Berghofer Medical Research InstituteHerstonQLDAustralia
| | | | - Scott C McKenzie
- Faculty of MedicineThe University of QueenslandSt LuciaQueenslandAustralia
- Advanced Heart Failure and Cardiac Transplant UnitThe Prince Charles HospitalChermsideQLDAustralia
| | - Adèle C Green
- Population Health DepartmentQIMR Berghofer Medical Research InstituteHerstonQLDAustralia
- CRUK Manchester Institute and University of ManchesterManchester Academic Health Science CentreManchesterUK
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Nelson J, Alvey N, Bowman L, Schulte J, Segovia M, McDermott J, Te HS, Kapila N, Levine DJ, Gottlieb RL, Oberholzer J, Campara M. Consensus recommendations for use of maintenance immunosuppression in solid organ transplantation: Endorsed by the American College of Clinical Pharmacy, American Society of Transplantation, and the International Society for Heart and Lung Transplantation. Pharmacotherapy 2022; 42:599-633. [DOI: 10.1002/phar.2716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 03/29/2022] [Accepted: 04/08/2022] [Indexed: 12/17/2022]
Affiliation(s)
- Joelle Nelson
- Department of Pharmacotherapy and Pharmacy Services University Health San Antonio Texas USA
- Pharmacotherapy Education and Research Center University of Texas Health San Antonio San Antonio Texas USA
- Department of Pharmacy, Pharmacotherapy Division, College of Pharmacy The University of Texas at Austin Austin Texas USA
| | - Nicole Alvey
- Department of Pharmacy Rush University Medical Center Chicago Illinois USA
- Science and Pharmacy Roosevelt University College of Health Schaumburg Illinois USA
| | - Lyndsey Bowman
- Department of Pharmacy Tampa General Hospital Tampa Florida USA
| | - Jamie Schulte
- Department of Pharmacy Services Thomas Jefferson University Hospital Philadelphia Pennsylvania USA
| | | | - Jennifer McDermott
- Richard DeVos Heart and Lung Transplant Program, Spectrum Health Grand Rapids Michigan USA
- Department of Medicine, Michigan State University College of Human Medicine Grand Rapids Michigan USA
| | - Helen S. Te
- Liver Transplantation, Center for Liver Diseases, Department of Medicine University of Chicago Medical Center Chicago Illinois USA
| | - Nikhil Kapila
- Department of Transplant Hepatology Duke University Hospital Durham North Carolina USA
| | - Deborah Jo Levine
- Division of Critical Care Medicine, Department of Medicine The University of Texas Health Science Center at San Antonio San Antonio Texas USA
| | - Robert L. Gottlieb
- Baylor University Medical Center and Baylor Scott and White Research Institute Dallas Texas USA
| | - Jose Oberholzer
- Department of Surgery/Division of Transplantation University of Virginia Charlottesville Virginia USA
| | - Maya Campara
- Department of Surgery University of Illinois Chicago Chicago Illinois USA
- Department of Pharmacy Practice University of Illinois Chicago Chicago Illinois USA
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Dyslipidemia in Transplant Patients: Which Therapy? J Clin Med 2022; 11:jcm11144080. [PMID: 35887846 PMCID: PMC9318180 DOI: 10.3390/jcm11144080] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 07/11/2022] [Accepted: 07/11/2022] [Indexed: 12/17/2022] Open
Abstract
Cardiovascular disease is the most important cause of death worldwide in recent years; an increasing trend is also shown in organ transplant patients subjected to immunosuppressive therapies, in which cardiovascular diseases represent one of the most frequent causes of long-term mortality. This is also linked to immunosuppressant-induced dyslipidemia, which occurs in 27 to 71% of organ transplant recipients. The aim of this review is to clarify the pathophysiological mechanisms underlying dyslipidemia in patients treated with immunosuppressants to identify immunosuppressive therapies which do not cause dyslipidemia or therapeutic pathways effective in reducing hypercholesterolemia, hypertriglyceridemia, or both, without further adverse events.
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Abstract
An increased risk of cardiovascular disease, independent of conventional risk factors, is present even at minor levels of renal impairment and is highest in patients with end-stage renal disease (ESRD) requiring dialysis. Renal dysfunction changes the level, composition and quality of blood lipids in favour of a more atherogenic profile. Patients with advanced chronic kidney disease (CKD) or ESRD have a characteristic lipid pattern of hypertriglyceridaemia and low HDL cholesterol levels but normal LDL cholesterol levels. In the general population, a clear relationship exists between LDL cholesterol and major atherosclerotic events. However, in patients with ESRD, LDL cholesterol shows a negative association with these outcomes at below average LDL cholesterol levels and a flat or weakly positive association with mortality at higher LDL cholesterol levels. Overall, the available data suggest that lowering of LDL cholesterol is beneficial for prevention of major atherosclerotic events in patients with CKD and in kidney transplant recipients but is not beneficial in patients requiring dialysis. The 2013 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for Lipid Management in CKD provides simple recommendations for the management of dyslipidaemia in patients with CKD and ESRD. However, emerging data and novel lipid-lowering therapies warrant some reappraisal of these recommendations.
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Warden BA, Duell PB. Management of dyslipidemia in adult solid organ transplant recipients. J Clin Lipidol 2019; 13:231-245. [PMID: 30928441 DOI: 10.1016/j.jacl.2019.01.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 01/21/2019] [Accepted: 01/22/2019] [Indexed: 02/07/2023]
Abstract
Solid organ transplantation (SOT) has revolutionized treatment of end-stage disease. Improvements in the SOT continuum of care have unmasked a significant burden of cardiovascular disease, manifesting as a leading cause of morbidity and mortality. Although several risk factors for development of post-transplant cardiovascular disease exist, dyslipidemia remains one of the most frequent and modifiable risks. An important contributor to dyslipidemia in SOT recipients is the off-target metabolic effects of immunosuppressive medications, which may alter lipoproteins and their metabolism. Dyslipidemia management is paramount as lipid-lowering therapy with statins has demonstrated reductions in graft vasculopathy, decreased rejection rates, and improved survival. Several nonstatin medication options are available, but data supporting their benefit in the SOT population are minimal, typically extrapolated from studies in the general population. Further compounding dyslipidemia management is the complex interplay of drug interactions between lipid-lowering and immunosuppressant medications, which can result in serious toxicity and/or therapeutic failure.
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Affiliation(s)
- Bruce A Warden
- Center for Preventive Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - P Barton Duell
- Center for Preventive Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA.
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Temporal Changes on the Risks and Complications of Posttransplantion Diabetes Mellitus Following Cardiac Transplantation. J Transplant 2018; 2018:9205083. [PMID: 30533218 PMCID: PMC6250037 DOI: 10.1155/2018/9205083] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 09/27/2018] [Accepted: 10/21/2018] [Indexed: 01/14/2023] Open
Abstract
Background Recent changes in the demographic of cardiac donors and recipients have modulated the rate and risk, associated with posttransplant diabetes mellitus (PTDM). We investigated the secular trends of the risk of PTDM at 1 year and 3 years after transplantation over 30 years and explored its effect on major outcomes. Methods Three hundred and three nondiabetic patients were followed for a minimum of 36 months, after a first cardiac transplantation performed between 1983 and 2011. Based on the year of their transplantation, the patients were divided into 3 eras: (1983-1992 [era 1], 1993-2002 [era 2], and 2003-2011 [era 3]). Results In eras 1, 2, and 3, the proportions of patients with PTDM at 1 versus 3 years were 23% versus 39%, 21% versus 26%, and 33% versus 38%, respectively. Independent risk factors predicting PTDM at one year were recipient's age, duration of cold ischemic time, treatment with furosemide, and tacrolimus. There was a trend for overall survival being worse for patients with PTDM in comparison to patients without PTDM (p = 0.08). Patients with PTDM exhibited a significantly higher rate of renal failure over a median follow-up of 10 years (p = 0.03). Conclusion The development of PTDM following cardiac transplantation approaches 40% at 3 years and has not significantly changed over thirty years. The presence of PTDM is weakly associated with an increased mortality and is significantly associated with a worsening in renal function long-term following cardiac transplantation.
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Effect of immunosuppressive therapy on the serum fatty acids of phospholipids fraction in patients after heart transplantation. Transplant Proc 2014; 46:2825-9. [PMID: 25380928 DOI: 10.1016/j.transproceed.2014.09.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND The effects of tacrolimus (Tac) and cyclosporine (CsA) on lipid profile is well known; however, little is known about the changes in fatty acids (FA) of phosholipids fraction (PL) in heart transplant patients after treatment with these immunosuppressants. This study aimed to investigate the effect of Tac and CsA on serum FA of PL in heart transplant patients. METHODS The study included 23 patients after heart transplantation on Tac (n = 14; group II) or CsA (n = 9; group I). Eleven healthy persons served as a control group. Serum FA of PL were extracted, separated on Sep-Pak NH2, methylated, and measured with the use of gas chromatography. Chemstation software was used to analyze the data. RESULTS No differences between the studied groups and control were noted for saturated FA, monounsaturated FA, polyunsaturated FA (PUFA), total FA, and PUFA n-6. The mean value of PUFA n-3 was significantly higher in the CsA group compared with the Tac group (P < .015) and control (P < .002) as well as in the Tac group compared with control (P < .001). For individual FA, higher mean concentration, compared with control, was found for C24, C20:2, C20:4, and C22:6 (P < .001 in all cases) and lower for C18:2cis (P < .001 in both groups) and for C18:3 in the Tac group. The mean values of PUFA n-6 to PUFA n-3 ratios were lower than in control (both P < .001). CONCLUSIONS Different pattern of FA of PL may indicate the different FA metabolism in heart transplant patients treated by different immunosuppressants. This should be taken into account when FA supplementation in these patients is considered.
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Scheffert JL, Raza K. Immunosuppression in lung transplantation. J Thorac Dis 2014; 6:1039-53. [PMID: 25132971 DOI: 10.3978/j.issn.2072-1439.2014.04.23] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Accepted: 04/16/2014] [Indexed: 01/10/2023]
Abstract
Lung transplantation can be a life-saving procedure for those with end-stage lung diseases. Unfortunately, long term graft and patient survival are limited by both acute and chronic allograft rejection, with a median survival of just over 6 years. Immunosuppressive regimens are employed to reduce the rate of rejection, and while protocols vary from center to center, conventional maintenance therapy consists of triple drug therapy with a calcineurin inhibitor (cyclosporine or tacrolimus), antiproliferative agents [azathioprine (AZA), mycophenolate, sirolimus (srl), everolimus (evl)], and corticosteroids (CS). Roughly 50% of lung transplant centers also utilize induction therapy, with polyclonal antibody preparations [equine or rabbit anti-thymocyte globulin (ATG)], interleukin 2 receptor antagonists (IL2RAs) (daclizumab or basiliximab), or alemtuzumab. This review summarizes these agents and the data surrounding their use in lung transplantation, as well as additional common and novel therapies in lung transplantation. Despite the progression of the management of lung transplant recipients, they continue to be at high risk of treatment-related complications, and poor graft and patient survival. Randomized clinical trials are needed to allow for the development of better agents, regimens and techniques to address above mentioned issues and reduce morbidity and mortality among lung transplant recipients.
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Affiliation(s)
- Jenna L Scheffert
- 1 NewYork-Presbyterian Hospital/Columbia University Medical Center, Department of Pharmacy, USA ; 2 Lung Transplant Program, Department of Pulmonary, Allergy and Critical Care Medicine, Columbia University Medical Center, USA
| | - Kashif Raza
- 1 NewYork-Presbyterian Hospital/Columbia University Medical Center, Department of Pharmacy, USA ; 2 Lung Transplant Program, Department of Pulmonary, Allergy and Critical Care Medicine, Columbia University Medical Center, USA
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Lachance K, White M, Carrier M, Mansour A, Racine N, Liszkowski M, Ducharme A, de Denus S. Long-term evolution, secular trends, and risk factors of renal dysfunction following cardiac transplantation. Transpl Int 2014; 27:824-37. [DOI: 10.1111/tri.12340] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 03/03/2014] [Accepted: 04/13/2014] [Indexed: 01/20/2023]
Affiliation(s)
- Kim Lachance
- Montreal Heart Institute; Montreal QC Canada
- Faculty of Pharmacy; Université de Montréal; Montreal QC Canada
| | - Michel White
- Montreal Heart Institute; Montreal QC Canada
- Faculty of Medicine; Université de Montréal; Montreal QC Canada
| | - Michel Carrier
- Montreal Heart Institute; Montreal QC Canada
- Faculty of Medicine; Université de Montréal; Montreal QC Canada
| | - Asmaa Mansour
- Montreal Health Innovations Coordinating Center; a Division of the Montreal Heart Institute; Montreal QC Canada
| | - Normand Racine
- Montreal Heart Institute; Montreal QC Canada
- Faculty of Medicine; Université de Montréal; Montreal QC Canada
| | - Mark Liszkowski
- Montreal Heart Institute; Montreal QC Canada
- Faculty of Medicine; Université de Montréal; Montreal QC Canada
| | - Anique Ducharme
- Montreal Heart Institute; Montreal QC Canada
- Faculty of Medicine; Université de Montréal; Montreal QC Canada
| | - Simon de Denus
- Montreal Heart Institute; Montreal QC Canada
- Faculty of Pharmacy; Université de Montréal; Montreal QC Canada
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Wegrzyn P, Popiolek M, Przybylowski P, Wierzbicki K, Zareba K, Milaniak I, Kapelak B, Bartus K, Pfitzner R, Sadowski J. The risk of cholelithiasis in patients after heart transplantation. Arch Med Sci 2014; 10:53-7. [PMID: 24701214 PMCID: PMC3953977 DOI: 10.5114/aoms.2014.40733] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Revised: 10/21/2012] [Accepted: 12/01/2012] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Extended immunosuppressive treatment in patients after heart transplantation modifies etiopathogenesis and occurrence of many diseases in this population. The aim of the present study was to evaluate the frequency and to define risk factors for cholelithiasis after heart transplantation (HTX). MATERIAL AND METHODS The study population consisted of 176 subjects. Of them, 24 patients (group A) presented with symptomatic cholelithiasis. Another group of 24 patients without cholelithiasis (group B) served as controls. Both groups were similar with respect to age, gender and follow-up after the transplant. Clinical interview, surgical and hospitalization data were collected from medical records. RESULTS The groups did not differ in demographic features. There were statistical differences (p < 0.05) between group A and B in rejection reaction, doses of immunosuppressive drugs, type 2 diabetes, serum lipid disorders and acute rejection episodes. These events were caused by modification of treatment, especially the immunosuppressive regimen. Group A consisted of 75% men and 25% women. The frequency of symptomatic cholelithiasis was 11.7% in men and 27.3% in women, on average 19.5%. Mean time to cholelithiasis following HTX was 37.9 ±4.9 (Me = 41.5) months, 27.7 ±8.2 (Me = 30.0) months in women and 41.3 ±5.9 (Me = 41.5) months in men. The female to male ratio was 2.3: 1. CONCLUSIONS Cholelithiasis following HTX was significantly more frequent as compared with the non-transplant population. Patients with cholelithiasis required more aggressive immunosuppression because of more frequent episodes of acute transplant rejection. Patients with cholelithiasis significantly more frequently showed increased glycemia and blood lipids, which could be the side effect of intensive immunosuppressive therapy.
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Affiliation(s)
- Piotr Wegrzyn
- Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University, John Paul II Hospital, Krakow, Poland
| | - Marcin Popiolek
- Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University, John Paul II Hospital, Krakow, Poland
| | - Piotr Przybylowski
- Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University, John Paul II Hospital, Krakow, Poland
| | - Karol Wierzbicki
- Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University, John Paul II Hospital, Krakow, Poland
| | - Kornelia Zareba
- Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University, John Paul II Hospital, Krakow, Poland
| | - Irena Milaniak
- Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University, John Paul II Hospital, Krakow, Poland
| | - Boguslaw Kapelak
- Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University, John Paul II Hospital, Krakow, Poland
| | - Krzysztof Bartus
- Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University, John Paul II Hospital, Krakow, Poland
| | - Roman Pfitzner
- Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University, John Paul II Hospital, Krakow, Poland
| | - Jerzy Sadowski
- Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University, John Paul II Hospital, Krakow, Poland
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Annaloro C, Airaghi L, Saporiti G, Onida F, Cortelezzi A, Deliliers GL. Metabolic syndrome in patients with hematological diseases. Expert Rev Hematol 2014; 5:439-58. [DOI: 10.1586/ehm.12.35] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Gillis KA, Patel RK, Jardine AG. Cardiovascular complications after transplantation: treatment options in solid organ recipients. Transplant Rev (Orlando) 2013; 28:47-55. [PMID: 24412041 DOI: 10.1016/j.trre.2013.12.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Accepted: 12/01/2013] [Indexed: 12/14/2022]
Abstract
Premature cardiovascular disease is the commonest cause of death in solid organ transplant recipients, with coronary artery disease, sudden cardiac death and heart failure being highly prevalent. There are unique factors leading to CV disease in organ transplant recipients that include underlying comorbidities, and metabolic effects of immunosuppression. As a consequence management strategies developed in the general population may have limited benefit. In this review, we will focus on renal transplantation, where most research has been carried out and, despite incomplete understanding of the disease process, the incidence of cardiovascular disease appears to be falling.
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Metabolic profile of patients after heart transplantation. COR ET VASA 2013. [DOI: 10.1016/j.crvasa.2013.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Penninga L, Penninga EI, Møller CH, Iversen M, Steinbrüchel DA, Gluud C. Tacrolimus versus cyclosporin as primary immunosuppression for lung transplant recipients. Cochrane Database Syst Rev 2013:CD008817. [PMID: 23728681 DOI: 10.1002/14651858.cd008817.pub2] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Lung transplantation is a well-accepted treatment for people with most end-stage lung diseases. Although both tacrolimus and cyclosporin are used as primary immunosuppressive agents in lung transplant recipients, it is unclear which of these drugs is better in reducing rejection and death without causing adverse effects. OBJECTIVES To assess the benefits and harms of tacrolimus versus cyclosporin for primary immunosuppression in lung transplant recipients. SEARCH METHODS We searched the Cochrane Renal Group's Specialised Register to 10 April 2013 through contact with the Trials Search Co-ordinator using search terms relevant to this review. We also searched Science Citation Index Expanded and the Transplant Library to 20 April 2013. SELECTION CRITERIA We included all randomised controlled trials (RCT) that compared any dose and duration of administration of tacrolimus versus cyclosporin as primary immunosuppressive treatment in lung transplant recipients. Our selection criteria required that all included patients received the same additional immunosuppressive therapy within each study. DATA COLLECTION AND ANALYSIS Three authors extracted data. For dichotomous data we used risk ratio (RR) and used mean difference (MD) for continuous data, each with 95% confidence intervals (CI). Methodological components of the included studies were used to assess risk of systematic errors (bias). Trial sequential analysis was used to assess risk of random errors (play of chance). MAIN RESULTS We included three studies that enrolled a total of 413 adult patients that compared tacrolimus with microemulsion or oral solution cyclosporin. All studies were found to be at high risk of bias. Tacrolimus seemed to be significantly superior to cyclosporin regarding the incidence of bronchiolitis obliterans syndrome (RR 0.46, 95% CI 0.29 to 0.74), lymphocytic bronchitis score (MD -0.60, 95% CI -1.04 to -0.16), treatment withdrawal (RR 0.27, 95% CI 0.16 to 0.46), and arterial hypertension (RR 0.67, 95% CI 0.50 to 0.89). However, the finding for arterial hypertension was not confirmed when analysed using a random-effects model (RR 0.54, 95% CI 0.17 to 1.73). Furthermore, trial sequential analysis found that none of the meta-analyses reached the required information sizes and cumulative Z-curves did not cross trial sequential monitoring boundaries. Diabetes mellitus occurred more frequently among people in the tacrolimus group compared with the cyclosporin group when the fixed-effect model was applied (RR 4.24, 95% CI 1.58 to 11.40), but no difference was found when the random-effects model was used for analysis (RR 4.43, 95% CI 0.75 to 26.05). Again, trial sequential analysis found that the required information threshold was not reached and cumulative Z-curve did not cross the trial sequential monitoring boundary. No significant difference between treatment groups was observed regarding mortality (RR 1.06, 95% CI 0.75 to 1.49), incidence of acute rejection (RR 0.89, 95% CI 0.77 to 1.03), numbers of infections/100 patient-days (MD -0.15, 95% CI -0.30 to 0.00), cancer (RR 0.21, 95% CI 0.04 to 1.16), kidney dysfunction (RR 1.41, 95% CI 0.93 to 2.14), kidney failure (RR 1.57, 95% CI 0.28 to 8.94), neurotoxicity (RR 7.06, 95% CI 0.37 to 135.19), and hyperlipidaemia (RR 0.60, 95% CI 0.30 to 1.20). Trial sequential analysis showed the required information thresholds were not reached for any of these outcome measures. AUTHORS' CONCLUSIONS Tacrolimus may be superior to cyclosporin regarding bronchiolitis obliterans syndrome, lymphocytic bronchitis, treatment withdrawal, and arterial hypertension, but may be inferior regarding development of diabetes. No difference in mortality and acute rejection was observed between patients treated with tacrolimus and cyclosporin. There were few studies comparing tacrolimus and cyclosporin after lung transplantation, and the numbers of patients and events in the included studies were limited. Furthermore, the included studies were deemed to be at high risk of bias. Hence, more RCTs are needed to assess the results of the present review. Such studies ought to be conducted with low risks of systematic errors (bias) and of random errors (play of chance).
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Affiliation(s)
- Luit Penninga
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital,Copenhagen, Denmark. .
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White M, Montezano AC, Touyz RM. Angiotensin II signalling and calcineurin in cardiac fibroblasts: differential effects of calcineurin inhibitors FK506 and cyclosporine A. Ther Adv Cardiovasc Dis 2011; 6:5-14. [PMID: 22184128 DOI: 10.1177/1753944711432901] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Cardiac remodelling is controlled by complex systems, including activation of the renin-angiotensin system (RAS) and signalling through MAP kinases and Ca2+-activated calcineurin. Whether Ang II, which increases [Ca2+]i and stimulates MAP kinases, mediates myocardial effects through calcineurin-dependent pathways remain unclear. We investigated effects of two calcineurin inhibitors, cyclosporine A (CsA) and tacrolimus (FK506) (10-10-10-6 mol/L, 20 mins) on activation of MAP kinases and on growth, pro-fibrotic and pro-inflammatory responses in Ang II-stimulated rat cardiac fibroblasts. METHODS AND RESULTS Ang II increased phosphorylation of ERK1/2 and p38MAPK (1.5-1.8-fold, p<0.05) without effect on JNK. FK506, but not CsA, attenuated Ang II-stimulated MAP kinase activation. Molecular indices of cell growth (proliferating cell nuclear antigen (PCNA)), fibrosis (fibronectin, pro-collagen) and inflammation (iNOS), were upregulated by Ang II (12 hrs). FK506 and CsA inhibited PCNA effects. Ang II-induced pro-fibrotic and pro-inflammatory responses were inhibited by CsA. Ang II receptors, AT1R and AT2R, were not influenced by calcineurin inhibitors. Our data indicate differential calcineurin inhibitor sensitivity of MAP kinases and cellular responses in Ang II-stimulated fibroblasts. p38MAP kinase and ERK1/2 are regulated in a FK506-sensitive manner, whereas fibrosis and inflammation are CsA-sensitive. Cell proliferation is inhibited by both FKC506 and CsA. These are post-receptor phenomena, since AT1R and AT2R status was unaltered by treatment. CONCLUSIONS Our findings identify an important role for calcineurin in MAP kinase/growth/pro-fibrotic/pro-inflammatory signalling by Ang II in cardiac fibroblasts. Although both FK506 and CsA inhibit calcineurin, they exert differential effects on molecular and cellular responses. Such differences may contribute to variable clinical responses of these agents.
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Affiliation(s)
- Michel White
- Montreal Heart Institute, University of Montreal, Montreal, QC, Canada
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de Denus S, Zakrzewski M, Barhdadi A, Leblanc MH, Racine N, Bélanger F, Carrier M, Ducharme A, Dubé MP, Turgeon J, White M. Association between renal function and CYP3A5 genotype in heart transplant recipients treated with calcineurin inhibitors. J Heart Lung Transplant 2011; 30:326-31. [DOI: 10.1016/j.healun.2010.09.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2010] [Revised: 08/27/2010] [Accepted: 09/21/2010] [Indexed: 10/18/2022] Open
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Dubchak N, Falasca GF. New and improved strategies for the treatment of gout. Int J Nephrol Renovasc Dis 2010; 3:145-66. [PMID: 21694941 PMCID: PMC3108771 DOI: 10.2147/ijnrd.s6048] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2010] [Indexed: 12/16/2022] Open
Abstract
The Western world appears to be in the midst of the third great gout epidemic of all time. In this century, gout is increasing in prevalence despite an increased understanding of its risk factors and pathophysiology, and the availability of reasonably effective treatment. The main cultural factors responsible for this appear to be diet, obesity, ethanol use and medications. Excess fructose consumption is a newly recognized modifiable risk factor. The debate has been renewed concerning hyperuricemia as an independent risk factor for renal insufficiency and cardiovascular disease. Prevention is still rooted in lifestyle choices. Existing treatments have proven to be unsatisfactory in many patients with comorbidities. New treatments are available today and on the horizon for tomorrow, which offer a better quality of life for gout sufferers. These include febuxostat, a nonpurine inhibitor of xanthine oxidase with a potentially better combination of efficacy and safety than allopurinol, and investigational inhibitors of URAT-1, an anion exchanger in the proximal tubule that is critical for uric acid homeostasis. New abortive treatments include interleukin-1 antagonists that can cut short the acute attack in 1 to 2 days in persons who cannot take nonsteroidal anti-inflammatory drugs, colchicine or corticosteroids. Lastly, newer formulations of uricase have the ability to dissolve destructive tophi over weeks or months in patients who cannot use currently available hypouricemic agents. Diagnostically, ultrasound and magnetic resonance imaging offer advanced ways to diagnose gout noninvasively, and just as importantly, a way to follow the progress of tophus dissolution. The close association of hyperuricemia with metabolic syndrome, hypertension and renal insufficiency ensures that nephrologists will see increasing numbers of gout-afflicted patients.
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Affiliation(s)
- Natalie Dubchak
- Division of Rheumatology, Cooper University Hospital, UMDNJ – Robert Wood Johnson Medical School at Camden, Camden, NJ, USA
| | - Gerald F Falasca
- Division of Rheumatology, Cooper University Hospital, UMDNJ – Robert Wood Johnson Medical School at Camden, Camden, NJ, USA
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Penninga L, Penninga EI, Møller CH, Steinbrüchel DA, Gluud C. Tacrolimus versus cyclosporin as primary immunosuppression for lung transplant recipients. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2010. [DOI: 10.1002/14651858.cd008817] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Puk CG, Bocchi EA, Lo Prete AC, Ferreira SMA, Stolf NAG, Maranhão RC. Transfer of Cholesterol and Other Lipids From a Lipid Nanoemulsion to High-density Lipoprotein in Heart Transplant Patients. J Heart Lung Transplant 2009; 28:1075-80. [DOI: 10.1016/j.healun.2009.05.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2008] [Revised: 05/15/2009] [Accepted: 05/17/2009] [Indexed: 11/30/2022] Open
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Tacrolimus-Induced Elevation in Plasma Triglyceride Concentrations After Administration to Renal Transplant Patients Is Partially Due to a Decrease in Lipoprotein Lipase Activity and Plasma Concentrations. Transplantation 2009; 88:62-8. [DOI: 10.1097/tp.0b013e3181aa7d04] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Ye F, Ying-Bin X, Yu-Guo W, Hetzer R. Tacrolimus versus cyclosporine microemulsion for heart transplant recipients: a meta-analysis. J Heart Lung Transplant 2008; 28:58-66. [PMID: 19134532 DOI: 10.1016/j.healun.2008.10.004] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2008] [Revised: 10/09/2008] [Accepted: 10/14/2008] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Tacrolimus and cyclosporine microemulsion are the 2 major immunosuppressants for heart transplantation. Several studies have compared these 2 drugs, but the outcomes were not consistent. This meta-analysis of randomized controlled trials compared the beneficial and harmful effects of tacrolimus and microemulsion cyclosporine for heart transplant recipients. METHODS Electronic databases and manual bibliography searches were conducted. A meta-analysis was performed of all randomized controlled trials comparing tacrolimus with cyclosporine microemulsion as primary immunosuppression for heart transplant recipients. Data for mortality, acute rejection, withdrawals, and adverse events were extracted. The combined results of the data of the randomized controlled trials were summarized as relative risk with 95% confidence intervals. RESULTS The study assessed 7 randomized controlled trials including 885 patients. There was no difference in mortality at 1 year between recipients treated with tacrolimus and cyclosporine microemulsion. Tacrolimus-treated patients had less acute rejection risk at 6 months and 1 year. Fewer patients stopped tacrolimus than cyclosporine microemulsion. The rate of new-onset diabetes mellitus requiring insulin treatment was higher with tacrolimus. More post-transplantation hypertension occurred with cyclosporine microemulsion. The groups had comparable incidences of malignancy and renal failure needing dialysis. CONCLUSIONS The use of tacrolimus as primary immunosuppressant for heart transplant recipients results in comparable survival and a significant reduction in acute rejection compared with cyclosporine microemulsion.
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Affiliation(s)
- Fan Ye
- Department of Cardiothoracic and Vascular Surgery, Chongqing Xinqiao Hospital, Third Military Medical University, Chongqing, China
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Wang CH, Chou NK, Ko WJ, Chi NH, Tsao CI, Wang SS. The impact on biochemical profiles and allograft function for patients converted from cyclosporine to tacrolimus after clinical heart transplantation. Transplant Proc 2008; 40:2600-2. [PMID: 18929812 DOI: 10.1016/j.transproceed.2008.08.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Tacrolimus, a potent calcineurin inhibitor, is a widely used immunosuppressant. This study sought to determine whether conversion from cyclosporine to tacrolimus afforded benefits on biochemical profiles and graft function among Chinese heart transplantation recipients. METHODS Forty-nine patients (44 men and 5 women) among 252 heart transplantations performed from 1995 to 2005 were converted from cyclosporine to tacrolimus due to rejection (69%) or to cyclosporine intolerance (31%). The median age of these recipients at transplantation was 46.4 years (range, 5 months to 68 years). Their median body weight was 60 kg (range, 4-84 kg). The allograft median ischemic time was 145 minutes (range, 52-300 minutes). We compared the biochemical markers, rejection episodes and allograft function. RESULTS The mean duration from heart transplantation to conversion was 419 days. After conversion, the serum bilirubin and alanine transaminase levels were significantly improved at 1 year. The lipid profiles, including triglycerides, total cholesterol, and low-density lipoprotein were nonsignificantly changed. The rejection episodes significantly decreased from 1.53 to 0.15 per patient per year (P < .001). The left ventricular ejection fraction significantly improved from 54.3 +/- 17.9% to 63.2 +/- 10.9% (P < .01). The right atrial pressure significantly decreased from 9.1 +/- 5.8 mmHg to 6.3 +/- 4.3 mm Hg (P < .01). The pulmonary capillary wedge pressure significantly decreased from 15.3 +/- 9.5 mm Hg to 10.8 +/- 5.3 mm Hg (P = .04). CONCLUSION In heart transplantation, conversion to tacrolimus owing to rejection or cyclosporine intolerance showed better liver profiles with fewer rejection episodes and improved graft function.
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Affiliation(s)
- C H Wang
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
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Registry of Randomized Controlled Trials in Transplantation: July 1 to December 31, 2006. Transplantation 2007; 84:940-53. [DOI: 10.1097/01.tp.0000286319.97951.45] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Abstract
Tacrolimus is a calcineurin inhibitor recently approved in the US and throughout the EU for the prevention of allograft rejection in heart transplant recipients. It is commonly administered orally for long-term immunosuppression. The incidence of mild to severe acute rejection in the first 6 months following heart transplantation was significantly lower in tacrolimus recipients than in ciclosporin recipients (54% vs 66%) in a large, phase III trial conducted in Europe. A large, phase III trial conducted in the US did not show a significant difference between tacrolimus and ciclosporin in the incidence of severe rejection or haemodynamic compromise rejection requiring treatment within the first 6 months post-transplant (22% vs 32%), but did show a significant difference in the incidence at 1 year (23% vs 37%). In phase III trials, 1-year patient survival was similar between tacrolimus and ciclosporin recipients in the EU (93% vs 92%) and the US (95% vs 90%). Tacrolimus was shown to be effective in the prevention of rejection in paediatric and African American heart transplant recipients. The tolerability profile of tacrolimus in heart transplant recipients was broadly similar to that of ciclosporin, although tacrolimus was usually associated with lower incidences of post-transplant hypertension and dyslipidaemia.
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White M, Ross H, Haddad H, LeBlanc MH, Racine N, Pflugfelder P, Giannetti N, Davies R, Azevedo E, Isaac D, Burton J, Ferguson R, Genest J. Subclinical Inflammation and Prothrombotic State in Heart Transplant Recipients: Impact of Cyclosporin Microemulsion vs. Tacrolimus. Transplantation 2006; 82:763-70. [PMID: 17006323 DOI: 10.1097/01.tp.0000232286.22319.e0] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Subclinical inflammation is related to adverse events in patients with coronary artery disease. In the present study, we determined the changes in hemostatic parameters and inflammatory markers in a large cohort of dyslipidemic cardiac transplant recipients compared with dyslipidemic healthy controls, and the effect of cyclosporin microemulsion (CsA) vs. tacrolimus immunoprophylaxis on these parameters. METHODS Stable cardiac transplant recipients (n=129) aged 56.7+/-10.1 years, 79+/-42 months postcardiac transplantation, and 26 mildly dyslipidemic healthy control subjects had serum measurements for lipids and lipoproteins, hemostatic parameters, and selected inflammatory markers. Transplant recipients were randomized to either continuation of CsA maintenance or conversion to tacrolimus immunoprophylaxis and were reassessed after six months. RESULTS CsA-maintained cardiac transplant recipients exhibited a significant elevation in Factor VIII, Von Willebrand factor, fibrinogen and PAI-I compared with healthy control subjects (all P<0.05). Similarly, cardiac transplant patients yielded a significantly elevated C-reactive protein (CRP) (4.11+/-6.25 [transplant group (TX)] vs. 2.09+/-2.21 mg/L [control group (CTL)]; P=0.0195), and homocysteine (19.2+/-8.8 [TX] vs. 9.70+/-2.45 microM [CTL]; P<0.001). VCAM, ICAM, E- and P-selectins were also significantly higher in transplant patients than in controls (all P<0.05). The conversion from CsA to tacrolimus resulted in a significant decrease in uric acid, total- and LDL-cholesterol, apolipoprotein B, creatinine, and homocysteine levels (all P<0.05). CONCLUSIONS Stable long-term CsA-maintained cardiac transplant patients exhibit a significant and general increase in hemostatic parameters and markers for subclinical inflammation. Tacrolimus conversion improved the patient lipid profile and decreased serum creatinine, uric acid, and homocysteine without any significant effect on the other markers.
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Affiliation(s)
- Michel White
- Research Center, Montreal Heart Institute, Montreal, Quebec, Canada.
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Hoitsma AJ, Hilbrands LB. Relative risk of new-onset diabetes during the first year after renal transplantation in patients receiving tacrolimus or cyclosporine immunosuppression. Clin Transplant 2006; 20:659-64. [PMID: 16968494 DOI: 10.1111/j.1399-0012.2006.00535.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Clinical trials have consistently shown a higher incidence of new-onset diabetes mellitus with tacrolimus than cyclosporine. However, in protocol-driven studies steroid doses are comparable in both treatment arms, while in clinical practice steroid dose used in conjunction with tacrolimus or cyclosporine may differ. This retrospective study analysed renal transplant recipients without pre-existing diabetes receiving tacrolimus (n = 100) or cyclosporine (n = 100) for whom one-year follow-up data were available. Diabetes was defined as use of insulin or oral hypoglycemic agents; fasting glucose >6.9 mmol/L; or non-fasting glucose >11 mmol/L on three consecutive occasions. Tacrolimus-treated patients were significantly older than cyclosporine-treated patients (49 +/- 14 vs. 44 +/- 13 yr, p < 0.05) and received a significantly lower cumulative dose of corticosteroids over the first three months post-transplant (1284 +/- 379 vs. 1714 +/- 486 mg, p < 0.0001). At 3, 6, 9 and 12 months significantly more tacrolimus-treated patients had new-onset diabetes than cyclosporine- treated patients. At 12 months, 18 patients receiving tacrolimus and two receiving cyclosporine had diabetes (p < 0.0001). There was a clear relationship between age and incidence of new-onset diabetes at three months in the tacrolimus cohort. After stratifying patients by age group, the frequency of diabetes was significantly higher with tacrolimus than with cyclosporine in patients aged 40-60 yr [8/46 (17.4%) vs. 2/48 (4.2%), p < 0.05] and >60 yr [9/28 (32.1%) vs. 0/14 (0%), p < 0.05]. The mean tacrolimus trough level during the first three months was similar in patients with diabetes (13.1 +/- 2.3 ng/mL) or without diabetes (13.0 +/- 2.8 ng/mL, n.s.). These results indicate that new-onset diabetes is strongly and significantly associated with tacrolimus vs. cyclosporine in renal transplant recipients, even when steroid dosing is lower with tacrolimus.
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Affiliation(s)
- Andries J Hoitsma
- Division of Nephrology, Radboud University Nijmegen, Medical Centre, Nijmegen, The Netherlands.
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Kobashigawa JA, Patel J, Furukawa H, Moriguchi JD, Yeatman L, Takemoto S, Marquez A, Shaw J, Oeser BT, Subherwal S, Wu GW, Kawano J, Laks H. Five-year results of a randomized, single-center study of tacrolimus vs microemulsion cyclosporine in heart transplant patients. J Heart Lung Transplant 2006; 25:434-9. [PMID: 16563974 DOI: 10.1016/j.healun.2005.11.452] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2005] [Revised: 11/04/2005] [Accepted: 11/14/2005] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Previous multicenter, randomized trials, lacking standardized post-transplant protocols, have compared tacrolimus (Tac) and cyclosporine (CyA, Sandimmune) and demonstrated similar outcomes with some different adverse effects. The microemulsion form of CyA (mCyA, Neoral) has replaced Sandimmune CyA as the more widely utilized CyA formulation. This is the first 5-year follow-up study of a large, single-center trial (n = 67) under a standardized post-transplant protocol comparing Tac and mCyA. METHODS Sixty-seven heart transplant patients were randomized to Tac (n = 33) or mCyA (n = 34), both in combination with corticosteroids and azathioprine without cytolytic induction. Five-year end-points included survival, Grade > or = 3A or treated rejection, angiographic cardiac allograft vasculopathy (CAV; any lesion > or = 30% stenosis), renal dysfunction (creatinine > or = 2.0 mg/dl), use of two or more anti-hypertensive medications, percent diabetic and lipid levels. RESULTS Five-year survival, freedom from Grade > or = 3A or any treated rejection and angiographic CAV, mean cholesterol level and percent diabetic were similar between the two groups. The Tac group had a significantly lower 5-year mean triglyceride level (Tac 97 +/- 34 vs mCyA 175 +/- 103 mg/dl, p = 0.011) and average serum creatinine level (Tac 1.2 +/- 0.5 mg/dl vs mCyA 1.5 +/- 0.4 mg/dl, p = 0.044). There was a trend toward fewer patients requiring two or more anti-hypertensive drugs in the Tac group (Tac 33% vs mCyA 59%, p = 0.065). CONCLUSIONS Tac and mCyA appear to be comparable with regard to 5-year survival, freedom from rejection and CAV. However, compared with mCyA, Tac appears to reduce the adverse effect profile for hypertriglyceridemia and renal dysfunction and the need for hypertensive medications.
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Affiliation(s)
- Jon A Kobashigawa
- Division of Cardiology, Department of Medicine, University of California, Los Angeles, California, USA.
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