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Donald EM, Driggin E, Choe J, Batra J, Vargas F, Lindekens J, Fried JA, Raikhelkar JK, Bae DJ, Oh KT, Yuzefpolskaya M, Colombo PC, Latif F, Sayer G, Uriel N, Clerkin KJ, DeFilippis EM. Cardio-Renal-Metabolic Outcomes Associated With the Use of GLP-1 Receptor Agonists After Heart Transplantation. Clin Transplant 2024; 38:e15401. [PMID: 39023081 DOI: 10.1111/ctr.15401] [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: 04/21/2024] [Revised: 06/09/2024] [Accepted: 06/24/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND The use of glucagon-like-peptide 1 receptor agonists (GLP1-RA) has dramatically increased over the past 5 years for diabetes mellitus type 2 (T2DM) and obesity. These comorbidities are prevalent in adult heart transplant (HT) recipients. However, there are limited data evaluating the efficacy of this drug class in this population. The aim of the current study was to describe cardiometabolic changes in HT recipients prescribed GLP1-RA at a large-volume transplant center. METHODS We retrospectively reviewed all adult HT recipients who received GLP1-RA after HT for a minimum of 1-month. Cardiometabolic parameters including body mass index (BMI), lipid panel, hemoglobin A1C, estimated glomerular filtration rate (eGFR), and NT-proBNP were compared prior to initiation of the drug and at most recent follow-up. We also evaluated for significant dose adjustments to immunosuppression after drug initiation and adverse effects leading to drug discontinuation. RESULTS Seventy-four patients were included (28% female, 53% White, 20% Hispanic) and followed for a median of 383 days [IQR 209, 613] on a GLP1-RA. The majority of patients (n = 56, 76%) were prescribed semaglutide. The most common indication for prescription was T2DM alone (n = 33, 45%), followed by combined T2DM and obesity (n = 26, 35%). At most recent follow-up, mean BMI decreased from 33.3 to 31.5 kg/m2 (p < 0.0001), HbA1C from 7.3% to 6.7% (p = 0.005), LDL from 78.6 to 70.3 mg/dL (p = 0.018) and basal insulin daily dose from 32.6 to 24.8 units (p = 0.0002). CONCLUSION HT recipients prescribed GLP1-RA therapy showed improved glycemic control, weight loss, and cholesterol levels during the study follow-up period. GLP1-RA were well tolerated and were rarely associated with changes in immunosuppression dosing.
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Affiliation(s)
- Elena M Donald
- Department of Medicine, Division of Cardiology New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York, USA
| | - Elissa Driggin
- Department of Medicine, Division of Cardiology New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York, USA
| | - Jason Choe
- Department of Medicine, Division of Cardiology New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York, USA
| | - Jaya Batra
- Department of Medicine, Division of Cardiology New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York, USA
| | - Fabian Vargas
- Department of Medicine, Division of Cardiology New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York, USA
| | - Jordan Lindekens
- Department of Medicine, Division of Cardiology New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York, USA
| | - Justin A Fried
- Department of Medicine, Division of Cardiology New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York, USA
| | - Jayant K Raikhelkar
- Department of Medicine, Division of Cardiology New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York, USA
| | - David J Bae
- Department of Medicine, Division of Cardiology New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York, USA
| | - Kyung T Oh
- Department of Medicine, Division of Cardiology New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York, USA
| | - Melana Yuzefpolskaya
- Department of Medicine, Division of Cardiology New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York, USA
| | - Paolo C Colombo
- Department of Medicine, Division of Cardiology New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York, USA
| | - Farhana Latif
- Department of Medicine, Division of Cardiology New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York, USA
| | - Gabriel Sayer
- Department of Medicine, Division of Cardiology New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York, USA
| | - Nir Uriel
- Department of Medicine, Division of Cardiology New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York, USA
| | - Kevin J Clerkin
- Department of Medicine, Division of Cardiology New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York, USA
| | - Ersilia M DeFilippis
- Department of Medicine, Division of Cardiology New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York, USA
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2
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Holt MF, Holmen S, Rolid K, Englund KVB, Østby CM, Ravnestad H, Andreassen AK, Gullestad L, Gude E, Broch K. The association between body mass index, exercise capacity, and health-related quality of life in heart transplant recipients. FRONTIERS IN TRANSPLANTATION 2024; 3:1379695. [PMID: 38993775 PMCID: PMC11235288 DOI: 10.3389/frtra.2024.1379695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 04/30/2024] [Indexed: 07/13/2024]
Abstract
Introduction Pre-transplant obesity and weight gain after heart transplantation are both associated with increased risk of poor clinical outcomes. We aimed to assess the association between overweight or obesity, exercise capacity, and health-related quality of life in heart transplant recipients. Methods This study is based on baseline data from the IronIC trial, in which we randomized 102 heart transplant recipients with iron deficiency to ferric derisomaltose or placebo. We performed cardio pulmonary exercise testing in all participants. To assess quality of life, we used the SF-36v2 questionnaire, using two sum scores: the physical component summary and the mental component summary. A minimal clinically important difference was defined as ≥2 and ≥3 for the physical and the mental component summary, respectively. Results 24/102 heart transplant recipients (24%) had a body mass index (BMI) ≥30 kg/m2. Peak oxygen consumption was 17.3 ± 4.6 ml/kg/min in the obese group vs. 24.7 ± 6.4 ml/kg/min in the group with a BMI <30 for a between-group difference of 7.4 (95% confidence interval 4.7-10.2) ml/kg/min: p < 0.001. The physical component summary score was on average 5.2 points lower in the patients with a body mass index ≥30 than in the lower weight group (p = 0.04). Conclusion Almost a quarter of our heart transplant recipients in long-term follow-up had a BMI ≥30 kg/m2. These patients had substantially lower exercise capacity and lower quality of life in the physical domain.
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Affiliation(s)
- Margrethe Flesvig Holt
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Stine Holmen
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Medicine, Innlandet Hospital Trust, Hamar, Norway
| | - Katrine Rolid
- Department of Health and Public Sector, The Research Council of Norway, Oslo, Norway
| | | | - Charlotte M. Østby
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Håvard Ravnestad
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Arne K. Andreassen
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Lars Gullestad
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- KG Jebsen Center for Cardiac Research, University of Oslo, Oslo, Norway
| | - Einar Gude
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Kaspar Broch
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- KG Jebsen Center for Cardiac Research, University of Oslo, Oslo, Norway
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3
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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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4
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Miura K, Yu R, Entwistle TR, McKenzie SC, Green AC. Changes in body weight and serum cholesterol after heart transplant in relation to ventricular assist device implantation. Int J Artif Organs 2022; 45:1037-1041. [PMID: 35982584 DOI: 10.1177/03913988221118942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Weight gain is common after implantation of a ventricular assist device (VAD) prior to heart transplantation, but post-transplant changes in weight and also in blood lipids in those with VAD is virtually unknown. This study aimed to determine the influence of pre-transplant VAD implantation on body weight, blood cholesterol and triglyceride levels in Australian adult heart transplant recipients (HTRs), 1990-2017, from time of transplantation to 36 months post-transplantation. Information on VAD implantation, weight and blood lipids was collected for HTRs from medical records. Changes in weight and blood lipids from post-transplant to 12-, 24 and 36 months later, were assessed by VAD status using linear mixed-effects models. Of 236 heart transplant recipients, 48 (20%) had VAD implants. HTRs irrespective of VAD status, tended to increase their mean weight (p < 0.001) over 36 months (VAD implant: 76.9-84.4 kg; no VAD: 81.3-88.2 kg). Patients with VAD tended to have lower mean blood lipids but experienced increases similar to those with no VAD, from baseline to 36 months (cholesterol: VAD: 4.24-4.66 mmol/l; no VAD: 4.73-4.88 mmol/l; p = 0.05; triglycerides: VAD 1.59-1.63 mmol/l; no VAD 1.85-2.22 mmol/l; p = 0.09). We conclude that HTRs in general experience weight gain and lipid increases in the first 36 months after transplantation, regardless of prior VAD implantation.
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Affiliation(s)
- Kyoko Miura
- Population Health Department, QIMR Berghofer Medical Research Institute, Herston, QLD, Australia.,Faculty of Medicine, The University of Queensland, St Lucia, QLD, Australia
| | - Regina Yu
- Population Health Department, QIMR Berghofer Medical Research Institute, Herston, QLD, Australia
| | | | - Scott C McKenzie
- Faculty of Medicine, The University of Queensland, St Lucia, QLD, Australia.,Advanced Heart Failure and Cardiac Transplant Unit, The Prince Charles Hospital, Chermside QLD, Australia
| | - Adèle C Green
- Population Health Department, QIMR Berghofer Medical Research Institute, Herston, QLD, Australia.,CRUK Manchester Institute and University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
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5
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Weight Gain After Heart Transplantation in Adults: Systematic Review and Meta-Analysis. ASAIO J 2021; 68:1107-1116. [PMID: 34560719 DOI: 10.1097/mat.0000000000001566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Gain in weight is common after heart transplantation but the magnitude of usual weight gain and whether this varies by country is unknown. We systematically reviewed all relevant studies to quantify weight change among heart transplant recipients (HTRs) in the years after transplantation and assess variation with geographic location. We searched PubMed, Cumulative Index to Nursing and Allied Health Literature, and Excerpta Medica Database databases to September 2020. Eligible studies reported adult HTRs' mean/median weight and/or body mass index (BMI) up to time of transplantation (baseline) and posttransplantation in any language. Weighted mean differences (WMDs) (95% confidence intervals [CIs]) of weight/BMI from baseline to posttransplantation were estimated using a random-effects model. Ten studies met the inclusion criteria. Pooled analysis showed weight gain of 7.1 kg (95% CI, 4.4-9.8 kg) in HTRs 12 months posttransplant, with corresponding BMI increase of 1.69 kg/m2 (95% CI, 0.83-2.55 kg/m2). Greatest weight gain at 12 months posttransplant occurred in US HTRs (WMD weight 10.42 kg, BMI 3.25 kg/m2) and least, in European HTRs (WMD weight 3.10 kg, BMI 0.78 kg/m2). In conclusion, HTRs gain substantial weight in the years after transplantation, but varying widely by geographic location.
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Bhat M, Usmani SE, Azhie A, Woo M. Metabolic Consequences of Solid Organ Transplantation. Endocr Rev 2021; 42:171-197. [PMID: 33247713 DOI: 10.1210/endrev/bnaa030] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Indexed: 12/12/2022]
Abstract
Metabolic complications affect over 50% of solid organ transplant recipients. These include posttransplant diabetes, nonalcoholic fatty liver disease, dyslipidemia, and obesity. Preexisting metabolic disease is further exacerbated with immunosuppression and posttransplant weight gain. Patients transition from a state of cachexia induced by end-organ disease to a pro-anabolic state after transplant due to weight gain, sedentary lifestyle, and suboptimal dietary habits in the setting of immunosuppression. Specific immunosuppressants have different metabolic effects, although all the foundation/maintenance immunosuppressants (calcineurin inhibitors, mTOR inhibitors) increase the risk of metabolic disease. In this comprehensive review, we summarize the emerging knowledge of the molecular pathogenesis of these different metabolic complications, and the potential genetic contribution (recipient +/- donor) to these conditions. These metabolic complications impact both graft and patient survival, particularly increasing the risk of cardiovascular and cancer-associated mortality. The current evidence for prevention and therapeutic management of posttransplant metabolic conditions is provided while highlighting gaps for future avenues in translational research.
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Affiliation(s)
- Mamatha Bhat
- Multi Organ Transplant program and Division of Gastroenterology & Hepatology, University Health Network, Ontario M5G 2N2, Department of Medicine, University of Toronto, Ontario, Canada.,Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Shirine E Usmani
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada.,Division of Endocrinology and Metabolism, Department of Medicine, University Health Network, Ontario, and Sinai Health System, Ontario, University of Toronto, Toronto, Ontario, Canada
| | - Amirhossein Azhie
- Multi Organ Transplant program and Division of Gastroenterology & Hepatology, University Health Network, Ontario M5G 2N2, Department of Medicine, University of Toronto, Ontario, Canada.,Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Minna Woo
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada.,Division of Endocrinology and Metabolism, Department of Medicine, University Health Network, Ontario, and Sinai Health System, Ontario, University of Toronto, Toronto, Ontario, Canada
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7
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Ram E, Klempfner R, Peled A, Kassif Y, Sternik L, Lavee J, Peled Y. Weight gain post-heart transplantation is associated with an increased risk for allograft vasculopathy and rejection. Clin Transplant 2020; 35:e14187. [PMID: 33314309 DOI: 10.1111/ctr.14187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 11/24/2020] [Accepted: 12/07/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Obesity and overweight are associated with an increased risk for cardiovascular disease. Since fat mass (FM) and fat-free mass (FFM) both contribute to total body weight (TBW), we characterized the post-heart transplantation (HT) change in TBW and its implications for outcomes. METHODS Post-HT changes in TBW, FM, and FFM were reviewed for 211 HT patients assessed during 1997-2017. Endpoints included cardiac allograft vasculopathy (CAV) and rejection. RESULTS Median TBW increased by 7.3% at 1 year, with a significant rise in the obese category (28% vs. 13%, p < 0.001) and with FM versus FFM making the main contribution (23% vs. 3%, p < 0.001). When patients were divided according to median TBW change ("high" vs. "low"), Kaplan-Meier analysis showed that 10-year freedom from CAV (log-rank p < 0.005) and rejection (log-rank p < 0.01) was significantly higher for the "low" TBW change group. Consistently, multivariable analyses showed that the "high" group was independently associated with significant 3.5-fold and 4.2-fold increased risks for CAV (95% CI 1.4-8.7, p = 0.01) and rejection (95% CI 1.2-15.4, p = 0.03), respectively. CONCLUSIONS Weight gain, contributed mostly by FM, is independently associated with an increased risk for CAV and rejection. Follow-up emphasis should be placed on weight gain and preventative measures.
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Affiliation(s)
- Eilon Ram
- Heart Transplantation Unit, Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Hashomer, Israel.,Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Robert Klempfner
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Israeli Association for Cardiovascular Trials, Ramat Gan, Israel
| | - Amir Peled
- Clalit Health Services, Central Region, Israel
| | - Yigal Kassif
- Heart Transplantation Unit, Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Hashomer, Israel.,Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Leonid Sternik
- Heart Transplantation Unit, Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Hashomer, Israel.,Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jacob Lavee
- Heart Transplantation Unit, Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Hashomer, Israel.,Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Peled
- Heart Transplantation Unit, Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Hashomer, Israel.,Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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8
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Bondi BC, Banh TM, Vasilevska-Ristovska J, Szpindel A, Chanchlani R, Hebert D, Solomon M, Dipchand AI, Kim SJ, Ng VL, Parekh RS. Incidence and Risk Factors of Obesity in Childhood Solid-Organ Transplant Recipients. Transplantation 2020; 104:1644-1653. [PMID: 32732843 DOI: 10.1097/tp.0000000000003025] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Obesity is a significant public health concern; however, the incidence post solid-organ transplantation is not well reported. METHODS This study determined the incidence and risk factors of obesity among pediatric solid-organ transplant recipients (heart, lung, liver, kidney, multiorgan) at The Hospital for Sick Children (2002-2011), excluding prevalent obesity. Follow-up occurred from transplantation until development of obesity, last follow-up, or end of study. Incidence of obesity was determined overall, by baseline body mass index, and organ group. Risk factors were assessed using Cox proportional-hazards regression. RESULTS Among 410 (55% male) children, median transplant age was 8.9 (interquartile range [IQR]: 1.0-14.5) years. Median follow-up time was 3.6 (IQR: 1.5-6.4) years. Incidence of obesity was 65.2 (95% confidence interval [CI]: 52.7-80.4) per 1000 person-years. Overweight recipients had a higher incidence, 190.4 (95% CI: 114.8-315.8) per 1000 person-years, than nonoverweight recipients, 56.1 (95% CI: 44.3-71.1). Cumulative incidence of obesity 5-years posttransplant was 24.1%. Kidney relative to heart recipients had the highest risk (3.13 adjusted hazard ratio [aHR]; 95% CI: 1.53-6.40) for obesity. Lung and liver recipients had similar rates to heart recipients. Those with higher baseline body mass index (z-score; 1.72 aHR; 95% CI: 1.39-2.14), overweight status (2.63 HR; 95% CI: 1.71-4.04), and younger transplant age (y; 1.18 aHR; 95% CI: 1.12-1.25) were at highest risk of obesity. Higher cumulative steroid dosage (per 10 mg/kg) was associated with increased risk of obesity after adjustment. CONCLUSIONS Among all transplanted children at The Hospital for Sick Children, 25% developed obesity within 5-years posttransplant. Kidney recipients, younger children, those overweight at transplant, and those with higher cumulative steroid use (per 10 mg/kg) were at greatest risk. Early screening and intervention for obesity are important preventative strategies.
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Affiliation(s)
- Bianca C Bondi
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Tonny M Banh
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | | | - Aliya Szpindel
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Rahul Chanchlani
- Division of Nephrology, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Diane Hebert
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, ON, Canada
- Division of Pediatric Nephrology, The Hospital for Sick Children, Toronto, ON, Canada
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Melinda Solomon
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, ON, Canada
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Division of Pediatric Respiratory Medicine, Hospital for Sick Children, ON, Canada
| | - Anne I Dipchand
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, ON, Canada
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Labatt Family Heart Centre, Hospital for Sick Children, Toronto, ON, Canada
| | - S Joseph Kim
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University Health Network, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Vicky L Ng
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, ON, Canada
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Toronto, ON, Canada
| | - Rulan S Parekh
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- Division of Pediatric Nephrology, The Hospital for Sick Children, Toronto, ON, Canada
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University Health Network, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Canada Research Chair (Tier 1) in Chronic Kidney Disease Epidemiology, University of Toronto, Canadian Institutes of Health Research, Toronto, ON, Canada
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9
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Satapathy SK, Jiang Y, Agbim U, Wu C, Bernstein DE, Teperman LW, Kedia SK, Aithal GP, Bhamidimarri KR, Duseja A, Maiwall R, Maliakkal B, Jalal P, Patel K, Puri P, Ravinuthala R, Wong VWS, Abdelmalek MF, Ahmed A, Thuluvath PJ, Singal AK. Posttransplant Outcome of Lean Compared With Obese Nonalcoholic Steatohepatitis in the United States: The Obesity Paradox. Liver Transpl 2020; 26:68-79. [PMID: 31665561 DOI: 10.1002/lt.25672] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 09/20/2019] [Indexed: 02/07/2023]
Abstract
Morbid obesity is considered a relative contraindication for liver transplantation (LT). We investigated if body mass index (BMI; lean versus obese) is a risk factor for post-LT graft and overall survival in nonalcoholic steatohepatitis (NASH) and non-NASH patients. Using the United Network for Organ Sharing (UNOS) database, LT recipients from January 2002 to June 2013 (age ≥18 years) with follow-up until 2017 were included. The association of BMI categories calculated at LT with graft and overall survival after LT were examined. After adjusting for confounders, all obesity cohorts (overweight and class 1, class 2, and class 3 obesity) among LT recipients for NASH had significantly reduced risk of graft and patient loss at 10 years of follow-up compared with the lean BMI cohort. In contrast, the non-NASH group of LT recipients had no increased risk for graft and patient loss for overweight, class 1, and class 2 obesity groups but had significantly increased risk for graft (P < 0.001) and patient loss (P = 0.005) in the class 3 obesity group. In this retrospective analysis of the UNOS database, adult recipients selected for first LT and NASH patients with the lowest BMI have the worse longterm graft and patient survival as opposed to non-NASH patients where the survival was worse with higher BMI.
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Affiliation(s)
- Sanjaya K Satapathy
- Division of Hepatology, Sandra Atlas Bass Center for Liver Diseases, Northshore University Hospital, Northwell Health, Manhasset, NY.,Department of Medicine, Division of Hepatology, Donald and Barbara Zucker School of Medicine at Hofstra, Northwell Health, Manhasset, NY
| | - Yu Jiang
- School of Public Health, University of Memphis, Memphis, TN
| | - Uchenna Agbim
- Division of Surgery, Methodist University Hospital Transplant Institute, Memphis, TN
| | - Cen Wu
- Department of Statistics, Kansas State University, Manhattan, KS
| | - David E Bernstein
- Division of Hepatology, Sandra Atlas Bass Center for Liver Diseases, Northshore University Hospital, Northwell Health, Manhasset, NY.,Department of Medicine, Division of Hepatology, Donald and Barbara Zucker School of Medicine at Hofstra, Northwell Health, Manhasset, NY
| | - Lewis W Teperman
- Division of Transplant, Northwell Health System Transplant Center, Northshore University Hospital, Northwell Health, Manhasset, NY
| | - Satish K Kedia
- School of Public Health, University of Memphis, Memphis, TN
| | - Guruprasad P Aithal
- Nottingham Digestive Diseases Centre, University of Nottingham, Nottingham, United Kingdom
| | | | - Ajay Duseja
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rakhi Maiwall
- Institute of Liver & Biliary Sciences, New Delhi, India
| | - Benedict Maliakkal
- Division of Surgery, Methodist University Hospital Transplant Institute, Memphis, TN
| | - Prasun Jalal
- St. Luke's Medical Center, Baylor College of Medicine, Houston, TX
| | - Keyur Patel
- Division of Gastroenterology, University of Toronto, Toronto, ON, Canada
| | - Puneet Puri
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University, Richmond, VA
| | | | - Vincent Wai-Sun Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Manal F Abdelmalek
- Division of Gastroenterology and Hepatology, Duke University, Durham, NC
| | - Aijaz Ahmed
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA
| | - Paul J Thuluvath
- Institute of Digestive Health & Liver Disease, University of Maryland School of Medicine, Baltimore, MD
| | - Ashwani K Singal
- Division of Gastroenterology and Hepatology, University of South Dakota, Avera McKenna University Health Center and Transplant Institute, Sioux Falls, SD
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Doumouras BS, Fan CS, Mueller B, Dipchand AI, Manlhiot C, Stehlik J, Ross HJ, Alba AC. The effect of pre–heart transplant body mass index on posttransplant outcomes: An analysis of the ISHLT Registry Data. Clin Transplant 2019; 33:e13621. [DOI: 10.1111/ctr.13621] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 05/25/2019] [Accepted: 05/28/2019] [Indexed: 12/18/2022]
Affiliation(s)
- Barbara S. Doumouras
- Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre University Health Network, University of Toronto Toronto Ontario Canada
| | - Chun‐Po S. Fan
- Cardiovascular Data Management Centre, The Hospital for Sick Children University of Toronto Toronto Ontario Canada
| | - Brigitte Mueller
- Cardiovascular Data Management Centre, The Hospital for Sick Children University of Toronto Toronto Ontario Canada
| | - Anne I. Dipchand
- Labatt Family Heart Centre, The Hospital for Sick Children University of Toronto Toronto Ontario Canada
| | - Cedric Manlhiot
- Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre University Health Network, University of Toronto Toronto Ontario Canada
- Cardiovascular Data Management Centre, The Hospital for Sick Children University of Toronto Toronto Ontario Canada
| | - Josef Stehlik
- Division of Cardiovascular Medicine University of Utah Health Salt Lake City Utah USA
| | - Heather J. Ross
- Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre University Health Network, University of Toronto Toronto Ontario Canada
| | - Ana C. Alba
- Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre University Health Network, University of Toronto Toronto Ontario Canada
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11
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Chen AC, Rosenthal DN, Couch SC, Berry S, Stauffer KJ, Brabender J, McDonald N, Lee D, Barkoff L, Nourse SE, Kazmucha J, Wang CJ, Olson I, Selamet Tierney ES. Healthy hearts in pediatric heart transplant patients with an exercise and diet intervention via live video conferencing-Design and rationale. Pediatr Transplant 2019; 23:e13316. [PMID: 30393915 DOI: 10.1111/petr.13316] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 09/12/2018] [Accepted: 10/02/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pediatric heart transplant (PedHtx) patients have increased cardiovascular risk profiles that affect their long-term outcomes and quality of life. We designed a 12- to 16-week diet and exercise intervention delivered via live video conferencing to improve cardiovascular health. Our methodology and baseline assessment of the first 13 enrolled patients are reported. METHODS Inclusion criteria are as follows: (a) 8-19 years old; (b) heart transplant >12 months; (c) ability to fast overnight; (d) cardiac clearance by cardiologist; and (e) presence of an adult at home during exercise sessions for patients <14 years old. Exclusion criteria are as follows: (a) acute illness; (b) latex allergy; (c) transplant rejection <3 months ago; and (d) multi-organ transplantation. The intervention consists of one diet and three exercise sessions weekly via live video conferencing. Study visits are conducted at baseline, intervention completion, and end of maintenance period. RESULTS A total of 13 participants (15.2 [2.3] years) have been enrolled. Median percent-predicted VO2 max was 56.8 [20.7]% (10 patients <70%). Ten patients had abnormal endothelial function (reactive hyperemia index <1.9; 1.4 [0.325]) and 11 patients had stiff arteries (pulse wave velocity ≧5.5 m/s for 15-19 years, ≧4.5 m/s for 8-14 years; 5.6 [0.7] m/s). Patients had suboptimal diets (saturated fat: 22.7 [23.8] g/d, sodium: 2771 [1557] mg/d) and were sedentary at a median of 67.5 [13.8]% of their time. CONCLUSIONS Baseline assessment confirms that PedHtx patients have abnormal cardiac, vascular, and functional health indices, poor dietary habits, and are sedentary. These results support the rationale to test the feasibility and impact of a non-pharmacologic lifestyle intervention in this patient population.
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Affiliation(s)
- Angela C Chen
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University Medical Center, Palo Alto, California
| | - David N Rosenthal
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University Medical Center, Palo Alto, California
| | - Sarah C Couch
- Department of Rehabilitation, Exercise and Nutrition Sciences, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Samuel Berry
- American Council on Exercise, San Diego, California
| | - Katie J Stauffer
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University Medical Center, Palo Alto, California
| | - Jerrid Brabender
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University Medical Center, Palo Alto, California
| | - Nancy McDonald
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University Medical Center, Palo Alto, California
| | - Donna Lee
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University Medical Center, Palo Alto, California
| | - Lynsey Barkoff
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University Medical Center, Palo Alto, California
| | - Susan E Nourse
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University Medical Center, Palo Alto, California
| | - Jeffrey Kazmucha
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University Medical Center, Palo Alto, California
| | - C Jason Wang
- Division of General Pediatrics, Center for Policy, Outcomes and Prevention, Stanford University, Palo Alto, California
| | - Inger Olson
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University Medical Center, Palo Alto, California
| | - Elif Seda Selamet Tierney
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University Medical Center, Palo Alto, California
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12
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Quadriceps Muscle Strength and Body Mass Index Are Associated With Estimates of Physical Activity Postheart Transplantation. Transplantation 2018; 103:1253-1259. [PMID: 30335695 DOI: 10.1097/tp.0000000000002488] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although exercise capacity improves postheart transplantation (HTx), it remains unclear if the level of physical activity (PA) shows similar improvement. The purpose of this study was to (1) describe PA levels and (2) identify factors which may be associated with levels of PA post-HTx. METHODS A prospective observational cross-sectional study was conducted at a single center HTx outpatient clinic. Medically stable adult recipients 6 months or longer post-HTx were recruited. Physical activity level (PAL) and average daily time spent at least moderately active (≥3 metabolic equivalents) were estimated using a multisensor device. Factors investigated were demographic (age, sex, body mass index [BMI], time post-HTx, and reason for HTx), corticosteroid use, exercise capacity (6-min walk distance), and quadriceps muscle strength corrected for body weight (QS%). RESULTS The mean post-HTx time of the 75 participants was 9.2 ± 7.0 years (0.5-26 y). Twenty-seven (36%) participants were classified as extremely inactive (PAL, <1.40), 26 (34.6%) sedentary (1.40 ≤ PAL ≤ 1.69), and 22 (29.3%) active (PAL, ≥1.70). Multivariable analysis showed greater QS% (β = 0.004 (0.002-0.006) P = 0.001) to be independently associated with increased PAL. For increased time, 3 or more metabolic equivalents both greater QS% (β = 0.0164 [0.003-0.029]; P = 0.014) and lower BMI (β = -0.0626 [-0.115 to -0.0099]; P = 0.021) were independently associated. CONCLUSIONS The degree of observed sedentary behavior post-HTx is surprising, with the majority of participants not reaching levels of PA recommended for health benefits. QS% and BMI were the only factors found to be independently associated with estimates of PA. Further quality trials are required to demonstrate the long-term benefits of regular PA and investigate ways of increasing adherence to PA post-HTx.
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13
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Obesity in patients with end-stage heart failure. POLISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2018; 15:176-179. [PMID: 30310396 PMCID: PMC6180018 DOI: 10.5114/kitp.2018.78442] [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: 12/03/2017] [Accepted: 03/10/2018] [Indexed: 11/22/2022]
Abstract
Obesity poses an increasing problem in patients with end-stage heart failure (HF). The most commonly used indicator of obesity is body mass index. The value of this parameter is widely taken into consideration when selecting the best way of treatment for patients with advanced HF. The aim of this paper is to outline the recent knowledge about obesity in the abovementioned group of patients.
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14
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De Santo LS, Moscariello C, Zebele C. Implications of obesity in cardiac surgery: pattern of referral, physiopathology, complications, prognosis. J Thorac Dis 2018; 10:4532-4539. [PMID: 30174906 DOI: 10.21037/jtd.2018.06.104] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
A U-shaped relationship between body mass index (BMI) and outcomes emerged after cardiac surgery. This review analyses the physio pathologic basis of obesity related complications and evaluates prognostic implications. Both leaner and morbid obese should be considered pre-operatively rather than reactively and, when referred for elective surgery, should undergo a focused metabolic status management, and a thorough evaluation of health status. Adherence to sound surgical principles, and tailored patient blood management and perioperative care are mandatory.
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Affiliation(s)
- Luca Salvatore De Santo
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy.,Division of Cardiac Surgery, Casa di Cura Montevergine, GVM Care & Research, Mercogliano, AV, Italy
| | - Caesar Moscariello
- Division of Cardiac Surgery, Casa di Cura Montevergine, GVM Care & Research, Mercogliano, AV, Italy
| | - Carlo Zebele
- Division of Cardiac Surgery, Casa di Cura Montevergine, GVM Care & Research, Mercogliano, AV, Italy
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15
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Giglio Canelhas de Abreu L, Proença Vieira L, Teixeira Gomes T, Bacal F. Clinical and Nutritional Factors Associated With Early Mortality After Heart Transplantation. Transplant Proc 2018; 49:874-877. [PMID: 28457415 DOI: 10.1016/j.transproceed.2017.01.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this work was to verify the association between clinical and nutritional factors and mortality in the 1st 30 days after heart transplantation. METHODS This was a retrospective study of patients who underwent heart transplantation in a public hospital in Brazil from January 2013 to August 2015. The clinical and nutritional factors analyzed were: body mass index, body surface area, cachexia, infection, duration of orotracheal intubation, ejection fraction, mean pulmonary pressure, Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) score, hemoglobin, and diabetes mellitus. The primary outcome was mortality in the 1st 30 days after heart transplantation, and secondary outcomes were infection, acute kidney insufficiency, and duration of orotracheal intubation. We performed chi-square test, unpaired t test, and logistic regression in the analyses. A P value of < .05 was considered to be significant. RESULTS The sample had 103 patients, of which 16 patients (15.53%) died within 30 days after heart transplantation. We observed a relationship between death and orotracheal intubation duration (P < .01), postoperative creatinine (P < .01), acute kidney injury (P < .01), and INTERMACS score (P = .01) in the bivariate analysis but not in the multivariate model. CONCLUSIONS Clinical and nutritional factors had no impact on mortality up to 30 days after heart transplantation in this study, although orotracheal intubation duration, postoperative creatinine, acute kidney injury, and INTERMACS score were individually associated with early death.
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Affiliation(s)
- L Giglio Canelhas de Abreu
- Dietic and Nutrition Department, Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
| | - L Proença Vieira
- Dietic and Nutrition Department, Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - T Teixeira Gomes
- Dietic and Nutrition Department, Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - F Bacal
- Heart Transplant Unit, Heart Institute (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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16
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Osteoporosis following heart transplantation and immunosuppressive therapy. Transplant Rev (Orlando) 2017; 31:232-239. [PMID: 28865930 DOI: 10.1016/j.trre.2017.08.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Revised: 07/21/2017] [Accepted: 08/03/2017] [Indexed: 12/20/2022]
Abstract
Heart transplantation (HT) remains the ultimate final therapy for patients with end-stage heart failure, who despite optimal medical and surgical treatments exhibit severe symptoms. To prevent rejection of the transplanted organ, HT patients require life-long immunosuppressive therapy. The goal of the immunosuppression is to minimise the risk of immune-mediated graft rejection, while avoiding clinical side-effects. Current immunosuppressive agents have yielded good survival outcome, however, complications of the immunosuppressive therapy, such as impaired bone strength and increased fracture risk, are common among HT patients rendering increased morbidity and mortality rates. The main aim of the present review was to summarise current knowledge on bone strength impairment after HT and concomitant immunosuppressive therapy.
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17
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Chan KH, Szymanski KM, Li X, Ofner S, Flack C, Judge B, Whittam B, Misseri R, Kaefer M, Rink RC, Cain MP. Effect of baseline obesity and postoperative weight gain on the risk of channel revision following continent catheterizable urinary channel surgery. J Pediatr Urol 2016; 12:249.e1-7. [PMID: 27480466 DOI: 10.1016/j.jpurol.2016.05.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Accepted: 05/22/2016] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Prior studies suggest that obese patients are at increased risk for complications following continent catheterizable urinary (CCU) channel surgery. We hypothesized that postoperative weight gain increases the risk of channel angulation, difficulty catheterizing, and possible channel perforation requiring subfascial revision. The purpose of this study was to evaluate whether baseline obesity or becoming overweight/obese postoperatively was associated with a greater risk of subfascial revision. METHOD We reviewed retrospectively an institutional database of patients who underwent CCU channel surgery between the ages of ≥2 and <20 years from January 1990 to May 2013, excluding those with continent urinary reservoirs, continent vesicostomies, and those without body mass index (BMI) data. We collected data on patient/procedure characteristics, baseline/most recent BMI, and subfascial revision(s). We used Cox proportional hazard multivariable regression to assess the association of being overweight/obese at baseline (≥85% BMI) with time to first subfascial revision, and Fisher's exact test to compare rates of subfascial revision between those who became overweight/obese and those who did not. RESULTS Of the patients, 328/501 (65.5%) had baseline and post-baseline BMI data available: 53.4% male, 90.6% white, median age 7.4 years; median follow-up 76.4 months. Of the 328 patients, 38 (11.6%) had subfascial revisions. Baseline BMI data were available for 378 patients, and, of these, 130 (34.4%) were overweight/obese at baseline. Overweight/obese patients were more likely to undergo umbilical Monti (10% vs. 8.1%), non-umbilical spiral Monti (33.8% vs. 13.7%), and spiral umbilical Monti channels (13.8% vs. 7.3%) versus normal/underweight patients (p < 0.0001). From a multivariable Cox proportional hazard model controlling for age, BMI category, diagnosis, and ambulatory status, the hazard of subfascial revision for spiral umbilical Monti channels was 2.1× that of other channels (hazard ratio (HR) 2.1 [95% CI 1.2-3.8], p = 0.01). Fifty-one out of 328 patients (15.6%) became overweight/obese postoperatively, with 7.8% having a subfascial revision vs. 12.3% of those whose weight category decreased or remained stable (p = 0.3) (Table 1). CONCLUSIONS Patients who were overweight/obese at baseline were more likely to have channels constructed that are at the highest risk of subfascial revision. Patients who became overweight/obese postoperatively were not at greater risk of subfascial revision. Limitations include potential bias because of differential follow-up and inaccuracy of BMI percentile as a measurement of obesity.
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Affiliation(s)
- Katherine H Chan
- Division of Pediatric Urology, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN, USA; Department of Biostatistics, Indiana University-Purdue University, Indianapolis, IN, USA.
| | - Konrad M Szymanski
- Division of Pediatric Urology, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Xiaochun Li
- Center for Pediatric and Adolescent Comparative Effectiveness Research, Arkanasas, USA
| | - Susan Ofner
- Center for Pediatric and Adolescent Comparative Effectiveness Research, Arkanasas, USA
| | - Chandra Flack
- Division of Pediatric Urology, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Benjamin Judge
- Division of Pediatric Urology, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Benjamin Whittam
- Division of Pediatric Urology, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Rosalia Misseri
- Division of Pediatric Urology, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Martin Kaefer
- Division of Pediatric Urology, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Richard C Rink
- Division of Pediatric Urology, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mark P Cain
- Division of Pediatric Urology, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, Indianapolis, IN, USA
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18
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Jalowiec A, Grady KL, White-Williams C. Clinical outcomes in overweight heart transplant recipients. Heart Lung 2016; 45:298-304. [PMID: 27086571 PMCID: PMC4935635 DOI: 10.1016/j.hrtlng.2016.03.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 02/28/2016] [Accepted: 03/03/2016] [Indexed: 12/28/2022]
Abstract
BACKGROUND Few studies have examined the impact of patient weight on heart transplant (HT) outcomes. OBJECTIVES Nine outcomes were compared in 2 groups of HT recipients (N = 347) based on their mean body mass index (BMI) during the first 3 years post-HT. METHODS Group 1 consisted of 108 non-overweight patients (BMI <25; mean age 52; 29.6% females; 16.7% minorities). Group 2 consisted of 239 overweight patients (BMI ≥25; mean age 52; 15.9% females; 13.8% minorities). Outcomes were: survival, re-hospitalization, rejections, infections, cardiac allograft vasculopathy (CAV), stroke, renal dysfunction, diabetes, and lymphoma. RESULTS Non-overweight patients had shorter survival, were re-hospitalized more days after the HT discharge, and had more lymphoma and severe renal dysfunction. Overweight patients had more CAV, steroid-induced diabetes, and acute rejections. CONCLUSIONS Overweight HT patients had better survival, but more rejections, CAV, and diabetes. Non-overweight HT patients had worse survival, plus more re-hospitalization time, lymphoma, and renal dysfunction.
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Affiliation(s)
- Anne Jalowiec
- School of Nursing, Loyola University of Chicago, Chicago, IL, USA.
| | - Kathleen L Grady
- Center for Heart Failure, Bluhm Cardiovascular Institute, Division of Cardiac Surgery, Northwestern Memorial Hospital, Chicago, IL, USA; Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Connie White-Williams
- Center for Nursing Excellence, University of Alabama at Birmingham Hospital, Birmingham, AL, USA; University of Alabama at Birmingham School of Nursing, Birmingham, AL, USA
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19
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Salyer J, Flattery M, Joyner P, Friend J, Elswick RK. Community-Based Weight Management in Long-Term Heart Transplant Recipients: A Pilot Study. Prog Transplant 2016; 17:315-23. [DOI: 10.1177/152692480701700410] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Heart transplant recipients often suffer from obesity, dyslipidemia, and hypertension thought to be related to triple-drug immunosuppression and poor adherence to diet and exercise. A lifestyle intervention that allows recipients to attend a community-based weight management program may improve health outcomes. Objective To determine (1) the effects of attending a community-based weight management program on weight, systolic and diastolic blood pressure, and the lipid profile; and (2) the feasibility of a community-based program for weight management. Methods Twenty-one patients (81% male; age 57 years, 99.7 months since transplantation) participated in a randomized clinical trial and received either weight management counseling (control) or a 6-month scholarship to a structured commercial program (treatment). Using simple analysis of covariance models, group differences were assessed and reported as marginal means. Results At baseline, there were no demographic differences between groups. There were no differences in outcome variables except weight (control, 102.1 kg vs treatment, 98.3 kg; P = .05). After 6 months, significant differences were found in weight (control, 100.5 kg vs treatment, 95.6 kg; P = .047) and high-density lipoprotein cholesterol (control, 40.6 mg/dL vs treatment, 49.1 mg/dL; P = .044). A marginally significant difference was found in systolic blood pressure (control, 138 mm Hg vs treatment, 121 mm Hg; P=.07). A decrease in diastolic blood pressure (6 mm Hg) was attributed to treatment effect ( P = .16). No differences were noted in total cholesterol, triglycerides, or low-density lipoprotein cholesterol. Conclusions The structured commercial program appears to be an effective, feasible alternative to usual care. Findings need to be confirmed in future research with a larger sample.
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Affiliation(s)
- Jeanne Salyer
- Virginia Commonwealth University, Richmond, VA (JS, MF, JF, RKE), McGuire Veterans' Administration Medical Center, Richmond, VA (PJ)
| | - Maureen Flattery
- Virginia Commonwealth University, Richmond, VA (JS, MF, JF, RKE), McGuire Veterans' Administration Medical Center, Richmond, VA (PJ)
| | - Pamela Joyner
- Virginia Commonwealth University, Richmond, VA (JS, MF, JF, RKE), McGuire Veterans' Administration Medical Center, Richmond, VA (PJ)
| | - Jennifer Friend
- Virginia Commonwealth University, Richmond, VA (JS, MF, JF, RKE), McGuire Veterans' Administration Medical Center, Richmond, VA (PJ)
| | - R. K. Elswick
- Virginia Commonwealth University, Richmond, VA (JS, MF, JF, RKE), McGuire Veterans' Administration Medical Center, Richmond, VA (PJ)
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20
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Kugler C, Einhorn I, Gottlieb J, Warnecke G, Schwarz A, Barg-Hock H, Bara C, Haller H, Haverich A. Postoperative weight gain during the first year after kidney, liver, heart, and lung transplant: a prospective study. Prog Transplant 2015; 25:49-55. [PMID: 25758801 DOI: 10.7182/pit2015668] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
CONTEXT Studies of all types of organ transplant recipients have suggested that weight gain, expressed as an increase in body mass index (BMI), after transplant is common. OBJECTIVES To describe weight gain during the first year after transplant and to determine risk factors associated with weight gain with particular attention to type of transplant. DESIGN, SETTING, AND PARTICIPANTS A prospective study of 502 consecutive organ transplant recipients (261 kidney, 73 liver, 29 heart, 139 lung) to identify patterns of BMI change. Measurements were made during regular outpatient clinical visits at 2, 6, and 12 months after transplant. Data were retrieved from patients' charts and correlated with maintenance corticosteroid doses. RESULTS Overall, mean BMI (SD; range) was 23.9 (4.5; 13.6-44.1) at 2 months and increased to 25.4 (4.0; 13.0-42.2) by the end of the first postoperative year. BMI levels organized by World Health Organization categories showed a trend toward overweight/obesity in kidney (53.4%), liver (51.5%), heart (51.7%), and lung (33.1%) patients by 12 months after transplant. BMI changed significantly (P= .05) for all organ types and between all assessment points, except in kidney recipients. Maintenance corticosteroid doses were not a predictor of BMI at 12 months after transplant for most patients. CONCLUSIONS Weight gain was common among patients undergoing kidney, liver, heart, and lung transplant; however, many showed BMI values close to normality at the end of the first year after transplant. In most cases, increased BMI levels were related to obesity before transplant and not to maintenance corticosteroid therapy.
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21
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Time-to-Referral, Use, and Efficacy of Cardiac Rehabilitation After Heart Transplantation. Transplantation 2015; 99:594-601. [DOI: 10.1097/tp.0000000000000361] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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22
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Milaniak I, Przybyłowski P, Wierzbicki K, Sadowski J. Post-Transplantation Body Mass Index in Heart Transplant Recipients: Determinants and Consequences. Transplant Proc 2014; 46:2844-7. [DOI: 10.1016/j.transproceed.2014.09.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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23
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DiCecco SR, Francisco-Ziller N. Obesity and organ transplantation: successes, failures, and opportunities. Nutr Clin Pract 2014; 29:171-91. [PMID: 24503157 DOI: 10.1177/0884533613518585] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The increasing rate of societal obesity is also affecting the transplant world through obesity in candidates and donors as well as its posttransplant repercussions. Being overweight and obese has been shown to have significant effects on both short- and long-term complications as well as patient and graft survival. However, much of the comorbidity can be controlled or prevented with careful patient selection and aggressive management. A team approach to managing obesity and its comorbidities both pre- and posttransplant is essential for successful transplant outcomes. Complicating understanding the results of obesity research is the inclusion different weight categories, use of listing vs transplant weights, patient populations large enough for statistical power, and changes in transplant management, especially immunosuppression protocols, anti-infection protocols, and operative techniques. Much more research is needed regarding many elements, including safe weight loss before transplantation, prevention of weight gain after transplant, genomic influences, and the role of bariatric surgery in the transplant process.
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Affiliation(s)
- Sara R DiCecco
- Sara R. DiCecco, Mayo Clinic Hospital-Rochester Methodist Campus, 201 West Center Street, Rochester, MN 55902, USA.
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24
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Cheng RK, DePasquale EC, Deng MC, Nsair A, Horwich TB. Obesity in heart failure: impact on survival and treatment modalities. Expert Rev Cardiovasc Ther 2013; 11:1141-53. [PMID: 23944985 DOI: 10.1586/14779072.2013.824691] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Heart failure (HF) and obesity are commonly seen in the USA. Although obesity is associated with traditional cardiovascular disease, its relationship with HF is complex. Obesity is an accepted risk factor for incident HF. However, in patients with established HF, there exists a paradoxical correlation, with escalating BMI incrementally protective against adverse outcomes. Despite this relationship, patients with HF may desire to lose weight to reduce comorbidities or to improve quality of life. Thus far, studies have shown that intentional weight loss in obese patients with HF does not increase risk, with strategies including dietary modification, physical activity, pharmacotherapy, and/or surgical intervention.
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Affiliation(s)
- Richard K Cheng
- Department of Medicine, Division of Cardiology,University of Washington School of Medicine, Seattle, WA, USA
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Caceres M, Czer L, Esmailian F, Ramzy D, Moriguchi J. Bariatric Surgery in Severe Obesity and End-stage Heart Failure With Mechanical Circulatory Support as a Bridge to Successful Heart Transplantation: A Case Report. Transplant Proc 2013; 45:798-9. [DOI: 10.1016/j.transproceed.2012.10.036] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Accepted: 10/09/2012] [Indexed: 01/31/2023]
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Health behaviors contribute to quality of life in patients with advanced heart failure independent of psychological and medical patient characteristics. Qual Life Res 2012; 22:1603-11. [PMID: 23161327 DOI: 10.1007/s11136-012-0312-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2012] [Indexed: 12/20/2022]
Abstract
BACKGROUND Little is known about the contribution of health behaviors to quality of life (QoL) in heart transplant candidates. We examined physical activity, dietary habits, psychological, and medical patient characteristics as correlates of QoL among patients enrolled in the multisite Waiting for a New Heart Study. METHOD QoL (Minnesota Living with Heart Failure Questionnaire), demographic variables, psychological variables (e.g., depression, coping styles), and health behaviors (physical activity, dietary habits) were assessed in 318 patients (82% male, 53 ± 11 years) at the time of wait-listing and analyzed in 312 patients (excluding six underweight patients). Eurotransplant provided BMI and medical variables to compute the Heart Failure Survival Score (HFSS). Hierarchical multiple regression models were used to assess the independent contribution of health behaviors to QoL. RESULTS The HFSS was unrelated to QoL. As expected, psychological characteristics (depression, anxiety, vigilant coping style) contributed to impaired QoL, accounting for 22.9, 35.9, and 12.9% of the variance in total, emotional, and physical QoL, respectively. Physical inactivity further impaired QoL (total: 4.1%, p < 0.001; physical: 7.4%, p < 0.001). Dietary habits typically considered as unhealthy (i.e., infrequent consumption of fruits/vegetables/legumes; frequent intake of foods high in saturated fats) were related to enhanced physical QoL, but only among the overweight and obese patients. CONCLUSION Lifestyle interventions to modify negative emotions and to increase physical activity could help to improve QoL in heart transplant candidates, regardless of their disease severity. The role of eating habits in QoL among obese and overweight patients needs further exploration.
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Le Dinh H, Weekers L, Bonvoisin C, Krzesinski J, Monard J, de Roover A, Squifflet J, Meurisse M, Detry O. Delayed Graft Function Does Not Harm the Future of Donation-After-Cardiac Death in Kidney Transplantation. Transplant Proc 2012; 44:2795-802. [DOI: 10.1016/j.transproceed.2012.09.087] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Recipient and donor body mass index as important risk factors for delayed kidney graft function. Transplantation 2012; 93:524-9. [PMID: 22362367 DOI: 10.1097/tp.0b013e318243c6e4] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Obesity is increasingly impacting the overall health status and the global costs for health care. The increase in body mass index (BMI) is also observed in kidney allograft recipients and deceased organ donors. METHODS In a retrospective single-center study, we analyzed 1132 deceased donor kidney grafts, transplanted at our institution between 2000 and 2009 for recipient and donor BMI and its correlation with delayed graft function (DGF). Recipients/donors were classified according to their BMI (<18.5, 18.5-24.9, 25-29.9, and >30 kg/m(2)). DGF was defined as requirement for one dialysis within the first week after transplantation. RESULTS Overall DGF rate was 32.4%, mean recipient BMI was 23.64 ± 3.75 kg/m(2), and mean donor BMI was 24.69 ± 3.44 kg/m(2). DGF rate was 25.2%, 29.8%, 40.9%, and 52.6% in recipients with BMI less than 18.5, 18.5 to 24.9, 25 to 29.9, and more than 30 kg/m, respectively (P<0.0001). Donor BMI less than 18.5, 18.5 to 24.9, 25 to 29.9, more than 30 kg/m(2) resulted in a DGF rate of 22.5%, 31.0%, 37.3%, and 51.2% (P < 0.0001). Multivariate analysis revealed recipient BMI and dialysis duration as independent risk factors for DGF. DGF results in inferior 1- and 5-year graft and patient survival. CONCLUSION Recipient and donor BMI correlate with the incidence of DGF. Awareness thereof should have an impact on peri- and posttransplant measures in renal transplant recipients.
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Baldwin WM, Halushka MK, Valujskikh A, Fairchild RL. B cells in cardiac transplants: from clinical questions to experimental models. Semin Immunol 2011; 24:122-30. [PMID: 21937238 DOI: 10.1016/j.smim.2011.08.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Accepted: 08/24/2011] [Indexed: 12/31/2022]
Abstract
After many years of debate, there is now general agreement that B cells can participate in the immune response to cardiac transplants. Acute antibody-mediated rejection (AMR) is the best defined manifestation of B cell responses, but diagnostic and mechanistic questions still surround AMR. Many complement dependent mechanisms of antibody-mediated injury have been elucidated. C5 has become a therapeutic target that may not just truncate complement activation, but also may tip the balance away from inflammation by altering macrophage function. Additional complement independent effects have been identified. These may escape diagnosis and progress to chronic graft injury. The function of B cell infiltrates in cardiac transplants is even more enigmatic. Nodular endocardial infiltrates that contain B cells and plasma cells have been described in protocol biopsies of cardiac transplants for decades, but an understanding of their significance is still evolving based on more critical morphological and molecular evaluation of these infiltrates. A range of infiltrates containing B cells has also been described in the epicardial fat in transplants with advanced chronic rejection. B cells have been observed in endocardial and epicardial tertiary lymphoid nodules, but their impact on antigen presentation or antibody production remains to be determined. Experimental models in small and large animals suggest that B cells could be essential for the formation of lymphoid nodules through cytokine production. Similarly, the role of proinflammatory adipokines in the formation or function of epicardial lymphoid nodules has not been studied. These clinical observations provide critical questions to be addressed in experimental models.
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Affiliation(s)
- William M Baldwin
- Department of Immunology and the Glickman Urological and Kidney Disease Institute, The Cleveland Clinic, Cleveland, OH, USA.
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Forli L, Bollerslev J, Simonsen S, Isaksen GA, Godang K, Pripp AH, Bjortuft O. Disturbed energy metabolism after lung and heart transplantation. Clin Transplant 2010; 25:E136-43. [DOI: 10.1111/j.1399-0012.2010.01379.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Kalil AC, Mattei J, Florescu DF, Sun J, Kalil RS. Recommendations for the assessment and reporting of multivariable logistic regression in transplantation literature. Am J Transplant 2010; 10:1686-94. [PMID: 20642690 PMCID: PMC2909008 DOI: 10.1111/j.1600-6143.2010.03141.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Multivariable logistic regression is an important method to evaluate risk factors and prognosis in solid organ transplant literature. We aimed to assess the quality of this method in six major transplantation journals. Eleven analytical criteria and four documentation criteria were analyzed for each selected article that used logistic regression. A total of 106 studies (6%) out of 1,701 original articles used logistic regression analyses from January 1, 2005 to January 1, 2006. The analytical criteria and their respective reporting percentage among the six journals were: Linearity (25%); Beta coefficient (48%); Interaction tests (19%); Main estimates (98%); Ovefitting prevention (84%); Goodness-of-fit (3.8%); Multicolinearity (4.7%); Internal validation (3.8%); External validation (8.5%). The documentation criteria were reported as follows: Selection of independent variables (73%); Coding of variables (9%); Fitting procedures (49%); Statistical program (65%). No significant differences were found among different journals or between general versus subspecialty journals with respect to reporting quality. We found that the report of logistic regression is unsatisfactory in transplantation journals. Because our findings may have major consequences for the care of transplant patients and for the design of transplant clinical trials, we recommend a practical solution for the use and reporting of logistic regression in transplantation journals.
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Affiliation(s)
- Andre C. Kalil
- Infectious Diseases Division, University of Nebraska Medical Center, Omaha, NE
| | - Jane Mattei
- Hospital Nossa Senhora da Conceicao, Porto Alegre, Brazil
| | - Diana F. Florescu
- Infectious Diseases Division, University of Nebraska Medical Center, Omaha, NE
| | - Junfeng Sun
- Critical Care Medicine Department, National Institutes of Health, Bethesda, MD
| | - Roberto S. Kalil
- Nephrology Division, University of Iowa Hospitals and Clinics, Iowa City, IA
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Abstract
BACKGROUND Low levels of plasma adiponectin, an adipocytokine that possesses anti-inflammatory and antiatherogenic properties, frequently observed among obese subjects correlate with higher prevalence of several cardiovascular diseases. This study investigated whether adiponectin modulates allograft rejection in major histocompatibility complex class II-mismatched cardiac transplants. METHODS We heterotopically transplanted Bm12 allografts into adiponectin-deficient (APN-/-, C57BL/6 background) or wild-type (APN+/+) mice. Some APN-/- mice received adiponectin reconstitution by adenovirus. Histologic analyses assessed allograft rejection, and real-time reverse-transcriptase polymerase chain reaction evaluated the genes for cytokines/chemokines associated with the immune and inflammatory responses. In addition, we tested the effect of adiponectin on proliferation and cytokine/chemokine production in mouse T lymphocytes stimulated in vitro with anti-CD3 antibodies. RESULTS Allografts transplanted to APN-/- mice showed severe acute rejection relative to transplants in APN+/+ hosts accompanied by increased accumulation of CD4- and CD8-positive T lymphocytes and Mac3-positive macrophages. Adiponectin provision by adenovirus in APN-/- mice reversed these exacerbated responses to allografting. The rejected allografts in APN-/- mice contained significantly higher levels of tumor necrosis factor-alpha, interferon-gamma, and regulated on activation normal t expressed and presumably secreted. Moreover, adiponectin significantly suppressed proliferation and production of tumor necrosis factor-alpha, interferon-gamma, regulated on activation normal t expressed and presumably secreted, monocyte chemotactic protein-1, and interferon-gamma inducible protein-10 in mouse T lymphocytes stimulated in vitro with anti-CD3 antibodies. CONCLUSIONS These observations provide new mechanistic insight into immunoregulation in allograft recipients relative to obesity, an increasingly prevalent risk factor. Adiponectin may offer a new therapeutic target for allograft rejection after cardiac transplantation.
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Unes Kunju S, Naim HJ, Czer L, Simsir S, Schwarz ER. Acute cellular transplant rejection following laparoscopic adjustable gastric banding in a morbidly obese patient post heart transplantation. J Cardiovasc Med (Hagerstown) 2009; 11:695-9. [PMID: 19910801 DOI: 10.2459/jcm.0b013e328332e6f1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Obesity is a worldwide health problem that is often worsened after organ transplantation. As obesity is associated with increased incidence of metabolic syndrome, cardiovascular events and death, it is essential to control weight and avoid weight gain in patients especially following cardiac transplantation. Of the various strategies that are available for weight reduction, bariatric surgery seems to be the most effective in achieving weight loss and in maintaining the reduced body weight. However, this has not been frequently performed in organ-transplant recipients. CASE REPORT We are reporting a unique case of a bariatric surgery procedure performed in a patient after cardiac transplantation. A 30-year-old African-American man with a history of end-stage heart failure due to idiopathic dilated cardiomyopathy underwent orthotopic cardiac transplantation. Three years after transplantation, the patient underwent laparoscopic adjustable gastric banding surgery for morbid obesity. Two months later, the patient presented with severe heart failure and was diagnosed with acute cellular rejection as evidenced by endomyocardial biopsy results despite continued combined immunosuppressive therapy that had not been changed but with significantly reduced blood levels of calcineurin inhibitors. CONCLUSION We hypothesize that the altered gastro-intestinal motility and delayed gastric emptying due to laparoscopic adjustable gastric banding may have caused incomplete absorption of the administered immunosuppressant drugs in this particular case, as evidenced by the low tacrolimus level, resulting in acute cellular rejection of the transplanted heart, which has never been described before.
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Affiliation(s)
- Shebna Unes Kunju
- Division of Cardiology, Cedars Sinai Medical Center, 8700 Beverly Blvd, Suite 6215, Los Angeles, CA 90048, USA
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Weiss ES, Allen JG, Russell SD, Shah AS, Conte JV. Impact of Recipient Body Mass Index on Organ Allocation and Mortality in Orthotopic Heart Transplantation. J Heart Lung Transplant 2009; 28:1150-7. [DOI: 10.1016/j.healun.2009.06.009] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2009] [Revised: 06/12/2009] [Accepted: 06/12/2009] [Indexed: 11/28/2022] Open
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Interactions among donor characteristics influence post-transplant survival: a multi-institutional analysis. J Heart Lung Transplant 2009; 29:291-8. [PMID: 19804989 DOI: 10.1016/j.healun.2009.08.007] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2009] [Revised: 07/31/2009] [Accepted: 08/02/2009] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Quantification of donor-associated risk in a specific heart transplant recipient is often difficult. Our aim was to identify donor characteristics that affect survival in the contemporary era. METHODS Between 1990 and 2006, 7,322 patients from 32 centers in the Cardiac Transplant Research Database underwent heart transplantation. Multivariable logistic regression analysis was used to identify donor-associated risk predictors and important interactions between these donor characteristics. Recipient survival was examined using parametric regression analysis in the hazard function domain. RESULTS Donor characteristics associated with post-transplant death included donor age, donor requirement for vasoactive therapy, positive donor cytomegalovirus serology, longer graft ischemic time, and lower donor body weight. Several interactions between individual donor characteristics affected survival. In male donors, history of hypertension and diabetes mellitus were risk factors for death (p = 0.006, p = 0.04, respectively), but not in female donors (p = 0.5, p = 0.8, respectively). There was a significant interaction between donor age and recipient-donor weight difference. If the donor was of younger age, increasing recipient-donor weight difference did not result in increased death. With increasing donor age, weight difference did result in compromised survival (p < 0.0003). Donor and recipient gender further modified the degree of risk: risk was higher in female donors and when recipients were male (p < 0.0003). CONCLUSIONS This multi-institutional analysis identified important interactions between donor characteristics that affect post-transplant survival that explain some of the discrepancies in the results of previous studies. The results are likely to aid in efficient organ allocation.
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Kaufman BD, Chuai S, Dobbels F, Shaddy RE. Wasting or obesity at time of transplant does not predict pediatric heart transplant outcomes: analysis of ISHLT pediatric heart transplant registry. J Heart Lung Transplant 2009; 28:1273-8. [PMID: 19783177 DOI: 10.1016/j.healun.2009.07.020] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2009] [Revised: 07/24/2009] [Accepted: 07/27/2009] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Body mass index (BMI) both before and after heart transplant (HT) is used to risk stratify in adult HT. Single-center studies identify BMI as a potential predictor of outcome after HT in children; large-scale analyses in pediatric HT have not been performed. METHODS The ISHLT pediatric heart transplant registry was queried for HT recipients >2 years old between 1996 and 2006 with data for BMI percentile (BMI%ile) at HT. Survival and morbidity rates post-HT were compared between BMI%ile cohorts defined as: wasted, <5th BMI%ile; normal, 5th to 95th BMI%ile; and obese, >95th BMI%ile at HT. RESULTS Data from 2,333 pediatric HT patients were available for analysis. Incidence of abnormal BMI%ile at HT was: wasted = 23% and obese = 8%. Wasting and obesity were similar in patients with congenital or cardiomyopathic diagnoses. Wasted or obese patients at HT did not differ from patients with normal BMI in survival on Kaplan-Meier or multivariate analyses. There were no significant differences in pre-, peri- or post-operative adverse events between patients with wasting or obesity and those with normal BMI%ile at HT. CONCLUSIONS In contrast to adults, abnormal body mass at time of transplant was not associated with decreased survival in pediatric HT recipients. Potential pediatric transplant candidates should not be excluded based on the perception that wasting or obesity will increase the risk of adverse outcomes.
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Affiliation(s)
- Beth D Kaufman
- Pediatric Heart Transplant Program, Department of Pediatrics, School of Medicine, University of Pennsylvania, Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104-4399, USA.
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Dick AAS, Spitzer AL, Seifert CF, Deckert A, Carithers RL, Reyes JD, Perkins JD. Liver transplantation at the extremes of the body mass index. Liver Transpl 2009; 15:968-77. [PMID: 19642131 DOI: 10.1002/lt.21785] [Citation(s) in RCA: 133] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Controversies exist regarding the morbidity and mortality of patients undergoing liver transplantation at the extremes of the body mass index (BMI). A review of the United Network for Organ Sharing database from 1987 through 2007 revealed 73,538 adult liver transplants. Patients were stratified into 6 BMI categories established by the World Health Organization: underweight, <18.5 kg/m(2); normal weight, 18.5 to <25 kg/m(2); overweight, 25 to <30 kg/m(2); obese, 30 to <35 kg/m(2); severely obese, 35 to <40 kg/m(2); and very severely obese, > or =40 kg/m(2). Survival rates were compared among these 6 categories via Kaplan-Meier survival curves with the log-rank test. The underweight and very severely obese groups had significantly lower survival. There were 1827 patients in the underweight group, 1447 patients in the very severely obese group, and 68,172 patients in the other groups, which became the control. Groups with extreme BMI (<18.5 and > or =40) were compared to the control to assess significant differences. Underweight patients were more likely to die from hemorrhagic complications (P < 0.002) and cerebrovascular accidents (P < 0.04). When compared with the control, the very severely obese patients had a higher number of infectious complications and cancer events (P = 0.02) leading to death. In 3 different eras of liver transplantation, multivariable analysis showed that underweight and very severe obesity were significant predictors of death. In conclusion, liver transplantation holds increased risk for patients at the extremes of BMI. Identifying these patients and instituting aggressive new policies may improve outcomes. Liver Transpl 15:968-977, 2009. (c) 2009 AASLD.
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Affiliation(s)
- André A S Dick
- Division of Transplantation, Department of Surgery, University of Washington Medical Center, Seattle, WA, USA.
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Thuluvath PJ. Morbid obesity and gross malnutrition are both poor predictors of outcomes after liver transplantation: what can we do about it? Liver Transpl 2009; 15:838-41. [PMID: 19642129 DOI: 10.1002/lt.21824] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Jalowiec A, Grady KL, White-Williams C. Predictors of rehospitalization time during the first year after heart transplant. Heart Lung 2009; 37:344-55. [PMID: 18790335 DOI: 10.1016/j.hrtlng.2007.10.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Patient problems after heart transplant (HT) can lead to rehospitalization. OBJECTIVE To examine rehospitalization patterns and identify predictors of the number of days rehospitalized at the transplant site during the first year after HT surgery. METHODS Hierarchical regression identified predictors of greater rehospitalization time from chart data collected from two transplant sites during the first posttransplant year on 269 adult HT recipients. Variables (total = 32) were entered in six steps: clinical site, demographics, perioperative variables, cardiac function, immunosuppressant dosages, and post-HT complications. RESULTS The number of days rehospitalized at the transplant site during the first year after HT ranged from 0 to 142 (mean = 25, median = 16); 64% were rehospitalized; 37% were rehospitalized more than once. Main reasons were rejections, infections, cardiovascular problems, and gastrointestinal (GI) problems. The regression model explained 48.7% of the variance in rehospitalization time, with post-HT complications explaining the most variance. Ten predictors were significant: intravenously treated infections, treated acute rejections, shorter stay for HT surgery, GI complications, higher prednisone dose, female gender, coma, sex mismatch between donor and recipient, renal complications, and clinical site. CONCLUSION Sixty-four percent of the patients were rehospitalized at the transplant site during the first year after HT surgery (with a median of 16 hospital days); 37% were rehospitalized more than once. Significant predictors of the amount of time rehospitalized pertained to five types of complications (rejections, infections, GI, renal, coma), shorter HT surgical stay, female gender, higher prednisone dose, sex-mismatched donor, and clinical site. The study identifies who uses the most hospital resources during the first year after HT.
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Donor-recipient race mismatch and graft survival after pediatric heart transplantation. Ann Thorac Surg 2009; 87:204-9; discussion 209-10. [PMID: 19101298 DOI: 10.1016/j.athoracsur.2008.09.074] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2008] [Revised: 09/25/2008] [Accepted: 09/29/2008] [Indexed: 11/21/2022]
Abstract
BACKGROUND Black recipient race has been shown to predict poorer graft survival after pediatric heart transplantation. We analyzed our single-center experience comparing graft survival by race and the impact of donor-recipient race mismatch. METHODS One hundred sixty-nine consecutive primary pediatric heart transplant patients were analyzed by donor and recipient race (white recipient, 99; black recipient, 60; other, 10). The groups were similar in preoperative characteristics. There were fewer donor-recipient race matches in blacks compared with whites (10 versus 71; p < 0.0001). RESULTS Although 30-day and 6-month graft survival was similar for black and white recipients (93.9% and 85.8% versus 93.3% and 83.3%, respectively), overall actuarial graft survival was significantly lower in blacks (p < 0.019). Blacks tended to have a higher incidence of positive retrospective crossmatch (n = 26, 43%) than whites (n = 29, 29%), but this was not statistically significant (p = 0.053). The median graft survival for black recipients was 5.5 years compared with 11.6 years for whites. Donor-recipient race mismatch predicted poorer graft survival (5-year graft survival 48.9% versus 72.3%; p = 0.0032). The median graft survival for donor-recipient race-matched patients was more than twice that for mismatched patients (11.6 years versus 4.4 years). Cox proportional hazard analysis showed that donor-recipient race mismatch neutralized the effect of race on graft survival. CONCLUSIONS Graft survival after pediatric heart transplantation is inferior for black recipients compared with white recipients. These differences may be explained by a high incidence of donor-recipient race mismatch, which also predicts poorer outcome for all racial groups with pediatric heart transplantation. These data may have implications for future donor allocation schemes.
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Guida B, Perrino NR, Laccetti R, Trio R, Nastasi A, Pesola D, Maiello C, Marra C, De Santo LS, Cotrufo M. Role of dietary intervention and nutritional follow-up in heart transplant recipients. Clin Transplant 2009; 23:101-7. [DOI: 10.1111/j.1399-0012.2008.00915.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Hasse J. Pretransplant obesity: a weighty issue affecting transplant candidacy and outcomes. Nutr Clin Pract 2008; 22:494-504. [PMID: 17906274 DOI: 10.1177/0115426507022005494] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Because of the global increase in prevalence of obesity, many more overweight and obese individuals are undergoing evaluation for transplantation than in the past. Although obesity seems to provide a survival benefit in dialysis patients, obesity has traditionally been considered a contraindication for transplantation of most organs. It is theorized that obesity will contribute to worse transplant outcomes, including lower rates of graft and patient survival and higher rates of delayed graft function and infection. This review evaluates the available literature evaluating outcomes of obese patients with end-stage organ failure who undergo transplantation. Obesity seems to be associated with increased rates of wound infection after transplantation. However, other adverse transplant outcomes related to obesity seem to be dependent on the type of organ being transplanted and the degree of obesity. For example, a body mass index (BMI) of 30 kg/m(2) may reduce short-term survival in lung transplant recipients; however, obesity does not seem to confer an adverse effect on short- or long-term survival in liver transplant patients until a much higher BMI is reached (such as 35 or 40 kg/m(2)). Each transplant center must determine weight guidelines and criteria for identifying the level of obesity as a contraindication for transplantation. This must be based on organ type, each center's transplant and complication statistics, and available donor pools. Guidelines must also consider the morbidity and mortality risks of the obese patient with organ failure who does not receive a transplant.
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Affiliation(s)
- Jeanette Hasse
- Baylor Regional Transplant Institut, Baylor University Medical Center, Dallas, TX 75243, USA.
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Thuluvath PJ. Morbid obesity with one or more other serious comorbidities should be a contraindication for liver transplantation. Liver Transpl 2007; 13:1627-9. [PMID: 18044753 DOI: 10.1002/lt.21211] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Salyer J, Flattery M, Joyner P, Friend J, Elswick R. Community-based weight management in long-term heart transplant recipients: a pilot study. Prog Transplant 2007. [DOI: 10.7182/prtr.17.4.k5h3675752545079] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Villarino Marín AL, Posada Moreno P, Zaragoza García I, Ortuño Soriano I, Mora Torres P, Casañas García de Cortázar I. [Nutritional analysis of 25 heart transplanted patients]. Med Clin (Barc) 2007; 129:530-1. [PMID: 17983531 DOI: 10.1157/13111424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND OBJECTIVE Malnutrition could be very important in patients under surgery. Moreover, the immunosuppressive therapy can cause metabolic and nutritional disorders to the transplanted patients. The aim of this study was to obtain information about the nutritional situation of the cardiac transplanted patients with biochemical and anthropometric parameters. PATIENTS AND METHOD A retrospective descriptive transversal study. We reviewed clinic records of cardiac transplanted patients between 2004 and 2005. Biochemical and anthropometric parameters recorded before surgery, in the intensive care unit and at the hospital discharge. RESULTS At discharge, there is a decrease of the following parameters: albumin, 68%; creatinine, 68%; proteins, 92%, and body mass index, 64%; whereas one year after discharge an increase of the body mass index was observed (60%). It was observed that 36% of the patients presented high results of triglycerides, after both a month and a year after discharge. The percentage is of 32% of glucose and between 52% and 24% for cholesterol, respectively. CONCLUSIONS In patients submitted to cardiac transplantation, there is a tendency for a damaged nutritional situation, both at discharge and after a year. It is important to point out the need for a nutritional education to decrease possible complications.
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Affiliation(s)
- Antonio Luis Villarino Marín
- Escuela Universitaria de Enfermería, Fisioterapia y Podología, Universidad Complutense de Madrid, Madrid, España.
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Grady KL, Naftel DC, Young JB, Pelegrin D, Czerr J, Higgins R, Heroux A, Rybarczyk B, McLeod M, Kobashigawa J, Chait J, White-Williams C, Myers S, Kirklin JK. Patterns and predictors of physical functional disability at 5 to 10 years after heart transplantation. J Heart Lung Transplant 2007; 26:1182-91. [PMID: 18022086 DOI: 10.1016/j.healun.2007.08.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2007] [Revised: 08/01/2007] [Accepted: 08/02/2007] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Researchers have not examined relationships between perception of physical functional disability and demographic, clinical, and psychological variables at 5 to 10 years after heart transplantation. Therefore, the purposes of this study were to describe physical functional disability over time and identify predictors of physical functional disability from 5 to 10 years after heart transplantation. METHODS The study enrolled 555 patients who were between 5 and 10 years post-heart transplant (age, 54 +/- 9 years; 78% male, 88% white, 79% married). Patients completed 6 instruments that measure physical functional disability and factors that may impact physical functional disability. Statistical analyses included calculation of frequencies, means +/- standard deviation (plotted over time), Pearson correlation coefficients, and multiple regression coupled with repeated measures. RESULTS Between 5 and 10 years after heart transplantation, physical functional disability was low, and 34% to 45% of patients reported having no functional disability. More physical functional disability was associated with having more symptoms, having depression/mood/negative affect and lower use of negative coping strategies, having more comorbidities and more specific comorbidities (e.g., more orthopedic problems and diabetes); higher New York Heart Association functional class; having more acute rejection, infection, or cardiac allograft vasculopathy; being female, older, less educated, and unemployed; higher body mass index; and more hospital readmissions (explaining 46% of variance [F = 84.75, p < 0.0001]). CONCLUSIONS Demographic, clinical, and psychological factors were significantly related to physical functional disability. Knowledge of these factors provides the basis for development of therapeutic plans of care.
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Clark AL, Knosalla C, Birks E, Loebe M, Davos CH, Tsang S, Negassa A, Yacoub M, Hetzer R, Coats AJS, Anker SD. Heart transplantation in heart failure: The prognostic importance of body mass index at time of surgery and subsequent weight changes. Eur J Heart Fail 2007; 9:839-44. [PMID: 17532263 DOI: 10.1016/j.ejheart.2007.03.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2006] [Revised: 01/25/2007] [Accepted: 03/05/2007] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Heart transplantation is an important treatment for end-stage chronic heart failure. We studied the effect of body mass index (BMI), and the effect of subsequent weight change, on survival following transplantation in 1902 consecutive patients. METHODS AND RESULTS Patients were recruited from: London (n=553), Berlin (N=971) and Boston (N=378). Patients suitable for transplantation due to symptoms, low left ventricular ejection fraction (<or=30%) and peak oxygen consumption (<or=16 ml kg(-1) min(-1)) (N=237) were used as a comparator. In surviving transplanted patients, average duration of follow-up was 80 (SD 34) months. There were 805 deaths. One year survival was 72.7% (95% CI 72.68-72.72) and 5 year survival was 60.96% (61.94-61.99). Baseline BMI did not effect survival either as a continuous variable (hazard ratio (95% CI): 1.02; 0.99-1.04). Weight loss between transplant and 3 months was associated with worse survival (HR (95% CI) 2.6 (1.42-4.74)) compared with those who gained weight. In the reference group, increasing body mass index was related to survival. CONCLUSIONS Chronic heart failure patients with very low body weight can be transplanted successfully. The presence of underweight need not be an exclusion criterion for heart transplantation. Underweight patients appear to have a greater benefit from transplantation. Body weight increases after transplantation are not associated with adverse prognosis.
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Affiliation(s)
- Andrew L Clark
- Department of Cardiology, Univerity of Hull, and Department of Cardiac Surgery, Royal Brompton Hospital, London, UK.
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Risk stratification for renal transplantation after cardiac or lung transplantation: single-center experience and review of the literature. Kidney Blood Press Res 2007; 30:260-6. [PMID: 17622737 DOI: 10.1159/000104867] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2006] [Accepted: 05/22/2007] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Long-term survival after heart (HTx) or lung (LuTx) transplantation increases the risk for end-stage renal disease (ESRD). After HTx ESRD was reported to enhance mortality, and kidney transplantation (KTx) was shown to improve survival. However, prognostic factors in ESRD after HTx or LuTx are largely unknown. METHODS Single-center observational study in HTx and LuTx patients who accessed the KTx waiting list; baseline characteristics were correlated with mortality. RESULTS KTx was performed in 15 of 65 study patients. Survival was comparable on the KTx waiting list and in reference patients from the same center without ESRD. KTx significantly improved survival (5 years' survival 84.6% with KTx vs. 56.5% on the KTx waiting list, p = 0.030). None of the baseline parameters predicted mortality in the KTx group. Only on the KTx waiting list BMI (median 24.7 vs. 20.7; p < 0.05) and left ventricular ejection fraction (LVEF, median 63 vs. 53%, p < 0.008) significantly correlated with survival. CONCLUSIONS The risk for mortality after HTx or LuTx is not increased by ESRD, provided that patients meet access criteria for the KTx waiting list. KTx improves survival in ESRD after HTx or LuTx. BMI and LVEF may predict outcome in HTx/LuTx patients on the KTx waiting list.
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