1
|
Bansal N, Everitt MD, Nandi D, Spinner J, Conway J, Magnetta DA, Profita EL, Townsend M, Alejos JC, Deshpande SR. Clinical approach to acute cellular rejection from the pediatric heart transplant society. Pediatr Transplant 2022; 26:e14393. [PMID: 36377327 DOI: 10.1111/petr.14393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 08/04/2022] [Accepted: 08/29/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Early detection of cardiac allograft rejection is crucial for post-transplant graft survival. Despite the progress made in immunosuppression strategies, acute cellular rejection remains a serious complication during and after the first post-transplant year, and there is a continued lack of consensus regarding its treatment, especially in pediatric transplant patients. METHODS An open request was placed via the listserv to the membership of the Pediatric Heart Transplant Society (PHTS). Along with a broad literature search, numerous institutional protocols were pooled, analyzed and consolidated. A clinical approach document was generated highlighting areas of consensus and practice variation. RESULTS The clinical approach document divides cellular rejection by International Society for Heart and Lung Transplantation grades and provides management strategies for each, including persistent cellular rejection. CONCLUSIONS Cellular rejection treatment can be tailored to the clinical status, graft function, and the grade of cellular rejection. A case of mild and asymptomatic rejection may not require treatment, whereas a higher-grade rejection or rejection with graft dysfunction or hemodynamic compromise may require aggressive intravenous therapies, changes to maintenance immunosuppression therapy and augmented surveillance.
Collapse
Affiliation(s)
- Neha Bansal
- Children's Hospital at Montefiore, Bronx, New York, USA
| | | | - Deipanjan Nandi
- Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
| | - Joseph Spinner
- Baylor College of Medicine/Texas Children's Hospital, Houston, Texas, USA
| | - Jennifer Conway
- Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Defne A Magnetta
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | | | | | | | | |
Collapse
|
2
|
Tuite GC, Quintessenza JA, Asante-Korang A, Ghazarian SR, Wisotzkey BL, Shah S, Stapleton GE, Decker JA, Herbert CE, Kartha V, Alexander P, Carapellucci J, Krasnopero D, Hanson J, Goldenberg NA, Do NL, Mavroudis C, Karl TR, Boucek RJ, Kutty S, Vricella LA, van Gelder HM, Jacobs JP. Heart Transplantation for Pediatric and Congenital Cardiac Disease: A Comparison of Two Eras over 23 Years and 188 Transplants at a Single Institution. World J Pediatr Congenit Heart Surg 2021; 12:17-26. [PMID: 33407028 DOI: 10.1177/2150135120954149] [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
BACKGROUND To assess changes in patterns of practice and outcomes over time, we reviewed all patients who underwent heart transplantation (HTx) at our institution and compared two consecutive eras with significantly different immunosuppressive protocols (cohort 1 [80 HTx, June 1995-June 2006]; cohort 2 [108 HTx, July 2006-September 2018]). METHODS Retrospective study of 180 patients undergoing 188 HTx (June 1995-September 2018; 176 first time HTx, 10 second HTx, and 2 third HTx). In 2006, we commenced pre-HTx desensitization for highly sensitized patients and started using tacrolimus as our primary postoperative immunosuppressive agent. The primary outcome was mortality. Survival was modeled by the Kaplan-Meier method. Univariable and multivariable Cox proportional hazard models were created to identify prognostic factors for survival. RESULTS Our 188 HTx included 18 neonates, 85 infants, 83 children, and 2 adults (>18 years). Median age was 260.0 days (range: 5 days-23.8 years). Median weight was 7.5 kg (range: 2.2-113 kg). Patients in cohort 1 were less likely to have been immunosensitized preoperatively (12.5% vs 28.7%, P = .017). Nevertheless, Kaplan-Meier analysis suggested superior survival in cohort 2 (P = .0045). Patients in cohort 2 were more likely to be alive one year, five years, and ten years after HTx. Multivariable analysis identified the earlier era (hazard ratio [HR] [95% confidence interval] for recent era = 0.32 [0.14-0.73]), transplantation after prior Norwood operation (HR = 4.44 [1.46-13.46]), and number of prior cardiac operations (HR = 1.33 [1.03-1.71]) as risk factors for mortality. CONCLUSIONS Our analysis of 23 years of pediatric and congenital HTx reveals superior survival in the most recent 12-year era, despite the higher proportion of patients with elevated panel reactive antibody in the most recent era. This improvement was temporally associated with changes in our immunosuppressive strategy.
Collapse
Affiliation(s)
- Genevieve C Tuite
- Johns Hopkins All Children's Heart Institute, Saint Petersburg, FL, USA
| | | | | | | | | | - Shawn Shah
- Johns Hopkins All Children's Heart Institute, Saint Petersburg, FL, USA
| | - Gary E Stapleton
- Pediatric Interventional Cardiology, Texas Children's Hospital, Houston, TX, USA
| | - Jamie A Decker
- Johns Hopkins All Children's Heart Institute, Saint Petersburg, FL, USA
| | - Carrie E Herbert
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Vyas Kartha
- Johns Hopkins All Children's Heart Institute, Saint Petersburg, FL, USA
| | - Plato Alexander
- Johns Hopkins All Children's Heart Institute, Saint Petersburg, FL, USA
| | | | - Diane Krasnopero
- Children's Heart Center, Children's Healthcare of Atlanta, Emory University, Atlanta, GA, USA
| | - Jade Hanson
- Johns Hopkins All Children's Heart Institute, Saint Petersburg, FL, USA
| | - Neil A Goldenberg
- Johns Hopkins All Children's Heart Institute, Saint Petersburg, FL, USA
| | - Nhue L Do
- Division of Pediatric Cardiac Surgery, Vanderbilt University, Nashville, TN, USA
| | | | - Tom R Karl
- Johns Hopkins All Children's Heart Institute, Saint Petersburg, FL, USA
| | | | - Shelby Kutty
- Division of Pediatric Cardiology, 1466Johns Hopkins University, Baltimore, MD, USA
| | - Luca A Vricella
- Division of Pediatric Cardiac Surgery, 2462University of Chicago, IL, USA
| | - Hugh M van Gelder
- Cardiac Surgery, US Department of Veteran Affairs, Tampa, Florida, USA
| | - Jeffrey P Jacobs
- Congenital Heart Center, Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, FL, USA
| |
Collapse
|
3
|
Pediatric Cardiac Intensive Care Society 2014 Consensus Statement: Pharmacotherapies in Cardiac Critical Care Immune Therapy. Pediatr Crit Care Med 2016; 17:S69-76. [PMID: 26945331 DOI: 10.1097/pcc.0000000000000626] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE In this Consensus Statement, we review the etiology and pathophysiology of inflammatory processes seen in critically ill children with cardiac disease. Immunomodulatory therapies aimed at improving outcomes in patients with myocarditis, heart failure, and transplantation are extensively reviewed. DATA SOURCES The author team experience and along with an extensive review of the medical literature were used as data sources. DATA SYNTHESIS The authors synthesized the data in the literature to present current immumodulatory therapies. For each drug, the physiologic rationale, mechanism of action, and pharmacokinetics are synthesized, and the evidence in the literature to support the therapy is discussed. CONCLUSIONS Immunomodulation has a crucial role in the treatment of certain pediatric cardiac diseases. Immunomodulatory treatments that have been used to treat myocarditis include corticosteroids, IV immunoglobulin, cyclosporine, and azathioprine. Contemporary outcomes of pediatric transplant recipients have improved over the past few decades, partly related to improvements in immunomodulatory therapy to prevent rejection of the donor heart. Immunosuppression therapy is commonly divided into induction, maintenance, and acute rejection therapy. Common induction medications include antithymocyte globulin, muromonab-CD3, and basiliximab. Maintenance therapy includes chronic medications that are used daily to prevent rejection episodes. Examples of maintenance medications are corticosteroids, cyclosporine, tacrolimus, sirolimus, everolimus, azathioprine, and mycophenolate mofetil. Rejection of the donor heart is diagnosed either by clinically or by biopsy and is treated with intensification of immunosuppression.
Collapse
|
4
|
Notaro E, Brown L, Albers E, Law S, Kemna M. Dose conversion factor between cyclosporine and tacrolimus in pediatric heart transplant recipients. J Heart Lung Transplant 2014; 33:766-8. [PMID: 24854566 DOI: 10.1016/j.healun.2014.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Revised: 03/05/2014] [Accepted: 04/16/2014] [Indexed: 11/29/2022] Open
Affiliation(s)
- Eliza Notaro
- School of Medicine, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Lisa Brown
- Department of Biostatistics, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Erin Albers
- Division of Pediatric Cardiology, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Sabrina Law
- Division of Pediatric Cardiology, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Mariska Kemna
- Division of Pediatric Cardiology, Seattle Children's Hospital, University of Washington, Seattle, Washington
| |
Collapse
|
5
|
Rodríguez-Serrano M, Sánchez-Lázaro I, Almenar-Bonet L, Martínez-Dolz L, Portolés-Sanz M, Rivera-Otero M, Salvador-Sanz A. Does the calcineurin inhibitor have influence on cytomegalovirus infection in heart transplantation? Clin Transplant 2013; 28:88-95. [PMID: 24325305 DOI: 10.1111/ctr.12282] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2013] [Indexed: 12/19/2022]
Abstract
Cytomegalovirus (CMV) infection is a major cause of morbidity and mortality in heart transplant (HTx). Our aim was to analyze the rate of CMV infection in HTx patients receiving treatment with cyclosporine (CsA) or tacrolimus (Tac). Ninety-five patients were randomized to receive either CsA (53.7%) or Tac (46.3%). We performed prophylaxis with valganciclovir in patients with the highest risk of CMV infection. We considered CMV infection as an increased viral load or the presence of CMV in histological samples. We analyzed baseline characteristics, CMV infection, and other complications. Event-free rates were calculated using the Kaplan-Meier method. There were no significant differences in baseline characteristics between both groups. CMV infection was detected in 31.6% of patients (in 66.7% due to asymptomatic replication). The group treated with Tac had a lower rate of CMV infection (15.9% vs. 45.1%, p = 0.002) and longer CMV infection-free survival time (1440 vs. 899 d, p = 0.001). No differences were observed in the complications analyzed in both groups. The independent risk factors for infection identified in the multivariate analysis were treatment with CsA and bacterial infections. This was the first study to demonstrate a lower rate of CMV infection in patients treated with Tac vs. those treated with CsA after HTx.
Collapse
Affiliation(s)
- María Rodríguez-Serrano
- Heart Failure and Transplantation Unit, Department of Cardiology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | | | | | | | | | | | | |
Collapse
|
6
|
Ten-Year Results of a Randomized Trial Comparing Tacrolimus Versus Cyclosporine A in Combination With Mycophenolate Mofetil After Heart Transplantation. Transplantation 2013; 95:629-34. [DOI: 10.1097/tp.0b013e318277e378] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
7
|
Schumacher KR, Gajarski RJ. Postoperative care of the transplanted patient. Curr Cardiol Rev 2013; 7:110-22. [PMID: 22548034 PMCID: PMC3197086 DOI: 10.2174/157340311797484286] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Revised: 06/09/2011] [Accepted: 06/29/2011] [Indexed: 11/22/2022] Open
Abstract
The successful delivery of optimal peri-operative care to pediatric heart transplant recipients is a vital determinant of their overall outcomes. The practitioner caring for these patients must be familiar with and treat multiple simultaneous issues in a patient who may have been critically ill preoperatively. In addition to the complexities involved in treating any child following cardiac surgery, caretakers of newly transplanted patients encounter multiple transplant-specific issues. This chapter details peri-operative management strategies, frequently encountered early morbidities, initiation of immunosuppression including induction, and short-term outcomes.
Collapse
|
8
|
Schure AY, Kussman BD. Pediatric heart transplantation: demographics, outcomes, and anesthetic implications. Paediatr Anaesth 2011; 21:594-603. [PMID: 20880157 DOI: 10.1111/j.1460-9592.2010.03418.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The evolving demographics, outcomes, and anesthetic management of pediatric heart transplant recipients are reviewed. As survival continues to improve, an increasing number of these patients will present to our operating rooms and sedation suites. It is therefore important that all anesthesiologists, not only those specialized in cardiac anesthesia, have a basic understanding of the physiologic changes in the transplanted heart and the anesthetic implications thereof.
Collapse
Affiliation(s)
- Annette Y Schure
- Department of Anesthesiology, Perioperative and Pain Medicine, Children's Hospital Boston, 300 Longwood Avenue, Boston, MA 02115, USA.
| | | |
Collapse
|
9
|
Abstract
Despite more than 40 years' experience in pediatric heart transplantation, cellular rejection remains a significant cause of morbidity and mortality. In this review, strategies and agents to prevent acute cellular rejection are discussed. Strategies to prevent rejection are divided into two phases - induction and maintenance therapies. Currently, the most commonly used induction agents are polyclonal antibodies (rabbit or equine antithymocyte globulin) and interleukin-2 receptor antibodies (daclizumab or basiliximab). Induction therapies have reduced early rejection, are renal sparing, and can reduce corticosteroid exposure, but have not yet been shown to have a longer term survival benefit. Multiple maintenance immunosuppressants are available. Nearly all regimens include a calcineurin inhibitor (either ciclosporin [cyclosporine] or tacrolimus). Most combinations in pediatric heart transplantation include an antiproliferative agent (azathioprine, mycophenolate mofetil or, less commonly, sirolimus). Everolimus has seen increasing use in adult heart transplant patients in Europe but, to date, its use is rare in pediatric heart transplantation. The use of corticosteroids as a third agent is still common, but strategies to avoid or minimize their use are increasing. The 'best' combination of therapies varies between studies. By gaining a better understanding of individuals' genetic and environmental risk factors, we may in the future be able to better predict the course of cardiac allografts and enhance our ability to tailor immunosuppression to individual patient variables with the ultimate goal of inducing a state of immune tolerance.
Collapse
Affiliation(s)
- Susan W Denfield
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas 77030, USA.
| |
Collapse
|
10
|
Penninga L, Møller CH, Gustafsson F, Steinbrüchel DA, Gluud C. Tacrolimus versus cyclosporine as primary immunosuppression after heart transplantation: systematic review with meta-analyses and trial sequential analyses of randomised trials. Eur J Clin Pharmacol 2010; 66:1177-87. [PMID: 20882273 DOI: 10.1007/s00228-010-0902-6] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2010] [Accepted: 09/05/2010] [Indexed: 01/08/2023]
Abstract
PURPOSE We conducted a systematic review of randomized trials to compare the benefits and harms of tacrolimus versus cyclosporine as primary immunosuppression after heart transplantation. METHODS AND RESULTS We searched electronic databases and bibliographies up to April 2010. Our review followed the Cochrane and PRISMA guidelines. The meta-analysis included 10 randomized trials with 952 patients. Tacrolimus was significantly superior to cyclosporine (both formula-combined) with regard to hypertension (relative risk [RR] 0.8; 95% confidence interval [CI] 0.69-0.93, p = 0.003), hyperlipidaemia (RR 0.57; 95% CI 0.44-0.74, p < 0.0001), hirsutism (RR 0.17 95% CI 0.04-0.62, p = 0.008), and gingival hyperplasia (RR 0.07 95% CI 0.01-0.37, p = 0.002). No significant differences between the two calcineurin inhibitors were found with regard to acute rejections causing haemodynamic instability, diabetes, renal dysfunction, infection, malignancy, or neurotoxicity. Tacrolimus was significantly superior to microemulsion cyclosporine with regard to mortality (RR 0.64; 95% CI 0.42-0.96, p = 0.03), acute severe biopsy-proven rejection (RR 0.71; 95% CI 0.56-0.90, p = 0.004), hyperlipidaemia (RR 0.57; 95% CI 0.41-0.79, p = 0.0009), hirsutism (RR 0.17 95% CI 0.04-0.62, p = 0.008), and gingival hyperplasia (RR 0.07; 95% CI 0.01-0.37, p = 0.002). Tacrolimus was significantly superior to oil-based cyclosporine with regard to hypertension (RR 0.66; 95% CI 0.54-0.80, p < 0.0001), and hyperlipidaemia (RR 0.57; 95% CI 0.38-0.87, p = 0.009). CONCLUSION Tacrolimus seems to be superior to cyclosporine in heart transplant patients with regard to hypertension, hyperlipidaemia, gingival hyperplasia and hirsutism. In addition, tacrolimus seems to be superior to microemulsion cyclosporine in heart transplant patients with regard to a number of outcomes, including death. More trials with a low risk of bias are needed to determine if the results of the present meta-analysis can be confirmed.
Collapse
Affiliation(s)
- Luit Penninga
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Cochrane Hepato-biliary Group, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
| | | | | | | | | |
Collapse
|
11
|
Sánchez-Lázaro IJ, Almenar L, Martínez-Dolz L, Buendía-Fuentes F, Agüero J, Navarro-Manchón J, Vicente JL, Salvador A. A prospective randomized study comparing cyclosporine versus tacrolimus combined with daclizumab, mycophenolate mofetil, and steroids in heart transplantation. Clin Transplant 2010; 25:606-13. [PMID: 20682020 DOI: 10.1111/j.1399-0012.2010.01309.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Ignacio J Sánchez-Lázaro
- Heart Failure and Transplantation Unit, Cardiology Department, Hospital Universitario La Fe, Valencia, Spain.
| | | | | | | | | | | | | | | |
Collapse
|
12
|
Gossett JG, Canter CE, Zheng J, Schechtman K, Blume ED, Rodgers S, Naftel DC, Kirklin JK, Scheel J, Fricker FJ, Kantor P, Pahl E. Decline in rejection in the first year after pediatric cardiac transplantation: a multi-institutional study. J Heart Lung Transplant 2010; 29:625-32. [PMID: 20207171 DOI: 10.1016/j.healun.2009.12.009] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2009] [Revised: 11/25/2009] [Accepted: 12/07/2009] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Rejection is a major cause of morbidity and mortality after pediatric heart transplantation (HTx). Survival after pediatric HTx has improved over time, but whether there has been an era-related improvement in the occurrence of allograft rejection is unknown. METHODS The Pediatric Heart Transplant Study (PHTS) database was queried for patients who underwent HTx from January 1993 to December 2005 to determine the incidence of rejection and identify factors associated with the first episode of rejection in the first year after HTx. RESULTS Data were reviewed in 1,852 patients from 36 centers. The incidence of rejection declined over 13 years at a rate of -2.58 +/- 0.41 (p < 0.001) from approximately 60% to 40% (p < 0.001). The mean number of episodes of rejection also significantly fell at a rate of -0.05 +/- 0.01 per patient/year from 1.19 to 0.66 (p < 0.001). The incidence of rejection with hemodynamic compromise and death from rejection did not change. Multivariate analysis for the risk of a first rejection episode demonstrated decreased risk of rejection with later year of HTx (odds ratio [OR], 0.88; 95% confidence interval [CI], 0.85-0.91; p < 0.001) and use of mechanical support (OR, 0.65; 95% CI, 0.42-0.99; p = 0.046). Increased risk of rejection was associated with positive donor-specific crossmatch (OR, 1.85; 95% CI, 1.18-2.88; p = 0.007) and older recipient age (OR, 1.05; 95% CI, 1.02-1.07; p < 0.001). CONCLUSIONS Although the overall incidence and prevalence of rejection has substantially decreased over time in pediatric HTx recipients in the first year after HTx, the rate of rejection with hemodynamic compromise or death from rejection remains unchanged.
Collapse
Affiliation(s)
- Jeffrey G Gossett
- Department of Pediatrics, Children's Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
13
|
Bharat W, Manlhiot C, McCrindle BW, Pollock-BarZiv S, Dipchand AI. The profile of renal function over time in a cohort of pediatric heart transplant recipients. Pediatr Transplant 2009; 13:111-8. [PMID: 18093086 DOI: 10.1111/j.1399-3046.2007.00848.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
To assess the burden over time of renal dysfunction in pediatric heart transplant patients using an objective measure on an annual basis for serial comparison. GFR was measured at regular interval by nuclear medicine scintigraphy. Results were analyzed in relation to age, time post-transplantation, gender, and average calcineurin-inhibitor dose for the first two months post-transplantation. Results were compared with cGFR using the Schwartz equation. A total of 91 patients (56 males) transplanted between 1990 and 2004 underwent 373 GFR measurements. Median age at transplantation was 3.3 yr (birth - 17.8). Median first GFR at 0.7 yr (0.1-4.1) post-transplant was normal (94 mL/kg/1.73 m(2)). Freedom from at least mild renal insufficiency was 84% and 33% at one and five years post-transplant. Females had better renal function early post-transplant (GFR 105 mL/min/1.73 m(2)) but an increased probability of an abnormal GFR over time. Higher calcineurin inhibitor dose in the first two months post-transplantation was associated with an increasing probability of an abnormal GFR over time. The cGFR overestimated the measured GFR by 33 +/- 26 mL/kg/1.73 m(2). Renal insufficiency is an important morbidity after pediatric transplantation with the majority of patients experiencing at least mild renal dysfunction. Calculated GFR significantly underestimates the burden of renal insufficiency in this patient population.
Collapse
Affiliation(s)
- Winston Bharat
- Labatt Family Heart Centre, Hospital for Sick Children and Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | | | | | | | | |
Collapse
|
14
|
Ameduri RK, Canter CE. Current practice in immunosuppression in pediatric cardiac transplantation. PROGRESS IN PEDIATRIC CARDIOLOGY 2009. [DOI: 10.1016/j.ppedcard.2008.10.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
15
|
Abd-Allah S, Checchia PA. Heart Transplantation. CARDIOVASCULAR PEDIATRIC CRITICAL ILLNESS AND INJURY 2009:1-22. [DOI: 10.1007/978-1-84800-923-3_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
|
16
|
Ye F, Ying-Bin X, Yu-Guo W, Hetzer R. Tacrolimus versus cyclosporine microemulsion for heart transplant recipients: a meta-analysis. J Heart Lung Transplant 2008; 28:58-66. [PMID: 19134532 DOI: 10.1016/j.healun.2008.10.004] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2008] [Revised: 10/09/2008] [Accepted: 10/14/2008] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Tacrolimus and cyclosporine microemulsion are the 2 major immunosuppressants for heart transplantation. Several studies have compared these 2 drugs, but the outcomes were not consistent. This meta-analysis of randomized controlled trials compared the beneficial and harmful effects of tacrolimus and microemulsion cyclosporine for heart transplant recipients. METHODS Electronic databases and manual bibliography searches were conducted. A meta-analysis was performed of all randomized controlled trials comparing tacrolimus with cyclosporine microemulsion as primary immunosuppression for heart transplant recipients. Data for mortality, acute rejection, withdrawals, and adverse events were extracted. The combined results of the data of the randomized controlled trials were summarized as relative risk with 95% confidence intervals. RESULTS The study assessed 7 randomized controlled trials including 885 patients. There was no difference in mortality at 1 year between recipients treated with tacrolimus and cyclosporine microemulsion. Tacrolimus-treated patients had less acute rejection risk at 6 months and 1 year. Fewer patients stopped tacrolimus than cyclosporine microemulsion. The rate of new-onset diabetes mellitus requiring insulin treatment was higher with tacrolimus. More post-transplantation hypertension occurred with cyclosporine microemulsion. The groups had comparable incidences of malignancy and renal failure needing dialysis. CONCLUSIONS The use of tacrolimus as primary immunosuppressant for heart transplant recipients results in comparable survival and a significant reduction in acute rejection compared with cyclosporine microemulsion.
Collapse
Affiliation(s)
- Fan Ye
- Department of Cardiothoracic and Vascular Surgery, Chongqing Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | | | | | | |
Collapse
|
17
|
Sulemanjee NZ, Merla R, Lick SD, Aunon SM, Taylor M, Manson M, Czer LSC, Schwarz ER. The first year post-heart transplantation: use of immunosuppressive drugs and early complications. J Cardiovasc Pharmacol Ther 2008; 13:13-31. [PMID: 18287587 DOI: 10.1177/1074248407309916] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
A large number of heart transplants are performed annually in different transplant centers in the United States. This is partly because of the improved survival of patients who undergo cardiac transplantation, thus making it a more viable option in the management of end-stage heart failure. The survival benefit after heart transplantation is a result of newer immunosuppressive drug regimens and a better understanding of their effects and interactions. Several studies, mostly involving a small number of patients, describe use and comparison of the many distinct immunosuppressive drugs available to date. Interestingly, many transplant centers perform in-house typical induction treatment regimens because of their own experience and intra-institutional preference. This review summarizes current practices of immunosuppressive drug therapy in the first year post-heart transplant based on the available clinical evidence and discusses future options of heart transplant immunosuppressive drug therapies.
Collapse
Affiliation(s)
- Nasir Z Sulemanjee
- Division of Cardiology, Department of Internal Medicine, The University of Texas Medical Branch, Galveston, TX, USA
| | | | | | | | | | | | | | | |
Collapse
|
18
|
Hachem RR, Yusen RD, Chakinala MM, Meyers BF, Lynch JP, Aloush AA, Patterson GA, Trulock EP. A randomized controlled trial of tacrolimus versus cyclosporine after lung transplantation. J Heart Lung Transplant 2007; 26:1012-8. [PMID: 17919621 DOI: 10.1016/j.healun.2007.07.027] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2007] [Revised: 07/11/2007] [Accepted: 07/15/2007] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND The optimal maintenance immunosuppressive regimen after lung transplantation is uncertain. METHODS We conducted a randomized controlled trial of tacrolimus versus cyclosporine in combination with azathioprine and prednisone after lung transplantation. Ninety adults were randomized to tacrolimus (n = 44) or cyclosporine (n = 46). The primary end point was a composite of a cumulative acute rejection A score of 3 or higher, a cumulative lymphocytic bronchitis B score of 4 or higher, or the onset of bronchiolitis obliterans syndrome (BOS) stage 0-p. RESULTS Recipients randomized to cyclosporine were significantly more likely to develop the primary end point than those randomized to tacrolimus. During the study period, the primary end point developed in 39 of 46 cyclosporine subjects compared with 24 of 44 tacrolimus subjects (p = 0.002); acute rejection or lymphocytic bronchitis end points developed in 29 of 46 cyclosporine subjects compared with 18 of 44 tacrolimus subjects (p = 0.036). Furthermore, BOS stage 0-p was more likely to develop in the cyclosporine group than in the tacrolimus group, but this was not statistically significant (log-rank p = 0.1). In addition, there was a trend to a higher incidence of diabetes among those in the tacrolimus group, but there was no significant difference in graft survival or the total number of infections, or in the incidence of hypertension, chronic kidney disease, or cancer between the 2 groups. CONCLUSIONS Tacrolimus is associated with a lower burden of acute rejection and lymphocytic bronchitis and a trend to a greater freedom from BOS stage 0-p than cyclosporine after lung transplantation.
Collapse
Affiliation(s)
- Ramsey R Hachem
- Division of Pulmonary & Critical Care, Washington University School of Medicine, St. Louis, Missouri 63110, USA.
| | | | | | | | | | | | | | | |
Collapse
|
19
|
Abstract
Tacrolimus is a calcineurin inhibitor recently approved in the US and throughout the EU for the prevention of allograft rejection in heart transplant recipients. It is commonly administered orally for long-term immunosuppression. The incidence of mild to severe acute rejection in the first 6 months following heart transplantation was significantly lower in tacrolimus recipients than in ciclosporin recipients (54% vs 66%) in a large, phase III trial conducted in Europe. A large, phase III trial conducted in the US did not show a significant difference between tacrolimus and ciclosporin in the incidence of severe rejection or haemodynamic compromise rejection requiring treatment within the first 6 months post-transplant (22% vs 32%), but did show a significant difference in the incidence at 1 year (23% vs 37%). In phase III trials, 1-year patient survival was similar between tacrolimus and ciclosporin recipients in the EU (93% vs 92%) and the US (95% vs 90%). Tacrolimus was shown to be effective in the prevention of rejection in paediatric and African American heart transplant recipients. The tolerability profile of tacrolimus in heart transplant recipients was broadly similar to that of ciclosporin, although tacrolimus was usually associated with lower incidences of post-transplant hypertension and dyslipidaemia.
Collapse
|
20
|
Hirano T. Cellular pharmacodynamics of immunosuppressive drugs for individualized medicine. Int Immunopharmacol 2007; 7:3-22. [PMID: 17161812 DOI: 10.1016/j.intimp.2006.09.020] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2006] [Revised: 09/04/2006] [Accepted: 09/17/2006] [Indexed: 12/13/2022]
Abstract
The therapeutic effects of immunosuppressive drugs are known to deviate largely between patients, but efficient strategies for the differentiation of patients who show clinical resistance to immunosuppressive therapies have not been established. Accordingly, a considerable number of patients receive treatment with immunosuppressive drugs despite the onset of serious side effects and poor responses. Cellular pharmacodynamics of immunosuppressive drugs in vitro using peripheral lymphocytes derived from each patient, an attractive way to distinguish resistant patients, is respected and has been applied to the carrying out of individualized immunosuppressive therapy. In this article, I summarize experimental procedures for assaying immune cell responses to immunosuppressive drugs in vitro, and highlight the relationship between cellular sensitivity to immunosuppressive drugs and the therapeutic efficacy of drugs in organ transplantation and several immunological disorders. I will also overview the molecular mechanisms and genetic bases for cellular and clinical resistance to immunosuppressive drugs. Lastly, the future clinical prospects for the application of in vitro drug sensitivity tests for "patient-tailored" immunosuppressive therapies are discussed.
Collapse
Affiliation(s)
- Toshihiko Hirano
- Department of Clinical Pharmacology, School of Pharmacy, Tokyo University of Pharmacy and Life Science, 1432-1 Horinouchi, Hachioji, Tokyo 192-0392, Japan.
| |
Collapse
|
21
|
Abstract
During the past two decades, several advances have resulted in marked improvement in medium-term survival for infants and children undergoing heart transplantation. Unfortunately, progress has been less dramatic in the field of lung and heart-lung transplantation, where there is little evidence of improved outcomes. The procedures remain palliative and all transplant recipients are at risk for the adverse effects of non-specific immunosuppression, including infections, lymphoproliferative disorders, and non-lymphoid malignancies. In addition, current immunosuppressive agents have narrow therapeutic windows and exhibit a wide array of organ toxicities, posing special challenges for the young patient who must endure life-long immunosuppression. New immunosuppressive regimens have lowered the rates of acute rejection but appear to have had relatively little impact on the incidence of chronic rejection, the principal cause of late graft loss. The ultimate goal is to induce a state of donor-specific tolerance, wherein the recipient will accept the allograft indefinitely without the need for long-term immunosuppression. This quest is currently being realised in animal models of solid organ transplantation, and offers great hope for children undergoing heart and lung transplantation in the future.
Collapse
Affiliation(s)
- Steven A Webber
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | | | | |
Collapse
|
22
|
Pengel L, Barcena L, Morris PJ. Registry of randomized controlled trials in transplantation: January 1 to June 30, 2005. Transplantation 2006; 81:1071-86. [PMID: 16641590 DOI: 10.1097/01.tp.0000221632.63426.5c] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Liset Pengel
- Centre for Evidence in Transplantation, Clinical Effectiveness Unit, Royal College of Surgeons of England and London School of Hygiene and Tropical Medicine, University of London, London, UK
| | | | | |
Collapse
|
23
|
Kim JJ, Dreyer WJ, O'Brian Smith E, Price JF, Clunie S, Dimas VV, Jefferies JL, Rosenblatt H, Radovancevic B, Towbin JA, Denfield SW. Leukocyte Suppression is Associated with Improved Clinical Outcomes in Children’s Status after Orthotopic Heart Transplantation. J Heart Lung Transplant 2006; 25:195-9. [PMID: 16446220 DOI: 10.1016/j.healun.2005.09.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2005] [Revised: 08/26/2005] [Accepted: 09/05/2005] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Leukocyte suppression is a sequela of immunosuppressive therapy after orthotopic heart transplantation and may result in discontinuation of anti-proliferative agents. Clinical outcomes in this patient population have not been well delineated. METHODS This study was a retrospective review of children who underwent orthotopic heart transplantation at our institution from 1986 to 2003. Leukocyte suppression was defined as a white blood cell count <5,000, prompting the withdrawal of anti-proliferative agents. The population was divided into 2 groups, leukosuppressed (LS) and non-leukosuppressed (NLS), and their clinical outcomes were compared. RESULTS The study included 109 patients, of which 44 (40%) became leukosuppressed. The 2 groups were similar regarding demographic data and initial management. The LS Group had a significantly decreased incidence of rejection, being 7 times less likely to have recurrent rejection (p = 0.001). The median time to rejection was 0.8 +/- 0.6 years for the NLS Group, whereas the median time to rejection was not yet reached at 17 years for the LS Group. The LS Group also tended toward a decreased incidence of retransplantation or death (p = 0.06). The organ "half-life" in the NLS Group was 7.5 years vs 12.5 years in the LS Group. There was no difference between the 2 groups in regards to other adverse effects of immunosuppression. CONCLUSIONS Children who have undergone orthotopic heart transplantation and subsequently become leukosuppressed have a lower incidence of rejection and a tendency toward less organ loss than children who do not become leukosuppressed, without having an increased incidence of adverse side effects.
Collapse
Affiliation(s)
- Jeffrey J Kim
- Section of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas 77030, USA.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|