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Raven LM, Muir CA, Kessler Iglesias C, Bart NK, Muthiah K, Kotlyar E, Macdonald P, Hayward CS, Jabbour A, Greenfield JR. Sodium glucose co-transporter 2 inhibition with empagliflozin on metabolic, cardiac and renal outcomes in recent cardiac transplant recipients (EMPA-HTx): protocol for a randomised controlled trial. BMJ Open 2023; 13:e069641. [PMID: 36990488 PMCID: PMC10069602 DOI: 10.1136/bmjopen-2022-069641] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/31/2023] Open
Abstract
INTRODUCTION Cardiac transplantation (CTx) is a life-saving operation that can improve the quality and length of a recipient's life. Immunosuppression medication, required to prevent rejection, can result in adverse metabolic and renal effects. Clinically significant complications include metabolic effects such as diabetes and weight gain, renal impairment, and cardiac disease such as allograft vasculopathy and myocardial fibrosis. Sodium glucose co-transporter 2 (SGLT2) inhibitors are a class of oral medication that increase urinary excretion of glucose. In patients with type 2 diabetes, SGLT2 inhibitors improve cardiovascular, metabolic and renal outcomes. Similar benefits have been shown in patients with heart failure and reduced ejection fraction irrespective of diabetes status. In patients with post-transplant diabetes mellitus, SGLT2 inhibitors improve metabolic parameters; however, their benefit and safety have not been evaluated in randomised prospective studies. This study will potentially provide a novel therapy to improve or prevent complications (diabetes, kidney failure and heart fibrosis) that occur with immunosuppressive medications. METHODS The EMPA-HTx study is a randomised, placebo-controlled trial of the SGLT2 inhibitor empagliflozin 10 mg daily versus placebo in recent CTx recipients. One hundred participants will be randomised 1:1 and commence the study medication within 6-8 weeks of transplantation with treatment and follow-up until 12 months after transplantation. Demographic information, anthropomorphic measurements, pathology tests and cardiac magnetic resonance (CMR) scan will be recorded at baseline and follow-up. Patients will be reviewed monthly during the study until 12 months post-CTx and data will be collected for each patient at each study visit. The overall aim of the study is to assess the safety and efficacy of empagliflozin in CTx recipients. The primary outcome is glycaemic improvement measured as change in glycated haemoglobin and/or fructosamine. Key secondary outcomes are cardiac interstitial fibrosis measured by CMR and renal function measured by estimated glomerular filtration rate. ETHICS AND DISSEMINATION This study has been approved by St Vincent's Hospital Human Research Ethics Committee (2021/ETH12184). The findings will be presented at national and international scientific meetings and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER ACTRN12622000978763.
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Affiliation(s)
- Lisa Mary Raven
- Department of Diabetes and Endocrinology, St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
- Clinical Diabetes, Appetite and Metabolism Laboratory, Garvan Institute of Medical Research, Darlinghurst, New South Wales, Australia
- School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Christopher A Muir
- Department of Diabetes and Endocrinology, St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
- School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Cassia Kessler Iglesias
- School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Heart and Lung Transplantation, St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
- Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia
| | - Nicole K Bart
- School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Heart and Lung Transplantation, St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
- Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia
| | - Kavitha Muthiah
- School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Heart and Lung Transplantation, St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
- Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia
| | - Eugene Kotlyar
- School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Heart and Lung Transplantation, St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
- Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia
| | - Peter Macdonald
- School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Heart and Lung Transplantation, St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
- Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia
| | - Christopher S Hayward
- School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Heart and Lung Transplantation, St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
- Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia
| | - Andrew Jabbour
- School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Heart and Lung Transplantation, St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
- Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia
| | - Jerry R Greenfield
- Department of Diabetes and Endocrinology, St Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia
- Clinical Diabetes, Appetite and Metabolism Laboratory, Garvan Institute of Medical Research, Darlinghurst, New South Wales, Australia
- School of Clinical Medicine, St Vincent's Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
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Kuczaj A, Pawlak S, Śliwka J, Przybyłowski P. Pregnancies After Orthotopic Heart Transplantation: A Single-Center Experience. Transplant Proc 2022; 54:1065-1069. [PMID: 35303995 DOI: 10.1016/j.transproceed.2022.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 01/07/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Patients who underwent orthotopic heart transplantation have improved survival and quality of live. Some of them are women of childbearing age and have a wish to be pregnant. If the decision to have a child is made, the patient needs a multidisciplinary approach. MATERIAL AND METHODS We analyzed the whole cohort of patients after orthotopic heart transplantation. From the whole group we extracted women of childbearing age between 16 and 45 years and at least 1 year after transplantation (85 patients). From this group, 8 patients gave birth to children. RESULTS No cardiocirculatory problems were observed in the mothers during pregnancy and in follow-ups. Strong changes in immunosuppressive drug levels were observed during and directly after the pregnancies. Two children were born prematurely (at 31 and in 34 weeks of gestation). Two children developed cardiomyopathy (the same as in mother). CONCLUSION The decision of childbearing should be made individually considering each patient's medical history and potential risks connected with the pregnancy. Pregnancy after heart transplantation is relatively safe for the mother. Risk of transmitting cardiomyopathies to the children, especially hypertrophic cardiomyopathy, is high. The patients should be aware of this fact and be carefully counseled preconceptionally.
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Affiliation(s)
- Agnieszka Kuczaj
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Zabrze, Poland; Department of Cardiac Transplantation and Mechanical Circulatory Support, Silesian Center for Heart Diseases, Zabrze, Poland.
| | - Szymon Pawlak
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Zabrze, Poland; Cardiac Surgery, Transplantology and Mechanical Circulatory Support in Children, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Joanna Śliwka
- Cardiac Surgery, Transplantology and Mechanical Circulatory Support in Children, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Piotr Przybyłowski
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Zabrze, Poland; Department of Cardiac Transplantation and Mechanical Circulatory Support, Silesian Center for Heart Diseases, Zabrze, Poland
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Akintoye E, Alvarez P, Salih M, Sellke F, Briasoulis A. Outcomes of diabetic patients with end-stage heart failure listed for heart transplantation: A propensity-matched analysis. Clin Transplant 2022; 36:e14590. [PMID: 35018661 DOI: 10.1111/ctr.14590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 01/03/2022] [Accepted: 01/10/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND We investigated the current trends and outcomes of diabetic patients listed for heart transplants in the U.S. and provided a method for risk-stratification. METHODS Using data from the United Network for Organ Sharing (UNOS), we identified heart failure patients listed for heart transplants between 2010 and 2019. Diabetic patients were propensity-matched with non-diabetics, and waitlist mortality as well as post-transplant graft survival were compared between the two groups. Further risk-stratification of diabetic patients was done based on the risk factors that independently predict graft failure. RESULTS 28,928 adult patients (30% diabetic) with end-stage heart failure were added to the waitlist over the study period. In the propensity-matched cohort, waitlist mortality was higher in diabetic patients compared to non-diabetics (HR = 1.13 (95% CI = 1.04-1.22, p = 0.002). Over the study period, 5739 patients with diabetes were transplanted. In the propensity-matched cohorts of transplant recipients, the rate of graft failure was significantly higher for diabetic patients (23.3%) compared to non-diabetics (20.4%); HR = 1.17, 95% CI = 1.08-1.26, p<0.001. We identified 12 risk factors of graft failure among diabetic patients and developed a risk score that further risk-stratify these patients. Diabetic patients at low risk (score≤4) had similar graft survival as patients without diabetes (HR = 0.91, 95% CI = 0.82-1.01, p = 0.06). On the other hand, high-risk diabetic patients had worse graft survival compared to non-diabetics (HR = 1.52, 95% CI = 1.38-1.67, P<0.001). CONCLUSION Among patients with end-stage heart failure, pre-existing diabetes was associated with higher waitlist mortality and worse graft survival. However, with careful patient selection, graft survival is similar to those without diabetes. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Emmanuel Akintoye
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Paulino Alvarez
- Division of Heart failure and Cardiac Transplantation, Cleveland Clinic, Cleveland, OH, United States
| | - Mohamed Salih
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Frank Sellke
- Department of Cardiothoracic Surgery, Brown University, Providence, RI, United States
| | - Alexandros Briasoulis
- Division of Heart Failure and Transplant, University of Iowa Hospitals and Clinics, Iowa, IA, United States
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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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