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Shah HA, Faulkes R, Coldham C, Shetty S, Shah T. Effects of transplantation-related immunosuppression on co-existent neuroendocrine tumours. QJM 2022; 115:661-664. [PMID: 35143660 PMCID: PMC9737287 DOI: 10.1093/qjmed/hcac036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 12/30/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Here we detail our experience of managing patients found to have a neuroendocrine neoplasm (NEN) whilst on immunosuppression for a transplanted organ. AIM We aimed to quantify the behaviour of NENs under solid-organ transplant-related immunosuppression. DESIGN This was an observational, retrospective case series. METHODS Ten patients were identified from a prospectively kept database. Three were excluded. RESULTS Four patients received a liver, two a kidney, and one a heart transplant. All but one received calcineurin-based immunosuppression. NENs were found in five patients post-transplant: one had surgery for transverse colonic neuroendocrine carcinoma NEC (pT4N1M0, Ki67 60%), was cancer-free after four years; one had cold biopsy of duodenal NEN (pT1N0M0, Ki67 2%), cancer-free at four months; one 7 mm pancreatic NEN (pT1N0M0), untreated and stable for seven years; one small-bowel NEN with mesenteric metastasis (pTxNxM1), alive four years after diagnosis; and one untreated small-bowel NEN with mesenteric metastasis, stable at 1 year after liver transplantation. Two NENs were discovered pre-transplant, one pancreatic NEN (pT1N0M0, Ki67 5%), remains untreated and stable at three years. One gastric NEN (type 3, pT1bN0M0, Ki67 2%) remains stable without treatment for two years. CONCLUSIONS NENs demonstrate indolent behaviour in the presence of transplant-related immunosuppression.
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Affiliation(s)
- H A Shah
- Address correspondence to H.A. Shah, Liver and Hepato-Pancreato-Biliary (HPB) Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2WB, UK.
| | - R Faulkes
- From the Liver and Hepato-Pancreato-Biliary (HPB) Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2WB, UK
| | - C Coldham
- From the Liver and Hepato-Pancreato-Biliary (HPB) Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2WB, UK
| | - S Shetty
- From the Liver and Hepato-Pancreato-Biliary (HPB) Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2WB, UK
| | - T Shah
- From the Liver and Hepato-Pancreato-Biliary (HPB) Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2WB, UK
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2
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Moayedi Y, Fan CPS, Tremblay-Gravel M, Miller RJH, Kawana M, Henricksen E, Parizo J, Wainwright R, Fearon WF, Ross HJ, Khush KK, Teuteberg JJ. Risk factors for early development of cardiac allograft vasculopathy by intravascular ultrasound. Clin Transplant 2020; 34:e14098. [DOI: 10.1111/ctr.14098] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 08/26/2020] [Accepted: 08/28/2020] [Indexed: 12/21/2022]
Affiliation(s)
- Yasbanoo Moayedi
- Section of Heart Failure Cardiac Transplant, and Mechanical Circulatory Support Department of Medicine Stanford University Stanford CA USA
- Ted Rogers Centre of Excellence for Heart Research Peter Munk Cardiac Centre University Health Network Toronto Canada
| | - Chun Po S. Fan
- Ted Rogers Centre of Excellence for Heart Research Peter Munk Cardiac Centre University Health Network Toronto Canada
| | - Maxime Tremblay-Gravel
- Section of Heart Failure Cardiac Transplant, and Mechanical Circulatory Support Department of Medicine Stanford University Stanford CA USA
| | - Robert J. H. Miller
- Section of Heart Failure Cardiac Transplant, and Mechanical Circulatory Support Department of Medicine Stanford University Stanford CA USA
| | - Matsaka Kawana
- Section of Heart Failure Cardiac Transplant, and Mechanical Circulatory Support Department of Medicine Stanford University Stanford CA USA
| | - Erik Henricksen
- Section of Heart Failure Cardiac Transplant, and Mechanical Circulatory Support Department of Medicine Stanford University Stanford CA USA
| | - Justin Parizo
- Section of Heart Failure Cardiac Transplant, and Mechanical Circulatory Support Department of Medicine Stanford University Stanford CA USA
| | - Rebecca Wainwright
- Section of Heart Failure Cardiac Transplant, and Mechanical Circulatory Support Department of Medicine Stanford University Stanford CA USA
| | - William F. Fearon
- Division of Cardiovascular Medicine Department of Medicine Stanford University School of Medicine Stanford USA
| | - Heather J. Ross
- Ted Rogers Centre of Excellence for Heart Research Peter Munk Cardiac Centre University Health Network Toronto Canada
| | - Kiran K. Khush
- Section of Heart Failure Cardiac Transplant, and Mechanical Circulatory Support Department of Medicine Stanford University Stanford CA USA
| | - Jeffrey J. Teuteberg
- Section of Heart Failure Cardiac Transplant, and Mechanical Circulatory Support Department of Medicine Stanford University Stanford CA USA
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3
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mTOR Inhibitor Everolimus in Regulatory T Cell Expansion for Clinical Application in Transplantation. Transplantation 2019; 103:705-715. [PMID: 30451741 DOI: 10.1097/tp.0000000000002495] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Experimental and preclinical evidence suggest that adoptive transfer of regulatory T (Treg) cells could be an appropriate therapeutic strategy to induce tolerance and improve graft survival in transplanted patients. The University of Kentucky Transplant Service Line is developing a novel phase I/II clinical trial with ex vivo expanded autologous Treg cells as an adoptive cellular therapy in renal transplant recipients who are using everolimus (EVR)-based immunosuppressive regimen. METHODS The aim of this study was to determine the mechanisms of action and efficacy of EVR for the development of functionally competent Treg cell-based adoptive immunotherapy in transplantation to integrate a common EVR-based regimen in vivo (in the patient) and ex vivo (in the expansion of autologous Treg cells). CD25 Treg cells were selected from leukapheresis product with a GMP-compliant cell separation system and placed in 5-day (short) or 21-day (long) culture with EVR or rapamycin (RAPA). Multi-parametric flow cytometry analyses were used to monitor the expansion rates, phenotype, autophagic flux, and suppressor function of the cells. phosphoinositide 3-kinase/protein kinase B/mammalian target of rapamycin signaling pathway profiles of treated cells were analyzed by Western blot and cell bioenergetic parameters by extracellular flux analysis. RESULTS EVR-treated cells showed temporary slower growth, lower metabolic rates, and reduced phosphorylation of protein kinase B compared with RAPA-treated cells. In spite of these differences, the expansion rates, phenotype, and suppressor function of long-term Treg cells in culture with EVR were similar to those with RAPA. CONCLUSIONS Our results support the feasibility of EVR to expand functionally competent Treg cells for their clinical use.
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4
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Arora S, Andreassen AK, Karason K, Gustafsson F, Eiskjær H, Bøtker HE, Rådegran G, Gude E, Ioanes D, Solbu D, Dellgren G, Ueland T, Aukrust P, Gullestad L. Effect of Everolimus Initiation and Calcineurin Inhibitor Elimination on Cardiac Allograft Vasculopathy in De Novo Heart Transplant Recipients. Circ Heart Fail 2019; 11:e004050. [PMID: 30354362 DOI: 10.1161/circheartfailure.117.004050] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Cardiac allograft vasculopathy (CAV) limits survival after heart transplantation, and the effect of different immunosuppressive regimens on CAV is not fully understood. The randomized SCHEDULE trial (Scandinavian Heart Transplant Everolimus De Novo Study With Early Calcineurin Inhibitors Avoidance) evaluated whether initiation of the proliferation signal inhibitor everolimus and early cyclosporine elimination can reduce CAV development. Methods and Results The SCHEDULE trial was a multicenter Scandinavian trial, where 115 de novo heart transplantation recipients were randomized to everolimus with complete cyclosporine withdrawal 7 to 11 weeks after heart transplantation or standard cyclosporine-based immunosuppression. Seventy-six (66%) patients had matched intravascular ultrasound examinations at baseline and 12 and 36 months. Intravascular ultrasound analysis evaluated maximal intimal thickness, percent atheroma volume, and total atheroma volume. Qualitative plaque analysis using virtual histology assessed fibrous, fibrofatty, and calcified tissue as well as necrotic core. Serum inflammatory markers were measured in parallel. The everolimus group (n=37) demonstrated significantly reduced CAV progression as compared with the cyclosporine group (n=39) at 36 months (Δ maximal intimal thickness, 0.09±0.05 versus 0.15±0.16 mm [ P=0.03]; Δ percent atheroma volume, 5.3±2.8% versus 7.6±5.9% [ P=0.03]; and Δ total atheroma volume, 33.9±71.2 versus 54.2±96.0 mm3 [ P=0.34], respectively]. At 36 months the number of everolimus patients with rejection graded ≥2R was 15 (41%) as compared with 5 (13%) in the cyclosporine group ( P=0.01). Everolimus did not affect CAV morphology or immune marker activity during the follow-up period. Conclusions The SCHEDULE trial demonstrates that everolimus initiation and early cyclosporine elimination significantly reduces CAV progression at 12 months, and this beneficial effect is clearly sustained at 36 months. Clinical trial registration URL: https://www.clinicaltrials.gov . Unique identifier: NCT01266148.
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Affiliation(s)
- Satish Arora
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Norway (S.A., A.K.A., E.G., L.G.).,Center for Heart Failure Research, University of Oslo and Faculty of Medicine, University of Oslo, Norway (S.A.)
| | - Arne K Andreassen
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Norway (S.A., A.K.A., E.G., L.G.)
| | - Kristjan Karason
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden (K.K., D.I.)
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark (F.G.)
| | - Hans Eiskjær
- Department of Cardiology, Aarhus University Hospital, Denmark (H.E., H.E.B.)
| | - Hans Erik Bøtker
- Department of Cardiology, Aarhus University Hospital, Denmark (H.E., H.E.B.)
| | - Göran Rådegran
- The Section for Heart Failure and Valvular Disease, VO Heart and Lung Medicine, Skåne University Hospital and Department of Clinical Sciences, Lund University, Sweden (G.R.)
| | - Einar Gude
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Norway (S.A., A.K.A., E.G., L.G.)
| | - Dan Ioanes
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden (K.K., D.I.)
| | - Dag Solbu
- Novartis Norge AS, Oslo, Norway (D.S.)
| | - Göran Dellgren
- Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden (G.D.)
| | - Thor Ueland
- Research Institute of Internal Medicine, Oslo University Hospital, Rikshospitalet, Norway (T.U., P.A.).,K.G. Jebsen Inflammatory Research Center, Faculty of Medicine, University of Oslo, Norway (T.U., P.A.).,K. G. Jebsen Thrombosis Research and Expertise Center, University of Tromsø, Norway (T.U., P.A.).,Faculty of Medicine, University of Oslo, Norway (T.U., P.A., L.G.)
| | - Pål Aukrust
- Research Institute of Internal Medicine, Oslo University Hospital, Rikshospitalet, Norway (T.U., P.A.).,Section of Clinical Immunology and Infectious Diseases, Oslo University Hospital, Rikshospitalet, Norway (P.A.).,K.G. Jebsen Inflammatory Research Center, Faculty of Medicine, University of Oslo, Norway (T.U., P.A.).,K. G. Jebsen Thrombosis Research and Expertise Center, University of Tromsø, Norway (T.U., P.A.).,Faculty of Medicine, University of Oslo, Norway (T.U., P.A., L.G.)
| | - Lars Gullestad
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Norway (S.A., A.K.A., E.G., L.G.).,Faculty of Medicine, University of Oslo, Norway (T.U., P.A., L.G.)
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5
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Chiang TY, Tsao CI, Wang SS. Renal Function Changes Under Everolimus Plus Cyclosporine or Everolimus Plus Tacrolimus After Heart Transplantation. Transplant Proc 2018; 50:2756-2758. [PMID: 30401391 DOI: 10.1016/j.transproceed.2018.03.065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 03/02/2018] [Indexed: 11/15/2022]
Abstract
Everolimus (EVR) can be used with calcineurin inhibitors to reduce the risk of renal dysfunction, with similar immunosuppressive effect. In this study, we compared renal function after heart transplantation (HT) under EVR with cyclosporine (CSA) or tacrolimus (TAC). Between 2004 and 2014, EVR with CSA or TAC was used in 117 HT at the National Taiwan University Hospital. After HT, all patients received corticosteroid, EVR (C0 target 3-8 ng/mL) and CSA (C0 blood level 100-200 ng/mL), or TAC (Co blood level 5-10 ng/mL). Renal function was evaluated before HT, every month after HT for up to 1 year, and then every 3 months for up to 2 years. Blood-drug levels of EVR, CSA, and TAC were also monitored simultaneously with renal function. The estimated mean glomerular filtration rate (eGFR) was 76.5 mL/min/1.73 m2 before HT. After HT, the eGFR was 64 mL/min/1.73 m2 at the third month, and 64 mL/min/1.73 m2 at the end of first year. The difference was significant between pre-HT and post-HT (P = .00) during the first year. No significant differences were noted between the CSA and TAC groups. Careful monitoring of blood-drug level and renal function is crucial after heart transplantation. It is concluded that under close monitoring blood-drug level and renal function, it is possible to reach acceptable postoperative renal function with no difference of renal function between EVR plus CSA and EVR plus TAC.
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Affiliation(s)
- T-Y Chiang
- Department of Surgery, National Taiwan University Hospital, and National Taiwan University College of Medicine, Taipei, Taiwan
| | - C-I Tsao
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - S-S Wang
- Department of Surgery, National Taiwan University Hospital, and National Taiwan University College of Medicine, Taipei, Taiwan; Department of Surgery, Fu Jen Catholic University Hospital, New Taipei City, Taiwan; Fu Jen Catholic University College of Medicine, New Taipei City, Taiwan.
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6
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van Dijk M, van Roon AM, Said MY, Bemelman FJ, Homan van der Heide JJ, de Fijter HW, de Vries APJ, Bakker SJL, Sanders JSF. Long-term cardiovascular outcome of renal transplant recipients after early conversion to everolimus compared to calcineurin inhibition: results from the randomized controlled MECANO trial. Transpl Int 2018; 31:1380-1390. [DOI: 10.1111/tri.13322] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 06/10/2018] [Accepted: 07/20/2018] [Indexed: 12/13/2022]
Affiliation(s)
- Marja van Dijk
- Department of Internal Medicine; Division of Nephrology; University Medical Center Groningen; University of Groningen; Groningen The Netherlands
| | - Arie M. van Roon
- Department of Vascular Medicine; University Medical Center Groningen; University of Groningen; Groningen The Netherlands
| | - M. Yusof Said
- Department of Internal Medicine; Division of Nephrology; University Medical Center Groningen; University of Groningen; Groningen The Netherlands
| | | | | | - Hans W. de Fijter
- Department of Nephrology; Leiden University Medical Centre; Leiden The Netherlands
| | - Aiko P. J. de Vries
- Department of Nephrology; Leiden University Medical Centre; Leiden The Netherlands
| | - Stephan J. L. Bakker
- Department of Internal Medicine; Division of Nephrology; University Medical Center Groningen; University of Groningen; Groningen The Netherlands
| | - Jan Stephan F. Sanders
- Department of Internal Medicine; Division of Nephrology; University Medical Center Groningen; University of Groningen; Groningen The Netherlands
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7
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Abstract
PURPOSE OF REVIEW Despite the improvement in medical therapy for heart failure and the advancements in mechanical circulatory support, heart transplantation (HT) still remains the best therapeutic option to improve survival and quality of life in patients with advanced heart failure. Nevertheless, HT recipients are exposed to the risk of several potential complications that may impair their outcomes. In this article, we aim to provide a practical and scholarly framework for clinicians approaching heart transplant medicine, as well as a concise update for the experienced readers on the most relevant post-HT complications. RECENT FINDINGS While recognizing that most of the treatments herein discussed are based more on experience than on solid scientific evidence, significant step forward has been made in particular in the recognition and management of primary graft dysfunction, antibody-mediated rejection, and renal dysfunction. Complications after HT may vary according to the time from surgery and can be related to graft function and pathology or to diseases and dysfunctions occurring in other organs or systems, mainly as side effects of immunosuppressive drugs and progression of pre-existing conditions. Future research needs to focus on improving precision diagnostics of causes of graft dysfunction and on reaching an optimal and customized balance between efficacy and toxicities of immunosuppressive strategies.
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Affiliation(s)
- Luciano Potena
- Heart Transplant Program, Bologna Academic Hospital, Policlinico S. Orsola-Malpighi, Building 25, Via Massarenti, 9, 40138, Bologna, Italy.
| | - Andreas Zuckermann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Francesco Barberini
- Heart Transplant Program, Bologna Academic Hospital, Policlinico S. Orsola-Malpighi, Building 25, Via Massarenti, 9, 40138, Bologna, Italy
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8
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Lin LM, Kuo SC, Chiu YC, Lin HF, Kuo ML, Elsarawy AM, Chen CL, Lin CC. Cost Analysis and Determinants of Living Donor Liver Transplantation in Taiwan. Transplant Proc 2018; 50:2601-2605. [PMID: 30401359 DOI: 10.1016/j.transproceed.2018.03.061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 03/02/2018] [Indexed: 01/27/2023]
Abstract
BACKGROUND Liver transplantation (LT) has become established therapy for end-stage liver disease and small-cell hepatocellular carcinoma (HCC), relying mainly on living donor LT (LDLT) in Taiwan. The cost of LDLT varies in different countries depending on the insurance system, the costs of the facility, and staff. In this study we aimed to investigate cost outcomes and determinants of LDLT in Taiwan. METHODS From January 2014 to December 2015, 184 LDLT patients were enrolled in a study performed at the Kaohsiung Chang Gung Memorial Hospital. Patients' transplantation costs were defined as expense from immediately after surgery to discharge during hospitalization for LDLT. Antiviral therapy and hepatitis B immunoglobulin (HBIG) for prevention of hepatitis B virus (HBV) were included, but direct-acting antiviral (DAA) therapy for hepatitis C (HCV) was excluded. RESULTS The median total, intensive care unit (ICU), and ward costs of LT were US$64,250, $43,357, and $16,138 (currency ratio 1:30), respectively. HBV significantly increased the total cost of LT, followed by postoperative reintubation and bile duct complications. CONCLUSION The charges associated with anti-HBV viral therapy and HBIG increase the cost of LDLT. Disease severity of liver cirrhosis showed less importance in predicting cost. Postoperative complications such as reintubation or bile duct complications should be avoided to reduce the cost of LT.
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Affiliation(s)
- L-M Lin
- Department of Nursing, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - S-C Kuo
- Department of Surgery, Liver Transplantation Center, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Y-C Chiu
- Department of Nursing, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - H-F Lin
- Department of Nursing, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - M-L Kuo
- Department of Nursing, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - A M Elsarawy
- Department of Surgery, Liver Transplantation Center, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - C-L Chen
- Department of Surgery, Liver Transplantation Center, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - C-C Lin
- Department of Surgery, Liver Transplantation Center, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.
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9
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Everolimus immunosuppression for renal protection, reduction of allograft vasculopathy and prevention of allograft rejection in de-novo heart transplant recipients: could we have it all? Curr Opin Organ Transplant 2017; 22:198-206. [PMID: 28463861 DOI: 10.1097/mot.0000000000000409] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW De-novo introduction of everolimus (Eve) in heart transplant recipients opens for early reduction of calcineurin inhibitors (CNI) and potential of preserving renal function, attenuate progression of coronary allograft vasculopathy (CAV) and maintain rejection efficacy. RECENT FINDINGS The first trials demonstrated adequate rejection prophylaxis and favorable outcomes on CAV, but observed enhanced nephrotoxicity because of insufficient CNI reduction. The SCHEDULE trial compared de-novo Eve with significantly reduced CNI exposure and conversion to CNI-free treatment week 7-11 postheart transplant, with standard CNI immunosuppression. Improved renal function and attenuation of CAV was found among Eve patients, with higher numbers of treated acute rejections observed. With sustained superior renal and CAV related data also after 36 months with the Eve protocol, cardiac function was equally well preserved in both groups. According to the International Society of Heart and Lunge Transplantation registry, mammalian target of rapamycin inhibitor treatment is uncommon during the first postoperative year, with a prevalence of 20% in patients after 5 years. SUMMARY Current evidence suggests a greater benefit from these immunosuppressives if introduced at an earlier timepoint. Immunosuppressive protocols based on Eve treatment in de-novo patients should be further investigated and developed, enabling CNI avoidance before accelerating side-effects lead to irreversible damage.
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10
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Hu YN, Lee NY, Roan JN, Hsu CH, Luo CY. High-dose calcineurin inhibitor-free everolimus as a maintenance regimen for heart transplantation may be a risk factor for Pneumocystis pneumonia. Transpl Infect Dis 2017; 19. [PMID: 28425200 DOI: 10.1111/tid.12709] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 12/21/2016] [Accepted: 01/15/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Everolimus reduces the incidence of cardiac-allograft vasculopathy (CAV) and is less renally toxic than are calcineurin inhibitors (CNIs). We evaluated the safety of CNI-free everolimus for post-heart transplant (HTx) patients. METHODS We retrospectively reviewed the records of 36 consecutive patients who had undergone an HTx between January 2006 and December 2013 in National Cheng Kung University Hospital. All patients initially had been treated with the standard tacrolimus regimen. The Study group-12 patients with CAV, renal impairment, or a history of malignancy-were switched from tacrolimus to everolimus. The Control group consisted of 19 patients who remained on the standard regimen. The target everolimus trough concentration was 8-14 ng/mL. The primary outcome was survival, and the secondary outcomes were bacterial, viral, fungal, and other infections; Pneumocystis jirovecii pneumonia (PJP); and rejection (≥2R). RESULTS During a 53.3±25.6-month follow-up, the survival rate, rejection rate, and number of infections, except for PJP, were not significantly different between the two groups. In the Study group, 6 patients were diagnosed with PJP 33±18.2 months after switching. None of the Control group patients were diagnosed with PJP during follow-up. CONCLUSIONS A high-dose CNI-free everolimus maintenance regimen might yield a higher incidence of post-transplantation PJP.
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Affiliation(s)
- Yu-Ning Hu
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Nan-Yao Lee
- Division of Infection, Department of Internal Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Jun-Neng Roan
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Institute of Clinical Medicine, National Cheng Kung University Hospital and College of Medicine, Tainan, Taiwan
| | - Chi-Hsin Hsu
- Institute of Clinical Medicine, National Cheng Kung University Hospital and College of Medicine, Tainan, Taiwan.,Division of Critical Care Medicine, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chwan-Yau Luo
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Cardiovascular Research Center, National Cheng Kung University, Tainan, Taiwan
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11
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Helmschrott M, Rivinius R, Bruckner T, Katus HA, Doesch AO. Renal function in heart transplant patients after switch to combined mammalian target of rapamycin inhibitor and calcineurin inhibitor therapy. DRUG DESIGN DEVELOPMENT AND THERAPY 2017; 11:1673-1680. [PMID: 28652705 PMCID: PMC5472407 DOI: 10.2147/dddt.s135503] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND A calcineurin inhibitor (CNI)-based immunosuppression combined with mammalian target of rapamycin inhibitors (mTORs) seems to be attractive in patients after heart transplantation (HTX) in special clinical situations, for example, in patients with adverse drug effects of prior immunosuppression. Previous studies in patients after HTX detected advantageous effects regarding renal function of a tacrolimus (TAC)-based vs cyclosporine-A (CSA)-based immunosuppression (in combination with mycophenolate mofetil). However, data regarding renal function after HTX in mTOR/CNI patients remain limited. AIM Primary end point of the present study was to analyze renal function in HTX patients 1 year after switch to an mTOR/CNI-based immunosuppression. METHODS Data of 80 HTX patients after change to mTOR/CNI-based immunosuppression were retrospectively analyzed. Renal function was assessed by measured serum creatinine and by estimated glomerular filtration rate (eGFR) calculated from Modification of Diet in Renal Disease equation. RESULTS Twenty-nine patients received mTOR/CSA-based treatment and 51 patients received mTOR/TAC-based therapy. At time of switch and at 1-year follow-up, serum creatinine and eGFR did not differ significantly between both study groups (all P=not statistically significant). Analysis of variances with repeated measurements detected a similar change of renal function in both study groups. CONCLUSION The present study detected no significant differences between both mTOR/CNI study groups, indicating a steady state of renal function in HTX patients after switch of immunosuppressive regimen.
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Affiliation(s)
| | | | - Thomas Bruckner
- Institute for Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
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12
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Effect of Calcineurin Inhibitor-Free, Everolimus-Based Immunosuppressive Regimen on Albuminuria and Glomerular Filtration Rate After Heart Transplantation. Transplantation 2017; 101:2793-2800. [PMID: 28230646 DOI: 10.1097/tp.0000000000001706] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Albuminuria in maintenance heart transplantation (HTx) is associated with poor renal response when switching to a calcineurin inhibitor (CNI)-lowered or CNI-free immunosuppressive regimen using everolimus (EVR), but the significance of albuminuria associated with EVR treatment after early CNI withdrawal in de novo HTx is unknown. METHODS We tested if measured glomerular filtration rate (mGFR, by chrome-ethylenediaminetetraacetic acid clearance) was associated with urine albumin/creatinine ratio (UACR) post-HTx in a subgroup of patients included in the Scandinavian Heart Transplant Everolimus De Novo Study With Early Calcineurin Inhibitor Avoidance trial, where de novo HTx patients (n = 115) were randomized to EVR with complete CNI elimination 7 to 11 weeks post-HTx or standard CNI immunosuppression. RESULTS In 66 patients, UACR measures were available at 1 year. In 7 patients in the EVR group, a CNI was reintroduced within 12 months. Median mGFR was significantly higher in the EVR group both 1 and 3 years post-HTx (P = 0.0004 and P = 0.03, respectively). Median UACR at 1 year was significantly higher in the EVR group (P = 0.002). There was no correlation between log(UACR) at 1 year and mGFR at 1 or 3 years (r = -0.01, P = 0.9 and r = 0.15, P = 0.26, respectively) and in the EVR group between log(UACR) at 1 year and change in mGFR (Δ1-3 years) (r = 0.27, P = 0.14). Excluding patients in the EVR group in whom a CNI was reintroduced did not significantly change the results. CONCLUSIONS The effects of EVR with early CNI withdrawal after HTx on albuminuria and renal function seem dissociated; hence, the clinical significance of albuminuria in this setting is uncertain and should not necessarily rule out EVR-based immunosuppression.
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Recent Advances in Mammalian Target of Rapamycin Inhibitor Use in Heart and Lung Transplantation. Transplantation 2016; 100:2558-2568. [DOI: 10.1097/tp.0000000000001432] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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14
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Cardiac Rehabilitation After Complex Procedures. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2016. [DOI: 10.1007/s40141-016-0127-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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15
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Dieterlen MT, John K, Haase S, Garbade J, Tarnok A, Mohr FW, Bittner HB, Barten MJ. Effect of confounding factors on a phospho-flow assay of ribosomal S6 protein for therapeutic drug monitoring of the mTOR-inhibitor everolimus in heart transplanted patients. Biomarkers 2016; 22:86-92. [DOI: 10.1080/1354750x.2016.1210676] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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16
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Dumortier J, Dharancy S, Calmus Y, Duvoux C, Durand F, Salamé E, Saliba F. Use of everolimus in liver transplantation: The French experience. Transplant Rev (Orlando) 2016; 30:161-70. [DOI: 10.1016/j.trre.2015.12.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Accepted: 12/14/2015] [Indexed: 12/18/2022]
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Andreassen AK, Andersson B, Gustafsson F, Eiskjaer H, Rådegran G, Gude E, Jansson K, Solbu D, Karason K, Arora S, Dellgren G, Gullestad L. Everolimus Initiation With Early Calcineurin Inhibitor Withdrawal in De Novo Heart Transplant Recipients: Three-Year Results From the Randomized SCHEDULE Study. Am J Transplant 2016; 16:1238-47. [PMID: 26820618 DOI: 10.1111/ajt.13588] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 10/18/2015] [Accepted: 10/18/2015] [Indexed: 01/25/2023]
Abstract
In a randomized, open-label trial, de novo heart transplant recipients were randomized to everolimus (3-6 ng/mL) with reduced-exposure calcineurin inhibitor (CNI; cyclosporine) to weeks 7-11 after transplant, followed by increased everolimus exposure (target 6-10 ng/mL) with cyclosporine withdrawal or standard-exposure cyclosporine. All patients received mycophenolate mofetil and corticosteroids. A total of 110 of 115 patients completed the 12-month study, and 102 attended a follow-up visit at month 36. Mean measured GFR (mGFR) at month 36 was 77.4 mL/min (standard deviation [SD] 20.2 mL/min) versus 59.2 mL/min (SD 17.4 mL/min) in the everolimus and CNI groups, respectively, a difference of 18.3 mL/min (95% CI 11.1-25.6 mL/min; p < 0.001) in the intention to treat population. Multivariate analysis showed treatment to be an independent determinant of mGFR at month 36. Coronary intravascular ultrasound at 36 months revealed significantly reduced progression of allograft vasculopathy in the everolimus group compared with the CNI group. Biopsy-proven acute rejection grade ≥2R occurred in 10.2% and 5.9% of everolimus- and CNI-treated patients, respectively, during months 12-36. Serious adverse events occurred in 37.3% and 19.6% of everolimus- and CNI-treated patients, respectively (p = 0.078). These results suggest that early CNI withdrawal after heart transplantation supported by everolimus, mycophenolic acid and steroids with lymphocyte-depleting induction is safe at intermediate follow-up. This regimen, used selectively, may offer adequate immunosuppressive potency with a sustained renal advantage.
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Affiliation(s)
- A K Andreassen
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - B Andersson
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - F Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - H Eiskjaer
- Department of Cardiology, Aarhus University Hospital, Skejby, Denmark
| | - G Rådegran
- Section for Heart Failure and Valvular Disease, Skåne University Hospital and Department of Clinical Sciences, Cardiology, Lund University, Lund, Sweden
| | - E Gude
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - K Jansson
- Department of Cardiology, Heart and Medicine Center County Council of Ostergotland and Linkoping University, Linkoping, Sweden
| | - D Solbu
- Novartis Norge AS, Oslo, Norway
| | - K Karason
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - S Arora
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - G Dellgren
- Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - L Gullestad
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway.,K.G. Jebsen Cardiac Research Center and Center for Heart Failure Research, Faculty of Medicine, University of Oslo, Oslo, Norway
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Malignancy After Heart Transplantation Under Everolimus Versus Mycophenolate Mofetil Immunosuppression. Transplant Proc 2016; 48:969-73. [DOI: 10.1016/j.transproceed.2015.12.071] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 12/07/2015] [Indexed: 01/20/2023]
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19
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Lesche D, Sigurdardottir V, Setoud R, Englberger L, Fiedler GM, Largiadèr CR, Mohacsi P, Sistonen J. Influence ofCYP3A5genetic variation on everolimus maintenance dosing after cardiac transplantation. Clin Transplant 2015; 29:1213-20. [DOI: 10.1111/ctr.12653] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2015] [Indexed: 02/06/2023]
Affiliation(s)
- Dorothea Lesche
- Institute of Clinical Chemistry; University Hospital (Inselspital Bern); University of Bern; Bern Switzerland
- Graduate School for Cellular and Biomedical Sciences; University of Bern; Bern Switzerland
| | | | | | - Lars Englberger
- Department of Cardiovascular Surgery; Swiss Cardiovascular Centre; University Hospital (Inselspital Bern); Bern Switzerland
| | - Georg M. Fiedler
- Institute of Clinical Chemistry; University Hospital (Inselspital Bern); University of Bern; Bern Switzerland
| | - Carlo R. Largiadèr
- Institute of Clinical Chemistry; University Hospital (Inselspital Bern); University of Bern; Bern Switzerland
| | | | - Johanna Sistonen
- Institute of Clinical Chemistry; University Hospital (Inselspital Bern); University of Bern; Bern Switzerland
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Deuse T, Bara C, Barten MJ, Hirt SW, Doesch AO, Knosalla C, Grinninger C, Stypmann J, Garbade J, Wimmer P, May C, Porstner M, Schulz U. The MANDELA study: A multicenter, randomized, open-label, parallel group trial to refine the use of everolimus after heart transplantation. Contemp Clin Trials 2015; 45:356-363. [DOI: 10.1016/j.cct.2015.09.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 09/02/2015] [Accepted: 09/04/2015] [Indexed: 12/18/2022]
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21
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Tang CY, Shen A, Wei XF, Li QD, Liu R, Deng HJ, Wu YZ, Wu ZJ. Everolimus in de novo liver transplant recipients: a systematic review. Hepatobiliary Pancreat Dis Int 2015; 14:461-9. [PMID: 26459721 DOI: 10.1016/s1499-3872(15)60419-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Everolimus has no nephrotoxicity and is used to treat patients with post-liver transplant chronic renal insufficiency. The present systematic review was to evaluate the efficacy and safety of everolimus in de novo liver transplant patients. DATA SOURCES Randomized controlled trials comparing everolimus for de novo liver transplant in PubMed, the Cochrane Library, and ScienceDirect published up to March 31, 2014 were searched by two independent reviewers. Mean differences and 95% confidence interval (95% CI) for renal function, relative risk (RR) and 95% CI for treated biopsy-proven acute rejection (tBPAR), graft loss, death, neoplasms/tumor recurrence, and adverse events were collected. Meta-analyses were performed with RevMan version 5.10. RESULTS A total of four randomized controlled trials covering 1119 cases were included. The meta-analyses revealed that compared with standard exposure of calcineurin inhibitors (CNIs), everolimus combined with reduced CNIs improved creatinine clearance (calculated with the Cockcroft-Gault formula) by 5.13 mL/min at one year (95% CI: 0.42-9.84; P=0.03), and decreased tBPAR (RR: 0.56; 95% CI: 0.35-0.90; P=0.02). Everolimus initiation with CNIs elimination improved glomerular filtration rate (GFR, measured with the modification of diet in renal disease formula) of 10.42 mL/min/1.73 m2 (95% CI: 3.44-17.41; P<0.01) one year after treatment, but increased tBPAR (RR: 1.71; 95% CI: 1.15-2.53; P<0.01). Everolimus decreased the risk of neoplasms/tumor recurrence after liver transplant (RR: 0.60; 95% CI: 0.34-1.03; P=0.06), but was associated with greater risk of adverse events which resulted in drug discontinuation (RR: 1.98; 95% CI: 1.49-2.64; P<0.01). CONCLUSIONS Early introduction of everolimus combined with low-dose or no CNI in de novo liver transplant significantly improves renal function one year post treatment. Everolimus combined with low-dose CNI decreases the risk of tBPAR one year after liver transplant, but everolimus administered without CNIs increases tBPAR.
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Affiliation(s)
- Cheng-Yong Tang
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Chongqing Medical University, Chongqing 404100, China.
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Arora S, Andreassen AK, Andersson B, Gustafsson F, Eiskjaer H, Bøtker HE, Rådegran G, Gude E, Ioanes D, Solbu D, Sigurdardottir V, Dellgren G, Erikstad I, Solberg OG, Ueland T, Aukrust P, Gullestad L. The Effect of Everolimus Initiation and Calcineurin Inhibitor Elimination on Cardiac Allograft Vasculopathy in De Novo Recipients: One-Year Results of a Scandinavian Randomized Trial. Am J Transplant 2015; 15:1967-75. [PMID: 25783974 DOI: 10.1111/ajt.13214] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2014] [Revised: 12/23/2014] [Accepted: 12/31/2014] [Indexed: 01/25/2023]
Abstract
Early initiation of everolimus with calcineurin inhibitor therapy has been shown to reduce the progression of cardiac allograft vasculopathy (CAV) in de novo heart transplant recipients. The effect of de novo everolimus therapy and early total elimination of calcineurin inhibitor therapy has, however, not been investigated and is relevant given the morbidity and lack of efficacy of current protocols in preventing CAV. This 12-month multicenter Scandinavian trial randomized 115 de novo heart transplant recipients to everolimus with complete calcineurin inhibitor elimination 7-11 weeks after HTx or standard cyclosporine immunosuppression. Ninety-five (83%) patients had matched intravascular ultrasound examinations at baseline and 12 months. Mean (± SD) recipient age was 49.9 ± 13.1 years. The everolimus group (n = 47) demonstrated significantly reduced CAV progression as compared to the calcineurin inhibitor group (n = 48) (ΔMaximal Intimal Thickness 0.03 ± 0.06 and 0.08 ± 0.12 mm, ΔPercent Atheroma Volume 1.3 ± 2.3 and 4.2 ± 5.0%, ΔTotal Atheroma Volume 1.1 ± 19.2 mm(3) and 13.8 ± 28.0 mm(3) [all p-values ≤ 0.01]). Everolimus patients also had a significantly greater decline in levels of soluble tumor necrosis factor receptor-1 as compared to the calcineurin inhibitor group (p = 0.02). These preliminary results suggest that an everolimus-based CNI-free can potentially be considered in suitable de novo HTx recipients.
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Affiliation(s)
- S Arora
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - A K Andreassen
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - B Andersson
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - F Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - H Eiskjaer
- Department of Cardiology, Aarhus University Hospital, Skejby, Denmark
| | - H E Bøtker
- Department of Cardiology, Aarhus University Hospital, Skejby, Denmark
| | - G Rådegran
- The Clinic for Heart Failure and Valvular Disease, Skåne University Hospital and Lund University, Lund, Sweden
| | - E Gude
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - D Ioanes
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - D Solbu
- Novartis Norge AS, Oslo, Norway
| | - V Sigurdardottir
- Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - G Dellgren
- Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - I Erikstad
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - O G Solberg
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - T Ueland
- Research Institute for Internal Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,K.G. Jebsen Inflammatory Research Center, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - P Aukrust
- Research Institute for Internal Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,K.G. Jebsen Inflammatory Research Center, Faculty of Medicine, University of Oslo, Oslo, Norway.,Section of Clinical Immunology and Infectious Diseases, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - L Gullestad
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway.,K.G. Jebsen Cardiac Research Center and Center for Heart Failure Research, Faculty of Medicine, University of Oslo, Oslo, Norway
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23
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De novo sirolimus with low-dose tacrolimus versus full-dose tacrolimus with mycophenolate mofetil after heart transplantation—8-year results. J Heart Lung Transplant 2015; 34:634-42. [DOI: 10.1016/j.healun.2014.11.025] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Revised: 10/29/2014] [Accepted: 11/19/2014] [Indexed: 12/22/2022] Open
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Holdaas H, Potena L, Saliba F. mTOR inhibitors and dyslipidemia in transplant recipients: a cause for concern? Transplant Rev (Orlando) 2014; 29:93-102. [PMID: 25227328 DOI: 10.1016/j.trre.2014.08.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Revised: 07/19/2014] [Accepted: 08/22/2014] [Indexed: 02/06/2023]
Abstract
Post-transplant dyslipidemia is exacerbated by mammalian target of rapamycin (mTOR) inhibitors. Early clinical trials of mTOR inhibitors used fixed dosing with no concomitant reduction in calcineurin inhibitor (CNI) exposure, leading to concerns when consistent and marked dyslipidemia was observed. With use of modern concentration-controlled mTOR inhibitor regimens within CNI-free or reduced-exposure CNI regimens, however, the dyslipidemic effect persists but is less pronounced. Typically, total cholesterol levels are at the upper end of normal, or indicate borderline risk, in kidney and liver transplant recipients, and are lower in heart transplant patients under near-universal statin therapy. Of note, it is possible that mTOR inhibitors may offer a cardioprotective effect. Experimental evidence for delayed progression of atherosclerosis is consistent with evidence from heart transplantation that coronary artery intimal thickening and the incidence of cardiac allograft vasculopathy are reduced with everolimus versus cyclosporine therapy. Preliminary data also indicate that mTOR inhibitors may improve arterial stiffness, a predictor of cardiovascular events, and may reduce ventricular remodeling and decrease left ventricular mass through an anti-fibrotic effect. Post-transplant dyslipidemia under mTOR inhibitor therapy should be monitored and managed closely, but unless unresponsive to therapy should not be regarded as a barrier to its use.
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Affiliation(s)
- Hallvard Holdaas
- Section of Nephrology, Department of Transplant Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway.
| | - Luciano Potena
- Heart Failure and Heart Transplant Program, Academic Hospital S. Orsola-Malpighi, Alma-Mater University of Bologna, Bologna, Italy
| | - Faouzi Saliba
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France
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25
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DePasquale EC, Schweiger M, Ross HJ. A contemporary review of adult heart transplantation: 2012 to 2013. J Heart Lung Transplant 2014; 33:775-84. [DOI: 10.1016/j.healun.2014.04.019] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2014] [Revised: 03/14/2014] [Accepted: 04/30/2014] [Indexed: 02/07/2023] Open
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