HBV and HCV infections in heart transplant recipients

Hepatitis C and heart transplantation: An update

There are limited data regarding heart transplantation in the setting of hepatitis C virus (HCV) infection in either recipients or donors, as the practice was infrequent, given concerns of worse post-transplant outcomes. This changed dramatically after the development of highly effective HCV therapies, namely direct-acting antivirals (DAAs). Additionally, nucleic acid testing currently in use establishes more precisely the risk of HCV transmission from donors. As a result, chronic HCV infection in itself is no longer a barrier for heart transplant candidates, and the use of HCV-positive organs for HCV-infected and non-infected transplant candidates has increased dramatically. A review of the literature revealed that in the pre-DAA era, HCV seropositive heart transplant patients had a higher mortality than their seronegative counterparts. However, short-term data suggest that the differences in survival have been erased in the DAA era. Heart transplantation from HCV-viremic donors to HCV-uninfected recipients has become increasingly common as the number of deceased donors with HCV viremia has increased over the past years. Preliminary outcome reports are very encouraging, although further data are needed with regard to long-term safety. New information continues to be incorporated to optimize protocols that guide this practice.

Sofosbuvir-based Interferon-Free Direct Acting Antiviral Regimens for Heart Transplant Recipients With Chronic Hepatitis C Virus Infection

We assessed the effectiveness and safety of sofosbuvir (SOF) combined with ledipasvir (LDV) or daclatasvir (DCV) in 12 heart transplant recipients with chronic hepatitis C virus (HCV). The sustained virologic response (SVR12) rate was 100% [95% confidence interval [CI]: 75.8%-100%]. All patients tolerated treatment well without interruption, death, or serious adverse events.

Pre-emptive pangenotypic direct acting antiviral therapy in donor HCV-positive to recipient HCV-negative heart transplantation: an open-label study

BACKGROUND

Low donor heart availability underscores the need to identify all potentially transplantable organs. We sought to determine whether pre-emptive administration of pangenotypic direct-acting antiviral therapy can safely prevent the development of chronic hepatitis C virus (HCV) infection in uninfected recipients of HCV-infected donor hearts.

METHODS

Patients were recruited for this an open-label, single-centre, proof-of-concept study from Nov 1, 2017, to Nov 30, 2018. Following enrolment, the recipient's status on the heart transplantation waiting list was updated to reflect a willingness to accept either an HCV-positive or HCV-negative heart donor. Patients who underwent transplantation with a viraemic donor heart, as determined by nucleic acid testing (NAT), received pre-emptive oral glecaprevir-pibrentasvir before transport to the operating room followed by an 8-week course of glecaprevir-pibrentasvir after transplantation. Patients receiving HCV antibody-positive donor hearts without detectable circulating HCV RNA were followed using a reactive approach and started glecaprevir-pibrentasvir only if they developed viraemia. The primary outcome was achievement of sustained virological response 12 weeks after completion of glecaprevir-pibrentasvir therapy (SVR12). Patients were followed from study enrolment to 1 year after transplantation. This is an interim analysis, initiated after all enrolled patients reached the primary outcome. Results reflect data from Nov 1, 2017, to May 30, 2019. This trial is registered with ClinicalTrials.gov, number NCT03208244.

FINDINGS

55 patients were assessed for eligibility and 52 consented to enrolment. 25 patients underwent heart transplantation with HCV-positive donor hearts (20 NAT-positive, five NAT-negative), three of whom underwent simultaneous heart-kidney transplantation. All 20 recipients of NAT-positive hearts tolerated glecaprevir-pibrentasvir and showed rapid viral suppression (median time to clearance 3·5 days, IQR 0·0-8·3), with the subsequent achievement of SVR12 by all 20. The five recipients of NAT-negative grafts did not become viraemic. Median pre-transplant waiting time for patients following enrolment in the HCV protocol was 20 days (IQR 8-57). Patient and allograft survival were 100% at a median follow-up of 10·7 months (range 6·5-18·0).

INTERPRETATION

Pre-emptive administration of glecaprevir-pibrentasvir therapy results in expedited organ transplantation, rapid HCV suppression, prevention of chronic HCV infection, and excellent early allograft function in patients receiving HCV-infected donor hearts. Long-term outcomes are not yet known.

FUNDING

American Association for the Study of Liver Diseases, National Institutes of Health, and the Massachusetts General Hospital.

Balancing the risk and rewards of utilizing organs from hepatitis C viremic donors

PURPOSE OF REVIEW

Owing to long waitlist times and high waitlist morbidity and mortality, strategies to increase utilization of hepatitis C viremic-deceased donor organs are under investigation in kidney, liver, heart, and lung transplantation.

RECENT FINDINGS

Direct-acting antiviral medications for hepatitis C virus infection have high cure rates and are well tolerated. Small, single-center trials in kidney and heart transplant recipients have demonstrated that with early posttransplant direct-acting antiviral therapy, 100% of uninfected recipients of hepatitis C viremic organs have been cured of infection after transplantation.

SUMMARY

In this manuscript, we review the risks and rewards of utilizing hepatitis C viremic organs for transplantation.

AISF position paper on HCV in immunocompromised patients

This report summarizes the clinical features and the indications for treating HCV infection in immunocompromised and transplanted patients in the Direct Acting Antiviral drugs era.

Hepatitis E virus serum antibodies and RNA prevalence in patients evaluated for heart and kidney transplantation

BACKGROUND

Acute hepatitis E virus (HEV) infection in solid organ transplant recipients is rare, but can cause severe hepatic and extrahepatic complications. We sought to identify the pretransplant prevalence of HEV infection in heart and kidney candidates and any associated risk factors for infection.

MATERIAL AND METHODS

Stored frozen serum from patients undergoing evaluation for transplant was tested for HEV immunoglobulin G (IgG) antibodies and HEV RNA. All patients were seen at Mayo Clinic Hospital, Phoenix, Arizona, with 333 patients evaluated for heart (n = 132) or kidney (n = 201) transplant. HEV IgG antibodies (anti-HEV IgG) were measured by enzyme-linked immunosorbent assay, and HEV RNA by a noncommercial nucleic acid amplification assay.

RESULTS

The prevalence of anti-HEV IgG was 11.4% (15/132) for heart transplant candidates and 8.5% (17/201) for kidney transplant candidates, with an overall seroprevalence of 9.6% (32/333). None of the patients tested positive for HEV RNA in the serum. On multivariable analysis, age older than 60 years was associated with HEV infection (adjusted odds ratio, 3.34; 95% CI, 1.54-7.24; P = 0.002).

CONCLUSIONS

We conclude that there was no evidence of acute HEV infection in this pretransplant population and that older age seems to be associated with positive anti-HEV IgG.

Successful Treatment of Chronic Hepatitis C Infection With Direct-Acting Antivirals in a Heart Transplant Recipient: A Case Report

BACKGROUND

Heart transplant (HT) recipients with chronic hepatitis C virus (HCV) infection are noted to have higher rates of HCV related morbidity and mortality. Treatment of HCV in the past was fraught with low cure rates, increased risk of graft rejection, and medication-related side effects.

CASE REPORT

We report a case of successful treatment of HCV infection in a HT recipient. The patient was found to have HCV during his pretransplant workup. He underwent uneventful orthotopic HT in 2000. The HCV infection was monitored with regular liver enzymes and the surveillance liver biopsies at 2 and 5 years after HT showed mild but stable liver disease, and he stayed on chronic immunosuppression. He was not offered interferon-based HCV therapy because of the risk of steroid-resistant graft failure and cardiac decompensation. With the availability of the new direct-acting antivirals (DAA) for HCV infection, and worsening of liver fibrosis on noninvasive testing, we treated him with sofosbuvir and simeprevir for 12 weeks. During treatment, he remained clinically stable from a cardiac standpoint and he showed biochemical improvement in his liver and renal functions. Tacrolimus levels remained stable and did not require any dose adjustment. He showed rapid virologic response and subsequently achieved sustained virologic response at 12 weeks.

CONCLUSION

DAA use was safe and effective in treating HCV infection in a HT recipient.

Hepatitis C virus infection in nonliver solid organ transplant candidates and recipients

PURPOSE OF REVIEW

Transplantation is the best treatment for many patients with end-stage organ failure. Hepatitis C infection is prevalent among solid organ candidates and recipients and continues to represent a major source of morbidity and mortality. Prior interferon (IFN)-based therapies have been associated with limited efficacy and high rates of adverse events. Furthermore, prior IFN-based regimens are associated with high rates of allograft rejection limiting their use post-transplant. This review will outline the limited experience with current treatment regimens and how to incorporate the new hepatitis C virus (HCV) treatment regimens.

RECENT FINDINGS

The introduction of new direct-acting antiviral (DAA) agents against HCV has dramatically altered the landscape of treatment for HCV. Different all-oral regimens are currently available and are rapidly becoming the standard for treating patients with chronic hepatitis C. Excluding patients with liver disease or those who received liver transplant, those regimens have not been studied in patients awaiting solid organ transplant, or those transplanted.

SUMMARY

The safety and efficacy of DAAs in patients awaiting liver transplant and liver transplant recipients provide us with some insight and guidance on how to use those all-oral IFN-free regimens to allow effective treatment for patients who received or are awaiting nonliver solid organ transplants.

Should we consider patients with coexistent hepatitis B or C infection for orthotopic heart transplantation?

Heart transplantation (HTX) is the gold standard surgical treatment for patients with advanced heart failure. The prevalence of hepatitis B and hepatitis C infection in HTX recipients is over 10%. Despite its increased prevalence, the long-term outcome in this cohort is still not clear. There is a reluctance to place these patients on transplant waiting list given the increased incidence of viral reactivation and chronic liver disease after transplant. The emergence of new antiviral therapies to treat this cohort seems promising but their long-term outcome is yet to be established. The aim of this paper is to review the literature and explore whether it is justifiable to list advanced heart failure patients with coexistent hepatitis B/C infection for HTX.

Hepatitis C virus and nonliver solid organ transplantation

: Hepatitis C virus (HCV) infection is common in solid organ allograft recipients and is a significant cause of morbidity and mortality after transplantation, so effective management will improve outcomes. In this review, we discuss the extent of the problem associated with HCV infection in donors and kidney, heart, and lung transplant candidates and recipients and recommend follow-up and treatment.Patients with end-stage kidney disease without cirrhosis and selected patients with early-stage cirrhosis can be considered for kidney transplant alone. In HCV-infected kidney allograft recipients, the progression of fibrosis should be evaluated serially by Fibroscan or serologic measures of fibrosis. Transplantation of kidneys from HCV-positive donors should be restricted to HCV-positive recipients as it is associated with a reduced time waiting for a graft and does not affect posttransplant outcomes. Hepatitis C virus antiviral therapy should be considered for all HCV-RNA-positive kidney transplant candidates, irrespective of the baseline liver histopathology. Protease inhibitors have yet to be fully evaluated in patients with renal dysfunction and in the transplant population. As these agents may cause anemia in patients with normal renal function, tolerability may be a problem in patients with end-stage kidney disease.The impact of HCV infection on survival in heart and lung transplantation is unclear. Because of the shortage of organs, few HCV-infected patients are accepted for transplantation.Universal use of nucleic acid amplification testing (NAT) for the screening of potential organ donors should be reserved to high-risk donors. Assays that quantify HCV core antigen may become more cost-effective than NAT for the screening of potential organ donors.

The outcome of heart transplantation in hepatitis C-positive recipients

BACKGROUND

Clinical outcomes of heart transplantation (HTx) among recipients with chronic hepatitis C virus (HCV) infection are poorly understood especially in Asia. Therefore, this study evaluated these clinical outcomes.

METHODS

Using retrospective chart review we collected data on 385 patients including 20 HCV-positive recipients at the time of transplantation. We obtained information on demographics features, serial transaminases, graft function, patient survival as well as the incidences of acute hepatitis and transplant coronary artery disease.

RESULTS

Between 1987 and 2010, the 20 HCV-positive patients had a median age at transplantation of 52 years (range, 30-63). Seventeen were men and three women. All the patients were classified as Child-Pugh class A; two had cirrhosis prior to HTx. Over a mean follow-up of 63 months (range, 2 days to 187 months), there were 11 deaths, including two hospital mortalities and nine subsequent deaths. Only one mortality (5%) was related to Child-Pugh class C cirrhosis, despite liver transplantation. Among the other 19 deceased or surviving recipients, there was no evidence of hepatic dysfunction or hepatocellular carcinoma. Transplant coronary artery disease was detected in six patients (30%). There was no significant difference in Kaplan-Meier actuarial survival between the HCV-positive and HCV-negative recipients (P = .59).

CONCLUSIONS

There was no significant difference in patient survival or graft function between HCV-positive and HCV-negative HTx recipients. Additionally, HCV-positive recipients were not at an increased risk of hepatic failure or accelerated transplant coronary artery disease.

A concise review of hepatitis C in heart and lung transplantation

Hepatitis C (HCV) infection is prevalent in recipients of, and candidates for, solid organ transplants. The outcomes of HCV infection in cardiac and lung transplant recipients have yet to be clearly established, and future prospective studies are needed. In the absence of safe and effective antiviral treatment for HCV infection in heart and lung transplant recipients, the management of these patients remains a challenge and must be considered on an individual basis. Interferon therapy for HCV before transplantation appears to improve outcomes; however, post-transplant interferon therapy in the cardiac and pulmonary transplant setting may be associated with an increased risk of graft rejection. Given the paucity of information regarding HCV treatment in these transplant recipients, and with appropriate concerns that graft loss from rejection may not be amenable to a second transplant (given the scarcity of suitable cadaveric organs), multicentre, randomized controlled trials are needed to determine the optimal approach for treatment of HCV infection in this population.

Peginterferon alpha-2b and acute allograft failure in a heart transplant recipient

Reports of heart transplant recipients with hepatitis C viral infection treated with peginterferon alpha-2b and ribavirin are very rare. We report a fatal case of acute allograft failure and hepatitis C viral infection in a 50-year-old orthotopic heart transplant recipient. At autopsy, the patient was found to have patent coronary arteries, diffuse severe fatty degeneration of heart myocytes, and no evidence of cellular or humoral rejection, confirming this as a fatal case of cardiotoxicity from peginterferon alpha-2b.

Management of HBV infection during immunosuppressive treatment

The literature on hepatitis B virus (HBV) in immunocompromised patients is heterogeneous and refers mainly to the pre-antivirals era. Currently, a rational approach to the problem of hepatitis B in these patients provides for: a) the evaluation of HBV markers and of liver condition in all subjects starting immunosuppressive therapies (baseline), b) the treatment with antivirals (therapy) of active carriers, c) the pre-emptive use of antivirals (prophylaxis) in inactive carriers, especially if they are undergoing immunosuppressive therapies judged to be at high risk, d) the biochemical and HBsAg monitoring (or universal prophylaxis in case of high risk immunosuppression, as in onco-haematologic patients and bone marrow transplantation) in subjects with markers of previous contact with HBV (HBsAg-negative and antiHBc-positive), in order to prevent reverse seroconversion. Moreover in solid organ transplants it is suggested a strict adherence to the criteria of allocation based on the virological characteristics of both recipients and donors and the universal prophylaxis or therapy with nucleos(t)ides analogs

Course of Patients With Chronic Hepatitis C Virus Infection Undergoing Heart Transplantation

OBJECTIVE

The objective of this study was to describe the clinical course of patients with chronic hepatitis C virus (HCV) infection undergoing heart transplantation (HT).

MATERIALS AND METHODS

Among 499 patients transplanted in our hospital between January 1989 and September 2006, 11 subjects (2.2%) had chronic HCV infection. We analyzed liver function laboratory parameters pretransplantation as well as at 3, 6, 12 months, and last available, pre- and postsurgical hepatobiliary ultrasounds, and mortality. The mean time since HT was 32 +/- 23 months.

RESULTS

No abnormalities in the liver parenchyma were observed on the ultrasound examinations performed before or after transplantation. There were 3 deaths (27%), none of which was related to HCV infection. Liver function laboratory parameters remained stable during the follow-up.

CONCLUSIONS

The clinical course of patients with chronic HCV infection undergoing HT whose presurgical assessment did not show significant liver damage was favorable. No morphological or laboratory abnormalities were observed that would suggest reactivation of the infection during the follow-up.

Prophylaxis and treatment of hepatitis B in immunocompromised patients

The literature on hepatitis B virus (HBV) in immunocompromised patients is heterogeneous and referred mainly to the pre-antivirals era. Today a rational approach to the problem of hepatitis B in these patients provides for: (a) the evaluation of HBV markers and of liver condition in all subjects starting immunosuppressive therapies (baseline), (b) the treatment with antivirals (therapy) of active carriers, (c) the pre-emptive use of antivirals (prophylaxis) in inactive carriers, especially if they are undergoing immunosuppressive therapies judged to be at high risk, (d) the biochemical and hepatitis B surface antigen (HBsAg) monitoring (or universal prophylaxis, in case of high risk immunosuppression) in subjects with markers of previous contact with HBV (HBsAg negative and anti-HBc positive), in order to prevent reverse seroconversion. Moreover it is suggested a strict adherence to criteria of allocation based on the virological characteristics of both recipients and donors in the general setting of transplants and in liver transplantation the universal prophylaxis with nucleos(t)ides analogues (frequently combined with specific anti-HBV immunoglobulins) in HBsAg positive candidates and in HBsAg negative recipients of anti-HBc positive grafts.

Hepatitis C in transplant recipients of solid organs, other than liver

Hepatitis C virus (HCV) infection is prevalent in candidates for, and recipients of, solid organ transplants. HCV infection can lead to diminished patient and allograft survival in the long-term in recipients of kidney transplants. Outcomes in recipients of other solid organ transplants (lung, heart, small bowel, pancreas, pancreas-kidney) are not well established. Large, well-designed, prospective studies are needed to answer these questions. Interferon therapy for HCV before transplantation can lead to improved outcomes. Therefore, transplant candidates should be considered for and offered interferon therapy before embarking on organ transplantation. Posttransplant interferon therapy can be complicated by acute allograft rejection and is not recommended, except with advanced liver disease.

Improved outcome of chronic hepatitis B after heart transplantation by long-term antiviral therapy

Chronic hepatitis B progresses to cirrhosis in the majority of immunosuppressed patients. The outcome of long-term antiviral therapy in HBV-infected organ transplant recipients is unknown. In 1996, we included 20 heart transplant (HT) recipients in a pilot trial to treat chronic hepatitis B with famciclovir. At that time, bridging fibrosis or cirrhosis was evident in 15 individuals (75%). From 1998 onwards, patients were switched to lamivudine in case of primary or secondary virological nonresponse to famciclovir. Adefovir or tenofovir became available at our centre for HT recipients in 2002. After 103 months, one patient was still on famciclovir showing a complete virological response. Sixteen patients were switched to lamivudine after 0.5-4 years of famciclovir therapy. Six of those showed a long-term response to lamivudine therapy lasting for up to 7 years. Lamivudine resistance developed in the remaining 10 patients (63%), in 4 of them successful rescue therapy (adefovir n = 3, tenofovir n = 1) could be initiated. Only one hepatocellular carcinoma developed, which was successfully treated by locoregional ablative therapy. Nine patients died (45%), with lamivudine-resistance-related liver failure as the cause of death in five cases. Significant improvement of Ishak fibrosis scores could be demonstrated in six of the seven patients with more than two sequential liver biopsies available. Long-term antiviral therapy of chronic hepatitis B can lead to regression of liver cirrhosis in patients after organ transplantation, unless viral resistance occurs. This study demonstrates the urgent need for further antivirals to overcome antiviral resistance.

Can Donors With Prior Hepatitis Be Safely Used for Heart Transplantation?

BACKGROUND

Heart transplantation represents a significant life-saving and increased quality-of-life intervention for patients with refractory cardiac failure. Successful transplantation requires continuous immunosuppression to avoid immune rejection. Unfortunately, persistent viral infections in donors may be transmitted to recipients in the process of heart transplantation. With the severe shortage of available organs and significant waiting list mortality there is a rationale for considering use of organs from donors with evidence of prior hepatitis B and/or hepatitis C infection.

METHODS

Published literature articles were searched using Medline, PaperChase and further review of references in relevant articles on issues related to hepatitis B and hepatitis C and heart transplantation.

RESULTS

Donor and recipient testing for hepatitis B and hepatitis C is important for relative risk assessment. Nucleic acid testing for hepatitis B DNA and hepatitis C RNA represent emerging technologies, which may add valuable information to traditional serologic testing.

CONCLUSIONS

Heart transplant recipient risk may be modified by vaccination against hepatitis B before transplantation. There is currently no available vaccine for hepatitis C. Recently described effective treatments for hepatitis B and hepatitis C provide further rationale for reconsideration of using hearts from donors with evidence of hepatitis B and/or hepatitis C infection.

Acceptable recipient outcomes with the use of hearts from donors with hepatitis-B core antibodies

BACKGROUND

The shortage of available donors limits cardiac transplantation. Use of hearts from patients with hepatitis-B core antibodies could expand the donor pool but are usually avoided because of concern about virus transmission. We conducted a retrospective review to determine the safety of transplanting hearts from donors with hepatitis-B core antibodies.

METHODS

We reviewed donor and recipient charts for patients who underwent transplantation at our center between January 1, 1997, and December 1, 2002.

RESULTS

A total of 541 heart transplantations were performed in this time period. Thirty-three patients (aged 47.5 +/- 18.8 years) received hearts from core-antibody-positive donors (aged 37.7 +/- 10.8 years). Of these, 5 patients received prophylactic antibiotic treatment with lamivudine after transplantation. Only 1 patient (baseline surface-antigen-negative and without prophylaxis) experienced donor-transmitted hepatitis B infection 10 months after transplantation that was treated with lamivudine. Two patients (baseline surface-antibody-negative) had hepatitis B seroconversion, becoming surface-antibody positive without evidence of infection. None of the 5 patients who received prophylaxis with lamivudine had donor-transmitted hepatitis, and only 1 lamivudine-treated patient had surface antibodies. Post-transplant survival in this small cohort was similar to that for all patients who underwent transplantation at our center during this time period.

CONCLUSIONS

Transplantation of hearts from donors with hepatitis-B core antibodies is associated with a small viral-transmission risk, with or without post-transplant, anti-viral prophylaxis. Use of these donor hearts should be considered safe and may help to augment the available donor pool.

[Piercing and tattoos in patients with congenital heart disease -- is it a problem?]

Piercing and tattooing enjoy widespread popularity in modern society. Patients with congenital heart disease are at elevated risk for infective endocarditis. However, it is not yet known whether piercing and tattooing are dangerous for these patients.A search of the literature provided 10 published cases of infective endocarditis after piercing or tattooing. Affected patients were adolescents or young adults ranging in age from 13 to 30 years (5 male, 5 female). Four of the patients had a known cardiac risk factor for endocarditis (bicuspid aortic valve, postoperative trans-position of the great arteries, postoperative coarctation, postoperative aortic valve stenosis). Piercing preceded endocarditis in 9 cases (4 times mouth, 2 ear, 1 nose, 1 breast, 1 navel), one tattoo. The following agents were isolated: S. aureus in 4 cases, 2 S. epidermidis, 1 Str. viridans, 1 Neisseria mucosa, 1 Haemophilus aphrophilus, 1 Haemophilus parainfluenzae. All patients were treated with antibiotics. Six patients underwent cardiac surgery (5 of them valve replacement). Patients with congenital heart disease constitute less than 1% of the population. Thus, they are clearly overrepresented in the published literature. Epidemiologic conclusions are not possible from these data. However, patients with congenital heart disease and their parents should be strongly advised against piercing and tattooing with regard to the risk of infective endocarditis.

Effects of autoantibodies against β1-adrenoceptor in hepatitis virus myocarditis on action potential and L-type Ca2+ currents

AIM: To investigate the effects of autoantibodies against β₁-adrenoceptor in hepatitis virus myocarditis on action potential and L-type Ca²⁺ currents.

METHODS: Fifteen samples of autoantibodies against β₁-adrenoceptor positive sera of patients with hepatitis virus myocarditis were obtained and IgGs were purified by octanoic acid extraction. Binding of autoantibodies against β₁-adrenoceptor to guinea pig cardiac myocytes was examined by immunofluorescence. Using the patch clamp technique, the effects on the action potential and I_Ca-L of guinea pig cardiac myocytes caused by autoantibodies against β₁-adrenoceptor in the absence and presence of metoprolol were investigated. Cell toxicity was examined by observing cell morphology and permeability of cardiac myocytes to trypan blue.

RESULTS: The specific binding of autoantibodies against β₁-adrenoceptor to guinea pig cardiomyocytes was observed. Autoantibodies against β₁-adrenoceptor diluted at 1:80 prolonged APD₂₀, APD₅₀ and APD₉₀ by 39.2%, 29.1% and 15.2% respectively, and only by 7.2%, 5.3% and 4.1% correspondingly in the presence of 1 μmol/L metoprolol. Autoantibodies against β₁-adrenoceptor diluted at 1:80, 1:100 and 1:120 significantly increased the I_Ca-L peak current amplitude at 0 mV by 55.87 ± 4.39%, 46.33 ± 5.01% and 29.29 ± 4.97% in a concentration-dependent manner. In contrast, after blocking of β₁-adrenoceptors (1 μmol/L metoprolol), autoantibodies against β₁-adrenoceptor diluted at 1:80 induced a slight increase of I_Ca-L peak amplitude only by 6.81 ± 1.61%. A large number of cardiac myocytes exposed to high concentrations of autoantibodies against β₁-adrenoceptor (1:80 and 1:100) were turned into rounded cells highly permeable to trypan blue.

CONCLUSION: Autoantibodies against β₁-adrenoceptor may result in arrhythmias and/or impairment of myocardiums in HVM, which would be mediated by the enhancement of I_Ca-L.

Five-year follow-up of hepatitis C-naïve heart transplant recipients who received hepatitis C-positive donor hearts

BACKGROUND

Due to the risk of transmission of hepatitis C virus, the use of hepatitis C seropositive donors in heart transplantation is controversial. The transmission rate of hepatitis C in this patient population is estimated to range from 67% to 80%. Long-term clinical outcomes of heart transplant recipients of hepatitis C-positive donor hearts are not well described. We report the 5-year long-term outcome of seven hepatitis C-naïve heart transplant recipients who received hepatitis C-positive donor hearts.

METHODS

Retrospective analysis of clinical course, liver biochemistry, serology, and hepatitis C virology data.

RESULTS

Seven hearts transplant recipients, six men and one woman were included in our study. After a mean follow-up of 63.3 +/- 20.4 months (range 28.2 to 85.9), four of seven (57.1%) patients are hepatitis C-negative, have normal liver function tests, and no clinical evidence of hepatitis. Three of seven (43%) have been diagnosed with hepatitis C by liver biopsy or the HCV-RNA reverse transcriptase polymerase chain reaction at a mean follow-up of 35.1 months (18.8 months posttransplantation). One had an accelerated course of hepatitis that was ultimately fatal, one was successfully treated with interferon, and the third died from other causes than liver injury. Overall, the 5-year survival was 71.4%.

CONCLUSIONS

The 5-year survival of hepatitis C-naïve recipients of hearts from hepatitis C-positive donors is similar to heart transplant recipients with hepatitis-negative donor hearts. Nevertheless, the transmission rate is high and hepatitis C infection in this population can lead to considerable morbidity and accelerated, fatal hepatitis.

Natural leukocyte interferon alfa for the treatment of chronic viral hepatitis in heart transplant recipients

BACKGROUND

A more rapid and aggressive course of hepatitis B virus (HBV)-related and hepatitis C virus (HCV)-related infection in organ transplant recipients has been described. Interferon alfa is the most accepted drug for treating HBV and HCV chronic infections. However, the use of interferon alfa-N3 has been contraindicated in heart transplant (HTx) recipients because of the hypothesized greater risk of triggering acute cellular rejection. The aim of this clinical pilot study was to evaluate tolerability, safety, and efficacy of natural leukocyte interferon alfa in the treatment of chronic HBV and HCV in HTx recipients.

METHODS

Seven HTx recipients were enrolled in the study: two with HBV, four with HCV, and one with combined HBV-HCV chronic infection. The patients had a mean follow-up after heart transplantation of 8.5+/-3 years, before starting interferon alfa-N3 treatment at a dose of 6 MU three times per week, intramuscularly for 12 months.

RESULTS

All patients completed the treatment with no major side effects. No unexpected episodes of acute cellular rejection were observed during the treatment. Mean aminotransferase serum levels were significantly lower than before transplantation at 3 (P<0.03), 6 (P<0.02), and 12 (P<0.02) months of treatment and at the 12-month follow-up (P<0.02). A complete and sustained response was achieved in all subjects with HBV-related chronic hepatitis, whereas sustained virologic response was observed in one of four HCV patients.

CONCLUSIONS

The preliminary data emerging from our study indicate that natural leukocyte interferon alfa-N3 can be safely administered in HTx recipients with chronic HBV or HCV viral hepatitis. Further studies with larger numbers of patients are needed to assess the efficacy of interferon alfa-N3 on HCV virologic response.

Infections in the heart transplant recipient

The overall incidence of infection after transplantation has decreased with improved immunosuppressive agents, increased knowledge and use of prophylaxis, and better detection and treatment of infection. Nevertheless, infection continues to be a major cause of morbidity and mortality in heart transplant recipients. The knowledgeable nurse in any setting who cares for a transplant recipient must be aware of the lifelong susceptibility to common and opportunistic infections. The transplant recipient and his or her family must also be aware of the risks of early opportunistic infection. Infection is a lifelong concern for all persons on immunosuppressant medications, and the individual must learn appropriate precautions to reduce this risk. Hand washing and avoidance of infected individuals are the most important self-care actions that the transplant patient should adopt. Recipients must also learn to monitor for subtle signs of infection. The nurse is responsible for teaching self-care to patients and family members. Ultimately, a team effort by the patient, family, nurses, and physicians can reduce the risk of infection in this vulnerable population.