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Issues of Immunological and Hemodynamic Monitoring Before and During Kidney Transplantation in Sensitized Heart Transplant Recipient. Transplant Proc 2018; 50:1919-1921. [PMID: 30056929 DOI: 10.1016/j.transproceed.2018.02.162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 02/06/2018] [Indexed: 11/22/2022]
Abstract
Previously transplanted highly sensitized patients experience problems with subsequent transplantation. It is also difficult to provide optimal hemodynamic conditions during successive kidney transplantation in heart transplant recipients. PATIENT AND METHODS We present a case of a 56-year old patient with end-stage renal failure after heart transplantation performed 21 years ago and hemodialyzed using arteriovenous fistula. The patient had 69% panel-reactive antibodies, had been on the active waiting list since 2013, and presented 335 positive crossmatches with deceased donors. He also positively crossmatched with a potential living donor. Detailed examination of anti-HLA antibodies revealed the absence of IgG donor-specific antibodies and negative crossmatch with dithiothreitol-treated serum. The transplantation from his wife was performed with positive crossmatch after 4 plasma exchanges and thymoglobulin induction. Because sympathetic and parasympathetic denervation of the transplanted heart and the presence of arteriovenous fistula induced volume overload of the right heart, we used central venous pressure (CVP) and the PiCCO2 for postsurgical assessment of cardiac output. RESULTS Monitoring, like CVP and other static exponents of preload obtained by PICCO (extravascular lung water, global end-diastolic volume index) as well as the dynamic parameters obtained by PiCCO2 (pulse pressure variation, stroke volume variation), was not sensitive enough to describe recipient volume status. The immediate graft function was observed, and after 11 months satisfactory estimated glomerular filtration rate is noted with the absence of donor-specific antibodies. CONCLUSION The history of heart transplantation with existing arteriovenous fistula makes clinical tools such as continuous cardiac output monitoring and CVP parameter inadequate for describing the hemodynamic situation. The high level of panel-reactive antibodies and positive crossmatch possibly caused by IgM antibodies do not have to withdraw the recipient from kidney transplantation.
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Lachance K, White M, Carrier M, Mansour A, Racine N, Liszkowski M, Ducharme A, de Denus S. Long-term evolution, secular trends, and risk factors of renal dysfunction following cardiac transplantation. Transpl Int 2014; 27:824-37. [DOI: 10.1111/tri.12340] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 03/03/2014] [Accepted: 04/13/2014] [Indexed: 01/20/2023]
Affiliation(s)
- Kim Lachance
- Montreal Heart Institute; Montreal QC Canada
- Faculty of Pharmacy; Université de Montréal; Montreal QC Canada
| | - Michel White
- Montreal Heart Institute; Montreal QC Canada
- Faculty of Medicine; Université de Montréal; Montreal QC Canada
| | - Michel Carrier
- Montreal Heart Institute; Montreal QC Canada
- Faculty of Medicine; Université de Montréal; Montreal QC Canada
| | - Asmaa Mansour
- Montreal Health Innovations Coordinating Center; a Division of the Montreal Heart Institute; Montreal QC Canada
| | - Normand Racine
- Montreal Heart Institute; Montreal QC Canada
- Faculty of Medicine; Université de Montréal; Montreal QC Canada
| | - Mark Liszkowski
- Montreal Heart Institute; Montreal QC Canada
- Faculty of Medicine; Université de Montréal; Montreal QC Canada
| | - Anique Ducharme
- Montreal Heart Institute; Montreal QC Canada
- Faculty of Medicine; Université de Montréal; Montreal QC Canada
| | - Simon de Denus
- Montreal Heart Institute; Montreal QC Canada
- Faculty of Pharmacy; Université de Montréal; Montreal QC Canada
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Gustafsson F, Gude E, Sigurdardottir V, Aukrust P, Solbu D, Goetze JP, Gullestad L. Plasma NGAL and glomerular filtration rate in cardiac transplant recipients treated with standard or reduced calcineurin inhibitor levels. Biomark Med 2014; 8:239-45. [PMID: 24521021 DOI: 10.2217/bmm.13.95] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
AIM Predictors of renal recovery following conversion from calcineurin inhibitor- to proliferation signal inhibitor-based therapy are lacking. We hypothesized that plasma NGAL (P-NGAL) could predict improvement in glomerular filtration rate (GFR) after conversion to everolimus. PATIENTS & METHODS P-NGAL was measured in 88 cardiac transplantation patients (median 5 years post-transplant) with renal dysfunction randomized to continuation of conventional calcineurin inhibitor-based immunosuppression or switching to an everolimus-based regimen. RESULTS P-NGAL correlated with measured GFR (mGFR) at baseline (R(2) = 0.21; p < 0.001). Randomization to everolimus improved mGFR after 1 year (median [25-75 % percentiles]: ΔmGFR 5.5 [-0.5-11.5] vs -1 [-7-4] ml/min/1.73 m(2); p = 0.006). Baseline P-NGAL predicted mGFR after 1 year (R(2) = 0.18; p < 0.001), but this association disappeared after controlling for baseline mGFR. CONCLUSION P-NGAL and GFR correlate with renal dysfunction in long-term heart transplantation recipients. P-NGAL did not predict improvement of renal function after conversion to everolimus-based immunosuppression.
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Affiliation(s)
- Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark.
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Abstract
Immunosuppressive therapy in pediatrics continues to evolve. Over the past decade, newer immunosuppressive agents have been introduced into adult and pediatric transplant patients with the goal of improving patient and allograft survival. Unfortunately, large-scale randomized clinical trials are not commonly performed in children. The purpose of this review is to discuss the newer immunosuppressive agents available for induction therapy, maintenance immunosuppression, and the treatment of rejection.
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Affiliation(s)
- Christina Nguyen
- Division of Pediatric Nephrology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, United States
| | - Ron Shapiro
- Division of Transplant Surgery, UPMC Thomas E. Starzl Transplantation Institute, Pittsburgh, PA, United States
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Gonzalez-Vilchez F, Vazquez de Prada JA, Paniagua MJ, Gomez-Bueno M, Arizon JM, Almenar L, Roig E, Delgado J, Lambert JL, Perez-Villa F, Sanz-Julve ML, Crespo-Leiro M, Segovia J, Lopez-Granados A, Martinez-Dolz L, Mirabet S, Escribano P, Diaz-Molina B, Farrero M, Blasco T. Use of mTOR inhibitors in chronic heart transplant recipients with renal failure: calcineurin-inhibitors conversion or minimization? Int J Cardiol 2013; 171:15-23. [PMID: 24309084 DOI: 10.1016/j.ijcard.2013.11.036] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Revised: 11/08/2013] [Accepted: 11/17/2013] [Indexed: 01/13/2023]
Abstract
BACKGROUND In the last decade, mTOR inhibitors (mTOR-is) have become the cornerstone of the calcineurin inhibitor (CNI)-reduced/free regimens aimed to the preservation of post-transplant renal function. We compared utility and safety of the total replacement of calcineurin inhibitors with a mTOR-i with a strategy based on calcineurin inhibitor minimization and concomitant use of m-TOR-i. METHODS In a retrospective multi-center cohort of 394 maintenance cardiac recipients with renal failure (GFR<60 mL/min/1.73 m(2)), we compared 235 patients in whom CNI was replaced with a mTOR-i (sirolimus or everolimus) with 159 patients in whom mTOR-is were used to minimize CNIs. A propensity score analysis was carried out to balance between group differences. RESULTS Overall, after a median time of 2 years from mTOR-i initiation, between group differences for the evolution of renal function were not observed. In a multivariate adjusted model, improvement of renal function was limited to patients with mTOR-i usage within 5years after transplantation, particularly with the conversion strategy, and in those patients who could maintain mTOR-i therapy. Significant differences between strategies were not found for mortality, infection and mTOR-i withdrawal due to drug-related adverse events. However, conversion group tended to have a higher acute rejection incidence than the minimization group (p=0.07). CONCLUSION In terms of renal benefits, our results support an earlier use of mTOR-is, irrespective of the strategy. The selection of either a conversion or a CNI minimization protocol should be based on the clinical characteristics of the patients, particularly their rejection risk.
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Affiliation(s)
- F Gonzalez-Vilchez
- Heart Failure and Cardiac Transplantation Unit, Cardiology Service, University Hospital Marques de Valdecilla, Instituto de Formación e Investigación Marqués de Valdecilla (IFIMAV), Santander, Spain.
| | - J A Vazquez de Prada
- Heart Failure and Cardiac Transplantation Unit, Cardiology Service, University Hospital Marques de Valdecilla, Instituto de Formación e Investigación Marqués de Valdecilla (IFIMAV), Santander, Spain
| | - M J Paniagua
- Heart Failure and Cardiac Transplantation Unit, Cardiology Service, University Hospital de La Coruña, La Coruña, Spain
| | - M Gomez-Bueno
- Heart Failure and Cardiac Transplantation Unit, Cardiology Service, University Hospital Puerta de Hierro, Majadahonda, Madrid, Spain
| | - J M Arizon
- Heart Failure and Cardiac Transplantation Unit, Cardiology Service, University Hospital Reina Sofia, Cordoba, Spain
| | - L Almenar
- Heart Failure and Cardiac Transplantation Unit, Cardiology Service, University Hospital La Fe, Valencia, Spain
| | - E Roig
- Heart Failure and Cardiac Transplantation Unit, Cardiology Service, University Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - J Delgado
- Heart Failure and Cardiac Transplantation Unit, Cardiology Service, University Hospital 12 de Octubre, Madrid, Spain
| | - J L Lambert
- Heart Failure and Cardiac Transplantation Unit, Cardiology Service, University Hospital Central de Asturias, Oviedo, Spain
| | - F Perez-Villa
- Heart Failure and Cardiac Transplantation Unit, Cardiology Service, University Hospital Clinic de Barcelona, Barcelona, Spain
| | - M L Sanz-Julve
- Heart Failure and Cardiac Transplantation Unit, Cardiology Service, University Hospital Miguel Servet, Zaragoza, Spain
| | - M Crespo-Leiro
- Heart Failure and Cardiac Transplantation Unit, Cardiology Service, University Hospital de La Coruña, La Coruña, Spain
| | - J Segovia
- Heart Failure and Cardiac Transplantation Unit, Cardiology Service, University Hospital Puerta de Hierro, Majadahonda, Madrid, Spain
| | - A Lopez-Granados
- Heart Failure and Cardiac Transplantation Unit, Cardiology Service, University Hospital Reina Sofia, Cordoba, Spain
| | - L Martinez-Dolz
- Heart Failure and Cardiac Transplantation Unit, Cardiology Service, University Hospital La Fe, Valencia, Spain
| | - S Mirabet
- Heart Failure and Cardiac Transplantation Unit, Cardiology Service, University Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - P Escribano
- Heart Failure and Cardiac Transplantation Unit, Cardiology Service, University Hospital 12 de Octubre, Madrid, Spain
| | - B Diaz-Molina
- Heart Failure and Cardiac Transplantation Unit, Cardiology Service, University Hospital Central de Asturias, Oviedo, Spain
| | - M Farrero
- Heart Failure and Cardiac Transplantation Unit, Cardiology Service, University Hospital Clinic de Barcelona, Barcelona, Spain
| | - T Blasco
- Heart Failure and Cardiac Transplantation Unit, Cardiology Service, University Hospital Miguel Servet, Zaragoza, Spain
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Chinnock TJ, Shankel T, Deming D, Cutler D, Sahney S, Fitts J, Chinnock RE. Calcineurin inhibitor minimization using sirolimus leads to improved renal function in pediatric heart transplant recipients. Pediatr Transplant 2011; 15:746-9. [PMID: 21883751 DOI: 10.1111/j.1399-3046.2011.01566.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The introduction of cyclosporine revolutionized the practice of immunosuppression for solid organ transplant recipients, and has resulted in a significant increase in survival. While CNI use has been the mainstay of immunosuppressive therapy in pediatric heart transplantation, CNIs have been associated with an increased risk of nephropathy leading to significant morbidity and mortality. We evaluated the effect on renal function of a CNI minimization protocol using SRL in pediatric heart transplant patients with CNI induced renal insufficiency. An IRB approved retrospective chart review and case control study was performed. There were 20 patients identified with renal insufficiency who had been converted to SRL (target 5-8 ng/mL) and cyclosporine (target 50-75 vs. 125-150 ng/mL). Renal insufficiency was defined as isotopic (Indium 111 DTPA) GFR <60 mL/min per 1.73 m(2) or sCr >1 mg/dL. Outcome variables evaluated were GFR and sCr at time of conversion and at two yr post conversion. Comparison was made with case control subjects matched for age at Tx, time from Tx to conversion, and initial GFR. The median age at Tx = 81 days (S.D. ±26), median time of conversion after Tx = 10 yrs (s.d. ±0.65). Self-limited/treatable side effects included hypercholesterolemia (10), neutropenia (6), aphthous ulcer (3), edema (2), anemia (2), and tremor (1). One patient rejected in the two yr prior to conversion, and one patient had two rejection episodes following conversion. GFR at conversion for study group was 51 ± 14 vs. 60 ± 2 at two yr, p = 0.018. GFR at inclusion for control group was 56 ± 20 vs. 53 ± 21, p = 0.253. This report demonstrates that minimizing CNI exposure by addition of SRL to the immunosuppressant regimen in pediatric heart transplant recipients result in improved renal function in comparison to historically managed patients. Furthermore, immunotherapy with SRL and lower-dose CNI can effectively prevent rejection with an acceptable side-effect profile.
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Affiliation(s)
- Timothy J Chinnock
- Department of Pediatrics, Naval Medical Center San Diego, CA 92277, USA.
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Urschel S, Altamirano-Diaz LA, West LJ. Immunosuppression armamentarium in 2010: mechanistic and clinical considerations. Pediatr Clin North Am 2010; 57:433-57, table of contents. [PMID: 20371046 DOI: 10.1016/j.pcl.2010.01.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Effective immunosuppression is the key to successful organ transplantation, with success being defined as minimal rejection risk with concomitant minimal drug toxicities. Despite the general recognition of this fact, a paucity of appropriate clinical trials in children has contributed to lack of standardization of clinical management regimens, resulting in an extensive diversity of favored approaches. Nonetheless, although consensus has not been reached on the ideal approach to immunosuppression in pediatric transplantation, new drug therapies have contributed to a continuing improvement in graft and patient survival. Future clinical research must focus on diminishing the extensive burden of toxicities of these therapeutic agents in children.
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Affiliation(s)
- Simon Urschel
- Cardiac Transplant Research, University of Alberta, Alberta Diabetes Institute, Edmonton, AB T6G 2E1, Canada
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