1
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Khalid H, Fareed MM, Dandekar T, Shityakov S. Calcineurin and mTOR inhibitors in kidney transplantation: integrative metamodeling on transplant survival and kidney function. Int Urol Nephrol 2024; 56:1403-1414. [PMID: 37751051 DOI: 10.1007/s11255-023-03754-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 08/18/2023] [Indexed: 09/27/2023]
Abstract
In our study, we examined the efficacy of mTOR (mammalian target of rapamycin) inhibitors, specifically rapamycin (Rap), compared to calcineurin inhibitors (CNIs) in kidney transplantation. By conducting a comprehensive search across reputable databases (EMBASE, Scopus, PubMed, Cochrane, and Crossref), we gathered data for a six-month post-transplantation period. Our analysis revealed that mTOR inhibitor administration resulted in improved glomerular filtration rate (GFR) and serum creatinine levels. However, it is important to note that the mTOR inhibitor group had a higher incidence of acute rejection after biopsy. Through molecular modeling, we observed that Rap exhibited a superior binding affinity for mTOR compared to CNIs' binding to calcineurin, probably contributing to the transplant rejection. Our meta-analysis supports the cautious use of an optimal mTOR inhibitor in conjunction with careful consideration of clinical features when minimizing CNIs early in the transplantation process. This is because mTOR inhibitors have complementary mechanisms of action, a low nephrotoxicity profile, and favorable outcomes in serum creatinine and GFR, which contribute to improved transplant survival.
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Affiliation(s)
- Hina Khalid
- Faculty of Life Sciences, Department of Bioinformatics and Biotechnology, Government College University, Faisalabad, Pakistan.
| | - Muhammad Mazhar Fareed
- School of Science and Engineering, Department of Computer Science, Università degli studi di Verona, Verona, Italy
| | - Thomas Dandekar
- Department of Bioinformatics, Biocenter, University of Würzburg, Würzburg, Germany
| | - Sergey Shityakov
- Laboratory of Chemoinformatics, Infochemistry Scientific Center, ITMO University, Saint-Petersburg, Russian Federation
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2
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Chaemchoi T, Ittiwattanakul W, Ritteeverakul P, Intrarakamhang AL, Thammanatsakul K, Sinphurmsukskul S, Siwamogsatham S, Puwanant S, Ariyachaipanich A. The decline in kidney function after heart transplantation and its impact on survival. Clin Transplant 2023; 37:e15112. [PMID: 37676472 DOI: 10.1111/ctr.15112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 08/11/2023] [Accepted: 08/18/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Evidence of decline in native renal function after heart transplantation (HTx) in the Asian population is limited. This study determined the incidence and risk factors associated with declining kidney function after HTx and its impact on survival. METHODS A retrospective study of consecutive adult heart transplant patients was conducted in a single center between 2010 and 2020. The decline in kidney function was defined as the presence of one of the following criteria, including a ≥ 40% decline in eGFR, absolute value <15 mL/min/1.73 m2 (calculated by the CKD-EPI method), doubling of serum creatinine, or dialysis. RESULTS A total of 79 patients (77% male, mean age 44.5 ± 11.53 years, with a mean eGFR at discharge from the heart transplant admission of 87.9 ± 25.48 mL/min/1.73 m2 ) were included. During the median follow-up of 42 months, the rate of decline in eGFR was 3.9 mL/min/1.73 m2 per year, with a cumulative probability of decline in kidney function of 22% at 1 year and 43% at 5 years. The need for dialysis was 2.5% at 1 year and 5% at 5 years. The decline in kidney function within 1 year after discharge (hazard ratio (HR), 22.24; p = .007) and pre-HTx diabetes mellitus (DM) (HR, 8.99; p = .034) were independently associated with the need for dialysis. Post-HTx dialysis predicted all-cause mortality (HR, 4.47; p = .017). CONCLUSIONS Approximately 20% of HTx patients developed a decline in kidney function within 1 year after discharge. These individuals and pre-HTx DM patients needed preventive measures to prevent progression to chronic dialysis, which impacted survival. (thaiclinicaltrials.org number, TCTR20230620004).
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Affiliation(s)
- Tasigan Chaemchoi
- Department of Pharmacy, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
| | - Wannee Ittiwattanakul
- Department of Pharmacy, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
| | - Puangpen Ritteeverakul
- Department of Pharmacy, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
| | - Ai-Lada Intrarakamhang
- Excellent Center for Organ Transplantation, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
| | - Kanokwan Thammanatsakul
- Excellent Center for Organ Transplantation, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
| | - Supanee Sinphurmsukskul
- Excellent Center for Organ Transplantation, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
| | - Sarawut Siwamogsatham
- Chula Clinical Research Center, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Sarinya Puwanant
- Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Aekarach Ariyachaipanich
- Excellent Center for Organ Transplantation, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
- Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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3
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Ivulich S, Paul E, Kirkpatrick C, Dooley M, Snell G. Everolimus Based Immunosuppression Strategies in Adult Lung Transplant Recipients: Calcineurin Inhibitor Minimization Versus Calcineurin Inhibitor Elimination. Transpl Int 2023; 36:10704. [PMID: 36744051 PMCID: PMC9894878 DOI: 10.3389/ti.2023.10704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 01/02/2023] [Indexed: 01/21/2023]
Abstract
Everolimus (EVE) provides an alternative to maintenance immunosuppression when conventional immunosuppression cannot be tolerated. EVE can be utilized with a calcineurin inhibitor (CNI) minimization or elimination strategy. To date, clinical studies investigating EVE after lung transplant (LTx) have primarily focused on the minimization strategy to preserve renal function. The primary aim was to determine the preferred method of EVE utilization for lung transplant recipients (LTR). To undertake this aim, we compared the safety and efficacy outcomes of EVE as part of minimization and elimination immunosuppressant regimens. Single center retrospective study of 217 LTR initiated on EVE (120 CNI minimization and 97 CNI elimination). Survival outcomes were calculated from the date of EVE commencement. On multivariate analysis, LTR who received EVE as part of the CNI elimination strategy had poorer survival outcomes compared to the CNI minimization strategy [HR 1.61, 95% CI: 1.11-2.32, p=0.010]. Utilization of EVE for renal preservation was associated with improved survival compared to other indications [HR 0.64, 95% CI: 0.42-0.97, p=0.032]. EVE can be successfully utilized for maintenance immunosuppression post LTx, particularly for renal preservation. However, immunosuppressive regimens containing low dose CNI had superior survival outcomes, highlighting the importance of retaining a CNI wherever possible.
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Affiliation(s)
- Steven Ivulich
- The Alfred Hospital, Melbourne, VIC, Australia,Centre for Medication Use and Safety, Monash University, Melbourne, VIC, Australia,*Correspondence: Steven Ivulich,
| | - Eldho Paul
- Public Health and Preventative Medicine, Monash University, Melbourne, VIC, Australia
| | - Carl Kirkpatrick
- Centre for Medication Use and Safety, Monash University, Melbourne, VIC, Australia
| | - Michael Dooley
- The Alfred Hospital, Melbourne, VIC, Australia,Centre for Medication Use and Safety, Monash University, Melbourne, VIC, Australia
| | - Greg Snell
- The Alfred Hospital, Melbourne, VIC, Australia
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4
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Schmucki K, Hofmann P, Fehr T, Inci I, Kohler M, Schuurmans MM. Mammalian Target of Rapamycin Inhibitors and Kidney Function After Thoracic Transplantation: A Systematic Review and Recommendations for Management of Lung Transplant Recipients. Transplantation 2023; 107:53-73. [PMID: 36508646 PMCID: PMC9746343 DOI: 10.1097/tp.0000000000004336] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/18/2022] [Accepted: 07/19/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Chronic kidney disease (CKD) after lung transplantation is common and limits the survival of transplant recipients. The calcineurin inhibitors (CNI), cyclosporine A, and tacrolimus being the cornerstone of immunosuppression are key mediators of nephrotoxicity. The mammalian target of rapamycin (mTOR) inhibitors, sirolimus and everolimus, are increasingly used in combination with reduced CNI dosage after lung transplantation. METHODS This systematic review examined the efficacy and safety of mTOR inhibitors after lung transplantation and explored their effect on kidney function. RESULTS mTOR inhibitors are often introduced to preserve kidney function. Several clinical trials have demonstrated improved kidney function and efficacy of mTOR inhibitors. The potential for kidney function improvement and preservation increases with early initiation of mTOR inhibitors and low target levels for both mTOR inhibitors and CNI. No defined stage of CKD for mTOR inhibitor initiation exists, nor does severe CKD preclude the improvement of kidney function under mTOR inhibitors. Baseline proteinuria may negatively predict the preservation and improvement of kidney function. Discontinuation rates of mTOR inhibitors due to adverse effects increase with higher target levels. CONCLUSIONS More evidence is needed to define the optimal immunosuppressive regimen incorporating mTOR inhibitors after lung transplantation. Not only the indication criteria for the introduction of mTOR inhibitors are needed, but also the best timing, target levels, and possibly discontinuation criteria must be defined more clearly. Current evidence supports the notion of nephroprotective potential under certain conditions.
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Affiliation(s)
- Katja Schmucki
- Division of Pulmonology, University Hospital Zurich, Zurich, Switzerland
- Department of Internal Medicine, Cantonal Hospital Graubünden, Chur, Switzerland
| | - Patrick Hofmann
- Division of Pulmonology, University Hospital Zurich, Zurich, Switzerland
- Department of Internal Medicine, Cantonal Hospital Graubünden, Chur, Switzerland
| | - Thomas Fehr
- Department of Internal Medicine, Cantonal Hospital Graubünden, Chur, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Ilhan Inci
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
- Department of Thoracic Surgery, Zurich University Hospital, Zurich, Switzerland
| | - Malcolm Kohler
- Division of Pulmonology, University Hospital Zurich, Zurich, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Macé M. Schuurmans
- Division of Pulmonology, University Hospital Zurich, Zurich, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
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5
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Calcineurin inhibitors' impact on cardiovascular and renal function, a descriptive study in lung transplant recipients from the North of Spain. Sci Rep 2022; 12:21207. [PMID: 36481797 PMCID: PMC9732215 DOI: 10.1038/s41598-022-25445-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 11/30/2022] [Indexed: 12/13/2022] Open
Abstract
Patients undergoing lung transplantation (LTx) need administration of immunosuppressive therapy following the procedure to prevent graft rejection. However, these drugs are not exempt from potential risks. The development of cardiovascular risk factors and impaired renal function in the post-transplantation period are conditions that may be favoured by the use of calcineurin inhibitor (CNI) drugs which could have repercussions on the quality of life and the post-transplantation evolution. To evaluate the cardiovascular and renal toxicity following the administration of CNI as maintenance immunosuppression in lung transplant recipients (LTRs) we reviewed a total number of 165 patients undergoing LTx between 01/01/2015 and 08/12/2018. They were divided into two groups according to the CNI drug administrated: cyclosporine (CsA-group) with 11 patients or tacrolimus (Tac-group), with 154 patients. We evaluated the de novo occurrence of arterial hypertension (HTN), diabetes mellitus (DM), hyperlipidemia and impaired renal function after initiation of CNI administration. In addition to that, the time until each of these events was assessed. A higher rate for developing HTN (p < 0.001) and impaired renal function (p = 0.047) was observed within the CsA-group. The new onset of hyperlipidemia was similar between both CNI groups and de novo appearance of DM was only documented in those LTRs receiving tacrolimus. In this LTRs retrospective study, it was observed that having ≥ 4 tacrolimus trough levels above the upper limit of the proposed interval for each specific post-LTx period was associated with an increased risk for developing renal impairment. No other statistically significant association was found between supratherapeutic CNIs blood levels and the evaluated toxicities.
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Velleca A, Shullo MA, Dhital K, Azeka E, Colvin M, DePasquale E, Farrero M, García-Guereta L, Jamero G, Khush K, Lavee J, Pouch S, Patel J, Michaud CJ, Shullo M, Schubert S, Angelini A, Carlos L, Mirabet S, Patel J, Pham M, Urschel S, Kim KH, Miyamoto S, Chih S, Daly K, Grossi P, Jennings D, Kim IC, Lim HS, Miller T, Potena L, Velleca A, Eisen H, Bellumkonda L, Danziger-Isakov L, Dobbels F, Harkess M, Kim D, Lyster H, Peled Y, Reinhardt Z. The International Society for Heart and Lung Transplantation (ISHLT) Guidelines for the Care of Heart Transplant Recipients. J Heart Lung Transplant 2022; 42:e1-e141. [PMID: 37080658 DOI: 10.1016/j.healun.2022.10.015] [Citation(s) in RCA: 108] [Impact Index Per Article: 54.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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7
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Velleca A, Shullo MA, Dhital K, Azeka E, Colvin M, DePasquale E, Farrero M, García-Guereta L, Jamero G, Khush K, Lavee J, Pouch S, Patel J, Michaud CJ, Shullo M, Schubert S, Angelini A, Carlos L, Mirabet S, Patel J, Pham M, Urschel S, Kim KH, Miyamoto S, Chih S, Daly K, Grossi P, Jennings D, Kim IC, Lim HS, Miller T, Potena L, Velleca A, Eisen H, Bellumkonda L, Danziger-Isakov L, Dobbels F, Harkess M, Kim D, Lyster H, Peled Y, Reinhardt Z. The International Society for Heart and Lung Transplantation (ISHLT) Guidelines for the Care of Heart Transplant Recipients. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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8
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Turkkan S, Basaran FC, Sahin MF, Beyoglu MA, Yilmaz E, Ozay HY, Bindal M, Yazicioglu A, Yekeler E. Everolimus Use in Lung Transplant Recipients. Transplant Proc 2022; 54:2317-2324. [PMID: 36192210 DOI: 10.1016/j.transproceed.2022.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 08/09/2022] [Accepted: 08/26/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Most lung transplantation centers prefer triple immunosuppressive therapy with tacrolimus, mycophenolate mofetil, and corticosteroids. However, to prevent complications and comorbidities caused by tacrolimus, replacing the drug with everolimus has been considered. METHODS This is a retrospective observational study investigating everolimus switch for different reasons. The population was divided into 3 groups: chronic lung allograft dysfunction (CLAD), kidney impairment, and malignant neoplasm groups. We investigated whether we achieved the goal of the switch and the frequency of rejection, cytomegalovirus and fungal infections, and everolimus adverse effects. RESULTS Nineteen patients received everolimus therapy, and 5 of these were for CLAD, 7 for tacrolimus nephrotoxicity, and 7 for explant/de novo malignant neoplasm. The patients were followed up for a mean (SD) of 30 (16.7) months under the therapy. The number of acute cellular rejection, cytomegalovirus infection, and aspergillosis infection cases before switch were 7, 13, and 2, respectively, and 7, 2, and 3 after that. The mean values of creatinine and estimated glomerular filtration rate of the whole population after the switch improved with no statistical significance, whereas it was significant in tacrolimus nephrotoxicity group. Three patients in the CLAD group remained stable after switching, whereas 2 progressed. Only 1 of the 7 patients with malignant neoplasms had a recurrence during 31.1 (16.5) months of median follow-up. Eleven cases of everolimus adverse effects occurred in 9 patients (47.3%), with 2 (10.5%) withdrawal events. Kidney impairment (P = .02) and age (P = .05) stood out as significant risk factors for drug adverse effects. CONCLUSIONS After lung transplant, everolimus can be a safe alternative for immunosuppression with acceptable adverse effects.
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Affiliation(s)
- Sinan Turkkan
- Department of Thoracic Surgery and Lung Transplantation, University of Health Sciences, Ankara City Hospital, Ankara, Turkey.
| | - Fatmanur Celik Basaran
- Department of Thoracic Surgery and Lung Transplantation, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Mehmet Furkan Sahin
- Department of Thoracic Surgery and Lung Transplantation, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Muhammet Ali Beyoglu
- Department of Thoracic Surgery and Lung Transplantation, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Emre Yilmaz
- Department of Thoracic Surgery and Lung Transplantation, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Hülya Yigit Ozay
- Department of Anesthesiology and Reanimation, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Mustafa Bindal
- Department of Anesthesiology and Reanimation, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Alkin Yazicioglu
- Department of Thoracic Surgery and Lung Transplantation, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Erdal Yekeler
- Department of Thoracic Surgery and Lung Transplantation, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
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9
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de Souza AR, Dos Santos TAGM, Von Jakitsch CB, de Sant'Anna ALGG, de Claudio JCM, Branco JNR, Giovanazzi RSD, Junior NAH, Pimentel WDS, da Costa SACM, Girones P, Machado RC. Mammalian Target of Rapamycin Inhibitors Vs Calcineurin Inhibitors in Chronic Graft Rejection After Lung Transplantation: A Systematic Review and Meta-Analysis. Transplant Proc 2021; 53:3056-3064. [PMID: 34785027 DOI: 10.1016/j.transproceed.2021.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 08/24/2021] [Accepted: 09/22/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND The number of lung transplantations has been rising constantly. However, use of this therapeutic resource is limited by several issues that are difficult to resolve, such as chronic graft rejection and complications secondary to immunosuppression. METHODS This systematic review compared mammalian target of rapamycin (mTOR) inhibitor immunosuppression associated with low-dose calcineurin inhibitors with isolated calcineurin inhibitor immunosuppression on the new-onset chronic rejection development and mortality 12 months after lung transplantation. Three controlled randomized clinical trials (SHITRIT, NOCTET, and 4EVERLUNG) were selected from electronic databases. RESULTS Meta-analysis of the data at 12 months postintervention showed that only 4EVERLUNG assessed chronic graft rejection, with a higher incidence in the control group; however, the difference was not statistically significant (P = .197). Significant data were related to an increase in the number of adverse events (P = .0064) and improved renal function (P < .0001) in the mTOR inhibitor-based scheme. The other outcomes indicated a trend toward greater risk of death and acute graft rejection with the use of mTORs. CONCLUSIONS The researchers suggest considering the use of mTOR inhibitors, whose greatest benefit is felt by patients with renal dysfunction, in association with the use of calcineurin inhibitors, because of the imminent risk of death among patients with renal failure.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Puri Girones
- Hospital Universitari i Politècnic La Fe, Valencia, Spain
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10
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Mejia C, Yadav A. Kidney Disease After Nonkidney Solid Organ Transplant. Adv Chronic Kidney Dis 2021; 28:577-586. [PMID: 35367026 DOI: 10.1053/j.ackd.2021.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 10/26/2021] [Accepted: 10/28/2021] [Indexed: 11/11/2022]
Abstract
Nonkidney solid organ transplants (NKSOTs) are increasing in the United States with improving long-term allograft and patient survival. CKD is prevalent in patients with NKSOT and is associated with increased morbidity and mortality especially in those who progress to end-stage kidney disease. Calcineurin inhibitor nephrotoxicity is a main contributor to CKD after NKSOT, but other factors in the pretransplant, peritransplant, and post-transplant period can predispose to progressive kidney dysfunction. The management of CKD after NKSOT generally follows society guidelines for native kidney disease. Kidney-protective and calcineurin inhibitor-sparing immunosuppression has been explored in this population and warrants a discussion with transplant teams. Kidney transplantation in NKSOT recipients remains the kidney replacement therapy of choice for suitable candidates, as it provides a survival benefit over remaining on dialysis.
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11
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Tedesco-Silva H, Saliba F, Barten MJ, De Simone P, Potena L, Gottlieb J, Gawai A, Bernhardt P, Pascual J. An overview of the efficacy and safety of everolimus in adult solid organ transplant recipients. Transplant Rev (Orlando) 2021; 36:100655. [PMID: 34696930 DOI: 10.1016/j.trre.2021.100655] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 09/17/2021] [Accepted: 09/17/2021] [Indexed: 12/15/2022]
Abstract
As the risk of graft loss due to acute rejection has declined, the goal of post-transplant management has switched to long-term preservation of organ function. Minimizing calcineurin inhibitor (CNI)-related nephrotoxicity is a key component of this objective. Everolimus is a mammalian target of rapamycin inhibitor/proliferation-signal inhibitor with potent immunosuppressive and anti-proliferative effects. It has been widely investigated in large randomized clinical studies that have shown it to have similar anti-rejection efficacy compared with standard-of-care regimens across organ transplant indications. With demonstrated potential to facilitate the reduction of CNI therapy and preserve renal function, everolimus is an alternative to the current standard-of-care CNI-based regimens used in de novo and maintenance solid organ transplantation recipients. Here, we provide an overview of the evidence from the everolimus clinical study program across kidney, liver, heart, and lung transplants, as well as other key data associated with its use in CNI reduction strategies in adult transplant recipients.
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Affiliation(s)
| | - Faouzi Saliba
- AP-HP_Hôpital Paul Brousse, Hepato-Biliary Centre, Villejuif, France; Université Paris-Saclay, INSERM Unit 1193, France
| | - Markus J Barten
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Hamburg, Germany
| | | | - Luciano Potena
- Heart Failure and Transplant Program, Cardiology Unit, IRCCS Policlinico di Sant'Orsola, Bologna, Italy
| | - Jens Gottlieb
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | | | | | - Julio Pascual
- Department of Nephrology, Hospital del Mar, Barcelona, Spain.
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12
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Induction and maintenance immunosuppression in lung transplantation. Indian J Thorac Cardiovasc Surg 2021; 38:300-317. [DOI: 10.1007/s12055-021-01225-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 06/04/2021] [Accepted: 06/13/2021] [Indexed: 10/20/2022] Open
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Patrucco F, Allara E, Boffini M, Rinaldi M, Costa C, Albera C, Solidoro P. Twelve-month effects of everolimus on renal and lung function in lung transplantation: differences in chronic lung allograft dysfunction phenotypes. Ther Adv Chronic Dis 2021; 12:2040622321993441. [PMID: 33717427 PMCID: PMC7925948 DOI: 10.1177/2040622321993441] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 01/15/2021] [Indexed: 12/25/2022] Open
Abstract
Background: Chronic lung allograft dysfunction (CLAD), a complication affecting the survival of lung transplanted patients, includes two clinical phenotypes: bronchiolitis obliterans syndrome (BOS) and restrictive allograft syndrome (RAS). Everolimus is used in CLAD because of its antiproliferative mechanism. In lung transplant patients treated with everolimus, the clinical course of renal and lung function has not yet been assessed systematically in CLAD, BOS and RAS patients for more than 6 months. Methods: We retrospectively evaluated the 12-month follow-up of renal and lung function of lung-transplanted patients switched to everolimus and evaluated the reduction in immunosuppressant dosage (ISD) and mortality. Subgroups were based on indication for everolimus treatment: CLAD and non-CLAD patients, BOS and RAS among CLAD patients. Results: We included 26 patients, 17 with CLAD (10 BOS, seven RAS). After 1 year from the everolimus switch, we observed renal function improvement (serum creatinine −17%, estimated glomerular filtration rate +24%) and stable pulmonary function [forced expiratory volume in the first second (FEV1) −0.5%, forced vital capacity (FVC) +0.05%]. RAS patients had progressive functional loss, whereas BOS patients had FEV1 improvement and FVC stability. All-cause mortality was higher in the CLAD versus non-CLAD group (41% versus 11%), without differences between BOS and RAS patients (p > 0.05). All patients had significant and persistent ISD reduction. Conclusion: Lung transplant patients treated with everolimus had improvements in renal function and reduced ISD. We observed sustained improvements in lung function for CLAD related to BOS subgroup results, whereas RAS confirmed the 1-year worsening functional trend. Data seem to suggest one more piece of the puzzle in CLAD phenotyping.
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Affiliation(s)
- Filippo Patrucco
- Division of Respiratory Diseases, Cardiovascular and Thoracic Department, University of Turin, Città della Salute e della Scienza di Torino, C.so Bramante 88/90, 10100 Torino, Italy
| | - Elias Allara
- Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Massimo Boffini
- Division of Cardiac Surgery, Cardiovascular and Thoracic Department, University of Turin, Città della Salute e della Scienza di Torino, Torino, Italy
| | - Mauro Rinaldi
- Division of Cardiac Surgery, Cardiovascular and Thoracic Department, University of Turin, Città della Salute e della Scienza di Torino, Torino, Italy
| | - Cristina Costa
- Division of Virology, Department of Public Health and Pediatrics, University of Turin, Città della Salute e della Scienza di Torino, Torino, Italy
| | - Carlo Albera
- Division of Respiratory Diseases, Medical Sciences Department University of Turin and Cardiovascular and Thoracic Department, AOU Città della Salute e della Scienza di Torino, Torino, Italy
| | - Paolo Solidoro
- Division of Respiratory Diseases, Medical Sciences Department University of Turin and Cardiovascular and Thoracic Department, AOU Città della Salute e della Scienza di Torino, Torino, Italy
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14
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Benazzo A, Cho A, Nechay A, Schwarz S, Frommlet F, Wekerle T, Hoetzenecker K, Jaksch P. Combined low-dose everolimus and low-dose tacrolimus after Alemtuzumab induction therapy: a randomized prospective trial in lung transplantation. Trials 2021; 22:6. [PMID: 33397442 PMCID: PMC7783986 DOI: 10.1186/s13063-020-04843-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 10/23/2020] [Indexed: 11/28/2022] Open
Abstract
Background Long-term outcomes of lung transplantation are severely affected by comorbidities and development of chronic rejection. Among the comorbidities, kidney insufficiency is one of the most frequent and it is mainly caused by the cumulative effect of calcineurin inhibitors (CNIs). Currently, the most used immunosuppression protocols worldwide include induction therapy and a triple-drug maintenance immunosuppression, with one calcineurin inhibitor, one anti-proliferative drug, and steroids. Our center has pioneered the use of alemtuzumab as induction therapy, showing promising results in terms of short- and long-term outcomes. The use of alemtuzumab followed by a low-dose double drug maintenance immunosuppression, in fact, led to better kidney function along with excellent results in terms of acute rejection, chronic lung allograft dysfunction, and survival (Benazzo et al., PLoS One 14(1):e0210443, 2019). The hypothesis driving the proposed clinical trial is that de novo introduction of low-dose everolimus early after transplantation could further improve kidney function via a further reduction of tacrolimus. Based on evidences from kidney transplantation, moreover, alemtuzumab induction therapy followed by a low-dose everolimus and low-dose tacrolimus may have a permissive action on regulatory immune cells thus stimulating allograft acceptance. Methods A randomized prospective clinical trial has been set up to answer the research hypothesis. One hundred ten patients will be randomized in two groups. Treatment group will receive the new maintenance immunosuppression protocol based on low-dose tacrolimus and low-dose everolimus and the control group will receive our standard immunosuppression protocol. Both groups will receive alemtuzumab induction therapy. The primary endpoint of the study is to analyze the effect of the new low-dose immunosuppression protocol on kidney function in terms of eGFR change. The study will have a duration of 24 months from the time of randomization. Immunomodulatory status of the patients will be assessed with flow cytometry and gene expression analysis. Discussion For the first time in the field of lung transplantation, this trial proposes the combined use of significantly reduced tacrolimus and everolimus after alemtuzumab induction. The new protocol may have a twofold advantage: (1) further reduction of nephrotoxic tacrolimus and (2) permissive influence on regulatory cells development with further reduction of rejection episodes. Trial registration EUDRACT Nr 2018-001680-24. Registered on 15 May 2018
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Affiliation(s)
| | - Ara Cho
- Medizinische Universitat Wien, Vienna, Austria
| | - Anna Nechay
- Medizinische Universitat Wien, Vienna, Austria
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15
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Nguyen LS, Suc G, Kheav VD, Coutance G, Carmagnat M, Rouvier P, Zahr N, Salem JE, Leprince P, Ouldammar S, Varnous S. Quadritherapy vs standard tritherapy immunosuppressant regimen after heart transplantation: A propensity score-matched cohort analysis. Am J Transplant 2020; 20:2791-2801. [PMID: 32180354 DOI: 10.1111/ajt.15849] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 02/20/2020] [Accepted: 03/09/2020] [Indexed: 01/25/2023]
Abstract
After heart transplant, adding everolimus (EVL) to standard immunosuppressive regimen mostly relies on converting calcineurin inhibitors (CNIs) into EVL. The aim of this study was to describe the effects of combining low-dose EVL and CNIs in maintenance immunosuppression regimen (quadritherapy) and compare it with standard tritherapy associating standard-dose CNIs, mycophenolate mofetil, and corticosteroids. In the 3-year registry cohort of heart transplanted patients, those who received quadritherapy were compared with those who received tritherapy. EVL was added after 3 months posttransplant. Three analyses were performed to control for confounders: propensity score matching, multivariable survival, and inverse probability score weighting analyses. Among 213 patients who were included (75 with quadritherapy), propensity score matching selected 64 unique pairs of patients with similar characteristics. In the matched cohort (n = 128), quadritherapy was associated with fewer deaths (3 [4.7%] vs 17 [21.9%], P = .007) and biopsy-proven acute rejections (15 [23.4%] vs 31 [48.4%], P = .002). These results were confirmed in the overall cohort (n = 213), after multivariable and inverse probability score weighting analyses. Renal function and donor-specific HLA-antibodies remained similar in both groups. Low-dose combination quadritherapy was associated with fewer deaths and rejections, compared with standard immunosuppression tritherapy.
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Affiliation(s)
- Lee S Nguyen
- Department of Cardiothoracic Surgery, Pitié-Salpétrière Hospital, AP.HP.6 Sorbonne Université, Paris, France.,Department of Research & Innovation (RICAP), CMC Ambroise Paré, Neuilly-sur-Seine, France
| | - Gaspard Suc
- Department of Cardiology, Pitié-Salpétrière Hospital, AP.HP.6 Sorbonne Université, Paris, France
| | - Vissal David Kheav
- Laboratory of Immunology and Histocompatibility, AP-HP St-Louis Hospital, Paris, France
| | - Guillaume Coutance
- Department of Cardiothoracic Surgery, Pitié-Salpétrière Hospital, AP.HP.6 Sorbonne Université, Paris, France
| | - Maryvonnick Carmagnat
- Laboratory of Immunology and Histocompatibility, AP-HP St-Louis Hospital, Paris, France
| | - Philippe Rouvier
- Department of Pathology, Pitié-Salpétrière Hospital, AP.HP.6 Sorbonne Université, Paris, France
| | - Noel Zahr
- Department of Research & Innovation (RICAP), CMC Ambroise Paré, Neuilly-sur-Seine, France
| | - Joe-Elie Salem
- Department of Research & Innovation (RICAP), CMC Ambroise Paré, Neuilly-sur-Seine, France.,Department of Medicine and Pharmacology, Cardio-Oncology Program, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Pascal Leprince
- Department of Cardiothoracic Surgery, Pitié-Salpétrière Hospital, AP.HP.6 Sorbonne Université, Paris, France
| | - Salima Ouldammar
- Department of Cardiothoracic Surgery, Pitié-Salpétrière Hospital, AP.HP.6 Sorbonne Université, Paris, France
| | - Shaida Varnous
- Department of Cardiothoracic Surgery, Pitié-Salpétrière Hospital, AP.HP.6 Sorbonne Université, Paris, France
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16
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van der Mark SC, Hoek RAS, Hellemons ME. Developments in lung transplantation over the past decade. Eur Respir Rev 2020; 29:29/157/190132. [PMID: 32699023 PMCID: PMC9489139 DOI: 10.1183/16000617.0132-2019] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 01/30/2020] [Indexed: 12/12/2022] Open
Abstract
With an improved median survival of 6.2 years, lung transplantation has become an increasingly acceptable treatment option for end-stage lung disease. Besides survival benefit, improvement of quality of life is achieved in the vast majority of patients. Many developments have taken place in the field of lung transplantation over the past decade. Broadened indication criteria and bridging techniques for patients awaiting lung transplantation have led to increased waiting lists and changes in allocation schemes worldwide. Moreover, the use of previously unacceptable donor lungs for lung transplantation has increased, with donations from donors after cardiac death, donors with increasing age and donors with positive smoking status extending the donor pool substantially. Use of ex vivo lung perfusion further increased the number of lungs suitable for lung transplantation. Nonetheless, the use of these previously unacceptable lungs did not have detrimental effects on survival and long-term graft outcomes, and has decreased waiting list mortality. To further improve long-term outcomes, strategies have been proposed to modify chronic lung allograft dysfunction progression and minimise toxic immunosuppressive effects. This review summarises the developments in clinical lung transplantation over the past decade. Many developments have taken place in lung transplantation over the last decade: indications have broadened, donor criteria expanded, allocations systems changed, and novel therapeutic interventions implemented, leading to improved long-term survivalhttp://bit.ly/2vnpwc1
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Affiliation(s)
- Sophie C van der Mark
- Dept of Pulmonary Medicine, Division of Interstitial Lung Disease, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands.,Authors contributed equally
| | - Rogier A S Hoek
- Dept of Pulmonary Medicine, Division of Lung Transplantation, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands.,Authors contributed equally
| | - Merel E Hellemons
- Dept of Pulmonary Medicine, Division of Interstitial Lung Disease, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands .,Dept of Pulmonary Medicine, Division of Lung Transplantation, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands
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17
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Felodipine and renal function in lung transplantation: A randomized placebo-controlled trial. J Heart Lung Transplant 2020; 39:541-550. [DOI: 10.1016/j.healun.2020.01.1342] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Revised: 01/14/2020] [Accepted: 01/24/2020] [Indexed: 11/17/2022] Open
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18
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Abstract
Lung transplantation is a viable option for those with end-stage lung disease which is evidenced by the continued increase in the number of lung transplantations worldwide. However, patients and clinicians are constantly faced with acute and chronic rejection, infectious complications, drug toxicities, and malignancies throughout the lifetime of the lung transplant recipient. Conventional maintenance immunosuppression therapy consisting of a calcineurin inhibitor (CNI), anti-metabolite, and corticosteroids have become the standard regimen but newer agents and modalities continue to be developed. Here we will review induction agents, maintenance immunosuppressives, adjunctive therapies and other strategies to improve long-term outcomes.
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Affiliation(s)
- Paul A Chung
- Division of Pulmonary and Critical Care, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA
| | - Daniel F Dilling
- Division of Pulmonary and Critical Care, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA
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19
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Abstract
Lung transplantation is an accepted therapeutic option for end-stage lung diseases. Its history starts in the 1940s, initially hampered by early deaths due to perioperative problems and acute rejection. Improvement of surgical techniques and the introduction of immunosuppressive drugs resulted in longer survival. Chronic lung allograft dysfunction (CLAD), a new complication appeared and remains the most serious complication today. CLAD, the main reason why survival after lung transplantation is impaired compared to other solid-organ transplantations is characterized by a gradually increasing shortness of breath, reflected in a deterioration of pulmonary function status, respiratory insufficiency and possibly death.
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20
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Nikolova AP, Kobashigawa JA. Cardiac Allograft Vasculopathy: The Enduring Enemy of Cardiac Transplantation. Transplantation 2019; 103:1338-1348. [PMID: 31241553 DOI: 10.1097/tp.0000000000002704] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Cardiac allograft vasculopathy remains a major limiting factor in the long-term survival of the heart transplant recipient. Our understanding of its pathogenesis is continuously evolving as advances in imaging modalities have allowed a direct window into the natural history of the disease. Innovation in diagnostic modalities has spurred the proliferation of prognostic tools and biomarkers. And in parallel, pharmacological advances have emerged that have helped ameliorate the disease's progressive course.
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Affiliation(s)
- Andriana P Nikolova
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Jon A Kobashigawa
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
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21
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Gottlieb J, Neurohr C, Müller‐Quernheim J, Wirtz H, Sill B, Wilkens H, Bessa V, Knosalla C, Porstner M, Capusan C, Strüber M. A randomized trial of everolimus-based quadruple therapy vs standard triple therapy early after lung transplantation. Am J Transplant 2019; 19:1759-1769. [PMID: 30615259 PMCID: PMC6590654 DOI: 10.1111/ajt.15251] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 12/04/2018] [Accepted: 12/27/2018] [Indexed: 01/25/2023]
Abstract
Calcineurin inhibitor (CNI) therapy after lung transplantation increases risk of kidney failure. Early everolimus-based quadruple low CNI immunosuppression may improve renal function without compromising efficacy or safety. A prospective, randomized, open-label, 12-month multicenter trial was conducted at 8 German sites. Patients 3-18 months after lung transplantation were randomized (1:1), stratified by baseline estimated glomerular filtration rate (eGFR). In the quadruple low CNI regimen, patients received everolimus (target trough level 3-5 ng/mL) with reduced CNI (tacrolimus 3-5 ng/mL or cyclosporine 25-75 ng/mL) and a cell cycle inhibitor plus prednisone. In the standard triple CNI regimen, patients received tacrolimus (target trough level >5 ng/mL) or cyclosporine (>100 ng/mL) and a cell cycle inhibitor plus prednisone. Of the 180 patients screened, 130 were randomized: 67 in the quadruple low CNI group and 63 in the standard triple CNI group. The primary endpoint (eGFR after 12 months) demonstrated superiority of the quadruple low CNI regimen: 64.5 mL/min vs 54.6 mL/min for the standard triple group (least squares mean, analysis of covariance; P < .001). Key efficacy parameters (biopsy-proven acute rejection, chronic lung allograft dysfunction, and death) and safety endpoints were similar between both groups. Quadruple low CNI immunosuppression early after lung transplantation was demonstrated to be efficacious and safe. Clinical trials registry: ClinicalTrials.gov NCT01404325.
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Affiliation(s)
- Jens Gottlieb
- Department of Respiratory MedicineHannover Medical SchoolHannoverGermany,Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH)Member of the German Center for Lung Research (DZL)HannoverGermany
| | - Claus Neurohr
- Grosshadern Medical Clinic and Policlinic VLMU Munich University HospitalMunichGermany
| | | | - Hubert Wirtz
- Internal Medicine/Department of PneumologyLeipzig University HospitalLeipzigGermany
| | - Bjoern Sill
- Department of Cardiovascular SurgeryHamburg‐Eppendorf University HospitalHamburgGermany
| | - Heinrike Wilkens
- Internal Medicine VUniversity Hospital of SaarlandHomburg SaarGermany
| | - Vasiliki Bessa
- Department of PneumologyRuhrlandklinikWest German Center for Lung TransplantationUniversity Hospital EssenUniversity Duisburg‐EssenEssenGermany
| | - Christoph Knosalla
- Department of Cardiothoracic and Vascular SurgeryGerman Heart Institute BerlinDZHK (German Center for Cardiovascular Research)BerlinGermany
| | | | | | - Martin Strüber
- Department of Cardiothoracic SurgeryNewark Beth Israel Medical CenterChildren's Hospital of New JerseyNewarkNew Jersey
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22
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Norum HM, Michelsen AE, Lekva T, Arora S, Otterdal K, Olsen MB, Kong XY, Gude E, Andreassen AK, Solbu D, Karason K, Dellgren G, Gullestad L, Aukrust P, Ueland T. Circulating delta-like Notch ligand 1 is correlated with cardiac allograft vasculopathy and suppressed in heart transplant recipients on everolimus-based immunosuppression. Am J Transplant 2019; 19:1050-1060. [PMID: 30312541 DOI: 10.1111/ajt.15141] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 10/02/2018] [Accepted: 10/07/2018] [Indexed: 02/06/2023]
Abstract
Cardiac allograft vasculopathy (CAV) causes heart failure after heart transplantation (HTx), but its pathogenesis is incompletely understood. Notch signaling, possibly modulated by everolimus (EVR), is essential for processes involved in CAV. We hypothesized that circulating Notch ligands would be dysregulated after HTx. We studied circulating delta-like Notch ligand 1 (DLL1) and periostin (POSTN) and CAV in de novo HTx recipients (n = 70) randomized to standard or EVR-based, calcineurin inhibitor-free immunosuppression and in maintenance HTx recipients (n = 41). Compared to healthy controls, plasma DLL1 and POSTN were elevated in de novo (P < .01; P < .001) and maintenance HTx recipients (P < .001; P < .01). Use of EVR was associated with a treatment effect for DLL1. For de novo HTx recipients, a change in DLL1 correlated with a change in CAV at 1 (P = .021) and 3 years (P = .005). In vitro, activation of T cells increased DLL1 secretion, attenuated by EVR. In vitro data suggest that also endothelial cells and vascular smooth muscle cells (VSMCs) could contribute to circulating DLL1. Immunostaining of myocardial specimens showed colocalization of DLL1 with T cells, endothelial cells, and VSMCs. Our findings suggest a role of DLL1 in CAV progression, and that the beneficial effect of EVR on CAV could reflect a suppressive effect on DLL1. Trial registration numbers-SCHEDULE trial: ClinicalTrials.gov NCT01266148; NOCTET trial: ClinicalTrials.gov NCT00377962.
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Affiliation(s)
- Hilde M Norum
- Research Institute of Internal Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway.,Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway.,Division of Emergencies and Critical Care, Department for Research and Development, Oslo University Hospital, Oslo, Norway
| | - Annika E Michelsen
- Research Institute of Internal Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway.,Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway
| | - Tove Lekva
- Research Institute of Internal Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Satish Arora
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway.,Center for Heart Failure Research, Medical Faculty, University of Oslo, Oslo, Norway
| | - Kari Otterdal
- Research Institute of Internal Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Maria Belland Olsen
- Research Institute of Internal Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Xiang Yi Kong
- Research Institute of Internal Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway.,Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway
| | - Einar Gude
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Arne K Andreassen
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | | | - Kristjan Karason
- Sahlgrenska University Hospital, Transplant Institute, Gothenburg, Sweden.,Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Göran Dellgren
- Sahlgrenska University Hospital, Transplant Institute, Gothenburg, Sweden.,Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden.,Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lars Gullestad
- Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway.,Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Pål Aukrust
- Research Institute of Internal Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway.,Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway.,Section of Clinical Immunology and Infectious Diseases, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Thor Ueland
- Research Institute of Internal Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway.,Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway.,K.G. Jebsen TREC, University of Tromsø, Tromsø, Norway
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23
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Barten MJ, Hirt SW, Garbade J, Bara C, Doesch AO, Knosalla C, Grinninger C, Stypmann J, Sieder C, Lehmkuhl HB, Porstner M, Schulz U. Comparing everolimus-based immunosuppression with reduction or withdrawal of calcineurin inhibitor reduction from six months after heart transplantation: the randomized MANDELA study. Am J Transplant 2019; 19:S1600-6135(22)09293-0. [PMID: 30884079 DOI: 10.1111/ajt.15361] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
In the 12-month, open-label MANDELA study, patients were randomized at month 6 after heart transplantation to (i) convert to calcineurin inhibitor (CNI)-free immunosuppression with everolimus (EVR), mycophenolic acid and steroids (CNI-free, n=71), or to (ii) continue reduced-exposure CNI, with EVR and steroids (EVR/redCNI, n=74). Tacrolimus was administered in 48.8% of EVR/redCNI patients and 52.6% of CNI-free patients at radomization. Both strategies improved and stabilized renal function based on the primary endpoint (estimated GFR at month 18 post-transplant post-randomization) with superiority of the CNI-free group versus EVR/redCNI : mean 64.1mL/min/1.73m2 versus 52.9mL/min/1.73m2 ; difference +11.3mL/min/1.73m2 (p<0.001). By month 18, estimated GFR had increased by ≥10mL/min/1.732 in 31.8% and 55.2% of EVR/redCNI and CNI-free patients, respectively, and by ≥25 mL/min/1.73m2 in 4.5% and 20.9%. Rates of biopsy-proven acute rejection (BPAR) were 6.8% and 21.1%; all cases were without hemodynamic compromise. BPAR was less frequent with EVR/redCNI versus the CNI-free regimen (p=0.015); 6/15 episodes in CNI-free patients occurred with EVR concentration <5ng/mL. Rates of adverse events and associated discontinuations were comparable EVR/redCNI from month 6 achieved stable renal function with infrequent BPAR. One-year renal function can be improved by early conversion to EVR-based CNI-free therapy but requires close EVR monitoring. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Markus J Barten
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Martinistrasse 52, 20246, Hamburg, Germany
| | - Stephan W Hirt
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Jens Garbade
- University Department of Cardiac Surgery, Leipzig Heart Center, Strümpellstraße 39 Leipzig, Germany
| | - Christoph Bara
- Division of Cardiovascular, Thoracic and Transplantation Surgery, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Andreas O Doesch
- Department of Cardiology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Christoph Knosalla
- Department of Cardiothoracic and Vascular Surgery, German Heart Institute Berlin, DZHK (German Centre for Cardiovascular Research), partner site Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Carola Grinninger
- Department of Cardiac Surgery, Munich Transplantation Center, Klinikum Großhadern LMU, Marchioninistraße 15, 81377, Munich, Germany
| | - Jörg Stypmann
- Department of Cardiovascular Medicine, Division of Cardiology, University Hospital Münster, Albert-Schweitzer-Straße 33, 48149, Münster, Germany
| | | | - Han B Lehmkuhl
- University Department of Cardiac Surgery, Leipzig Heart Center, Strümpellstraße 39 Leipzig, Germany
| | | | - Uwe Schulz
- Department of Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, Ruhr University Bochum, Georgstrasse 11, 32545, Bad Oeynhausen, Germany
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24
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Jo KW, Hong SB, Kim DK, Jung SH, Kim HR, Choi SH, Lee GD, Lee SO, Do KH, Chae EJ, Choi IC, Choi DK, Kim IO, Park SI, Shim TS. Long-Term Outcomes of Adult Lung Transplantation Recipients: A Single-Center Experience in South Korea. Tuberc Respir Dis (Seoul) 2019; 82:348-356. [PMID: 31583875 PMCID: PMC6778743 DOI: 10.4046/trd.2019.0016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 05/19/2019] [Accepted: 05/21/2019] [Indexed: 12/28/2022] Open
Abstract
Background Recently, the number of lung transplants in South Korea has increased. However, the long-term outcome data is limited. In this study, we aimed to investigate the long-term outcomes of adult lung transplantation recipients. Methods Among the patients that underwent lung transplantation at a tertiary referral center in South Korea between 2008 and 2017, adults patient who underwent deceased-donor lung transplantation with available follow-up data were enrolled. Their medical records were retrospectively reviewed. Results Through eligibility screening, we identified 60 adult patients that underwent lung (n=51) or heart-lung transplantation (n=9) during the observation period. Idiopathic pulmonary fibrosis (46.7%, 28/60) was the most frequent cause of lung transplantation. For all the 60 patients, the median follow-up duration for post-transplantation was 2.6 years (range, 0.01–7.6). During the post-transplantation follow-up period, 19 patients (31.7%) died at a median duration of 194 days. The survival rates were 75.5%, 67.6%, and 61.8% at 1 year, 3 years, and 5 years, respectively. Out of the 60 patients, 8 (13.3%) were diagnosed with chronic lung allograft dysfunction (CLAD), after a mean duration of 3.3±2.8 years post-transplantation. The CLAD development rate was 0%, 17.7%, and 25.8% at 1 year, 3 years, and 5 years, respectively. The most common newly developed post-transplantation comorbidity was the chronic kidney disease (CKD; 54.0%), followed by diabetes mellitus (25.9%). Conclusion Among the adult lung transplantation recipients at a South Korea tertiary referral center, the long-term survival rates were favorable. The proportion of patients who developed CLAD was not substantial. CKD was the most common post-transplantation comorbidity.
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Affiliation(s)
- Kyung Wook Jo
- Division of Pulmonology and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Bum Hong
- Division of Pulmonology and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Kwan Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung Ho Jung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyeong Ryul Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Se Hoon Choi
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Geun Dong Lee
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Oh Lee
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyung Hyun Do
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun Jin Chae
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - In Cheol Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dae Kee Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - In Ok Kim
- Organ Transplantation Center, Asan Medical Center, Seoul, Korea
| | - Seung Il Park
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| | - Tae Sun Shim
- Division of Pulmonology and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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25
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Abstract
Renal complications are common following heart and/or lung transplantation and lead to increased morbidity and mortality. Renal dysfunction is also associated with increased mortality for patients on the transplant wait list. Dialysis dependence is a relative contraindication for heart or lung transplantation at most centers, and such patients are often listed for a simultaneous kidney transplant. Several factors contribute to the impaired renal function in patients undergoing heart and/or lung transplantation, including the interplay between cardiopulmonary and renal hemodynamics, complex perioperative issues, and exposure to nephrotoxic medications, mainly calcineurin inhibitors.
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26
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Kelsh SE, Girgis R, Dickinson M, McDermott JK. Everolimus Use for Intolerance or Failure of Baseline Immunosuppression in Adult Heart and Lung Transplantation. Ann Transplant 2018; 23:744-750. [PMID: 30348935 PMCID: PMC6248067 DOI: 10.12659/aot.910952] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background Everolimus can be utilized after heart or lung transplantation to reduce calcineurin inhibitor associated nephrotoxicity, due to cell cycle inhibitor adverse effects, and as adjunct therapy for rejection, cardiac allograft vasculopathy, and bronchiolitis obliterans syndrome. Material/Methods A single-center, retrospective cohort study was conducted including 51 adult heart transplant patients (n=32) and lung transplant patients (n=19) started on everolimus due to immunosuppressive therapy intolerance or failure, between 2010 and 2017. Everolimus indication, response, efficacy, and tolerability were assessed. Results Everolimus was most commonly initiated due to leukopenia/neutropenia (n=17, 33%) or renal dysfunction (n=13, 25%). Leukopenia/neutropenia resolved in 76% of patients (13 out of 17 patients). Renal function (GFR) increased 7.4 mL/min from baseline to 3 months after everolimus initiation (P=0.011). The most common adverse effects were edema (n=23, 45%) and hyperlipidemia (n=25, 49%). A high discontinuation rate was observed (n=21, 41%), mostly from edema. Conclusions Everolimus might be beneficial in heart and lung transplant patients with leukopenia or neutropenia and lead to modest, short-term renal function improvement. Patient selection is crucial because adverse effects frequently lead to everolimus discontinuation.
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Affiliation(s)
- Shelby E Kelsh
- Richard DeVos Heart and Lung Transplant Program, Spectrum Health, Grand Rapids, MI, USA
| | - Reda Girgis
- Richard DeVos Heart and Lung Transplant Program, Spectrum Health, Grand Rapids, MI, USA.,Department of Medicine, Michigan State University, College of Human Medicine, Grand Rapids, MI, USA
| | - Michael Dickinson
- Richard DeVos Heart and Lung Transplant Program, Spectrum Health, Grand Rapids, MI, USA.,Department of Medicine, Michigan State University, College of Human Medicine, Grand Rapids, MI, USA
| | - Jennifer K McDermott
- Richard DeVos Heart and Lung Transplant Program, Spectrum Health, Grand Rapids, MI, USA.,Department of Medicine, Michigan State University, College of Human Medicine, Grand Rapids, MI, USA
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Krezdorn N, Tasigiorgos S, Wo L, Lopdrup R, Turk M, Kiwanuka H, Ahmed S, Petruzzo P, Bueno E, Pomahac B, Riella LV. Kidney Dysfunction After Vascularized Composite Allotransplantation. Transplant Direct 2018; 4:e362. [PMID: 30046652 PMCID: PMC6056276 DOI: 10.1097/txd.0000000000000795] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 03/26/2018] [Accepted: 04/02/2018] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Kidney dysfunction is a major complication after nonrenal solid organ transplants. Transplantation of vascularized composite allografts (VCA) has yielded successful midterm outcomes despite high rates of acute rejection and greater requirements of immunosuppression. Whether this translates in higher risks of kidney complications is unknown. METHODS Ninety-nine recipients of facial or extremity transplants from the Brigham and Women's Hospital (BWH) and the International Registry on Hand and Composite Tissue Transplantation (IR) were reviewed. We assessed immunosuppression, markers of renal function over time, as well as pretransplant and posttransplant renal risk factors. RESULTS Data were obtained from 10 patients from BWH (age at transplant, 42.5 ± 13.8 years) and 89 patients (37.8 ± 11.5 years) from IR. A significant rise in creatinine levels (BWH, P = 0.0195; IR, P < 0.0001) and drop in estimated glomerular filtration rate (GFR) within the first year posttransplant was observed. The BWH and IR patients lost a mean of 22 mL/min GFR and 60 mL/min estimated GFR in the first year, respectively. This decrease occurred mostly in the first 6 months posttransplant (BWH). Pretransplant creatinine levels were not restored in either cohort. A mixed linear model identified multiple variables correlating with renal dysfunction, particularly tacrolimus trough levels. CONCLUSIONS Kidney dysfunction represents a major complication posttransplantation in VCA recipients early on. Strategies to mitigate this complication, such as reducing calcineurin inhibitor trough levels or using alternative immunosuppressive agents, may improve long-term patient outcomes. Standardizing laboratory and data collection of kidney parameters and risk factors in VCA patients will be critical for better understanding of this complication.
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Affiliation(s)
- Nicco Krezdorn
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Hannover Medical School, Hannover, Germany
| | - Sotirios Tasigiorgos
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Luccie Wo
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Rachel Lopdrup
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Marvee Turk
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Harriet Kiwanuka
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Salman Ahmed
- Transplantation Research Center, Renal Division, Brigham & Women's Hospital, Harvard Medical School, Boston, MA
| | - Palmina Petruzzo
- Department of Transplantation, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
- Department of Surgery, University of Cagliari, Cagliari, Italy
| | - Ericka Bueno
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Bohdan Pomahac
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Leonardo V. Riella
- Transplantation Research Center, Renal Division, Brigham & Women's Hospital, Harvard Medical School, Boston, MA
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Abstract
Immunosuppressive therapy is arguably the most important component of medical care after lung transplantation. The goal of immunosuppression is to prevent acute and chronic rejection while maximizing patient survival and long-term allograft function. However, the benefits of immunosuppressive therapy must be balanced against the side effects and major toxicities of these medications. Immunosuppressive agents can be classified as induction agents, maintenance therapies, treatments for acute rejection and chronic rejection and antibody directed therapies. Although induction therapy remains an area of controversy in lung transplantation, it is still used in the majority of transplant centers. On the other hand, maintenance immunosuppression is less contentious; but, unfortunately, since the creation of three-drug combination therapy, including a glucocorticoid, calcineurin inhibitor and anti-metabolite, there have been relatively modest improvements in chronic maintenance immunosuppressive regimens. The presence of HLA antibodies in transplant candidates and development of de novo antibodies after transplantation remain a major therapeutic challenge before and after lung transplantation. In this chapter we review the medications used for induction and maintenance immunosuppression along with their efficacy and side effect profiles. We also review strategies and evidence for HLA desensitization prior to lung transplantation and management of de novo antibody formation after transplant. Finally, we review immune tolerance and the future of lung transplantation to limit the toxicities of conventional immunosuppressive therapy.
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Affiliation(s)
- Luke J Benvenuto
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, New York, USA
| | - Michaela R Anderson
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, New York, USA
| | - Selim M Arcasoy
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, New York, USA
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29
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Abstract
Immunosuppression management after lung transplantation continues to evolve, with an increasing number of agents available for use in various combinations allowing for more choice and individualization of immunosuppressive therapy. Therapeutic developments have led to improved outcomes including lower acute rejection rates and improved survival. However, a one size fits all approach for any immunosuppressive strategy may not be best suited to the individual patient and ultimately patient specific factors must be considered when designing the immunosuppressive regimen. Recipient factors including age, race, co-morbidities, immunologic risk, genetic polymorphisms, concomitant and previous pharmacotherapy, and overall immunosuppression burden should be considered. There are several significant drug-drug interactions with select immunosuppressive agents utilized in lung transplant pharmacotherapy that must be considered when choosing and devising a dosing strategy for an individual immunosuppressive agent. Herein, considerations for immunosuppression management in the individual patient will be reviewed.
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Affiliation(s)
- Jennifer K McDermott
- Richard DeVos Heart and Lung Transplant Program, Spectrum Health, Grand Rapids, Michigan.,Michigan State University College of Human Medicine, Grand Rapids, Michigan
| | - Reda E Girgis
- Michigan State University College of Human Medicine, Grand Rapids, Michigan
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31
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Reichart D, Reichenspurner H, Barten MJ. Renal protection strategies after heart transplantation. Clin Transplant 2018; 32. [DOI: 10.1111/ctr.13157] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2017] [Indexed: 01/14/2023]
Affiliation(s)
- Daniel Reichart
- Department of Cardiovascular Surgery; , University Heart Center Hamburg; Hamburg Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery; , University Heart Center Hamburg; Hamburg Germany
| | - Markus Johannes Barten
- Department of Cardiovascular Surgery; , University Heart Center Hamburg; Hamburg Germany
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32
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Clinical trials in heart transplantation: The evolution of evidence in immunosuppression. J Heart Lung Transplant 2017; 36:1286-1290. [DOI: 10.1016/j.healun.2017.10.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 10/16/2017] [Indexed: 11/24/2022] Open
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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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34
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Broch K, Gude E, Andreassen AK, Gullestad L. Newer Immunosuppression and Strategies on the Horizon in Heart Transplantation. CURRENT TRANSPLANTATION REPORTS 2017. [DOI: 10.1007/s40472-017-0159-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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35
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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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36
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Kumar J, Reccia I, Kusano T, Julie BM, Sharma A, Halawa A. Systemic meta-analysis assessing the short term applicability of early conversion to mammalian target of rapamycin inhibitors in kidney transplant. World J Transplant 2017; 7:144-151. [PMID: 28507917 PMCID: PMC5409914 DOI: 10.5500/wjt.v7.i2.144] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 01/24/2017] [Accepted: 03/02/2017] [Indexed: 02/05/2023] Open
Abstract
AIM To consolidate the present evidence of effectiveness in renal functioning and graft survival following early introduction of mammalian target of rapamycin (mTOR) inhibitors with or without calcineurin inhibitors (CNIs) in renal transplant recipients.
METHODS We analysed the current literature following PROSPERO approval describing the role of immunosuppressive agent, mTOR inhibitors as an alternative to CNI within six months of renal transplant by searching the PubMed, EMBASE, Cochrane, Crossref, and Scopus using MeSH terms.
RESULTS Six articles of early withdrawal of CNI and introduction of mTOR-inhibitors within six months of renal transplantation were sought. Glomerular filtration rate (GFR) and serum creatinine were significantly better in mTOR inhibitor group with equivalent survival at 12 mo, even though Biopsy Proven Acute rejection was significantly higher in mTOR-inhibitor group.
CONCLUSION The evidence reviewed in this meta-analysis suggests that early introduction mTOR-inhibitors substantial CNI minimization. The mTOR inhibitors such as everolimus and sirolimus, due to their complementary mechanism of action and favourable nephrotoxicity profile; better glomerular filtration, lower serum creatinine with equivalent survival. Having said that, due to the higher rejection rate, may influence the use of these regimens to patients with moderate to high immunological risk patients.
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The CECARI Study: Everolimus (Certican®) Initiation and Calcineurin Inhibitor Withdrawal in Maintenance Heart Transplant Recipients with Renal Insufficiency: A Multicenter, Randomized Trial. J Transplant 2017; 2017:6347138. [PMID: 28316834 PMCID: PMC5337890 DOI: 10.1155/2017/6347138] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Accepted: 01/31/2017] [Indexed: 12/28/2022] Open
Abstract
In this 3-year, open-label, multicenter study, 57 maintenance heart transplant recipients (>1 year after transplant) with renal insufficiency (eGFR 30–60 mL/min/1.73 m2) were randomized to start everolimus with CNI withdrawal (N = 29) or continue their current CNI-based immunosuppression (N = 28). The primary endpoint, change in measured glomerular filtration rate (mGFR) from baseline to year 3, did not differ significantly between both groups (+7.0 mL/min in the everolimus group versus +1.9 mL/min in the CNI group, p = 0.18). In the on-treatment analysis, the difference did reach statistical significance (+9.4 mL/min in the everolimus group versus +1.9 mL/min in the CNI group, p = 0.047). The composite safety endpoint of all-cause mortality, major adverse cardiovascular events, or treated acute rejection was not different between groups. Nonfatal adverse events occurred in 96.6% of patients in the everolimus group and 57.1% in the CNI group (p < 0.001). Ten patients (34.5%) in the everolimus group discontinued the study drug during follow-up due to adverse events. The poor adherence to the everolimus therapy might have masked a potential benefit of CNI withdrawal on renal function.
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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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Abstract
In 2014, the Immunosuppressive Drugs Scientific Committee of the International Association of Therapeutic Drug Monitoring and Clinical Toxicology called a meeting of international experts to provide recommendations to guide therapeutic drug monitoring (TDM) of everolimus (EVR) and its optimal use in clinical practice. EVR is a potent inhibitor of the mammalian target of rapamycin, approved for the prevention of organ transplant rejection and for the treatment of various types of cancer and tuberous sclerosis complex. EVR fulfills the prerequisites for TDM, having a narrow therapeutic range, high interindividual pharmacokinetic variability, and established drug exposure-response relationships. EVR trough concentrations (C0) demonstrate a good relationship with overall exposure, providing a simple and reliable index for TDM. Whole-blood samples should be used for measurement of EVR C0, and sampling times should be standardized to occur within 1 hour before the next dose, which should be taken at the same time everyday and preferably without food. In transplantation settings, EVR should be generally targeted to a C0 of 3-8 ng/mL when used in combination with other immunosuppressive drugs (calcineurin inhibitors and glucocorticoids); in calcineurin inhibitor-free regimens, the EVR target C0 range should be 6-10 ng/mL. Further studies are required to determine the clinical utility of TDM in nontransplantation settings. The choice of analytical method and differences between methods should be carefully considered when determining EVR concentrations, and when comparing and interpreting clinical trial outcomes. At present, a fully validated liquid chromatography tandem mass spectrometry assay is the preferred method for determination of EVR C0, with a lower limit of quantification close to 1 ng/mL. Use of certified commercially available whole-blood calibrators to avoid calibration bias and participation in external proficiency-testing programs to allow continuous cross-validation and proof of analytical quality are highly recommended. Development of alternative assays to facilitate on-site measurement of EVR C0 is encouraged.
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40
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Kumar J, Bridson JM, Sharma A, Halawa A. Systematic Review on Role of Mammalian Target of Rapamycin Inhibitors as an Alternative to Calcineurin Inhibitors in Renal Transplant: Challenges and Window to Excel. EXP CLIN TRANSPLANT 2016; 15:241-252. [PMID: 27915965 DOI: 10.6002/ect.2016.0270] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVES This review focuses on the current limited evidence of graft function and graft survival in various immunosuppressive regimens involving mammalian target of rapamycin inhibitors with or without calcineurin inhibitors. MATERIALS AND METHODS We evaluated the current literature for describing the role of mammalian target of rapamycin inhibitors as an alternative to calcineurin inhibitors by searching the PubMed, EMBASE, Cochrane, Crossref, and Scopus databases using medical subject heading terms. RESULTS Our detailed analyses of all relevant literature showed use of mammalian target of rapamycin inhibitor-based de novo regimens, early calcineurin inhibitor withdrawal with subsequent introduction of mammalian target of rapamycin inhibitor-based regimens, and late conversion from a calcineurin inhibitor-based regimen to mammalian target of rapamycin inhibitor-based regimens. Notably, early calcineurin inhibitor withdrawal with subsequent introduction of mammalian target of rapamycin inhibitor-based regimen seemed to be a more practical and realistic approach toward immunosuppressive treatment of renal transplant recipients. However, in view of the high rejection rate observed in these studies, it is advisable not to offer these regimens to patients with moderate to high immunologic risk. CONCLUSIONS The present evidences suggest that treatment with mammalian target of rapamycin inhibitors allows early and substantial calcineurin inhibitor minimization. The mammalian target of rapamycin inhibitors everolimus and sirolimus are preferred due to their complementary mechanisms of action and favorable nephrotoxicity profile, which have opened the way for calcineurin inhibitor reduction/withdrawal in the early posttransplant period.
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Affiliation(s)
- Jayant Kumar
- From the Department of Hepato-Pancreato-Biliary Surgery, Hammersmith Hospital, Imperial College, London, United Kingdom; and the Faculty of Health and Sciences, Institute of Learning and Teaching, University of Liverpool, United Kingdom
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41
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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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42
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Strueber M, Warnecke G, Fuge J, Simon AR, Zhang R, Welte T, Haverich A, Gottlieb J. Everolimus Versus Mycophenolate Mofetil De Novo After Lung Transplantation: A Prospective, Randomized, Open-Label Trial. Am J Transplant 2016; 16:3171-3180. [PMID: 27104933 DOI: 10.1111/ajt.13835] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 03/27/2016] [Accepted: 04/16/2016] [Indexed: 01/25/2023]
Abstract
The role of mammalian target of rapamycin (mTOR) inhibitors in de novo immunosuppression after lung transplantation is not well defined. We compared Everolimus versus mycophenolate mofetil in an investigator-initiated single-center trial in Hannover, Germany. A total of 190 patients were randomly assigned 1:1 on day 28 posttransplantation to mycophenolate mofetil (MMF) or Everolimus combined with cyclosporine A (CsA) and steroids. Patients were followed up for 2 years. The primary endpoint was freedom from bronchiolitis obliterans syndrome (BOS). The secondary endpoints were incidence of acute rejections, infections, treatment failure and kidney function. BOS-free survival in intention-to-treat (ITT) analysis was similar in both groups (p = 0.174). The study protocol was completed by 51% of enrolled patients. The per-protocol analysis shows incidence of bronchiolitis obliterans syndrome (BOS): 1/43 in the Everolimus group and 8/54 in the MMF group (p = 0.041). Less biopsy-proven acute rejection (AR) (p = 0.005), cytomegalovirus (CMV) antigenemia (p = 0.005) and lower respiratory tract infection (p = 0.003) and no leucopenia were seen in the Everolimus group. The glomerular filtration rate (GFR) decreased in both groups about 50% within 6 months. Due to a high withdrawal rate, the study was underpowered to prove a difference in BOS-free survival. The dropout rate was more pronounced in the Everolimus group. Secondary endpoints indicate potential advantages of Everolimus-based protocols but also a potentially higher rate of drug-related serious adverse events.
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Affiliation(s)
- M Strueber
- Richard DeVos Heart & Lung Transplant Program, Frederik Meijer Heart & Vascular Institute, Grand Rapids, MI.
| | - G Warnecke
- Department of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.,German Centre of Lung Research (DZL/BREATH), Hannover Medical School, Hannover, Germany
| | - J Fuge
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - A R Simon
- Department of Heart and Lung Transplantation/VAD, Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom
| | - R Zhang
- Department of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - T Welte
- German Centre of Lung Research (DZL/BREATH), Hannover Medical School, Hannover, Germany.,Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - A Haverich
- Department of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.,German Centre of Lung Research (DZL/BREATH), Hannover Medical School, Hannover, Germany
| | - J Gottlieb
- German Centre of Lung Research (DZL/BREATH), Hannover Medical School, Hannover, Germany.,Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
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43
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Nowacki M, Nazarewski Ł, Kloskowski T, Tyloch D, Pokrywczyńska M, Pietkun K, Jundziłł A, Tyloch J, Habib SL, Drewa T. Novel surgical techniques, regenerative medicine, tissue engineering and innovative immunosuppression in kidney transplantation. Arch Med Sci 2016; 12:1158-1173. [PMID: 27695507 PMCID: PMC5016594 DOI: 10.5114/aoms.2016.61919] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2014] [Accepted: 02/08/2015] [Indexed: 01/09/2023] Open
Abstract
On the 60th anniversary of the first successfully performed renal transplantation, we summarize the historical, current and potential future status of kidney transplantation. We discuss three different aspects with a potential significant influence on kidney transplantation progress: the development of surgical techniques, the influence of regenerative medicine and tissue engineering, and changes in immunosuppression. We evaluate the standard open surgical procedures with modern techniques and compare them to less invasive videoscopic as well as robotic techniques. The role of tissue engineering and regenerative medicine as a potential method for future kidney regeneration or replacement and the interesting search for novel solutions in the field of immunosuppression will be discussed. After 60 years since the first successfully performed kidney transplantation, we can conclude that the greatest achievements are associated with the development of surgical techniques and with planned systemic immunosuppression.
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Affiliation(s)
- Maciej Nowacki
- Chair of Urology, Department of Regenerative Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
- Chair of Surgical Oncology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
| | - Łukasz Nazarewski
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Tomasz Kloskowski
- Chair of Urology, Department of Regenerative Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
| | - Dominik Tyloch
- Chair of Urology, Department of Regenerative Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
| | - Marta Pokrywczyńska
- Chair of Urology, Department of Regenerative Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
| | - Katarzyna Pietkun
- Chair of Urology, Department of Regenerative Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
| | - Arkadiusz Jundziłł
- Chair of Urology, Department of Regenerative Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
| | - Janusz Tyloch
- Chair of Urology, Department of Regenerative Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
| | - Samy L. Habib
- Department of Geriatrics, Geriatric Research, Education, and Clinical Center, South Texas Veterans Healthcare System, San Antonio, TX, USA
- Department of Cellular and Structural Biology, University of Texas Health Science Center, San Antonio, TX, USA
| | - Tomasz Drewa
- Chair of Urology, Department of Regenerative Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
- Department of General and Oncological Urology, Nicolaus Copernicus Hospital, Torun, Poland
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Qiu Y, Wang X, Fan J, Rao Z, Lu Y, Lin T. Conversion From Calcineurin Inhibitors to Mammalian Target-of-Rapamycin Inhibitors in Heart Transplant Recipients: A Meta-Analysis of Randomized Controlled Trials. Transplant Proc 2016; 47:2952-6. [PMID: 26707320 DOI: 10.1016/j.transproceed.2015.09.059] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 09/17/2015] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Conversion from calcineurin inhibitors (CNIs) to mammalian target-of-rapamycin inhibitors (mTORi) was systematically evaluated in heart transplant recipients (HTRs) for the first time. METHODS MEDLINE (PUBMED), EMBASE, Cochrane Library, and clinical trial registries were searched comprehensively. After screening for eligibility, the randomized controlled trials (RCTs) comparing continuation of CNI with conversion to mTORi therapy underwent review, quality assessment, and data extraction. Outcomes analyzed including creatinine clearance, serum creatinine level, rejection, adverse effects, and triglyceride levels were expressed as mean differences (MDs) or as risk ratios (RRs) with 95% confidence intervals (CIs). RESULTS This is the first systematic review evaluating converting from CNI to mTORi therapy in HTRs. A total of 4 RCTs (231 HTRs, 117 vs 114) were included in our analysis. Patients converted to mTORi had a higher creatinine clearance (MD, 19.31; 95% CI [11.16, 27.46]; P < .00001) and lower serum creatinine levels (MD, -0.15; 95% CI [-0.25, -0.05]; P = .002). Patients converted to mTORi had a significantly higher occurrence of adverse effects, which included skin diseases, gastrointestinal side effects, bone marrow suppression, and infections. There was no significant difference between the 2 groups regarding graft rejection and triglyceride levels (RR, 2.61; 95% CI [0.08, 81.25]; P = .58; MD, 22.89; 95% CI [-21.86, 67.63]; P = .32). CONCLUSIONS Conversion from CNI to mTORi therapy may improve the renal function in HTRs, but the patients may suffer from a high incidence of mTORi-associated adverse events. Therefore, conversion to mTORi must be carefully assessed for the benefits and risks.
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Affiliation(s)
- Y Qiu
- Department of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - X Wang
- Department of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - J Fan
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Z Rao
- Department of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Y Lu
- Department of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - T Lin
- Department of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Institute of Urology, West China Hospital, Sichuan University, Chengdu, Sichuan, China; Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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45
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Gullestad L, Eiskjaer H, Gustafsson F, Riise GC, Karason K, Dellgren G, Rådegran G, Hansson L, Gude E, Bjørtuft Ø, Jansson K, Schultz HH, Solbu D, Iversen M. Long-term outcomes of thoracic transplant recipients following conversion to everolimus with reduced calcineurin inhibitor in a multicenter, open-label, randomized trial. Transpl Int 2016; 29:819-29. [DOI: 10.1111/tri.12783] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Revised: 01/20/2016] [Accepted: 04/07/2016] [Indexed: 12/24/2022]
Affiliation(s)
- Lars Gullestad
- Department of Cardiology; Oslo University Hospital Rikshospitalet; Oslo Norway
- Faculty of Medicine; K.G. Jebsen Cardiac Research Centre and Center for Heart Failure Research; University of Oslo; Oslo Norway
| | - Hans Eiskjaer
- Department of Cardiology; Aarhus University Hospital; Skejby Aarhus Denmark
| | - Finn Gustafsson
- Department of Cardiology; Rigshospitalet; Copenhagen Denmark
| | - Gerdt C. Riise
- Department of Respiratory Medicine; Sahlgrenska University Hospital; Gothenburg Sweden
| | - Kristjan Karason
- Department of Cardiology and Transplant Institute; Sahlgrenska University Hospital; Gothenburg Sweden
| | - Göran Dellgren
- Department of Cardiology and Transplant Institute; Sahlgrenska University Hospital; Gothenburg Sweden
| | - Göran Rådegran
- Department of Clinical Sciences Lund, Cardiology; Lund University and the Section for Heart Failure and Valvular Disease; Skåne University Hospital; Lund Sweden
| | - Lennart Hansson
- Department of Respiratory Medicine; Lund University Hospital and Skåne University Hospital; Lund Sweden
| | - Einar Gude
- Department of Cardiology; Oslo University Hospital Rikshospitalet; Oslo Norway
- Faculty of Medicine; K.G. Jebsen Cardiac Research Centre and Center for Heart Failure Research; University of Oslo; Oslo Norway
| | - Øystein Bjørtuft
- Department of Respiratory Medicine; Oslo University Hospital Rikshospitalet; Oslo Norway
| | - Kjell Jansson
- Department of Cardiology, Heart Center; University Hospital; Linkoping Sweden
| | - Hans Henrik Schultz
- Division of Lung Transplantation; Department of Cardiology; Rigshospitalet; Copenhagen Denmark
| | | | - Martin Iversen
- Division of Lung Transplantation; Department of Cardiology; Rigshospitalet; Copenhagen Denmark
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46
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Söderlund C, Löfdahl E, Nilsson J, Reitan Ö, Higgins T, Rådegran G. Chronic kidney disease after heart transplantation: a single-centre retrospective study at Skåne University Hospital in Lund 1988-2010. Transpl Int 2016; 29:529-39. [DOI: 10.1111/tri.12710] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 06/15/2015] [Accepted: 10/27/2015] [Indexed: 01/01/2023]
Affiliation(s)
- Carl Söderlund
- Department of Clinical Sciences Lund; Cardiology; Lund University; Lund Sweden
- The Haemodynamic Lab; The Section for Heart Failure and Valvular Disease; Skåne University Hospital; Lund Sweden
| | - Eveline Löfdahl
- Department of Clinical Sciences Lund; Cardiology; Lund University; Lund Sweden
- The Haemodynamic Lab; The Section for Heart Failure and Valvular Disease; Skåne University Hospital; Lund Sweden
| | - Johan Nilsson
- Department of Clinical Sciences Lund; Cardiothoracic Surgery; Lund University and Skåne University Hospital; Lund Sweden
| | - Öyvind Reitan
- Department of Clinical Sciences Lund; Cardiology; Lund University; Lund Sweden
- The Haemodynamic Lab; The Section for Heart Failure and Valvular Disease; Skåne University Hospital; Lund Sweden
| | - Thomas Higgins
- Children's Heart Centre and Pediatric Surgery; Skåne University Hospital; Lund Sweden
| | - Göran Rådegran
- Department of Clinical Sciences Lund; Cardiology; Lund University; Lund Sweden
- The Haemodynamic Lab; The Section for Heart Failure and Valvular Disease; Skåne University Hospital; Lund Sweden
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47
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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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48
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Imamura T, Kinugawa K, Nitta D, Kinoshita O, Nawata K, Ono M. Everolimus Attenuates Myocardial Hypertrophy and Improves Diastolic Function in Heart Transplant Recipients. Int Heart J 2016; 57:204-10. [PMID: 26973270 DOI: 10.1536/ihj.15-320] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Everolimus (EVL), one of the mammalian targets of rapamycin, is a next generation immunosuppressant that may have accessory anti-proliferative effects in heart transplant (HTx) recipients. However, little is known about the clinical relationship between EVL and regression of cardiac hypertrophy. A total of 42 HTx recipients received EVL therapy at post-HTx 150 days on median and had been followed at our institute for > 1 year between 2008 and 2014 [EVL (+) group]. We also observed 18 patients without EVL from post-HTx 150 days for 1 year [EVL (-) group]. There were no significant differences in baseline variables between the two groups. Left ventricular mass index (LVMI) and the ratio of early transmitral filling velocity to the peak early diastolic mitral annular motion velocity (E/e') decreased significantly during 1-year EVL treatment compared with the EVL (-) group. There were no differences in blood pressure and medications between the 2 groups. Improvement of LVMI and the E/e' ratio was not associated with trough levels of calcineurin inhibitors or EVL, but correlated with each baseline value. In conclusion, this EVL-incorporated immunosuppressant regimen attenuated cardiac hypertrophy as well as diastolic dysfunction in HTx recipients.
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Affiliation(s)
- Teruhiko Imamura
- Department of Therapeutic Strategy for Heart Failure, Graduate School of Medicine, The University of Tokyo
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49
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Rashidi M, Esmaily S, Fiane AE, Gude E, A Tønseth K, Ueland T, Gustafsson F, Eiskjær H, Rådegran G, Dellgren G. Wound complications and surgical events in de novo heart transplant patients treated with everolimus: Post-hoc analysis of the SCHEDULE trial. Int J Cardiol 2016; 210:80-4. [PMID: 26938682 DOI: 10.1016/j.ijcard.2016.02.075] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 02/05/2016] [Accepted: 02/07/2016] [Indexed: 12/01/2022]
Abstract
OBJECTIVES The use of mammalian target of rapamycin (mTOR) inhibitors have been limited by adverse events (AE), including delayed wound healing. We retrospectively reviewed all AE and serious AE (SAE) in The Scandinavian heart transplant (HTx) everolimus (EVE) de novo trial with early calcineurin (CNI) avoidance (SCHEDULE). The aim of the study was to compare wound complications between EVE and CNI based regimen. MATERIALS AND METHODS A total of 115 patients (mean age 51 ± 13 years, 73% men) were randomized within five days post-HTx to low dose EVE and reduced dose Cyclosporine (CyA) followed by early CyA withdrawal (EVE group; n=56) or standard CyA regimen (CyA group; n=59). All AE/SAEs were prospectively recorded according to the SCHEDULE study protocol, and re-assessed retrospectively by two independent reviewers. Wound complication as primary endpoint was defined as any complication associated with failure of tissue healing. Secondary endpoint was total number of events involving surgical intervention. RESULTS There were no significant differences between the groups with regards to wound complications (EVE=20, CyA=12)(p=0.08) or total surgical events (EVE=38, CyA=34) (p=0.44). Age>54.5 years (median) was an overall risk factor for surgical wound complications regardless of treatment group (p=0.025). There was no difference in the EVE versus CyA group with regards to other surgical events. Majority of events were in 1/3 of the patients. CONCLUSION De novo initiation of EVE and early CyA withdrawal in HTx patients did not show any significant differences in wound complications or in total surgical events. Majority of complications were seen in a small number of patients.
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Affiliation(s)
- Mitra Rashidi
- Department of Cardiothoracic Surgery, Oslo University Hospital, Oslo, Norway; Department of Plastic and Reconstructive Surgery, Oslo University Hospital, Oslo, Norway.
| | - Sorosh Esmaily
- Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Arnt E Fiane
- Department of Cardiothoracic Surgery, Oslo University Hospital, Oslo, Norway; Faculty of Medicine, University of Oslo, Norway
| | - Einar Gude
- Department of Cardiology, Oslo University Hospital, Oslo, Norway
| | - Kim A Tønseth
- Department of Plastic and Reconstructive Surgery, Oslo University Hospital, Oslo, Norway; Faculty of Medicine, University of Oslo, Norway
| | - Thor Ueland
- Faculty of Medicine, University of Oslo, Norway; Research Institute of Internal Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway; K.G. Jebsen Inflammatory Research Center, University of Oslo, Oslo, Norway; K.G. Jebsen Thrombosis Research and Expertise Center, University of Tromsø, Norway
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Hans Eiskjær
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Göran Rådegran
- The Clinic for Heart Failure and Valvular Disease, Skåne University Hospital and Department of Clinical Sciences Lund, Cardiology, Lund University, Lund, Sweden
| | - Göran Dellgren
- Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
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50
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Manito N, Delgado JF, Crespo-Leiro MG, Arizón JM, Segovia J, González-Vílchez F, Mirabet S, Lage E, Pascual-Figal D, Díaz B, Palomo J, Rábago G, Sanz M, Blasco T, Roig E. Twelve-month efficacy and safety of the conversion to everolimus in maintenance heart transplant recipients. World J Transplant 2015; 5:310-319. [PMID: 26722659 PMCID: PMC4689942 DOI: 10.5500/wjt.v5.i4.310] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 07/31/2015] [Accepted: 10/13/2015] [Indexed: 02/05/2023] Open
Abstract
AIM: To determine the clinical reasons for conversion to everolimus (EVL) and long-term outcomes in heart transplant (HT) recipients.
METHODS: A retrospective 12-mo study has been carried out in 14 Spanish centres to assess the efficacy and safety of conversion to EVL in maintenance HT recipients.
RESULTS: Two hundred and twenty-two patients were included (mean age: 53 ± 10.5 years; mean time from HT: 8.1 ± 4.5 years). The most common reasons for conversion were nephrotoxicity (30%), chronic allograft vasculopathy (20%) and neoplasms (17%). The doses and mean levels of EVL at baseline (conversion to EVL) and after one year were 1.3 ± 0.3 and 1.2 ± 0.6 mg/d and 6.4 ± 3.4 and 5.6 ± 2.5 ng/mL, respectively. The percentage of patients receiving calcineurin inhibitors (CNIs) at baseline and on the final visit was 95% and 65%, respectively. The doses and mean levels of CNIs decreased between baseline and month 12 from 142.2 ± 51.6 to 98.0 ± 39.4 mg/d (P < 0.001) and from 126.1 ± 50.9 to 89.2 ± 47.7 ng/mL (P < 0.001), respectively, for cyclosporine, and from 2.9 ± 1.8 to 2.6 ± 1.9 mg/d and from 8.3 ± 4.0 to 6.5 ± 2.7 ng/mL (P = 0.011) for tacrolimus. In the subgroup of patients converted because of nephrotoxicity, creatinine clearance increased from 34.9 ± 10.1 to 40.4 ± 14.4 mL/min (P < 0.001). There were 37 episodes of acute rejection in 24 patients (11%). The most frequent adverse events were oedemas (12%), infections (9%) and gastrointestinal problems (6%). EVL was suspended in 44 patients (20%). Since the database was closed at the end of the study, no further follow-up data is available.
CONCLUSION: Conversion to EVL in maintenance HT recipients allowed minimisation or suspension of the CNIs, with improved kidney function in the patients with nephrotoxicity, after 12 mo.
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