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Elezaby A, Dexheimer R, Sallam K. Cardiovascular effects of immunosuppression agents. Front Cardiovasc Med 2022; 9:981838. [PMID: 36211586 PMCID: PMC9534182 DOI: 10.3389/fcvm.2022.981838] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 08/30/2022] [Indexed: 11/26/2022] Open
Abstract
Immunosuppressive medications are widely used to treat patients with neoplasms, autoimmune conditions and solid organ transplants. Key drug classes, namely calcineurin inhibitors, mammalian target of rapamycin (mTOR) inhibitors, and purine synthesis inhibitors, have direct effects on the structure and function of the heart and vascular system. In the heart, immunosuppressive agents modulate cardiac hypertrophy, mitochondrial function, and arrhythmia risk, while in vasculature, they influence vessel remodeling, circulating lipids, and blood pressure. The aim of this review is to present the preclinical and clinical literature examining the cardiovascular effects of immunosuppressive agents, with a specific focus on cyclosporine, tacrolimus, sirolimus, everolimus, mycophenolate, and azathioprine.
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Affiliation(s)
- Aly Elezaby
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, United States
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA, United States
| | - Ryan Dexheimer
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, United States
| | - Karim Sallam
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, United States
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA, United States
- *Correspondence: Karim Sallam
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Obremska M, Szymczak M, Letachowicz K, Zyśko D, Boratyńska M, Łukaszewski M, Krajewska M. The Global Longitudinal Strain in Renal Transplant Recipients and Immunosuppressive Regimen. Transplant Proc 2020; 52:2310-2314. [PMID: 32446693 DOI: 10.1016/j.transproceed.2020.01.117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 01/26/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Echocardiographic global longitudinal strain (GLS) has recently been considered as a more effective assessment than the ejection fraction (EF) in detecting subtle changes of left ventricular (LV) systolic function. The aim of the study is to compare GLS in renal transplant recipients (RTrs) with preserved LVEF, depending on the recipient's immunosuppressive regimen. The impaired GLS was considered to be > -18%. METHODS A total of 84 RTrs were divided into 2 groups depending on immunosuppressive regimen: group 1, which included 32 patients (aged 62.3 ± 7.5) receiving mammalian target of rapamycin inhibitors, and group 2, which included 52 patients (aged 58.9 ± 13.9 treated with calcineurin inhibitors. In all patients, echocardiography was performed, including calculation of GLS, and laboratory and clinical markers of cardiovascular risk were assessed. RESULTS The frequency of men was significantly higher in group 1 (P = .01). There were no differences between the groups in age, body mass index, frequency of diabetes, hypertension, time of hemodialysis (HD) before kidney transplantation (KTx), time after KTx, concentration of cholesterol and creatinine, echocardiographic linear parameters, and LV mass. The estimated glomerular filtration rate and triglyceride concentration were significantly higher in group 1. The mean value of GLS was similar in both groups (-19.8 [-3.5] vs -18.9 [-3.0]; P = .22). The multivariate logistic regression analysis revealed that duration of HD > 26 months is associated with GLS ≥ -18% (odds ratio 2.95, 95% CI 1.08-7.99, P = .03) CONCLUSIONS: The frequency of impaired GLS in RTr was similar regardless of the type of the immunosuppressive regimen. The impaired GLS was associated with duration of HD before KTx.
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Affiliation(s)
- Marta Obremska
- Department of Emergency Medical Services, Wrocław Medical University, Wrocław, Poland; Centre of Heart Diseases, University Hospital, Wrocław, Poland.
| | - Maciej Szymczak
- Department and Clinic of Nephrology and Transplantation Medicine, Wrocław Medical University, Wrocław, Poland
| | - Krzysztof Letachowicz
- Department and Clinic of Nephrology and Transplantation Medicine, Wrocław Medical University, Wrocław, Poland
| | - Dorota Zyśko
- Department of Emergency Medicine, Wrocław Medical University, Wrocław, Poland
| | - Maria Boratyńska
- Faculty of Medical Sciences and Technology, The Karkonosze State University of Applied Sciences, Jelenia Góra, Poland
| | - Marceli Łukaszewski
- Department and Clinic of Anaesthesiology and Intensive Therapy, Wroclaw Medical University, Wrocław, Poland
| | - Magdalena Krajewska
- Department and Clinic of Nephrology and Transplantation Medicine, Wrocław Medical University, Wrocław, Poland
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Hahn D, Hodson EM, Hamiwka LA, Lee VWS, Chapman JR, Craig JC, Webster AC. Target of rapamycin inhibitors (TOR-I; sirolimus and everolimus) for primary immunosuppression in kidney transplant recipients. Cochrane Database Syst Rev 2019; 12:CD004290. [PMID: 31840244 PMCID: PMC6953317 DOI: 10.1002/14651858.cd004290.pub3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Kidney transplantation is the therapy of choice for many patients with end-stage kidney disease (ESKD) with an improvement in survival rates and satisfactory short term graft survival. However, there has been little improvement in long-term survival. The place of target of rapamycin inhibitors (TOR-I) (sirolimus, everolimus), which have different modes of action from other commonly used immunosuppressive agents, in kidney transplantation remains uncertain. This is an update of a review first published in 2006. OBJECTIVES To evaluate the short and long-term benefits and harms of TOR-I (sirolimus and everolimus) when used in primary immunosuppressive regimens for kidney transplant recipients. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 20 September 2019 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register were identified through searches of CENTRAL, MEDLINE and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA All randomised controlled trials (RCTs) and quasi-RCTs in which drug regimens, containing TOR-I commenced within seven days of transplant, were compared to alternative drug regimens, were included without age restriction, dosage or language of report. DATA COLLECTION AND ANALYSIS Three authors independently assessed study eligibility, risk of bias, and extracted data. Results were reported as risk ratios (RR) with 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) with 95% CI for continuous outcomes. Statistical analyses were performed using the random-effects model. The certainty of the evidence was assessed using GRADE MAIN RESULTS: Seventy studies (17,462 randomised participants) were included; eight studies included two comparisons to provide 78 comparisons. Outcomes were reported at six months to three years post transplant. Risk of bias was judged to be low for sequence generation in 25 studies, for allocation concealment in 23 studies, performance bias in four studies, detection bias in 65 studies, attrition bias in 45 studies, selective reporting bias in 48 studies, and for other potential bias in three studies. Risk of bias was judged to be at high risk of bias for sequence generation in two studies, allocation concealment in two studies, performance bias in 61 studies, detection bias in one study, attrition bias in four studies, for selective reporting bias in 11 studies and for other potential risk of bias in 46 studies. Compared with CNI and antimetabolite, TOR-I with antimetabolite probably makes little or no difference to death (RR 1.31, 95% CI 0.87 to 1.98; 19 studies) or malignancies (RR 0.86, 95% CI 0.50 to 1.48; 10 studies); probably increases graft loss censored for death (RR 1.32, 95% CI 0.96 to 1.81; 15 studies), biopsy-proven acute rejection (RR 1.60, 95% CI 1.25 to 2.04; 15 studies), need to change treatment (RR 2.42, 95% CI 1.88 to 3.11; 14 studies) and wound complications (RR 2.56, 95% CI 1.94 to 3.36; 12 studies) (moderate certainty evidence); but reduces CMV infection (RR 0.43, 95% CI 0.29 to 0.63; 13 studies) (high certainty evidence). Compared with antimetabolites and CNI, TOR-I with CNI probably makes little or no difference to death (RR 1.06, 95% CI 0.84 to 1.33; 31 studies), graft loss censored for death (RR 1.09, 95% CI 0.82 to 1.45; 26 studies), biopsy-proven acute rejection (RR 0.95, 95% CI 0.81 to 1.12; 24 studies); and malignancies (RR 0.83, 95% CI 0.64 to 1.07; 17 studies); probably increases the need to change treatment (RR 1.56, 95% CI 1.28 to 1.90; 25 studies), and wound complications (RR 1.56, 95% CI 1.28 to 1.91; 17 studies); but probably reduces CMV infection (RR 0.44, 95% CI 0.34 to 0.58; 25 studies) (moderate certainty evidence). Lower dose TOR-I and standard dose CNI compared with higher dose TOR-I and reduced dose CNI probably makes little or no difference to death (RR 1.07, 95% CI 0.64 to 1.78; 9 studies), graft loss censored for death (RR 1.09, 95% CI 0.54 to 2.20; 8 studies), biopsy-proven acute rejection (RR 0.87, 95% CI 0.67 to 1.13; 8 studies), and CMV infection (RR 1.42, 95% CI 0.78 to 2.60; 5 studies) (moderate certainty evidence); and may make little or no difference to wound complications (RR 0.95, 95% CI 0.53 to 1.71; 3 studies), malignancies (RR 1.04, 95% CI 0.36 to 3.04; 7 studies), and the need to change treatments (RR 1.18, 95% CI 0.58 to 2.42; 5 studies) (low certainty evidence). Lower dose of TOR-I compared with higher doses probably makes little or no difference to death (RR 0.84, 95% CI 0.67 to 1.06; 13 studies), graft loss censored for death (RR 0.92, 95% CI 0.71 to 1.19; 12 studies), biopsy-proven acute rejection (RR 1.26, 95% CI 1.10 to 1.43; 11 studies), CMV infection (RR 0.87, 95% CI 0.63 to 1.21; 9 studies), wound complications (RR 0.92, 95% CI 0.66 to 1.29; 7 studies), and malignancy (RR 0.84, 95% CI 0.54 to 1.32; 10 studies) (moderate certainty evidence); and may make little or no difference to the need to change treatments (RR 0.91, 95% CI 0.78 to 1.05; 10 studies) (low certainty evidence). It is uncertain whether sirolimus and everolimus differ in their effects on kidney function and lipid levels because the certainty of the evidence is very low based on a single small study with only three months of follow-up. AUTHORS' CONCLUSIONS In studies with follow-up to three years, TOR-I with an antimetabolite increases the risk of graft loss and acute rejection compared with CNI and an antimetabolite. TOR-I with CNI potentially offers an alternative to an antimetabolite with CNI as rates of graft loss and acute rejection are similar between interventions and TOR-I regimens are associated with a reduced risk of CMV infections. Wound complications and the need to change immunosuppressive medications are higher with TOR-I regimens. While further new studies are not required, longer-term follow-up data from participants in existing methodologically robust RCTs are needed to determine how useful immunosuppressive regimens, which include TOR-I, are in maintaining kidney transplant function and survival beyond three years.
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Affiliation(s)
- Deirdre Hahn
- The Children's Hospital at WestmeadDepartment of NephrologyLocked Bag 4001WestmeadNSWAustralia2145
| | - Elisabeth M Hodson
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchLocked Bag 4001WestmeadNSWAustralia2145
| | - Lorraine A Hamiwka
- University of Calgary/Alberta Children's HospitalDepartment of Medicine/Pediatrics2888 Shaganappi Trail NW Children's HospitalCalgaryAlbertaCanadaT3B 6A8
| | - Vincent WS Lee
- Westmead & Blacktown HospitalsDepartment of Renal MedicineDarcy RdWestmeadNSWAustralia2145
- The University of Sydney at WestmeadCentre for Transplant and Renal Research, Westmead Millennium InstituteWestmeadAustralia
| | - Jeremy R Chapman
- Westmead Millennium Institute, The University of Sydney at WestmeadCentre for Transplant and Renal ResearchDarcy RdWestmeadNSWAustralia2145
| | - Jonathan C Craig
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchLocked Bag 4001WestmeadNSWAustralia2145
- Flinders UniversityCollege of Medicine and Public HealthAdelaideSAAustralia5001
| | - Angela C Webster
- The University of Sydney at WestmeadCentre for Transplant and Renal Research, Westmead Millennium InstituteWestmeadAustralia
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
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Paoletti E, Citterio F, Corsini A, Potena L, Rigotti P, Sandrini S, Bussalino E, Stallone G. Everolimus in kidney transplant recipients at high cardiovascular risk: a narrative review. J Nephrol 2019; 33:69-82. [DOI: 10.1007/s40620-019-00609-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 04/05/2019] [Indexed: 12/20/2022]
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Abstract
Left ventricular hypertrophy (LVH) is highly prevalent in kidney transplant recipients and is associated with poor clinical outcome. Immunosuppressive agents might affect LVH behavior after kidney transplantation. This review is an appraisal of available data regarding LVH in renal transplantation and especially of studies that evaluated LVH response to treatment. In particular, the role of mammalian target of rapamycin inhibitors adopted as immunosuppressive agents in kidney transplantation is reviewed in the light of recent studies that have shown LVH regression induced by this class of medications in kidney transplant recipients with posttransplant cardiomyopathy. Larger randomized controlled trials are warranted to confirm these findings and to ascertain the impact of such LVH regression on hard endpoints in kidney transplant recipients with posttransplant cardiomyopathy.
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Cardiovascular Parameters to 2 years After Kidney Transplantation Following Early Switch to Everolimus Without Calcineurin Inhibitor Therapy: An Analysis of the Randomized ELEVATE Study. Transplantation 2017; 101:2612-2620. [PMID: 28333860 DOI: 10.1097/tp.0000000000001739] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Mammalian target of rapamycin inhibitors may confer cardioprotective advantages, but clinical data are limited. METHODS In the open-label ELEVATE trial, kidney transplant patients were randomized at 10 to 14 weeks after transplant to convert from calcineurin inhibitor (CNI) to everolimus or remain on standard CNI therapy. Prespecified end points included left ventricular mass index and, in a subpopulation of patients, arterial stiffness as measured by pulse wave velocity. RESULTS The mean change in left ventricular mass index from randomization was similar with everolimus versus CNI (month 24, -4.37 g/m versus -5.26 g/m; mean difference, 0.89 [p = 0.392]). At month 24, left ventricular hypertrophy was present in 41.7% versus 37.7% of everolimus and CNI patients, respectively. Mean pulse wave velocity remained stable with both everolimus (mean change from randomization to month 12, -0.24 m/s; month 24, -0.03 m/s) and CNI (month 12, 0.11 m/s; month 24, 0.16 m/s). The change in mean ambulatory nighttime blood pressure from randomization showed a benefit for diastolic pressure at month 12 (P = 0.039) but not at month 24. Major adverse cardiac events occurred in 1.1% and 4.2% of everolimus-treated and CNI-treated patients, respectively, by month 12 (P = 0.018) and 2.3% (8/353) and 4.5% by month 24 (P = 0.145). CONCLUSIONS Overall, these data do not suggest a clinically relevant effect on cardiac end points after early conversion from CNI to a CNI-free everolimus-based regimen.
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Karpe KM, Talaulikar GS, Walters GD. Calcineurin inhibitor withdrawal or tapering for kidney transplant recipients. Cochrane Database Syst Rev 2017; 7:CD006750. [PMID: 28730648 PMCID: PMC6483545 DOI: 10.1002/14651858.cd006750.pub2] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Calcineurin inhibitors (CNI) can reduce acute transplant rejection and immediate graft loss but are associated with significant adverse effects such as hypertension and nephrotoxicity which may contribute to chronic rejection. CNI toxicity has led to numerous studies investigating CNI withdrawal and tapering strategies. Despite this, uncertainty remains about minimisation or withdrawal of CNI. OBJECTIVES This review aimed to look at the benefits and harms of CNI tapering or withdrawal in terms of graft function and loss, incidence of acute rejection episodes, treatment-related side effects (hypertension, hyperlipidaemia) and death. SEARCH METHODS We searched the Cochrane Kidney and Transplant Specialised Register to 11 October 2016 through contact with the Information Specialist using search terms relevant to this review. Studies contained in the Specialised Register are identified through search strategies specifically designed for CENTRAL, MEDLINE, and EMBASE; handsearching conference proceedings; and searching the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA All randomised controlled trials (RCTs) where drug regimens containing CNI were compared to alternative drug regimens (CNI withdrawal, tapering or low dose) in the post-transplant period were included, without age or dosage restriction. DATA COLLECTION AND ANALYSIS Two authors independently assessed studies for eligibility, risk of bias, and extracted data. Results were expressed as risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI). MAIN RESULTS We included 83 studies that involved 16,156 participants. Most were open-label studies; less than 30% of studies reported randomisation method and allocation concealment. Studies were analysed as intent-to-treat in 60% and all pre-specified outcomes were reported in 54 studies. The attrition and reporting bias were unclear in the remainder of the studies as factors used to judge bias were reported inconsistently. We also noted that 50% (47 studies) of studies were funded by the pharmaceutical industry.We classified studies into four groups: CNI withdrawal or avoidance with or without substitution with mammalian target of rapamycin inhibitors (mTOR-I); and low dose CNI with or without mTOR-I. The withdrawal groups were further stratified as avoidance and withdrawal subgroups for major outcomes.CNI withdrawal may lead to rejection (RR 2.54, 95% CI 1.56 to 4.12; moderate certainty evidence), may make little or no difference to death (RR 1.09, 95% CI 0.96 to 1.24; moderate certainty), and probably slightly reduces graft loss (RR 0.85, 95% CI 0.74 to 0.98; low quality evidence). Hypertension was probably reduced in the CNI withdrawal group (RR 0.82, 95% CI 0.71 to 0.95; low certainty), while CNI withdrawal may make little or no difference to malignancy (RR 1.10, 95% CI 0.93 to 1.30; low certainty), and probably makes little or no difference to cytomegalovirus (CMV) (RR 0.87, 95% CI 0.52 to 1.45; low certainty)CNI avoidance may result in increased acute rejection (RR 2.16, 95% CI 0.85 to 5.49; low certainty) but little or no difference in graft loss (RR 0.96, 95% CI 0.79 to 1.16; low certainty). Late CNI withdrawal increased acute rejection (RR 3.21, 95% CI 1.59 to 6.48; moderate certainty) but probably reduced graft loss (RR 0.84, 95% CI 0.72 to 0.97, low certainty).Results were similar when CNI avoidance or withdrawal was combined with the introduction of mTOR-I; acute rejection was probably increased (RR 1.43; 95% CI 1.15 to 1.78; moderate certainty) and there was probably little or no difference in death (RR 0.96; 95% CI 0.69 to 1.36, moderate certainty). mTOR-I substitution may make little or no difference to graft loss (RR 0.94, 95% CI 0.75 to 1.19; low certainty), probably makes little of no difference to hypertension (RR 0.86, 95% CI 0.64 to 1.15; moderate), and probably reduced the risk of cytomegalovirus (CMV) (RR 0.60, 95% CI 0.44 to 0.82; moderate certainty) and malignancy (RR 0.69, 95% CI 0.47 to 1.00; low certainty). Lymphoceles were increased with mTOR-I substitution (RR 1.45, 95% CI 0.95 to 2.21; low certainty).Low dose CNI combined with mTOR-I probably increased glomerular filtration rate (GFR) (MD 6.24 mL/min, 95% CI 3.28 to 9.119; moderate certainty), reduced graft loss (RR 0.75, 95% CI 0.55 to 1.02; moderate certainty), and made little or no difference to acute rejection (RR 1.13 ; 95% CI 0.91 to 1.40; moderate certainty). Hypertension was decreased (RR 0.98, 95% CI 0.80 to 1.20; low certainty) as was CMV (RR 0.41, 95% CI 0.16 to 1.06; low certainty). Low dose CNI plus mTOR-I makes probably makes little of no difference to malignancy (RR 1.22, 95% CI 0.42 to 3.53; low certainty) and may make little of no difference to death (RR 1.16, 95% CI 0.71 to 1.90; moderate certainty). AUTHORS' CONCLUSIONS CNI avoidance increased acute rejection and CNI withdrawal increases acute rejection but reduced graft loss at least over the short-term. Low dose CNI with induction regimens reduced acute rejection and graft loss with no major adverse events, also in the short-term. The use of mTOR-I reduced CMV infections but increased the risk of acute rejection. These conclusions must be tempered by the lack of long-term data in most of the studies, particularly with regards to chronic antibody-mediated rejection, and the suboptimal methodological quality of the included studies.
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Affiliation(s)
- Krishna M Karpe
- Canberra HospitalRenal ServicesYamba DriveGarranACTAustralia2605
- Australian National University Medical SchoolActonACTAustralia2601
| | - Girish S Talaulikar
- Canberra HospitalRenal ServicesYamba DriveGarranACTAustralia2605
- Australian National University Medical SchoolActonACTAustralia2601
| | - Giles D Walters
- Canberra HospitalRenal ServicesYamba DriveGarranACTAustralia2605
- Australian National University Medical SchoolActonACTAustralia2601
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Cruzado JM, Pascual J, Sánchez‐Fructuoso A, Serón D, Díaz JM, Rengel M, Oppenheimer F, Hernández D, Paravisini A, Saval N, Morales JM. Controlled randomized study comparing the cardiovascular profile of everolimus with tacrolimus in renal transplantation. Transpl Int 2016; 29:1317-1328. [DOI: 10.1111/tri.12862] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 05/03/2016] [Accepted: 09/16/2016] [Indexed: 01/06/2023]
Affiliation(s)
- Josep M. Cruzado
- Nephrology Department IDIBELL Hospital de Bellvitge Barcelona Spain
| | - Julio Pascual
- Nephrology Department Hospital del Mar Barcelona Spain
| | | | - Daniel Serón
- Nephrology Department Hospital Vall Hebron Barcelona Spain
| | - Joan M. Díaz
- Nephrology Department Fundació Puigvert Barcelona Spain
| | - Manuel Rengel
- Nephrology Department Hospital Gregorio Marañón Madrid Spain
| | - Federico Oppenheimer
- Kidney Transplant Department Hospital Clínic i Provincial de Barcelona Barcelona Spain
| | | | | | - Núria Saval
- Medical Department Novartis Farmacéutica Barcelona Spain
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Pecoits-Filho R, Calice-Silva V. Unchain the heart: impact of left ventricular myocardial hypertrophy regression in kidney transplant outcomes. Nephrol Dial Transplant 2016; 31:1025-6. [PMID: 26797262 DOI: 10.1093/ndt/gfv424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 11/17/2015] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Viviane Calice-Silva
- School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, Brazil
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Paoletti E, Bellino D, Signori A, Pieracci L, Marsano L, Russo R, Massarino F, Ravera M, Fontana I, Carta A, Cassottana P, Garibotto G. Regression of asymptomatic cardiomyopathy and clinical outcome of renal transplant recipients: a long-term prospective cohort study. Nephrol Dial Transplant 2015; 31:1168-74. [PMID: 26472820 DOI: 10.1093/ndt/gfv354] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 09/14/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Asymptomatic left ventricular hypertrophy (LVH) is highly prevalent and associated with an adverse outcome in renal transplant recipients (RTRs). Nonetheless, there are currently no available studies analyzing the effect of LVH regression on solid clinical endpoints in these patients. METHODS This study is the prospective observational extension of two randomized controlled trials aimed at assessing the effect of active intervention on post-transplant LVH in RTRs. We evaluated the incidence of a composite of death and any cardiovascular (CV) or renal event in 60 RTRs in whom LVH regression was observed and in 40 whose LVH remained unchanged or worsened. RESULTS During an 8.4 ± 3.5-year follow-up, 8 deaths, 18 CV events and 6 renal events occurred in the entire cohort. Multivariable analysis showed that age [hazard ratio (HR) 1.07, 95% confidence interval (CI) 1.03-1.12 each 1 year, P = 0.002] and LVH regression (HR 0.42, 95% CI 0.22-0.87, P = 0.019) were significant predictors of the composite endpoint. Kaplan-Meier estimates showed better survival rates in patients in whom actual LVH regression was achieved (P < 0.001, log-rank test). Age (HR 1.09, 95% CI 1.03-1.15 each 1 year, P = 0.004), better graft function (HR 0.95, 95% CI 0.91-0.99 each 1 mL/min/1.73 m(2) increase in estimated glomerular filtration rate, P = 0.03) and LVH regression (HR 0.41, 95% CI 0.22-0.79, P = 0.01) were significant predictors of the CV endpoint. Patients with a left ventricular mass index decrease also showed better cardiac event-free survival (P = 0.0022, log-rank test). CONCLUSIONS This is the first study to demonstrate that LVH regression, regardless of the therapeutic strategy adopted to achieve it, portends better long-term clinical outcome in RTRs.
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Affiliation(s)
- Ernesto Paoletti
- Division of Nephrology, Dialysis, and Transplantation, University of Genoa, IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Genoa, Italy
| | - Diego Bellino
- Division of Nephrology, Dialysis, and Transplantation, University of Genoa, IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Genoa, Italy
| | - Alessio Signori
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Laura Pieracci
- Division of Nephrology, Dialysis, and Transplantation, University of Genoa, IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Genoa, Italy
| | - Luigina Marsano
- Division of Nephrology, Dialysis, and Transplantation, University of Genoa, IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Genoa, Italy
| | - Rodolfo Russo
- Division of Nephrology, Dialysis, and Transplantation, University of Genoa, IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Genoa, Italy
| | - Fabio Massarino
- Division of Nephrology, Dialysis, and Transplantation, University of Genoa, IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Genoa, Italy
| | - Maura Ravera
- Division of Nephrology, Dialysis, and Transplantation, University of Genoa, IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Genoa, Italy
| | - Iris Fontana
- Kidney Transplant Unit, IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Genoa, Italy
| | - Annalisa Carta
- Division of Nephrology, Dialysis, and Transplantation, University of Genoa, IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Genoa, Italy
| | - Paolo Cassottana
- Division of Cardiology, IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Genoa, Italy
| | - Giacomo Garibotto
- Division of Nephrology, Dialysis, and Transplantation, University of Genoa, IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Genoa, Italy
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Murbraech K, Massey R, Undset LH, Midtvedt K, Holdaas H, Aakhus S. Cardiac response to early conversion from calcineurin inhibitor to everolimus in renal transplant recipients--a three-yr serial echocardiographic substudy of the randomized controlled CENTRAL trial. Clin Transplant 2015; 29:678-84. [PMID: 25982053 DOI: 10.1111/ctr.12565] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2015] [Indexed: 12/31/2022]
Abstract
BACKGROUND In transplant recipients, calcineurin inhibitors (CNIs) are associated with adverse cardiac effects while mTOR inhibitors have been reported to be beneficial. We performed a randomized controlled trial (RCT) in de novo renal transplant recipients examining cardiac responses of everolimus vs. CNI. METHODS This was a substudy of the three-yr CENTRAL study, an RCT on safety and efficacy of early (week 7 post-engraftment) conversion from cyclosporine A (CsA) to everolimus vs. continued CsA. Thirty-nine recipients [median age 64 yr, (range 31-81)] completed echocardiographic evaluations at baseline, one, and three yr. RESULTS After three yr, there was no difference between groups in left ventricle (LV) diastolic function, LV systolic function, LV morphology, and blood pressure response. We observed a relevant decrease in LV mass (CsA; 9.6%, p = 0.008, vs. everolimus; 7.0% reduction, p = 0.15), stabilized LV diastolic function, and a trend toward lower systolic blood pressure with 6 mmHg decrease in both arms (CsA, p = 0.08; everolimus, p = 0.14). Diastolic blood pressure was significantly reduced (8 mmHg decrease, p = 0.002) only in everolimus patients. CONCLUSIONS After three-yr follow-up, no clinically relevant effect on cardiac function of an early conversion from CsA to an everolimus-based immunosuppressive regimen was detected in de novo renal transplant recipients.
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Affiliation(s)
- Klaus Murbraech
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Norway
| | - Richard Massey
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Norway
| | - Liv H Undset
- Department of Medicine, Baerum County Hospital, Baerum, Norway
| | - Karsten Midtvedt
- Department of Nephrology, Department of Transplant Medicine, Oslo University Hospital, Rikshospitalet, Norway
| | - Hallvard Holdaas
- Department of Nephrology, Department of Transplant Medicine, Oslo University Hospital, Rikshospitalet, Norway
| | - Svend Aakhus
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Norway
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Regression of cardiac growth in kidney transplant recipients using anti-m-TOR drugs plus RAS blockers: a controlled longitudinal study. BMC Nephrol 2014; 15:65. [PMID: 24755192 PMCID: PMC4005821 DOI: 10.1186/1471-2369-15-65] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 04/16/2014] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Left ventricular hypertrophy (LVH) is common in kidney transplant (KT) recipients. LVH is associated with a worse outcome, though m-TOR therapy may help to revert this complication. We therefore conducted a longitudinal study to assess morphological and functional echocardiographic changes after conversion from CNI to m-TOR inhibitor drugs in nondiabetic KT patients who had previously received RAS blockers during the follow-up. METHODS We undertook a 1-year nonrandomized controlled study in 30 non-diabetic KT patients who were converted from calcineurin inhibitor (CNI) to m-TOR therapy. A control group received immunosuppressive therapy based on CNIs. Two echocardiograms were done during the follow-up. RESULTS Nineteen patients were switched to SRL and 11 to EVL. The m-TOR group showed a significant reduction in LVMi after 1 year (from 62 ± 22 to 55 ± 20 g/m2.7; P=0.003, paired t-test). A higher proportion of patients showing LVMi reduction was observed in the m-TOR group (53.3 versus 29.3%, P=0.048) at the study end. In addition, only 56% of the m-TOR patients had LVH at the study end compared to 77% of the control group (P=0.047). A significant change from baseline in deceleration time in early diastole was observed in the m-TOR group compared with the control group (P=0.019). CONCLUSIONS Switching from CNI to m-TOR therapy in non-diabetic KT patients may regress LVH, independently of blood pressure changes and follow-up time. This suggests a direct non-hemodynamic effect of m-TOR drugs on cardiac mass.
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