1
|
Nunez M, Kelkar AA. Hepatitis C and heart transplantation: An update. Clin Transplant 2023; 37:e15111. [PMID: 37650430 DOI: 10.1111/ctr.15111] [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: 06/05/2023] [Revised: 08/15/2023] [Accepted: 08/18/2023] [Indexed: 09/01/2023]
Abstract
There are limited data regarding heart transplantation in the setting of hepatitis C virus (HCV) infection in either recipients or donors, as the practice was infrequent, given concerns of worse post-transplant outcomes. This changed dramatically after the development of highly effective HCV therapies, namely direct-acting antivirals (DAAs). Additionally, nucleic acid testing currently in use establishes more precisely the risk of HCV transmission from donors. As a result, chronic HCV infection in itself is no longer a barrier for heart transplant candidates, and the use of HCV-positive organs for HCV-infected and non-infected transplant candidates has increased dramatically. A review of the literature revealed that in the pre-DAA era, HCV seropositive heart transplant patients had a higher mortality than their seronegative counterparts. However, short-term data suggest that the differences in survival have been erased in the DAA era. Heart transplantation from HCV-viremic donors to HCV-uninfected recipients has become increasingly common as the number of deceased donors with HCV viremia has increased over the past years. Preliminary outcome reports are very encouraging, although further data are needed with regard to long-term safety. New information continues to be incorporated to optimize protocols that guide this practice.
Collapse
Affiliation(s)
- Marina Nunez
- Department of Internal Medicine, Section on Infectious Diseases, Wake Forest School of Medicine, Medical Center Boulevard, Winston Salem, North Carolina, USA
| | - Anita A Kelkar
- U.S. Department of Veterans Affairs, Kernersville VA Health Care System, Kernesville, North Carolina, USA
| |
Collapse
|
2
|
Xie MW, Keenan SP, Toma M, Levy RD, Slaunwhite A, Rose C. Outcomes following heart or bilateral-lung transplantation from donors who died of drug toxicity in British Columbia, Canada. Clin Transplant 2023; 37:e14866. [PMID: 36512481 DOI: 10.1111/ctr.14866] [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: 06/30/2022] [Revised: 10/31/2022] [Accepted: 11/21/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The illicit drug toxicity (overdose) crisis has worsened across Canada; between 2016 and 2021, more than 28,000 individuals have died of drug toxicity. Organ donation from persons who experience drug toxicity death (DTD) has increased in recent years. This study examines whether survival after heart or bilateral-lung transplantation differed by donor cause of death. METHODS We studied transplant recipients in British Columbia who received heart (N = 110) or bilateral-lung (N = 223) transplantation from deceased donors aged 12-70 years between 2013 and 2019. Transplant recipient survival was compared by donor cause of death from drug toxicity or other. Five-year Kaplan-Meier estimates of survival and 3-year inverse probability treatment weighted Cox proportional hazards models were conducted. RESULTS DTD donors made up 36% (40/110) of heart and 24% (54/223) of bilateral-lung transplantations. DTD donors were more likely to be young, white, and male. Unadjusted 5-year recipient survival was similar by donor cause of death (heart: 87% for DTD and 86% for non-DTD, p = .75; bilateral- lung: 80% for DTD and 76% for non-DTD, p = .65). Adjusted risk of mortality at 3-years post-transplant was similar between recipients of DTD and non-DTD donor heart (hazard ratio [HR]: .94, 95% confidence interval (CI): .22-4.07, p = .938) and bilateral-lung (HR: 1.06, 95% CI: .41-2.70, p = .908). CONCLUSION Recipient survival after heart or bilateral-lung transplantation from DTD donors and non-DTD donors was similar. Donation from DTD donors is safe and should be considered more broadly to increase organ donation.
Collapse
Affiliation(s)
- Max Wenheng Xie
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - Sean Patrick Keenan
- British Columbia Transplant, Vancouver, BC, Canada.,University of British Columbia, Vancouver, BC, Canada
| | - Mustafa Toma
- Division of Cardiology, St. Paul's Hospital, Vancouver, BC, Canada
| | - Robert Daniel Levy
- British Columbia Transplant, Vancouver, BC, Canada.,University of British Columbia, Vancouver, BC, Canada
| | - Amanda Slaunwhite
- British Columbia Centre for Disease Control, Vancouver, BC, Canada.,University of British Columbia, Vancouver, BC, Canada
| | - Caren Rose
- British Columbia Centre for Disease Control, Vancouver, BC, Canada.,University of British Columbia, Vancouver, BC, Canada
| |
Collapse
|
3
|
Donor substance abuse and heart transplantation outcomes. Heart Fail Rev 2023; 28:207-215. [PMID: 35435527 DOI: 10.1007/s10741-022-10241-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/07/2022] [Indexed: 02/07/2023]
Abstract
Heart failure continues to account for millions of cases and deaths worldwide. Heart transplant is the gold standard for treatment of advanced heart failure. Unfortunately, the supply of donor hearts continues to be limited with the increase in demand for heart transplantation. In this review, we aim to explore the safety and efficacy of using hearts from donors with history of substance use. Despite the theoretical effect of cocaine and alcohol on the cardiovascular system, several studies demonstrate no difference in outcomes (overall survival, graft rejection, graft vasculopathy) when using hearts from patients with history of cocaine and alcohol use. The opioid epidemic has expanded the potential donor pool where the current studies have not shown any adverse outcomes when considering donors with history of opioid use. The currently available evidence would support the use of donor hearts from patients with history of alcohol, cocaine, opioids, and marijuana use. Further studies are needed to evaluate the safety of using donor hearts from patients with history of nicotine use.
Collapse
|
4
|
Optimal, Early Postoperative Management of Cardiac Transplant and Durable Left Ventricular Assist Recipients. Curr Cardiol Rep 2022; 24:2023-2029. [PMID: 36327054 DOI: 10.1007/s11886-022-01823-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/19/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE OF REVIEW Summarize developments in the early postoperative care of patients undergoing cardiac transplantation or left ventricular assist device implantation. Provide a practical approach with personal insights to highly complex patients at risk for prolonged hospitalization. RECENT FINDINGS Advancements in technology allow for percutaneous mechanical circulatory support of both the right and left ventricles either isolated or combined via subclavian and neck vessels. Since the adult heart allocation system has been changed to reduce waitlist mortality, the use of temporary mechanical circulatory support has increased. This has influenced preoperative optimization by enabling ambulation and majorly changed postoperative strategy. New doors have been opened for a multidisciplinary approach to facilitate rapid weaning of inotropic medications, limitation of sedation, early liberation from mechanical ventilation, and mobilization. Individualized percutaneous mechanical circulatory support offers new possibilities for the early postoperative management of highly complex patients undergoing cardiac transplantation or durable left ventricular assist device implantation.
Collapse
|
5
|
Dutch MJ, Patrick CJ, Boan PA, Knott JC, Opdam HI. Prevalence of Blood-Borne Viruses and Predictors of Risk in Potential Organ Donors in Australia. Transpl Int 2022; 35:10395. [PMID: 35592445 PMCID: PMC9110643 DOI: 10.3389/ti.2022.10395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 04/06/2022] [Indexed: 11/17/2022]
Abstract
Internationally, the designation of a patient as an increased viral risk organ donor has been associated with lower utilisation rates. The actual prevalence of blood borne viruses in Australian potential organ donors, and the predictive performance of questionnaires administered to stratify this risk, remains unknown. We conducted a retrospective review of all patients who commenced workup for donation on the national database between 2014-2020. The prevalence of HIV, Active HBV and Active HCV in 3650 potential organ donors was 0.16%, 0.9%, and 2.2%, respectively. The behavioural risk profile was assessed in a subset of 3633 patients. Next-of-kin reported increased risk behaviours were associated with an increased prevalence of HCV but not of HIV or HBV (OR 13.8, p < 0.01, OR 0.3. p = 0.42, OR 1.5, p = 0.14). Furthermore, the majority of HIV and HBV infections occurred in potential donors without a disclosed history of increased risk behaviours. In this series, donors had a higher prevalence of HCV, and similar rates of HBV and HIV to the broader community. Behavioural transmission risks were poorly predictive of HIV and HBV. Rather than pre-transplantation behavioural risk screening, routine post-transplant recipient screening may provide a more powerful tool in mitigating the consequences of unexpected viral transmission.
Collapse
Affiliation(s)
- Martin J. Dutch
- Royal Melbourne Hospital, Melbourne, VIC, Australia
- DonateLife (Victoria), Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
| | - Cameron J. Patrick
- Statistical Consultancy Unit, University of Melbourne, Melbourne, VIC, Australia
| | - Peter A. Boan
- Microbiology Department, PathWest Laboratory Medicine, Perth, WA, Australia
- Department of Infectious Disease, Fiona Stanley Hospital, Perth, WA, Australia
| | - Jonathan C. Knott
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
- Emergency Department, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Helen I. Opdam
- Intensive Care Unit, Austin Hospital, Melbourne, VIC, Australia
- Australian Organ and Tissue Authority, Canberra, ACT, Australia
| |
Collapse
|
6
|
Baran DA, Lansinger J, Long A, Herre JM, Yehya A, Sawey EJ, Badiye AP, Old W, Copeland J, Stelling K, Copeland H. Intoxicated Donors and Heart Transplant Outcomes: Long-Term Safety. Circ Heart Fail 2021; 14:e007433. [PMID: 34315226 PMCID: PMC8366767 DOI: 10.1161/circheartfailure.120.007433] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Supplemental Digital Content is available in the text. Background: The opioid crisis has led to an increase in available donor hearts, although questions remain about the long-term outcomes associated with the use of these organs. Prior studies have relied on historical information without examining the toxicology results at the time of organ offer. The objectives of this study were to examine the long-term survival of heart transplants in the recent era, stratified by results of toxicological testing at the time of organ offer as well as comparing the toxicology at the time of donation with variables based on reported history. Methods: The United Network for Organ Sharing database was requested as well as the donor toxicology field. Between 2007 and 2017, 23 748 adult heart transplants were performed. United Network for Organ Sharing historical variables formed a United Network for Organ Sharing Toxicology Score and the measured toxicology results formed a Measured Toxicology Score. Survival was examined by the United Network for Organ Sharing Toxicology Score and Measured Toxicology Score, as well as Cox proportional hazards models incorporating a variety of risk factors. Results: The number and percent of donors with drug use has significantly increased over the study period (P<0.0001). Cox proportional hazards modeling of survival including toxicological and historical data did not demonstrate differences in post-transplant mortality. Combinations of drugs identified by toxicology were not associated with differences in survival. Lower donor age and ischemic time were significantly positively associated with survival (P<0.0001). Conclusions: Among donors accepted for transplantation, neither history nor toxicological evidence of drug use was associated with significant differences in survival. Increasing use of such donors may help alleviate the chronic donor shortage.
Collapse
Affiliation(s)
- David A Baran
- Division of Cardiology, Sentara Heart Hospital, Norfolk, VA (D.A.B., J.L., A.L., J.M.H., A.Y., E.J.S., A.P.B., W.O., K.S.)
| | - Justin Lansinger
- Division of Cardiology, Sentara Heart Hospital, Norfolk, VA (D.A.B., J.L., A.L., J.M.H., A.Y., E.J.S., A.P.B., W.O., K.S.)
| | - Ashleigh Long
- Division of Cardiology, Sentara Heart Hospital, Norfolk, VA (D.A.B., J.L., A.L., J.M.H., A.Y., E.J.S., A.P.B., W.O., K.S.)
| | - John M Herre
- Division of Cardiology, Sentara Heart Hospital, Norfolk, VA (D.A.B., J.L., A.L., J.M.H., A.Y., E.J.S., A.P.B., W.O., K.S.)
| | - Amin Yehya
- Division of Cardiology, Sentara Heart Hospital, Norfolk, VA (D.A.B., J.L., A.L., J.M.H., A.Y., E.J.S., A.P.B., W.O., K.S.)
| | - Edward J Sawey
- Division of Cardiology, Sentara Heart Hospital, Norfolk, VA (D.A.B., J.L., A.L., J.M.H., A.Y., E.J.S., A.P.B., W.O., K.S.)
| | - Amit P Badiye
- Division of Cardiology, Sentara Heart Hospital, Norfolk, VA (D.A.B., J.L., A.L., J.M.H., A.Y., E.J.S., A.P.B., W.O., K.S.)
| | - Wayne Old
- Division of Cardiology, Sentara Heart Hospital, Norfolk, VA (D.A.B., J.L., A.L., J.M.H., A.Y., E.J.S., A.P.B., W.O., K.S.)
| | | | - Kelly Stelling
- Division of Cardiology, Sentara Heart Hospital, Norfolk, VA (D.A.B., J.L., A.L., J.M.H., A.Y., E.J.S., A.P.B., W.O., K.S.)
| | | |
Collapse
|
7
|
Altshuler PJ, Helmers MR, Atluri P. Organ allocation and procurement in cardiac transplantation. Curr Opin Organ Transplant 2021; 26:282-289. [PMID: 33938464 DOI: 10.1097/mot.0000000000000872] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW There is a critical shortage of organs in cardiac transplantation. Recent advancements in both organ allocation and donor utilization have intended to address this shortage and optimally allocate allografts. This review evaluates several important aspects of recipient and donor management. For recipients, the focus is placed on the evolving mechanical circulatory support population and its bidirectional impact on organ allocation. From the donor standpoint, organ utilization is assessed with respect to increasing access to previously unused allografts. RECENT FINDINGS Implementation of the new heart allocation system in the United States has better stratified waitlist candidates by illness acuity. Compared to the prior system, those requiring venoarterial extracorporeal membrane oxygenation support are less likely to die on the waitlist, although conflicting data exists whether this has improved their posttransplant survival. The use of pretransplant intra-aortic balloon pumps has markedly increased, whereas transplantation of patients with dischargeable left ventricular assist devices has decreased. Although some studies have reported inferior short- to mid-term posttransplant survival in the new system compared to its predecessor, others report similar outcomes.Several recent advancements in donor utilization have also been noted. Coinciding with the global increase in drug overdose deaths, efforts have been made to increase use of these donors who are frequently considered 'increased risk' and are hepatitis C-positive. Grafts from these donors appear safe to use. These, alongside donation after circulatory death donors, represent potentially underutilized populations that may effectively expand the donor pool. SUMMARY Recent changes in organ allocation, alongside efforts to expand the donor pool, have attempted to improve cardiac allograft utilization and reduce the imbalance between organ supply and demand. Ongoing monitoring and continuous re-evaluation of these efforts will help guide future practice.
Collapse
Affiliation(s)
- Peter J Altshuler
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | |
Collapse
|