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Masarone D, Lombardi C, Falco L, Coscioni E, Metra M. Recent Advances across the Spectrum of Heart Failure and Heart Transplant. J Clin Med 2024; 13:1427. [PMID: 38592320 PMCID: PMC10932249 DOI: 10.3390/jcm13051427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 02/27/2024] [Indexed: 04/10/2024] Open
Abstract
In recent years, remarkable progress has been accomplished in the heart failure (HF) landscape, with novel drugs and groundbreaking device approaches [...].
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Affiliation(s)
- Daniele Masarone
- Heart Failure Unit, AOS dei Colli-Monaldi Hospital, 80121 Naples, Italy;
| | - Carlo Lombardi
- Cardiology Unit, Department of Medical and Surgical Specialities, Radiological Sciences and Public Health, University of Brescia, 25121 Brescia, Italy; (C.L.); (M.M.)
| | - Luigi Falco
- Heart Failure Unit, AOS dei Colli-Monaldi Hospital, 80121 Naples, Italy;
| | - Enrico Coscioni
- Cardiac Surgery Division, AOU San Leonardo, 84100 Salerno, Italy;
| | - Marco Metra
- Cardiology Unit, Department of Medical and Surgical Specialities, Radiological Sciences and Public Health, University of Brescia, 25121 Brescia, Italy; (C.L.); (M.M.)
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Santoro F, Casanova A, Simone S, Alfieri C, Falcone A, Dello Strologo A, Grandinetti V, Busutti M, Comai G, Marvulli TM, Zippo MG, Castellano G, La Manna G, Gesualdo L, Giuseppe G, Pesce F. Immunosuppressive therapy and oral anticoagulation in kidney transplant recipients: Direct oral anticoagulants versus vitamin-k antagonists. Eur J Intern Med 2024; 119:71-77. [PMID: 37573220 DOI: 10.1016/j.ejim.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 07/31/2023] [Accepted: 08/01/2023] [Indexed: 08/14/2023]
Abstract
BACKGROUND direct oral anticoagulants (DOACs) are an alternative to conventional antagonist of vitamin-K (AVK). However, immune suppressive drugs (ISDs) may interfere with DOACs pharmacokinetic. AIM OF THIS STUDY evaluate safety and efficacy profile of DOACs compared to AVK in kidney transplant recipients (KTRs) treated with ISDs. METHODS a multi-center study from 4 Italian University hospitals enrolling consecutive KTRs on DOACs or AVK was carried out. Sixty-six patients on DOACs were compared with fifty patients on AVK with similar clinical features. Serial evaluation of renal function and serum levels of ISDs during 18 months follow-up (FU) was performed. RESULTS Mean age of DOACs patients was 67±9 and mean eGFR was 58,3± 30,4mL/min/1.73m2. ISDs included tacrolimus (n=47, 71%), cyclosporin (n=13, 20%), everolimus (n=10, 7%) and sirolimus (n=4, 6%). After 14 days of DOACs therapy initiation there was a slight increase of serum levels of tacrolimus (+0.19±0.67 p=0.80) and cyclosporine (+0.12±0.25 p=0.94) not statistically significant. Levels of Tacrolimus and cyclosporin were stable at serial evaluation during 18-months follow-up. There were no thromboembolic events among patients treated with DOACs or AVK and no differences in term of major bleeding (6% vs 4% p=0.69), at long-term follow-up. There was no difference in term of eGFR decline from start therapy to 18 months FU between DOACs vs AVK therapy (-3.9±1 vs -3.8±2 p=0.82). CONCLUSION DOACs have similar safety and efficacy than AVK among KTRs treated with ISDs. However, careful evaluation of potential drug interaction and ISDs serum levels is needed.
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Affiliation(s)
- Francesco Santoro
- Department of Medical and Surgical sciences, University of Foggia, Italy;.
| | - Annalisa Casanova
- Nephrology, Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area - (DiMePRe-J), University of Bari "A. Moro", Bari, Italy;.
| | - Simona Simone
- Nephrology, Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area - (DiMePRe-J), University of Bari "A. Moro", Bari, Italy;.
| | - Carlo Alfieri
- Department of Clinical Sciences and Community Health, University of Milan, Italy;; Unit of Nephrology Dialysis and Renal Transplantation, IRCCS Cà Granda Ospedale Maggiore Policlinico Milan, Italy.
| | - Adele Falcone
- Department of Clinical Sciences and Community Health, University of Milan, Italy;; Unit of Nephrology Dialysis and Renal Transplantation, IRCCS Cà Granda Ospedale Maggiore Policlinico Milan, Italy.
| | - Andrea Dello Strologo
- Department of Translational Medicine and Surgery, University Cattolica Sacro Cuore, Rome, Italy;.
| | - Valeria Grandinetti
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.
| | - Marco Busutti
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.
| | - Giorgia Comai
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.
| | - Tommaso Maria Marvulli
- Nephrology, Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area - (DiMePRe-J), University of Bari "A. Moro", Bari, Italy;.
| | - Maria Grazia Zippo
- Nephrology, Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area - (DiMePRe-J), University of Bari "A. Moro", Bari, Italy;.
| | - Giuseppe Castellano
- Department of Clinical Sciences and Community Health, University of Milan, Italy;; Unit of Nephrology Dialysis and Renal Transplantation, IRCCS Cà Granda Ospedale Maggiore Policlinico Milan, Italy.
| | - Gaetano La Manna
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Department of medical and surgery sciences, Alma Mater Studiorum University of Bologna, Italy.
| | - Loreto Gesualdo
- Nephrology, Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area - (DiMePRe-J), University of Bari "A. Moro", Bari, Italy;.
| | - Grandaliano Giuseppe
- Department of Translational Medicine and Surgery, University Cattolica Sacro Cuore, Rome, Italy;; Nephrology Unit, Dept. of Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS.
| | - Francesco Pesce
- Division of Renal Medicine, "Fatebenefratelli Isola Tiberina-Gemelli Isola", Rome, Italy.
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Darche FF, Fabricius LC, Helmschrott M, Rahm AK, Ehlermann P, Bruckner T, Sommer W, Warnecke G, Frey N, Rivinius R. Oral Anticoagulants after Heart Transplantation-Comparison between Vitamin K Antagonists and Direct Oral Anticoagulants. J Clin Med 2023; 12:4334. [PMID: 37445369 DOI: 10.3390/jcm12134334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/25/2023] [Accepted: 06/26/2023] [Indexed: 07/15/2023] Open
Abstract
AIMS Patients after heart transplantation (HTX) often require oral anticoagulants (OACs) due to atrial arrhythmias or thromboembolic events but little is known about the post-transplant use of direct oral anticoagulants (DOACs). We investigated the frequency, indications, and complications of DOACs and vitamin K antagonists (VKAs) after HTX. METHODS We screened all adult patients for the use of post-transplant OACs who underwent HTX at Heidelberg Heart Center between 2000 and 2021. Patients were stratified by type of OAC (DOAC or VKA) and by DOAC agents (apixaban, dabigatran, edoxaban, or rivaroxaban). Indications for OACs comprised atrial fibrillation, atrial flutter, pulmonary embolism, upper and lower extremity deep vein thrombosis, as well as intracardiac thrombus. RESULTS A total of 115 of 459 HTX recipients (25.1%) required OACs, including 60 patients with DOACs (52.2%) and 55 patients with VKAs (47.8%). Concerning DOACs, 28 patients were treated with rivaroxaban (46.7%), 27 patients with apixaban (45.0%), and 5 patients with edoxaban (8.3%). We found no significant differences between both groups concerning demographics, immunosuppressive drugs, concomitant medications, indications for OACs, ischemic stroke, thromboembolic events, or OAC-related death. Patients with DOACs after HTX had a significantly lower one-year rate of overall bleeding complications (p = 0.002) and a significantly lower one-year rate of gastrointestinal hemorrhage (p = 0.011) compared to patients with VKAs after HTX in the Kaplan-Meier estimator. CONCLUSIONS DOACs were comparable to VKAs concerning the risk of ischemic stroke, thromboembolic events, or OAC-related death but were associated with significantly fewer bleeding complications in HTX recipients.
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Affiliation(s)
- Fabrice F Darche
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Heidelberg Center for Heart Rhythm Disorders (HCR), Heidelberg University Hospital, 69120 Heidelberg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, 69120 Heidelberg, Germany
| | - Lisa C Fabricius
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Matthias Helmschrott
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Ann-Kathrin Rahm
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Heidelberg Center for Heart Rhythm Disorders (HCR), Heidelberg University Hospital, 69120 Heidelberg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, 69120 Heidelberg, Germany
| | - Philipp Ehlermann
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, 69120 Heidelberg, Germany
| | - Tom Bruckner
- Institute for Medical Biometry, University of Heidelberg, 69120 Heidelberg, Germany
| | - Wiebke Sommer
- Department of Cardiac Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Gregor Warnecke
- Department of Cardiac Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Norbert Frey
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Heidelberg Center for Heart Rhythm Disorders (HCR), Heidelberg University Hospital, 69120 Heidelberg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, 69120 Heidelberg, Germany
| | - Rasmus Rivinius
- Department of Cardiology, Angiology and Pneumology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Heidelberg Center for Heart Rhythm Disorders (HCR), Heidelberg University Hospital, 69120 Heidelberg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, 69120 Heidelberg, Germany
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Firth C, Shamoun F, Apolinario M, Lim ES, Zhang N, Keddis MT. Safety and mortality outcomes for direct oral anticoagulants in renal transplant recipients. PLoS One 2023; 18:e0285412. [PMID: 37192210 DOI: 10.1371/journal.pone.0285412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 04/20/2023] [Indexed: 05/18/2023] Open
Abstract
PURPOSE Direct oral anticoagulants (DOACs) are increasingly used in renal transplant recipients (RTR), but relatively understudied in this population. We assess the safety of post-transplant anticoagulation with DOACs compared to warfarin. METHODS We conducted a retrospective study of RTRs at the Mayo Clinic sites (2011-present) that were anticoagulated for greater than 3 months excluding the 1st month post-transplant. The main safety outcomes were bleeding and all-cause mortality. Concomitant antiplatelet and interacting drugs were noted. DOAC dose adjustment was assessed according to common US prescribing practices, guidelines, and/or FDA labeling. RESULTS The median follow-up was longer for RTRs on warfarin (1098 days [IQR 521, 1517]) than DOACs (449 days [IQR 338, 942]). Largely, there were no differences in baseline characteristics and comorbidities between RTRs on DOACs (n = 208; apixaban 91.3%, rivaroxaban 8.7%) versus warfarin (n = 320). There was no difference in post-transplant use of antiplatelets, immunosuppressants, most antifungals assessed, or amiodarone. There was no significant difference in incident major bleeding (8.4 vs. 5.3%, p = 0.89), GI bleeding (4.4% vs. 1.9%, p = 0.98), or intra-cranial hemorrhage (1.9% vs. 1.4%, p = 0.85) between warfarin and DOAC. There was no significant difference in mortality in the warfarin group compared to DOACs when adjusted for follow-up time (22.2% vs. 10.1%, p = 0.21). Rates of post-transplant venous thromboembolism, atrial fibrillation or stroke were similar between the two groups. 32% (n = 67) of patients on DOACs were dose reduced, where 51% of those reductions were warranted. 7% of patients that were not dose reduced should have been. CONCLUSIONS DOACs did not have inferior bleeding or mortality outcomes compared to warfarin in RTRs. There was greater use of warfarin compared to DOACs and a high rate of improper DOAC dose reduction.
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Affiliation(s)
- Christine Firth
- Department of Cardiovascular Diseases, Scottsdale, AZ, United States of America
| | - Fadi Shamoun
- Department of Cardiovascular Diseases, Scottsdale, AZ, United States of America
| | - Michael Apolinario
- Department of Internal Medicine, Scottsdale, AZ, United States of America
| | - Elisabeth S Lim
- Department of Quantitative Health Sciences, Scottsdale, AZ, United States of America
| | - Nan Zhang
- Department of Quantitative Health Sciences, Scottsdale, AZ, United States of America
| | - Mira T Keddis
- Department of Nephrology, Mayo Clinic, Scottsdale, AZ, United States of America
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A Review of Direct-acting Oral Anticoagulants and Their Use in Solid Organ Transplantation. Transplantation 2022; 106:2143-2154. [PMID: 35642975 DOI: 10.1097/tp.0000000000004195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Direct-acting oral anticoagulant (DOAC) use has increased dramatically since their introduction because of the growing evidence of proven efficacy and enhanced safety compared with warfarin and the low-molecular-weight heparins in the general population. Unfortunately, there is a dearth of quality data regarding the safety and efficacy of the DOACs in patients awaiting organ transplant and those who received a solid organ transplant. This review aims to evaluate the available literature and considerations regarding anticoagulation use in transplant recipients, focusing on preoperative, perioperative, and postoperative DOAC use.
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