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Townsend M, Khoury M, Koehl D, Kirklin JK, Cantor R, Beasley G, Chen CY, Boyle G, Parent JJ, Baez Hernandez N, Halnon N. Uncertain benefit of statins in pediatric heart transplant recipients: A PHTS analysis. J Heart Lung Transplant 2024; 43:703-713. [PMID: 38065240 DOI: 10.1016/j.healun.2023.11.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 11/27/2023] [Accepted: 11/30/2023] [Indexed: 05/07/2024] Open
Abstract
BACKGROUND Cardiac allograft vasculopathy (CAV) is a leading cause of graft failure in pediatric heart transplant recipients (HTRs). Early statin use has been shown to reduce CAV incidence and all-cause mortality in adult HTRs. We sought to evaluate the contemporary prevalence and trends of statin use in pediatric HTRs and the association between statin use with CAV development and graft failure. METHODS Patients aged <17 years at the time of primary heart transplant who survived to ≥3 years without CAV were identified from the Pediatric Heart Transplant Society database (2001-2018). Statin use in the first 3 years posttransplant was defined as consecutive, intermediate, or absent. Kaplan-Meier survival, multivariable modeling, and propensity score-matched analyses evaluated associations between statin use and CAV incidence and graft survival, with subanalyses performed on subjects aged ≥10 years at transplant. RESULTS Among 3,485 (of which 1,086 aged ≥10 years) HTRs, 584 (17%) received consecutive statin therapy, 647 (19%) received intermediate use, and 2,254 (65%) received no statin therapy. Statin use varied widely between sites, with increasing use in the ≥10-year-old cohort over time. By multivariate analysis, statin use was not associated with graft loss. Consecutive statin use was also not associated with graft survival or freedom from CAV development when compared to absent statin use in unmatched or propensity-matched analyses. CONCLUSIONS While statins remain commonly utilized in pediatric HTRs, early consecutive statin therapy did not decrease CAV incidence or graft loss. The differing effects of statins on CAV development and progression in pediatric vs adult HTRs suggest differing risk and mediating factors and require further study.
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Affiliation(s)
| | - Michael Khoury
- Stollery Children's Hospital University of Alberta, Edmonton, Alberta, Canada
| | - Devin Koehl
- Kirklin Institute for Research in Surgical Outcomes, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - James K Kirklin
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ryan Cantor
- Kirklin Institute for Research in Surgical Outcomes, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Gary Beasley
- University of Iowa Stead Family Children's Hospital, Iowa City, Iowa
| | - Chiu-Yu Chen
- Lucile Packard Children's Hospital Stanford, Palo Alto, California
| | | | - John J Parent
- Riley Hospital for Children University of Indiana, Indianapolis, Indiana
| | | | - Nancy Halnon
- Mattel Children's Hospital UCLA, Los Angeles, California
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Heart Transplant, Kawasaki Disease, and Bone Marrow Transplant: Are There Consequences? Curr Atheroscler Rep 2022; 24:243-251. [PMID: 35132571 DOI: 10.1007/s11883-022-00997-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2021] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW This article reviews the current landscape of cardiovascular disease (CVD) risk factors, focusing on dyslipidemia, which contribute to atherosclerosis in three unique populations: youth less than 18 years-of-age with a history of Kawasaki disease, and those who have undergone orthotopic heart and bone marrow transplants. RECENT FINDINGS Atherosclerosis, the major cause of CVD, begins in childhood. Acquired and genetic disorders of lipid and lipoprotein metabolism, present at an early age, are major contributors to early precursors of atherosclerosis, which accelerate after age 20. Treatment of the underlying medical condition and optimum management of all risk factors is critical in improving outcomes. Nonetheless, limited data is available to assist clinical decision-making, with the aim of improving outcomes. Atherosclerosis, beginning in childhood, is multifactorial in origin with complex interplay of inflammation, infection, endothelial dysfunction, and dyslipidemia. Future studies are needed to help elucidate the specific roles of disease mechanisms, with an emphasis on early intervention and prediction of subclinical disease. In addition to a heart healthy lifestyle, there may be a role for use of lipid-lowering medications beginning at an early age.
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Khoury M, McCrindle BW. The Rationale, Indications, Safety, and Use of Statins in the Pediatric Population. Can J Cardiol 2020; 36:1372-1383. [PMID: 32735868 DOI: 10.1016/j.cjca.2020.03.041] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 03/16/2020] [Accepted: 03/26/2020] [Indexed: 10/24/2022] Open
Abstract
Together with heart-healthy lifestyle habits, statins serve as the cornerstone of primary and secondary prevention of atherosclerotic cardiovascular disease in adults. Several conditions, most notably familial hypercholesterolemia (FH), cause early dyslipidemia and vascular disease, contributing to the development and progression of atherosclerosis from childhood and increased cardiovascular risk. In recent decades, studies increasingly have evaluated the safety and efficacy of statins in such high-risk youth. The strongest evidence for pediatric statin use is for the heterozygous FH population, whereby statin use has been shown to lower low-density lipoprotein cholesterol effectively, slow the progression of atherosclerosis and vascular dysfunction, and significantly reduce cardiovascular risk in early adulthood. Numerous meta-analyses and Cochrane reviews have demonstrated that attributed adverse effects, including liver toxicity, myositis, and rhabdomyolysis, occur no more frequently in youth receiving statins than placebos, with no impact on growth or development. However, further studies evaluating the long-term safety of pediatric statin use are required. In the current review, we summarize the pediatric experience of statin use to date, focusing on its utility for FH, Kawasaki disease, post-heart transplantation, and other at-risk populations. Current guidelines and indications for use are summarized, and the short- and medium-term safety experience is reviewed. Finally, a clinical approach to the indications, initiation, and monitoring of statins in youth is provided.
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Affiliation(s)
- Michael Khoury
- Division of Pediatric Cardiology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.
| | - Brian W McCrindle
- Labatt Family Heart Center, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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de Ferranti SD, Steinberger J, Ameduri R, Baker A, Gooding H, Kelly AS, Mietus-Snyder M, Mitsnefes MM, Peterson AL, St-Pierre J, Urbina EM, Zachariah JP, Zaidi AN. Cardiovascular Risk Reduction in High-Risk Pediatric Patients: A Scientific Statement From the American Heart Association. Circulation 2019; 139:e603-e634. [PMID: 30798614 DOI: 10.1161/cir.0000000000000618] [Citation(s) in RCA: 197] [Impact Index Per Article: 39.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This scientific statement presents considerations for clinical management regarding the assessment and risk reduction of select pediatric populations at high risk for premature cardiovascular disease, including acquired arteriosclerosis or atherosclerosis. For each topic, the evidence for accelerated acquired coronary artery disease and stroke in childhood and adolescence and the evidence for benefit of interventions in youth will be reviewed. Children and adolescents may be at higher risk for cardiovascular disease because of significant atherosclerotic or arteriosclerotic risk factors, high-risk conditions that promote atherosclerosis, or coronary artery or other cardiac or vascular abnormalities that make the individual more vulnerable to the adverse effects of traditional cardiovascular risk factors. Existing scientific statements and guidelines will be referenced when applicable, and suggestions for risk identification and reduction specific to each setting will be described. This statement is directed toward pediatric cardiologists, primary care providers, and subspecialists who provide clinical care for these young patients. The focus will be on management and justification for management, minimizing information on pathophysiology and epidemiology.
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Newman CB, Preiss D, Tobert JA, Jacobson TA, Page RL, Goldstein LB, Chin C, Tannock LR, Miller M, Raghuveer G, Duell PB, Brinton EA, Pollak A, Braun LT, Welty FK. Statin Safety and Associated Adverse Events: A Scientific Statement From the American Heart Association. Arterioscler Thromb Vasc Biol 2019; 39:e38-e81. [PMID: 30580575 DOI: 10.1161/atv.0000000000000073] [Citation(s) in RCA: 375] [Impact Index Per Article: 75.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
One in 4 Americans >40 years of age takes a statin to reduce the risk of myocardial infarction, ischemic stroke, and other complications of atherosclerotic disease. The most effective statins produce a mean reduction in low-density lipoprotein cholesterol of 55% to 60% at the maximum dosage, and 6 of the 7 marketed statins are available in generic form, which makes them affordable for most patients. Primarily using data from randomized controlled trials, supplemented with observational data where necessary, this scientific statement provides a comprehensive review of statin safety and tolerability. The review covers the general patient population, as well as demographic subgroups, including the elderly, children, pregnant women, East Asians, and patients with specific conditions such as chronic disease of the kidney and liver, human immunodeficiency viral infection, and organ transplants. The risk of statin-induced serious muscle injury, including rhabdomyolysis, is <0.1%, and the risk of serious hepatotoxicity is ≈0.001%. The risk of statin-induced newly diagnosed diabetes mellitus is ≈0.2% per year of treatment, depending on the underlying risk of diabetes mellitus in the population studied. In patients with cerebrovascular disease, statins possibly increase the risk of hemorrhagic stroke; however, they clearly produce a greater reduction in the risk of atherothrombotic stroke and thus total stroke, as well as other cardiovascular events. There is no convincing evidence for a causal relationship between statins and cancer, cataracts, cognitive dysfunction, peripheral neuropathy, erectile dysfunction, or tendonitis. In US clinical practices, roughly 10% of patients stop taking a statin because of subjective complaints, most commonly muscle symptoms without raised creatine kinase. In contrast, in randomized clinical trials, the difference in the incidence of muscle symptoms without significantly raised creatinine kinase in statin-treated compared with placebo-treated participants is <1%, and it is even smaller (0.1%) for patients who discontinued treatment because of such muscle symptoms. This suggests that muscle symptoms are usually not caused by pharmacological effects of the statin. Restarting statin therapy in these patients can be challenging, but it is important, especially in patients at high risk of cardiovascular events, for whom prevention of these events is a priority. Overall, in patients for whom statin treatment is recommended by current guidelines, the benefits greatly outweigh the risks.
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Tremoulet AH, Jain S, Jone PN, Best BM, Duxbury EH, Franco A, Printz B, Dominguez SR, Heizer H, Anderson MS, Glodé MP, He F, Padilla RL, Shimizu C, Bainto E, Pancheri J, Cohen HJ, Whitin JC, Burns JC. Phase I/IIa Trial of Atorvastatin in Patients with Acute Kawasaki Disease with Coronary Artery Aneurysm. J Pediatr 2019; 215:107-117.e12. [PMID: 31561960 PMCID: PMC6878161 DOI: 10.1016/j.jpeds.2019.07.064] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 07/17/2019] [Accepted: 07/24/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To determine the safety, tolerability, pharmacokinetics, and immunomodulatory effects of a 6-week course of atorvastatin in patients with acute Kawasaki disease with coronary artery (CA) aneurysm (CAA). STUDY DESIGN This was a Phase I/IIa 2-center dose-escalation study of atorvastatin (0.125-0.75 mg/kg/day) in 34 patients with Kawasaki disease (aged 2-17 years) with echocardiographic evidence of CAA. We measured levels of the brain metabolite 24(S)-hydroxycholesterol (24-OHC), serum lipids, acute-phase reactants, liver enzymes, and creatine phosphokinase; peripheral blood mononuclear cell populations; and CA internal diameter normalized for body surface area before atorvastatin treatment and at 2 and 6 weeks after initiation of atorvastatin treatment. RESULTS A 6-week course of up to 0.75 mg/kg/day of atorvastatin was well tolerated by the 34 subjects (median age, 5.3 years; IQR, 2.6-6.4 years), with no serious adverse events attributable to the study drug. The areas under the curve for atorvastatin and its metabolite were larger in the study subjects compared with those reported in adults, suggesting a slower rate of metabolism in children. The 24-OHC levels were similar between the atorvastatin-treated subjects and matched controls. CONCLUSIONS Atorvastatin was safe and well tolerated in our cohort of children with acute Kawasaki disease and CAA. A Phase III efficacy trial is warranted in this patient population, which may benefit from the known anti-inflammatory and immunomodulatory effects of this drug.
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Affiliation(s)
- Adriana H. Tremoulet
- Kawasaki Disease Research Center, Department of Pediatrics, University of California San Diego, La Jolla, California, USA; Rady Children’s Hospital San Diego, San Diego, California, USA
| | - Sonia Jain
- Biostatistics Research Center, Department of Family Medicine and Public Health, University of California San Diego, La Jolla, California
| | - Pei-Ni Jone
- Pediatric Cardiology, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Brookie M. Best
- Kawasaki Disease Research Center, Department of Pediatrics, University of California San Diego, La Jolla, California, USA; Rady Children’s Hospital San Diego, San Diego, California, USA,Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA
| | - Elizabeth H. Duxbury
- Kawasaki Disease Research Center, Department of Pediatrics, University of California San Diego, La Jolla, California, USA; Rady Children’s Hospital San Diego, San Diego, California, USA,Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA
| | - Alessandra Franco
- Kawasaki Disease Research Center, Department of Pediatrics, University of California San Diego, La Jolla, California, USA; Rady Children’s Hospital San Diego, San Diego, California, USA
| | - Beth Printz
- Kawasaki Disease Research Center, Department of Pediatrics, University of California San Diego, La Jolla, California, USA; Rady Children’s Hospital San Diego, San Diego, California, USA
| | - Samuel R. Dominguez
- Pediatric Infectious Disease, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Heather Heizer
- Pediatric Infectious Disease, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Marsha S. Anderson
- Pediatric Infectious Disease, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Mary P. Glodé
- Pediatric Infectious Disease, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Feng He
- Biostatistics Research Center, Department of Family Medicine and Public Health, University of California San Diego, La Jolla, California
| | - Robert L. Padilla
- Kawasaki Disease Research Center, Department of Pediatrics, University of California San Diego, La Jolla, California, USA; Rady Children’s Hospital San Diego, San Diego, California, USA
| | - Chisato Shimizu
- Kawasaki Disease Research Center, Department of Pediatrics, University of California San Diego, La Jolla, California, USA; Rady Children’s Hospital San Diego, San Diego, California, USA
| | - Emelia Bainto
- Kawasaki Disease Research Center, Department of Pediatrics, University of California San Diego, La Jolla, California, USA; Rady Children’s Hospital San Diego, San Diego, California, USA
| | - Joan Pancheri
- Kawasaki Disease Research Center, Department of Pediatrics, University of California San Diego, La Jolla, California, USA; Rady Children’s Hospital San Diego, San Diego, California, USA
| | | | - John C. Whitin
- Department of Pediatrics, Stanford University, Stanford, CA
| | - Jane C. Burns
- Kawasaki Disease Research Center, Department of Pediatrics, University of California San Diego, La Jolla, California, USA; Rady Children’s Hospital San Diego, San Diego, California, USA
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Abstract
Heart transplantation is offered to children with heart failure that is not amenable to medical or surgical therapy. Indications for heart transplant include unrepairable congenital heart disease, failed palliation of congenital heart disease, and cardiomyopathies. There has been tremendous progress in this field since the first heart transplant was performed in 1967. Each year, approximately 500 pediatric heart transplants take place worldwide. Pediatric heart transplant survivors are living longer with their initial transplant. Many pediatric practitioners are faced with caring for these patients before as well as after the heart transplant and, therefore, they should be knowledgeable about basic principles related to heart transplant. There are certain complications that are unique to this population, and medication side-effects, evaluation and management of a febrile illness, opportunistic infections, vaccination, pregnancy, and exercise recommendations are areas that require special consideration. [Pediatr Ann. 2018;47(4):e172-e178.].
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Daly KP, Stack M, Eisenga MF, Keane JF, Zurakowski D, Blume ED, Briscoe DM. Vascular endothelial growth factor A is associated with the subsequent development of moderate or severe cardiac allograft vasculopathy in pediatric heart transplant recipients. J Heart Lung Transplant 2016; 36:434-442. [PMID: 27865734 DOI: 10.1016/j.healun.2016.09.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 09/08/2016] [Accepted: 09/16/2016] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Cardiac allograft vasculopathy (CAV) is the leading cause of chronic allograft loss after pediatric heart transplantation. We hypothesized that biomarkers of endothelial injury and repair would predict CAV development in pediatric heart transplant recipients. METHODS Blood was collected from pediatric heart transplant recipients at the time of routine annual coronary angiography, and the concentrations of 13 angiogenesis-related molecules were determined. The primary end point was the presence of moderate or severe CAV by angiography during a 5-year follow-up period. RESULTS The study enrolled 48 recipients (57% male) with a median age of 15.5 years (range, 2-22 years) and median time post-transplant of 5.8 years (range, 2-15 years). Eight recipients developed moderate/severe CAV at a median follow-up of 4.7 years, of whom 3 died, 3 underwent retransplantation, 1 had a myocardial infarction, and 1 was listed for retransplantation. Clinical characteristics associated with the development of moderate/severe CAV included prednisone use at enrollment (p = 0.03) and positive recipient cytomegalovirus immunoglobulin G at the time of transplant (p = < 0.01). Multivariable Cox proportional hazards regression identified plasma vascular endothelial growth factor (VEGF)-A concentration greater than 90 pg/ml at the time of blood draw as a significant predictor of time to moderate or severe CAV (hazard ratio, 14.3; 95% confidence interval, 1.3-163). Receiver operating characteristic curve analysis demonstrated that VEGF-A shows moderate performance for association with the subsequent development of CAV (area under the curve, 0.77; 95% confidence interval, 0.61-0.92). CONCLUSIONS VEGF-A levels in pediatric heart transplant recipients are associated with clinically important CAV progression within the subsequent 5 years.
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Affiliation(s)
- Kevin P Daly
- Transplant Research Program, Department of Medicine, Boston, Massachusetts; Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Maria Stack
- Transplant Research Program, Department of Medicine, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; Division of Nephrology, Department of Medicine, Boston, Massachusetts
| | - Michele F Eisenga
- Transplant Research Program, Department of Medicine, Boston, Massachusetts; Division of Nephrology, Department of Medicine, Boston, Massachusetts
| | - John F Keane
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - David Zurakowski
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; Department of Anesthesia, Boston Children's Hospital, Boston, Massachusetts; Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts
| | - Elizabeth D Blume
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - David M Briscoe
- Transplant Research Program, Department of Medicine, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; Division of Nephrology, Department of Medicine, Boston, Massachusetts.
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Greenway SC, Butts R, Naftel DC, Pruitt E, Kirklin JK, Larsen I, Urschel S, Knecht K, Law Y. Statin therapy is not associated with improved outcomes after heart transplantation in children and adolescents. J Heart Lung Transplant 2016; 35:457-65. [DOI: 10.1016/j.healun.2015.10.040] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Revised: 09/25/2015] [Accepted: 10/31/2015] [Indexed: 01/16/2023] Open
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Marcos-Alonso S, Bautista-Hernandez V, Portela Torrón F. Successful cardiac transplantation in a patient with congenital generalized lipodystrophy. Pediatr Transplant 2016; 20:321-4. [PMID: 26821845 DOI: 10.1111/petr.12656] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/16/2015] [Indexed: 11/30/2022]
Abstract
We report a case of a 12-yr-old boy referred to our unit with congenital generalized lipodystrophy and dilated cardiomyopathy related to a lamin gene mutation. He progressively developed end-stage heart failure and was referred for heart transplant evaluation. The patient's lipid profile, glucose level, and renal function were normal, and vascular retinopathy was ruled out. He underwent orthotopic bicaval HT and had an uneventful recovery. He was discharged home two wk after surgery with good graft function. During follow-up, he developed hyperglycemia and dyslipidemia, which were controlled by increasing leptin dose and starting oral antidiabetic drugs. The patient is currently doing well two yr after transplantation.
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Affiliation(s)
- Sonia Marcos-Alonso
- Congenital Heart Diseases and Pediatric Cardiology Unit, Pediatric Department, Hospital Materno Infantil, Complejo Hospitalario Universitario A Coruña, A Coruna, Spain
| | - Víctor Bautista-Hernandez
- Congenital Heart Diseases and Pediatric Cardiology Unit, Cardiac Surgery Department, Complejo Hospitalario Universitario A Coruña, A Coruna, Spain
| | - Francisco Portela Torrón
- Congenital Heart Diseases and Pediatric Cardiology Unit, Cardiac Surgery Department, Complejo Hospitalario Universitario A Coruña, A Coruna, Spain
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Abstract
AIM The aim of this study was to perform an audit of the use of statins in Australian pediatric hospitals. METHODS A retrospective audit of patients prescribed statins during a visit to a pediatric hospital, as in- or outpatients, was performed in four major children's hospitals in three Australian states. Patients were identified through hospital pharmacy dispensing records. Statin use (dose, type) as well as medical history was recorded. RESULTS A total of 157 patients under the age of 18 were included in the audit. The most common reasons for being prescribed a statin included history of organ transplantation, renal disease and familial hypercholesterolemia (FH). Four statins were prescribed: atorvastatin (n = 77), pravastatin (n = 45), simvastatin (n = 25) and rosuvastatin (n = 10). All statins, apart from rosuvastatin, were used in very young children (1-7 years old). Polypharmacy was common in these patients, including combinations with calcineurin inhibitors and diltiazem, which can increase systemic statin exposure. A small number of very young children were prescribed high doses of statin, based on mg/kg dosing. CONCLUSIONS Statins were prescribed to children younger than suggested by current Australian guidelines, with atorvastatin being the preferred statin of choice. Long-term safety studies on the use of statins in children have only included FH patients so far, who are generally healthy besides their raised lipid levels. Further long-term safety studies are needed to include the more vulnerable transplant and renal patients, identified in this audit as being prescribed statins. This can help formulate guidelines for the safest possible use of this class of drugs in the pediatric setting, including the possibility of weight-based recommendations for younger children.
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Abstract
Pediatric heart transplantation (HTx) remains an important treatment option in the care of children with end-stage heart disease, whether it is secondary to cardiomyopathy or congenital heart disease (CHD). As surgical outcomes for CHD have improved, the indications for pediatric HTx have had to be dynamic, not only for children with CHD but also for the growing population of adults with CHD. As the field of pediatric HTx has evolved, the outcomes for children undergoing HTx have improved. This is undoubtedly due to the continued research efforts of both single-center studies, as well as research collaboratives such as the International Society for Heart and Lung Transplantation (ISHLT) and the Pediatric Heart Transplant Study (PHTS) group. Research collaboratives are increasingly important in pediatric HTx as single center studies for a limited patient population may not elicit strong enough evidence for practice evolution. Similarly, complications that limit the long term graft survival may occur in a minority of patients thus pooled experience is essential. This review focuses on the indications and outcomes for pediatric HTx, with a special emphasis on studies generated by these research collaboratives.
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Affiliation(s)
- Philip T Thrush
- 1 The Heart Center, Nationwide Children's Hospital, 2 Department of Pediatrics, The Ohio State University, Columbus, OH, USA
| | - Timothy M Hoffman
- 1 The Heart Center, Nationwide Children's Hospital, 2 Department of Pediatrics, The Ohio State University, Columbus, OH, USA
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Thrush PT, Hoffman TM. Pediatric heart transplantation-indications and outcomes in the current era. J Thorac Dis 2014; 6:1080-96. [PMID: 25132975 DOI: 10.3978/j.issn.2072-1439.2014.06.16] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 06/04/2014] [Indexed: 12/20/2022]
Abstract
Pediatric heart transplantation (HTx) remains an important treatment option in the care of children with end-stage heart disease, whether it is secondary to cardiomyopathy or congenital heart disease (CHD). As surgical outcomes for CHD have improved, the indications for pediatric HTx have had to be dynamic, not only for children with CHD but also for the growing population of adults with CHD. As the field of pediatric HTx has evolved, the outcomes for children undergoing HTx have improved. This is undoubtedly due to the continued research efforts of both single-center studies, as well as research collaboratives such as the International Society for Heart and Lung Transplantation (ISHLT) and the Pediatric Heart Transplant Study (PHTS) group. Research collaboratives are increasingly important in pediatric HTx as single center studies for a limited patient population may not elicit strong enough evidence for practice evolution. Similarly, complications that limit the long term graft survival may occur in a minority of patients thus pooled experience is essential. This review focuses on the indications and outcomes for pediatric HTx, with a special emphasis on studies generated by these research collaboratives.
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Affiliation(s)
- Philip T Thrush
- 1 The Heart Center, Nationwide Children's Hospital, 2 Department of Pediatrics, The Ohio State University, Columbus, OH, USA
| | - Timothy M Hoffman
- 1 The Heart Center, Nationwide Children's Hospital, 2 Department of Pediatrics, The Ohio State University, Columbus, OH, USA
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14
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Chen CK, Dipchand AI. The current state and key issues of pediatric heart transplantation. INDIAN JOURNAL OF TRANSPLANTATION 2013. [DOI: 10.1016/j.ijt.2013.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Costanzo MR, Dipchand A, Starling R, Anderson A, Chan M, Desai S, Fedson S, Fisher P, Gonzales-Stawinski G, Martinelli L, McGiffin D, Smith J, Taylor D, Meiser B, Webber S, Baran D, Carboni M, Dengler T, Feldman D, Frigerio M, Kfoury A, Kim D, Kobashigawa J, Shullo M, Stehlik J, Teuteberg J, Uber P, Zuckermann A, Hunt S, Burch M, Bhat G, Canter C, Chinnock R, Crespo-Leiro M, Delgado R, Dobbels F, Grady K, Kao W, Lamour J, Parry G, Patel J, Pini D, Towbin J, Wolfel G, Delgado D, Eisen H, Goldberg L, Hosenpud J, Johnson M, Keogh A, Lewis C, O'Connell J, Rogers J, Ross H, Russell S, Vanhaecke J, Russell S, Vanhaecke J. The International Society of Heart and Lung Transplantation Guidelines for the care of heart transplant recipients. J Heart Lung Transplant 2010; 29:914-56. [PMID: 20643330 DOI: 10.1016/j.healun.2010.05.034] [Citation(s) in RCA: 1147] [Impact Index Per Article: 81.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2010] [Accepted: 05/31/2010] [Indexed: 12/26/2022] Open
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Mascitelli L, Pezzetta F, Goldstein MR. The epidemic of nonmelanoma skin cancer and the widespread use of statins: Is there a connection? DERMATO-ENDOCRINOLOGY 2010; 2:37-8. [PMID: 21547147 PMCID: PMC3084964 DOI: 10.4161/derm.2.1.12128] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2010] [Accepted: 04/20/2010] [Indexed: 12/12/2022]
Abstract
We hypothesize that some of the mechanisms involved in the "epidemic" of nonmelanoma skin cancer might also be due to widespread use of cholesterol lowering statin drugs.
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Affiliation(s)
- Luca Mascitelli
- Comando Brigata Alpina “Julia”; Medical Service; Udine, Italy
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Goldstein MR, Mascitelli L, Pezzetta F. Statins, regulatory T cells, and pediatric graft coronary artery disease. Pediatr Transplant 2009; 13:139-40. [PMID: 18564306 DOI: 10.1111/j.1399-3046.2008.00995.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Collins RT, Hanna B, Shaddy RE. Letter to editor in response to "Prevention of pediatric graft coronary artery disease: atorvastatin", by Chin et al. Pediatr Transplant 2009; 13:141. [PMID: 19172670 DOI: 10.1111/j.1399-3046.2008.01051.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Safety and Efficacy of Statin Therapy in Patients Switched From Cyclosporine A to Sirolimus After Cardiac Transplantation. Transplantation 2008; 86:1771-6. [DOI: 10.1097/tp.0b013e3181910eb2] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Tredger JM, Brown NW, Dhawan A. Calcineurin inhibitor sparing in paediatric solid organ transplantation : managing the efficacy/toxicity conundrum. Drugs 2008; 68:1385-414. [PMID: 18578558 DOI: 10.2165/00003495-200868100-00004] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Despite their efficacy, the calcineurin inhibitors (CNIs) ciclosporin and tacrolimus carry a risk of debilitating adverse effects, especially nephrotoxicity, that affect the long-term outcome and survival of children who are given organ transplants. Simple reduction in dosage of CNI has little or no long-term benefit on their adverse effects, and complete withdrawal without threatening graft outcome may only be possible after liver transplantation. Until the last decade, the only option was to increase corticosteroid and/or azathioprine doses, which imposed additional long-term hazards. Considered here are the emerging generation of new agents offering an opportunity for improving long-term graft survival, minimizing CNI-related adverse events and ensuring patient well-being.A holistic, multifaceted strategy may need to be considered - initial selection and optimized use and monitoring of immunosuppressant regimens, early recognition of indicators of patient and graft dysfunction, and, where applicable, early introduction of CNI-sparing regimens facilitating CNI withdrawal. The evidence reviewed here supports these approaches but remains far from definitive in paediatric solid organ transplantation. Because de novo immunosuppression uses CNI in more than 93% of patients, reduction of CNI-related adverse effects has focused on CNI sparing or withdrawal.A recurring theme where sirolimus and mycophenolate mofetil have been used for this purpose is the importance of their early introduction to limit CNI damage and provide long-term benefit: for example, long-term renal function critically reflects that at 1 year post-transplant. While mycophenolic acid shows advantages over sirolimus in preserving renal function because the latter is associated with proteinuria, sirolimus appears the more potent immunosuppressant but also impairs early wound healing. The use of CNI-free immunosuppressant regimens with depleting or non-depleting antibodies plus sirolimus and mycophenolic acid needs much wider investigation to achieve acceptable rejection rates and conserve renal function. The adverse effects of the alternative immunosuppressants, particularly the dyslipidaemia associated with sirolimus, needs to be minimized to avoid replacing one set of adverse effects (from CNIs) with another. While we can only conjecture that judicious combinations with the second generation of novel immunosuppressants currently in development will provide these solutions, a rationale of low-dose therapy with multiple immunosuppressants acting by complementary mechanisms seems to hold the promise for efficacy with minimal toxicity until the vision of tolerance achieves reality.
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Affiliation(s)
- J Michael Tredger
- Institute of Liver Studies, King's College Hospital and King's College London School of Medicine, London, UK.
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