Low incidence of malignancy after transplantation in Chinese heart allograft recipients

Prevalence of Post-Heart Transplant Malignancies: A Systematic Review and Meta-Analysis

The prevalence of different cancers after heart transplant (HT) is unclear due to small and conflicting prior studies. Herein, we report a systematic review and meta-analysis to highlight the prevalence and pattern of malignancies post-HT. We conducted an extensive literature search on PubMed, Scopus, Cochrane databases for prospective or retrospective studies reporting malignancies after HT. The proportions from each study were subjected to random effects model that yielded the pooled estimate with 95% confidence intervals (CI). Fifty-five studies comprising 60,684 HT recipients reported 7,759 total cancers during a mean follow-up of 9.8 ± 5.9 years, with an overall incidence of 15.3% (95% CI = 12.7%-18.1%). Mean time from HT to cancer diagnosis was 5.1 ± 4 years. The most frequent cancers were gastrointestinal (7.6%), skin (5.7%), and hematologic/blood (2.5%). Meta-regression showed no association between incidence of cancer and mean age at HT (coeff: -0.008; p=0.25), percentage of male recipients (coeff: -0.001; p=0.81), donor age (coeff: -0.011; p=0.44), 5-year (coeff: 0.003; p=0.12) and 10-year (coeff: 0.02; p=0.68) post-transplant survival. There is a substantial risk of malignancies in HT recipients, most marked for gastrointestinal, skin, and hematologic. Despite their occurrence, survival is not significantly impacted.

Impact of pretransplant bloodstream infection on clinical outcomes after heart transplantation

BACKGROUND

Active bloodstream infection (BSI) is a contraindication for heart transplantation (HT). However, some critical patients with BSI may undergo HT as a life-saving procedure. We aimed to investigate the impact of pretransplant BSI on the clinical outcomes after HT.

METHODS

We enrolled 511 consecutive patients who underwent HT between 1999 and 2019. Patients were divided into two groups based on the presence of BSI within 30 days preoperatively. Forty-three patients (8.4%) with BSI who were clinically stable and had no metastatic infection were considered for HT on an individual basis. In-hospital mortality, incidence of early postoperative BSI, length of postoperative hospital stays, and long-term survival were compared between the groups. Logistic and Cox regression analyses were performed to identify risk factors for in-hospital and 1-year mortality.

RESULTS

Patients with pretransplant BSI had a high incidence of previous cardiopulmonary resuscitation, pretransplant ventilator use, mechanical circulatory support use, renal replacement therapy, United Network for Organ Sharing status 1A, and a prolonged preoperative hospital waiting period. The in-hospital mortality rate was higher in patients with pretransplant BSI (21% versus 12%, p = 0.081), and the mortality rate was very high (33.3%) for those with BSI 0-15 days before HT. In addition, patients with pretransplant BSI had a significantly longer postoperative hospital stay than patients in the control group. However, long-term survival was similar in both groups.

CONCLUSIONS

Although pretransplant BSI was associated with higher in-hospital mortality and prolonged postoperative hospital stay, patients who survived the early period had a similar long-term prognosis. This article is protected by copyright. All rights reserved.

Impact of Pretransplant Renal Replacement Therapy on Clinical Outcome After Isolated Heart Transplantation

End stage renal disease (ESRD) is a contraindication to isolated heart transplantation (HT). However, heart candidates with cardiogenic shock may experience acute kidney injury and require renal replacement therapy (RRT) and isolated HT as a life-saving operation. The outcomes, including survival and renal function, are rarely reported. We enrolled 569 patients undergoing isolated HT from 1989 to 2018. Among them, 66 patients required RRT before HT (34 transient and 32 persistent). The survival was worse in patients with RRT than those without (65.2% vs 84.7%; 27.3% vs 51.1% at 1- and 10-year, p < 0.001 and p = 0.012, respectively). Multivariate Cox analysis identified pre-transplant hyperbilirubinemia (Hazard ratio (HR) 2.534, 95% confidence interval (CI) 1.098–5.853, p = 0.029), post-transplant RRT (HR 5.551, 95%CI 1.280–24.068, p = 0.022) and post-transplant early bloodstream infection (HR 3.014, 95%CI 1.270–7.152, p = 0.012) as independent risk factors of 1-year mortality. The majority of operative survivors (98%) displayed renal recovery after HT. Although patients with persistent or transient RRT before HT had a similar long-term survival, patients with persistent RRT developed a high incidence (49.2%) of dialysis-dependent ESRD at 10 years. In transplant candidates with pretransplant RRT, hyperbilirubinemia should be carefully re-evaluated for the eligibility of HT whereas prevention and management of bloodstream infection after HT improve survival.

Post-transplant Lymphoproliferative Disorder Following Cardiac Transplantation

Post-transplant lymphoproliferative disorder (PTLD) is a spectrum of lymphoid conditions frequently associated with the Epstein Barr Virus (EBV) and the use of potent immunosuppressive drugs after solid organ transplantation. PTLD remains a major cause of long-term morbidity and mortality following heart transplantation (HT). Epstein-Barr virus (EBV) is a key pathogenic driver in many PTLD cases. In the majority of PTLD cases, the proliferating immune cell is the B-cell, and the impaired T-cell immune surveillance against infected B cells in immunosuppressed transplant patients plays a key role in the pathogenesis of EBV-positive PTLD. Preventive screening strategies have been attempted for PTLD including limiting patient exposure to aggressive immunosuppressive regimens by tailoring or minimizing immunosuppression while preserving graft function, anti-viral prophylaxis, routine EBV monitoring, and avoidance of EBV seromismatch. Our group has also demonstrated that conversion from calcineurin inhibitor to the mammalian target of rapamycin (mTOR) inhibitor, sirolimus, as a primary immunosuppression was associated with a decreased risk of PTLD following HT. The main therapeutic measures consist of immunosuppression reduction, treatment with rituximab and use of immunochemotherapy regimens. The purpose of this article is to review the potential mechanisms underlying PTLD pathogenesis, discuss recent advances, and review potential therapeutic targets to decrease the burden of PTLD after HT.

Cancer After Heart Transplantation: A 25-year Single-center Perspective

BACKGROUND

Cancer is a major cause of morbidity and mortality after heart transplantation.

METHODS

We studied 541 heart transplant patients from a single center over a period of 25 years, with a mean follow-up of 10.7 years. We determined incidence, type, risk factors, and prognosis for cancer after heart transplantation.

RESULTS

Cancer was diagnosed in 181 patients, at a mean of 7.7 years after transplantation. Cumulative incidence of cancer at 5, 10, and 20 years was 14%, 29%, and 60%, respectively. The most frequent cancers were spinocellular skin cancer (22%), basocellular skin cancer (19%), lung cancer (16%), lymphoma (11%) and prostate cancer (10%). Age at transplantation > 50 years (hazard ratio, 2.9; P < .001) and male recipient gender (hazard ratio, 1.7; P = .038) were significant risk factors for posttransplant malignancy on multivariate Cox proportional hazards analysis. Median patient survival after diagnosis of cancer was 2.9 years for patients with noncutaneous cancer, versus 13.1 years for patients with only skin cancer (P < .001).

Malignancy after heart transplantation

BACKGROUND

The purpose of this study was to assess the incidence and type of malignancies after heart transplantation at a medical institute in Taiwan.

METHODS

From January 1987 to December 2008, a total of 66 patients who survived more than 30 days after transplantation were enrolled in this study.

RESULTS

Of the 66 heart transplant recipients, 8 (12.1%) post-transplant malignancies were diagnosed: 5 posttransplant lymphoproliferative diseases (PTLD), 1 prostate cancer, 1 lung cancer, and 1 squamous cell carcinoma of the cheek. The clinical presentations were diverse, and the diagnoses were confirmed by biopsy. Only 1 patient died of PTLD and subsequent multiple organ failure.

CONCLUSION

Cancer is a limiting factor for long-term survival after heart transplantation. The most common type in this study was PTLD. Early detection and aggressive treatment results in good response and preserves the allograft.

Outcome for Pediatric Cardiac Transplantation With and Without Bridge Methods

Heart transplantation is indicated for children with end-stage heart failure or complex inoperable congenital defects. Due to the shortage of pediatric donor hearts, various bridge techniques have been used for pediatric recipients to prolong patient survival until a heart is available. This study evaluates long-term outcome of bridge and nonbridge support for pediatric heart transplantation. Between March 1995 and June 2004, 18 pediatric patients underwent heart transplantation. Six patients (33.3%) underwent biological or mechanical bridge techniques before transplantation. Eight patients (44.4%) required perioperatively extracorporeal membrane oxygenation (ECMO) support. Patient data and records were retrospectively reviewed. Causes of death and long-term outcome were analyzed. Five of eight patients in the ECMO group (62.5%) were successfully decannulated and discharged home with excellent functional classes. No differences in rejection rate, survival rate, and functional class existed between the bridged and nonbridged groups. Overall 1-year and 5-year survival rates were both 83.3% and all have a good functional class. Pediatric heart transplantation can be accomplished with excellent early survival despite multiple prior cardiac operations and relatively severe illness. For the variety in small, low-body-weight pediatric patients, mechanical circulatory support using ECMO is suitable for managing sudden collapse while waiting for heart transplantation, and graft dysfunction after cardiac transplantation. The mortality rate is acceptable in this very high-risk group of patients and long-term outcome is good.