1
|
Kuang W, Raven LM, Muir CA. Early post-transplant hyperglycemia and post-transplant diabetes mellitus following heart transplantation. Expert Rev Endocrinol Metab 2024; 19:129-140. [PMID: 38251642 DOI: 10.1080/17446651.2024.2307011] [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: 08/07/2023] [Accepted: 01/15/2024] [Indexed: 01/23/2024]
Abstract
INTRODUCTION Heart transplantation is an important treatment for end-stage heart failure. Early post-transplant hyperglycemia (EPTH) and post-transplant diabetes mellitus (PTDM) are common following heart transplantation and are associated with increased morbidity and mortality. AREAS COVERED This review summarizes the clinical characteristics, diagnosis, and treatment of EPTH and PTDM in cardiac transplant patients, incorporating findings from non-cardiac solid organ transplant studies where relevant due to limited heart-specific research. EXPERT OPINION EPTH following heart transplantation is common yet understudied and is associated with the later development of PTDM. PTDM is associated with adverse outcomes including infection, renal dysfunction, microvascular disease, and an increased risk of re-transplantation and mortality. Risk factors for EPTH include the post-operative immunosuppression regimen, recipient and donor age, body mass index, infections, and chronic inflammation. Early insulin treatment is recommended for EPTH, whereas PTDM management is varied and includes lifestyle modification, anti-glycemic agents, and insulin. Given the emerging evidence on the transplant benefits associated with effective glucose control, and the cardioprotective potential of newer anti-glycemic agents, further focus on the management of EPTH and PTDM within heart transplant recipients is imperative.
Collapse
Affiliation(s)
- William Kuang
- School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Kensington, NSW, Australia
| | - Lisa M Raven
- School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Kensington, NSW, Australia
- Department of Endocrinology, St. Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Christopher A Muir
- School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Kensington, NSW, Australia
- Department of Endocrinology, St. Vincent's Hospital, Darlinghurst, NSW, Australia
| |
Collapse
|
2
|
Bogle C, Marma Perak A, Wilkens SJ, Aljiffry A, Rychlik K, Costello JM, Lloyd-Jones DM, Pahl E. Cardiovascular health in pediatric heart transplant patients. BMC Cardiovasc Disord 2022; 22:139. [PMID: 35365073 PMCID: PMC8973961 DOI: 10.1186/s12872-022-02575-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 03/21/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ideal "cardiovascular health" (CVH)-optimal diet, exercise, nonsmoking, BMI, BP, lipids, and glucose-is associated with healthy longevity in adults. Pediatric heart transplant (HT) patients may be at risk for suboptimal CVH. METHODS Single-center retrospective study of HT patients 2003-2014 who survived 1 year post-transplant. Five CVH metrics were collected at listing, 1, 3 and 5 years post-transplant (diet and exercise were unavailable). CVH was scored by summing individual metrics: ideal = 2, intermediate = 1, and poor = 0 points; total scores of 8-10 points were considered high (favorable). CVH was compared between HT patients and the US pediatric population (GP) utilizing NHANES 2007-2016. Logistic regression was performed to examine the association of CVH 1 year post-transplant with a composite adverse outcome (death, re-listing, coronary vasculopathy, or chronic kidney disease) 3 years post-transplant. RESULTS We included 110 HT patients (median age at HT: 6 years [range 0.1-21]) and 19,081 NHANES participants. CVH scores among HT patients were generally high at listing (75%), 1 (74%), 3 (87%) and 5 (76%) years post-transplant and similar to GP, but some metrics (e.g., glucose) were worse among HT patients. Among HT patients, CVH was poorer with older age and non-Caucasian race/ethnicity. Per 1-point higher CVH score, the demographic-adjusted OR for adverse outcomes was 0.95 (95% CI, 0.7-1.4). CONCLUSIONS HT patients had generally favorable CVH, but some metrics were unfavorable and CVH varied by age and race/ethnicity. No significant association was detected between CVH and adverse outcomes in this small sample, but study in a larger sample is warranted.
Collapse
Affiliation(s)
- Carmel Bogle
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA. .,University of Maryland Children's Heart Program, Baltimore, MD, USA.
| | - Amanda Marma Perak
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.,Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Sarah J Wilkens
- University of Louisville School of Medicine, Louisville, KY, USA
| | | | - Karen Rychlik
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.,Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - John M Costello
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.,Medical University of South Carolina Children's Health, Charleston, SC, USA
| | | | - Elfriede Pahl
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.,Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| |
Collapse
|
3
|
Garekar S, Meeran T, Patel V, Patil S, Dhake S, Mali S, Mhatre A, Bind D, Gaur A, Sinha S, Shetty V, Sabnis K, Soni B, Malankar D, Mulay A. Early experience with pediatric cardiac transplantation in a limited resource setting. Ann Pediatr Cardiol 2020; 13:220-226. [PMID: 32863657 PMCID: PMC7437633 DOI: 10.4103/apc.apc_105_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 03/23/2020] [Accepted: 05/21/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Pediatric heart transplantation is a now a well-established and standard treatment option for end stage heart failure for various conditions in children. Due to logistic issues, it is not an option for in most pediatric cardiac centres in the third world. AIM We sought to describe our early experience in the current era in India. METHODS This is a short term retrospective chart review of pediatric patients who underwent heart transplantation at our centre. Mean/Median with standard deviation /range was used to present data. RESULTS Twenty patients underwent orthotopic heart transplant between January 2016 and June 2019. The median age at transplant was 12.4years (range 3.3 to 17.3 years). The median weight was 23.2kg (range 10-80kg). The mean donor/recipient weight ratio was 1.62± 0.84. The mean ICU stay was 12.1days. The mean follow up post transplant was 2.03± 0.97years (range 10 days-3.57years). The 1 month and the 1 year survival was 100%. Biopsies were positive for significant rejection in 7 patients (35%). At the time of last follow-up, 3 patients (15%) had expired. The major post transplant morbidities were mechanical circulatory support (n=3), hypertension with seizure complex (n=3), post transplant lympho-proliferative disorder (n=1), pseudocyst of pancreas (n=1), coronary allograft vasculopathy (n=3) and systemic hypertension (n=7). All surviving patients (n=17) were asymptomatic at last follow up. CONCLUSION The results suggest acceptable short term outcomes in Indian pediatric patients can be achieved after heart transplantation in the current era. Significant rejection episodes and coronary allograft vasculopathy need careful follow up.
Collapse
Affiliation(s)
- Swati Garekar
- Division of Pediatric Cardiology, Fortis Hospital, Mumbai, Maharashtra, India
| | - Talha Meeran
- Division of Advanced Heart Failure, Cardiac Transplant and Pulmonary Hypertension, Fortis Hospital, Mumbai, Maharashtra, India
| | - Vinay Patel
- Division of Pediatric Cardiology, Fortis Hospital, Mumbai, Maharashtra, India
| | - Sachin Patil
- Division of Pediatric Anesthesiology and Intensive Care, Fortis Hospital, Mumbai, Maharashtra, India
| | - Shyam Dhake
- Division of Pediatric Anesthesiology and Intensive Care, Fortis Hospital, Mumbai, Maharashtra, India
| | - Shivaji Mali
- Division of Pediatric Anesthesiology and Intensive Care, Fortis Hospital, Mumbai, Maharashtra, India
| | - Amit Mhatre
- Division of Intensive Care, Fortis Hospital, Mumbai, Maharashtra, India
| | - Dilip Bind
- Division of Intensive Care, Fortis Hospital, Mumbai, Maharashtra, India
| | - Ashish Gaur
- Division of Cardiothoracic Surgery, Fortis Hospital, Mumbai, Maharashtra, India
| | - Sandeep Sinha
- Division of Cardiothoracic Surgery, Fortis Hospital, Mumbai, Maharashtra, India
| | - Vijay Shetty
- Division of Anesthesiology, Fortis Hospita, Mumbai, Maharashtra, India
| | - Kirtis Sabnis
- Division of Infectious Diseases, Fortis Hospital, Mumbai, Maharashtra, India
| | - Bharat Soni
- Division of Pediatric Cardiothoracic Surgery, Fortis Hospital, Mumbai, Maharashtra, India
| | - Dhananjay Malankar
- Division of Pediatric Cardiothoracic Surgery, Fortis Hospital, Mumbai, Maharashtra, India
| | - Anvay Mulay
- Division of Cardiothoracic Surgery, Fortis Hospital, Mumbai, Maharashtra, India
| |
Collapse
|
4
|
Lamour JM, Mason KL, Hsu DT, Feingold B, Blume ED, Canter CE, Dipchand AI, Shaddy RE, Mahle WT, Zuckerman WA, Bentlejewski C, Armstrong BD, Morrison Y, Diop H, Iklé DN, Odim J, Zeevi A, Webber SA. Early outcomes for low-risk pediatric heart transplant recipients and steroid avoidance: A multicenter cohort study (Clinical Trials in Organ Transplantation in Children - CTOTC-04). J Heart Lung Transplant 2019; 38:972-981. [PMID: 31324444 PMCID: PMC8359669 DOI: 10.1016/j.healun.2019.06.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 06/12/2019] [Accepted: 06/16/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Immunosuppression strategies have changed over time in pediatric heart transplantation. Thus, comorbidity profiles may have evolved. Clinical Trials in Organ Transplantation in Children-04 is a multicenter, prospective, cohort study assessing the impact of pre-transplant sensitization on outcomes after pediatric heart transplantation. This sub-study reports 1-year outcomes among recipients without pre-transplant donor-specific antibodies (DSAs). METHODS We recruited consecutive candidates (<21 years) at 8 centers. Sensitization status was determined by a core laboratory. Immunosuppression was standardized as follows: Thymoglobulin induction with tacrolimus and/or mycophenolate mofetil maintenance. Steroids were not used beyond 1 week. Rejection surveillance was by serial biopsy. RESULTS There were 240 transplants. Subjects for this sub-study (n = 186) were non-sensitized (n = 108) or had no DSAs (n = 78). Median age was 6 years, 48.4% were male, and 38.2% had congenital heart disease. Patient survival was 94.5% (95% confidence interval, 90.1-97.0%). Freedom from any type of rejection was 67.5%. Risk factors for rejection were older age at transplant and presence of non-DSAs pre-transplant. Freedom from infection requiring hospitalization/intravenous anti-microbials was 75.4%. Freedom from rehospitalization was 40.3%. New-onset diabetes mellitus and post-transplant lymphoproliferative disorder (PTLD) occurred in 1.6% and 1.1% of subjects, respectively. There was no decline in renal function over the first year. Corticosteroids were used in 14.5% at 1 year. CONCLUSIONS Pediatric heart transplantation recipients without DSAs at transplant and managed with a steroid avoidance regimen have excellent short-term survival and a low risk of first-year diabetes mellitus and PTLD. Rehospitalization remains common. These contemporary observations allow for improved caregiver and/or patient counseling and provide the necessary outcomes data to help design future randomized controlled trials.
Collapse
Affiliation(s)
- Jacqueline M Lamour
- Division of Pediatric Cardiology, Children's Hospital at Montefiore, Bronx, New York, New York.
| | | | - Daphne T Hsu
- Division of Pediatric Cardiology, Children's Hospital at Montefiore, Bronx, New York, New York
| | - Brian Feingold
- Departments of Pediatrics and Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Elizabeth D Blume
- Department of Pediatric Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Charles E Canter
- Division of Pediatric Cardiology, Washington University School of Medicine, St. Louis, Missouri
| | - Anne I Dipchand
- Department of Paediatrics, Labatt Family Heart Center, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Robert E Shaddy
- Division of Pediatric Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - William T Mahle
- Division of Pediatric Cardiology, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Warren A Zuckerman
- Division of Pediatric Cardiology, Columbia University Medical Center, New York, New York
| | - Carol Bentlejewski
- Division of Pediatric Cardiology, Columbia University Medical Center, New York, New York
| | | | | | - Helena Diop
- Rho Federal Systems Division, Chapel Hill, North Carolina
| | - David N Iklé
- Rho Federal Systems Division, Chapel Hill, North Carolina
| | - Jonah Odim
- Transplantation Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Adriana Zeevi
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Steven A Webber
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
| |
Collapse
|
5
|
Sparks JD, Cantor RS, Pruitt E, Kirklin JK, Carboni M, Dreyer W, Kindel S, Ryan TD, Morrow WR. New-onset diabetes after pediatric heart transplantation: A review of the Pediatric Heart Transplant Study. Pediatr Transplant 2019; 23:e13476. [PMID: 31124221 DOI: 10.1111/petr.13476] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 01/25/2019] [Accepted: 02/16/2019] [Indexed: 11/30/2022]
Abstract
NDT is a well-defined complication after solid organ transplantation. Little has been published describing the incidence, risk factors, and effect on outcome after pediatric heart transplantation. We performed a retrospective evaluation of pediatric patients from the PHTS registry from 2004 to 2014. Group comparison, associated factors, incidence using Kaplan-Meier method, and risk factor and outcome analysis for NDT at 1 year post-transplant. Of the 2185 recipients, 1756 were alive and followed at 1 year. Overall freedom from NDT was 98.9%, 94.7%, and 92.6% at 1, 5, and 10 years, respectively. Patients with NDT were more likely to be black (non-Hispanic; P = 0.002), older at time of transplant (P < 0.0001), and have a higher BMI percentile at time of transplant (P < 0.0001). Adjusted risk factors for NDT at 1 year were older age at transplant (years; >12 years, OR: 8.8 and 5-12 years, HR: 8.0), obese BMI percentile at time of transplant (OR: 3.8), and steroid use at 30 days after transplant (OR: 4.7). Though uncommon, NDT occurs with a constant hazard after pediatric heart transplant; it occurs more often in older patients at transplant, those who are of black race, those who are obese, and those who use steroids. Therefore, targeted weight reduction and selective steroid use in at-risk populations could reduce the incidence of early NDT. Further data are needed to determine the risk imparted by transplantation, factors that predict late-onset NDT, and whether NDT alters the outcome after transplant.
Collapse
Affiliation(s)
| | - Ryan S Cantor
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | | | | | - Steven Kindel
- Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Thomas D Ryan
- University Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | |
Collapse
|
6
|
Abstract
Solid organ transplantation (SOT) is a life-saving procedure and an established treatment for patients with end-stage organ failure. However, transplantation is also accompanied by associated cardiovascular risk factors, of which post-transplant diabetes mellitus (PTDM) is one of the most important. PTDM develops in 10-20% of patients with kidney transplants and in 20-40% of patients who have undergone other SOT. PTDM increases mortality, which is best documented in patients who have received kidney and heart transplants. PTDM results from predisposing factors (similar to type 2 diabetes mellitus) but also as a result of specific post-transplant risk factors. Although PTDM has many characteristics in common with type 2 diabetes mellitus, the prevention and treatment of the two disorders are often different. Over the past 20 years, the lifespan of patients who have undergone SOT has increased, and PTDM becomes more common over the lifespan of these patients. Accordingly, PTDM becomes an important condition not only to be aware of but also to treat. This Review presents the current knowledge on PTDM in patients receiving kidney, heart, liver and lung transplants. This information is not only for transplant health providers but also for endocrinologists and others who will meet these patients in their clinics.
Collapse
Affiliation(s)
- Trond Jenssen
- Department of Transplantation Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway.
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
| | - Anders Hartmann
- Department of Transplantation Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| |
Collapse
|
7
|
Ho CY, Chuang GT, Lin WC, Tsai IJ. The presentation of proteinuria in an adolescent with new-onset diabetes after heart transplantation. Pediatr Neonatol 2019; 60:114-115. [PMID: 30466798 DOI: 10.1016/j.pedneo.2018.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 08/23/2018] [Accepted: 11/02/2018] [Indexed: 10/27/2022] Open
Affiliation(s)
- Chin Yee Ho
- Department of Pediatrics, Taipei Tzu Chi Hospital, New Taipei City, Taiwan; Division of Nephrology, Department of Pediatrics, National Taiwan University Children Hospital, Taiwan
| | - Gwo-Tsann Chuang
- Division of Nephrology, Department of Pediatrics, National Taiwan University Children Hospital, Taiwan
| | - Wei-Chou Lin
- Department of Pathology, National Taiwan University Hospital, Taiwan
| | - I-Jung Tsai
- Division of Nephrology, Department of Pediatrics, National Taiwan University Children Hospital, Taiwan.
| |
Collapse
|
8
|
Moore DJ. New onset diabetes mellitus after heart transplantation in children is a common but potentially modifiable burden. Pediatr Transplant 2016; 20:886-887. [PMID: 27726266 DOI: 10.1111/petr.12785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Daniel J Moore
- Ian Burr Division of Endocrinology and Diabetes, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| |
Collapse
|