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Tang WHW, Bakitas MA, Cheng XS, Fang JC, Fedson SE, Fiedler AG, Martens P, McCallum WI, Ogunniyi MO, Rangaswami J, Bansal N. Evaluation and Management of Kidney Dysfunction in Advanced Heart Failure: A Scientific Statement From the American Heart Association. Circulation 2024; 150:e280-e295. [PMID: 39253806 DOI: 10.1161/cir.0000000000001273] [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] [Indexed: 09/11/2024]
Abstract
Early identification of kidney dysfunction in patients with advanced heart failure is crucial for timely interventions. In addition to elevations in serum creatinine, kidney dysfunction encompasses inadequate maintenance of sodium and volume homeostasis, retention of uremic solutes, and disrupted endocrine functions. Hemodynamic derangements and maladaptive neurohormonal upregulations contribute to fluctuations in kidney indices and electrolytes that may recover with guideline-directed medical therapy. Quantifying the extent of underlying irreversible intrinsic kidney disease is crucial in predicting whether optimization of congestion and guideline-directed medical therapy can stabilize kidney function. This scientific statement focuses on clinical management of patients experiencing kidney dysfunction through the trajectory of advanced heart failure, with specific focus on (1) the conceptual framework for appropriate evaluation of kidney dysfunction within the context of clinical trajectories in advanced heart failure, including in the consideration of advanced heart failure therapies; (2) preoperative, perioperative, and postoperative approaches to evaluation and management of kidney disease for advanced surgical therapies (durable left ventricular assist device/heart transplantation) and kidney replacement therapies; and (3) the key concepts in palliative care and decision-making processes unique to individuals with concomitant advanced heart failure and kidney disease.
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Gupta SK, Mostofsky E, Motiwala SR, Hage A, Mittleman MA. Induction immunosuppression and post-transplant diabetes mellitus: a propensity-matched cohort study. Front Endocrinol (Lausanne) 2023; 14:1248940. [PMID: 37929038 PMCID: PMC10623448 DOI: 10.3389/fendo.2023.1248940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 10/02/2023] [Indexed: 11/07/2023] Open
Abstract
Introduction Post-transplant diabetes mellitus (PTDM) is a common complication among cardiac transplant recipients, causing diabetes-related complications and death. While certain maintenance immunosuppressive drugs increase PTDM risk, it is unclear whether induction immunosuppression can do the same. Therefore, we evaluated whether induction immunosuppression with IL-2 receptor antagonists, polyclonal anti-lymphocyte antibodies, or Alemtuzumab given in the peri-transplant period is associated with PTDM. Methods We used the Scientific Registry of Transplant Recipients database to conduct a cohort study of US adults who received cardiac transplants between January 2008-December 2018. We excluded patients with prior or multiple organ transplants and those with a history of diabetes, resulting in 17,142 recipients. We created propensity-matched cohorts (n=7,412) using predictors of induction immunosuppression and examined the association between post-transplant diabetes and induction immunosuppression by estimating hazard ratios using Cox proportional-hazards models. Results In the propensity-matched cohort, the average age was 52.5 (SD=13.2) years, 28.7% were female and 3,706 received induction immunosuppression. There were 867 incident cases of PTDM during 26,710 person-years of follow-up (32.5 cases/1,000 person-years). There was no association between induction immunosuppression and post-transplant diabetes (Hazard Ratio= 1.04, 95% confidence interval 0.91 - 1.19). Similarly, no associations were observed for each class of induction immunosuppression agents and post-transplant diabetes. Conclusion The use of contemporary induction immunosuppression in cardiac transplant patients was not associated with post-transplant diabetes.
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Affiliation(s)
- Suruchi K. Gupta
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, United States
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Elizabeth Mostofsky
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Shweta R. Motiwala
- Harvard Medical School, Boston, MA, United States
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Ali Hage
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, United States
- London Health Sciences Centre, Schulich School of Medicine, Western University, London, ON, Canada
| | - Murray A. Mittleman
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
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Nesseler N, Mansour A, Cholley B, Coutance G, Bouglé A. Perioperative Management of Heart Transplantation: A Clinical Review. Anesthesiology 2023; 139:493-510. [PMID: 37458995 DOI: 10.1097/aln.0000000000004627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
In this clinical review, the authors summarize the perioperative management of heart transplant patients with a focus on hemodynamics, immunosuppressive strategies, hemostasis and hemorrage, and the prevention and treatment of infectious complications.
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Affiliation(s)
- Nicolas Nesseler
- Department of Anesthesia and Critical Care, Pontchaillou, University Hospital of Rennes, France; National Institute of Health and Medical Research, Center of Clinical Investigation, Nutrition, Metabolism, Cancer Mixed Research Unit, University Hospital Federation Survival Optimization in Organ Transplantation, Rennes, France
| | - Alexandre Mansour
- Department of Anesthesia and Critical Care, Pontchaillou, University Hospital of Rennes, France; National Institute of Health and Medical Research, Center of Clinical Investigation, Nutrition, Research Institute for Environmental and Occupational Health Mixed Research Unit, Rennes, France
| | - Bernard Cholley
- Department of Anesthesiology and Intensive Care Medicine, European Hospital Georges Pompidou, Public Hospitals of Paris, Paris, France; Paris Cité University, National Institute of Health and Medical Research Mixed Research Unit, Paris, France
| | - Guillaume Coutance
- Sorbonne University, Public Hospitals of Paris, Department of Cardiac and Thoracic Surgery, Cardiology Institute, Pitié-Salpêtrière Hospital, Paris, France
| | - Adrien Bouglé
- Sorbonne University, Clinical Research Group in Anesthesia, Resuscitation, and Perioperative Medicine, Public Hospitals of Paris, Department of Anesthesiology and Critical Care, Cardiology Institute, Pitié-Salpêtrière Hospital, Paris, France
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Zang S, Zhang X, Niu J, Das BB. Impact of induction therapy on cytomegalovirus infection and post-transplant outcomes in pediatric heart transplant recipients receiving routine antiviral prophylaxis. Clin Transplant 2023; 37:e14836. [PMID: 36259556 DOI: 10.1111/ctr.14836] [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: 07/10/2022] [Revised: 10/10/2022] [Accepted: 10/12/2022] [Indexed: 01/18/2023]
Abstract
OBJECTIVES Induction therapy has been increasingly used in pediatric heart transplantation. This study evaluated the impact of anti-thymocyte globulin (ATG) versus basiliximab as induction therapy on post-transplant cytomegalovirus (CMV) infection, rejection at 1 year, coronary allograft vasculopathy (CAV), and mortality in pediatric heart transplant recipients receiving antiviral prophylaxis. RESULTS Of the 96 patients (age < 18 years) analyzed, 46 (47.9%) patients received basiliximab, and 50 (52.1%) received ATG. Median follow-up was 3.0 (IQR, 1.7-4.9) years with 32.3% reporting CMV infection. The ATG group, as compared with the basiliximab group, had similar incidences of CMV infection (36% vs. 28.3%, p = .418), CMV viremia (22% vs. 19.6%, p = .769), and CMV-positive tissue biopsy (30% vs. 22%, p = .486). The ATG group had lower incidences of rejection at 1 year (16% vs. 36.9%, p = .022) and CAV (4% vs. 23.9%, p = .006) with no difference in mortality (8% vs. 15.2%, p = .343), compared with the basiliximab group. Multivariate analysis showed that induction with ATG was associated with a lower risk of rejection at 1 year (OR, .31; 95% CI, .09-.94; p = .039) with no impact on the incidences of CMV infection (HR, 2.06; 95% CI, .54-7.89; p = .292), CAV (HR, .30; 95% CI, .04-2.58; p = .275), and mortality (HR, .39; 95% CI, .09-1.82; p = .233) compared to basiliximab induction. DISCUSSION AND CONCLUSIONS In conclusion, induction with ATG was associated with reduction in risk of rejection at 1 year with no effects on CMV infection, CAV, and mortality in pediatric heart transplant recipients with universal antiviral prophylaxis compared with basiliximab induction therapy.
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Affiliation(s)
- Suhua Zang
- Department of Cardiac Surgery, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xin Zhang
- Department of Cardiac Surgery, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jianli Niu
- Office of Human Research, Memorial Healthcare System, Hollywood, Florida, USA
| | - Bibhuti B Das
- Office of Human Research, Memorial Healthcare System, Hollywood, Florida, USA.,Department of Pediatrics, Division of Pediatric Cardiology, Mississippi Children's Hospital, University of Mississippi Medical Center, Jackson, Mississippi, USA
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Effectiveness of Prophylactic Human Cytomegalovirus Hyperimmunoglobulin in Preventing Cytomegalovirus Infection following Transplantation: A Systematic Review and Meta-Analysis. Life (Basel) 2022; 12:life12030361. [PMID: 35330112 PMCID: PMC8955988 DOI: 10.3390/life12030361] [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: 01/25/2022] [Revised: 02/18/2022] [Accepted: 02/28/2022] [Indexed: 11/29/2022] Open
Abstract
Cytomegalovirus (CMV) is a common infection occurring in patients undergoing solid organ transplantation (SOT) or hematopoietic stem cell transplantation (HSCT). CMV-specific hyperimmunoglobulin (CMVIG) has been used for the past four decades and is typically administered either prophylactically or pre-emptively. The present meta-analysis evaluated CMV infection rates in SOT patients who received prophylactic CMVIG. PubMed and the Cochrane Library were searched for studies published up to October 2021. The primary endpoint was CMV infection rate. Thirty-two SOT studies were identified (n = 1521 CMVIG-treated and n = 1196 controls). Prophylactic CMVIG treatment was often associated with a lower risk of CMV infection in transplant recipients. The average CMV infection rate was 35.8% (95% confidence interval [CI]: 33.4−38.2%) in patients treated prophylactically with CMVIG and 41.4% (95% CI: 38.6−44.2%) in the control group not receiving CMVIG (p = 0.003). Similar results were observed in analyses limited to publications evaluating currently available CMVIG products (Cytotect CP and Cytogam; p < 0.001). In combination with the established safety profile for CMVIG, these results suggest that prophylactic CMVIG treatment in patients undergoing solid organ transplantation may be beneficial, particularly in those at high risk of CMV infection or disease.
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Ghaleb S, Wittekind SG, Martinez H, Kasten J, Gao Z, Hengehold T, Chin C. Antithymocyte globulin induction therapy and myocardial complement deposition in pediatric heart transplantation. Pediatr Transplant 2021; 25:e13998. [PMID: 33704881 DOI: 10.1111/petr.13998] [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] [Received: 04/21/2020] [Revised: 10/11/2020] [Accepted: 02/16/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Antithymocyte globulin (ATG) consists of polyclonal antibodies directed primarily against human T lymphocytes but may contain antibodies with affinity for other tissues in the transplanted organ, resulting in complement (C4d) deposition. This phenomenon has been demonstrated in endomyocardial biopsies (EMBs) of adult cardiac transplants. We examined the relationship of induction immunosuppression with ATG and C4d deposition in EMB of pediatric cardiac transplants. METHODS Results of C4d immunohistochemistry were available from all EMB of patients transplanted at our center between June 2012 and April 2018 (n = 48) who received induction immunosuppression with either ATG (n = 20) or basiliximab (n = 28) as the standard of care. RESULTS C4d deposition in the first year post-heart transplant was more commonly seen among patients who received ATG induction (20% of EMBs in ATG group vs 1% of EMBs in basiliximab group; p < .0001). C4d deposition related to ATG was observed early post-transplant (50% ATG vs 0% basiliximab on first EMB; p < .0001 and 35% ATG vs 0% basiliximab on the second EMB; p = .0012). While this difference waned by the third EMB (5% ATG vs 0% basiliximab; p = .41), positive C4d staining persisted to the sixth EMB in the ATG group only (6%). CONCLUSION C4d deposition is common on EMB up to 1 year post-pediatric cardiac transplant following ATG induction. This high rate of positive C4d staining in the absence of histologic AMR after ATG induction therapy must be accounted for in making clinical decisions regarding cardiac allograft rejection diagnosis and treatment.
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Affiliation(s)
- Stephanie Ghaleb
- The Heart Institute, Cincinnati Children's Medical Center, Cincinnati, OH, USA
| | - Samuel G Wittekind
- The Heart Institute, Cincinnati Children's Medical Center, Cincinnati, OH, USA
| | - Hugo Martinez
- The Heart Institute, Cincinnati Children's Medical Center, Cincinnati, OH, USA
| | - Jennifer Kasten
- Department of Pathology, Cincinnati Children's Medical Center, Cincinnati, OH, USA
| | - Zhiqian Gao
- The Heart Institute, Cincinnati Children's Medical Center, Cincinnati, OH, USA
| | - Tricia Hengehold
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Clifford Chin
- The Heart Institute, Cincinnati Children's Medical Center, Cincinnati, OH, USA
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van Alem CMA, Metselaar JM, van Kooten C, Rotmans JI. Recent Advances in Liposomal-Based Anti-Inflammatory Therapy. Pharmaceutics 2021; 13:pharmaceutics13071004. [PMID: 34371695 PMCID: PMC8309101 DOI: 10.3390/pharmaceutics13071004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 06/27/2021] [Accepted: 06/28/2021] [Indexed: 01/13/2023] Open
Abstract
Liposomes can be seen as ideal carriers for anti-inflammatory drugs as their ability to (passively) target sites of inflammation and release their content to inflammatory target cells enables them to increase local efficacy with only limited systemic exposure and adverse effects. Nonetheless, few liposomal formulations seem to reach the clinic. The current review provides an overview of the more recent innovations in liposomal treatment of rheumatoid arthritis, psoriasis, vascular inflammation, and transplantation. Cutting edge developments include the liposomal delivery of gene and RNA therapeutics and the use of hybrid systems where several liposomal bilayer features, or several drugs, are combined in a single formulation. The majority of the articles reviewed here focus on preclinical animal studies where proof-of-principle of an improved efficacy-safety ratio is observed when using liposomal formulations. A few clinical studies are included as well, which brings us to a discussion about the challenges of clinical translation of liposomal nanomedicines in the field of inflammatory diseases.
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Affiliation(s)
- Carla M. A. van Alem
- Department of Internal Medicine, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (C.M.A.v.A.); (C.v.K.)
| | - Josbert M. Metselaar
- Institute for Experimental Molecular Imaging, Faculty of Medicine, RWTH Aachen University, 52074 Aachen, Germany;
| | - Cees van Kooten
- Department of Internal Medicine, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (C.M.A.v.A.); (C.v.K.)
| | - Joris I. Rotmans
- Department of Internal Medicine, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (C.M.A.v.A.); (C.v.K.)
- Correspondence: ; Tel.: +31-(0)-7152-62148
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8
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Grazioli A, Athale J, Tanaka K, Madathil R, Rabin J, Kaczorowski D, Mazzeffi M. Perioperative Applications of Therapeutic Plasma Exchange in Cardiac Surgery: A Narrative Review. J Cardiothorac Vasc Anesth 2020; 34:3429-3443. [DOI: 10.1053/j.jvca.2020.01.054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 01/26/2020] [Accepted: 01/31/2020] [Indexed: 12/17/2022]
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9
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Report from the 2018 consensus conference on immunomodulating agents in thoracic transplantation: Access, formulations, generics, therapeutic drug monitoring, and special populations. J Heart Lung Transplant 2020; 39:1050-1069. [DOI: 10.1016/j.healun.2020.06.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 06/29/2020] [Indexed: 01/06/2023] Open
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10
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Amin AA, Araj FG, Ariyamuthu VK, Drazner MH, Ayvaci MUS, Mammen PPA, Mete M, Urey MA, Tanriover B. Impact of induction immunosuppression on patient survival in heart transplant recipients treated with tacrolimus and mycophenolic acid in the current allocation era. Clin Transplant 2019; 33:e13651. [PMID: 31230375 DOI: 10.1111/ctr.13651] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 04/01/2019] [Accepted: 06/16/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND The practice of induction therapy with either rabbit anti-thymocyte globulin (r-ATG) or interleukin-2 receptor antagonists (IL-2RA) is common among heart transplant recipients. However, its benefits in the setting of contemporary maintenance immunosuppression with tacrolimus/mycophenolic acid (TAC/MPA) are unknown. METHODS We compared post-transplant mortality among three induction therapy strategies (r-ATG vs IL2-RA vs no induction) in a retrospective cohort analysis of heart transplant recipients maintained on TAC/MPA in the Organ Procurement Transplant Network (OPTN) database between the years 2006 and 2015. We used a multivariable model adjusting for clinically important co-morbidities, and a propensity score analysis using the inverse probability weighted (IPW) method in the final analysis. RESULTS In multivariable IPW analysis, r-ATG (HR = 1.23; 95% CI = 1.05-1.46, P = 0.01) remained significantly associated with a higher mortality. There was a trend toward having a higher mortality in the IL2-RA (HR = 1.11; 95% CI = 1.00-1.24, P = 0.06) group. Subgroup analyses failed to show a patient survival benefit in using either r-ATG or IL2-RA among any of the subgroups analyzed. CONCLUSION In this contemporary cohort of heart transplant recipients receiving TAC/MPA, neither r-ATG nor IL2-RA were associated with a survival benefit. On the contrary, adjusted analyses showed a significantly higher mortality in the r-ATG group and a trend toward higher mortality in the IL2-RA group. While caution is needed in interpreting treatment effects in an observational cohort, these data call into question the benefit of induction therapy as a common practice and highlight the need for more studies.
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Affiliation(s)
- Alpesh A Amin
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Faris G Araj
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Mark H Drazner
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Mehmet U S Ayvaci
- Information Systems, Naveen Jindal School of Business, University of Texas at Dallas, Dallas, Texas
| | - Pradeep P A Mammen
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Mutlu Mete
- Department of Computer Science, Texas A&M University-Commerce, Commerce, Texas
| | - Marcus A Urey
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Bekir Tanriover
- Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, Texas
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11
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Jewani PK, Pouch SM, Kissling KT. Incidence of cytomegalovirus in cardiac transplant recipients receiving induction immunosuppression with antithymocyte globulin. Clin Transplant 2018; 32:e13420. [PMID: 30290013 DOI: 10.1111/ctr.13420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 09/23/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) is a major cause of morbidity and mortality in cardiac transplant recipients. Use of induction immunosuppression in cardiac transplantation may have an impact on the incidence of CMV, but literature is limited. METHODS Single-center, retrospective cohort study comparing the risk of CMV infection and disease in cardiac transplant patients receiving antithymocyte globulin (ATG) induction therapy to those receiving no antibody induction. RESULTS A total of 75 patients were included in our analysis, 50 who received ATG induction and 25 who did not. CMV infection occurred in 10 (20%) and 5 (20%) patients in the ATG and No ATG groups, respectively (P > 0.99). CMV disease occurred in 10 (20%) and 4 (16%) patients in the ATG and No ATG groups, respectively (P = 0.763). The median time from transplant to CMV infection was 200.0 [142.5, 364.5] days in the ATG group vs 221.0 [192.0, 299.0] days in the No ATG group (P = 0.723). The median time from end of CMV prophylaxis to CMV infection was 94.5 [66.5, 151.0] days in the ATG group vs 53.0 [41.0,149.5] days in the No ATG group (P = 0.202). Freedom from CMV infection was highest in the D+/R+ group and lowest in the D+/R- group. CONCLUSION In cardiac transplant recipients, ATG induction was not associated with an increased incidence of CMV infection or disease in the setting of valganciclovir prophylaxis and an initial maintenance immunosuppression regimen of primarily steroids, mycophenolate mofetil, and tacrolimus.
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Affiliation(s)
- Poonam K Jewani
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, Illinois
| | - Stephanie M Pouch
- Division of Infectious Diseases, Department of Internal Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Kevin T Kissling
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio
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12
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Sánchez-Enrique C, Jorde UP, González-Costello J. Trasplante cardiaco y soporte circulatorio mecánico para pacientes con insuficiencia cardiaca avanzada. Rev Esp Cardiol 2017. [DOI: 10.1016/j.recesp.2016.10.032] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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13
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Sánchez-Enrique C, Jorde UP, González-Costello J. Heart Transplant and Mechanical Circulatory Support in Patients With Advanced Heart Failure. ACTA ACUST UNITED AC 2017; 70:371-381. [DOI: 10.1016/j.rec.2016.12.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Accepted: 11/28/2016] [Indexed: 12/27/2022]
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14
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Ruan V, Czer LSC, Awad M, Kittleson M, Patel J, Arabia F, Esmailian F, Ramzy D, Chung J, De Robertis M, Trento A, Kobashigawa JA. Use of Anti-Thymocyte Globulin for Induction Therapy in Cardiac Transplantation: A Review. Transplant Proc 2017; 49:253-259. [PMID: 28219580 DOI: 10.1016/j.transproceed.2016.11.034] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 11/16/2016] [Indexed: 01/20/2023]
Abstract
The most common causes of death after heart transplantation (HTx) include acute rejection and multi-organ failure in the early period and malignancy and cardiac allograft vasculopathy (CAV) in the late period. Polyclonal antibody preparations such as rabbit anti-thymocyte globulin (ATG) may reduce early acute rejection and the later occurrence of CAV after HTx. ATG therapy depletes T cells, modulates adhesion and cell-signaling molecules, interferes with dendritic cell function, and induces B-cell apoptosis and regulatory and natural killer T-cell expansion. Evidence from animal studies and from retrospective clinical studies in humans indicates that ATG can be used to delay calcineurin inhibitor (CNI) exposure after HTx, thus benefiting renal function, and to reduce the incidence of CAV and ischemia-reperfusion injury in the transplanted heart. ATG may reduce de novo antibody production after HTx. ATG does not appear to increase cytomegalovirus infection rates with longer prophylaxis (6-12 months). In addition, ATG may reduce the risk of lymphoproliferative disease and does not appear to confer an additive effect on acquiring lymphoma after HTx. Randomized, controlled trials may provide stronger evidence of ATG association with patient survival, graft rejection, renal protection through delayed CNI initiation, as well as other benefits. It can also help establish optimal dosing and patient criteria to maximize treatment benefits.
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Affiliation(s)
- V Ruan
- Division of Cardiology, Cedars-Sinai Medical Center, and Cedars-Sinai Heart Institute, Los Angeles, California
| | - L S C Czer
- Division of Cardiology, Cedars-Sinai Medical Center, and Cedars-Sinai Heart Institute, Los Angeles, California.
| | - M Awad
- Division of Cardiology, Cedars-Sinai Medical Center, and Cedars-Sinai Heart Institute, Los Angeles, California
| | - M Kittleson
- Division of Cardiology, Cedars-Sinai Medical Center, and Cedars-Sinai Heart Institute, Los Angeles, California
| | - J Patel
- Division of Cardiology, Cedars-Sinai Medical Center, and Cedars-Sinai Heart Institute, Los Angeles, California
| | - F Arabia
- Division of Cardiothoracic Surgery, Cedars-Sinai Medical Center, and Cedars-Sinai Heart Institute, Los Angeles, California
| | - F Esmailian
- Division of Cardiothoracic Surgery, Cedars-Sinai Medical Center, and Cedars-Sinai Heart Institute, Los Angeles, California
| | - D Ramzy
- Division of Cardiothoracic Surgery, Cedars-Sinai Medical Center, and Cedars-Sinai Heart Institute, Los Angeles, California
| | - J Chung
- Division of Cardiothoracic Surgery, Cedars-Sinai Medical Center, and Cedars-Sinai Heart Institute, Los Angeles, California
| | - M De Robertis
- Division of Cardiothoracic Surgery, Cedars-Sinai Medical Center, and Cedars-Sinai Heart Institute, Los Angeles, California
| | - A Trento
- Division of Cardiothoracic Surgery, Cedars-Sinai Medical Center, and Cedars-Sinai Heart Institute, Los Angeles, California
| | - J A Kobashigawa
- Division of Cardiology, Cedars-Sinai Medical Center, and Cedars-Sinai Heart Institute, Los Angeles, California
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15
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Hayes D, McConnell PI, Yates AR, Tobias JD, Galantowicz M, Mansour HM, Tumin D. Induction immunosuppression for combined heart-lung transplantation. Clin Transplant 2016; 30:1332-1339. [DOI: 10.1111/ctr.12827] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2016] [Indexed: 01/26/2023]
Affiliation(s)
- Don Hayes
- Department of Pediatrics; The Ohio State University College of Medicine; Columbus OH USA
- Department of Internal Medicine; The Ohio State University College of Medicine; Columbus OH USA
- Department of Surgery; The Ohio State University College of Medicine; Columbus OH USA
- Center for Pediatric Transplant Research; Nationwide Children's Hospital; Columbus OH USA
- Section of Pulmonary Medicine; Nationwide Children's Hospital; Columbus OH USA
| | - Patrick I. McConnell
- Department of Surgery; The Ohio State University College of Medicine; Columbus OH USA
- Center for Pediatric Transplant Research; Nationwide Children's Hospital; Columbus OH USA
- Department of Cardiothoracic Surgery; Nationwide Children's Hospital; Columbus OH USA
| | - Andrew R. Yates
- Department of Pediatrics; The Ohio State University College of Medicine; Columbus OH USA
- Center for Pediatric Transplant Research; Nationwide Children's Hospital; Columbus OH USA
- Section of Cardiology; Nationwide Children's Hospital; Columbus OH USA
| | - Joseph D. Tobias
- Department of Anesthesiology; The Ohio State University College of Medicine; Columbus OH USA
- Center for Pediatric Transplant Research; Nationwide Children's Hospital; Columbus OH USA
- Department of Anesthesiology & Pain Medicine; Nationwide Children's Hospital; Columbus OH USA
| | - Mark Galantowicz
- Department of Surgery; The Ohio State University College of Medicine; Columbus OH USA
- Center for Pediatric Transplant Research; Nationwide Children's Hospital; Columbus OH USA
- Department of Cardiothoracic Surgery; Nationwide Children's Hospital; Columbus OH USA
| | - Heidi M. Mansour
- Center for Pediatric Transplant Research; Nationwide Children's Hospital; Columbus OH USA
- The University of Arizona Colleges of Pharmacy and Medicine; Tucson AZ USA
| | - Dmitry Tumin
- Department of Pediatrics; The Ohio State University College of Medicine; Columbus OH USA
- Center for Pediatric Transplant Research; Nationwide Children's Hospital; Columbus OH USA
- Department of Anesthesiology & Pain Medicine; Nationwide Children's Hospital; Columbus OH USA
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16
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A Proposal for Early Dosing Regimens in Heart Transplant Patients Receiving Thymoglobulin and Calcineurin Inhibition. Transplant Direct 2016; 2:e81. [PMID: 27500271 PMCID: PMC4946520 DOI: 10.1097/txd.0000000000000594] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 04/10/2016] [Indexed: 12/19/2022] Open
Abstract
There is currently no consensus regarding the dose or duration of rabbit antithymocyte globulin (rATG) induction in different types of heart transplant patients, or the timing and intensity of initial calcineurin inhibitor (CNI) therapy in rATG-treated individuals. Based on limited data and personal experience, the authors propose an approach to rATG dosing and initial CNI administration. Usually rATG is initiated immediately after exclusion of primary graft failure, although intraoperative initiation may be appropriate in specific cases. A total rATG dose of 4.5 to 7.5 mg/kg is advisable, tailored within that range according to immunologic risk and adjusted according to immune monitoring. Lower doses (eg, 3.0 mg/kg) of rATG can be used in patients at low immunological risk, or 1.5 to 2.5 mg/kg for patients with infection on mechanical circulatory support. The timing of CNI introduction is dictated by renal recovery, varying between day 3 and day 0 after heart transplantation, and the initial target exposure is influenced by immunological risk and presence of infection. Rabbit antithymocyte globulin and CNI dosing should not overlap except in high-risk cases. There is a clear need for more studies to define the optimal dosing regimens for rATG and early CNI exposure according to risk profile in heart transplantation.
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Azarbal B, Cheng R, Vanichsarn C, Patel JK, Czer LS, Chang DH, Kittleson MM, Kobashigawa JA. Induction Therapy With Antithymocyte Globulin in Patients Undergoing Cardiac Transplantation Is Associated With Decreased Coronary Plaque Progression as Assessed by Intravascular Ultrasound. Circ Heart Fail 2016; 9:e002252. [PMID: 26747860 DOI: 10.1161/circheartfailure.115.002252] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Antithymocyte globulin (ATG) is used as induction therapy after cardiac transplant for enhancing immunosuppression and delaying the initiation of nephrotoxic drugs. It is unknown if ATG induction is associated with decreased coronary plaque progression by intravascular ultrasound (IVUS). METHODS AND RESULTS Patients transplanted between March 2010 and December 2012 with baseline and 1-year IVUS were included. All patients transplanted were included in a secondary analysis. Change in plaque progression was measured in a blinded fashion on matched coronary segments and contrasted between patients induced with ATG and those who were not. One hundred and three patients were included in IVUS arms. Mean age at transplant was 55.8 ± 12.6 years, and 33.0% were female. Patients induced with ATG were more sensitized (54.3% versus 14.3%). Plaque progression was attenuated in patients who received ATG by changes in maximal intimal area (1.0 ± 1.2 versus 2.3 ± 2.6 mm(2); P = 0.001), maximal percent stenosis (6.3 ± 7.9 versus 12.8 ± 12.3%; = 0.003), maximal intimal thickness (0.2 ± 0.2 versus 0.3 ± 0.3 mm; P = 0.035), and plaque volume (0.5 ± 0.7 versus 1.0 ± 1.3 mm(3)/mm; P = 0.016). Rapid plaque progression by maximal percent stenosis (≥ 20%) occurred less frequently in the ATG arm (4.3% versus 26.3; P = 0.003). Survival (P = 0.242) and any treated rejection (P = 0.166) were not statistically different between groups. Patients receiving ATG had a higher rate of first-year infection (P = 0.003), perhaps related to increased intravenous antibiotic use immediately postoperatively, and a trend toward more biopsy-proven rejection (P = 0.073). CONCLUSIONS Induction therapy with ATG is associated with reduced first-year coronary plaque progression as assessed by IVUS, despite an increased prevalence of sensitized patients with a trend toward more rejection.
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Affiliation(s)
- Babak Azarbal
- From the Cedars-Sinai Heart Institute, Los Angeles, CA.
| | - Richard Cheng
- From the Cedars-Sinai Heart Institute, Los Angeles, CA
| | | | | | | | - David H Chang
- From the Cedars-Sinai Heart Institute, Los Angeles, CA
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18
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Ansari D, Lund LH, Stehlik J, Andersson B, Höglund P, Edwards L, Nilsson J. Induction with anti-thymocyte globulin in heart transplantation is associated with better long-term survival compared with basiliximab. J Heart Lung Transplant 2015; 34:1283-91. [DOI: 10.1016/j.healun.2015.04.001] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 04/01/2015] [Accepted: 04/16/2015] [Indexed: 11/16/2022] Open
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19
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Söderlund C, Rådegran G. Immunosuppressive therapies after heart transplantation — The balance between under- and over-immunosuppression. Transplant Rev (Orlando) 2015; 29:181-9. [DOI: 10.1016/j.trre.2015.02.005] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Revised: 01/16/2015] [Accepted: 02/22/2015] [Indexed: 01/06/2023]
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20
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Mohty M, Bacigalupo A, Saliba F, Zuckermann A, Morelon E, Lebranchu Y. New directions for rabbit antithymocyte globulin (Thymoglobulin(®)) in solid organ transplants, stem cell transplants and autoimmunity. Drugs 2015; 74:1605-34. [PMID: 25164240 PMCID: PMC4180909 DOI: 10.1007/s40265-014-0277-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In the 30 years since the rabbit antithymocyte globulin (rATG) Thymoglobulin® was first licensed, its use in solid organ transplantation and hematology has expanded progressively. Although the evidence base is incomplete, specific roles for rATG in organ transplant recipients using contemporary dosing strategies are now relatively well-identified. The addition of rATG induction to a standard triple or dual regimen reduces acute cellular rejection, and possibly humoral rejection. It is an appropriate first choice in patients with moderate or high immunological risk, and may be used in low-risk patients receiving a calcineurin inhibitor (CNI)-sparing regimen from time of transplant, or if early steroid withdrawal is planned. Kidney transplant patients at risk of delayed graft function may also benefit from the use of rATG to facilitate delayed CNI introduction. In hematopoietic stem cell transplantation, rATG has become an important component of conventional myeloablative conditioning regimens, following demonstration of reduced acute and chronic graft-versus-host disease. More recently, a role for rATG has also been established in reduced-intensity conditioning regimens. In autoimmunity, rATG contributes to the treatment of severe aplastic anemia, and has been incorporated in autograft projects for the management of conditions such as multiple sclerosis, Crohn’s disease, and systemic sclerosis. Finally, research is underway for the induction of tolerance exploiting the ability of rATG to induce immunosuppresive cells such as regulatory T-cells. Despite its long history, rATG remains a key component of the immunosuppressive armamentarium, and its complex immunological properties indicate that its use will expand to a wider range of disease conditions in the future.
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Affiliation(s)
- Mohamad Mohty
- Department of Hematology and Cellular Therapy, CHU Hôpital Saint Antoine, 184, rue du Faubourg Saint Antoine, 75571, Paris Cedex 12, France,
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21
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Whitson BA, Kilic A, Lehman A, Wehr A, Hasan A, Haas G, Hayes D, Sai-Sudhakar CB, Higgins RSD. Impact of induction immunosuppression on survival in heart transplant recipients: a contemporary analysis of agents. Clin Transplant 2014; 29:9-17. [PMID: 25284138 DOI: 10.1111/ctr.12469] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2014] [Indexed: 01/23/2023]
Abstract
INTRODUCTION The impact of induction immunosuppression on long-term survival in heart transplant recipients is unclear. Over the past three decades, practices have varied as induction agents have changed and experiences grew. We sought to evaluate the effect of contemporary induction immunosuppression agents in heart transplant recipients with the primary endpoint of survival, utilizing national registry data. METHODS We queried the United Network for Organ Sharing (UNOS) data registry for all heart transplants from 1987 to 2012. We restricted our analysis to adult (≥18 yr) recipients performed from 2001-2011 (to allow for the potential for a minimum of 12 months post-transplant follow-up) who received either: no antibody based induction (NONE) or the contemporary agents (INDUCED) of either: basiliximab/daclizumab (IL-2Rab), alemtuzumab, or ATG/ALG/thymoglobulin. Kaplan-Meier estimates of the survival function as well as Cox proportional hazards models were utilized. RESULTS Of the 17 857 heart transplants that met the inclusion criteria, there were 4635 (26%) reported deaths during the follow-up period. There were 8216 (46%) patients who were INDUCED. Of the INDUCED agents, 55% were IL-2Rab, 4% alemtuzumab, and 40% ALG/ATG/thymoglobulin. Donor and recipient characteristics were evaluated. Overall, being INDUCED did not significantly affect survival in univariable (p = 0.522) and multivariable (p = 0.130) Cox models as well as a propensity score adjusted model (p = 0.733). Among those induced, ATG/ALG/thymoglobulin appeared to have superior survival as compared with IL-2Rab (log-rank p = 0.007, univariable hazard ratio [HR] = 0.886; 95% CI: 0.811-0.968; p = 0.522). However, in a multivariable Cox model that adjusted for recipient age, VAD, BMI, steroid use, CMV match, and ischemic time, the hazard ratio for ALG/ATG/thymoglobulin vs. IL-2Rab was no longer statistically significant (HR = 0.948; 95% CI: 0.850-1.058; p = 0.341). CONCLUSION In a contemporary analysis of heart transplant recipients, an overall analysis of induction agents does not appear to impact survival, as compared to no induction immunosuppression. While ALG/ATG/thymoglobulin appeared to have a beneficial effect on survival compared to IL-2Rab in the univariable model, this difference was no longer statistically significant once we adjusted for clinically relevant covariates.
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Affiliation(s)
- Bryan A Whitson
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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22
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Zuckermann A, Schulz U, Deuse T, Ruhpawar A, Schmitto JD, Beiras-Fernandez A, Hirt S, Schweiger M, Kopp-Fernandes L, Barten MJ. Thymoglobulin induction in heart transplantation: patient selection and implications for maintenance immunosuppression. Transpl Int 2014; 28:259-69. [PMID: 25363471 PMCID: PMC4359038 DOI: 10.1111/tri.12480] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Revised: 09/18/2014] [Accepted: 10/24/2014] [Indexed: 01/12/2023]
Abstract
Clinical data relating to rabbit antithymocyte globulin (rATG) induction in heart transplantation are far less extensive than for other immunosuppressants, or indeed for rATG in other indications. This was highlighted by the low grade of evidence and the lack of detailed recommendations for prescribing rATG in the International Society for Heart and Lung Transplantation (ISHLT) guidelines. The heart transplant population includes an increasing frequency of patients on mechanical circulatory support (MCS), often with ongoing infection and/or presensitization, who are at high immunological risk but also vulnerable to infectious complications. The number of patients with renal impairment is also growing due to lengthening waiting times, intensifying the need for strategies that minimize calcineurin inhibitor (CNI) toxicity. Additionally, the importance of donor-specific antibodies (DSA) in predicting graft failure is influencing immunosuppressive regimens. In light of these developments, and in view of the lack of evidence-based prescribing criteria, experts from Germany, Austria, and Switzerland convened to identify indications for rATG induction in heart transplantation and to develop an algorithm for its use based on patient characteristics.
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Affiliation(s)
- Andreas Zuckermann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
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Mazimba S, Tallaj JA, George JF, Kirklin JK, Brown RN, Pamboukian SV. Infection and rejection risk after cardiac transplantation with induction vs. no induction: a multi-institutional study. Clin Transplant 2014; 28:946-52. [DOI: 10.1111/ctr.12395] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2014] [Indexed: 11/27/2022]
Affiliation(s)
- Sula Mazimba
- Division of Cardiovascular Diseases; University of Alabama at Birmingham; Birmingham AL USA
| | - Jose A. Tallaj
- Division of Cardiovascular Diseases; University of Alabama at Birmingham; Birmingham AL USA
| | - James F. George
- Division of Cardiothoracic Surgery; University of Alabama at Birmingham; Birmingham AL USA
| | - James K. Kirklin
- Division of Cardiothoracic Surgery; University of Alabama at Birmingham; Birmingham AL USA
| | - Robert N. Brown
- Division of Cardiothoracic Surgery; University of Alabama at Birmingham; Birmingham AL USA
| | - Salpy V. Pamboukian
- Division of Cardiovascular Diseases; University of Alabama at Birmingham; Birmingham AL USA
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Tonsho M, Michel S, Ahmed Z, Alessandrini A, Madsen JC. Heart transplantation: challenges facing the field. Cold Spring Harb Perspect Med 2014; 4:4/5/a015636. [PMID: 24789875 DOI: 10.1101/cshperspect.a015636] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
There has been significant progress in the field of heart transplantation over the last 45 years. The 1-yr survival rates following heart transplantation have improved from 30% in the 1970s to almost 90% in the 2000s. However, there has been little change in long-term outcomes. This is mainly due to chronic rejection, malignancy, and the detrimental side effects of chronic immunosuppression. In addition, over the last decade, new challenges have arisen such as increasingly complicated recipients and antibody-mediated rejection. Most, if not all, of these obstacles to long-term survival could be prevented or ameliorated by the induction of transplant tolerance wherein the recipient's immune system is persuaded not to mount a damaging immune response against donor antigens, thus eliminating the need for chronic immunosuppression. However, the heart, as opposed to other allografts like kidneys, appears to be a tolerance-resistant organ. Understanding why organs like kidneys and livers are prone to tolerance induction, whereas others like hearts and lungs are tolerance-resistant, could aid in our attempts to achieve long-term, immunosuppression-free survival in human heart transplant recipients. It could also advance the field of pig-to-human xenotransplantation, which, if successful, would eliminate the organ shortage problem. Of course, there are alternative futures to the field of heart transplantation that may include the application of total mechanical support, stem cells, or bioengineered whole organs. Which modality will be the first to reach the ultimate goal of achieving unlimited, long-term, circulatory support with minimal risk to longevity or lifestyle is unknown, but significant progress in being made in each of these areas.
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Affiliation(s)
- Makoto Tonsho
- MGH Transplantation Center, Massachusetts General Hospital, Boston, Massachusetts 02114
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