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López-López I, López AIR, Prado JMAD, Benot AR, Cabrera SS, Morales MLA. Prevalence of Chronic Kidney Disease After Heart Transplant: A Single Center Experience. Transplant Proc 2022. [DOI: 10.1016/j.transproceed.2022.09.002] [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]
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2
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Mete M, Ayvaci MU, Ariyamuthu VK, Amin A, Peltz M, Thibodeau JT, Grodin JL, Mammen PP, Garg S, Araj F, Morlend R, Drazner MH, AbdulRahim N, Kim Y, Salam Y, Gungor AB, Delibasi B, Kotla SK, MacConmara MP, Mohan P, Gupta G, Tanriover B. Predicting Post-Heart Transplant Composite Renal Outcome Risk in Adults: A Machine Learning Decision Tool. Kidney Int Rep 2022; 7:1410-1415. [PMID: 35685329 PMCID: PMC9171705 DOI: 10.1016/j.ekir.2022.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 03/29/2022] [Accepted: 04/04/2022] [Indexed: 12/02/2022] Open
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3
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Myocardial Vascular Function Assessed by Dynamic Oxygenation-sensitive Cardiac Magnetic Resonance Imaging Long-term Following Cardiac Transplantation. Transplantation 2021; 105:1347-1355. [PMID: 32804801 DOI: 10.1097/tp.0000000000003419] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Coronary vascular function is related to adverse outcomes following cardiac transplantation (CTx) in patients with or without cardiac allograft vasculopathy (CAV). The noninvasive assessment of the myocardial vascular response using oxygenation-sensitive cardiac magnetic resonance (OS-CMR has not been investigated in stable long-term CTx recipients). METHODS CTx patients were prospectively recruited to complete a CMR study with a breathing maneuver of hyperventilation followed by a voluntary apnea. Changes in OS-sensitive signal intensity reflecting the myocardial oxygenation response were monitored and expressed as % change in response to these breathing maneuvers. Myocardial injury was further investigated with T2-weighted imaging, native and postcontrast T1 measurements, extracellular volume measurements, and late gadolinium enhancement. RESULTS Forty-six CTx patients with (n = 23) and without (n = 23) CAV, along with 25 healthy controls (HC), were enrolled. The OS response was significantly attenuated in CTx compared with HC at the 30-second time-point into the breath-hold (2.63% ± 4.16% versus 6.40% ± 5.96%; P = 0.010). Compared with HC, OS response was lower in CTx without CAV (2.62% ± 4.60%; P < 0.05), while this response was further attenuated in patients with severe CAV (grades 2-3, -2.24% ± 3.65%). An inverse correlation was observed between OS-CMR, ventricular volumes, and diffuse fibrosis measured by extracellular volume mapping. CONCLUSIONS In heart transplant patients, myocardial oxygenation is impaired even in the absence of CAV suggesting microvascular dysfunction. These abnormalities can be identified by oxygenation-sensitive CMR using simple breathing maneuvers.
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Diaz-Castrillon CE, Huckaby LV, Hickey G, Sultan I, Kilic A. Induction Immunosuppression and Renal Outcomes in Adult Heart Transplantation. J Surg Res 2020; 259:14-23. [PMID: 33278793 DOI: 10.1016/j.jss.2020.11.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 09/09/2020] [Accepted: 11/02/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND This study explores the use of induction therapy in orthotopic heart transplantation as it relates to preoperative renal function and evaluates the impact of its utilization on post-transplant outcomes. METHODS We conducted a retrospective analysis using the United Network for Organ Sharing database from 2000 to 2018 evaluating the initiation of de novo dialysis after transplantation. We examined the relationship between induction immunosuppression and pre-transplant estimated glomerular filtration rate with post-transplant outcomes, accounting for inter-center variability through a mixed-effects logistic regression model. RESULTS In total, 16,201 patients were included with a median age of 57 y (interquartile range 47, 63); 26% were women (n = 4222) and 28% (n = 4552) had a history of diabetes mellitus. The median estimated glomerular filtration rate (eGFR) was 67.5 mL/min (interquartile range 53.1, 86.7); 51.2% (n = 3068) of the recipients with eGFR < 60 received induction therapy compared to 42.5% (n = 4336) within the eGFR ≥ 60 group (P < 0.001). Adjusted multivariable analysis found that induction therapy was associated with de novo dialysis (odds ratio 1.25, 95% confidence interval 1.10-1.43, P < 0.001), with the most significant effect on patients with eGFR ≥ 60. Although significant, there was a weak correlation between center-level induction utilization and mean eGFR (r = -0.2, P < 0.001). CONCLUSION In this analysis, the use of induction immunosuppression in orthotopic heart transplantation varied widely between centers and did not correlate strongly with pre-transplant eGFR. In addition, its utilization did not mitigate the risk of renal replacement therapy after transplantation and in fact was associated with increased risk even after adjusting for confounders most notably in patients with eGFR ≥ 60.
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Affiliation(s)
| | - Lauren V Huckaby
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Gavin Hickey
- Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ibrahim Sultan
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Arman Kilic
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
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5
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Shiraishi Y, Amiya E, Hatano M, Katsuki T, Bujo C, Tsuji M, Nitta D, Maki H, Ishida J, Kagami Y, Endo M, Kimura M, Ando M, Shimada S, Kinoshita O, Ono M, Komuro I. Impact of tacrolimus versus cyclosporin A on renal function during the first year after heart transplant. ESC Heart Fail 2020; 7:1842-1849. [PMID: 32445260 PMCID: PMC7373882 DOI: 10.1002/ehf2.12749] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 04/02/2020] [Accepted: 04/24/2020] [Indexed: 12/22/2022] Open
Abstract
AIMS Nephrotoxicity of calcineurin inhibitors (CNIs) is associated with adverse events in patients undergoing heart transplant (HTx), although studies directly comparing tacrolimus (TAC) versus cyclosporin A (CsA), especially in combination with everolimus and low-dose CNIs approach, are limited. Thus, we sought to investigate the associations of TAC and CsA with clinical outcomes in HTx recipients, with specific focus on renal function. METHODS AND RESULTS From August 2007 to February 2017, 72 consecutive patients (39 treated with TAC vs. 33 with CsA) receiving de novo HTx in a single transplant centre were retrospectively evaluated. We used the instrumental variable method to account for unmeasured confounding. The study outcomes were percentage change in estimated glomerular filtration rates (eGFR) (safety endpoint) and biopsy-proven acute rejection (efficacy endpoint) within the first year after HTx. The enrolled patients (median age 40 years) were predominantly men (68%). There were no significant differences in baseline characteristics, including eGFR (64.8 [45.7-96.4] mL/min/1.73 m2 in TAC vs. 65.6 [57.9-83.0] mL/min/1.73 m2 for CsA; P = 0.48), other than sex (male, 49% for TAC vs. 91% for CsA; P < 0.001) between the two groups. Within the first year after HTx, 23 (59%) in the TAC group switched mycophenolate mofetil to everolimus, whereas 16 (48%) in the CsA group (P = 0.52). At 12 months, the rates of mortality and end-stage renal disease requiring renal replacement therapies were both 0%. In the instrumental variable analysis, no differences in renal function as well as graft rejection for 1 year after HTx existed between the TAC and CsA groups. These results were similar when taking into account of everolimus use. CONCLUSIONS Irrespective of everolimus use with low-dose CNIs, our analysis using the instrumental variable method showed no differences in renal function as well as graft rejection during the first year after HTx between HTx recipients who received TAC or CsA.
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Affiliation(s)
- Yasuyuki Shiraishi
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Eisuke Amiya
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Therapeutic Strategy for Heart Failure, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masaru Hatano
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Therapeutic Strategy for Heart Failure, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Toshiomi Katsuki
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Chie Bujo
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masaki Tsuji
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Daisuke Nitta
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hisataka Maki
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Junichi Ishida
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yukie Kagami
- Department of Organ Transplantation, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Miyoko Endo
- Department of Organ Transplantation, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Mitsutoshi Kimura
- Department of Cardiovascular Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masahiko Ando
- Department of Cardiovascular Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shogo Shimada
- Department of Cardiovascular Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Osamu Kinoshita
- Department of Cardiovascular Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Minoru Ono
- Department of Cardiovascular Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Issei Komuro
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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6
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Suarez-Pierre A, Lui C, Zhou X, Crawford TC, Fraser CD, Giuliano K, Hsu S, Higgins RS, Zehr KJ, Whitman GJ, Choi CW, Kilic A. Early Outcomes After Heart Transplantation in Recipients Bridged With a HeartMate 3 Device. Ann Thorac Surg 2019; 108:467-473. [DOI: 10.1016/j.athoracsur.2019.01.084] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 11/27/2018] [Accepted: 01/29/2019] [Indexed: 01/06/2023]
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7
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Tsao CI, Ting M, Chou NK, Chi NH, Chen YS, Huang SC, Tsan CY, Wang CH, Yu HY, Shun CT, Wang SS. Changes in Renal Function After Heart Transplantation. Transplant Proc 2018; 50:2751-2755. [PMID: 30401390 DOI: 10.1016/j.transproceed.2018.02.196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 02/26/2018] [Indexed: 11/28/2022]
Abstract
Renal function after heart transplantation (HTx) typically follows a biphasic pattern and an initial decay within 1 to 2 years. Trajectory of renal function after HTx is less reported, especially in Asia. The aims of this cohort study were to describe the changes in HTx recipients' serum creatinine and estimated glomerular filtration rate (eGFR) levels 5 years following HTx in Taiwan. METHODS We retrospectively reviewed 5 years of 440 consecutive adult patients (≥ 18 years) who underwent first HTx from June 1987 to December 2014 at the National Taiwan University Hospital. RESULTS Among 422 participants, they received induction therapy consisting of intravenous rabbit antithymocyte globulin. Here, we illustrated the trends over the years by dividing the subjects into 2 groups based on their immunosuppressive regimen of transplantation (1987-2002 and 2003-2014) The pretransplantation median serum creatinine concentration level was 1.2 mg/dL, rose to 1.4 mg/dL at 3 months after surgery, and remained steady over 5 years after HTx. Pretransplant median eGFR was 67 mL/min/1.73 m2.The median serum creatinine concentration level and eGFR at baseline were all significantly difference than pretransplantation (P > .05). This result has showed that an initial steep decline within 3 months after transplant remained stable 5 years after HTx. CONCLUSION As renal function deteriorates after HTx, we observed a steep decline in serum creatinine level and glomerular filtration rate within the 3 months after HTx, followed by a slow rate of deterioration over the following months. We found a time-related progressive deterioration in renal function during the 5 years after HTx.
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Affiliation(s)
- C I Tsao
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - M Ting
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - N K Chou
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - N-H Chi
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Y-S Chen
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - S-C Huang
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - C-Y Tsan
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - C-H Wang
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - H-Y Yu
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - C T Shun
- Department of Pathology, National Taiwan University Hospital, Taipei, Taiwan
| | - S-S Wang
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan; Department of Surgery, Fu Jen Catholic University Hospital and Fu Jen Catholic University College of Medicine, New Taipei City, Taiwan.
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8
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Influence of Blood Pressure and Calcineurin Inhibitors on Kidney Function After Heart or Liver Transplantation. Transplantation 2018; 102:845-852. [DOI: 10.1097/tp.0000000000002023] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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9
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Fortrie G, Manintveld OC, Constantinescu AA, van de Woestijne PC, Betjes MGH. Renal function at 1 year after cardiac transplantation rather than acute kidney injury is highly associated with long-term patient survival and loss of renal function - a retrospective cohort study. Transpl Int 2017; 30:788-798. [DOI: 10.1111/tri.12940] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 08/18/2016] [Accepted: 02/14/2017] [Indexed: 01/21/2023]
Affiliation(s)
- Gijs Fortrie
- Division of Nephrology and Transplantation; Department of Internal Medicine; Erasmus MC; Rotterdam The Netherlands
| | | | | | | | - Michiel G. H. Betjes
- Division of Nephrology and Transplantation; Department of Internal Medicine; Erasmus MC; Rotterdam The Netherlands
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10
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Perrault LP, Carrier M. Kidney transplantation as a therapeutic option for end-stage renal disease long after heart transplantation: Should we all do it? J Heart Lung Transplant 2017; 36:378-379. [PMID: 28325435 DOI: 10.1016/j.healun.2017.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 01/10/2017] [Accepted: 01/11/2017] [Indexed: 11/19/2022] Open
Affiliation(s)
- Louis P Perrault
- Department of Surgery, Montreal Heart Institute, Montreal, Quebec, Canada.
| | - Michel Carrier
- Department of Surgery, Montreal Heart Institute, Montreal, Quebec, Canada
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11
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Grupper A, Grupper A, Daly RC, Pereira NL, Hathcock MA, Kremers WK, Cosio FG, Edwards BS, Kushwaha SS. Kidney transplantation as a therapeutic option for end-stage renal disease developing after heart transplantation. J Heart Lung Transplant 2016; 36:297-304. [PMID: 27642059 DOI: 10.1016/j.healun.2016.08.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 07/25/2016] [Accepted: 08/10/2016] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Progressive renal failure is a frequent complication after heart transplantation (HTx). It may result in end-stage renal disease (ESRD), prompting consideration of kidney Tx after HTx (KAH). METHODS We performed a retrospective single-center study of 268 HTx recipients to evaluate outcomes after KAH compared with HTx recipients with and without ESRD. RESULTS During a median follow-up of 76 months, ESRD developed in 51 patients (19), and 39 of them (76%) underwent KAH. The mean time from HTx to ESRD was 83 months. The incidence of switching to a calcineurin inhibitor (CNI)-free regimen based on sirolimus was significantly lower among recipients with ESRD (6% vs 57%, p = 0.0001), and prolonged exposure to CNI significantly increased the risk for ESRD (hazard ratio, 1.09; 95% confidence interval, 1.03-1.15; p < 0.005). Death-censored renal graft survival after KAH was 95%, 95%, and 83% at 1, 5, and 10 years, respectively. Median long-term survival of KAH patients was comparable to HTx recipients without ESRD (17.5 vs 17.1 years, p = 0.27) and significantly better compared with HTx recipients with ESRD (17.5 vs 7.3 years, p < 0.001). CONCLUSIONS Prolonged exposure to CNI immunosuppression medications significantly increases the risk for ESRD among HTx recipients. KAH is a good therapeutic option for HTx recipients with ESRD, with survival benefit comparable to HTx without ESRD.
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Affiliation(s)
- Avishay Grupper
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota; William J. von Liebig Transplant Center, Mayo Clinic, Rochester, Minnesota
| | - Ayelet Grupper
- William J. von Liebig Transplant Center, Mayo Clinic, Rochester, Minnesota; Divisions of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Richard C Daly
- Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Naveen L Pereira
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota; William J. von Liebig Transplant Center, Mayo Clinic, Rochester, Minnesota
| | - Matthew A Hathcock
- Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Walter K Kremers
- Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Fernando G Cosio
- William J. von Liebig Transplant Center, Mayo Clinic, Rochester, Minnesota; Divisions of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Brooks S Edwards
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota; William J. von Liebig Transplant Center, Mayo Clinic, Rochester, Minnesota
| | - Sudhir S Kushwaha
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota; William J. von Liebig Transplant Center, Mayo Clinic, Rochester, Minnesota.
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13
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Gullestad L, Eiskjaer H, Gustafsson F, Riise GC, Karason K, Dellgren G, Rådegran G, Hansson L, Gude E, Bjørtuft Ø, Jansson K, Schultz HH, Solbu D, Iversen M. Long-term outcomes of thoracic transplant recipients following conversion to everolimus with reduced calcineurin inhibitor in a multicenter, open-label, randomized trial. Transpl Int 2016; 29:819-29. [DOI: 10.1111/tri.12783] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Revised: 01/20/2016] [Accepted: 04/07/2016] [Indexed: 12/24/2022]
Affiliation(s)
- Lars Gullestad
- Department of Cardiology; Oslo University Hospital Rikshospitalet; Oslo Norway
- Faculty of Medicine; K.G. Jebsen Cardiac Research Centre and Center for Heart Failure Research; University of Oslo; Oslo Norway
| | - Hans Eiskjaer
- Department of Cardiology; Aarhus University Hospital; Skejby Aarhus Denmark
| | - Finn Gustafsson
- Department of Cardiology; Rigshospitalet; Copenhagen Denmark
| | - Gerdt C. Riise
- Department of Respiratory Medicine; Sahlgrenska University Hospital; Gothenburg Sweden
| | - Kristjan Karason
- Department of Cardiology and Transplant Institute; Sahlgrenska University Hospital; Gothenburg Sweden
| | - Göran Dellgren
- Department of Cardiology and Transplant Institute; Sahlgrenska University Hospital; Gothenburg Sweden
| | - Göran Rådegran
- Department of Clinical Sciences Lund, Cardiology; Lund University and the Section for Heart Failure and Valvular Disease; Skåne University Hospital; Lund Sweden
| | - Lennart Hansson
- Department of Respiratory Medicine; Lund University Hospital and Skåne University Hospital; Lund Sweden
| | - Einar Gude
- Department of Cardiology; Oslo University Hospital Rikshospitalet; Oslo Norway
- Faculty of Medicine; K.G. Jebsen Cardiac Research Centre and Center for Heart Failure Research; University of Oslo; Oslo Norway
| | - Øystein Bjørtuft
- Department of Respiratory Medicine; Oslo University Hospital Rikshospitalet; Oslo Norway
| | - Kjell Jansson
- Department of Cardiology, Heart Center; University Hospital; Linkoping Sweden
| | - Hans Henrik Schultz
- Division of Lung Transplantation; Department of Cardiology; Rigshospitalet; Copenhagen Denmark
| | | | - Martin Iversen
- Division of Lung Transplantation; Department of Cardiology; Rigshospitalet; Copenhagen Denmark
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14
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Andreassen AK, Andersson B, Gustafsson F, Eiskjaer H, Rådegran G, Gude E, Jansson K, Solbu D, Karason K, Arora S, Dellgren G, Gullestad L. Everolimus Initiation With Early Calcineurin Inhibitor Withdrawal in De Novo Heart Transplant Recipients: Three-Year Results From the Randomized SCHEDULE Study. Am J Transplant 2016; 16:1238-47. [PMID: 26820618 DOI: 10.1111/ajt.13588] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 10/18/2015] [Accepted: 10/18/2015] [Indexed: 01/25/2023]
Abstract
In a randomized, open-label trial, de novo heart transplant recipients were randomized to everolimus (3-6 ng/mL) with reduced-exposure calcineurin inhibitor (CNI; cyclosporine) to weeks 7-11 after transplant, followed by increased everolimus exposure (target 6-10 ng/mL) with cyclosporine withdrawal or standard-exposure cyclosporine. All patients received mycophenolate mofetil and corticosteroids. A total of 110 of 115 patients completed the 12-month study, and 102 attended a follow-up visit at month 36. Mean measured GFR (mGFR) at month 36 was 77.4 mL/min (standard deviation [SD] 20.2 mL/min) versus 59.2 mL/min (SD 17.4 mL/min) in the everolimus and CNI groups, respectively, a difference of 18.3 mL/min (95% CI 11.1-25.6 mL/min; p < 0.001) in the intention to treat population. Multivariate analysis showed treatment to be an independent determinant of mGFR at month 36. Coronary intravascular ultrasound at 36 months revealed significantly reduced progression of allograft vasculopathy in the everolimus group compared with the CNI group. Biopsy-proven acute rejection grade ≥2R occurred in 10.2% and 5.9% of everolimus- and CNI-treated patients, respectively, during months 12-36. Serious adverse events occurred in 37.3% and 19.6% of everolimus- and CNI-treated patients, respectively (p = 0.078). These results suggest that early CNI withdrawal after heart transplantation supported by everolimus, mycophenolic acid and steroids with lymphocyte-depleting induction is safe at intermediate follow-up. This regimen, used selectively, may offer adequate immunosuppressive potency with a sustained renal advantage.
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Affiliation(s)
- A K Andreassen
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - B Andersson
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - F Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - H Eiskjaer
- Department of Cardiology, Aarhus University Hospital, Skejby, Denmark
| | - G Rådegran
- Section for Heart Failure and Valvular Disease, Skåne University Hospital and Department of Clinical Sciences, Cardiology, Lund University, Lund, Sweden
| | - E Gude
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - K Jansson
- Department of Cardiology, Heart and Medicine Center County Council of Ostergotland and Linkoping University, Linkoping, Sweden
| | - D Solbu
- Novartis Norge AS, Oslo, Norway
| | - K Karason
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - S Arora
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - G Dellgren
- Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - L Gullestad
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway.,K.G. Jebsen Cardiac Research Center and Center for Heart Failure Research, Faculty of Medicine, University of Oslo, Oslo, Norway
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15
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Carrier M, Perrault LP. Surgical Treatments for Patients With Terminal Heart Failure: Mechanical Support Compared With Transplantation. Can J Cardiol 2014; 30:S455-8. [DOI: 10.1016/j.cjca.2014.06.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Revised: 06/27/2014] [Accepted: 06/28/2014] [Indexed: 12/11/2022] Open
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16
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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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Haglund NA, Feurer ID, Dwyer JP, Stulak JM, DiSalvo TG, Keebler ME, Schlendorf KH, Wigger MA, Maltais S. Does renal dysfunction and method of bridging support influence heart transplant graft survival? Ann Thorac Surg 2014; 98:835-41. [PMID: 25069689 DOI: 10.1016/j.athoracsur.2014.05.059] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 05/06/2014] [Accepted: 05/07/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND Renal insufficiency is common in status 1B patients supported with inotropes or a continuous flow left ventricular device (CF-LVAD) as a bridge to heart transplantation. We evaluated the association of renal function and inotrope versus CF-LVAD support on posttransplant graft survival in status 1B patients. METHODS The Scientific Registry for Transplant Recipients database was analyzed for posttransplant survival in status 1B patients bridged with inotropes or CF-LVAD who underwent transplantation between 2003 and 2012. Pretransplant renal function was measured by estimating glomerular filtration rate (GFR) and was stratified as less than 45 mL · min(-1) · 1.73 m(-2), 45 to 59, and 60 or greater. Univariate Kaplan-Meier and multivariate Cox regression models were used to evaluate the main effects of GFR strata and inotropes versus CF-LVAD, and the interaction effect of GFR strata by CF-LVAD, on graft survival. RESULTS This study included 4,158 status 1B patients (74% male, aged 53 ± 12 years). Of those, 659 patients had a CF-LVAD (HeartMate-II [Thoratec, Pleasanton, CA], n = 638; HVAD [HeartWare, Framingham, MA], n = 21), and 3,530 were receiving inotropes (31 CF-LVAD patients were also receiving inotropes). Kaplan-Meier analyses demonstrated reduced graft survival (p = 0.022) in patients with pretransplant GFR less than 45 versus GFR 45 to 59 (p = 0.062) and versus GFR 60 or greater (p = 0.007), and no effect of inotrope versus CF-LVAD support on graft survival (p = 0.402). Multivariate analysis demonstrated that, after adjusting for the main effects of GFR stratum, CF-LVAD, and inotropes, status 1B patients bridged with a CF-LVAD and GFR in the lowest stratum had reduced graft survival (interaction effect p = 0.040). CONCLUSIONS Pretransplant renal insufficiency was associated with reduced posttransplant graft survival in status 1B patients. This risk is increased for patients bridged with a CF-LVAD (versus inotropes) who have GFR in the lowest stratum.
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Affiliation(s)
- Nicholas A Haglund
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Irene D Feurer
- Departments of Surgery and Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jamie P Dwyer
- Division of Nephrology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John M Stulak
- Division of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Thomas G DiSalvo
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mary E Keebler
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kelly H Schlendorf
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mark A Wigger
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Simon Maltais
- Division of Cardiovascular Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.
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