1
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Simonenko M, Hansen D, Niebauer J, Volterrani M, Adamopoulos S, Amarelli C, Ambrosetti M, Anker SD, Bayes-Genis A, Gal TB, Bowen TS, Cacciatore F, Caminiti G, Cavarretta E, Chioncel O, Coats AJS, Cohen-Solal A, D'Ascenzi F, de Pablo Zarzosa C, Gevaert AB, Gustafsson F, Kemps H, Hill L, Jaarsma T, Jankowska E, Joyce E, Krankel N, Lainscak M, Lund LH, Moura B, Nytrøen K, Osto E, Piepoli M, Potena L, Rakisheva A, Rosano G, Savarese G, Seferovic PM, Thompson DR, Thum T, Van Craenenbroeck EM. Prevention and rehabilitation after heart transplantation: A clinical consensus statement of the European Association of Preventive Cardiology, Heart Failure Association of the ESC, and the European Cardio Thoracic Transplant Association, a section of ESOT. Eur J Prev Cardiol 2024; 31:1385-1399. [PMID: 38894688 DOI: 10.1093/eurjpc/zwae179] [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: 03/11/2023] [Revised: 01/20/2024] [Accepted: 02/21/2024] [Indexed: 06/21/2024]
Abstract
Little is known either about either physical activity patterns, or other lifestyle-related prevention measures in heart transplantation (HTx) recipients. The history of HTx started more than 50 years ago but there are still no guidelines or position papers highlighting the features of prevention and rehabilitation after HTx. The aims of this scientific statement are (i) to explain the importance of prevention and rehabilitation after HTx, and (ii) to promote the factors (modifiable/non-modifiable) that should be addressed after HTx to improve patients' physical capacity, quality of life and survival. All HTx team members have their role to play in the care of these patients and multidisciplinary prevention and rehabilitation programmes designed for transplant recipients. HTx recipients are clearly not healthy disease-free subjects yet they also significantly differ from heart failure patients or those who are supported with mechanical circulatory support. Therefore, prevention and rehabilitation after HTx both need to be specifically tailored to this patient population and be multidisciplinary in nature. Prevention and rehabilitation programmes should be initiated early after HTx and continued during the entire post-transplant journey. This clinical consensus.
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Affiliation(s)
- Maria Simonenko
- Cardiopulmonary Exercise Test Research Department, Heart Transplantation Outpatient Department, V.A. Almazov National Medical Research Centre, St. Petersburg, Russia
| | - Dominique Hansen
- REVAL and BIOMED Rehabilitation Research Center, Hasselt University, Hasselt, Belgium
- Heart Centre Hasselt, Jessa Hospital, Hasselt, Belgium
| | - Josef Niebauer
- University Institute of Sports Medicine, Prevention and Rehabilitation, Paracelsus Medical University, Salzburg, Austria
| | | | - Stamatis Adamopoulos
- Heart Failure and Heart Transplantation Unit, Onassis Cardiac Surgery Center, Athens, Greece
| | - Cristiano Amarelli
- Department of Cardiac Surgery and Transplants, Monaldi Hospital, Azienda dei Colli, Naples, Italy
| | - Marco Ambrosetti
- Cardiovascular Rehabilitation Unit, ASST Crema, Santa Marta Hospital, Rivolta d'Adda (CR), Italy
| | - Stefan D Anker
- Department of Cardiology (CVK), Berlin Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | - Tuvia Ben Gal
- Heart Failure Unit, Cardiology Department, Rabin Medical Center, Petah Tikva and Sackler, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - T Scott Bowen
- School of Biomedical Sciences, Faculty of Biological Sciences, University of Leeds, Leeds, UK
| | - Francesco Cacciatore
- Department of Translational Medicine, University of Naples 'Federico II', Naples, Italy
| | | | - Elena Cavarretta
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Rome, Italy
- Mediterranea Cardiocentro, Naples, Italy
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', Bucharest, Romania
- University of Medicine Carol Davila, Bucharest, Romania
| | | | - Alain Cohen-Solal
- Cardiology Department, University of Paris, INSERM UMRS-942, Hopital Lariboisiere, AP-HP, Paris, France
| | - Flavio D'Ascenzi
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | | | - Andreas B Gevaert
- Research Group Cardiovascular Diseases, GENCOR, University of Antwerp, Antwerp, Belgium
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Hareld Kemps
- Department of Cardiology, Maxima Medical Centre, Eindhoven, The Netherlands
- Department of Industrial Design, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Loreena Hill
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Tiny Jaarsma
- Department of Health, Medicine and Caring Science, Linköping University, Linköping, Sweden
- Julius Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Emer Joyce
- Department of Cardiology, Mater University Hospital, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Nicolle Krankel
- Universitätsmedizin Berlin Campus Benjamin Franklin Klinik für Kardiologie Charite, Berlin, Germany
| | | | - Lars H Lund
- Department of Medicine, Karolinska Institutet and Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Brenda Moura
- Armed Forces Hospital, Porto, Portugal
- Centre for Health Technologies and Services Research, Faculty of Medicine of University of Porto, Porto, Portugal
| | - Kari Nytrøen
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Elena Osto
- Division of Physiology and Pathophysiology, Otto Loewi Research Center for Vascular Biology, Immunology and Inflammation, Medical University of Graz, Graz, Austria
- Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
| | - Massimo Piepoli
- Dipartimento Scienze Biomediche per la Salute, Universita' Degli Studi di Milan, Milan, Italy
- Cardiologia Universitaria, IRCCS Policlinico San Donato, Milan, Italy
| | | | - Amina Rakisheva
- Department of Cardiology, Scientific Institution of Cardiology and Internal Diseases, Almaty, Kazakhstan
- Department of Cardiology, Kapshagai City Hospital, Almaty, Kazakhstan
| | - Giuseppe Rosano
- St. George's Hospital NHS Trust University of London, London, UK
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Petar M Seferovic
- Faculty of Medicine and Heart Failure Center, University of Belgrade, Belgrade University Medical Center, Belgrade, Serbia
| | - David R Thompson
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School and Fraunhofer Institute for Toxicology and Experimental Research, Hannover, Germany
| | - Emeline M Van Craenenbroeck
- Research Group Cardiovascular Diseases, GENCOR, University of Antwerp, Antwerp, Belgium
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium
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2
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Tatarintseva ZG, Tkhatl LK, Barbuhatti KO, Kosmacheva ED. [A Case of Successful Treatment of Severe Hyperlipidemia After Heart Transplantation With Inclisiran]. KARDIOLOGIIA 2024; 64:72-76. [PMID: 39102576 DOI: 10.18087/cardio.2024.7.n2679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 06/11/2024] [Indexed: 08/07/2024]
Abstract
The prognosis after heart transplantation continues to improve. Therefore, the prevention of chronic post-transplant sequelae, such as chronic kidney disease, allograft vasculopathy, and malignancies is becoming increasingly important. Everolimus, an inhibitor of the mammalian target of rapamycin (mTOR), is increasingly used for immunosuppression after heart transplantation. However, everolimus may cause a characteristic complex of adverse effects, including dyslipidemia. Currently there are no guidelines for the long-term screening and treatment of dyslipidemia in heart transplant recipients treated with everolimus. This article presents a clinical case of hypercholesterolemia that developed after the start of the everolimus treatment in a heart recipient. The patient was a 39-year-old man who underwent orthotopic heart transplantation for ischemic cardiomyopathy in 2012 (at the age of 27). In 2019, the patient's immunosuppressive therapy was converted from mycophenolate mofetil to everolimus due to the development of cardiac allograft vasculopathy. The change in the immunosuppressive therapy was associated with increases in total cholesterol and low-density lipoprotein cholesterol, which were not reversed with a combined lipid-lowering therapy (maximum doses of rosuvastatin, ezetimibe, fenofibrate). A decrease in lipid levels was achieved with a blocker of hepatic proprotein convertase subtilisin/kexin type 9 synthesis at the level of microribonucleic acid (inclisiran). This case demonstrates the difficulties in correcting dyslipidemia in patients with cardiac allograft, since the treatment with the immunosuppressant everolimus worsens existing dyslipidemia. However, the combination lipid-lowering therapy, that affects various elements of the pathogenesis (specifically, the combined inhibition of hydroxymethylglutaryl-CoA reductase with a statin, cholesterol absorption from the small intestine with ezetimibe, and PCSK9 messenger RNA with inclisiran), provides an effective control of blood lipids and minimizing the adverse effects of immunosuppressive therapy, such as cardiac allograft vasculopathy.
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Affiliation(s)
- Z G Tatarintseva
- Research Institute, Ochapovsky Territorial Clinical Hospital #1, Krasnodar; Kuban State Medical University, Krasnodar
| | - L K Tkhatl
- Research Institute, Ochapovsky Territorial Clinical Hospital #1, Krasnodar; Kuban State Medical University, Krasnodar
| | - K O Barbuhatti
- Research Institute, Ochapovsky Territorial Clinical Hospital #1, Krasnodar; Kuban State Medical University, Krasnodar
| | - E D Kosmacheva
- Research Institute, Ochapovsky Territorial Clinical Hospital #1, Krasnodar; Kuban State Medical University, Krasnodar
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3
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Simonenko M, Hansen D, Niebauer J, Volterrani M, Adamopoulos S, Amarelli C, Ambrosetti M, Anker SD, Bayes-Genis A, Ben Gal T, Bowen TS, Cacciatore F, Caminiti G, Cavarretta E, Chioncel O, Coats AJS, Cohen-Solal A, D’Ascenzi F, de Pablo Zarzosa C, Gevaert AB, Gustafsson F, Kemps H, Hill L, Jaarsma T, Jankowska E, Joyce E, Krankel N, Lainscak M, Lund LH, Moura B, Nytrøen K, Osto E, Piepoli M, Potena L, Rakisheva A, Rosano G, Savarese G, Seferovic PM, Thompson DR, Thum T, Van Craenenbroeck EM. Prevention and Rehabilitation After Heart Transplantation: A Clinical Consensus Statement of the European Association of Preventive Cardiology, Heart Failure Association of the ESC, and the European Cardio Thoracic Transplant Association, a Section of ESOT. Transpl Int 2024; 37:13191. [PMID: 39015154 PMCID: PMC11250379 DOI: 10.3389/ti.2024.13191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Accepted: 05/30/2024] [Indexed: 07/18/2024]
Abstract
Little is known either about either physical activity patterns, or other lifestyle-related prevention measures in heart transplantation (HTx) recipients. The history of HTx started more than 50 years ago but there are still no guidelines or position papers highlighting the features of prevention and rehabilitation after HTx. The aims of this scientific statement are (i) to explain the importance of prevention and rehabilitation after HTx, and (ii) to promote the factors (modifiable/non-modifiable) that should be addressed after HTx to improve patients' physical capacity, quality of life and survival. All HTx team members have their role to play in the care of these patients and multidisciplinary prevention and rehabilitation programmes designed for transplant recipients. HTx recipients are clearly not healthy disease-free subjects yet they also significantly differ from heart failure patients or those who are supported with mechanical circulatory support. Therefore, prevention and rehabilitation after HTx both need to be specifically tailored to this patient population and be multidisciplinary in nature. Prevention and rehabilitation programmes should be initiated early after HTx and continued during the entire post-transplant journey. This clinical consensus statement focuses on the importance and the characteristics of prevention and rehabilitation designed for HTx recipients.
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Affiliation(s)
- Maria Simonenko
- Cardiopulmonary Exercise Test Research Department, Heart Transplantation Outpatient Department, V. A. Almazov National Medical Research Centre, St. Petersburg, Russia
| | - Dominique Hansen
- REVAL and BIOMED Rehabilitation Research Center, Hasselt University, Hasselt, Belgium
- Heart Centre Hasselt, Jessa Hospital, Hasselt, Belgium
| | - Josef Niebauer
- University Institute of Sports Medicine, Prevention and Rehabilitation, Paracelsus Medical University, Salzburg, Austria
| | | | - Stamatis Adamopoulos
- Heart Failure and Heart Transplantation Unit, Onassis Cardiac Surgery Center, Athens, Greece
| | - Cristiano Amarelli
- Department of Cardiac Surgery and Transplants, Monaldi Hospital, Azienda dei Colli, Naples, Italy
| | - Marco Ambrosetti
- Cardiovascular Rehabilitation Unit, ASST Crema, Santa Marta Hospital, Rivolta D’Adda, Italy
| | - Stefan D. Anker
- Department of Cardiology (CVK), Berlin Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) Partner Site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | - Tuvia Ben Gal
- Heart Failure Unit, Cardiology Department, Rabin Medical Center, Petah Tikva and Sackler, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - T. Scott Bowen
- School of Biomedical Sciences, Faculty of Biological Sciences, University of Leeds, Leeds, United Kingdom
| | - Francesco Cacciatore
- Department of Translational Medicine, University of Naples “Federico II”, Naples, Italy
| | | | - Elena Cavarretta
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Rome, Italy
- Mediterranea Cardiocentro, Naples, Italy
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases “Prof. C. C. Iliescu”, Bucharest, Romania
- University of Medicine Carol Davila, Bucharest, Romania
| | | | - Alain Cohen-Solal
- Cardiology Department, University of Paris, INSERM UMRS-942, Hopital Lariboisiere, AP-HP, Paris, France
| | - Flavio D’Ascenzi
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | | | - Andreas B. Gevaert
- Research Group Cardiovascular Diseases, Genetics, Pharmacology and Physiopathology of Heart, Blood Vessels and Skeleton (GENCOR) Department, University of Antwerp, Antwerp, Belgium
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Hareld Kemps
- Department of Cardiology, Maxima Medical Centre, Eindhoven, Netherlands
- Department of Industrial Design, Eindhoven University of Technology, Eindhoven, Netherlands
| | - Loreena Hill
- School of Nursing and Midwifery, Queen’s University Belfast, Belfast, United Kingdom
| | - Tiny Jaarsma
- Department of Health, Medicine and Caring Science, Linköping University, Linköping, Sweden
- Julius Center, University Medical Center Utrecht, Utrecht, Netherlands
| | - Ewa Jankowska
- Department of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Emer Joyce
- Department of Cardiology, Mater University Hospital, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Nicolle Krankel
- Universitätsmedizin Berlin Campus Benjamin Franklin Klinik für Kardiologie Charite, Berlin, Germany
| | | | - Lars H. Lund
- Department of Medicine, Karolinska Institutet and Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Brenda Moura
- Armed Forces Hospital, Porto, Portugal
- Centre for Health Technologies and Services Research, Faculty of Medicine of University of Porto, Porto, Portugal
| | - Kari Nytrøen
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Elena Osto
- Division of Physiology and Pathophysiology, Otto Loewi Research Center for Vascular Biology, Immunology and Inflammation, Medical University of Graz, Graz, Austria
- Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
| | - Massimo Piepoli
- Dipartimento Scienze Biomediche per la Salute, Universita’ Degli Studi di Milan, Milan, Italy
- Cardiologia Universitaria, IRCCS Policlinico San Donato, Milan, Italy
| | | | - Amina Rakisheva
- Department of Cardiology, Scientific Institution of Cardiology and Internal Diseases, Almaty, Kazakhstan
- Department of Cardiology, Kapshagai City Hospital, Almaty, Kazakhstan
| | - Giuseppe Rosano
- St. George’s Hospital NHS Trust University of London, London, United Kingdom
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Petar M. Seferovic
- Faculty of Medicine and Heart Failure Center, University of Belgrade, Belgrade University Medical Center, Belgrade, Serbia
| | - David R. Thompson
- School of Nursing and Midwifery, Queen’s University Belfast, Belfast, United Kingdom
| | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School and Fraunhofer Institute for Toxicology and Experimental Research, Hannover, Germany
| | - Emeline M. Van Craenenbroeck
- Research Group Cardiovascular Diseases, Genetics, Pharmacology and Physiopathology of Heart, Blood Vessels and Skeleton (GENCOR) Department, University of Antwerp, Antwerp, Belgium
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium
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4
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Guglielmo A, Potena L, Russo A, Masetti M, Prestinenzi P, Giovannini L, Vaccari S, Piraccini BM, Pileri A. New insights into the oncological risk in heart transplant recipients: could skin tumors represent a marker of increased risk for solid neoplasm? Ital J Dermatol Venerol 2023; 158:395-400. [PMID: 37916399 DOI: 10.23736/s2784-8671.23.07632-6] [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: 11/03/2023]
Abstract
BACKGROUND Solid organ transplant recipients are at increased risk for skin cancers due to immune-suppressive therapies. However, little is known about the risk and the characteristics of neoplasms in heart transplant recipients (HTRs). The aim of this study is to delineate the incidence of different skin tumors in HTRs and to correlate it with the incidence of other malignancies, including solid tumors and hematological neoplasms. METHODS Patients who underwent to HTRs between January 1991 and November 2021 were retrieved. Clinical data on immunosuppressive therapies, skin tumors, solid and hematological neoplasms were obtained. HTRs with skin tumors were included in group A, while patients with no evidence of skin tumors during the follow-up were included in group B. RESULTS One hundred and eight patients were retrieved. A significant increase in solid tumors was observed in group A, while no significant difference in hematological neoplasms was detected between the two groups. CONCLUSIONS HTRs with skin tumors showed a significantly higher incidence of solid neoplasms. In most of the cases the skin tumor preceded the onset of the solid neoplasm, suggesting that the skin tumor could represent a 'marker' of immunosuppression eventually leading to the development of an internal malignancy.
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Affiliation(s)
- Alba Guglielmo
- Dermatology Unit, S. Orsola-Malpighi Polyclinic Hospital, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy -
- Institute of Dermatology, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Udine, Italy -
| | - Luciano Potena
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Antonio Russo
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marco Masetti
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Paola Prestinenzi
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Laura Giovannini
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Sabina Vaccari
- Dermatology Unit, S. Orsola-Malpighi Polyclinic Hospital, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Bianca M Piraccini
- Dermatology Unit, S. Orsola-Malpighi Polyclinic Hospital, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Alessandro Pileri
- Dermatology Unit, S. Orsola-Malpighi Polyclinic Hospital, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
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5
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Grimm K, Lehner A, Fernandez Rodriguez S, Orban M, Fischer M, Rosenthal LL, Jakob A, Haas NA, Dalla Pozza R, Kozlik-Feldmann R, Ulrich SM. Conversion to everolimus in pediatric heart transplant recipients is a safe treatment option with an impact on cardiac allograft vasculopathy and renal function. Clin Transplant 2020; 35:e14191. [PMID: 33315277 DOI: 10.1111/ctr.14191] [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: 09/22/2020] [Revised: 11/24/2020] [Accepted: 12/07/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Cardiac allograft vasculopathy (CAV) and nephrotoxicity affect long-term survival after heart transplantation (HTX). Studies, mostly conducted in adults, showed a positive effect of everolimus (EVL) on these problems. We describe the effects of conversion of the immunosuppressive therapy to an everolimus including regime on CAV, renal function, and safety in heart transplanted children/adolescents. METHODS This retrospective single-center study included 36 participants (mean time after HTX 6.3 ± 4.7 years). Descriptive pre/post-comparisons were performed with an observation period partially up to 4 years. Impact on CAV was assessed based on intravascular imaging and Stanford grading. Safety analysis included cytomegalovirus (CMV)-infection and acute rejection. RESULTS In terms of CAV (9 out of 36 patients) four showed no progression, three an improvement, one a worsening; one new diagnosis. The average CrCl showed a significant improvement 6, 12, and 24 months after conversion regarding all patients (n = 29). There was no acute rejection or CMV-infection. CONCLUSION Conversion to an EVL-based therapy after pediatric HTX is a safe immunosuppressive regime without increasing risk of acute rejection or CMV-infection. There was some evidence of reduction in progression of CAV and a significant improvement of the renal function.
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Affiliation(s)
- Kathrin Grimm
- Department of Pediatric Cardiology and Intensive Care Medicine, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Anja Lehner
- Department of Pediatric Cardiology and Intensive Care Medicine, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Silvia Fernandez Rodriguez
- Department of Pediatric Cardiology and Intensive Care Medicine, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Madeleine Orban
- Department of Cardiology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Marcus Fischer
- Department of Pediatric Cardiology and Intensive Care Medicine, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Laura L Rosenthal
- Department of Pediatric Cardiac Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Andre Jakob
- Department of Pediatric Cardiology and Intensive Care Medicine, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Nikolaus A Haas
- Department of Pediatric Cardiology and Intensive Care Medicine, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Robert Dalla Pozza
- Department of Pediatric Cardiology and Intensive Care Medicine, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Rainer Kozlik-Feldmann
- Department of Pediatric Cardiology and Intensive Care Medicine, Ludwig-Maximilians-University Munich, Munich, Germany.,Department of Pediatric Cardiology, UKE Hamburg, Hamburg, Germany
| | - Sarah M Ulrich
- Department of Pediatric Cardiology and Intensive Care Medicine, Ludwig-Maximilians-University Munich, Munich, Germany
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6
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Lo P, Kearney K, Muir CA, Song N, Eisman JA, Macdonald PS. SEVERE HYPERTRIGLYCERIDEMIA ASSOCIATED WITH EVEROLIMUS TREATMENT AFTER HEART TRANSPLANTATION. AACE Clin Case Rep 2020; 6:e269-e272. [PMID: 32984536 DOI: 10.4158/accr-2020-0191] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 06/15/2020] [Indexed: 01/01/2023] Open
Abstract
Objective Everolimus, a mammalian target-ofrapamycin (mTOR) inhibitor, is increasingly used post-transplantation due to favorable effects on renal function and malignancy risk when compared to other immunosuppressive treatments such as calcineurin inhibitors. However, it can confer adverse effects such as dyslipidemia, which is not underpinned by any long-term screening and management of dyslipidemia in heart transplant recipients treated with everolimus. Methods We report a case of severe hypertriglyceridemia which developed after commencement of everolimus in a heart transplant recipient with a background of Dunnigan-type familial partial lipodystrophy. Results The patient is a 36-year-old woman who underwent heart transplantation for dilated cardiomyopathy. About 11 weeks following commencement of everolimus as part of her antirejection medication regime, serum triglyceride level concentration peaked at 5,093 mg/dL (normal, 0.0 to 177.2 mg/dL). There were no clinical complications with triglycerides at this elevated level and it improved substantially following cessation of everolimus and initiation of a high dose intravenous insulin-dextrose infusion. Conclusion This case highlights dyslipidemia as a potential complication of everolimus treatment and that appropriate screening is important as lipid lowering medication can effectively control levels and minimize adverse outcomes.
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Affiliation(s)
- Phillip Lo
- Heart Failure and Transplant Unit, St. Vincent's Hospital, Sydney, Australia.,Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Katherine Kearney
- Heart Failure and Transplant Unit, St. Vincent's Hospital, Sydney, Australia.,Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Christopher A Muir
- Faculty of Medicine, University of New South Wales, Sydney, Australia.,Department of Endocrinology, St. Vincent's Hospital, Sydney, Australia
| | - Ning Song
- Heart Failure and Transplant Unit, St. Vincent's Hospital, Sydney, Australia.,Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - John A Eisman
- Faculty of Medicine, University of New South Wales, Sydney, Australia.,Department of Endocrinology, St. Vincent's Hospital, Sydney, Australia.,Institute of Medical Research, Sydney, Australia.,School of Medicine Sydney, University of Notre Dame, Sydney, Australia
| | - Peter S Macdonald
- Heart Failure and Transplant Unit, St. Vincent's Hospital, Sydney, Australia.,Faculty of Medicine, University of New South Wales, Sydney, Australia.,Victor Chang Cardiac Research Institute, Sydney, Australia
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7
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The change of immunosuppressive regimen from calcineurin inhibitors to mammalian target of rapamycin (mTOR) inhibitors and its effect on malignancy following heart transplantation. Int Immunopharmacol 2019; 69:150-158. [PMID: 30711744 DOI: 10.1016/j.intimp.2019.01.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 01/24/2019] [Accepted: 01/25/2019] [Indexed: 12/11/2022]
Abstract
Malignancy is a significant cause of mortality after organ transplantation. There is an increased rate of malignancy following heart transplantation (HTx) compared to the general population and other organ transplant recipients. Post-HTx patients with a history of malignancy are also at a higher risk of developing new malignancies or exacerbation of their existing malignancies. Mammalian target of Rapamycin inhibitors (mTORIs) are newly introduced immunosuppressive drugs with a unique mechanism of action. By changing the immunosuppressive regimen from classic drugs, especially calcineurin inhibitors (CNIs) to mTORIs, the rate of developing de novo malignancies and the relapse of former malignancies is significantly reduced. However, issues like allograft function, total surveillance of patients, and post-transplantation complications should be considered during the conversion of drug regimens utilizing CNIs to drug regimens employing mTORIs. We reviewed different post-heart transplant maintenance immunosuppressive regimens and their effect on post-HTx malignancies with a focus on mTORIs, compared safety against effectiveness, and gathered conclusions based on our review of the literature, which may lead clinicians to make a better evidence-based decision regarding post-HTx maintenance immunosuppressive drug regimens. Overall, CNI to mTORI conversion in post-HTx maintenance immunosuppressive drug regimens was associated with a reduced rate of developing malignancy in post-HTx patients. Furthermore, nephrotoxicity decreased significantly while using mTORIs in combination with lower doses of CNIs and the rejection rate was equivalent to CNI-only regimens. In conclusion, mTORI-based maintenance immunosuppressive drug regimens seem to be safe and beneficial when considering efficacy vs. adverse effects, and all-cause mortality rates are significantly lower in patients switched to mTORIs when compared to CNI recipients.
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Nunoda S. Cardiac Allograft Vasculopathy - Heart Transplantation Provides Insights Into Pathogenesis and Treatment of Arteriosclerosis. Circ J 2018; 82:2943-2945. [PMID: 30404978 DOI: 10.1253/circj.cj-18-1128] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Shinichi Nunoda
- Department of Therapeutic Strategy for Severe Heart Failure, Graduate School of Medicine, Tokyo Women's Medical University
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Optimizing the Safety Profile of Everolimus by Delayed Initiation in De Novo Heart Transplant Recipients: Results of the Prospective Randomized Study EVERHEART. Transplantation 2018; 102:493-501. [PMID: 28930797 PMCID: PMC5828375 DOI: 10.1097/tp.0000000000001945] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Although everolimus potentially improves long-term heart transplantation (HTx) outcomes, its early postoperative safety profile had raised concerns and needs optimization. METHODS This 6-month, open-label, multicenter randomized trial was designed to compare the cumulative incidence of a primary composite safety endpoint comprising wound healing delays, pericardial effusion, pleural effusion needing drainage, and renal insufficiency events (estimated glomerular filtration rate ≤30/mL/min per 1.73 m) in de novo HTx recipients receiving immediate everolimus (EVR-I) (≤144 hours post-HTx) or delayed everolimus (EVR-D) (4-6 weeks post-HTx with mycophenolate mofetil as a bridge) with reduced-dose cyclosporine A. Cumulative incidence of biopsy-proven rejection ≥ 2R, rejection with hemodynamic compromise, graft loss, or death was the secondary composite efficacy endpoint. RESULTS Overall, 181 patients were randomized to the EVR-I (n = 89) or EVR-D (n = 92) arms. Incidence of primary safety endpoint was higher for EVR-I than EVR-D arm (44.9% vs 32.6%; P = 0.191), mainly driven by a higher rate of pericardial effusion (33.7% vs 19.6%; P = 0.04); wound healing delays, acute renal insufficiency events, and pleural effusion occurred at similar frequencies in the study arms. Efficacy failure was not significantly different in EVR-I arm versus EVR-D arm (37.1% vs 28.3%; P = 0.191). Three patients in the EVR-I arm and 1 in the EVR-D arm died. Incidence of clinically significant adverse events leading to discontinuation was higher in EVR-I arm versus EVR-D arm (P = 0.02). CONCLUSIONS Compared with immediate initiation, delayed everolimus initiation appeared to provide a clinically relevant early safety benefit in de novo HTx recipients, without compromising efficacy.
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Abstract
Inhibitors of the mechanistic target of rapamycin (mTOR) have unique antiatherosclerotic effects, such as depletion of plaque macrophages, induction of autophagy, and activation of cholesterol efflux. However, a common side effect of their use is dyslipidemia, a well-known risk factor for atherosclerosis. Indeed, mTOR inhibitors prevent lipid storage, increase low-density lipoprotein cholesterol levels, and activate lipolysis. Although the net effect of mTOR inhibition seems favorable, the use of cholesterol lowering drugs to manage dyslipidemia remains the most recommended strategy.
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11
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Lee MS, Tadwalkar RV, Fearon WF, Kirtane AJ, Patel AJ, Patel CB, Ali Z, Rao SV. Cardiac allograft vasculopathy: A review. Catheter Cardiovasc Interv 2018; 92:E527-E536. [DOI: 10.1002/ccd.27893] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 08/29/2018] [Indexed: 01/19/2023]
Affiliation(s)
- Michael S. Lee
- Division of Cardiology, UCLA Medical Center Los Angeles California
| | | | - William F. Fearon
- Division of CardiologyStanford University School of Medicine Stanford California
| | - Ajay J. Kirtane
- Division of CardiologyColumbia University Medical Center New York New York
| | - Amisha J. Patel
- Division of CardiologyColumbia University Medical Center New York New York
| | - Chetan B. Patel
- Division of CardiologyDuke University Medical Center Durham North Carolina
| | - Ziad Ali
- Division of CardiologyColumbia University Medical Center New York New York
| | - Sunil V. Rao
- Division of CardiologyDuke University Medical Center Durham North Carolina
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Bakir M, Jackson NJ, Han SX, Bui A, Chang E, Liem DA, Ardehali A, Ardehali R, Baas AS, Press MC, Cruz D, Deng MC, DePasquale EC, Fonarow GC, Khuu T, Kwon MH, Kubak BM, Nsair A, Phung JL, Reed EF, Schaenman JM, Shemin RJ, Zhang QJ, Tseng CH, Cadeiras M. Clinical phenomapping and outcomes after heart transplantation. J Heart Lung Transplant 2018; 37:956-966. [PMID: 29802085 PMCID: PMC6064662 DOI: 10.1016/j.healun.2018.03.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 03/12/2018] [Accepted: 03/14/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Survival after heart transplantation (HTx) is limited by complications related to alloreactivity, immune suppression, and adverse effects of pharmacologic therapies. We hypothesize that time-dependent phenomapping of clinical and molecular data sets is a valuable approach to clinical assessments and guiding medical management to improve outcomes. METHODS We analyzed clinical, therapeutic, biomarker, and outcome data from 94 adult HTx patients and 1,557 clinical encounters performed between January 2010 and April 2013. Multivariate analyses were used to evaluate the association between immunosuppression therapy, biomarkers, and the combined clinical end point of death, allograft loss, retransplantation, and rejection. Data were analyzed by K-means clustering (K = 2) to identify patterns of similar combined immunosuppression management, and percentile slopes were computed to examine the changes in dosages over time. Findings were correlated with clinical parameters, human leucocyte antigen antibody titers, and peripheral blood mononuclear cell gene expression of the AlloMap (CareDx, Inc., Brisbane, CA) test genes. An intragraft, heart tissue gene coexpression network analysis was performed. RESULTS Unsupervised cluster analysis of immunosuppressive therapies identified 2 groups, 1 characterized by a steeper immunosuppression minimization, associated with a higher likelihood for the combined end point, and the other by a less pronounced change. A time-dependent phenomap suggested that patients in the group with higher event rates had increased human leukocyte antigen class I and II antibody titers, higher expression of the FLT3 AlloMap gene, and lower expression of the MARCH8 and WDR40A AlloMap genes. Intramyocardial biomarker-related coexpression network analysis of the FLT3 gene showed an immune system-related network underlying this biomarker. CONCLUSIONS Time-dependent precision phenotyping is a mechanistically insightful, data-driven approach to characterize patterns of clinical care and identify ways to improve clinical management and outcomes.
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Affiliation(s)
- Maral Bakir
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine
| | | | | | | | - Eleanor Chang
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine
| | - David A Liem
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine
| | - Abbas Ardehali
- Department of Surgery, University of California, Los Angeles, Los Angeles, California
| | - Reza Ardehali
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine
| | - Arnold S Baas
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine
| | | | - Daniel Cruz
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine
| | - Mario C Deng
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine
| | - Eugene C DePasquale
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine
| | - Gregg C Fonarow
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine
| | - Tam Khuu
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine
| | - Murray H Kwon
- Department of Surgery, University of California, Los Angeles, Los Angeles, California
| | - Bernard M Kubak
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine
| | - Ali Nsair
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine
| | - Jennifer L Phung
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine
| | | | - Joanna M Schaenman
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine
| | - Richard J Shemin
- Department of Surgery, University of California, Los Angeles, Los Angeles, California
| | | | | | - Martin Cadeiras
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine.
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The Selective JAK1/3-Inhibitor R507 Mitigates Obliterative Airway Disease Both With Systemic Administration and Aerosol Inhalation. Transplantation 2017; 100:1022-31. [PMID: 26910327 DOI: 10.1097/tp.0000000000001110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND The efficacy of selective Janus kinase 1/3 inhibitor R507 to prevent obliterative airway disease was analyzed in preclinical airway transplantation models. METHODS Orthotopic trachea transplantations were performed between Lewis donors and Brown Norway rat recipients. Oral everolimus (4 mg/kg once per day) or oral respective inhaled R507 (60 mg/kg twice per day, each) was used for immunosuppression. Grafts were retrieved after 6 or 60 days. Toxicity and anti-inflammatory effects of R507 were analyzed on human airway epithelial cells. RESULTS In 6-day animals, oral and inhaled R507 more potently diminished mononuclear graft infiltration than everolimus and preserved ciliated pseudostratified columnar respiratory epithelium. Everolimus and R507 similarly suppressed systemic cellular and humoral immune activation. In untreated rats, marked obliterative airway disease developed over 60 days. Oral and inhaled R507 was significantly more effective in reducing airway obliteration and preserved the morphology of the airway epithelium. Luciferase-positive donors revealed that a substantial amount of smooth muscle cells within the obliterative tissue was of donor origin. Only everolimus but not R507, adversely altered kidney function and lipid profiles. The R507 aerosol did not show airway toxicity in vitro but effectively suppressed activation of inflammatory signaling pathways induced by IL-1β. CONCLUSIONS The Janus kinase 1/3 inhibitor R507 is a very well-tolerated immunosuppressant that similarly diminished obliterative airway disease with systemic or inhaled administration.
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Helmschrott M, Rivinius R, Bruckner T, Katus HA, Doesch AO. Renal function in heart transplant patients after switch to combined mammalian target of rapamycin inhibitor and calcineurin inhibitor therapy. DRUG DESIGN DEVELOPMENT AND THERAPY 2017; 11:1673-1680. [PMID: 28652705 PMCID: PMC5472407 DOI: 10.2147/dddt.s135503] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND A calcineurin inhibitor (CNI)-based immunosuppression combined with mammalian target of rapamycin inhibitors (mTORs) seems to be attractive in patients after heart transplantation (HTX) in special clinical situations, for example, in patients with adverse drug effects of prior immunosuppression. Previous studies in patients after HTX detected advantageous effects regarding renal function of a tacrolimus (TAC)-based vs cyclosporine-A (CSA)-based immunosuppression (in combination with mycophenolate mofetil). However, data regarding renal function after HTX in mTOR/CNI patients remain limited. AIM Primary end point of the present study was to analyze renal function in HTX patients 1 year after switch to an mTOR/CNI-based immunosuppression. METHODS Data of 80 HTX patients after change to mTOR/CNI-based immunosuppression were retrospectively analyzed. Renal function was assessed by measured serum creatinine and by estimated glomerular filtration rate (eGFR) calculated from Modification of Diet in Renal Disease equation. RESULTS Twenty-nine patients received mTOR/CSA-based treatment and 51 patients received mTOR/TAC-based therapy. At time of switch and at 1-year follow-up, serum creatinine and eGFR did not differ significantly between both study groups (all P=not statistically significant). Analysis of variances with repeated measurements detected a similar change of renal function in both study groups. CONCLUSION The present study detected no significant differences between both mTOR/CNI study groups, indicating a steady state of renal function in HTX patients after switch of immunosuppressive regimen.
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Affiliation(s)
| | | | - Thomas Bruckner
- Institute for Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
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Abstract
In 2014, the Immunosuppressive Drugs Scientific Committee of the International Association of Therapeutic Drug Monitoring and Clinical Toxicology called a meeting of international experts to provide recommendations to guide therapeutic drug monitoring (TDM) of everolimus (EVR) and its optimal use in clinical practice. EVR is a potent inhibitor of the mammalian target of rapamycin, approved for the prevention of organ transplant rejection and for the treatment of various types of cancer and tuberous sclerosis complex. EVR fulfills the prerequisites for TDM, having a narrow therapeutic range, high interindividual pharmacokinetic variability, and established drug exposure-response relationships. EVR trough concentrations (C0) demonstrate a good relationship with overall exposure, providing a simple and reliable index for TDM. Whole-blood samples should be used for measurement of EVR C0, and sampling times should be standardized to occur within 1 hour before the next dose, which should be taken at the same time everyday and preferably without food. In transplantation settings, EVR should be generally targeted to a C0 of 3-8 ng/mL when used in combination with other immunosuppressive drugs (calcineurin inhibitors and glucocorticoids); in calcineurin inhibitor-free regimens, the EVR target C0 range should be 6-10 ng/mL. Further studies are required to determine the clinical utility of TDM in nontransplantation settings. The choice of analytical method and differences between methods should be carefully considered when determining EVR concentrations, and when comparing and interpreting clinical trial outcomes. At present, a fully validated liquid chromatography tandem mass spectrometry assay is the preferred method for determination of EVR C0, with a lower limit of quantification close to 1 ng/mL. Use of certified commercially available whole-blood calibrators to avoid calibration bias and participation in external proficiency-testing programs to allow continuous cross-validation and proof of analytical quality are highly recommended. Development of alternative assays to facilitate on-site measurement of EVR C0 is encouraged.
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Imamura T, Amiya E, Nitta D, Kinugawa K. Everolimus-Incorporated Therapy Reduces Myocardial Hypertrophy in Recipients of Heart Transplantation. Int Heart J 2016; 57:389-90. [PMID: 27181041 DOI: 10.1536/ihj.16-040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Teruhiko Imamura
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo
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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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Sharmila D, Rao AL, Kalyani L. Development and Validation of Stability-indicating High Performance Liquid Chromatographic Method for the Estimation of Everolimus in Tablets. Indian J Pharm Sci 2016; 77:599-604. [PMID: 26798176 PMCID: PMC4700714 DOI: 10.4103/0250-474x.169044] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
The present study depicts the development of a validated reversed-phase high performance liquid chromatographic method for the determination of the everolimus in presence of degradation products or pharmaceutical excipients. Stress study was performed on everolimus and it was found that it degrade sufficiently in oxidizing and acidic conditions but less degradation was found in alkaline, neutral, thermal and photolytic conditions. The separation was carried out on Hypersil BDS C18 column (100×4.6 mm, 5 μ) column having particle size 5 μ using acetate buffer:acetonitrile (50:50 v/v) with pH 6.5 adjusted with orthophosphoric acid as mobile phase at flow rate of 1 ml/min. The wavelength of the detection was 280 nm. A retention time (Rt) nearly 3.110 min was observed. The calibration curve for everolimus was linear (r2=0.999) from range of 25-150 μg/ml with limit of detection and limit of quantification of 0.036 μg/ml and 0.109 μg/ml, respectively. Analytical validation parameters such as selectivity, specificity, linearity, accuracy and precision were evaluated and relative standard deviation value for all the key parameters were less than 2.0%. The recovery of the drug after standard addition was found to be 100.55%. Thus, the developed RP-HPLC method was found to be suitable for the determination of everolimus in tablets containing various excipients.
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Affiliation(s)
- D Sharmila
- Vallabhaneni Venkatadri Institute of Pharmaceutical Sciences, Seshadri Rao Knowledge, Krishna, Gudlavalleru-521 356, India
| | - A Lakshmana Rao
- Vallabhaneni Venkatadri Institute of Pharmaceutical Sciences, Seshadri Rao Knowledge, Krishna, Gudlavalleru-521 356, India
| | - L Kalyani
- Vallabhaneni Venkatadri Institute of Pharmaceutical Sciences, Seshadri Rao Knowledge, Krishna, Gudlavalleru-521 356, India
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Deuse T, Bara C, Barten MJ, Hirt SW, Doesch AO, Knosalla C, Grinninger C, Stypmann J, Garbade J, Wimmer P, May C, Porstner M, Schulz U. The MANDELA study: A multicenter, randomized, open-label, parallel group trial to refine the use of everolimus after heart transplantation. Contemp Clin Trials 2015; 45:356-363. [DOI: 10.1016/j.cct.2015.09.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 09/02/2015] [Accepted: 09/04/2015] [Indexed: 12/18/2022]
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Natural products as probes in pharmaceutical research. J Ind Microbiol Biotechnol 2015; 43:249-60. [PMID: 26438431 DOI: 10.1007/s10295-015-1691-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 09/16/2015] [Indexed: 10/23/2022]
Abstract
From the start of the pharmaceutical research natural products played a key role in drug discovery and development. Over time many discoveries of fundamental new biology were triggered by the unique biological activity of natural products. Unprecedented chemical structures, novel chemotypes, often pave the way to investigate new biology and to explore new pathways and targets. This review summarizes the recent results in the area with a focus on research done in the laboratories of Novartis Institutes for BioMedical Research. We aim to put the technological advances in target identification techniques in the context to the current revival of phenotypic screening and the increasingly complex biological questions related to drug discovery.
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De novo sirolimus with low-dose tacrolimus versus full-dose tacrolimus with mycophenolate mofetil after heart transplantation—8-year results. J Heart Lung Transplant 2015; 34:634-42. [DOI: 10.1016/j.healun.2014.11.025] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Revised: 10/29/2014] [Accepted: 11/19/2014] [Indexed: 12/22/2022] Open
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Ha SH, Park JH, Jang HR, Huh W, Lim HY, Kim YG, Kim DJ, Oh HY, Lee JE. Increased risk of everolimus-associated acute kidney injury in cancer patients with impaired kidney function. BMC Cancer 2014; 14:906. [PMID: 25466872 PMCID: PMC4265483 DOI: 10.1186/1471-2407-14-906] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 11/27/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Everolimus was recently introduced as a second-line treatment for renal cell carcinoma (RCC) and many other cancers. Several prospective studies have shown that serum creatinine levels are increased in a significant proportion of patients receiving everolimus. However, data on the occurrence of acute kidney injury (AKI) during everolimus treatment in clinical practice are sparse. Here, we report the incidence, risk factors, and clinical significance of AKI associated with everolimus treatment in patients with cancer. METHODS We analyzed patients who received everolimus for more than 4 weeks as an anticancer therapy. AKI was defined as increase in creatinine levels from baseline levels greater than 1.5-fold. RESULTS The majority of the 110 patients enrolled in this analysis had RCC (N=93, 84.5%). AKI developed in 21 (23%) RCC patients; none of the patients (N=17) with other cancers had AKI. Fourteen of 21 cases were considered to be everolimus-associated AKI, in which there were no other nephrotoxic insults other than everolimus at the onset of AKI. The incidence of AKI increased progressively as baseline estimated glomerular filtration rate (eGFR) decreased (10% in subjects with eGFR >90 mL/min/1.73 m2, 17% in subjects with eGFR 60-90 mL/min/1.73 m2, 28% in subjects with eGFR 30-60 mL/min/1.73 m2, and 100% in subjects with eGFR 15-30 mL/min/1.73 m2; P=0.029 for trend). Baseline eGFR was an independent risk factor for the development of everolimus-associated AKI (hazard ratio per 10 mL/min/1.73 m2 increase, 0.70; 95% confidential interval, 049-1.00; P=0.047). Nine of 14 patients with everolimus-associated AKI continued receiving the drug at a reduced dose or after a short-term off period. Administration of the drug was discontinued in four of 14 patients because of progression of an underlying malignancy. Only one patient stopped taking the drug because of AKI. CONCLUSIONS This paper suggests that AKI is a common adverse effect of everolimus treatment, especially in subjects with impaired renal function. However, the occurrence of AKI did not require the discontinuation of the drug, and the treatment decision should be made via a multidisciplinary approach, including the assessment of the oncological benefits of everolimus and other therapeutic options.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Jung Eun Lee
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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Kuik KTH, Trubiano J, Worth LJ, Harun NS, Steinfort D, Johnson D. Pneumocystis jirovecii pneumonia following everolimus treatment of metastatic breast cancer. Med Mycol Case Rep 2014; 6:34-6. [PMID: 25379397 PMCID: PMC4216328 DOI: 10.1016/j.mmcr.2014.08.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Revised: 08/25/2014] [Accepted: 08/29/2014] [Indexed: 01/22/2023] Open
Abstract
Everolimus is an inhibitor of mammalian target of rapamycin with anti-tumour activity. While everolimus is known to cause drug-induced pneumonitis, it is rarely associated with Pneumocystis jirovecii pneumonia (PJP). We report a patient on everolimus therapy for metastatic breast cancer that developed PJP. Diagnosis was based on clinical features and a quantitative polymerase chain reaction for P. jirovecii DNA. Clinicians should consider PJP as a potential cause of pulmonary infiltrates in patients treated with everolimus.
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Affiliation(s)
- Kelvin Teck-Hong Kuik
- Department of General Medicine, Peter MacCallum Cancer Centre, East Melbourne, Australia
| | - Jason Trubiano
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, East Melbourne, Australia
| | - Leon J Worth
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, East Melbourne, Australia ; Department of Medicine, University of Melbourne, Parkville, Australia
| | - Nur-Shirin Harun
- Department of General Medicine, Peter MacCallum Cancer Centre, East Melbourne, Australia
| | - Daniel Steinfort
- Department of General Medicine, Peter MacCallum Cancer Centre, East Melbourne, Australia
| | - Douglas Johnson
- Department of General Medicine, Peter MacCallum Cancer Centre, East Melbourne, Australia
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Seki A, Fishbein MC. Predicting the development of cardiac allograft vasculopathy. Cardiovasc Pathol 2014; 23:253-60. [DOI: 10.1016/j.carpath.2014.05.001] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2014] [Revised: 05/14/2014] [Accepted: 05/14/2014] [Indexed: 12/11/2022] Open
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Influence of proliferation signal inhibitors on vascular endothelial growth factor production in heart transplant recipients - preliminary report. POLISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2014; 11:173-7. [PMID: 26336417 PMCID: PMC4283867 DOI: 10.5114/kitp.2014.43846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/18/2014] [Revised: 02/07/2014] [Accepted: 04/02/2014] [Indexed: 11/20/2022]
Abstract
Proliferation signal inhibitors (PSI) are especially beneficial for heart transplant recipients, but are rarely used due to frequent side effects. As they may be caused by vascular endothelial growth factor (VEGF), we performed a prospective cross-sectional pilot study to assess the influence of PSI and/or calcineurin inhibitors (CNI) presence in immunosuppressive protocols of heart transplant recipients on VEGF secretion. All electively screened heart transplant recipients willing to participate were enrolled in the study. The preliminary report was based on the results of the first 89 serum samples. The study group (n = 84) consisted of the PSI group (n = 14) further divided into the PSI + CNI subgroup (n = 10) and PSIw/oCNI subgroup (n = 4) based on concomitant CNI use, and the CNIw/oPSI group (n = 70) receiving CNI without PSI. The control group (n = 5) consisted of patients not requiring immunosuppression. VEGF was present in serum of 70 (83%) study group patients: median (range) 18 (0-316) pg/mL, mean 35 ± 57 pg/mL; in 13 (93%) PSI group patients: 22 (0-110) pg/mL, 28 ± 28 pg/mL, with 19 (8-20) pg/mL, 16 ± 6 pg/mL in the PSI + CNI subgroup, and 29 (0-110) pg/mL, 32 ± 32 pg/mL in the PSIw/oCNI subgroup. In the CNIw/oPSI group VEGF was present in 57 (81%) patients: 16 (0-316) pg/mL, 37 ± 62 pg/mL, and in the control group in 3 (60%) patients: 4 (0-110) pg/mL, 32 ± 48 pg/mL. None of the differences observed between any compared groups and/or subgroups was significant (χ2 and Mann-Whitney U test). In conclusion, differences of VEGF concentration observed among groups imply the influence of PSI and CNI on VEGF production, but further studies involving higher numbers of participants are needed to prove it.
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