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Kella DK, Shoukat S, Sperling L. Plasma exchange for severe hypertriglyceridemia-induced pancreatitis in an orthotopic heart transplant recipient. J Clin Lipidol 2012; 6:474-6. [PMID: 23009784 DOI: 10.1016/j.jacl.2012.01.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Revised: 12/18/2011] [Accepted: 01/18/2012] [Indexed: 12/21/2022]
Abstract
We here report a 33-year old male with diabetes, hypertension and history of orthotopic heart transplantation treated by plasma exchange for severe HTG (hypertriglyceridemia) induced pancreatitis. At the time of presentation, his serum TG (triglyceride) level was 10,278 mg/dL. He underwent one of the three planned sessions of plasma exchange, resulting in a decrease in TG level from 4728 mg/dL to 1708 mg/dL. The hospital course was complicated with shock, hemorrhagic transformation of the pancreatitis and acute respiratory distress syndrome. This prevented any further plasma exchange sessions. He was subsequently discharged home in a stable state and TG level of 80 mg/dL. Plasma exchange can be safely used to manage HTG induced pancreatitis in heart transplant recipients.
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Affiliation(s)
- Danesh K Kella
- Emory University School of Medicine, 1365 Clifton Road, NE Building A, Suite 2200, Atlanta, GA 30322, USA
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2
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García-Sabina A, Gulín-Dávila J, Sempere-Serrano P, González-Juanatey C, Martínez-Pacheco R. [Specific considerations on the prescription and therapeutic interchange of statins]. FARMACIA HOSPITALARIA 2011; 36:97-108. [PMID: 21820929 DOI: 10.1016/j.farma.2011.02.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2010] [Revised: 02/07/2011] [Accepted: 02/16/2011] [Indexed: 10/17/2022] Open
Abstract
OBJECTIVE The pharmaceutical industry currently offers six different statins in Spain and there is one more soon to be available. Choosing the most appropriate drug and dose is determined by the therapeutic target (reduction in LDL-C levels). Statin doses that decrease LDL-C at the same percentage are considered equivalent. Evaluating the pharmacokinetic characteristics of each statin can be useful when setting selection criteria, helping to determine which statin may be more appropriate for a patient based on their individual characteristics and on the other co-administered drugs. METHODS We reviewed the pharmacokinetics properties of each statin and its possible involvement in drug interactions. RESULTS CYP3A4 was responsible for the metabolism of lovastatin, simvastatin and atorvastatin; fluvastatin depends on CYP2C9; P-glycoprotein is responsible for decreased atorvastatin, pravastatin, simvastatin and lovastatin concentrations. The OATPA1B1 transporter involved in all statins' access to the hepatocyte, except for fluvastatin, is essential for rosuvastatin and pravastatin. These circumstances cause those drugs inhibiting or inducing isoenzymes or transporters' activity not to have the same effect on the different statins. CONCLUSION The pharmacokinetics is important when choosing the best statin and could be a limitation in the use of interchange therapeutic programmes when other drugs are present.
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Affiliation(s)
- A García-Sabina
- Servicio de Farmacia, Hospital Universitario Lucus Augusti, Lugo, España.
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3
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Effect of ABCB1 genotype on pre- and post-cardiac transplantation plasma lipid concentrations. J Cardiovasc Transl Res 2011; 4:304-12. [PMID: 21445698 DOI: 10.1007/s12265-011-9269-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2010] [Accepted: 02/24/2011] [Indexed: 12/21/2022]
Abstract
Genetic variation of ATP-binding cassette subfamily B member 1 (ABCB1) which encodes P-glycoprotein (P-gp) has been associated with lipid levels and response to statins. Here, we studied these associations in patients with advanced heart failure who subsequently underwent transplantation. Fasting total cholesterol (TC), low density lipoprotein (LDL) cholesterol, high density lipoprotein (HDL) cholesterol and triglycerides (TG) concentrations in 268 adult heart transplant recipients were analysed retrospectively before and at 1 year after transplantation (n = 176). ABCB1 genotyping and haplotyping for C1236T, G2677T/A and C3435T was performed using polymerase chain reaction. Pre-transplant LDL cholesterol was found to be associated with the C3435T genotype and the G2677T/A-C3435T and C1236T-G2677T/A-C3435T haplotypes. T-allele carriers at all loci (n = 77) had higher LDL levels than non-T-allele carriers (n = 24, 3.5 ± 1.2 vs. 2.8 ± 1.2 mmol/L, respectively, p = 0.025). This association remained after adjustment for age, sex, body mass index, statin use and underlying ischaemic heart disease. ABCB1 genotype was not associated with post-transplant lipid parameters. Hypercholesterolaemia (TC >5.7 mmol/L) was more prevalent post-transplant than pre-transplant (51% vs. 30%, respectively) and was likely related to steroid and calcineurin inhibitor use. Muscle-related statin effects were only seen in patients possessing the T-haplotype. In conclusion, an association between ABCB1 haplotype and plasma fasting LDL cholesterol concentration was found in patients with advanced heart failure. This association was not seen 1 year after cardiac transplantation.
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Sosland RP, Gollub SB, Wilson DB, Moriarty PM. The First Case Report of the Treatment of Transplant Coronary Artery Disease With Dextran Sulfate Adsorption Lipid Apheresis. Ther Apher Dial 2010; 14:218-21. [DOI: 10.1111/j.1744-9987.2009.00749.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Khan UA, Williams SG, Fildes JE, Shaw SM. The pathophysiology of chronic graft failure in the cardiac transplant patient. Am J Transplant 2009; 9:2211-6. [PMID: 19764947 DOI: 10.1111/j.1600-6143.2009.02807.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Following cardiac transplantation, many patients develop chronic deterioration of graft function, which may lead to a clinical syndrome similar to native chronic heart failure (CHF). This condition of chronic cardiac graft failure (CGF) may also share pathophysiological processes comparable with that of CHF. However, the unique environment following cardiac transplantation may also contribute with a variety of unique mechanisms, deserved of special attention. This review article discusses the complex pathophysiology of CGF after cardiac transplantation, an important yet neglected condition of transplant medicine.
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Affiliation(s)
- U A Khan
- North West Regional Heart Centre and Transplant Unit, University of South Manchester NHS Foundation Trust, Wythenshawe Hospital, Manchester, UK
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Shaw SM, Najam O, Khan U, Yonan N, Williams SG, Fildes JE. Ezetimibe and atorvastatin both immunoregulate CD4+ T cells from cardiac transplant recipients invitro. Transpl Immunol 2009; 21:179-82. [PMID: 19332119 DOI: 10.1016/j.trim.2009.03.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2009] [Revised: 03/16/2009] [Accepted: 03/16/2009] [Indexed: 11/24/2022]
Abstract
BACKGROUND Statins are LDL lowering agents that reduce cardiac allograft vasculopathy (CAV) incidence after cardiac transplantation. Furthermore, 'pleiotropic effects' including immunomodulation have been demonstrated by statins following transplantation. It has also been previously suggested that ezetimibe may exert specific effects on the innate immune system in vitro. We compared the effects of ezetimibe and atorvastatin on T lymphocytes in vitro on the justification that these cells are implicated in the pathogenesis of atherosclerosis, allograft rejection and CAV. METHODS Peripheral blood mononuclear cells (PBMCs) were isolated from 30 cardiac transplant recipients and co-cultured with the study drug (or placebo) over 48 h. In total, 150 cultures were performed (5 per patient). Drug concentrations were calculated to simulate 10 mg or 100 mg daily in a 70 kg adult. Flow cytometry was performed to analyse T lymphocyte counts and functional characteristics. RESULTS Ezetimibe reduced the standard CD3+CD4+ T cell count and CD3+CD4+CD45ro T memory count by dose linear effect (p < 0.001). Atorvastatin also reduced the CD3+CD4+ T cell count and CD3+CD4+CD45ro T memory count by dose linear effect (p = 0.005). Neither drug affected CD3+CD8+ cytotoxic T cells. DISCUSSION Both atorvastatin and ezetimibe may have selective immunomodulatory properties independent of their mechanisms of LDL lowering, given that both drugs affect CD4 T helper cells but have no effect on CD8 cytotoxic lymphocytes in vitro. Although speculative, both of these agents could potentially offer benefits to the transplant patient by modulating important components of the adaptive immune system. CD4+ cells in particular are implicated in both CAV and rejection processes.
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Affiliation(s)
- Steven M Shaw
- North West Regional Heart Centre and Transplant Unit, University of South Manchester NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom
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7
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The Efficacy and Tolerability of Ezetimibe in Cardiac Transplant Recipients Taking Cyclosporin. Transplantation 2009; 87:771-5. [DOI: 10.1097/tp.0b013e318198d7d0] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Safety and Efficacy of Ezetimibe With Low Doses of Simvastatin in Heart Transplant Recipients. J Heart Lung Transplant 2008; 27:685-8. [DOI: 10.1016/j.healun.2008.02.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2007] [Revised: 02/11/2008] [Accepted: 02/17/2008] [Indexed: 11/20/2022] Open
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Hedman M, Pahlman R, Sundvall J, Ehnholm C, Syvänne M, Jokinen E, Jauhiainen M, Holmberg C, Antikainen M. Low HDL-C predicts the onset of transplant vasculopathy in pediatric cardiac recipients on pravastatin therapy. Pediatr Transplant 2007; 11:481-90. [PMID: 17631015 DOI: 10.1111/j.1399-3046.2007.00690.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The levels and protein/lipid compositions of major lipoprotein particles of 19 pediatric cardiac transplant recipients (4-18 yr of age) were studied in this prospective, open clinical follow-up study before and at one yr of pravastatin therapy (10 mg/day). The recipients were grouped into those with (n = 6; group A) and those without (n = 13; group B) angiographically detectable vasculopathy. Twenty-one pediatric non-transplant controls were studied at baseline. At baseline, the group A recipients had 29% lower HDL-C concentrations (p = 0.031) and 29% higher apoB-100/apoA-I ratios (p = 0.034) than the group B recipients. At one yr of pravastatin, the respective figures were 29% (p = 0.013) and 33% (p = 0.005). Compared with the healthy pediatric controls, the transplant recipients had significantly higher serum TG before pravastatin [median (range): 1.3 mmol/L (0.6-3.2) vs. 0.7 mmol/L (0.3-2.4), p = 0.0002] and at one yr [1.3 mmol/L (0.5-3.5) vs. 0.7 mmol/L (0.3-2.4), p = 0.0004]. The baseline apoB-100/apoA1 ratios of the recipients were 33% higher (p = 0.005). In conclusion, low HDL-C and high apoB-100/apoA-I ratio were associated with angiographically detectable vasculopathy. Even though pravastatin effectively lowered the TC and LDL-C and improved compositional properties of LDL and HDL(2) particles, it failed to normalize the elevated TG and, in some patients, to prevent the progression of transplant vasculopathy.
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Affiliation(s)
- Mia Hedman
- Hospital for Children and Adolescents, University of Helsinki, FIN-00029 HUS, Helsinki, Finland
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10
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Moriarty PM. LDL-apheresis therapy: current therapeutic practice and potential future use. ACTA ACUST UNITED AC 2006. [DOI: 10.2217/17460875.1.3.299] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Hindler K, Eltzschig HK, Fox AA, Body SC, Shernan SK, Collard CD. Influence of statins on perioperative outcomes. J Cardiothorac Vasc Anesth 2006; 20:251-8. [PMID: 16616673 DOI: 10.1053/j.jvca.2005.12.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2005] [Indexed: 11/11/2022]
Affiliation(s)
- Katja Hindler
- Division of Cardiovascular Anesthesia, Texas Heart Institute at Saint Luke's Episcopal Hospital, Houston, TX 77030, USA
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Yambe T, Meng X, Hou X, Wang Q, Sekine K, Shiraishi Y, Watanabe M, Yamaguchi T, Shibata M, Kuwayama T, Maruyama M, Konno S, Nitta S. Cardio-ankle vascular index (CAVI) for the monitoring of the atherosclerosis after heart transplantation. Biomed Pharmacother 2005; 59 Suppl 1:S177-9. [PMID: 16275490 DOI: 10.1016/s0753-3322(05)80028-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Atherosclerosis has been reported to progress rapidly after heart transplantation. A quantitative diagnosis is required for the diagnosis of atherosclerosis after heart transplantation. In this study, we compared brachial-ankle pulse wave velocity (baPWV) and cardio-ankle vascular index (CAVI) for the diagnosis. The average values of both baPWV and CAVI in the seven cases after heart transplantation were found to be signif-icantly large in comparison to the average values of the normal healthy people of the same age group. When comparisons were made before and after the heart transplantation in a particular case, CAVI was stable and baPWV changed sharply. A lot of parameters such as blood pressure, blood volume, etc. have been reported to influence baPWV. The results of this study suggested that CAVI was a stable parameter in comparison to baPWV even after heart transplantation. Thus, CAVI may be useful in the diagnosis of arteriosclerosis after heart transplantation.
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Affiliation(s)
- T Yambe
- Department of Medical Engineering and Cardiology, Institute of Development, Aging and Cancer, Tohoku University, 4-1 Seiryo-machi, Aoba-ku, Sendai 980-77, Japan.
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Ozduran V, Yamani MH, Chuang HH, Sipahi I, Cook DJ, Sendrey D, Tong L, Hobbs R, Rincon G, Bott-Silverman C, James K, Taylor DO, Young JB, Navia J, Banbury M, Smedira N, Starling RC. Survival Beyond 10 Years Following Heart Transplantation: The Cleveland Clinic Foundation Experience. Transplant Proc 2005; 37:4509-12. [PMID: 16387156 DOI: 10.1016/j.transproceed.2005.10.021] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2005] [Indexed: 11/29/2022]
Abstract
BACKGROUND Long-term survival after heart transplantation is a desirable although challenging goal. METHODS We analyzed clinical outcomes in the cohort of 170 patients who have undergone heart transplantation at The Cleveland Clinic Foundation and survived >10 years. RESULTS We found 10-year and 15-year survival rates of 54% and 41%, respectively, in these patients, but there was also a high incidence of complications, such as hypertension, renal dysfunction, transplant vasculopathy, and malignancy. CONCLUSIONS Long-term survival following cardiac transplantation is possible although complications are frequent. Beyond 10 years, malignancy is a major cause of death.
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Affiliation(s)
- V Ozduran
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Kaufman Center for Heart Failure, Cleveland, Ohio 44195, USA
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Koshman SL, Lalonde LD, Burton I, Tymchak WJ, Pearson GJ. Supratherapeutic Response to Ezetimibe Administered with Cyclosporine. Ann Pharmacother 2005; 39:1561-5. [PMID: 16030077 DOI: 10.1345/aph.1g015] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE: To report the case of a patient who underwent orthotopic heart transplant (OHT) and demonstrated a supratherapeutic response to ezetimibe when administered with cyclosporine. CASE SUMMARY: Ezetimibe 10 mg/day was added to the lipid-lowering regimen (atorvastatin 40 mg/day) of a 64-year-old male patient after OHT to achieve a target low-density lipoprotein cholesterol (LDL-C) level ≤97 mg/dL, as recommended by national guidelines. After 2 months of ezetimibe, the patient's LDL-C level had decreased by 60% to 51 mg/dL. Subsequently, the dose of ezetimibe was reduced to 5 mg/day and, after another 2 months, a repeat lipid panel revealed LDL-C 57 mg/dL. DISCUSSION: Hyperlipidemia is a common problem among heart transplant recipients. Combination therapy using a statin plus ezetimibe appears to be an attractive option to achieve target lipid levels in this population. However, the manufacturer warns that ezetimibe should be administered cautiously in patients concomitantly receiving cyclosporine. Unpublished data suggest a pharmacokinetic interaction between ezetimibe and cyclosporine that results in a significant 2.3- to 12-fold increase in exposure to total ezetimibe. An objective causality assessment in this case revealed that this supratherapeutic LDL-C reduction was probably related to coadministration of ezetimibe and cyclosporine. A potential mechanism to explain this interaction might be an alteration in glucuronidation induced by cyclosporine. CONCLUSIONS: When ezetimibe is prescribed for patients concomitantly receiving cyclosporine, it should be initiated at a lower than recommended dose (≤5 mg/day) and titrated upward. Careful and consistent monitoring of patients on this combination is also advised.
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Affiliation(s)
- Sheri L Koshman
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
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Badiou S, Perez V, Dupuy AM, Deswarte G, Frapier JM, Albat B, Cristol JP. High Prevalence of Small Dense LDL as an Underestimated Component of Heart Transplantation–Induced Dyslipidemia: Potential Role in Graft Coronary Vasculopathy? Transplant Proc 2005; 37:2877-8. [PMID: 16182840 DOI: 10.1016/j.transproceed.2005.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Heart transplantation-induced dyslipidemia is a recognized risk factor for cardiac allograft vasculopathy that affects survival prognosis. Beyond increased lipids, low-density lipoprotein (LDL) size and systemic factors, including glucose intolerance, oxidative stress, and inflammation, must be taken into account as components of the atherosclerotic risk. The aim of this study was to explore the atherogenic profile of heart transplant recipients (HTR) by assessing lipid parameters, glycemia, oxidative stress status, and inflammation in 59 transplant patients (follow-up of 6 +/- 3 years) compared to 20 healthy volunteers. Classical hypercholesterolemia and hypertriglyceridemia were observed in HTR compared to controls, associated with increased apoCIII levels (0.13 +/- 0.6 vs 0.07 +/- 0.03 g/L, P < .01). Mean LDL size was reduced in HTR compared to controls (25.22 +/- 0.72 vs 26.06 +/- 0.54 nm, P < .001) with an abnormally high prevalence (69% vs 0%, P < .001) of small dense LDL (<25.5 nm). Hyperglycemia (7.3 +/- 3 vs 5.4 +/- 0.8 mmol/L, P < .05) and inflammation (high-sensitive CRP: 3.1 +/- 3 vs 1.6 +/- 0.9 mg/L, P < .001) were evidenced in HTR since no difference in oxidative stress parameters was observed. In conclusion, a high prevalence of small dense LDL is an important component of posttransplantation dyslipidemia.
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Affiliation(s)
- S Badiou
- Laboratoire de Biochimie, Montpellier, France
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