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Fraser M, Page RL, Chow S, Alexy T, Peters L. Pharmacotherapy in the heart transplant recipient: A primer for nurse clinicians and pharmacists. Clin Transplant 2024; 38:e15252. [PMID: 38341767 DOI: 10.1111/ctr.15252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 01/02/2024] [Accepted: 01/17/2024] [Indexed: 02/13/2024]
Abstract
Heart transplantation (HT) is the definitive treatment for eligible patients with end-stage heart disease. A major complication of HT is allograft rejection which can lead to graft dysfunction and death. The guiding principle of chronic immunosuppression therapy is to prevent rejection of the transplanted organ while avoiding oversuppression of the immune system, which can cause opportunistic infections and malignancy. The purpose of this review is to describe immunosuppressive management of the HT recipient-including agent-specific pharmacology and pharmacokinetics, outcomes data, adverse effects, clinical considerations, and recent guideline updates. We will also provide recommendations for medical prophylaxis of immunosuppressed patients based on the most recent clinical guidelines. Additionally, we highlight the importance of medical therapy adherence and the effect of social determinants of health on the long-term management of HT. HT recipients are a complex and high-risk population. The objective of this review is to describe basic pharmacotherapy in HT and implications for nurses and pharmacists.
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Affiliation(s)
- Meg Fraser
- Division of Cardiology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Robert L Page
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado, USA
| | - Sheryl Chow
- Department of Pharmacy Practice and Administration, Western University of Health Sciences, Pomona, California, USA
- Department of Medicine, University of California, Irvine, USA
| | - Tamas Alexy
- Division of Cardiology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Laura Peters
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA
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2
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Zhou Y, Huang X, Liu L, Zeng F, Han Y, Zhang J, Zhou H, Zhang Y. Effect of Wuzhi preparations on tacrolimus in CYP3A5 expressers during the early period after transplantation: A real-life experience from heart transplant recipients. Transpl Immunol 2023; 76:101748. [PMID: 36423734 DOI: 10.1016/j.trim.2022.101748] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 11/16/2022] [Accepted: 11/19/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Genetic polymorphisms and drug interactions are associated with tacrolimus exposure. This study aimed to evaluate the effect of Wuzhi (WZ) preparations on tacrolimus (TAC) concentration and dose requirements in heart transplant recipients with the CYP3A5*1 allele during the early period after transplantation. METHODS A total of 167 adult heart transplant recipients with the CYP3A5*1 allele were included and divided into the WZ group (n = 115) and the WZ-free group (n = 52). Blood trough concentrations of TAC were detected and the dose-adjusted concentration (C0/D) and dose requirement for achieving the TAC therapeutic range were compared between the two groups. The change in C0/D and dose of TAC were evaluated before and after co-administration with WZ preparations. RESULTS No significant differences in TAC C0/D and dose requirement were observed between the WZ and WZ-free groups. However, the TAC C0/D in the WZ group was significantly increased an average of 2.10-fold after co-administration of WZ. Moreover, the degree of elevation was related to the dose of the active ingredient (Schisantherin A). Furthermore, ALT, AST, and TB levels were significantly reduced after administration of WZ preparations. CONCLUSION Co-administration of the WZ/TAC preparation, in heart transplant recipients carrying the CYP3A5*1 allele, considerably increased TAC concentration (C0/D) while decreased high levels of leading indicators in the liver function. More importantly, the effect of the WZ/TAC preparation on C0/D was a dose-dependent event. However, our finding needs to be further confirmed in a larger sample size.
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Affiliation(s)
- Ying Zhou
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, China
| | - Xiao Huang
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, China
| | - Li Liu
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, China
| | - Fang Zeng
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, China
| | - Yong Han
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, China
| | - Jing Zhang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hong Zhou
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, China.
| | - Yu Zhang
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Hubei Province Clinical Research Center for Precision Medicine for Critical Illness, Wuhan, China.
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Kopecky BJ, Dun H, Amrute JM, Lin CY, Bredemeyer AL, Terada Y, Bayguinov PO, Koenig AL, Frye CC, Fitzpatrick JAJ, Kreisel D, Lavine KJ. Donor Macrophages Modulate Rejection After Heart Transplantation. Circulation 2022; 146:623-638. [PMID: 35880523 PMCID: PMC9398940 DOI: 10.1161/circulationaha.121.057400] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 06/07/2022] [Indexed: 01/23/2023]
Abstract
BACKGROUND Cellular rejection after heart transplantation imparts significant morbidity and mortality. Current immunosuppressive strategies are imperfect, target recipient T cells, and have adverse effects. The innate immune response plays an essential role in the recruitment and activation of T cells. Targeting the donor innate immune response would represent the earliest interventional opportunity within the immune response cascade. There is limited knowledge about donor immune cell types and functions in the setting of cardiac transplantation, and no current therapeutics exist for targeting these cell populations. METHODS Using genetic lineage tracing, cell ablation, and conditional gene deletion, we examined donor mononuclear phagocyte diversity and macrophage function during acute cellular rejection of transplanted hearts in mice. We performed single-cell RNA sequencing on donor and recipient macrophages and monocytes at multiple time points after transplantation. On the basis of our imaging and single-cell RNA sequencing data, we evaluated the functional relevance of donor CCR2+ (C-C chemokine receptor 2) and CCR2- macrophages using selective cell ablation strategies in donor grafts before transplant. Last, we performed functional validation that donor macrophages signal through MYD88 (myeloid differentiation primary response protein 88) to facilitate cellular rejection. RESULTS Donor macrophages persisted in the rejecting transplanted heart and coexisted with recipient monocyte-derived macrophages. Single-cell RNA sequencing identified donor CCR2+ and CCR2- macrophage populations and revealed remarkable diversity among recipient monocytes, macrophages, and dendritic cells. Temporal analysis demonstrated that donor CCR2+ and CCR2- macrophages were transcriptionally distinct, underwent significant morphologic changes, and displayed unique activation signatures after transplantation. Although selective depletion of donor CCR2- macrophages reduced allograft survival, depletion of donor CCR2+ macrophages prolonged allograft survival. Pathway analysis revealed that donor CCR2+ macrophages are activated through MYD88/nuclear factor kappa light chain enhancer of activated B cells signaling. Deletion of MYD88 in donor macrophages resulted in reduced antigen-presenting cell recruitment, reduced ability of antigen-presenting cells to present antigen to T cells, decreased emergence of allograft-reactive T cells, and extended allograft survival. CONCLUSIONS Distinct populations of donor and recipient macrophages coexist within the transplanted heart. Donor CCR2+ macrophages are key mediators of allograft rejection, and deletion of MYD88 signaling in donor macrophages is sufficient to suppress rejection and extend allograft survival. This highlights the therapeutic potential of donor heart-based interventions.
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Affiliation(s)
- Benjamin J Kopecky
- Cardiovascular Division, Department of Medicine, Washington
University School of Medicine, St. Louis, Missouri, USA
| | - Hao Dun
- Department of Surgery, Washington University School of
Medicine, Saint Louis, Missouri, USA
| | - Junedh M Amrute
- Cardiovascular Division, Department of Medicine, Washington
University School of Medicine, St. Louis, Missouri, USA
| | - Chieh-Yu Lin
- Department of Pathology and Immunology, Washington
University School of Medicine, Saint Louis, Missouri, USA
| | - Andrea L Bredemeyer
- Cardiovascular Division, Department of Medicine, Washington
University School of Medicine, St. Louis, Missouri, USA
| | - Yuriko Terada
- Department of Surgery, Washington University School of
Medicine, Saint Louis, Missouri, USA
| | - Peter O Bayguinov
- Washington University Center for Cellular Imaging,
Washington University School of Medicine, St. Louis, Missouri, USA
| | - Andrew L Koenig
- Cardiovascular Division, Department of Medicine, Washington
University School of Medicine, St. Louis, Missouri, USA
| | - Christian C Frye
- Department of Surgery, Washington University School of
Medicine, Saint Louis, Missouri, USA
| | - James AJ Fitzpatrick
- Washington University Center for Cellular Imaging,
Washington University School of Medicine, St. Louis, Missouri, USA
- Departments of Neuroscience and Cell Biology &
Physiology, Washington University School of Medicine, Saint Louis, Missouri,
USA
| | - Daniel Kreisel
- Department of Surgery, Washington University School of
Medicine, Saint Louis, Missouri, USA
- Department of Pathology and Immunology, Washington
University School of Medicine, Saint Louis, Missouri, USA
| | - Kory J Lavine
- Cardiovascular Division, Department of Medicine, Washington
University School of Medicine, St. Louis, Missouri, USA
- Department of Pathology and Immunology, Washington
University School of Medicine, Saint Louis, Missouri, USA
- Department of Developmental Biology, Washington University
School of Medicine, Saint Louis, Missouri, USA
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4
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Costa C, Amador AF, Calvão J, Pinto R, Pereira PR, Torres JP, Amorim S, Macedo F. Late Cardiac Antibody-Mediated Rejection: A Only Heart Duel. INTERNATIONAL JOURNAL OF HEART FAILURE 2022; 4:117-121. [PMID: 36263105 PMCID: PMC9383344 DOI: 10.36628/ijhf.2021.0027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 03/13/2022] [Accepted: 03/16/2022] [Indexed: 06/16/2023]
Affiliation(s)
- Catarina Costa
- Department of Cardiology, Centro Hospitalar São João, Porto, Portugal
| | - Ana Filipa Amador
- Department of Cardiology, Centro Hospitalar São João, Porto, Portugal
| | - João Calvão
- Department of Cardiology, Centro Hospitalar São João, Porto, Portugal
| | - Roberto Pinto
- Department of Cardiology, Centro Hospitalar São João, Porto, Portugal
- University of Porto, Faculty of Medicine, Porto, Portugal
| | - Pedro Rodrigues Pereira
- Department of Pathology, Centro Hospitalar São João, and University of Porto, Faculty of Medicine, Porto, Portugal
| | - José Pinheiro Torres
- Department of Cardio-Thoracic Surgery, Centro Hospitalar São João, Porto, Portugal
| | - Sandra Amorim
- Department of Cardiology, Centro Hospitalar São João, Porto, Portugal
- University of Porto, Faculty of Medicine, Porto, Portugal
| | - Filipe Macedo
- Department of Cardiology, Centro Hospitalar São João, Porto, Portugal
- University of Porto, Faculty of Medicine, Porto, Portugal
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Yoshida S, Miyagawa S, Matsuzaki T, Ishii Y, Fukuda-Kawaguchi E, Kawamura T, Kawamura A, Nakamura Y, Toda K, Sawa Y. Chimerism through the activation of invariant natural killer T cells prolongs graft survival after transplantation of induced pluripotent stem cell–derived allogeneic cardiomyocytes. PLoS One 2022; 17:e0264317. [PMID: 35235568 PMCID: PMC8890721 DOI: 10.1371/journal.pone.0264317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 02/08/2022] [Indexed: 11/21/2022] Open
Abstract
The loss of functional cells through immunological rejection after transplantation reduces the efficacy of regenerative therapies for cardiac failure that use allogeneic induced pluripotent stem cell-derived cardiomyocytes (iPSC-CMs). Recently, mixed-chimera mice with donor-specific immunotolerance have been established using the RGI-2001 (liposomal formulation of α-galactosyl ceramide) ligand, which activates invariant natural killer T (iNKT) cells. The present study aimed to investigate whether mixed chimerism, established using RGI-2001, prolongs graft survival in allogeneic iPSC-CM transplantation. Mixed-chimera mice were established via combinatorial treatment with RGI-2001 and anti-CD154 antibodies in an irradiated murine bone marrow transplant model. Luciferase-expressing allogeneic iPSC-CMs were transplanted into mixed-chimera and untreated mice, followed by in vivo imaging. RGI-2001 enhanced iNKT cell activation in mice, and mixed chimerism was successfully established. In vivo imaging revealed that while the allografts were completely obliterated within 2 weeks when transplanted to untreated mice, their survivals were not affected in the mixed-chimera mice. Furthermore, numerous CD3+ cells infiltrated allografts in untreated mice, but fewer CD3+ cells were present in mixed-chimera mice. We conclude that mixed-chimera mice established using RGI-2001 showed prolonged graft survival after allogeneic iPSC-CM transplantation. This donor-specific immunotolerance might increase the efficacy of regenerative therapies for heart failure with allogeneic iPSC-CMs.
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Affiliation(s)
- Shohei Yoshida
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Shigeru Miyagawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Takashi Matsuzaki
- Department of DDS Pharmaceutical Development, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yasuyuki Ishii
- REGiMMUNE Corp, Tokyo, Japan
- Department of Immunological Diagnosis, Juntendo University Graduate School of Medicine, Bunkyo City, Japan
| | | | - Takuji Kawamura
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Ai Kawamura
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yuki Nakamura
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Koichi Toda
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
- * E-mail:
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6
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Jackson KC, Youmans QR, Wu T, Harap R, Anderson AS, Chicos A, Ezema A, Mandieka E, Ohiomoba R, Pawale A, Pham DT, Russell S, Sporn PHS, Yancy CW, Okwuosa IS. Heart transplantation outcomes in cardiac sarcoidosis. J Heart Lung Transplant 2021; 41:113-122. [PMID: 34756511 DOI: 10.1016/j.healun.2021.08.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 08/06/2021] [Accepted: 08/18/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Cardiac sarcoidosis (CS) is a progressive inflammatory cardiomyopathy that can lead to heart failure, arrhythmia, and death. There is limited data on Orthotopic Heart Transplantation (OHT) outcomes in patients with CS. Here we examine outcomes in patients with CS who have undergone OHT at centers throughout the United States from 1987 to 2019. METHODS This was an analysis of 63,947 adult patients undergoing OHT captured in the United Network for Organ Sharing (UNOS) registry. Patients were characterized as cardiac sarcoidosis (CS) or Non-CS. Baseline characteristics were compared using chi-square and Kruskal-Wallis Tests. Outcomes of interest included primary graft failure, patient survival, treated graft rejection, hospitalization for infection, and post-transplant malignancy. RESULTS During the study period 227 patients with CS underwent OHT. Patients with CS were younger, had higher proportion of non-white patients, and received transplants at more urgent statuses. After multivariable modeling there was no difference in survival (HR 0.86, CI 0.59-1.3, p = 0.446) or graft failure (HR 0.849, CI 0.58-1.23, p = 0.394) between patients with CS and Non-CS. Patients with CS had lower odds of rejection (OR 0.558, CI 0.315- 0.985, p = 0.0444). Patients with CS had similar odds of hospitalization for infection and post-transplant malignancy, as Non-CS patients. CONCLUSIONS Patients with CS and Non-CS had similar post OHT survival, odds of graft failure, hospitalizations for infection, and post-transplant malignancy. Results of this study confirm the role of heart transplantation as a viable option for patients with CS.
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Affiliation(s)
- K C Jackson
- Department of Medicine, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - Q R Youmans
- Division of Cardiology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - T Wu
- Department of Cardiac Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - R Harap
- Department of Cardiac Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - A S Anderson
- University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - A Chicos
- Division of Cardiology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - A Ezema
- Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - E Mandieka
- Department of Medicine, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - R Ohiomoba
- Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - A Pawale
- Department of Cardiac Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - D T Pham
- Department of Cardiac Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - S Russell
- Division of Pulmonary and Critical Care Medicine, Northwestern University, Feinberg School of Medicine
| | - P H S Sporn
- Division of Pulmonary and Critical Care Medicine, Northwestern University, Feinberg School of Medicine
| | - C W Yancy
- Division of Cardiology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - Ike S Okwuosa
- Division of Cardiology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois.
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7
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Yoon CH, Choi HJ, Kim MK. Corneal xenotransplantation: Where are we standing? Prog Retin Eye Res 2021; 80:100876. [PMID: 32755676 PMCID: PMC7396149 DOI: 10.1016/j.preteyeres.2020.100876] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 05/23/2020] [Accepted: 06/04/2020] [Indexed: 02/08/2023]
Abstract
The search for alternatives to allotransplants is driven by the shortage of corneal donors and is demanding because of the limitations of the alternatives. Indeed, current progress in genetically engineered (GE) pigs, the introduction of gene-editing technology by clustered regularly interspaced short palindromic repeats (CRISPR)-Cas9, and advanced immunosuppressants have made xenotransplantation a possible option for a human trial. Porcine corneal xenotransplantation is considered applicable because the eye is regarded as an immune-privileged site. Furthermore, recent non-human primate studies have shown long-term survival of porcine xenotransplants in keratoplasty. Herein, corneal immune privilege is briefly introduced, and xenogeneic reactions are compared with allogeneic reactions in corneal transplantation. This review describes the current knowledge on special issues of xenotransplantation, xenogeneic rejection mechanisms, current immunosuppressive regimens of corneal xenotransplantation, preclinical efficacy and safety data of corneal xenotransplantation, and updates of the regulatory framework to conduct a clinical trial on corneal xenotransplantation. We also discuss barriers that might prevent xenotransplantation from becoming common practice, such as ethical dilemmas, public concerns on xenotransplantation, and the possible risk of xenozoonosis. Given that the legal definition of decellularized porcine cornea (DPC) lies somewhere between a medical device and a xenotransplant, the preclinical efficacy and clinical trial data using DPC are included. The review finally provides perspectives on the current standpoint of corneal xenotransplantation in the fields of regenerative medicine.
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Affiliation(s)
- Chang Ho Yoon
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul, Republic of Korea; Laboratory of Ocular Regenerative Medicine and Immunology, Seoul Artificial Eye Center, Seoul National University Hospital Biomedical Research Institute, Seoul, Republic of Korea
| | - Hyuk Jin Choi
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul, Republic of Korea; Laboratory of Ocular Regenerative Medicine and Immunology, Seoul Artificial Eye Center, Seoul National University Hospital Biomedical Research Institute, Seoul, Republic of Korea; Department of Ophthalmology, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, Republic of Korea
| | - Mee Kum Kim
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul, Republic of Korea; Laboratory of Ocular Regenerative Medicine and Immunology, Seoul Artificial Eye Center, Seoul National University Hospital Biomedical Research Institute, Seoul, Republic of Korea.
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8
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Chang DH, Youn JC, Dilibero D, Patel JK, Kobashigawa JA. Heart Transplant Immunosuppression Strategies at Cedars-Sinai Medical Center. INTERNATIONAL JOURNAL OF HEART FAILURE 2021; 3:15-30. [PMID: 36263111 PMCID: PMC9536714 DOI: 10.36628/ijhf.2020.0034] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 09/15/2020] [Indexed: 12/22/2022]
Abstract
Heart transplant is the optimal treatment for selected patients with end-stage heart failure. Immunosuppression after heart transplantation has significantly reduced the incidence of rejection and improved patient outcomes with the routine use of calcineurin inhibitors. Antimetabolites and proliferation signal inhibitors add to the improvement in patient outcomes as well. The goal of induction therapy is to provide intense immunosuppression when the risk of allograft rejection is highest. Most maintenance immunosuppressive protocols employ a 3-drug regimen consisting of a calcineurin inhibitor, an antimetabolite agent and glucocorticoids. The management of rejection proceeds in a stepwise fashion based on the severity of rejection detected on biopsy and the patient's clinical presentation. This review will cover induction, maintenance, rejection therapy and some special considerations including sensitization, renal sparing protocol, and corticosteroid weaning. It will end in consideration of potential future directions in immunosuppressive strategies to promote patient and graft survival.
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Affiliation(s)
- David H. Chang
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jong-Chan Youn
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Deanna Dilibero
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jignesh K. Patel
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jon A. Kobashigawa
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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9
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Antibody-medicated rejection after heart transplantation: diagnosis and clinical implications. Curr Opin Organ Transplant 2020; 25:248-254. [PMID: 32304428 DOI: 10.1097/mot.0000000000000754] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW The present article will review the diagnosis of antibody-mediated rejection in heart transplant recipients and further explore the clinical implications. RECENT FINDINGS Improved diagnostic techniques have led to increased recognition of antibody-mediated rejection and better understanding of the long-term consequences in heart transplant recipients. Endomyocardial biopsy remains the gold standard for the diagnosis of antibody-medicated ejection; however, several advances in molecular testing have emerged, including the use of gene expression profiling, messenger RNA, and microRNA. Routine surveillance of donor-specific antibodies identifies recipients at high risk for graft compromise. Additionally, new monoclonal antibody therapies have broadened our repertoire in the treatment of rejection. SUMMARY Advances in molecular testing for antibody-mediated rejection may improve the associated long-term complication, while minimizing risk to the patient.
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10
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Cardiothoracic transplants in India: why adequate immunogenetic workup for potential recipients is a must. Indian J Thorac Cardiovasc Surg 2020; 37:118-119. [PMID: 33442220 DOI: 10.1007/s12055-020-01040-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 08/14/2020] [Accepted: 08/19/2020] [Indexed: 10/23/2022] Open
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11
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Abstract
Background: With an aging population, the prevalence of heart failure continues to rise. The use of guideline-directed medical therapy and mechanical circulatory support devices has helped to improve outcomes, but cardiac transplantation remains the definitive treatment for end-stage heart failure. Methods: We provide an update on cardiac transplantation and review indications, contraindications, and important aspects of perioperative and postoperative management. We also highlight the current challenges faced by the transplant community. Results: Advances in surgical techniques and immunosuppression have increased survival rates posttransplant. However, the risk of rejection and adverse effects from chronic immunosuppression continue to affect long-term outcomes. Conclusion: Despite tremendous progress in the management of cardiac transplant patients, we have much opportunity to further optimize cardiac transplant waitlisting and improve posttransplant outcomes.
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13
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Abstract
Bioengineering cardiac tissue constructs with adult cardiomyocytes may help treat adult heart defects and injury. In this study, we fabricated cardiac tissue constructs by seeding adult rat cardiomyocytes on a fibrin gel matrix and analyzed the electromechanical properties of the formed cardiac tissue constructs. Adult rat cardiomyocytes were isolated with a collagenase type II buffer using an optimized Langendorff perfusion system. Cardiac tissue constructs were fabricated using either indirect plating with cardiomyocytes that were cultured for 1 week and dedifferentiated or with freshly isolated cardiomyocytes. The current protocol generated (3.1 ± 0.5) × 10 (n = 5 hearts) fresh cardiomyocytes from a single heart. Tissue constructs obtained by both types of plating contracted up to 30 days, and electrogram (ECG) signals and contractile twitch forces were detected. The constructs bioengineered by indirect plating of dedifferentiated cardiomyocytes produced an ECG R wave amplitude of 15.1 ± 5.2 µV (n = 7 constructs), a twitch force of 70-110 µN, and a spontaneous contraction rate of about 390 bpm. The constructs bioengineered by direct plating of fresh cardiomyocytes generated an ECG R wave amplitude of 6.3 ± 2.5 µV (n = 8 constructs), a twitch force of 40-60 µN, and a spontaneous contraction rate of about 230 bpm. This study successfully bioengineered three-dimensional cardiac tissue constructs using primary adult cardiomyocytes.
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14
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Vega E, Schroder J, Nicoara A. Postoperative management of heart transplantation patients. Best Pract Res Clin Anaesthesiol 2017; 31:201-213. [PMID: 29110793 DOI: 10.1016/j.bpa.2017.06.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 06/01/2017] [Accepted: 06/16/2017] [Indexed: 01/17/2023]
Abstract
Heart transplant recipients are at risk for a number of post-transplantation complications such as graft dysfunction, rejection, and infection. The rates of many complications are decreasing over time, and prognosis is improving. However, these patients continue to experience significant morbidity and mortality. This review focuses on the optimal management of heart transplant recipients in the postoperative period, based on current knowledge. More information is needed about the best ways to predict, prevent, and treat primary graft dysfunction, right ventricular failure, and cellular and antibody-mediated rejection.
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Affiliation(s)
- Eleanor Vega
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA.
| | - Jacob Schroder
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA.
| | - Alina Nicoara
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA.
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Thomas KA, Valenzuela NM, Gjertson D, Mulder A, Fishbein MC, Parry GC, Panicker S, Reed EF. An Anti-C1s Monoclonal, TNT003, Inhibits Complement Activation Induced by Antibodies Against HLA. Am J Transplant 2015; 15:2037-49. [PMID: 25904443 PMCID: PMC4654252 DOI: 10.1111/ajt.13273] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Revised: 02/10/2015] [Accepted: 02/17/2015] [Indexed: 01/25/2023]
Abstract
Antibody-mediated rejection (AMR) of solid organ transplants (SOT) is characterized by damage triggered by donor-specific antibodies (DSA) binding donor Class I and II HLA (HLA-I and HLA-II) expressed on endothelial cells. While F(ab')2 portions of DSA cause cellular activation and proliferation, Fc regions activate the classical complement cascade, resulting in complement deposition and leukocyte recruitment, both hallmark features of AMR. We characterized the ability of an anti-C1s monoclonal antibody, TNT003, to inhibit HLA antibody (HLA-Ab)-induced complement activation. Complement deposition induced by HLA-Ab was evaluated using novel cell- and bead-based assays. Human aortic endothelial cells (HAEC) were cultured with HLA-Ab and human complement; production of activated complement proteins was measured by flow cytometry. Additionally, C3d deposition was measured on single antigen beads (SAB) mixed with HLA-Ab and human complement. TNT003 inhibited HLA-Ab mediated complement deposition on HAEC in a concentration-dependent manner; C3a, C4a and C5a anaphylatoxin production was also diminished by TNT003. Finally, TNT003 blocked C3d deposition induced by Class I (HLAI-Ab)- and Class II (HLAII-Ab)-specific antibodies on SAB. These data suggest TNT003 may be useful for modulating the effects of DSA, as TNT003 inhibits complement deposition and split product formation generated by HLA-I/II-Ab in vitro.
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Affiliation(s)
- K A Thomas
- Department of Pathology and Laboratory Medicine, University of CaliforniaLos Angeles, CA
| | - N M Valenzuela
- Department of Pathology and Laboratory Medicine, University of CaliforniaLos Angeles, CA
| | - D Gjertson
- Department of Pathology and Laboratory Medicine, University of CaliforniaLos Angeles, CA
| | - A Mulder
- Department of Immunohematology and Blood Transfusion, Leiden University Medical CenterLeiden, the Netherlands
| | - M C Fishbein
- Department of Pathology and Laboratory Medicine, University of CaliforniaLos Angeles, CA
| | - G C Parry
- True North Therapeutics, Inc.South San Francisco, CA
| | - S Panicker
- True North Therapeutics, Inc.South San Francisco, CA
| | - E F Reed
- Department of Pathology and Laboratory Medicine, University of CaliforniaLos Angeles, CA,*Corresponding author: Elaine F. Reed,
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Picascia A, Grimaldi V, Casamassimi A, De Pascale MR, Schiano C, Napoli C. Human leukocyte antigens and alloimmunization in heart transplantation: an open debate. J Cardiovasc Transl Res 2014; 7:664-75. [PMID: 25190542 DOI: 10.1007/s12265-014-9587-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 08/20/2014] [Indexed: 10/24/2022]
Abstract
Considerable advances in heart transplantation outcome have been achieved through the improvement of donor-recipient selection, better organ preservation, lower rates of perioperative mortality and the use of innovative immunosuppressive protocols. Nevertheless, long-term survival is still influenced by late complications. We support the introduction of HLA matching as an additional criterion in the heart allocation. Indeed, allosensitization is an important factor affecting heart transplantation and the presence of anti-HLA antibodies causes an increased risk of antibody-mediated rejection and graft failure. On the other hand, the rate of heart-immunized patients awaiting transplantation is steadily increasing due to the limited availability of organs and an increased use of ventricular assist devices. Significant benefits may result from virtual crossmatch approach that prevents transplantation in the presence of unacceptable donor antigens. A combination of both virtual crossmatch and a tailored desensitization therapy could be a good compromise for a favorable outcome in highly sensitized patients. Here, we discuss the unresolved issue on the clinical immunology of heart transplantation.
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Affiliation(s)
- Antonietta Picascia
- U.O.C. Division of Immunohematology, Transfusion Medicine and Transplant Immunology [SIMT], Regional Reference Laboratory of Transplant Immunology [LIT], Azienda Ospedaliera Universitaria (AOU), Second University of Naples, Piazza L. Miraglia 2, 80138, Naples, Italy,
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