Obesity and hypercholesterolemia following heart transplantation

Clinical outcomes in overweight heart transplant recipients

BACKGROUND

Few studies have examined the impact of patient weight on heart transplant (HT) outcomes.

OBJECTIVES

Nine outcomes were compared in 2 groups of HT recipients (N = 347) based on their mean body mass index (BMI) during the first 3 years post-HT.

METHODS

Group 1 consisted of 108 non-overweight patients (BMI <25; mean age 52; 29.6% females; 16.7% minorities). Group 2 consisted of 239 overweight patients (BMI ≥25; mean age 52; 15.9% females; 13.8% minorities). Outcomes were: survival, re-hospitalization, rejections, infections, cardiac allograft vasculopathy (CAV), stroke, renal dysfunction, diabetes, and lymphoma.

RESULTS

Non-overweight patients had shorter survival, were re-hospitalized more days after the HT discharge, and had more lymphoma and severe renal dysfunction. Overweight patients had more CAV, steroid-induced diabetes, and acute rejections.

CONCLUSIONS

Overweight HT patients had better survival, but more rejections, CAV, and diabetes. Non-overweight HT patients had worse survival, plus more re-hospitalization time, lymphoma, and renal dysfunction.

Reversibility of cardiac cachexia after heart transplantation

BACKGROUND

Cachexia is an independent risk factor for mortality in patients with chronic heart failure and increases mortality even after heart transplantation (HTx). We aimed to determine whether cardiac cachexia is reversible after HTx, and investigated differences specific to gender.

METHODS

We prospectively examined 106 patients before and serially 3, 6, 12 and 24 months after HTx (18 women, 88 men; median age at transplantation 53.7 +/- 9.7 years; n = 68 dilative cardiomyopathy, n = 33 coronary heart disease, n = 5 other origin of heart failure). Patients were sub-grouped as underweight (body mass index [BMI] < or =21 kg/m2, n = 15), normal weight (BMI 21 to 27 kg/m2, n = 64) and obese (BMI > or =27 kg/m2, n = 27).

RESULTS

Body weight increase was restricted to underweight patients: at 3 months (+6.8% vs pre-transplant weight); at 6 months (+11.3%), at 12 months (+15.6%); and at 24 months (+17.7%, all p < or = 0.03). The entire population had weight loss at 3 months (-2.9%), but had weight gain at 6 (+2.5%), 12 (+6.1%, all p < or = 0.02) and 24 months (+1.3%, p = 0.44). A lower BMI before HTx correlated significantly with greater weight increase after HTx at every follow-up time-point (r = 0.55; p < 0.001). There were no gender-specific differences for BMI or weight change. Weight loss within 3 months after HTx was associated with higher mortality during 4 years of follow-up.

CONCLUSIONS

Weight gain after HTx is particularly strong in underweight patients, and the increased cardiac function causes the cessation of cachexia. The weight increase of the entire heart transplant population is partially an effect of reversibility of cachexia and not affected by gender.

Adherence to the Therapeutic Regimen in Heart, Lung, and Heart-Lung Transplant Recipients

Optimal outcome after heart, lung, and heart-lung transplantation can only be obtained if patients are supported in adhering to a lifelong therapeutic regimen. The transplant patient's therapeutic regimen consists of a lifelong medication regimen, including immunosuppressive drugs; monitoring for signs and symptoms related to complications; avoidance of risk factors for cardiovascular disease and cancer (ie, diet and exercise prescriptions, nonsmoking); avoidance of abuse/dependence of alcohol or illegal drugs, as well as attending regular clinical checkups. Nonadherence to all aspects of this regimen is substantial. Nonadherence has been related to negative clinical outcome in view of acute rejections, graft vasculopathy, higher costs, and mortality. This review focuses on the prevalence, correlates, and consequences of nonadherence to the therapeutic regimen in heart, lung, and heart-lung transplantation. The current state of the-art on adherence-enhancing interventions is reported. Priorities for future research are outlined.

Management of hyperlipidaemia associated with heart transplantation

The past 20 years have seen considerable advances in the field of organ transplantation that have together led to a notable increase in survival rates and a reduction in postoperative morbidity of transplant recipients. However, these advances have been accompanied by the appearance of other complications of transplantation, such as post-transplant hyperlipidaemia, hypertension and graft coronary vasculopathy (GCV). GCV is an accelerated form of atherosclerosis in transplanted hearts that has proven to be one of the most important late complications of heart transplantation and is the single most limiting factor for long-term survival. The most important factors favouring the development of hyperlipidaemia after heart transplantation are inappropriate diet in combination with reduced physical activity, adverse effects of immunosuppressive therapy (ciclosporin [cyclosporin], corticosteroids) and polygenic hypercholesterolaemia in combination with ischaemic cardiomyopathy. The treatment of hyperlipidaemia in heart transplant recipients results in a variety of complications and side effects. In particular, interactions between lipid-lowering drugs and immunosuppressive therapy have been observed. Early attempts at treatment with bile acid binding agents and nicotinic acid derivatives often proved insufficiently effective, and led to unacceptable adverse effects and significant disturbances of ciclosporin metabolism. Fibric acid derivatives provided moderate reductions in triglyceride and total cholesterol levels that were mostly--with the exception of gemfibrozil--accompanied by significant impairment of renal function. Probucol achieved only an unsatisfactory reduction in low-density lipoprotein (LDL) cholesterol. Omega-3 fatty acids lower cholesterol levels and improve endothelial function in heart transplant recipients; however, the significance of these effects is still under discussion. As in the general patient population, use of HMG-CoA reductase inhibitors (statins) achieved significant reductions in cholesterol levels. Use of these substances has resulted in significantly extended long-term survival times, significantly less GCV and fewer severe graft rejections. Selective cholesterol absorption inhibitors, administered with or without statins, could provide another treatment option for heart transplant patients with hypercholesterolaemia. In severe familial hypercholesterolaemia, which is rarely observed in heart transplant recipients, treatment with statins can be combined with extracorporeal cholesterol elimination procedures such as heparin induced extracorporeal LDL cholesterol precipitation (HELP). HELP enables total cholesterol levels to be kept within any desired target range, and has been used successfully and without adverse effects in heart transplant recipients.

Psychosocial challenges in transplantation

The authors review the psychosocial aspects of transplantation. They first review psychosocial risk factors that place transplant patients at higher risk for noncompliance and negative outcomes. They then discuss what assessments should be included in a pretransplantation psychosocial evaluation. Goals of the psychosocial evaluation include selection of candidates most likely to benefit from transplantation and identification of areas for psychosocial intervention, both before and after transplantation. The assessment should address the patient's premorbid psychiatric state, past adaptation to stressors, history of compliance with treatment, substance abuse history, and level of social support, including community and faith-based support systems. Results of psychometric assessments may be helpful when considered in conjunction with a clinical interview and other sources of information about the patient. It may also be helpful to use a screening tool developed specifically to evaluate psychosocial factors relevant to transplantation, such as the Psychological Assessment of Candidates for Transplantation (PACT) scale and the Transplantation Evaluation Rating Scale (TERS). The authors then review issues related to psychopharmacologic interventions in transplant patients, including the use of antidepressant medication pre- and post-transplant, strategies for avoiding delirium associated with immunosuppressive medications immediately post-transplantation, neuropsychiatric symptoms associated with interferon alpha therapy for hepatitis C, and interactions between over-the-counter and herbal agents (e.g., St. John's Wort) and immunosuppressive agents. Although limited research has been done on nonpharmacologic interventions, such as transplant support groups, it appears that certain types of group therapy, in particular, cognitive-behavioral groups that target specific risk factors such as depression, distress, and compliance, may also offer promising approaches for dealing with the problems of transplant patients. The authors then focus on two special situations that create particular problems for transplantation teams: liver transplantation in patients with alcoholic liver disease (ALD) and obesity in transplant patients. The authors conclude that the prognosis for patients with ALD who receive liver transplantation is similar to that of non-alcoholics and that alcoholism is not a contraindication for liver transplantation. However, careful preliminary psychosocial assessment is essential to review candidates for factors that are predictive of relapse, while close follow-up post-transplantation can help improve outcomes. It appears that obesity can increase the risk of negative outcomes in transplant patients, although there is currently no consensus on the use of obesity as an exclusion criteria. Interventions that take into account the special psychological and medical needs of transplant patients need to be developed for treating obesity both pre- and post-transplantation. Improved strategies for identifying high-risk patients and finding ways to intervene both pre- and post-transplantation can not only help lengthen transplant recipients' life spans, but also improve their adaptation to transplantation and lead to improved quality of life.

Weight gain and cardiovascular risk after organ transplantation

Organ transplantation has become a common and effective approach to the management of patients with organ failure. The improvement in long-term survival has resulted in the emergence of cardiovascular disease as the primary cause of death in renal transplant patients and a significant complication in other organ recipients. A number of factors explain this trend, including a high incidence of hypertension, posttransplant diabetes, hyperlipidemia, and obesity-risk factors that are mediated by direct effects of immunosuppressive medications. Weight gain posttransplant affects approximately 50% of patients and represents a significant problem because of the potential synergism between obesity and immunosuppressive medication-induced effects on cardiovascular disease risk factor development. This review discusses the incidence and implications of cardiovascular disease risk factors in organ transplant recipients, strategies for clinical management, and future research directions.