First case of simultaneous heart plus kidney transplantation in Chile: case report

Advanced renal disease is a formal contraindication to heart transplantation, and heart failure may make a patient ineligible for kidney transplantation. The International Society of Heart and Lung Transplantation has reported 336 simultaneous heart and kidney transplantations with a 70% rate of 5 year survival. Herein we have presented the first case of simultaneous heart plus kidney transplantation in Chile. The patient is a 62-year-old man with diabetes mellitus and arterial hypertension who in 1997 had a myocardial infarction with cardiogenic shock and acute renal failure. He underwent a coronary bypass but developed progressive heart failure, with an ejection fraction less than 20% and moderate mitral regurgitation. He required chronic hemodialysis and survived a cardiac arrest, receiving an implantable cardioverter defibrillator. Transplantation was performed in 2004 in 2 phases: initially a heart, followed by a kidney transplantation. Immunosuppression included Daclizumab, cyclosporine, mycophenolate mofetil (MMF) and steroids. He developed acute renal failure but did not receive dialysis. He left the hospital at 25 days posttransplantation. Two years following double transplantation, he has not shown acute rejection episodes of either the cardiac or the kidney graft. Both cardiac and renal functions are normal. In conclusion, simultaneous heart plus kidney transplantations offer a good alternative treatment for patients with advanced disease of both organs.

Cytomegalovirus Infections in Cardiac Transplant Patients: An Experience at a Clinical Hospital, University of Chile

BACKGROUND

Since cytomegalovirus (CMV) infects between 20% and 50% of heart transplant patients, we reviewed our experience in 7 cases of this infection.

METHODS

A prospective analysis of CMV infection was performed in heart transplant patients who received cyclosporine, azathioprine, or mycophenolate mofetil, and prednisone. An elevated creatinine de novo was managed with antibody induction.

RESULTS

Between August 2001 and December 2005, we performed 22 heart transplants and 1 heart plus kidney transplant. Twenty-two patients were positive for CMV before transplantation. One patient died early because of graft failure. Immunosuppression included cyclosporine and prednisone (100%), azathioprine (52%), or mycophenolate (47%). Two recipients were induced with thymoglobulin and 13 with Daclizumab, while 8 did not receive any antibody. Nineteen patients received prophylaxis for CMV. Seven patients (30%) showed CMV infection, 6 of whom had received prophylaxis. Symptoms started at an average of 107 days posttransplantation in patients with prophylaxis. Three patients had gastritis, 2 pneumonia, and 1 colitis. One patient had concomitant lung aspergillosis. The two patients who received ATG developed CMV infections; 3 of the 12 with Daclizumab; and 2 who did not receive antibody. Of the CMV-infected subjects, 5 were on azathioprine and 2 on mycophenolate. All patients were treated with gancyclovir. The 1 patient with concomitant aspergillosis died.

CONCLUSIONS

The incidence of infection by CMV was 30%. Prophylaxis seemed to delay infection. Daclizumab induction did not increase the risk for CMV.

Elevated levels of serum interleukin-6 are associated with low grade cellular rejection in patients with heart transplantation

Endomyocardial biopsy is the gold-standard procedure to diagnose acute cellular rejection after heart transplantation. This study assessed whether the blood levels of cytokines involved in inflammation and immune activation are useful to detect the presence of acute cellular rejection.

METHODS

Blood specimens collected before 275 endomyocardial biopsies in 66 patients were assayed for levels of TNFalpha, IL6, IL1beta, and IL2 receptor. The biopsies were grouped according to the presence (n = 41) or absence (n = 234) of acute cellular rejection grade > or = 3A of the International Society for Heart and Lung Transplantation. We compared the levels of cytokines in the two groups.

RESULTS

Circulating IL6 levels were significantly higher when there was a low grade (0-2) cellular rejection in the biopsy versus the group of biopsies grade > or = 3A (19.8 +/- 27 versus 12.9 +/- 10 pg/mL; P = .001). An IL6 level higher than 30 pg/mL showed a negative predictive value of 95% for the presence of acute rejection grade > or = 3A.

CONCLUSION

In heart transplant patients, high levels of serum IL6 were associated with low grade cellular rejection. Determination of IL6 levels may be useful to reduce the number of endomyocardial biopsies during follow-up in these patients.

[Low energy transcatheter atrial defibrillation in one patient with refractory atrial fibrillation]

Most cases of atrial fibrillation are converted with antiarrhythmic medications or external electric defibrillation. However, in some refractory patients, an internal transcatheter defibrillation must be attempted. We report a 50 years old male with an atrial fibrillation of one year duration that was refractory to pharmacological treatment and in whom external cardioversion was unsuccessful. After the application of a bifasic shock of 10 joules between a catheter in the right atrium and another one located at the coronary sinus, the patient was converted to sinus rhythm. At two months of follow up, the patient continues in sinus rhythm.