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Noble J, Terrec F, Malvezzi P, Rostaing L. Adverse effects of immunosuppression after liver transplantation. Best Pract Res Clin Gastroenterol 2021; 54-55:101762. [PMID: 34874845 DOI: 10.1016/j.bpg.2021.101762] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 08/30/2021] [Indexed: 01/31/2023]
Abstract
After solid organ transplantation the cornerstone of immunosuppression is based on calcineurin inhibitors (CNIs), mostly tacrolimus. However, CNIs have a very narrow therapeutic window. The most important and serious side-effects of CNIs are nephrotoxicity, high blood pressure, post-transplant diabetes mellitus (PTMD), i.e., new-onset diabetes after transplantation (NODAT), dyslipidemia, and modification to the cardiovascular-risk profile. In this review, we will focus on tacrolimus-related toxicities in the setting of liver transplantation.
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Affiliation(s)
- Johan Noble
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, Grenoble University Hospital, Grenoble, France
| | - Florian Terrec
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, Grenoble University Hospital, Grenoble, France
| | - Paolo Malvezzi
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, Grenoble University Hospital, Grenoble, France
| | - Lionel Rostaing
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, Grenoble University Hospital, Grenoble, France; Grenoble Alpes University, Grenoble, France.
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Benrajab K, Godman M, Emhmed Ali S, Sorrell V, Salama F, Shah M, Mei X, Dela Cruz AC, Gedaly R. Alcohol-related cirrhosis is associated with high coronary artery calcium scores in patients undergoing evaluation for orthotopic liver transplantation. Clin Transplant 2021; 35:e14282. [PMID: 33690919 DOI: 10.1111/ctr.14282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 02/08/2021] [Accepted: 02/27/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIMS Coronary artery disease is a major cause of morbidity and mortality in liver transplant patients. Coronary artery calcium (CAC) score has been used to evaluate the risk of CAD in non-cirrhotic patients. However, its significance in cirrhotic patients is unknown. This study aimed to identify factors associated with elevated CAC scores in patients with end-stage liver disease undergoing liver transplant evaluation. METHODS We retrospectively reviewed all patients who underwent liver transplantation evaluation and had coronary CT scan between January 2015 and December 2018. Patients with prior history of CAD were excluded. CAC score was calculated based on the method described by Agatston. RESULTS Sixty-two patients were included. 37.1% had alcohol-related liver disease and 27.4% had NASH cirrhosis. Mean CAC score was 261.1 ± SD, 463.84. Alcohol-related liver disease, male gender, and hypertension were significantly associated with CAC score >100 and only alcohol-related liver disease was associated with CAC score >300. In logistic regression, patients with alcohol-related liver disease had more than sixfold increase in risk of having CAC scores >100 and 300 (OR 6.14, and 6.70, respectively). CONCLUSION Alcohol-related liver disease, male gender, and hypertension were significantly associated with an increased CAC score >100. However, alcohol-related liver disease was the only factor associated with CAC score >300.
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Affiliation(s)
- Karim Benrajab
- Department of Surgery - Transplant Division, University of Kentucky College of Medicine, Lexington, KY, USA.,Department of Medicine, Division of Digestive Diseases and Nutrition, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Macy Godman
- Department of Surgery - Transplant Division, University of Kentucky College of Medicine, Lexington, KY, USA.,Department of Medicine, Division of Digestive Diseases and Nutrition, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Saad Emhmed Ali
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, CA, USA
| | - Vincent Sorrell
- Department of Medicine, Division of Cardiology, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Fady Salama
- Department of Surgery - Transplant Division, University of Kentucky College of Medicine, Lexington, KY, USA.,Department of Medicine, Division of Digestive Diseases and Nutrition, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Malay Shah
- Department of Surgery - Transplant Division, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Xiaonan Mei
- Department of Surgery - Transplant Division, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Anna C Dela Cruz
- Department of Surgery - Transplant Division, University of Kentucky College of Medicine, Lexington, KY, USA.,Department of Medicine, Division of Digestive Diseases and Nutrition, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Roberto Gedaly
- Department of Surgery - Transplant Division, University of Kentucky College of Medicine, Lexington, KY, USA
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Kosmacheva ED, Babich AE. [Lipid spectrum and function of kidneys before and after liver transplantation]. ACTA ACUST UNITED AC 2019; 59:17-23. [PMID: 31340745 DOI: 10.18087/cardio.2611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 07/24/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND In patients after liver transplantation cardiovascular complications is the third main reason of death afer allograf failure and infections. The most important factors in the development of cardiovascular diseases are dyslipidemia and impaired renal function. The aim of the study was to investigate the lipid spectrum and renal function in liver recipients in real clinical practice and the correspondence of their correction to current clinical recommendations for the diagnosis and treatment of dyslipidemia and chronic kidney disease (CKD). METHODS A retrospective analysis of lipid spectrum and renal function in patients who underwent OLT in Research Institute - Regional Clinical Hospital №1, Krasnodar was performed. The level of creatinine, GFR and lipid spectrum was studied before and 36 months after liver transplantation. The GFR was calculated using the formula CKD‑EPI (Chronic Kidney Disease Epidemiology Collaboration). Statistical analysis of the study results was made using the program Statistica 10. RESULTS Liver recipients have a significantly higher total cholesterol by 31.0% (p<0.01) in comparison with the baseline before surgery. Total cholesterol was increased in 13.7% (p<0.01), triglycerides in 12.3% (p<0.01) before transplantation. Tree years after transplantation, the increasion in cholesterol was registered in 42.6% (p<0.01) and triglycerides in 37.9% (p <0.01), respectively. 3 years after transplantation reduction of GFR was observed in comparison with the baseline by 22.6% (p=0.00006). Verification of chronic kidney disease and statin administration in patients were carried out in some cases. The levels of total cholesterol and triglycerides had a reliable inverse correlation with GFR (r = ‑0.42; p<0.01 and r = ‑0.36; p<0.05). CONCLUSIONS In the long‑term postoperative period there was an impaired lipid metabolism and decreased level of GFR. Dyslipidemia was closely related to the progression of renal dysfunction in liver recipients, an inverse correlation was established between the glomerular filtration rate and the increasion in cholesterol and triglyceride levels. It is necessary to increase the attention of physicians with regard to timely correction of lipid metabolism disorders and detection of initial manifestations of renal dysfunction.
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Affiliation(s)
- E D Kosmacheva
- Kuban State Medical University; State Budgetary Healthcare Institution "Research Institute - Regional Clinical Hospital №1 n.a. professor S. V. Ochapovskiy" of Ministry of Health of Krasnodar Region
| | - A E Babich
- Kuban State Medical University; State Budgetary Healthcare Institution "Research Institute - Regional Clinical Hospital №1 n.a. professor S. V. Ochapovskiy" of Ministry of Health of Krasnodar Region
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Strydom K, Van Niekerk E, Dhansay MA. Factors affecting body composition in preterm infants: Assessment techniques and nutritional interventions. Pediatr Neonatol 2019; 60:121-128. [PMID: 29239827 DOI: 10.1016/j.pedneo.2017.10.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 07/26/2017] [Accepted: 10/20/2017] [Indexed: 11/19/2022] Open
Abstract
Limited research has been conducted that elucidates the growth and body composition of preterm infants. It is known that these infants do not necessarily achieve extra-utero growth rates and body composition similar to those of their term counterparts. Preterm infants, who have difficulty in achieving these growth rates, could suffer from growth failure. These infants display an increased intra-abdominal adiposity and abnormal body composition when they achieve catch-up growth. These factors affect the quality of weight gain, as these infants are not only shorter and lighter than term infants, they also have more fat mass (FM) and less fat-free mass (FFM), resulting in a higher total fat percentage. This could cause metabolic syndrome and cardiovascular problems to develop later in a preterm infant's life. The methods used to determine body composition in preterm infants should be simple, quick, non-invasive and inexpensive. Available literature was reviewed and the Dauncey anthropometric model, which includes skinfold thickness at two primary sites and nine body dimensions, is considered in this review the best method to accurately determine body composition in preterm infants, especially in resource-poor countries. It is imperative to accurately assess the quality of growth and body composition of this fragile population in order to determine whether currently prescribed nutritional interventions are beneficial to the overall nutritional status and quality of life-in the short- and long-term-of the preterm infant, and to enable timely implementation of appropriate interventions, if required.
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Affiliation(s)
- K Strydom
- Division of Human Nutrition, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa.
| | - E Van Niekerk
- Division of Human Nutrition, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
| | - M A Dhansay
- South African Medical Research Council, Burden of Disease Research Unit, Cape Town, South Africa; Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Szewc UZ, Czyżewski Ł, Wyzgał J, Szarpak Ł. Assessment of Arterial Stiffness and Body Composition in Stable Liver Transplant Recipients. Transplant Proc 2018; 50:2009-2013. [PMID: 30177099 DOI: 10.1016/j.transproceed.2018.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Revised: 04/16/2018] [Accepted: 05/07/2018] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Arterial stiffness and central arterial pressure are important factors in the diagnosis of cardiovascular diseases. The tendency of patients after liver transplantation to reach above-normal BMI values promotes the development of arterial stiffness and lipid disorders. METHODS The study was conducted on a group of 42 patients after liver transplantation at the Nephrology and Transplantology Outpatient Clinic, Medical University of Warsaw, the Infant Jesus Teaching Hospital, Warsaw 0.5-17 years after surgery. The body composition test was carried out with the Tanita Mc780 device, and the central pressure and pulse wave velocity (PWV) with the Schiller BR-102 PLUS PWA device, using the oscillometric method on the brachial artery. Medical documentation was analyzed and the laboratory parameters values routinely determined during follow-up visits were assessed. RESULTS There was a statistically significant correlation between central diastolic pressure and BMI (r = 0.46, P < .05), and a lack of correlation between patients' age and PWV value (r = 0.06, P < .05), which indicated the age of patients in this study was not associated the stiffness of their arteries. PWV level in patients after liver transplantation whose BMI value is within the normal range was 7.62 m/s, while overweight and obese patients had PVW values of 8.58 m/s (P < .05). CONCLUSIONS In conclusion, our data indicate that 1. the level of central arterial pressure increases with the development of stiffness in the arteries; 2. patients after liver transplantation tend to grow in terms of body weight and body fat content over time after surgery; and 3. the level of bilirubin in the blood is significantly increased among patients with fat content above the upper limit of the normal range.
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Affiliation(s)
- U Z Szewc
- Student Research Circle "NEFRON" at the Department of Nephrology Nursing, Medical University of Warsaw, Warsaw, Poland
| | - Ł Czyżewski
- Department of Nephrology Nursing, Medical University of Warsaw, Warsaw, Poland.
| | - J Wyzgał
- Department of Nephrology Nursing, Medical University of Warsaw, Warsaw, Poland
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Prospective evaluation of metabolic syndrome and its features in a single-center series of hematopoietic stem cell transplantation recipients. Ann Hematol 2018; 97:2471-2478. [PMID: 30054704 DOI: 10.1007/s00277-018-3452-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 07/19/2018] [Indexed: 02/01/2023]
Abstract
Available studies on metabolic syndrome (MS) after hematopoietic stem cell transplantation (HSCT) are retrospective with heterogeneous inclusion criteria, and little is known about the early post-transplant phase. In our prospective study, clinical and laboratory data were collected in 100 HSCT recipients, 48 allogeneic and 52 autologous, at baseline, at + 30, + 100 and + 360 days. At baseline, MS was observed in 24 patients, significantly associated with insulin resistance and leptin on multivariate analysis. At + 30, the diagnosis of MS was confirmed in 43 patients, significantly related to insulin resistance and allogeneic transplants. If the whole series was considered, patients with MS had significantly higher mortality from any cause. The baseline presence of any MS feature was a predictor of + 30 MS. Isolated occurrences of MS features were related to hyperleptinemia and hyperinsulinemia, except in the case of low HDL cholesterol, linked to adiponectin and resistin. Our data confirm that patients undergoing HSCT have a high prevalence of MS, with hyperleptinemia playing a major role. The early peak of new MS cases is primarily attributable to insulin resistance, notably but not exclusively immunosuppression-induced; the subsequent long-term increase in MS cases may be an effect of persistent adipokine imbalance.
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Oral health-related quality of life depending on dental and periodontal health in different patients before and after liver transplantation. Clin Oral Investig 2017; 22:2039-2045. [DOI: 10.1007/s00784-017-2298-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 12/06/2017] [Indexed: 12/12/2022]
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Resting and Exercise Energy Metabolism After Liver Transplantation for Nonalcoholic Steatohepatitis. Transplant Direct 2017; 3:e188. [PMID: 28795140 PMCID: PMC5540626 DOI: 10.1097/txd.0000000000000701] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 05/11/2017] [Indexed: 01/11/2023] Open
Abstract
Background Nonalcoholic steatohepatitis (NASH) is a leading indication for liver transplantation (LT). We hypothesized that weight gain after LT may be exacerbated by reduced metabolic rates due to the LT procedure, particularly during exercise. We aimed to compare resting and exercise energy expenditure between patients transplanted for NASH and nontransplant nonalcoholic fatty liver disease (NAFLD) subjects. Methods NASH LT recipients (>1-year post, n = 14) and NAFLD controls (n = 13) underwent analysis of body composition, resting energy expenditure (REE), and exercise energy expenditure (VO2max), the latter using a ramped-Bruce protocol assessed by expired gas analysis and peak heart rate. Results Participants were mean 61.5 ± 7.9 years, 48.1% men, and 66.7% white. Baseline comorbidities were similar between groups. Among men, mean REE adjusted for total (17.7 vs 18.8, P = 0.87) and lean body mass (23.5 vs 26.9, P = 0.26), as well as VO2 (20.1 vs 23.9, P = 0.29), was lower in NASH LT recipients compared with NAFLD controls, respectively, although not statistically significant. However, female NASH LT recipients had significantly lower mean REE than NAFLD controls when adjusted for total (14.2 vs 18.9, P = 0.01) and lean body mass (19.3 vs 26.5, P = 0.002), as well as significantly lower VO2max (14.4 vs 20.6, P = 0.017). Conclusions NASH LT recipients, particularly women, have lower REE and exercise energy expenditure compared with nontransplant NAFLD patients. More aggressive diet and exercise programs for post-LT NASH recipients to account for reduced resting and exercise metabolic rates may attenuate weight gain in this vulnerable population.
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Mangus RS, Fridell JA, Kubal CA, Loeffler AL, Krause AA, Bell JA, Tiwari S, Tector J. Worse Long-term Patient Survival and Higher Cancer Rates in Liver Transplant Recipients With a History of Smoking. Transplantation 2015; 99:1862-8. [PMID: 26308417 DOI: 10.1097/tp.0000000000000671] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND This study is a retrospective review of liver transplant (LT) recipients to determine the impact of tobacco exposure on 10-year survival and de novo cancer (CA) incidence. METHODS The records of 1275 consecutive LT patients were reviewed (2001 to 2011). Patients were categorized as current, previous, or never smokers (NS) at listing for LT. Additionally, smokers were stratified by pack-years of tobacco exposure. Events included patient death, cardiovascular events, and de novo cancers. Cox regression analysis was used to evaluate survival. A complete cause of death analysis is provided, as well as a detailed tumor registry. RESULTS Current (n = 279) and previous smokers (n = 323) were more likely to have hepatocellular carcinoma (HCC) at transplant (25%, 29% vs 18% [NS], P < 0.001), and these 2 groups had higher HCC recurrence rates (21%, 14% vs 11% [NS], P = 0.18). De novo non-HCC CA was higher for current and previous smokers, compared to NS (18%, 16% vs 12% [NS], P = 0.05). Among those with de novo CA (n = 180), the 2 smoking groups were more likely to have non-skin CA (60%, 54% vs 27% [NS], P < 0.001). Patient survival at 10 years was worse for current smokers than the other study groups (55% vs 70%, P < 0.01). These results were largely mirrored with increased tobacco exposure. CONCLUSIONS The LT outcomes are uniformly worse for patients with a history of smoking, and the risk of negative events increases with increasing tobacco use. Smokers have higher rates of HCC and recurrence, de novo cancer, and worse long-term survival. SUMMARY STATEMENT This study summarizes the clinical outcomes for 1275 LT patients over 10 years, analyzing the impact of pre transplant recipient tobacco use. There are 47% of patients with a history of smoking. Because of demonstrated higher cancer rates and decreased survival, patients with a significant smoking history should be carefully scrutinized for liver transplantation.
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Affiliation(s)
- Richard S Mangus
- Transplant Division, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
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Hara Y, Kawagishi N, Nakanishi W, Tokodai K, Nakanishi C, Miyagi S, Ohuchi N. Prevalence and risk factors of obesity, hypertension, dyslipidemia and diabetes mellitus before and after adult living donor liver transplantation. Hepatol Res 2015; 45:764-70. [PMID: 25196899 DOI: 10.1111/hepr.12418] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Revised: 08/30/2014] [Accepted: 09/02/2014] [Indexed: 02/08/2023]
Abstract
AIM The development of metabolic abnormalities after liver transplantation (LTx) contributes to cardiovascular events and mortality. We analyzed the prevalence and risk factors of obesity, hypertension, dyslipidemia and diabetes mellitus (DM) after adult living donor liver transplantation. METHODS Fifty-four adult recipients with a minimum follow up of 6 months receiving living donor liver transplantation between 2001 and 2012 at the Tohoku University Hospital were retrospectively analyzed. RESULTS The prevalence of hypertension increased from 18.5% before transplantation to 35.2% post-transplantation, and new-onset hypertension after transplantation was 57.9% of post-transplant hypertension. Univariate analysis showed that risk factors of post-transplant hypertension were age (>50 years, P = 0.0023), pretransplant body mass index (BMI) of 25 or more (P = 0.0123), pretransplant hypertension (P = 0.0012) and cyclosporin A (61.5% vs tacrolimus 25.0%, P = 0.0248). The incidence of obesity, dyslipidemia and DM did not change from before to after transplantation. LTx was curative in 77.8% of cases of pretransplant dyslipidemia and 20% of cases of pretransplant DM. Primary biliary cirrhosis cases comprised 85.7% of cases of pretransplant dyslipidemia that were cured by LTx. In univariate analysis, pretransplant BMI of 25 or more was the only risk factor of post-transplant dyslipidemia (P = 0.0098). The incidence of new-onset DM after transplantation was 20%. Risk factors of post-transplant DM were male sex (P = 0.0156), pretransplant DM (P < 0.0001), alcohol abuse (P = 0.0248) and mycophenolate mofetil (P = 0.0181) by univariate analysis. CONCLUSION The prevalence of hypertension increased after LTx and pretransplant obesity was associated with several post-transplant metabolic abnormalities.
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Affiliation(s)
- Yasuyuki Hara
- The Division of Advanced Surgical Science and Technology, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Naoki Kawagishi
- The Division of Advanced Surgical Science and Technology, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Wataru Nakanishi
- The Division of Advanced Surgical Science and Technology, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Kazuaki Tokodai
- The Division of Advanced Surgical Science and Technology, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Chikashi Nakanishi
- The Division of Advanced Surgical Science and Technology, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Shigehito Miyagi
- The Division of Advanced Surgical Science and Technology, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Noriaki Ohuchi
- The Division of Advanced Surgical Science and Technology, Graduate School of Medicine, Tohoku University, Sendai, Japan
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Aguiar CJ, Rocha-Franco JA, Sousa PA, Santos AK, Ladeira M, Rocha-Resende C, Ladeira LO, Resende RR, Botoni FA, Barrouin Melo M, Lima CX, Carballido JM, Cunha TM, Menezes GB, Guatimosim S, Leite MF. Succinate causes pathological cardiomyocyte hypertrophy through GPR91 activation. Cell Commun Signal 2014; 12:78. [PMID: 25539979 PMCID: PMC4296677 DOI: 10.1186/s12964-014-0078-2] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2014] [Accepted: 11/28/2014] [Indexed: 12/28/2022] Open
Abstract
Background Succinate is an intermediate of the citric acid cycle as well as an extracellular circulating molecule, whose receptor, G protein-coupled receptor-91 (GPR91), was recently identified and characterized in several tissues, including heart. Because some pathological conditions such as ischemia increase succinate blood levels, we investigated the role of this metabolite during a heart ischemic event, using human and rodent models. Results We found that succinate causes cardiac hypertrophy in a GPR91 dependent manner. GPR91 activation triggers the phosphorylation of extracellular signal-regulated kinase 1/2 (ERK1/2), the expression of calcium/calmodulin dependent protein kinase IIδ (CaMKIIδ) and the translocation of histone deacetylase 5 (HDAC5) into the cytoplasm, which are hypertrophic-signaling events. Furthermore, we found that serum levels of succinate are increased in patients with cardiac hypertrophy associated with acute and chronic ischemic diseases. Conclusions These results show for the first time that succinate plays an important role in cardiomyocyte hypertrophy through GPR91 activation, and extend our understanding of how ischemia can induce hypertrophic cardiomyopathy. Electronic supplementary material The online version of this article (doi:10.1186/s12964-014-0078-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Carla J Aguiar
- Department of Physiology and Biophysics, Federal University of Minas Gerais, Av. Antônio Carlos 6627, Belo Horizonte, MG - CEP: 31270-901, Brazil.
| | - João A Rocha-Franco
- Department of Physiology and Biophysics, Federal University of Minas Gerais, Av. Antônio Carlos 6627, Belo Horizonte, MG - CEP: 31270-901, Brazil.
| | - Pedro A Sousa
- Department of Physiology and Biophysics, Federal University of Minas Gerais, Av. Antônio Carlos 6627, Belo Horizonte, MG - CEP: 31270-901, Brazil.
| | - Anderson K Santos
- Department of Biochemistry and Immunology, Federal University of Minas Gerais, Av. Antônio Carlos 6627, Belo Horizonte, MG - CEP: 31270-901, Brazil.
| | - Marina Ladeira
- Department of Physiology and Biophysics, Federal University of Minas Gerais, Av. Antônio Carlos 6627, Belo Horizonte, MG - CEP: 31270-901, Brazil.
| | - Cibele Rocha-Resende
- Department of Physiology and Biophysics, Federal University of Minas Gerais, Av. Antônio Carlos 6627, Belo Horizonte, MG - CEP: 31270-901, Brazil.
| | - Luiz O Ladeira
- Department of Physics, Federal University of Minas Gerais, Av. Antônio Carlos 6627, Belo Horizonte, MG - CEP: 31270-901, Brazil.
| | - Rodrigo R Resende
- Department of Biochemistry and Immunology, Federal University of Minas Gerais, Av. Antônio Carlos 6627, Belo Horizonte, MG - CEP: 31270-901, Brazil.
| | - Fernando A Botoni
- Department of Medicine, Federal University of Minas Gerais, Av. Antônio Carlos 6627, Belo Horizonte, MG - CEP: 31270-901, Brazil.
| | - Marcos Barrouin Melo
- Department of Physiology and Biophysics, Federal University of Minas Gerais, Av. Antônio Carlos 6627, Belo Horizonte, MG - CEP: 31270-901, Brazil.
| | - Cristiano X Lima
- Department of Medicine, Federal University of Minas Gerais, Av. Antônio Carlos 6627, Belo Horizonte, MG - CEP: 31270-901, Brazil.
| | - José M Carballido
- Novartis Institutes for Biomedical Research, Basel, CH-4002, Switzerland.
| | - Thiago M Cunha
- Department of Pharmacology, Ribeirão Preto, Medical School, University of São Paulo, São Paulo, Brazil.
| | - Gustavo B Menezes
- Department of Morphology, Federal University of Minas Gerais, Av. Antônio Carlos 6627, Belo Horizonte, MG - CEP: 31270-901, Brazil.
| | - Silvia Guatimosim
- Department of Physiology and Biophysics, Federal University of Minas Gerais, Av. Antônio Carlos 6627, Belo Horizonte, MG - CEP: 31270-901, Brazil.
| | - M Fatima Leite
- Department of Physiology and Biophysics, Federal University of Minas Gerais, Av. Antônio Carlos 6627, Belo Horizonte, MG - CEP: 31270-901, Brazil.
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Holdaas H, Potena L, Saliba F. mTOR inhibitors and dyslipidemia in transplant recipients: a cause for concern? Transplant Rev (Orlando) 2014; 29:93-102. [PMID: 25227328 DOI: 10.1016/j.trre.2014.08.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Revised: 07/19/2014] [Accepted: 08/22/2014] [Indexed: 02/06/2023]
Abstract
Post-transplant dyslipidemia is exacerbated by mammalian target of rapamycin (mTOR) inhibitors. Early clinical trials of mTOR inhibitors used fixed dosing with no concomitant reduction in calcineurin inhibitor (CNI) exposure, leading to concerns when consistent and marked dyslipidemia was observed. With use of modern concentration-controlled mTOR inhibitor regimens within CNI-free or reduced-exposure CNI regimens, however, the dyslipidemic effect persists but is less pronounced. Typically, total cholesterol levels are at the upper end of normal, or indicate borderline risk, in kidney and liver transplant recipients, and are lower in heart transplant patients under near-universal statin therapy. Of note, it is possible that mTOR inhibitors may offer a cardioprotective effect. Experimental evidence for delayed progression of atherosclerosis is consistent with evidence from heart transplantation that coronary artery intimal thickening and the incidence of cardiac allograft vasculopathy are reduced with everolimus versus cyclosporine therapy. Preliminary data also indicate that mTOR inhibitors may improve arterial stiffness, a predictor of cardiovascular events, and may reduce ventricular remodeling and decrease left ventricular mass through an anti-fibrotic effect. Post-transplant dyslipidemia under mTOR inhibitor therapy should be monitored and managed closely, but unless unresponsive to therapy should not be regarded as a barrier to its use.
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Affiliation(s)
- Hallvard Holdaas
- Section of Nephrology, Department of Transplant Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway.
| | - Luciano Potena
- Heart Failure and Heart Transplant Program, Academic Hospital S. Orsola-Malpighi, Alma-Mater University of Bologna, Bologna, Italy
| | - Faouzi Saliba
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France
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Abstract
OBJECTIVE To provide an approach to the care of liver transplant (LT) patients, a growing patient population with unique needs. METHODS A literature search of PubMed for guidelines and review articles using the keywords "liver transplantation", "long term complications" and "medical management" was conducted, resulting in 77 articles. RESULTS As a result of being on immunosuppression, LT recipients are at increased risk of infections and must be screened regularly for metabolic complications and malignancies. DISCUSSION Although immunosuppression is key to maintaining allograft health after transplantation, it comes with its own set of medical issues to follow. Physicians following LT recipients must be aware of the greater risk for hypertension, diabetes, dyslipidemia, renal failure, metabolic bone disease and malignancies in these patients, all of whom require regular monitoring and screening. Vaccination, quality of life, sexual function and pregnancy must be specifically addressed in transplant patients.
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14
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Annaloro C, Airaghi L, Saporiti G, Onida F, Cortelezzi A, Deliliers GL. Metabolic syndrome in patients with hematological diseases. Expert Rev Hematol 2014; 5:439-58. [DOI: 10.1586/ehm.12.35] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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15
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Ali A, Bhardwaj HL, Heuman DM, Jovin IS. Coronary events in patients undergoing orthotopic liver transplantation: perioperative evaluation and management. Clin Transplant 2013; 27:E207-15. [DOI: 10.1111/ctr.12113] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2013] [Indexed: 12/12/2022]
Affiliation(s)
| | - Hem L. Bhardwaj
- Department of Medicine; Virginia Commonwealth University; Richmond; VA; USA
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16
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Abstract
BACKGROUND Increased blood pressure (BP) is common after liver transplantation. However, there is scarce information on its control. METHODS In this prospective, cross-sectional, multicenter study, we determined BP according to the recommended international standards in 921 liver transplant patients during one routine outpatient visit to assess their grade of control of BP. At the time of the study, 490 patients had been previously diagnosed with arterial hypertension and were receiving antihypertensive treatment, and 431 were not previously diagnosed as hypertensive. RESULTS In the hypertensive group, arterial hypertension was uncontrolled (BP >140/90 mm Hg [>130/80 in diabetics]) in 158 (32%) patients and controlled in 332 (68%) patients. In a multivariate analysis, only diabetes was identified as a significant predictor of uncontrolled hypertension. Among patients not previously diagnosed as hypertensive, BP was increased in 106 (25%) and normal in 325 (75%). On multivariate analysis, the only variable independently associated with increased BP in this group was metabolic syndrome. CONCLUSION BP is not adequately controlled in a noticeable percentage of liver transplant patients, especially in subjects with diabetes or metabolic syndrome.
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17
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Bayrakci US, Baskin E, Ozcay F, Gulleroglu K, Ozbay F, Sevmis S, Karakayali H, Haberal M. Abnormal circadian blood pressure regulation in liver transplanted children. Pediatr Transplant 2012; 16:160-4. [PMID: 22321218 DOI: 10.1111/j.1399-3046.2012.01646.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
HT is a frequent cardiovascular risk factor in liver transplant recipients. However, there are only few studies in the literature regarding the risk of HT in liver transplanted children. The aim of this study was to assess the 24 h BP profiles of liver transplanted patients and to compare the results with healthy children. ABPM was performed on 20 liver transplanted patients and 27 healthy children aged 7.1 ± 4.8 and 8.5 ± 2.9 yr, respectively. HT was defined as SDS > 1.64 (i.e., >95th percentile) adjusted for gender and height. The mean duration of post-transplant follow-up was 32 ± 19 months. Six (30%) patients were found to be hypertensive. The physiological nocturnal BP fall was attenuated significantly in the study group for diastolic BP (11.5 ± 6.1 mmHg vs. 17.7 ± 7.1 mmHg, p = 0.006). Specifically, the number of patients with high nighttime systolic and diastolic BP SDS (p = 0.02 and p = 0.004, respectively) as well as elevated nighttime systolic (p = 0.03) and diastolic (p = 0.003) BPLs was found to be significantly higher than those in the controls. Alteration of the "normal" circadian rhythm is very frequent in liver transplant recipients. Thus, it is recommended to perform ABPM on all liver transplanted children not to underdiagnose HT.
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Affiliation(s)
- Umut Selda Bayrakci
- Department of Pediatric Nephrology, Baskent University School of Medicine, Ankara, Turkey.
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18
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Najeed SA, Saghir S, Hein B, Neff G, Shaheen M, Ijaz H, Khan IA. Management of hypertension in liver transplant patients. Int J Cardiol 2011; 152:4-6. [DOI: 10.1016/j.ijcard.2010.12.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2010] [Accepted: 12/04/2010] [Indexed: 12/17/2022]
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19
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Oustecky DH, Riera AR, Rothstein KD. Long-term management of the liver transplant recipient: pearls for the practicing gastroenterologist. Gastroenterol Clin North Am 2011; 40:659-81. [PMID: 21893279 DOI: 10.1016/j.gtc.2011.06.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Liver transplantation is becoming more common and patients are surviving longer after transplantation. Special care must be paid to the long-term management of these patients because they are at increased risk for medical problems, malignancies, and adverse effects from immunosuppression. A stable and continuing relationship must be developed between the physician and the patient to optimize the long-term outcomes for these individuals.
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Affiliation(s)
- David H Oustecky
- Drexel University College of Medicine, Department of Gastroenterology and Hepatology, Mail Stop 913, 219 N. Broad Street, 5th Floor, Philadelphia, PA 19107, USA
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20
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Lorho R, Hardwigsen J, Dumortier J, Pageaux GP, Durand F, Bizollon T, Blanc AS, Di Giambattista F, Duvoux C. Regression of new-onset diabetes mellitus after conversion from tacrolimus to cyclosporine in liver transplant patients: results of a pilot study. Clin Res Hepatol Gastroenterol 2011; 35:482-8. [PMID: 21530445 DOI: 10.1016/j.clinre.2011.03.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2011] [Revised: 03/11/2011] [Accepted: 03/16/2011] [Indexed: 02/04/2023]
Abstract
INTRODUCTION New-onset diabetes mellitus (NODM) has important implications for long-term outcome following liver transplantation. AIM To evaluate the impact of conversion from tacrolimus to cyclosporine in liver transplant patients presenting NODM. METHOD In a 12-month pilot study, 39 liver transplant patients with NODM were converted from tacrolimus to cyclosporine. Most patients (59%) were receiving antidiabetic therapy (18% insulin, 41% oral) and all patients had received dietary advice prior to the study. RESULTS At month 12, NODM had significantly resolved (FBG<7 mmol/L without treatment) in 36% of patients (95% CI 20.8-51.0%). In the 16 patients not receiving antidiabetic drugs at baseline, mean FBG decreased from 8.1 mmol/L to 6.6 mmol/L (P=0.008) and mean HbA(1c) decreased from 6.4 to 6.0% (P=0.05). Steroids were stopped rapidly in the nine patients receiving steroids at inclusion but NODM resolution was observed in only one of these nine patients. No significant factors were identified that could have affected NODM resolution. There were three episodes of biopsy-proven acute rejection (7.7%), no graft losses and one death. Overall, cyclosporine tolerance was good with no significant change in creatinine clearance at month 12. Total cholesterol increased from 4.6 mmol/L to 5.1 mmol/L (P<0.001). CONCLUSIONS These results suggest that liver transplant patients with NODM may benefit from conversion to cyclosporine from tacrolimus through improved glucose metabolism. Confirmation in a prospective, randomized comparative study is required.
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Affiliation(s)
- R Lorho
- Hepatology and Liver Transplant Unit, Pontchaillou Hospital, 35033 Rennes cedex 9, France
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21
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Rossetto A, Bitetto D, Bresadola V, Lorenzin D, Baccarani U, De Anna D, Bresadola F, Adani GL. Cardiovascular risk factors and immunosuppressive regimen after liver transplantation. Transplant Proc 2011; 42:2576-8. [PMID: 20832547 DOI: 10.1016/j.transproceed.2010.05.160] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2010] [Revised: 04/26/2010] [Accepted: 05/12/2010] [Indexed: 01/07/2023]
Abstract
Cardiovascular and metabolic diseases represent important long-term complications after liver transplantation (LT), impairing long-term and disease-free survivals. A few mechanisms underlie the development of those complications, but the role of immunosuppressive drugs is major. Although several patients develop temporary metabolic diseases, which normalize after a short postoperative period and do not need long-term drug therapy, the incidences of de novo long-lasting arterial hypertension, hyperlipidemia, and diabetes mellitus are high during the first year after LT. The aim of this retrospective study was to evaluate new-onset arterial hypertension, hyperlipidemia, or diabetes among 100 LT patients at a single institution. We used chi-square statistical analysis to compare incidences during tacrolimus versus cyclosporine therapy. Hypertension did not seem to be more strongly related to tacrolimus than to cyclosporine, nor did diabetes, whereas there was a difference for the development of hyperlipidemia.
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Affiliation(s)
- A Rossetto
- Department of Surgery and Transplantation, University Hospital, Udine, Italy.
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22
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Dick AAS, Perkins JD, Spitzer AL, Lao OB, Healey PJ, Reyes JD. Impact of obesity on children undergoing liver transplantation. Liver Transpl 2010; 16:1296-302. [PMID: 21031545 DOI: 10.1002/lt.22162] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Controversies exist with respect to the mortality of patients undergoing liver transplantation at the extremes of the body mass index (BMI). For pediatric liver transplantation, weight is usually the only factor considered in survival analysis. A review of the United Network for Organ Sharing database (1987-2007) revealed 9701 pediatric patients (<18 years old) who underwent primary liver transplantation. Patients were stratified into 5 BMI categories established by the World Health Organization according to their Z score, which was based on age, gender, and BMI: -3, -2, 0, +2, and +3. The survival rates in these 5 categories were compared with Kaplan-Meier survival curves and log-rank testing. Patients with thinness (Z score = -2) and severe thinness (Z score = -3) had significantly (P < 0.0001) lower survival at 1 year (84.4%) versus the survival (88.7%) of the normal and overweight groups (Z score = 0 and Z score = + 2, respectively). For patients with obesity (Z score = +3), there was no significant difference in survival early after transplantation, but their mortality gradually increased in the later years after transplantation. By 12 years after liver transplantation, the obese group had significantly (P = 0.04) lower survival (72%) than the normal and overweight groups (77%). In conclusion, liver transplantation holds increased risk for obese pediatric patients. Thin pediatric patients experience early mortality after liver transplantation, and obese pediatric patients experience late mortality after liver transplantation. Transplant management can be modified to optimize the care of these patients.
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Affiliation(s)
- André A S Dick
- Division of Transplantation, Department of Surgery, University of Washington, Seattle, WA 98195, USA.
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23
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Abstract
Longer survival for orthotopic liver transplantation (OLT) patients over the last decade has focused emphasis on the metabolic complications that contribute to patient morbidity and mortality. The aim of our study was to analyze the prevalence of the metabolic syndrome (MS) and other risk factors after OLT among our patients at 1 year follow-up. From 2001 to 2008, we performed OLT in 210 patients with 62 exclusions leaving 148 patients for the study. We recorded age, gender, liver disease, smoking status, pre- and post-OLT body mass index, pre- and post-OLT arterial blood pressure, pre- and post-OLT fasting blood glucose, pre- and post-OLT high-density lipoproteins and triglycerides, family history of diabetes, hepatitis B and C virus status, immunosuppressive therapy, and corticosteroid bolus for rejection episodes. The MS was defined according to modified ATP III criteria. At month 12 after OLT, 29/148 patients (19.6%) developed the MS. The associated factors were obesity and hyperlipidemia pre-OLT, familial and personal history of diabetes as well as alcoholic cirrhosis. By multivariate analysis, pre-OLT body mass index (odds ratio, 3.7 [1.3-10.5]) and pre-OLT diabetes (odds ratio, 2.9 [1.1-7.9]) were independent risk factors.
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24
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Cardiovascular risk profile of patients with acute liver failure after liver transplantation when compared with the general population. Transplantation 2010; 89:61-8. [PMID: 20061920 DOI: 10.1097/tp.0b013e3181bcd682] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND As opposed to most solid-organ transplant recipients, patients with acute liver failure exhibit a pretransplant health status more comparable with the general population, and any posttransplant cardiovascular risk excess should thus be more attributable to transplantation-related factors alone. METHODS This study compared the cardiovascular risk of 77 consecutive patients with acute liver failure at 5 years after liver transplantation with that of the general population using age, sex, and residence area-standardized prevalence ratios (SPR). RESULTS At least one cardiovascular risk factor developed in 92% of patients. Treated hypertension, observed in 71% of patients at 5 years, was more common among patients than controls (SPR, 2.73; 95% confidence interval [CI], 2.06-3.55), whereas the 61% prevalence of dyslipidemia and 3% prevalence of impaired fasting glucose were significantly less frequent among patients (SPR, 0.69; 95% CI, 0.51-0.92 and SPR, 0.29; 95% CI, 0.04-1.00). The 5-year prevalence of diabetes (10%), overweight (32%), and obesity (13%) deviated nonsignificantly from controls (SPR 1.90, 0.85, and 0.58). Antibody therapy associated with a 1.49-fold increase in the risk of hypertension (95% CI, 1.15-1.94) and a 6.43-fold increase in the risk of diabetes (95% CI, 1.18-34.9). Immunosuppression-type, steroids, acute rejection, retransplantation, or graft steatosis revealed nonsignificant risk alterations. CONCLUSIONS Liver transplantation and associated immunosuppression evidently cause hypertension, and possibly elicit diabetes in susceptible individuals. Conversely, the often reported transplantation-associated increased burden of overweight/obesity and dyslipidemia might relate mostly to other factors.
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25
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Pagadala M, Dasarathy S, Eghtesad B, McCullough AJ. Posttransplant metabolic syndrome: an epidemic waiting to happen. Liver Transpl 2009; 15:1662-70. [PMID: 19938136 DOI: 10.1002/lt.21952] [Citation(s) in RCA: 117] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
With increasing survival after orthotopic liver transplantation (OLT), metabolic syndrome and its individual components, including diabetes mellitus, hypertension, dyslipidemia, and obesity, are increasingly being identified and contributing to cardiovascular complications and late morbidity and mortality. The prevalence of posttransplant metabolic syndrome (PTMS) and its individual components has been found to be higher post-OLT versus a comparable population without OLT. The development of nonalcoholic fatty liver disease (NAFLD) after liver transplantation for non-NAFLD cirrhosis is also being increasingly recognized. A number of predictors have been identified as potential risk factors related to these complications. The pretransplant risk factors include immunosuppression, a higher age at transplant, male gender, a history of smoking, the pretransplant body mass index, pre-OLT diabetes, the etiology of the underlying liver disease that resulted in OLT (hepatitis C, cryptogenic cirrhosis, or alcohol), an increased donor body mass index, and marital status. Although there is an increased risk of cardiovascular events, rejection, and infection among patients with PTMS, the overall impact on long-term survival and mortality remains inconclusive. Strategies to reduce the development of metabolic syndrome after transplantation should include lifestyle modifications involving alterations in diet and increased physical activity. Additional measures that may be potentially beneficial include the use of lipid-lowering agents, the optimal control of blood glucose, and the use of tacrolimus instead of cyclosporine.
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Affiliation(s)
- Mangesh Pagadala
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
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26
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Beckebaum S, Klein C, Varghese J, Sotiropoulos GC, Saner F, Schmitz K, Gerken G, Paul A, Cicinnati VR. Renal function and cardiovascular risk profile after conversion from ciclosporin to tacrolimus: prospective study in 80 liver transplant recipients. Aliment Pharmacol Ther 2009; 30:834-42. [PMID: 19624550 DOI: 10.1111/j.1365-2036.2009.04099.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Increased risk of cardiovascular and cerebrovascular disease in liver transplant recipients results in particular from the side effects of calcineurin inhibitor-based immunosuppressive therapy. Several studies have demonstrated a more favourable outcome for patients receiving tacrolimus (TAC) as compared with ciclosporin (CS). AIM To investigate the effects of conversion from CS to TAC on cardiovascular risk factors and renal function in liver transplant recipients. METHODS In a prospective study, all except two patients had chronic kidney disease stages 2-4 (n = 80), according to estimated glomerular filtration rate using the abbreviated Modification of Diet in Renal Disease equation. RESULTS Conversion was accompanied with a mean decrease of total cholesterol from 194.6 +/- 54.0 mg/dL to 175.8 +/- 44.2 mg/dL (P < 0.001), low density lipoprotein cholesterol from 106.7 +/- 39.2 mg/dL to 90.9 +/- 28.6 mg/dL (P < 0.001) and mean arterial blood pressure values from 102.2 +/- 13.2 mm Hg to 95.9 +/- 11.7 mm Hg (P < 0.001). Renal function remained stable. No cases of de novo diabetes mellitus were identified. The Framingham risk score was significantly reduced from 5.2 +/- 4.4 at baseline to 4.4 +/- 5.3 after 12 months (P = 0.006). CONCLUSIONS Conversion from CS to TAC has been shown to improve the cardiovascular risk profile and may retard further decline of renal function after liver transplantation.
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Affiliation(s)
- S Beckebaum
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, Essen, Germany.
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27
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Abstract
Liver transplantation has become a lifesaving procedure for patients who have chronic end-stage liver disease and acute liver failure. The satisfactory outcome of liver transplantation has led to insufficient supplies of deceased donor organs, particularly in East Asia. Hence, East Asian surgeons are concentrating on developing and performing living-donor liver transplantation (LDLT). This review article describes an update on the present status of liver transplantation, mainly in adults, and highlights some recent developments on indications for transplantation, patient selection, donor and recipient operation between LDLT and deceased-donor liver transplantation (DDLT), immunosuppression, and long-term management of liver transplant recipients. Currently, the same indication criteria that exist for DDLT are applied to LDLT, with technical refinements for LDLT. In highly experienced centers, LDLT for high-scoring (>30 points) Model of End-Stage Liver Disease (MELD) patients and acute-on-chronic liver-failure patients yields comparably good outcomes to DDLT, because timely liver transplantation with good-quality grafting is possible. With increasing numbers of liver transplantations and long-term survivors, specialized attention should be paid to complications that develop in the long term, such as chronic renal failure, hypertension, diabetes mellitus, dyslipidemia, obesity, bone or neurological complications, and development of de novo tumors, which are highly related to the immunosuppressive treatment.
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Affiliation(s)
- Deok-Bog Moon
- Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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28
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Orthotopic liver transplantation and what to do during follow-up: recommendations for the practitioner. ACTA ACUST UNITED AC 2008; 6:23-36. [PMID: 19029996 DOI: 10.1038/ncpgasthep1312] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2008] [Accepted: 10/01/2008] [Indexed: 12/18/2022]
Abstract
Improvements in surgical technique and the introduction of several new immunosuppressive medications mean that outcome after orthotopic liver transplantation (OLT) has improved continuously over the past 15 years. Given the increasing longevity of patients after OLT, the recognition and prevention of long-term complications after transplantation have become ever more important. With respect to graft function, physicians responsible for the everyday care of patients following transplantation should be particularly aware of the risk of late and chronic rejection episodes and of recurrence of the underlying liver disease. The major challenge of post-transplant care is, however, how best to prevent and manage the long-term adverse effects caused by the immunosuppressive medications prescribed. Screening investigations for early diagnosis of malignancy, strict control of cardiovascular risk factors, preservation of renal function, and prevention of infections are, therefore, fundamental. This Review suggests guidelines for the management of OLT recipients to improve long-term survival, overall outcome and health-related quality of life.
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29
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Bianchi G, Marchesini G, Marzocchi R, Pinna AD, Zoli M. Metabolic syndrome in liver transplantation: relation to etiology and immunosuppression. Liver Transpl 2008; 14:1648-54. [PMID: 18975273 DOI: 10.1002/lt.21588] [Citation(s) in RCA: 177] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Excessive weight gain, hypertension, hyperlipidemia, and diabetes are frequently observed in patients having undergone liver transplantation (LTx). These alterations are probably multifactorial in origin, and cluster to generate a metabolic syndrome (MS), increasing the risk of cardiovascular events. We assessed the prevalence of MS (National Cholesterol Education Program-Adult Treatment Panel III criteria) in 296 LTx patients in the course of regular follow-up, at least 6 months after transplantation (median, 38 months). Several pre-LTx and post-LTx data were collected to identify the factors associated with the presence of MS. In a subset of 99 patients, insulin resistance was measured by the homeostasis model assessment. High blood pressure was present in 53% of cases, hyperlipidemia in 51%, high glucose in 37%, and enlarged waist circumference in 32%. Overall, MS (defined as 3 or more of the above features) was present in 44.5% of cases. Insulin resistance (homeostasis model assessment > 2.7) was observed in 41% of cases. Hypertension and hyperlipidemia were more frequent in subjects on cyclosporine than in tacrolimus-treated cases, whereas the type of immunosuppressive drug had no effect on the prevalence of diabetes, enlarged waist, and MS. In a logistic regression analysis, only pre-LTx body mass index (odds ratio, 1.20), body mass index increase (odds ratio, 1.18), and pre-LTx diabetes (odds ratio, 2.36) predicted MS; age, gender, etiology of liver disease, time from LTx, type of immunosuppressive drug, and previous hepatocellular carcinoma were removed from the model. Disorders related to MS are frequent in LTx patients, and are related to both pre-LTx conditions and to weight gain. Weight control is mandatory in LTx patients to prevent risk factors of premature atherosclerosis.
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Affiliation(s)
- Giampaolo Bianchi
- Dipartimento di Medicina Interna and Centro Trapianti di Fegato e Multiorgano, Alma Mater Studiorum, Universitá di Bologna, Bologna, Italy.
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30
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Butte JM, Devaud N, Jarufe NP, Boza C, Pérez G, Torres J, Pérez-Ayuso RM, Arrese M, Martínez J. Sleeve gastrectomy as treatment for severe obesity after orthotopic liver transplantation. Obes Surg 2008; 17:1517-9. [PMID: 18219781 DOI: 10.1007/s11695-008-9432-z] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Obesity is highly prevalent in both liver transplant candidates and recipients, and can have a significant impact on perioperative morbidity and mortality and the overall cost of transplantation. Herein, we describe an obese patient who was managed sequentially with an intragastric balloon in the pre-transplant setting and a gastric sleeve following transplantation, with good long-term results. Sleeve gastrectomy is a non-malabsorptive bariatric procedure with potential benefit for liver transplant patients due to its lack of influence on the absorption of immunosuppressive agents.
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Affiliation(s)
- Jean M Butte
- Department of Digestive Surgery, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
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31
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Liangpunsakul S, Chalasani NP. Metabolic syndrome following liver transplantation is associated with major vascular events. Liver Transpl 2007; 13:1078-9. [PMID: 17663405 DOI: 10.1002/lt.21096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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32
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Laryea M, Watt KD, Molinari M, Walsh MJ, McAlister VC, Marotta PJ, Nashan B, Peltekian KM. Metabolic syndrome in liver transplant recipients: prevalence and association with major vascular events. Liver Transpl 2007; 13:1109-14. [PMID: 17663411 DOI: 10.1002/lt.21126] [Citation(s) in RCA: 223] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Cardiac and cerebral vascular diseases are leading causes of morbidity and death in solid organ transplant recipients. Immunosuppressant drugs are associated with dyslipidemia, hypertension, and hyperglycemia, which along with obesity are the main features of metabolic syndrome. In the nontransplant population, metabolic syndrome is associated with increased risk for major vascular complications. We postulated that metabolic syndrome is common post-liver transplantation and plays a significant role leading to cardiac and cerebrovascular events. Our Multi-Organ Transplant Program database was reviewed for all liver transplant recipients between January 1998 and June 2004 with follow-up until December 2005. We adapted the 2001 National Cholesterol Education Program-Adult Treatment Panel III Guidelines to define posttransplantation metabolic syndrome (PTMS) as the presence at least 3 of the following: 1) obesity (body mass index>30 kg/m2); 2) serum triglyceride level>or=1.7 mmol/L; 3) high density lipoprotein level<1 mmol/L in men and <1.3 mmol/L in women; 4) hypertension; and 5) fasting plasma glucose>or=5.6 mmol/L. A total of 118 patients were included. Among them, 69 patients (58%) had PTMS. The mean (+/-standard deviation) time from transplant was 59+/-21 months (no significant difference in patients with or without metabolic syndrome). Overall, patients with metabolic syndrome had a significantly higher average age, posttransplantation body mass index, fasting glucose, high-density lipoprotein levels, and serum triglycerides. There was no difference in creatinine, hemoglobin, or prednisone average dose between the 2 groups. There were 25 major vascular events affecting 21% of patients. There were significantly more vascular events in patients with metabolic syndrome posttransplantation than in those without (30% vs. 8%; P=0.003) during the study period. In conclusion, the prevalence of metabolic syndrome post-liver transplant is significantly higher than that estimated in the general population. Metabolic syndrome appears to be associated with an increased risk of major vascular events in our liver transplant population.
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Affiliation(s)
- Marie Laryea
- Multi-Organ Transplant Program, Capital District Health Authority, Queen Elizabeth II Health Sciences Center, Halifax, Nova Scotia, Canada
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33
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Abstract
As survival increases after liver transplantation, common issues that arise involve immunosuppression-related complications and primary health care. Proper emphasis on the prevention and treatment of post-liver transplant complications, such as diabetes mellitus, dyslipidemia, renal dysfunction, osteoporosis, and obesity, requires careful screening and long-term surveillance to minimize the progression of these complications. Active involvement by internists and subspecialists is necessary and a multidisciplinary approach should be undertaken. Liver transplantation should be viewed as a lifelong commitment by both patient and physician.
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Affiliation(s)
- Lawrence U Liu
- Division of Liver Diseases, Department of Medicine, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1104, New York, NY 10029, USA.
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34
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Sethi A, Stravitz RT. Review article: medical management of the liver transplant recipient - a primer for non-transplant doctors. Aliment Pharmacol Ther 2007; 25:229-45. [PMID: 17217455 DOI: 10.1111/j.1365-2036.2006.03166.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Survival 10 years after orthotopic liver transplantation now approaches 65%. Consequently, community doctors must manage the metabolic and neoplastic complications of orthotopic liver transplantation in an ageing population. AIMS To review common sources of morbidity and mortality in long-term orthotopic liver transplantation recipients, and to make evidence-based recommendations regarding their management. METHODS Pertinent studies and reviews were identified by literature search through PubMed. Where evidence-based recommendations could not be gleaned from the literature, expert opinion was obtained from syllabi of national meetings. RESULTS The two most common causes of morbidity and mortality in orthotopic liver transplantation recipients are atherosclerotic vascular disease and de novo malignancy. The pathogenesis of many complications begins before orthotopic liver transplantation, and many are potentially modifiable. Most complications, however, can be directly ascribed to immunosuppressive agents. Despite improvements in our understanding of the pathogenesis and epidemiology of the metabolic and neoplastic complications of orthotopic liver transplantation, remarkably few randomized-controlled studies exist to define their optimal management. CONCLUSIONS Orthotopic liver transplantation recipients experience and succumb to the same afflictions of old age as non-transplant patients, but with greater frequency and at an earlier age. Most recommendations regarding surveillance for, and treatment of, medical complications of orthotopic liver transplantation remain based upon expert opinion rather than evidence-based medicine.
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Affiliation(s)
- A Sethi
- Section of Hepatology and Liver Transplant Program, Virginia Commonwealth University, Richmond, VA 23298-0341, USA
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Urbani L, Mazzoni A, De Simone P, Catalano G, Coletti L, Petruccelli S, Biancofiore G, Bindi L, Scatena F, Filipponi F. Avoiding calcineurin inhibitors in the early post-operative course in high-risk liver transplant recipients: The role of extracorporeal photopheresis. J Clin Apher 2007; 22:187-94. [PMID: 17294458 DOI: 10.1002/jca.20111] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The aim of this work is to report on the results of a single-center, prospective study on the feasibility of calcineurin-inhibitor (CNI)-staggered immunosuppression by use of extracorporeal photopheresis (ECP) in liver transplant (LT) recipients at risk of renal and neurological complications. Patients were matched on a 1:1 basis with historical controls on standard CNI immunosuppression. ECP patients were treated with ECP plus antimetabolites and/or steroids, while CNIs were withheld until clinically indicated. Thirty-six patients were evaluated: 18 ECP patients and 18 controls. ECP was tolerated in 100% of cases. CNI were introduced at a median of 8 days (4-55) in 17 ECP patients, while one patient was on a fully CNI-sparing regimen 22 months after LT. Acute rejection occurred in 27.7% patients in ECP (5/18) versus 16.7% in controls (3/18) (P = ns) with a shorter time to rejection in ECP (36 +/- 31.3 days vs. 83.6 +/- 65.6 days; P = ns). All rejection episodes were amenable to medical treatment. Neurological and renal complications occurred in 22.2% (4/18) of patients in either group, but led to in-hospital mortality in 3 patients among controls versus 1 in ECP (P = ns). One-, 6-, and 12-month survival rates were 94.4, 88.1, and 88.1% in ECP versus 94.4, 77.7, and 72.2% among controls (P < 0.0001). ECP seems to allow for management of high-risk LT recipients in the early post-transplant course and reduction of CNI-related mortality. Continued data validation is favored to assess the impact of ECP on long-term graft and patient survival.
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Affiliation(s)
- Lucio Urbani
- Liver Transplant Unit, Azienda Ospedaliero-Universitaria Pisana, Ospedale Cisanello, Pisa, Italy.
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Cassiman D, Roelants M, Vandenplas G, Van der Merwe SW, Mertens A, Libbrecht L, Verslype C, Fevery J, Aerts R, Pirenne J, Muls E, Nevens F. Orlistat treatment is safe in overweight and obese liver transplant recipients: a prospective, open label trial. Transpl Int 2006; 19:1000-5. [PMID: 17081230 DOI: 10.1111/j.1432-2277.2006.00379.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Obesity is a frequent complication following liver transplantation and is insufficiently responsive to dietary and life style advice. We studied the safety of orlistat treatment in obese and overweight liver transplant recipients (n = 15) on a stable tacrolimus-based immunosuppressive regimen. For safety reasons, the treatment period was restricted (6 months 120 mg t.i.d., 3 months 120 mg daily). Three patients dropped out, tacrolimus dose was adjusted in six of 12 remaining patients (dose reduction in 4, increase in 2, P = N.S.). All dose adjustments occurred during the 6 months of orlistat 120 mg t.i.d. therapy. No drug intolerance, adverse events or episodes of rejection occurred during the study. Efficacy of orlistat treatment in this population could not be shown, because a formal control population was not included in this safety trial. Moreover, only a significant decrease of waist circumference (P < 0.01 versus start of the study), but not of weight or body mass index, was achieved in the treated group. Orlistat treatment is well tolerated in liver transplant recipients and can be started safely, provided immunosuppressive drug levels and dietary adherence are closely monitored.
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Affiliation(s)
- David Cassiman
- Department of Hepatology, University Hospital Gasthuisberg, University of Leuven, Belgium.
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