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Marfella R, Amarelli C, Cacciatore F, Balestrieri ML, Mansueto G, D'Onofrio N, Esposito S, Mattucci I, Salerno G, De Feo M, D'Amico M, Golino P, Maiello C, Paolisso G, Napoli C. Lipid Accumulation in Hearts Transplanted From Nondiabetic Donors to Diabetic Recipients. J Am Coll Cardiol 2020; 75:1249-1262. [PMID: 32192650 DOI: 10.1016/j.jacc.2020.01.018] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 12/30/2019] [Accepted: 01/07/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Early pathogenesis of diabetic cardiomyopathy (DMCM) may involve lipotoxicity of cardiomyocytes in the context of hyperglycemia. There are many preclinical studies of DMCM pathogenesis, but the human evidence is still poorly understood. OBJECTIVES By using a nondiabetic mellitus (non-DM) heart transplanted (HTX) in diabetes mellitus (DM) recipients, this study conducted a serial study of human heart transplant recipients evaluating cardiac effects of diabetic milieu (hyperglycemia and insulin resistance) on lipotoxic-mediated injury. We evaluated cardiomyocyte morpho-pathology by seriated biopsies of healthy implanted hearts in DM recipients during 12-month follow-up from HTX. Because metformin reduces ectopic lipid accumulation, we evaluated the effects of the drug in a nonrandomized subgroup. METHODS The DMCM-AHEAD (Diabetes and Lipid Accumulation and Heart Transplant) prospective ongoing study (NCT03546062) evaluated 158 first HTX recipients (82 non-DM, 76 DM of whom 35 [46%] were receiving metformin). HTX recipients were undergoing clinical standard evaluation (metabolic status, echocardiography, coronary computed tomography angiography, and endomyocardial biopsies). Biopsies evaluated immune response, Oil Red-O staining, ceramide, and triacylglycerol levels. Lipotoxic factors and insulin resistance were evaluated by reverse transcriptase-polymerase chain reaction. RESULTS There was a significant early and progressive cardiomyocyte lipid accumulation in DM but not in non-DM recipients (p = 0.019). In the subgroup receiving metformin, independently from immunosuppressive therapy that was similar among groups, lipid accumulation was reduced in comparison with DM recipients not receiving the drug (hazard ratio: 6.597; 95% confidence interval: 2.516 to 17.296; p < 0.001). Accordingly, lipotoxic factors were increased in DM versus non-DM recipients, and, relevantly, metformin use was associated with fewer lipotoxic factors. CONCLUSIONS Early pathogenesis of human DMCM started with cardiomyocyte lipid accumulation following HTX in DM recipients. Metformin use was associated with reduced lipid accumulation independently of immunosuppressive therapy. This may constitute a novel target for therapy of DMCM.
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Affiliation(s)
- Raffaele Marfella
- Department of Advanced Medical and Surgical Sciences (DAMSS), University of Campania "Luigi Vanvitelli," Naples, Italy.
| | - Cristiano Amarelli
- Unit of Cardiac Surgery and Transplants, AORN Ospedali dei Colli-Monaldi Hospital, Naples, Italy
| | - Francesco Cacciatore
- Department of Translational Medical Sciences, Federico II University of Naples, Naples, Italy
| | | | - Gelsomina Mansueto
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Nunzia D'Onofrio
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli," Naples, Italy
| | | | - Irene Mattucci
- Cardiology Division, University "Luigi Vanvitelli," Monaldi Hospital, Naples, Italy
| | - Gemma Salerno
- Cardiology Division, University "Luigi Vanvitelli," Monaldi Hospital, Naples, Italy
| | - Marisa De Feo
- Department of Cardio-Thoracic Sciences, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Michele D'Amico
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Paolo Golino
- Cardiology Division, University "Luigi Vanvitelli," Monaldi Hospital, Naples, Italy
| | - Ciro Maiello
- Unit of Cardiac Surgery and Transplants, AORN Ospedali dei Colli-Monaldi Hospital, Naples, Italy
| | - Giuseppe Paolisso
- Department of Advanced Medical and Surgical Sciences (DAMSS), University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Claudio Napoli
- Department of Advanced Medical and Surgical Sciences (DAMSS), University of Campania "Luigi Vanvitelli," Naples, Italy; IRCCS-SDN, Naples, Italy
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Impact of Rabbit Antithymocyte Globulin Dose on Long-term Outcomes in Heart Transplant Patients. Transplantation 2016; 100:685-93. [PMID: 26457604 DOI: 10.1097/tp.0000000000000950] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Optimal dosing strategies have not been established for rabbit antithymocyte globulin (rATG) after heart transplantation, and there is currently wide variability in rATG regimens with respect to both dose and duration. METHODS In a retrospective, single-center analysis, 523 patients undergoing heart transplantation during 1996 to 2009 were stratified by cumulative rATG dose: less than 4.5 mg/kg (group A), 4.5 to 7.5 mg/kg (group B) or greater than 7.5 mg/kg (group C). RESULTS Survival at 1 year after transplantation was 80% in group A, 90% in group B, and 88% in group C (P = 0.062). Incidence of acute rejection per 1000 patient-years was significantly higher in group A (hazards ratio [HR], 54.8; 95% confidence interval [95% CI], 33.9-83.8) compared to groups B (19.6; 95% CI, 11.4-31.4) and C (23.6; 95% CI, 17.5-31.3). Incidence of severe infection 10 years after transplantation was higher in group C (45%) than groups A (37%) or B (23%) (P < 0.001); cytomegalovirus infection rates were 35%, 20% and 23%, respectively (P = 0.009). Multivariable Cox regression showed an HR of 0.51 (95% CI, 0.25-1.02) for acute rejection with group B versus group A, and 0.54 (95% CI, 0.33-0.88; P = 0.013) for severe infection. The rate of malignancy per 1000 patient-years was higher in groups B (13.85) and C (14.95) than group A (7.83). CONCLUSIONS These retrospective data suggest that a cumulative rATG dose of 4.5 to 7.5 mg/kg may offer a better risk-benefit ratio than lower or higher doses, with acceptable rates of infection and posttransplant malignancy. Prospective trials are needed.
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Durante-Mangoni E, Andini R, Pinto D, Iossa D, Molaro R, Agrusta F, Casillo R, Grimaldi M, Utili R. Effect of the immunosuppressive regimen on the incidence of cytomegalovirus infection in 378 heart transplant recipients: A single centre, prospective cohort study. J Clin Virol 2015; 68:37-42. [DOI: 10.1016/j.jcv.2015.04.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 04/17/2015] [Accepted: 04/21/2015] [Indexed: 01/24/2023]
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Gharekhani A, Entezari-Maleki T, Dashti-Khavidaki S, Khalili H. A review on comparing two commonly used rabbit anti-thymocyte globulins as induction therapy in solid organ transplantation. Expert Opin Biol Ther 2013; 13:1299-313. [PMID: 23875884 DOI: 10.1517/14712598.2013.822064] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Two rabbit anti-thymocyte globulins (ATGs) (Thymoglobulin™ and ATG-Fresenius (ATG-F)™) have been used commonly for induction immunosuppression and treatment of acute rejection in solid organ transplantation. Therefore, literature review on comparative efficacy and side-effect profile of them would be of clinical interest. AREAS COVERED This review evaluated all comparative studies in English language, focusing on the solid organ transplant patients who received Thymoglobulin or ATG-F as induction therapy. This review concluded that compared to ATG-F, Thymoglobulin possibly provides better protection against acute rejection and improves patient and graft survival but may result in more cytomegalovirus infection and post-transplant malignancy. Thymoglobulin produced more leukocyte depletion with a greater delay to recover, while ATG-F had more reduction effects on platelet and erythrocyte counts with an increased need to erythropoiesis-stimulating agent. EXPERT OPINION The benefits of induction therapy with ATGs must be weighed against the costs and post-transplant complications. It is suggest that there is no substantial clinical difference between these two rabbit ATGs and each may be considered as induction therapy for solid organ transplantation based on availability and drug cost. Of special importance is adding antiviral therapy to the treatment regimen of patients who receive ATGs as induction therapy.
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Affiliation(s)
- Afshin Gharekhani
- Tehran University of Medical Sciences, Faculty of Pharmacy, Tehran, Iran
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Oliveira-Braga KA, Nepomuceno NA, Correia AT, Jatene FB, Pêgo-Fernandes PM. Effects of prednisone on mucociliary clearance in a murine model. Transplant Proc 2013; 44:2486-9. [PMID: 23026626 DOI: 10.1016/j.transproceed.2012.07.053] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
All transplant patients are at increased risk of developing pulmonary infections, a significant cause of morbidity and mortality. Immunosuppressants increase the incidence of lung infection by acting not only directly on the inflammatory cells, but also on the native immune system. Experimental studies have shown corticosteroid therapy, which is used in most immunosuppressive protocols after transplantation, to suppress mucus production by inhibiting calceiform. The objective of this study was to evaluate the effects of prednisone on mucociliary clearance. A total of 120 male Wistar rats were distributed into 4 groups. Animals in P1, P2, and P3 groups received daily doses of prednisone (0.625, 1.25, and 2.5 mg/kg/d), and hosts in the Sal group underwent gavage with saline solution (2.5 mL/d). After 7, 15, and 30 days, treatment, animals were killed. We assessed ciliary beating frequency (CBF), mucociliary transport velocity (MCTV), and mucus transportability (MT). There was no significant difference for CBF regarding dose (P = .089) or treatment duration (P = .175). MCTV values of 0.60 ± 0.14 in group P1, 0.59 ± 0.13 in group P2, 0.51 ± 0.19 in group P3, and 0.61 ± 0.08 Group Sal, showed P3 to significantly differ from P1 (P = .048) and Sal (P = .007) groups. Regardless of the prednisone dose, all groups displayed impaired MT compared with the Sal group: P1 (P = .02); P2 (P = .02) P3 (P = .03). There was no interaction between the therapy and the treatment time for CBF (P = .10), MCTV (P = .71), and MT (P = .64). Prednisone reduced the transportability of mucus even when administered at low doses; however, this change was not sufficient to alter the mucociliary clearance. Only high doses of prednisone impaired mucociliary clearance.
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Affiliation(s)
- K A Oliveira-Braga
- Laboratory of Thoracic Surgery Research, Heart Institute (InCor), Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
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Marks WH, Ilsley JN, Dharnidharka VR. Posttransplantation lymphoproliferative disorder in kidney and heart transplant recipients receiving thymoglobulin: a systematic review. Transplant Proc 2011; 43:1395-404. [PMID: 21693205 DOI: 10.1016/j.transproceed.2011.03.036] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2011] [Accepted: 03/09/2011] [Indexed: 01/04/2023]
Abstract
Posttransplantation lymphoproliferative disorder (PTLD) is an important complication of transplantation. Risk factors include increased overall immunosuppression exposure and inadequate antiviral prophylaxis; however, the effects of T-cell-depleting agents on PTLD are unclear. A systematic literature review was conducted to assess PTLD in clinical studies published 1999-2009 in transplant patients with ≥ 3 years follow-up who received Thymoglobulin for induction. Twenty studies were identified (12 kidney, 7 heart, and 1 liver), of which 3 were excluded for insufficient PTLD reporting. The final study group comprised 2,246 kidney and heart transplant recipients (liver study excluded) who received Thymoglobulin. At a median follow-up of 5 years, the incidence of PTLD was 0.98% (kidney, 0.93%; heart, 1.05%) among Thymoglobulin-treated patients. The cumulative Thymoglobulin dose reported in these studies was not associated with the development of PTLD (P = NS). However, incidence of PTLD was significantly lower with antiviral prophylaxis (0.63%) than without (1.87%; P = .013). Heart transplant recipients not receiving antiviral prophylaxis had the highest PTLD incidence, possibly attributable to a greater overall immunosuppressive burden. This analysis revealed that PTLD incidences in kidney and heart transplant recipients receiving Thymoglobulin were low overall and perhaps related more to concomitant anti-viral prophylaxis use.
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Affiliation(s)
- W H Marks
- Department of Organ Transplantation, Swedish Medical Center, Seattle, Washington, USA
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Antithymocyte Globulin Induction Therapy in Heart Transplantation: Prospective Randomized Study of High vs Standard Dosage. Transplant Proc 2010; 42:3679-87. [DOI: 10.1016/j.transproceed.2010.06.036] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2009] [Revised: 01/25/2010] [Accepted: 06/18/2010] [Indexed: 01/24/2023]
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Watanabe A, Carraro E, Kamikawa J, Leal É, Granato C, Bellei N. Rhinovirus species and their clinical presentation among different risk groups of non-hospitalized patients. J Med Virol 2010; 82:2110-5. [DOI: 10.1002/jmv.21914] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Opportunistic Infections in Heart Transplant Patients. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2010. [DOI: 10.1097/ipc.0b013e3181e9b7e8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Waid TH, Thompson JS, Siemionow M, Brown SA. T10B9 monoclonal antibody: a short-acting nonstimulating monoclonal antibody that spares gammadelta T-cells and treats and prevents cellular rejection. DRUG DESIGN DEVELOPMENT AND THERAPY 2009; 3:205-12. [PMID: 19920935 PMCID: PMC2769243 DOI: 10.2147/dddt.s2750] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
T10B9.1A-31/MEDI-500 is a nonmitogenic immunoglobulin M kappa murine monoclonal antibody (mAb) directed against the alpha-beta (αβ) heterodimer of the T-lymphocyte receptor complex. The hybridoma was first produced by fusing spleen cells from BALB/C mice immunized with human peripheral blood T-lymphocytes with SP2/O-Ag14 mutant myeloma cells. The mAb is produced and purified using multistep ion exchange and molecular sieve chromatography protocols. T10B9 has been used successfully to treat acute cellular rejection in renal transplantation and as an immunosuppression induction agent in heart and simultaneous kidney-pancreas transplantation. Because T10B9 is nonmitogenic and causes minimal cytokine release, both treatment of rejection and induction of immunosuppression were accomplished with significantly fewer and milder untoward effects (cytokine release syndrome) than its comparator OKT3. Since T10B9 is directed against the αβ heterodimer of the CD3 epitope, it spares the gamma delta (γδ) region. These gamma delta (γδ) T cells have a unique role in the immune response controlling many serious human diseases and perhaps facilitating the development of immunologic tolerance. T10B9 has a relatively short duration of action, depleting T cells for only 10 to 14 days, unlike the protracted depletion seen with thymoglobulin and Campath-1H. There is no B-lymphocyte depletion with T10B9 as there is with both of the aforementioned reagents. The lack of prolonged lymphocyte depletion may account for less infection observed with T10B9 treatment.
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Affiliation(s)
- Thomas H Waid
- Department of Internal Medicine, University of Kentucky, Lexington, Kentucky, USA.
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Fisher RA. Cytomegalovirus infection and disease in the new era of immunosuppression following solid organ transplantation. Transpl Infect Dis 2009; 11:195-202. [PMID: 19228345 DOI: 10.1111/j.1399-3062.2009.00372.x] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
As the most prevalent pathogen among transplant patients, cytomegalovirus (CMV) affects up to three-quarters of all solid organ transplant recipients. While we have made great strides in preventing CMV infection and disease in the early post-transplant period, late CMV infection and indirect effects due to viral immunomodulation remain problematic. Changing immunosuppression practices, including the increasing use of T-cell depleting induction antibodies, have the potential to affect the risk for CMV infection and disease, even in the face of good prophylactic and preemptive therapy. The purpose of this review article is to discuss the impact of CMV infection on long-term allograft outcomes and to re-evaluate the risks and management strategies for prevention of CMV in the framework of evolving modern immunosuppressive strategies.
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Affiliation(s)
- R A Fisher
- VCU Department of Surgery, Division of Transplantation Surgery, Virginia Commonwealth University, Richmond, Virginia 23298, USA.
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Goland S, Czer LS, Coleman B, De Robertis MA, Mirocha J, Zivari K, Schwarz ER, Kass RM, Trento A. Induction Therapy With Thymoglobulin After Heart Transplantation: Impact of Therapy Duration on Lymphocyte Depletion and Recovery, Rejection, and Cytomegalovirus Infection Rates. J Heart Lung Transplant 2008; 27:1115-21. [DOI: 10.1016/j.healun.2008.07.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2008] [Revised: 05/17/2008] [Accepted: 07/01/2008] [Indexed: 11/26/2022] Open
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Hamour IM, Lyster HS, Burke MM, Rose ML, Banner NR. Mycophenolate Mofetil May Allow Cyclosporine and Steroid Sparing in De Novo Heart Transplant Patients. Transplantation 2007; 83:570-6. [PMID: 17353776 DOI: 10.1097/01.tp.0000253883.52525.7c] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Mycophenolate mofetil (MMF) provides superior prophylaxis against acute rejection when compared with azathioprine (AZA) in heart and renal transplantation. However, it remains unclear whether this results in improved survival or reduced morbidity after heart transplantation. METHOD In a sequential study, 240 cardiac transplant patients were treated with either MMF (n=119) or AZA (n=121) both in combination with cyclosporine and corticosteroids after rabbit antithymocyte globulin induction. RESULTS By protocol lower cyclosporine levels were targeted in the MMF group during the first year (e.g. 203+/-52 ng/mL MMF vs. 236+/-59 ng/mL AZA, P=0.0006 at 6 months). Patient survival at 1 year (82% MMF vs. 79% AZA, P=0.55) and at 3 years was similar in both groups. The cumulative probability of receiving antirejection treatment within 1 year was lower in the MMF group, as was biopsy-proven acute rejection with International Society of Heart and Lung Transplantation grade > or =3A (24% vs. 35%, P=0.03). The MMF group also had fewer episodes requiring cytolytic therapy (6% vs. 13%, P=0.04) and more patients had steroids withdrawn by 1 year (66% vs. 32%, P<0.001). Renal function was better in the MMF group with lower creatinine levels at 1 year (133+/-45 vs. 155+/-46 micromol/L, P=0.0004). Calculated creatinine clearance (Cockcroft and Gault formula) at 1 year was also better (MMF 74+/-32 mL/min vs. AZA 62+/-24 mL/min, P=0.004). CONCLUSION Our results suggest that immunosuppression with MMF rather than AZA may allow lower cyclosporine levels, better renal function, and increased steroid weaning at 1 year while also achieving better control of acute rejection.
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Affiliation(s)
- Iman M Hamour
- Cardiology and Transplantation Unit, The Royal Brompton and Harefield NHS Trust, Harefield Hospital, Harefield, Middlesex, UK
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