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Moura AEO, Besseler MO, Pérez-de-Oliveira ME, Normando AGC, Neves ILI, Neves RS, Vargas PA, Azeka E, Santos-Silva AR, Montano TCP. Prevalence and clinical characteristics of oral lesions in heart transplant patients induced by sirolimus and everolimus: a systematic review and meta-analysis on a global scale. Oral Surg Oral Med Oral Pathol Oral Radiol 2024; 137:37-52. [PMID: 37925270 DOI: 10.1016/j.oooo.2023.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 09/24/2023] [Accepted: 09/26/2023] [Indexed: 11/06/2023]
Abstract
OBJECTIVE Sirolimus (SRL) and everolimus (EVL) are increasingly included in immunosuppressive protocols after heart transplantation. They present some side effects, including the appearance of painful lesions in the oral cavity. Therefore, this systematic review aimed to verify the global prevalence and clinical characteristics of oral lesions induced by SRL and EVL in heart transplant patients. STUDY DESIGN A systematic review was performed using 5 main electronic databases (Medline/PubMed, SCOPUS, EMBASE, Web of Science, and LILACS), in addition to the gray literature. Studies were independently assessed by 2 reviewers based on established eligibility criteria. The risk of bias was assessed using the Joanna Briggs Institute appraisal tools, and the certainty of evidence was evaluated through GRADE assessment. RESULTS Seventeen studies (860 patients) were included in the qualitative analysis. Of these, 11 studies were pooled in a meta-analysis of prevalence. The worldwide prevalence of oral lesions induced by SRL and EVL in heart transplant patients was 10.0%, and most lesions were described as ulcers >1.0 cm, related to significant pain. CONCLUSIONS Oral lesions induced by SRL and/or EVL, although not very prevalent, have a relevant impact on patient's lives and the continuity of treatment.
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Affiliation(s)
- Anne Evelyn Oliveira Moura
- Oral Diagnosis Department, Semiology and Oral Pathology Areas, Piracicaba Dental School, University of Campinas (UNICAMP), Piracicaba, São Paulo, Brazil.
| | - Mariana Oliveira Besseler
- Oral Diagnosis Department, Semiology and Oral Pathology Areas, Piracicaba Dental School, University of Campinas (UNICAMP), Piracicaba, São Paulo, Brazil
| | - Maria Eduarda Pérez-de-Oliveira
- Oral Diagnosis Department, Semiology and Oral Pathology Areas, Piracicaba Dental School, University of Campinas (UNICAMP), Piracicaba, São Paulo, Brazil
| | - Ana Gabriela Costa Normando
- Oral Diagnosis Department, Semiology and Oral Pathology Areas, Piracicaba Dental School, University of Campinas (UNICAMP), Piracicaba, São Paulo, Brazil
| | - Itamara Lucia Itagiba Neves
- Dental Unit, Instituto do Coração (InCor), Hospital das Clínicas, Medical School, University of São Paulo (HCFMUSP), São Paulo, Brazil
| | - Ricardo Simões Neves
- Dental Unit, Instituto do Coração (InCor), Hospital das Clínicas, Medical School, University of São Paulo (HCFMUSP), São Paulo, Brazil
| | - Pablo Agustin Vargas
- Oral Diagnosis Department, Semiology and Oral Pathology Areas, Piracicaba Dental School, University of Campinas (UNICAMP), Piracicaba, São Paulo, Brazil
| | - Estela Azeka
- Pediatric Cardiology Unit, Instituto do Coração (InCor), Hospital das Clínicas, Medical School, University of São Paulo (HCFMUSP), São Paulo, Brazil
| | - Alan Roger Santos-Silva
- Oral Diagnosis Department, Semiology and Oral Pathology Areas, Piracicaba Dental School, University of Campinas (UNICAMP), Piracicaba, São Paulo, Brazil
| | - Tânia Cristina Pedroso Montano
- Oral Diagnosis Department, Semiology and Oral Pathology Areas, Piracicaba Dental School, University of Campinas (UNICAMP), Piracicaba, São Paulo, Brazil; Dental Unit, Instituto do Coração (InCor), Hospital das Clínicas, Medical School, University of São Paulo (HCFMUSP), São Paulo, Brazil
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Söderlund C, Rådegran G. Immunosuppressive therapies after heart transplantation — The balance between under- and over-immunosuppression. Transplant Rev (Orlando) 2015; 29:181-9. [DOI: 10.1016/j.trre.2015.02.005] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Revised: 01/16/2015] [Accepted: 02/22/2015] [Indexed: 01/06/2023]
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Chronic renal insufficiency in heart transplant recipients: risk factors and management options. Drugs 2015; 74:1481-94. [PMID: 25134671 DOI: 10.1007/s40265-014-0274-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Renal dysfunction after heart transplantation is a frequently observed complication, in some cases resulting in significant limitation of quality of life and reduced survival. Since the pathophysiology of renal failure (RF) is multifactorial, the current etiologic paradigm for chronic kidney disease after heart transplantation relies on the concept of calcineurin inhibitor (CNI)-related nephrotoxicity acting on a predisposed recipient. Until recently, the management of RF has been restricted to the minimization of CNI dosage and general avoidance of classic nephrotoxic risk factors, with somewhat limited success. The recent introduction of proliferation signal inhibitors (PSIs) (sirolimus and everolimus), a new class of immunosuppressive drugs lacking intrinsic nephrotoxicity, has provided a completely new alternative in this clinical setting. As clinical experience with these new drugs increases, new renal-sparing strategies are becoming available. PSIs can be used in combination with reduced doses of CNIs and even in complete CNI-free protocols. Different strategies have been devised, including de novo use to avoid acute renal toxicity in high-risk patients immediately after transplantation, or more delayed introduction in those patients developing chronic RF after prolonged CNI exposure. In this review, the main information on the clinical relevance and pathophysiology of RF after heart transplantation, as well as the currently available experience with renal-sparing immunosuppressive regimens, particularly focused on the use of PSIs, is reviewed and summarized, including the key practical points for their appropriate clinical usage.
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Dickinson JM, Drummond MJ, Fry CS, Gundermann DM, Walker DK, Timmerman KL, Volpi E, Rasmussen BB. Rapamycin does not affect post-absorptive protein metabolism in human skeletal muscle. Metabolism 2013; 62:144-51. [PMID: 22959478 PMCID: PMC3680880 DOI: 10.1016/j.metabol.2012.07.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2012] [Revised: 06/22/2012] [Accepted: 07/11/2012] [Indexed: 10/27/2022]
Abstract
UNLABELLED Administration of the mTORC1 inhibitor, rapamycin, to humans blocks the increase in skeletal muscle protein synthesis in response to resistance exercise or amino acid ingestion. OBJECTIVE To determine whether rapamycin administration influences basal post-absorptive protein synthesis or breakdown in human skeletal muscle. MATERIALS/METHODS Six young (26±2 years) subjects were studied during two separate trials, in which each trial was divided into two consecutive 2 h basal periods. The trials were identical except during one trial a single oral dose (16 mg) of rapamycin was administered immediately prior to the second basal period. Muscle biopsies were obtained from the vastus lateralis at 0, 2, and 4 h to examine protein synthesis, mTORC1 signaling, and markers of autophagy (LC3B-I and LC3B-II protein) associated with each 2 h basal period. RESULTS During the Control trial, muscle protein synthesis, whole body protein breakdown (phenylalanine Ra), mTORC1 signaling, and markers of autophagy were similar between both basal periods (p>0.05). During the Rapamycin trial, these variables were similar to the Control trial (p>0.05) and were unaltered by rapamycin administration (p>0.05). Thus, post-absorptive muscle protein metabolism and mTORC1 signaling were not affected by rapamycin administration. CONCLUSIONS Short-term rapamycin administration may only impair protein synthesis in human skeletal muscle when combined with a stimulus such as resistance exercise or increased amino acid availability.
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Affiliation(s)
- Jared M. Dickinson
- Department of Nutrition and Metabolism, University of Texas Medical Branch, Galveston, TX 77555, USA
- Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Micah J. Drummond
- Department of Nutrition and Metabolism, University of Texas Medical Branch, Galveston, TX 77555, USA
- Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX 77555, USA
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Christopher S. Fry
- Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - David M. Gundermann
- Department of Nutrition and Metabolism, University of Texas Medical Branch, Galveston, TX 77555, USA
- Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Dillon K. Walker
- Department of Nutrition and Metabolism, University of Texas Medical Branch, Galveston, TX 77555, USA
- Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Kyle L. Timmerman
- Department of Nutrition and Metabolism, University of Texas Medical Branch, Galveston, TX 77555, USA
- Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX 77555, USA
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Elena Volpi
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX 77555, USA
- Department of Internal Medicine-Geriatrics, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Blake B. Rasmussen
- Department of Nutrition and Metabolism, University of Texas Medical Branch, Galveston, TX 77555, USA
- Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX 77555, USA
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX 77555, USA
- Corresponding author. University of Texas Medical Branch, Department of Nutrition and Metabolism, Division of Rehabilitation Sciences, Sealy Center on Aging, 301 University Blvd., Galveston, TX 77555-1124, USA. Tel.: +1 409 747 1619; fax: +1 409 747 1613. (B.B. Rasmussen)
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O'Reilly Zwald F, Brown M. Skin cancer in solid organ transplant recipients: advances in therapy and management: part I. Epidemiology of skin cancer in solid organ transplant recipients. J Am Acad Dermatol 2011; 65:253-261. [PMID: 21763561 DOI: 10.1016/j.jaad.2010.11.062] [Citation(s) in RCA: 160] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2010] [Revised: 11/04/2010] [Accepted: 11/06/2010] [Indexed: 12/25/2022]
Abstract
Skin cancer is the most frequent malignancy in organ transplant recipients, 95% of which are nonmelanoma skin cancer, especially squamous cell and basal cell carcinomas. This paper also discusses the incidence of other tumors (eg, melanoma, Merkel cell carcinoma, and Kaposi sarcoma) that are also increased in organ transplant patients compared to the general population. Part I of this two-part series describes the latest data concerning the epidemiologic and pathogenic aspects of nonmelanoma skin cancer development in solid organ transplant recipients. This review also highlights the concept of "field cancerization," represented by extensive areas of actinic damage and epidermal dysplasia, which accounts for increased risk of aggressive skin cancer development in susceptible patients.
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Affiliation(s)
- Fiona O'Reilly Zwald
- Department of Dermatology and Division of Transplantation, Department of Surgery, Emory University, Atlanta, Georgia.
| | - Marc Brown
- Department of Dermatology and Oncology, University of Rochester, Rochester, New York
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Dickinson JM, Fry CS, Drummond MJ, Gundermann DM, Walker DK, Glynn EL, Timmerman KL, Dhanani S, Volpi E, Rasmussen BB. Mammalian target of rapamycin complex 1 activation is required for the stimulation of human skeletal muscle protein synthesis by essential amino acids. J Nutr 2011; 141:856-62. [PMID: 21430254 PMCID: PMC3077888 DOI: 10.3945/jn.111.139485] [Citation(s) in RCA: 190] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
The relationship between mammalian target of rapamycin complex 1 (mTORC1) signaling and muscle protein synthesis during instances of amino acid surplus in humans is based solely on correlational data. Therefore, the goal of this study was to use a mechanistic approach specifically designed to determine whether increased mTORC1 activation is requisite for the stimulation of muscle protein synthesis following L-essential amino acid (EAA) ingestion in humans. Examination of muscle protein synthesis and signaling were performed on vastus lateralis muscle biopsies obtained from 8 young (25 ± 2 y) individuals who were studied prior to and following ingestion of 10 g of EAA during 2 separate trials in a randomized, counterbalanced design. The trials were identical except during 1 trial, participants were administered a single oral dose of a potent mTORC1 inhibitor (rapamycin) prior to EAA ingestion. In response to EAA ingestion, an ~60% increase in muscle protein synthesis was observed during the control trial, concomitant with increased phosphorylation of mTOR (Ser(2448)), ribosomal S6 kinase 1 (Thr(389)), and eukaryotic initiation factor 4E binding protein 1 (Thr(37/46)). In contrast, prior administration of rapamycin completely blocked the increase in muscle protein synthesis and blocked or attenuated activation of mTORC1-signaling proteins. The inhibition of muscle protein synthesis and signaling was not due to differences in either extracellular or intracellular amino acid availability, because these variables were similar between trials. These data support a fundamental role for mTORC1 activation as a key regulator of human muscle protein synthesis in response to increased EAA availability. This information will be useful in the development of evidence-based nutritional therapies targeting mTORC1 to counteract muscle wasting associated with numerous clinical conditions.
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Affiliation(s)
- Jared M. Dickinson
- Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX 77555
| | - Christopher S. Fry
- Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX 77555
| | - Micah J. Drummond
- Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX 77555,Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX 77555
| | - David M. Gundermann
- Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX 77555
| | - Dillon K. Walker
- Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX 77555
| | - Erin L. Glynn
- Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX 77555
| | - Kyle L. Timmerman
- Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX 77555,Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX 77555
| | - Shaheen Dhanani
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX 77555
| | - Elena Volpi
- Department of Internal Medicine, and University of Texas Medical Branch, Galveston, TX 77555,Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX 77555
| | - Blake B. Rasmussen
- Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX 77555,Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX 77555,To whom correspondence should be addressed. E-mail:
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Khandhar SJ, Shah HV, Shullo MA, Zomak R, Navoney M, McNamara DM, Kormos RL, Toyoda Y, Teuteberg JJ. Long-term effects on renal function of dose-reduced calcineurin inhibitor and sirolimus in cardiac transplant patients. Clin Transplant 2011; 26:42-9. [DOI: 10.1111/j.1399-0012.2011.01407.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Demirjian S, Stephany B, Abu Romeh I, Boumitri M, Yamani M, Poggio E. Conversion to sirolimus with calcineurin inhibitor elimination vs. dose minimization and renal outcome in heart and lung transplant recipients. Clin Transplant 2009; 23:351-60. [DOI: 10.1111/j.1399-0012.2009.00963.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Leet AS, Bergin PJ, Richardson M, Taylor AJ, Esmore D, Kaye DM. Outcomes following de novo CNI-free immunosuppression after heart transplantation: a single-center experience. Am J Transplant 2009; 9:140-8. [PMID: 18976296 DOI: 10.1111/j.1600-6143.2008.02456.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Renal impairment at the time of heart transplantation complicates the choice of subsequent immunosuppressive therapy. Calcineurin (CNI)-free regimens utilizing proliferation signal inhibitors (PSI) may mitigate against nephrotoxicity in this group; however, their effectiveness remains unclear. We present our 7-year experience with de novo CNI-free, PSI-based immunosuppression after heart transplantation. Of the 152 patients transplanted between July 1999 and July 2006, de novo immunosuppression regimens were 49 CNI-free, PSI-based, 88 CNI, 15 combination of CNI+PSI. Pretransplant creatinine clearance improved within 6 months in the PSI group (0.69 +/- 0.34 mL/s vs. 1.00 +/- 0.54 mL/s, p < 0.05) but not the CNI (1.32 +/- 0.54 mL/s vs. 1.36 +/- 0.53 mL/s, p = ns) or CNI+PSI (1.20 +/- 0.24 mL/s vs. 1.20 +/- 0.41 mL/s, p = ns) groups. The PSI group had more episodes of early (<or=6 months) acute rejection, bacterial or fungal infections and pleural effusions but less CMV infection (p < 0.05 for all comparisons). Early CNI addition occurred in 37% of the PSI group for acute rejection. 33% of the entire cohort changed immunosuppression regimens over 3.6 +/- 2.2 years follow-up. De novo CNI-free, PSI-based immunosuppression in patients with significant renal dysfunction allowed significant posttransplantation renal recovery but with increased early acute rejection, bacterial and fungal infections and pleural effusions.
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Affiliation(s)
- A S Leet
- Department of Cardiology, The Alfred Hospital, Melbourne, Australia.
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Zuckermann AO, Aliabadi AZ. Calcineurin-inhibitor minimization protocols in heart transplantation. Transpl Int 2009; 22:78-89. [DOI: 10.1111/j.1432-2277.2008.00771.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Surowiec D, DePestel DD, Carver PL. Concurrent Administration of Sirolimus and Voriconazole: A Pilot Study Assessing Safety and Approaches to Appropriate Management. Pharmacotherapy 2008; 28:719-29. [DOI: 10.1592/phco.28.6.719] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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