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Chowdhary P, Kale S, Kumar S, Patel M. Tacrolimus-induced nonischemic dilated cardiomyopathy in a postrenal transplant recipient - A case report. INDIAN JOURNAL OF TRANSPLANTATION 2022. [DOI: 10.4103/ijot.ijot_20_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Prosthetic Rehabilitation and Vascularized Composite Allotransplantation following Upper Limb Loss. Plast Reconstr Surg 2019; 143:1688-1701. [PMID: 31136485 DOI: 10.1097/prs.0000000000005638] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Upper limb loss is a devastating condition with dramatic physical, psychological, financial, and social consequences. Improvements in the fields of prosthetics and vascularized composite allotransplantation have opened exciting new frontiers for treatment and rehabilitation following upper limb loss. Each modality offers a unique set of advantages and limitations with regard to the restoration of hand function following amputation. METHODS Presented in this article is a discussion outlining the complex considerations and decisions encountered when determining patient appropriateness for either prosthetic rehabilitation or vascularized composite allotransplantation following upper limb loss. In this review, the authors examine how psychosocial factors, nature of injury, rehabilitation course, functional outcomes, and risks and benefits may affect overall patient selection for either rehabilitative approach. RESULTS This review summarizes the current state of the literature. Advancements in both prosthetic and biological strategies demonstrate promise with regard to facilitating rehabilitation following upper limb loss. However, there remains a dearth of research directly comparing outcomes in prosthetic rehabilitation to that following upper extremity transplantation. CONCLUSIONS Few studies have performed a direct comparison between patients undergoing vascularized composite allotransplantation and those undergoing prosthetic rehabilitation. Upper extremity transplantation and prosthetic reconstruction should not be viewed as competing options, but rather as two treatment modalities with different risk-to-benefit profiles and indications.
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Bowman LJ, Brennan DC, Delos-Santos R, LaRue SJ, Anwar S, Klein CL. Tacrolimus-Induced Cardiomyopathy in an Adult Renal Transplant Recipient. Pharmacotherapy 2015; 35:1109-16. [PMID: 26616582 DOI: 10.1002/phar.1666] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Tacrolimus-induced cardiomyopathy (TICM) is a rare but serious adverse effect of tacrolimus, which has been described primarily in pediatric non-renal transplant recipients. We describe a case of TICM in an adult renal transplant recipient that resulted in allograft dysfunction and multiple hospital admissions for heart failure exacerbation. Prompt and complete reversal of TICM occurred after tacrolimus discontinuation. Although tacrolimus-induced cardiomyopathy is reversible, availability of alternative immunosuppressants is limited, particularly in the setting of renal dysfunction. Available studies and patient-specific factors must be considered when determining an alternative maintenance immunosuppression regimen. We chose to use belatacept as alternative immunosuppression in this patient with TICM. Over the next 3 years, the patient remained free of hospital admissions and acute rejection, and demonstrated superior renal allograft function than was observed before her first heart failure admission. We believe that belatacept is an acceptable alternative to tacrolimus therapy for resolution of TICM.
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Affiliation(s)
- Lyndsey J Bowman
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Daniel C Brennan
- Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Rowena Delos-Santos
- Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Shane J LaRue
- Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Siddiq Anwar
- Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Christina L Klein
- Department of Medicine, Piedmont Transplant Institute, Atlanta, Georgia
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Lauro A, Diago Usò T, Masetti M, Di Benedetto F, Cautero N, De Ruvo N, Dazzi A, Quintini C, Begliomini B, Siniscalchi A, Ramacciato G, Risaliti A, Miller CM, Pinna AD. Liver Transplantation for Familial Amyloid Polyneuropathy Non-VAL30MET Variants: Are Cardiac Complications Influenced by Prophylactic Pacing and Immunosuppressive Weaning? Transplant Proc 2005; 37:2214-20. [PMID: 15964382 DOI: 10.1016/j.transproceed.2005.03.065] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2005] [Indexed: 11/15/2022]
Abstract
BACKGROUND Cardiac complications represent a cause of morbidity and mortality after liver transplantation among patients with familial amyloid polyneuropathy (FAP), especially for the non-VAL30MET variant types. METHODS We retrospectively evaluated 11 recipients from a nonendemic area including 90.9% affected by FAP variants. Preoperative cardiovascular symptoms were present in 81% of patients. An intraoperative pacemaker was placed prophylactically in 90.9% of all recipients. Since tacrolimus has been reported in the international literature to display cardiac toxicity, we evaluated the influence of intraoperative prophylactic pacing and rapid postoperative weaning from tacrolimus, mainly allowed by thymoglobulin on the occurrence of posttransplantation cardiac complications. RESULTS One patient received a combined heart-liver transplant, another, living donor liver transplantation. We did not observe any significant intraoperative cardiac complications. Postoperatively, the pacemaker was removed from all patients but 1. Five patients received tacrolimus and steroids; a subsequent, second group of 6 patients (54.5%) was treated with thymoglobulin followed by tacrolimus. At discharge the mean tacrolimus level was 10.6 ng/mL, whereas after 1 month it was 7.5 ng/mL. We observed a case of acute cellular rejection before discharge, which was successfully treated with intravenous steroids and OKT3. After a mean follow-up of 17.4 months (range, 1-31), 2 patients had died (18.1%): 1 due to sepsis and another, to MI. Two recipients experienced cardiac complications (18.1%), namely, the patient who died due to an myocardial infarction and a second one with a tachyarrhythmia, which was treated successfully with beta-blockers and amiodarone. CONCLUSION Prophylactic pacing and rapid weaning from immunosuppression are still associated with a significant rate of postoperative cardiac complications.
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Affiliation(s)
- A Lauro
- UO Chirurgia dei Trapianti di Fegato e Multiorgano, PAD 25-Policlinico S. Orsola-Malpighi, Universitá di Bologna, Via Massarenti 9, 40138 Bologna, Italy.
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Stewart KS, Rhim CH, Bahrain ML, Ashkezari ZD, Ozdemirli M, Fishbein TM, Johnson LB, Lu AD, Plotkin JS. Nonischemic cardiomyopathy after orthotopic liver transplantation: a report of three cases and a review of the literature. Liver Transpl 2005; 11:573-8. [PMID: 15838869 DOI: 10.1002/lt.20410] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In 2002 there were more than 5,000 liver transplantations performed in the United States. As of February 2004 there were more than 17,000 registrations for liver transplantation. As more organs are transplanted and surgical techniques improve, unique causes of morbidity and mortality will become apparent. We describe three cases of postoperative nonischemic dilated cardiomyopathy in patients who underwent orthotopic liver transplantation (OLT), one of whom underwent diagnostic myocardial biopsy. This paper will discuss the three patients, including biopsy results, and briefly review the relevant literature.
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Affiliation(s)
- Kenneth S Stewart
- Georgetown Transplant Institute, Georgetown University Medical Center, Washington, DC 20007, USA
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Abstract
This article briefly discusses the cardiac status of liver transplant recipients and their preoperative cardiac evaluation. It describes in detail perioperative and early and late postoperative complications as well as the cardiac problems associated with immunosuppression. The preoperative cardiovascular status of patients is important in determining how they cope with the stresses imposed by liver transplantation. Minor early cardiac events are common and may influence longer term cardiac morbidity. Immunosuppressive therapy may have short term effects but is likely to adversely affect long term cardiac risk.
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Hörnsten R, Wiklund U, Olofsson BO, Jensen SM, Suhr OB. Liver Transplantation Does Not Prevent the Development of Life-Threatening Arrhythmia in Familial Amyloidotic Polyneuropathy, Portuguese-Type (ATTR Val30Met) Patients. Transplantation 2004; 78:112-6. [PMID: 15257048 DOI: 10.1097/01.tp.0000133517.20972.27] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Orthotopic liver transplantation (OLT) is today the only available treatment to halt the progress of familial amyloidotic polyneuropathy (FAP). Because heart arrhythmia and conduction disturbances are well-known manifestations of FAP, the aim of this study was to investigate the occurrence and development of heart conduction and rhythm disturbances in Swedish FAP patients who underwent liver transplantation. METHODS Ambulatory 24-hour electrocardiography (ECG) recordings (Holter-ECGs) were available from 30 patients, who had been investigated before and reexamined after OLT. RESULTS.: The number of patients with abnormalities on their ECG recordings increased after OLT. Four patients developed serious arrhythmia after transplantation that necessitated the insertion of a pacemaker 40 months or longer after OLT. CONCLUSIONS The development of cardiac conduction disturbances and arrhythmias appear not to be halted by liver transplantation, indicating that the physician should be aware of the potential risk for FAP patients receiving transplants to develop fatal arrhythmia. The follow-up after liver transplantation should include Holter-ECG recordings.
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Affiliation(s)
- Rolf Hörnsten
- Department of Surgical and Perioperative Sciences, Clinical Physiology, Umeå University, Umeå, Sweden
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Therapondos G, Plevris JN, Dollinger MM, Hayes PC, Flapan AD. Cardiac hypertrophy in liver transplant recipients: tacrolimus, cyclosporine or both? Transplantation 2003; 76:446-7; author reply 447-8. [PMID: 12883220 DOI: 10.1097/01.tp.0000077419.91788.30] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Romero Tarín E, Martín Fernández M, Simarro García C, Brime Casanueva JI. [Cardiac hypertrophy in kidney transplanted female patient treated with tacrolimus]. Med Clin (Barc) 2002; 119:715. [PMID: 12459112 DOI: 10.1016/s0025-7753(02)73548-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Roberts CA, Stern DL, Radio SJ. Asymmetric cardiac hypertrophy at autopsy in patients who received FK506 (tacrolimus) or cyclosporine A after liver transplant. Transplantation 2002; 74:817-21. [PMID: 12364862 DOI: 10.1097/00007890-200209270-00015] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Cardiotoxicity has been described in a group of pediatric patients receiving FK506 as a part of immunosuppression for orthotopic liver transplantation (OLT). Information regarding the cardiac pathology related to this agent is limited. METHODS Among the first 975 liver transplants at our institution (1985-1995), autopsy hearts were available for 19 patients (14 adults and 5 children) who received FK506 for a minimum of 1 week prior to death. Patients with excessive alcohol use, significant coronary artery disease, valvular disease, diabetes mellitus, or pretransplant hypertension were excluded from analysis. We compared heart weight (HW), heart weight-to-body weight ratio (HW/BW), ventricular septal (VS) thickness with left ventricular (LV) thickness ratio (VS/LV), and cardiac histologic findings of 12 OLT patients (7 adults, 5 children) who received FK506 with a group of 75 OLT patients (48 adults, 27 children) who received Cyclosporine (CsA) and 20 (10 adults, 10 children) age-comparable control patients without OLT. RESULTS All FK506 and CsA children and adults had cardiomegaly by HW, HW/BW (P(FK506 peds) <0.024, P(CsA peds)<0.028, P(FK506 adults) <0.017, P(CsA adults)<0.006) and increased VS/LV ratio 1.25(FK506) (P <0.006) and 1.23(CsA) (P <0.006)(pediatric) and 1.09(FK506) (P <0.0122) and 1.21(CsA) (P <0.0009)(adults), compared with control. CONCLUSION Cardiomegaly by HW, HW/BW, and histology was uniformly present in both FK506 and CsA adult and pediatric OLT patients at autopsy. A relatively greater VS hypertrophy than LV was present in both transplant groups. We found no gross or histologic cardiac finding that separated these FK506 from CsA OLT patients at autopsy.
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Affiliation(s)
- Cory A Roberts
- ProPath Laboratory, Inc., Department of Pathology, St. Paul Medical Center, Dallas, Texas, USA
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Therapondos G, Flapan AD, Dollinger MM, Garden OJ, Plevris JN, Hayes PC. Cardiac function after orthotopic liver transplantation and the effects of immunosuppression: a prospective randomized trial comparing cyclosporin (Neoral) and tacrolimus. Liver Transpl 2002; 8:690-700. [PMID: 12149762 DOI: 10.1053/jlts.2002.34381] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
There are several case reports in the literature that describe cardiac complications in the first few weeks after orthotopic liver transplantation (OLT) in patients receiving tacrolimus as their primary immunosuppressive therapy. In this study, we investigated the cardiac function of patients on tacrolimus (T) compared with those on cyclosporin (C) (Neoral; Novartis, Basel, Switzerland) immunosuppression, after OLT, in a prospective randomized trial. We randomized 40 adult patients with cirrhosis to either T or C with azathioprine and prednisolone immunosuppression and followed up on them for 3 months after OLT. All had detailed clinical, biochemical, electrocardiographic and echocardiographic assessments at regular intervals. Abnormalities in cardiac function were common after OLT and significant deterioration in left ventricular diastolic function was demonstrable up to 3 months in both patient groups. Cardiac function was similar in the T and C arms and no significant electrocardiographic differences were observed, although reduced heart rate variability (HRV) and higher mean serum brain natriuretic peptide (BNP) levels were identified in the T group. The percentage increase in posterior wall thickness was higher in the T group. Cardiac dysfunction as shown by worsening echocardiographic measures of left ventricular diastolic function and by clinical cardiac events is common in the first 3 months after OLT in patients with cirrhosis. HRV and BNP values in the T group were worse than in the C group, but this was not translated to an increase in cardiac clinical events in this study.
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Affiliation(s)
- George Therapondos
- Department of Internal Medicine, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom.
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Olofsson BO, Backman C, Karp K, Suhr OB. Progression of cardiomyopathy after liver transplantation in patients with familial amyloidotic polyneuropathy, Portuguese type. Transplantation 2002; 73:745-51. [PMID: 11907421 DOI: 10.1097/00007890-200203150-00015] [Citation(s) in RCA: 109] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Transthyretin amyloidosis is today an accepted indication for orthotopic liver transplantation (OLT). For several mutations progression of the cardiomyopathy has been observed after OLT. The aim of this study was to assess the course of cardiac involvement in Swedish familial amyloidotic polyneuropathy (FAP), Portuguese type, after OLT. By comparison of the echocardiographic findings before OLT with those obtained after, the course of the heart involvement was followed. METHODS Twenty-three patients, who had undergone OLT and were examined with echocardiography 1-12 months before OLT, were available for the study. Twenty-one patients were examined 12-27 months after OLT, and 12 were re-examined 52-71 months after OLT. Two-dimensional and M-mode echocardiography were performed in accordance with the standards of the American Society of Echocardiography. RESULTS A significantly increased septal and left ventricular posterior wall thickness and a significantly increased left atrial dimension was observed at the post-OLT examinations, indicating a progression of the amyloid heart disease. This increase of the cardiac involvement was neither correlated to waiting time for OLT or to pre-operative signs of cardiomyopathy. CONCLUSIONS Even though the production of the amyloidogenic-mutated transthyretin is stopped by OLT, the cardiomyopathy may progress after the operation even for the Portuguese type of FAP. The increase of the septal and left ventricular posterior wall thickness after OLT is not restricted to patients with signs of left ventricular hypertrophy before the transplantation. The findings have important implications for the follow-up of FAP patients after OLT.
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Affiliation(s)
- Bert-Ove Olofsson
- Department of Internal Medicine, Umeå University Hospital, SE 901 85 Umeå, Sweden
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Espino G, Denney J, Furlong T, Fitzsimmons W, Nash RA. Assessment of myocardial hypertrophy by echocardiography in adult patients receiving tacrolimus or cyclosporine therapy for prevention of acute GVHD. Bone Marrow Transplant 2001; 28:1097-103. [PMID: 11803349 DOI: 10.1038/sj.bmt.1703304] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2001] [Accepted: 09/25/2001] [Indexed: 11/09/2022]
Abstract
The incidence of myocardial hypertrophy was determined in a comparative study of tacrolimus-based immunosuppression with cyclosporine-based immunosuppression for prevention of acute graft-versus-host disease (GVHD) after unrelated donor bone marrow transplantation. Patients were evaluated for clinical and echocardiographic abnormalities at baseline (prior to pretreatment conditioning and the first dose of study drug) and at 5-8 weeks after transplant when stable levels of oral tacrolimus or cyclosporine had been achieved. Left ventricular geometry and performance were assessed by echocardiography which included 2-D measurements and one Doppler measurement. Derived echocardiographic measurements and left ventricular mass index (LVMI) were also determined. A cut-off of <111 g/m(2) was used for the upper limit of normal for LVMI. Forty-four patients were included in this study (21 tacrolimus and 23 cyclosporine), of which 31 were evaluable for a comparison with both baseline and post-transplant values. There was no significant difference in the changes from baseline for mean left ventricular mass (LVM) or LVM index (LVMI) between treatment groups. Also, within the tacrolimus group there were no significant changes for these variables from baseline to post-transplant evaluations. Within the cyclosporine group there were significant increases from baseline for mean LVM (P = 0.011) and LVMI (P = 0.007). The incidence of myocardial hypertrophy (change of LVMI from <111 g/m(2) baseline to >111 g/m(2) post transplant) was 20% in the tacrolimus group and 56% in the cyclosporine group (P = 0.109). Changes in the LVMI from baseline to post baseline were greater with cyclosporine than with tacrolimus therapy, and there was no evidence that tacrolimus causes myocardial hypertrophy or significant clinical changes in adult bone marrow transplant patients. The increase in LVMI after transplant in the cyclosporine group was greater than in the tacrolimus group but was not associated with any significant clinical events.
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Affiliation(s)
- G Espino
- Clinical Research Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue N, Seattle, WA 98109-1024, USA
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Coley KC, Verrico MM, McNamara DM, Park SC, Cressman MD, Branch RA. Lack of tacrolimus-induced cardiomyopathy. Ann Pharmacother 2001; 35:985-9. [PMID: 11573873 DOI: 10.1345/aph.10299] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Hypertrophic cardiomyopathy (HCM) has been reported in pediatric transplant patients receiving tacrolimus. It is unclear whether tacrolimus is associated with HCM in adult transplant recipients. OBJECTIVE To determine the prevalence of HCM in noncardlac adult transplant patients receiving tacrolimus. METHODS A retrospective analysis of nonheart transplant recipients who received tacrolimus at our institution from January 1982 to April 1996 was conducted. Patients with left-ventricular hypertrophy (LVH) defined as a posterior or septal wall thickness > or = 1.3 cm by echocardiography (ECHO) were independently evaluated. RESULTS There were 3609 patients who met entry criteria including 2257 liver, 1333 kidney, and 19 other organ transplants. Of the 502 patients who had undergone ECHOs after transplantation, 171 had LVH. The etiology of LVH was categorized as valvular disease (36%), hypertensive disease (29%), ischemic heart disease (17%), or multifactonal (15%). There were six patients in whom, after detailed chart review, no underlying cause of LVH was evident. Five of these patients had HCM, representing an overall prevalence of 0.1% in the entire group of tacrolimus-treated patients, and 1% in patients referred for ECHO. CONCLUSIONS The prevalence of HCM in our tacrolimus-treated adult transplant population is similar to that reported in general population studies. These data suggest that tacrolimus is not a risk factor for HCM in adult transplant recipients.
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Affiliation(s)
- K C Coley
- School of Pharmacy, University of Pittsburgh, PA 15261-1909, USA.
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González MG, Hernandez-Madrid A, Sanromán AL, Monge G, De Vicente E, Barcena R. Comparison of post-liver transplantation electrocardiographic alterations between cyclosporine- and tacrolimus-treated patients. Transplant Proc 1999; 31:2423-4. [PMID: 10500652 DOI: 10.1016/s0041-1345(99)00459-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- M G González
- Servicio de Gastroenterología, Hospital Ramón y Cajal, Universidad de Alcalá de Henares, Madrid, Spain
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Pomfret EA, Lewis WD, Jenkins RL, Bergethon P, Dubrey SW, Reisinger J, Falk RH, Skinner M. Effect of orthotopic liver transplantation on the progression of familial amyloidotic polyneuropathy. Transplantation 1998; 65:918-25. [PMID: 9565095 DOI: 10.1097/00007890-199804150-00010] [Citation(s) in RCA: 103] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Familial amyloidotic polyneuropathy (FAP) is an autosomal dominant inherited disease associated with a mutant form of the protein transthyretin (TTR). It is characterized clinically by the systemic deposition of amyloid fibrils resulting in organ dysfunction and, ultimately, death. The majority of TTR is produced in the liver, and transplantation of the liver has been shown to ameliorate this source of mutant TTR, arresting the progression of this fatal disease. METHODS Thirteen patients with FAP have undergone successful liver transplant surgery at our center since 1992. The impact of liver transplantation on amyloid-related polyneuropathy, cardiovascular, and gastrointestinal dysfunction is reported in this study. Three patients who died before cardiovascular and neurological follow-up are excluded from the analysis. RESULTS Ten of 13 patients (77%) remain alive an average of 49 months (range, 17-64 months) after transplantation. Three patients suffered sudden death, with autopsy documentation of amyloid deposits involving the conduction system of the heart. Liver transplantation was performed more quickly, required less blood, and a shorter postoperative hospital stay in these patients, compared with patients with cirrhosis. Neurological and nutritional symptoms improved in the majority of affected patients. Those patients with echocardiographic evidence of ventricular wall and valve thickening before transplantation progressed postoperatively despite neurologic improvement. CONCLUSIONS Liver transplantation offers the only cure for the genetic defect causing FAP and appears to result in subjective and objective improvement in neurological dysfunction. Patients with preexisting cardiovascular abnormalities progress despite transplantation; therefore, consideration for combined heart-liver transplantation may be warranted in this subset of patients.
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Affiliation(s)
- E A Pomfret
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Affiliation(s)
- S V McDiarmid
- Department of Pediatrics, UCLA Medical Center 90095-1752, USA
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Dubrey SW, Davidoff R, Skinner M, Bergethon P, Lewis D, Falk RH. Progression of ventricular wall thickening after liver transplantation for familial amyloidosis. Transplantation 1997; 64:74-80. [PMID: 9233704 DOI: 10.1097/00007890-199707150-00014] [Citation(s) in RCA: 145] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Familial amyloidosis (FAP) is characterized by the progression of neurologic and cardiac impairment ultimately leading to death within 7 to 15 years after the onset of the disease. Liver transplantation represents the only definitive therapy for this disease and has been performed since 1990. METHODS To determine the effect of liver transplantation on disease progression, electrocardiography and Doppler echocardiography were performed and blindly analyzed on 11 patients with FAP who were followed 0.8 to 8.6 years before liver transplantation and 0.8 to 4.1 years after liver transplantation. RESULTS; After liver transplantation, five patients showed progression of left ventricular wall thickening with increased left ventricular mass, and three of these five showed a reduction in electrocardiographic voltage despite abolition of the mutant protein from the serum. Of the five patients showing progressive wall thickening, four had the transthyretin variant Glu 42 Gly and one patient had the Ala 36 Pro variant; none of the remaining six patients, all of whom possessed the Val 30 Met variant, showed echocardiographic changes. Although 9 of the 11 patients have shown symptomatic improvement in neurologic symptoms, 1 patient has developed heart failure and a second patient has suffered a sudden cardiac death. CONCLUSIONS After liver transplantation, patients with FAP should have regular clinical evaluations including electrocardiographic and echocardiographic examinations to look for continued deterioration in heart structure or function.
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Affiliation(s)
- S W Dubrey
- Department of Medicine, Boston University School of Medicine, Massachusetts 02118, USA
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Sawabe T, Mizuno S, Gondo H, Maruyama T, Niho Y. Sinus arrest during tacrolimus (FK506) and digitalis treatment in a bone marrow transplant recipient. Transplantation 1997; 64:182-3. [PMID: 9233725 DOI: 10.1097/00007890-199707150-00035] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Mrvos R, Hodgman M, Krenzelok EP. Tacrolimus (FK 506) overdose: a report of five cases. JOURNAL OF TOXICOLOGY. CLINICAL TOXICOLOGY 1997; 35:395-9. [PMID: 9204100 DOI: 10.3109/15563659709043372] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Tacrolimus (FK 506), a potent anti-T cell agent, has been shown to be effective in preventing the rejection of transplanted organs. Published research on tacrolimus has focused on effects associated with therapeutic use. Virtually no literature addresses the acute toxicity or the management of tacrolimus overdose. We report five cases of acute overdose with tacrolimus. CASE REPORTS A 2-year-old female with no prior medical history ingested 10 mg of tacrolimus. She remained asymptomatic. A 2-year-old female with a history of multiple visceral organ transplants ingested 11 mg of her tacrolimus. She was admitted to the hospital and activated charcoal was administered. Her renal function was monitored and no changes were noted in a 24 h period. She was discharged. A 29-year-old male renal transplant patient took 150 mg of tacrolimus. He recovered with only a minimal creatinine elevation. A 23-year-old heart and lung transplant patient ingested 375 mg of tacrolimus. She had no effects from the overdose. A 34-year-old female experienced an acute/chronic overdose of 7-9 mg and remained asymptomatic. DISCUSSION Tacrolimus is a neutral macrolide antibiotic that is extracted from the fermentation broth of the soil fungus Streptomyces tsukubaensis. Chronic oral dosing has been associated with numerous side effects. Although these patients ingested significant doses of tacrolimus, they suffered few toxic manifestations associated with tacrolimus. CONCLUSION Little information is available regarding acute tacrolimus overdosage. In this small series of patients, tacrolimus did not produce acute physiologic incapacitation.
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Affiliation(s)
- R Mrvos
- Pittsburgh Poison Center, Children's Hospital of Pittsburgh, PA 15213, USA.
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