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Wagner SJ, Turek JW, Maldonado J, Staron M, Edens RE. Less Is More in Post Pediatric Heart Transplant Care. Ann Thorac Surg 2018; 107:165-171. [PMID: 30071234 DOI: 10.1016/j.athoracsur.2018.06.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 05/24/2018] [Accepted: 06/15/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Historically, steroids and endomyocardial biopsies have, respectively, been part of standard immunosuppression for preventing cardiac transplant rejection and monitoring for rejection. However, these treatments come with numerous adverse effects. Some transplant programs have questioned whether the risks and costs outweigh the benefits or whether they may interfere with patient outcomes. METHODS Pediatric cardiac transplantations over 15 years (n = 49) were examined in a single-center retrospective study. Two groups of patients were formed: group 1 received induction steroids and underwent routine protocol biopsy (n = 18), and group 2 neither received steroids nor underwent routine biopsy (n = 13). RESULTS The 1-year survival rate was similar between the two approaches: group 1 survival was 94% and group 2 survival was 92%. However, differences between the two groups were observed for comorbidities. Group 1 had 11 patients that exhibited rejection, and group 2 had only 1 patient (p = 0.003). Group 2 had fewer cases of posttransplant hypertension (p = 0.001) and insulin dependence (p = 0.02). CONCLUSIONS This study suggests a less-invasive posttransplant approach that avoids biopsies and steroids was safely implemented in this single center. Both groups had similar survival. However, group 2 had statistically significant less posttransplant rejection, hypertension, and diabetes. Overall, this study shows no increased risk associated with steroid and biopsy avoidance in posttransplant patients, but with some clear benefits.
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Affiliation(s)
- Samantha J Wagner
- Department of Pediatrics, Stead Family Children's Hospital, University of Iowa, Iowa City, Iowa
| | - Joseph W Turek
- Department of Surgery, Stead Family Children's Hospital, University of Iowa, Iowa City, Iowa
| | - Jennifer Maldonado
- Department of Pediatrics, Stead Family Children's Hospital, University of Iowa, Iowa City, Iowa
| | - Michelle Staron
- Department of Pediatrics, Stead Family Children's Hospital, University of Iowa, Iowa City, Iowa
| | - R Erik Edens
- Department of Pediatrics, Stead Family Children's Hospital, University of Iowa, Iowa City, Iowa.
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Keating BJ, Pereira AC, Snyder M, Piening BD. Applying genomics in heart transplantation. Transpl Int 2018; 31:278-290. [PMID: 29363220 PMCID: PMC5990370 DOI: 10.1111/tri.13119] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 11/18/2017] [Accepted: 01/17/2018] [Indexed: 12/13/2022]
Abstract
While advances in patient care and immunosuppressive pharmacotherapies have increased the lifespan of heart allograft recipients, there are still significant comorbidities post-transplantation and 5-year survival rates are still significant, at approximately 70%. The last decade has seen massive strides in genomics and other omics fields, including transcriptomics, with many of these advances now starting to impact heart transplant clinical care. This review summarizes a number of the key advances in genomics which are relevant for heart transplant outcomes, and we highlight the translational potential that such knowledge may bring to patient care within the next decade.
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Affiliation(s)
- Brendan J. Keating
- Division of Transplantation, Department of Surgery, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA, USA
| | - Alexandre C. Pereira
- Laboratory of Genetics and Molecular Cardiology, Heart Institute (InCor), University of São Paulo Medical School Hospital, São Paulo, Brazil
| | - Michael Snyder
- Department of Genetics, Stanford University, Stanford, CA, USA
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Terzi A, Sezgin A, Tunca Z, Deniz E, Ayva EŞ, Haberal Reyhan N, Müderrisoğlu H, Özdemir BH. A single-center retrospective clinicopathologic study of endomyocardial biopsies after heart transplant at Baskent University Hospital in Ankara, 1993-2014. EXP CLIN TRANSPLANT 2015; 13 Suppl 1:346-51. [PMID: 25894188 DOI: 10.6002/ect.mesot2014.p197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES The purpose of this study was to investigate the frequency and prognostic importance of acute cellular rejection after heart transplant. MATERIALS AND METHODS All 84 heart transplant patients at our center from January 1993 to January 2014, including all 576 endomyocardial biopsies, were evaluated with retrospective review of clinical records and endomyocardial biopsies. Routine and clinically indicated endomyocardial biopsies after heart transplant were graded for acute cellular rejection (2005 International Society for Heart and Lung Transplantation Working Formulation). Survival analysis was performed using Kaplan-Meier method. RESULTS There were 61 male (73%) and 23 female recipients. Median age at heart transplant was 29 years (range, 1-62 y). Posttransplant early mortality rate was 17.9% (15 patients). In the other 69 patients, 23 patients died and 46 patients (66.7%) were alive at mean 69.3 ± 7.2 months after heart transplant. Mean follow-up was 35.4 ± 29.8 months (range, 0.07-117.5 mo). Mean 8.4 ± 4.2 endomyocardial biopsies (range, 1-19 biopsies) were performed per patient. Median first biopsy time was 7 days (range, 1-78 d). The frequency of posttransplant acute cellular rejection was 63.8% (44 of 69 patients) by histopathology; 86% patients experienced the first episode of acute cellular rejection within 6 months after transplant. There were 18 patients with acute cellular rejection ≥ grade 2R on ≥ 1 endomyocardial biopsy in 44 patients with acute cellular rejection. No significant difference was observed between survival rates of patients with grade 1R or ≥ grade 2R acute cellular rejection, or between survival rates of patients with or without diagnosis of any grade of acute cellular rejection. Acute cellular rejection was not related to any prognostic risk factor. CONCLUSIONS Acute cellular rejection had no negative effect on heart recipient long-term survival, but it was a frequent complication after heart transplant, especially within the first 6 months.
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Affiliation(s)
- Ayşen Terzi
- From the Department of Pathology, Başkent University Medical School, Ankara, Turkey
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Bader F, Islam N, Mehta N, Worthen N, Ishihara S, Stehlik J, Gilbert E, Litwin S. Noninvasive Diagnosis of Cardiac Allograft Rejection Using Echocardiography Indices of Systolic and Diastolic Function. Transplant Proc 2011; 43:3877-81. [DOI: 10.1016/j.transproceed.2011.09.039] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2011] [Accepted: 09/03/2011] [Indexed: 12/01/2022]
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Pretransplant predictors of posttransplant adherence and clinical outcome: an evidence base for pretransplant psychosocial screening. Transplantation 2009; 87:1497-504. [PMID: 19461486 DOI: 10.1097/tp.0b013e3181a440ae] [Citation(s) in RCA: 158] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION There is growing awareness, yet scant prospective evidence that pretransplant (TX) psychosocial factors may predict post-TX outcome. We examined which pre-TX psychosocial factors predict post-TX nonadherence with immunosuppression (NA) and clinical outcomes in heart, liver, and lung TX. METHODOLOGY We prospectively followed 141 patients (28 heart, 61 liver, and 52 lung) from pre-TX until 1 year post-TX. Multivariable analyses determined which pre-TX factors (i.e., anxiety, depression, personality traits, social support, adherence with medication, and smoking status) predict poor post-TX outcome (i.e., NA, late acute rejection, graft loss, and resource utilization), controlling for medical predictors of poor outcome. RESULTS Pre-TX self-reported medication nonadherence (odds ratio [OR]=7.9), lower received social support (OR=0.9), a higher education (OR=2.7), and lower "conscientiousness" (OR=0.8) were independent predictors of post-TX NA. Not living in a stable relationship predicted graft loss (OR=4.9). Pre-TX medication NA was the only predictor for presence of late acute rejection (OR=4.4). No other pre-TX predictors for poor outcome could be found. CONCLUSION This is the first prospective study demonstrating that selected pre-TX psychosocial factors predict post-TX NA and poor clinical outcome, implying that pre-TX screening should include this set of factors in addition to traditional medical criteria.
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Podichetty AK, Wagner S, Schröer S, Faust A, Schäfers M, Schober O, Kopka K, Haufe G. Fluorinated Isatin Derivatives. Part 2. New N-Substituted 5-Pyrrolidinylsulfonyl Isatins as Potential Tools for Molecular Imaging of Caspases in Apoptosis. J Med Chem 2009; 52:3484-95. [DOI: 10.1021/jm8015014] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Anil K. Podichetty
- Organisch-Chemisches Institut and International NRW Graduate School of Chemistry, Westfälische Wilhelms-Universität, Corrensstrasse 40, D-48149 Münster, Germany, Klinik und Poliklinik für Nuklearmedizin, Universitätsklinikum Münster, Albert-Schweitzer-Strasse 33, D-48129 Münster, Germany, European Institute of Molecular Imaging, Westfälische Wilhelms-Universität, Mendelstrasse 11, D-48149 Münster
| | - Stefan Wagner
- Organisch-Chemisches Institut and International NRW Graduate School of Chemistry, Westfälische Wilhelms-Universität, Corrensstrasse 40, D-48149 Münster, Germany, Klinik und Poliklinik für Nuklearmedizin, Universitätsklinikum Münster, Albert-Schweitzer-Strasse 33, D-48129 Münster, Germany, European Institute of Molecular Imaging, Westfälische Wilhelms-Universität, Mendelstrasse 11, D-48149 Münster
| | - Sandra Schröer
- Organisch-Chemisches Institut and International NRW Graduate School of Chemistry, Westfälische Wilhelms-Universität, Corrensstrasse 40, D-48149 Münster, Germany, Klinik und Poliklinik für Nuklearmedizin, Universitätsklinikum Münster, Albert-Schweitzer-Strasse 33, D-48129 Münster, Germany, European Institute of Molecular Imaging, Westfälische Wilhelms-Universität, Mendelstrasse 11, D-48149 Münster
| | - Andreas Faust
- Organisch-Chemisches Institut and International NRW Graduate School of Chemistry, Westfälische Wilhelms-Universität, Corrensstrasse 40, D-48149 Münster, Germany, Klinik und Poliklinik für Nuklearmedizin, Universitätsklinikum Münster, Albert-Schweitzer-Strasse 33, D-48129 Münster, Germany, European Institute of Molecular Imaging, Westfälische Wilhelms-Universität, Mendelstrasse 11, D-48149 Münster
| | - Michael Schäfers
- Organisch-Chemisches Institut and International NRW Graduate School of Chemistry, Westfälische Wilhelms-Universität, Corrensstrasse 40, D-48149 Münster, Germany, Klinik und Poliklinik für Nuklearmedizin, Universitätsklinikum Münster, Albert-Schweitzer-Strasse 33, D-48129 Münster, Germany, European Institute of Molecular Imaging, Westfälische Wilhelms-Universität, Mendelstrasse 11, D-48149 Münster
| | - Otmar Schober
- Organisch-Chemisches Institut and International NRW Graduate School of Chemistry, Westfälische Wilhelms-Universität, Corrensstrasse 40, D-48149 Münster, Germany, Klinik und Poliklinik für Nuklearmedizin, Universitätsklinikum Münster, Albert-Schweitzer-Strasse 33, D-48129 Münster, Germany, European Institute of Molecular Imaging, Westfälische Wilhelms-Universität, Mendelstrasse 11, D-48149 Münster
| | - Klaus Kopka
- Organisch-Chemisches Institut and International NRW Graduate School of Chemistry, Westfälische Wilhelms-Universität, Corrensstrasse 40, D-48149 Münster, Germany, Klinik und Poliklinik für Nuklearmedizin, Universitätsklinikum Münster, Albert-Schweitzer-Strasse 33, D-48129 Münster, Germany, European Institute of Molecular Imaging, Westfälische Wilhelms-Universität, Mendelstrasse 11, D-48149 Münster
| | - Günter Haufe
- Organisch-Chemisches Institut and International NRW Graduate School of Chemistry, Westfälische Wilhelms-Universität, Corrensstrasse 40, D-48149 Münster, Germany, Klinik und Poliklinik für Nuklearmedizin, Universitätsklinikum Münster, Albert-Schweitzer-Strasse 33, D-48129 Münster, Germany, European Institute of Molecular Imaging, Westfälische Wilhelms-Universität, Mendelstrasse 11, D-48149 Münster
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Wu GW, Kobashigawa JA, Fishbein MC, Patel JK, Kittleson MM, Reed EF, Kiyosaki KK, Ardehali A. Asymptomatic antibody-mediated rejection after heart transplantation predicts poor outcomes. J Heart Lung Transplant 2009; 28:417-22. [PMID: 19416767 PMCID: PMC3829690 DOI: 10.1016/j.healun.2009.01.015] [Citation(s) in RCA: 143] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2008] [Revised: 12/24/2008] [Accepted: 01/14/2009] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Antibody-mediated rejection (AMR) has been associated with poor outcome after heart transplantation. The diagnosis of AMR usually includes endomyocardial biopsy findings of endothelial cell swelling, intravascular macrophages, C4d+ staining, and associated left ventricular dysfunction. The significance of AMR findings in biopsy specimens of asymptomatic heart transplant patients (normal cardiac function and no symptoms of heart failure) is unclear. METHODS Between July 1997 and September 2001, AMR was found in the biopsy specimens of 43 patients. Patients were divided into 2 groups: asymptomatic AMR (AsAMR, n = 21) and treated AMR (TxAMR with associated left ventricular dysfunction, n = 22). For comparison, a control group of 86 contemporaneous patients, without AMR, was matched for age, gender, and time from transplant. Outcomes included 5-year actuarial survival and development of cardiac allograft vasculopathy (CAV). Patients were considered to have AMR if they had > or = 1 endomyocardial biopsy specimen positive for AMR. RESULTS The 5-year actuarial survival for the AsAMR (86%), TxAMR (68%), and control groups (79%) was not significantly different (p = 0.41). Five-year freedom from CAV (> or = 30% stenosis in any vessel) was AsAMR, 52%; TxAMR, 68%; and control, 79%. Individually, freedom from CAV was significantly lower in the AsAMR group compared with the control group (p = 0.02). There was no significant difference between AsAMR vs TxAMR and TxAMR vs control for CAV. CONCLUSIONS Despite comparable 5-year survival with controls after heart transplantation, AsAMR rejection is associated with a greater risk of CAV. Trials to treat AsAMR to alter outcome are warranted.
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Affiliation(s)
- Grace W Wu
- Division of Cardiology, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA 90095-6988, USA
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Synthesis, biological evaluation and radiochemical labeling of a dansylhydrazone derivative as a potential imaging agent for apoptosis. Bioorg Med Chem Lett 2008; 18:3573-7. [DOI: 10.1016/j.bmcl.2008.05.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2008] [Revised: 04/25/2008] [Accepted: 05/01/2008] [Indexed: 01/06/2023]
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Liu G, Ma H, Jiang L, Zhao Y. Allograft inflammatory factor-1 and its immune regulation. Autoimmunity 2007; 40:95-102. [PMID: 17453710 DOI: 10.1080/08916930601083946] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
The allograft inflammatory factor-1 (AIF-1) is a 17 kDa interferon-gamma (IFN-gamma) inducible Ca(2+)-binding EF-hand protein that is encoded within the HLA class III genomic region. Three proteins including ionized Ca(2+)-binding adaptor 1, microglia response factor-1, and daintain are identical with AIF-1. The expression of AIF-1 was mostly limited to the monocyte/macrophage lineage, and augmented by cytokines such as IFN-gamma. It was assumed that AIF-1 was a novel molecule involved in inflammatory responses, allograft rejection, as well as the activation and function of macrophages. However, it has been reported that AIF-1 is also expressed in macrophages and microglial cells in autoimmune diseases such as experimental autoimmune encephalomyelitis, neuritis and uveitis models, suggesting that AIF-1 may play a pivotal role in autoimmunity. In the present manuscript, the genomic and functional characteristics of AIF-1 family proteins as well as their immune regulatory effects are reviewed.
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Affiliation(s)
- Guangwei Liu
- Transplantation Biology Research Division, State Key Laboratory of Biomembrane and Membrane Biotechnology, Institute of Zoology, Chinese Academy of Sciences, Beisihuan Xi Road 25, Beijing 100080, China
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Kopka K, Faust A, Keul P, Wagner S, Breyholz HJ, Höltke C, Schober O, Schäfers M, Levkau B. 5-Pyrrolidinylsulfonyl Isatins as a Potential Tool for the Molecular Imaging of Caspases in Apoptosis. J Med Chem 2006; 49:6704-15. [PMID: 17154501 DOI: 10.1021/jm051217c] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Caspases are the unique enzymes responsible for the execution of the cell death program and may represent an exclusive target for the specific molecular imaging of apoptosis in vivo. 5-Pyrrolidinylsulfonyl isatins represent potent nonpeptidyl caspase inhibitors that may be suitable for the development of caspase binding radioligands (CBRs). (S)-5-[1-(2-Methoxymethylpyrrolidinyl)sulfonyl]isatin (7) served as a lead compound for modification of its N-1-position. Corresponding pairs of N-1-substituted 2-methoxymethyl- and 2-phenoxymethylpyrrolidinyl derivatives were examined in vitro by biochemical caspase inhibition assays. All target compounds possess high in vitro caspase inhibition potencies in the nanomolar to subnanomolar range for caspase-3 (Ki=0.2-56.1 nM). As shown for compound (S)-1-(4-(2-fluoroethoxy)benzyl)-5-[1-(2-methoxymethylpyrrolidinyl)sulfonyl]isatin (35), the class of N-1-substituted 5-pyrrolidinylsulfonyl isatins competitively inhibits caspase-3. All caspase inhibitors show selectivity for the effector caspases-3 and -7 in vitro. The 2-methoxymethylpyrrolidinyl versions of the isatins appear to possess superior caspase inhibition potencies in cellular apoptosis inhibition assays compared with the 2-phenoxymethylpyrrolidinyl inhibitors.
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Affiliation(s)
- Klaus Kopka
- Department of Nuclear Medicine, University Hospital of the Westfälische Wilhelms-Universität, Münster, Germany.
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Grimm M, Rinaldi M, Yonan NA, Arpesella G, Arizón Del Prado JM, Pulpón LA, Villemot JP, Frigerio M, Rodriguez Lambert JL, Crespo-Leiro MG, Almenar L, Duveau D, Ordonez-Fernandez A, Gandjbakhch J, Maccherini M, Laufer G. Superior prevention of acute rejection by tacrolimus vs. cyclosporine in heart transplant recipients--a large European trial. Am J Transplant 2006; 6:1387-97. [PMID: 16686762 DOI: 10.1111/j.1600-6143.2006.01300.x] [Citation(s) in RCA: 119] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We compared efficacy and safety of tacrolimus (Tac)-based vs. cyclosporine (CyA) microemulsion-based immunosuppression in combination with azathioprine (Aza) and corticosteroids in heart transplant recipients. During antibody induction, patients were randomized (1:1) to oral treatment with Tac or CyA. Episodes of acute rejection were assessed by protocol biopsies, which underwent local and blinded central evaluation. The full analysis set comprised 157 patients per group. Patient/graft survival was 92.9% for Tac and 89.8% for CyA at 18 months. The primary end point, incidence of first biopsy proven acute rejection (BPAR) of grade >/= 1B at month 6, was 54.0% for Tac vs. 66.4% for CyA (p = 0.029) according to central assessment. Also, incidence of first BPAR of grade >/= 3A at month 6 was significantly lower for Tac vs. CyA; 28.0% vs. 42.0%, respectively (p = 0.013). Significant differences (p < 0.05) emerged between groups for these clinically relevant adverse events: new-onset diabetes mellitus (20.3% vs. 10.5%); post-transplant arterial hypertension (65.6% vs. 77.7%); and dyslipidemia (28.7% vs. 40.1%) for Tac vs. CyA, respectively. Incidence and pattern of infections over 18 months were comparable between groups, as was renal function. Primary use of Tac during antibody induction resulted in superior prevention of acute rejection without an associated increase in infections.
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Affiliation(s)
- M Grimm
- Abteilung für Herz- und Thoraxchirurgie, AKH Vienna, Austria.
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Schweiger M, Wasler A, Prenner G, Tripolt M, Schwarz M, Tscheliessnigg KH. Late Acute Cardiac Allograft Rejection: New Therapeutic Options? Transplant Proc 2005; 37:4528-31. [PMID: 16387161 DOI: 10.1016/j.transproceed.2005.11.053] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Late acute cellular rejection is associated with decreased survival and the development of CAV. Among new immunosuppressive drugs introduced into clinical practice, everolimus, has been shown to be safe in cardiac transplantation. We report our experience with everolimus in heart transplant recipients who developed late acute cellular cardiac rejection. METHODS Patients with a history of previous rejection episodes who experienced cardiac rejection were switched to an everolimus, cyclosporine, and steroid immunosuppressive regimen. All patients had already received statins and antihypertensive medications. Everolimus, cyclosporine trough levels, and laboratory values were controlled monthly. Drug administration was adapted to an everolimus trough level between 3 and 8 ng/mL, mean maintenance dosage was 0.25 to 1.5 mg twice a day. Death, safety, side effects, biopsy-proven acute rejection episodes, laboratory values, and blood levels were evaluated retrospectively. RESULTS Four cardiac allograft recipients (two male, two female), at a median of 1473.25 days post-orthotopic heart transplantation (oHTx) (range = 65 to 3045), received 1 to 1.5 mg everolimus per day. Over a follow-up period of at least 2 month (range = 2 to 10) the mortality was 0%. The drug was well tolerated; no acute cellular rejection greater than grade 1a (ISHLT grading) was observed after 2 months. In one patient increased cholesterol values and in two others, elevated triglyceride levels were seen, but were controlled with increased statin therapy. No obvious increased creatinine values were seen with everolimus. CONCLUSION In conclusion, conversion to an everolimus-based immunosuppressive regimen after late cardiac rejection is safe and effective; no major side effects were observed.
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Affiliation(s)
- M Schweiger
- Department for Transplantation, Medical University Graz, University of Surgery, Graz, Austria.
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