Assessment of cyclosporine pharmacokinetic parameters to facilitate conversion from C0 to C2 monitoring in heart transplant recipients

BACKGROUND

Cyclosporine (CsA) 2-hour postdose (C2) monitoring is recommended to assess CsA exposure and predict clinical outcomes among heart transplant recipients. We correlated pharmacokinetic parameters and clinical outcomes in stable long-term heart transplant recipients monitored with C0 to develop an algorithm to convert patients from C0 to C2 monitoring.

METHODS

Paired CsA C0-C2 measurements and serum creatinine levels were obtained from 35 heart transplant recipients more than 2 years posttransplantation (mean 8.8+/-4.7 years).

RESULTS

The mean CsA dose and C0, C2, and C0/C2 ratio were 85+/-23 mg/12 hours, 123+/-41 ng/mL, 572+/-274 ng/mL and 4.8+/-2.1, respectively. C0 correlated weakly with C2 (r=.42, P=.011). The CsA dose correlated better with C2 (r=.58; P<.001) than with C0 (r=.37; P=.026). A good correlation was noted between C2 and the C2/C0 ratio (r=.73; P<.001), but none between C0 and the C2/C0 ratio. A borderline significant inverse correlation was noted between C0 and the worst endomyocardial biopsy score (r=-.34; P=.045), whereas none was noted with C2. Serum creatinine level did not correlate with either C2 or C0. Among patients with C0 within our target of 100 to 150 ug/L, six had C2 above 300 to 600 ug/L as suggested by the literature.

CONCLUSIONS

In long-term heart transplant recipients, we could not identify a single pharmacokinetic parameter that could be used to develop an algorithm to convert from C0 to C2 monitoring; however, C2 may be better than C0 for identifying patients at risk of overexposure to CsA.

Nursing management of the patient with bone metastases

OBJECTIVES

To review the problem of bone metastases and strategies aimed at the management of bone metastases.

DATA SOURCES

Review articles, book chapters, research studies, and clinical practice.

CONCLUSIONS

As patients survive for longer periods, effective management of bone metastases becomes critical to maintaining or improving quality of life. Controlling pain, preventing fractures and oncologic emergencies, and promoting mobility and function are the outcomes of successful management.

IMPLICATIONS FOR NURSING PRACTICE

Use of a clinical algorithm may assist the nurse in identifying bone metastases and managing the clinical sequelae, such as pain.

Bone metastases: Part I--Pathophysiology

Many cancers (especially breast, prostate, and lung cancers) metastasize to the bone. The most frequent site of bone involvement is the axial skeleton (i.e., cranium, ribs, spine, and pelvis). The sequelae of bone metastases include pain, hypercalcemia, pathologic fractures, and spinal cord compression. As patients survive for longer periods, effective management of bone metastases becomes critical to maintaining or improving quality of life. Controlling pain, preventing fractures and oncologic emergencies, and promoting mobility and function are the outcomes of successful management. Use of a clinical algorithm can assist the nurse in identifying bone metastases and managing the clinical sequelae. Knowledge of the pathophysiology and the ability to assess bone metastases will contribute to the nurse's ability to manage the clinical problems and to improve the quality of life of patients with cancer.

Bone metastases: Part II--Nursing management

Nurses play a crucial role in identifying bone metastases and managing clinical sequelae, such as pain. Understanding the metastatic process is necessary for delivering effective nursing care. Part I of this article described the pathophysiology and assessment. Part II will provide an overview of the nursing management of the sequelae of bone metastases, including pain, pathologic fractures, spinal cord compression, hypercalcemia, and anemia. Risk factor identification can lead to prevention and early detection of these clinically significant problems. Clinical management of bone metastases will contribute to the nurse's ability to improve the quality of life of patients with cancer.

Bacterial pericarditis after heart transplantation: successful management of two cases with catheter drainage and antibiotics

OBJECTIVE

To describe the diagnosis and management of bacterial pericarditis after heart transplantation.

PATIENTS AND METHODS

Two patients with Staphylococcus aureus pericarditis after heart transplantation were successfully treated conservatively with closed catheter drainage and antibiotics.

RESULTS

The patients were alive three and six years, respectively, following surgery. At follow-up, right heart catheterization demonstrated normal hemodynamics in one patient and a pattern of constrictive pericarditis in the other patient which was man-aged with furosemide.

CONCLUSIONS

Conservative management of bacterial pericarditis by closed catheter drainage and antibiotics can be considered in selected patients after heart transplantation.

Cardiac transplantation after mechanical circulatory support: a Canadian perspective

BACKGROUND

To assess the relative efficacy of cardiac transplantation after mechanical circulatory support with a variety of support systems, we analyzed our consecutive series of patients who had and did not have mechanical support before transplantation.

METHODS

A review of 209 patients undergoing cardiac transplantation from 1984 to May 1995 was performed. Group 1 consisted of 110 patients who were maintained on oral medications while awaiting transplantation, and group 2 consisted of 60 patients who required intravenous inotropic support. Group 3 included 39 patients who had transplantation after mechanical circulatory support for cardiogenic shock. The indication for device implantation was acute onset of cardiogenic shock in 38 patients and deterioration while awaiting transplantation in 1 patient. The support systems were an intraaortic balloon pump in 13 (subgroup 3A), a ventricular assist device in 7 (subgroup 3B), and a total artificial heart in 19 patients (subgroup 3C).

RESULTS

After transplantation, infection was more common in group 3 (56%) than in group 1 (28%) or group 2 (32%) (p = 0.005). Survival to discharge was lower for group 3 (71.7%) than for group 1 (90.9%) or 2 (88.3%) (p = 0.009). For mechanically supported patients, survival to discharge was 84.6% in subgroup 3A, 71.4% in subgroup 3B, and 63.1% in subgroup 3C (p = not significant).

CONCLUSIONS

Transplantation after mechanical support offers acceptable results in this group of patients for whom the only alternative is certain death. Patient selection and perioperative management remain the challenge to improving these results.

It's time to change visiting policies in critical care units

For years, hospitals have been highly structured organizations--a state often attributed to their early associations with the Church and military. Nurses have come to accept hospitals' many policies and procedures as part of their everyday lives. Little wonder, then, that it has taken considerable time and energy to question and dismantle policies that were accepted as military orders or gospel from a greater authority.

Determinants of hospital survival after cardiac transplantation

To identify the preoperative factors that influence hospital survival after transplantation we analyzed our consecutive experience of 183 transplantations in 179 patients over a 10-year period. There were 151 male and 29 female transplant recipients ranging in age from 10 days to 70 years (mean, 48 +/- 1 years). Diagnoses included coronary disease in 110 patients, cardiomyopathy in 55 patients, valvular disease in 6 patients, and congenital heart disease in 9 patients. Seventy-seven had undergone a previous cardiac operation, and 30 patients required preoperative mechanical support. Forty patients received hearts from donors who were 40 years old or older (range, 40 to 62 years). Ischemic time was greater than 240 minutes in 32 cases, and pulmonary vascular resistance was greater than 3 Wood units in 40 patients (range, 3.1 to 10.0 Wood units). Cyclosporine induction was used in 52 patients, whereas 128 recipients received polyclonal antibody prophylaxis. There were 25 hospital deaths. Recipient diagnosis, use of mechanical support, donor age, and the immune suppression protocol were related to hospital survival according to univariate analysis. Using multiple logistic regression, only the method of immune suppression induction and the use of mechanical assists were significant independent determinants of survival. In conclusion, we believe that extended ischemic times and donor age do not adversely affect the early success of transplantation, whereas induction with immune globulin may reduce early mortality. Patients requiring mechanical support before transplantation continue to be a challenge.

Lymphocyte tissue culture studies on human heart transplant recipients. III. Prediction of outcome of transplantation based on immunologic studies

Using in vitro lymphocyte tissue culture screening tests human heart transplant recipients during the academic year 1973/1974 were evaluated and an attempt made to predict their post-operative rejection course. The tests involved screening for serum depressive factors and screening for the recipient's lymphocyte reactivity. A scoring system was devised whereby the laboratory results could be converted to a predicted rejection score. Of the nine patients studied, eight are still doing well. Three recipient's who had a high postoperative rejection score as determined by an independent clinical team, were correctly identified pre-operatively and one of them had to be retransplanted. These screening tests may be helpful in the future in the selection of recipients.