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Deshpande SR, Zangwill SD, Richmond ME, Kindel SJ, Schroder JN, Gaglianello N, Bichell DP, Wigger MA, Knecht KR, Thrush PT, Mahle WT, North PE, Simpson PM, Zhang L, Dasgupta M, Tomita-Mitchell A, Mitchell ME. Evaluating threshold for donor fraction cell-free DNA using clinically available assay for rejection in pediatric and adult heart transplantation. Pediatr Transplant 2024; 28:e14708. [PMID: 38553812 PMCID: PMC10987078 DOI: 10.1111/petr.14708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 01/10/2024] [Accepted: 01/23/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND The aims of the study were to assess the performance of a clinically available cell-free DNA (cfDNA) assay in a large cohort of pediatric and adult heart transplant recipients and to evaluate performance at specific cut points in detection of rejection. METHODS Observational, non-interventional, prospective study enrolled pediatric and adult heart transplant recipients from seven centers. Biopsy-associated plasma samples were used for cfDNA measurements. Pre-determined cut points were tested for analytic performance. RESULTS A total of 487 samples from 160 subjects were used for the analysis. There were significant differences for df-cfDNA values between rejection [0.21% (IQR 0.12-0.69)] and healthy samples [0.05% (IQR 0.01-0.14), p < .0001]. The pediatric rejection group had a median df-cfDNA value of 0.93% (IQR 0.28-2.84) compared to 0.09% (IQR 0.04-0.23) for healthy samples, p = .005. Overall negative predictive value was 0.94 while it was 0.99 for pediatric patients. Cut points of 0.13% and 0.15% were tested for various types of rejection profiles and were appropriate to rule out rejection. CONCLUSION The study suggests that pediatric patients with rejection show higher levels of circulating df-cfDNA compared to adults and supports the specific cut points for clinical use in pediatric and adult patients with overall acceptable performance.
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Affiliation(s)
- Shriprasad R Deshpande
- Division of Pediatric Cardiology, Children's National Heart Institute, Children's National Hospital, Washington, DC, USA
| | - Steven D Zangwill
- Division of Cardiology, Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - Marc E Richmond
- Department of Pediatrics, Division of Pediatric Cardiology, College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Steven J Kindel
- Division of Pediatric Cardiology, Department of Pediatrics, Medical College of Wisconsin, Herma Heart Institute, Children's Wisconsin, Milwaukee, Wisconsin, USA
| | - Jacob N Schroder
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University, Durham, North Carolina, USA
| | - Nunzio Gaglianello
- Division of Cardiology, Department of Medicine, Froedtert and the Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - David P Bichell
- Division of Pediatric Cardiac Surgery, Department of Surgery, Vanderbilt University, Nashville, Tennessee, USA
| | - Mark A Wigger
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Kenneth R Knecht
- Department of Pediatrics, Arkansas Children's Hospital, Little Rock, Arkansas, USA
| | - Phillip T Thrush
- Department of Cardiology, Lurie Children's Hospital, Chicago, Illinois, USA
| | - William T Mahle
- Division of Cardiology, Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Paula E North
- Department of Pathology, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
| | - Pippa M Simpson
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Liyun Zhang
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Mahua Dasgupta
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Aoy Tomita-Mitchell
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Herma Heart Institute, Milwaukee, Wisconsin, USA
| | - Michael E Mitchell
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Herma Heart Institute, Children's Wisconsin, Milwaukee, Wisconsin, USA
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Richmond ME, Deshpande SR, Zangwill SD, Bichell DP, Kindel SJ, Mahle WT, Schroder JN, Wigger MA, Knecht KR, Pahl E, Gaglianello NA, Goetsch MA, Simpson P, Dasgupta M, Zhang L, North PE, Tomita-Mitchell A, Mitchell ME. Validation of donor fraction cell-free DNA with biopsy-proven cardiac allograft rejection in children and adults. J Thorac Cardiovasc Surg 2023; 165:460-468.e2. [PMID: 35643770 PMCID: PMC9617812 DOI: 10.1016/j.jtcvs.2022.04.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 04/04/2022] [Accepted: 04/19/2022] [Indexed: 01/18/2023]
Abstract
OBJECTIVES Donor-specific cell-free DNA shows promise as a noninvasive marker for allograft rejection, but as yet has not been validated in both adult and pediatric recipients. The study objective was to validate donor fraction cell-free DNA as a noninvasive test to assess for risk of acute cellular rejection and antibody-mediated rejection after heart transplantation in pediatric and adult recipients. METHODS Pediatric and adult heart transplant recipients were enrolled from 7 participating sites and followed for 12 months or more with plasma samples collected immediately before all endomyocardial biopsies. Donor fraction cell-free DNA was extracted, and quantitative genotyping was performed. Blinded donor fraction cell-free DNA and clinical data were analyzed and compared with a previously determined threshold of 0.14%. Sensitivity, specificity, negative predictive value, positive predictive value, and receiver operating characteristic curves were calculated. RESULTS A total of 987 samples from 144 subjects were collected. After applying predefined clinical and technical exclusions, 745 samples from 130 subjects produced 54 rejection samples associated with the composite outcome of acute cellular rejection grade 2R or greater and pathologic antibody-mediated rejection 2 or greater and 323 healthy samples. For all participants, donor fraction cell-free DNA at a threshold of 0.14% had a sensitivity of 67%, a specificity of 79%, a positive predictive value of 34%, and a negative predictive value of 94% with an area under the curve of 0.78 for detecting rejection. When analyzed independently, these results held true for both pediatric and adult cohorts at the same threshold of 0.14% (negative predictive value 92% and 95%, respectively). CONCLUSIONS Donor fraction cell-free DNA at a threshold of 0.14% can be used to assess for risk of rejection after heart transplantation in both pediatric and adult patients with excellent negative predictive value.
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Affiliation(s)
- Marc E Richmond
- Division of Pediatric Cardiology, Department of Pediatrics, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY.
| | - Shriprasad R Deshpande
- Division of Pediatric Cardiology, Children's National Heart Institute, Children's National Hospital, Washington, DC
| | | | - David P Bichell
- Division of Pediatric Cardiac Surgery, Department of Surgery, Vanderbilt University, Nashville, Tenn
| | - Steven J Kindel
- Division of Pediatric Cardiology, Department of Pediatrics, Medical College of Wisconsin, Herma Heart Institute, Children's Wisconsin, Milwaukee, Wis
| | - William T Mahle
- Division of Cardiology, Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Jacob N Schroder
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University, Durham, NC
| | - Mark A Wigger
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University, Nashville, Tenn
| | - Kenneth R Knecht
- Department of Pediatrics, Arkansas Children's Hospital, Little Rock, Ark
| | | | | | - Mary A Goetsch
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wis
| | - Pippa Simpson
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis
| | - Mahua Dasgupta
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis
| | - Liyun Zhang
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis
| | - Paula E North
- Department of Pathology, Medical College of Wisconsin, Children's Wisconsin, Milwaukee, Wis
| | - Aoy Tomita-Mitchell
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Herma Heart Institute, Milwaukee, Wis
| | - Michael E Mitchell
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Herma Heart Institute, Milwaukee, Wis
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Deshpande SR, Zangwill SD, Kindel SJ, Schroder JN, Bichell DP, Wigger MA, Richmond ME, Knecht KR, Pahl E, Gaglianello NA, Mahle WT, Stamm KD, Simpson PM, Dasgupta M, Zhang L, North PE, Tomita-Mitchell A, Mitchell ME. Relationship between donor fraction cell-free DNA and clinical rejection in heart transplantation. Pediatr Transplant 2022; 26:e14264. [PMID: 35258162 DOI: 10.1111/petr.14264] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 02/19/2022] [Accepted: 02/23/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Clinical rejection (CR) defined as decision to treat clinically suspected rejection with change in immunotherapy based on clinical presentation with or without diagnostic biopsy findings is an important part of care in heart transplantation. We sought to assess the utility of donor fraction cell-free DNA (DF cfDNA) in CR and the utility of serial DF cfDNA in CR patients in predicting outcomes of clinical interest. METHODS Patients with heart transplantation were enrolled in two sequential, multi-center, prospective observational studies. Blood samples were collected for surveillance or clinical events. Clinicians were blinded to the results of DF cfDNA. RESULTS A total of 835 samples from 269 subjects (57% pediatric) were included for this analysis, including 28 samples associated with CR were analyzed. Median DF cfDNA was 0.43 (IQR 0.15, 1.36)% for CR and 0.10 (IQR 0.07, 0.16)% for healthy controls (p < .0001). At cutoff value of 0.13%, the area under curve (AUC) was 0.82, sensitivity of 0.86, specificity of 0.67, and negative predictive value of 0.99. There was serial decline in DF cfDNA post-therapy, however, those with cardiovascular events (cardiac arrest, need for mechanical support or death) showed significantly higher levels of DF cfDNA on Day 0 (2.11 vs 0.31%) and Day 14 (0.51 vs 0.22%) compared to those who did not have such an event (p < .0001). CONCLUSION DF cfDNA has excellent agreement with clinical rejection and, importantly, serial measurement of DF cfDNA predict clinically significant outcomes post treatment for rejection in these patients.
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Affiliation(s)
- Shriprasad R Deshpande
- Division of Pediatric Cardiology, Children's National Heart Institute, Children's National Hospital, Washington, District of Columbia, USA
| | - Steven D Zangwill
- Division of Cardiology, Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - Steven J Kindel
- Division of Pediatric Cardiology, Department of Pediatrics, Medical College of Wisconsin, Herma Heart Institute, Children's Wisconsin, Milwaukee, Wisconsin, USA
| | - Jacob N Schroder
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University, Durham, North Carolina, USA
| | - David P Bichell
- Division of Pediatric Cardiac Surgery, Department of Surgery, Vanderbilt University, Nashville, Tennessee, USA
| | - Mark A Wigger
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Marc E Richmond
- Department of Pediatrics, Division of Pediatric Cardiology, College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Kenneth R Knecht
- Department of Pediatrics, Arkansas Children's Hospital, Little Rock, Arkansas, USA
| | - Elfriede Pahl
- Emeritus of Pediatrics, Cardiology, Lurie Children's Hospital, Chicago, Illinois, USA
| | | | - William T Mahle
- Division of Cardiology, Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Karl D Stamm
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Pippa M Simpson
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Mahua Dasgupta
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Liyun Zhang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Paula E North
- Department of Pathology, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
| | - Aoy Tomita-Mitchell
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Herma Heart Institute, Milwaukee, Wisconsin, USA
| | - Michael E Mitchell
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Herma Heart Institute, Children's Wisconsin, Milwaukee, Wisconsin, USA
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4
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Zangwill SD, Deshpande SR, Simpson PM, Liang HL, Zhang L, Dasgupta M, Richmond ME, Kindel SJ, Bichell DP, Mahle WT, Wigger MA, Schroder JN, Knecht KR, Pahl E, Gaglianello NA, North PE, Tomita-Mitchell A, Mitchell ME. Increase in nuclear cell-free DNA is associated with major adverse events in adult and pediatric heart transplant recipients. Clin Transplant 2021; 36:e14509. [PMID: 34649304 DOI: 10.1111/ctr.14509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 09/25/2021] [Accepted: 10/04/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Cell-free DNA is an emerging biomarker. While donor fraction may detect graft events in heart transplant recipients, the prognostic value of total nuclear cell-free DNA (ncfDNA) itself is largely unexplored. OBJECTIVE Explore the relationship between ncfDNA and clinical events in heart transplant recipients. METHODS We conducted a multi-center prospective study to investigate the value of cell-free DNA in non-invasive monitoring following heart transplantation. Over 4000 blood samples were collected from 388 heart transplant patients. Total ncfDNA and donor fraction were quantified. Generalized linear models with maximum likelihood estimation for repeated measures with subjects as clusters were used to explore the relationship of ncfDNA and major adverse events. Receiver operating characteristic curves were used to help choose cutpoints. RESULTS A ncfDNA threshold (50 ng/ml) was identified that was associated with increased risk of major adverse events. NcfDNA was elevated in patients who suffered cardiac arrest, required mechanical circulatory support or died post heart transplantation as well as in patients undergoing treatment for infection. CONCLUSIONS Elevated ncfDNA correlates with risk for major adverse events in adult and pediatric heart transplant recipients and may indicate a need for enhanced surveillance after transplant.
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Affiliation(s)
- Steven D Zangwill
- Division of Cardiology, Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - Shriprasad R Deshpande
- Division of Cardiology and Division of Cardiac Intensive Care, Children's National Hospital, Washington, District of Columbia, USA
| | - Pippa M Simpson
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Huan Ling Liang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Liyun Zhang
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Mahua Dasgupta
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Marc E Richmond
- Department of Pediatrics, Division of Pediatric Cardiology, College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Steven J Kindel
- Division of Pediatric Cardiology, Department of Pediatrics, Medical College of Wisconsin, Herma Heart Institute, Children's Wisconsin, Milwaukee, Wisconsin, USA
| | - David P Bichell
- Division of Pediatric Cardiac Surgery, Department of Surgery, Vanderbilt University, Nashville, Tennessee, USA
| | - William T Mahle
- Division of Cardiology, Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Mark A Wigger
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Jacob N Schroder
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University, Durham, North Carolina, USA
| | - Kenneth R Knecht
- Department of Pediatrics, Arkansas Children's Hospital, Little Rock, Arkansas, USA
| | - Elfriede Pahl
- Professor Emeritus Pediatrics, Cardiology, Lurie Children's Hospital, Chicago, Illinois, USA
| | | | - Paula E North
- Department of Pathology, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
| | - Aoy Tomita-Mitchell
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Herma Heart Institute, Milwaukee, Wisconsin, USA
| | - Michael E Mitchell
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Herma Heart Institute, Children's Wisconsin, Milwaukee, Wisconsin, USA
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5
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Hoffman JRH, Larson EE, Rahaman Z, Absi T, Levack M, Balsara KR, McMaster W, Brinkley M, Menachem JN, Punnoose LR, Sacks SB, Wigger MA, Zalawadiya SK, Stevenson LW, Schlendorf KH, Lindenfeld J, Shah AS. Impact of increased donor distances following adult heart allocation system changes: A single center review of 1-year outcomes. J Card Surg 2021; 36:3619-3628. [PMID: 34235763 DOI: 10.1111/jocs.15795] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 06/07/2021] [Accepted: 06/10/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND On October 18, 2018, several changes to the donor heart allocation system were enacted. We hypothesize that patients undergoing orthotopic heart transplantation (OHT) under the new allocation system will see an increase in ischemic times, rates of primary graft dysfunction, and 1-year mortality due to these changes. METHODS In this single-center retrospective study, we reviewed the charts of all OHT patients from October 2017 through October 2019. Pre- and postallocation recipient demographics were compared. Survival analysis was performed using the Kaplan-Meier method. RESULTS A total of 184 patients underwent OHT. Recipient demographics were similar between cohorts. The average distance from donor increased by more than 150 km (p = .006). Patients in the postallocation change cohort demonstrated a significant increase in the rate of severe left ventricle primary graft dysfunction from 5.4% to 18.7% (p = .005). There were no statistically significant differences in 30-day mortality or 1-year survival. Time on the waitlist was reduced from 203.8 to 103.7 days (p = .006). CONCLUSIONS Changes in heart allocation resulted in shorter waitlist times at the expense of longer donor distances and ischemic times, with an associated negative impact on early post-transplantation outcomes. No significant differences in 30-day or 1-year mortality were observed.
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Affiliation(s)
- Jordan R H Hoffman
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Emilee E Larson
- Section of Surgical Science, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Zakiur Rahaman
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Tarek Absi
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Melissa Levack
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Keki R Balsara
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - William McMaster
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Marshall Brinkley
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jonathan N Menachem
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Lynn R Punnoose
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Suzanne B Sacks
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Mark A Wigger
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sandip K Zalawadiya
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Lynne W Stevenson
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kelly H Schlendorf
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - JoAnn Lindenfeld
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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6
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Richmond ME, Zangwill SD, Kindel SJ, Deshpande SR, Schroder JN, Bichell DP, Knecht KR, Mahle WT, Wigger MA, Gaglianello NA, Pahl E, Simpson PM, Dasgupta M, North PE, Hidestrand M, Tomita-Mitchell A, Mitchell ME. Donor fraction cell-free DNA and rejection in adult and pediatric heart transplantation. J Heart Lung Transplant 2019; 39:454-463. [PMID: 31983667 DOI: 10.1016/j.healun.2019.11.015] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 11/14/2019] [Accepted: 11/20/2019] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Endomyocardial biopsy (EMB) is the current standard for rejection surveillance in heart transplant recipients. The quantification of donor-specific cell-free DNA (cfDNA) may be an appropriate biomarker for non-invasive rejection surveillance. A multicenter prospective blinded study (DNA-Based Transplant Rejection Test, DTRT) investigated the value of donor fraction (DF), defined as the ratio of cfDNA specific to the transplanted organ to the total amount of cfDNA present in a blood sample. METHODS A total of 241 heart transplant patients were recruited from 7 centers. Age at transplant ranged from 8 days to 73 years, with 146 subjects <18 years and 95 ≥18 years. All the patients were followed for at least 1 year, with blood samples drawn at routine and for-cause biopsies. A total of 624 biopsy-paired samples were included for analysis through a commercially available cfDNA assay (myTAIHEART, TAI Diagnostics Inc.). A blinded analysis of repeated measures compared the outcomes using receiver operating characteristic (ROC) curves. All primary clinical end-points were monitored at 100%. All analysis and conclusions were reviewed by both an independent external oversight committee and the National Institutes of Health-mandated DTRT steering committee. RESULTS DF in acute cellular rejection (ACR) 1R/2R (n = 15) was higher than ACR 0R (n = 42) (p = 0.02); DF in antibody-mediated rejection pAMR1 (n = 8) and pAMR2 (n = 12) (p = 0.05) were higher than pAMR0 (n = 466) (p = 0.04 and p = 0.05 respectively). An optimal DF threshold was determined by the use of an ROC analysis, which ruled out the presence of either ACR or antibody-mediated rejection. CONCLUSIONS The cell-free DNA DF holds promise as a non-invasive diagnostic test to rule out acute rejection in both adult and pediatric heart transplant populations.
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Affiliation(s)
- Marc E Richmond
- Department of Pediatrics, Division of Pediatric Cardiology, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Steven D Zangwill
- Division of Cardiology, Phoenix Children's Hospital, University of Arizona College of Medicine, Phoenix, Arizona
| | - Steven J Kindel
- Division of Pediatric Cardiology, Department of Pediatrics, Medical College of Wisconsin, Herma Heart Institute, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Shriprasad R Deshpande
- Division of Cardiology and Division of Cardiac Intensive Care, Children's National Hospital, Washington, District of Columbia
| | - Jacob N Schroder
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University, Durham, North Carolina
| | - David P Bichell
- Division of Pediatric Cardiac Surgery, Department of Surgery, Vanderbilt University, Nashville, Tennessee
| | - Kenneth R Knecht
- Department of Pediatrics, Arkansas Children's Hospital, Little Rock, Arkansas
| | - William T Mahle
- Division of Cardiology, Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Mark A Wigger
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Nunzio A Gaglianello
- Department of Medicine, Division of Cardiology Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Elfriede Pahl
- Ann & Robert H. Lurie Children's Hospital Chicago, Chicago, Illinois
| | - Pippa M Simpson
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Mahua Dasgupta
- Division of Critical Care, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Paula E North
- Department of Pathology, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Mats Hidestrand
- Division of Critical Care, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Aoy Tomita-Mitchell
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Herma Heart Institute, Milwaukee, Wisconsin
| | - Michael E Mitchell
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Herma Heart Institute, Milwaukee, Wisconsin.
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7
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Crow LD, Jambusaria‐Pahlajani A, Chung CL, Baran DA, Lowenstein SE, Abdelmalek M, Ahmed RL, Anadkat MJ, Arcasoy SM, Berg D, Bibee KP, Billingsley E, Black WH, Blalock TW, Bleicher M, Brennan DC, Brodland DG, Brown MR, Carroll BT, Carucci JA, Chang TW, Chaux G, Cusack CA, Dilling DF, Doyle A, Emtiazjoo AM, Ferguson NH, Fosko SW, Fox MC, Goral S, Gray AL, Griffin JR, Hachem RR, Hall SA, Hanlon AM, Hayes D, Hickey GW, Holtz J, Hopkins RS, Hu J, Huang CC, Brian Jiang SI, Kapnadak SG, Kraus ES, Lease ED, Leca N, Lee JC, Leitenberger JJ, Lim MA, Longo MI, Malik SM, Mallea JM, Menter A, Myers SA, Neuburg M, Nijhawan RI, Norman DJ, Otley CC, Paek SY, Parulekar AD, Patel MJ, Patel VA, Patton TJ, Pugliano‐Mauro M, Ranganna K, Ravichandran AK, Redenius R, Roll GR, Samie FH, Shin T, Singer JP, Singh P, Soon SL, Soriano T, Squires R, Stasko T, Stein JA, Taler SJ, Terrault NA, Thomas CP, Tokman S, Tomic R, Twigg AR, Wigger MA, Zeitouni NC, Arron ST. Initial skin cancer screening for solid organ transplant recipients in the United States: Delphi method development of expert consensus guidelines. Transpl Int 2019; 32:1268-1276. [DOI: 10.1111/tri.13520] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 03/25/2019] [Accepted: 09/02/2019] [Indexed: 12/25/2022]
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8
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Haglund NA, Davis ME, Tricarico NM, Ahmad RM, DiSalvo TG, Keebler ME, Schlendorf KH, Wigger MA, Stulak JM, Maltais S. Perioperative Blood Product Use: A Comparison Between HeartWare and HeartMate II Devices. Ann Thorac Surg 2014; 98:842-9. [DOI: 10.1016/j.athoracsur.2014.05.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2014] [Revised: 04/30/2014] [Accepted: 05/05/2014] [Indexed: 01/22/2023]
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9
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Haglund NA, Feurer ID, Dwyer JP, Stulak JM, DiSalvo TG, Keebler ME, Schlendorf KH, Wigger MA, Maltais S. Does renal dysfunction and method of bridging support influence heart transplant graft survival? Ann Thorac Surg 2014; 98:835-41. [PMID: 25069689 DOI: 10.1016/j.athoracsur.2014.05.059] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 05/06/2014] [Accepted: 05/07/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND Renal insufficiency is common in status 1B patients supported with inotropes or a continuous flow left ventricular device (CF-LVAD) as a bridge to heart transplantation. We evaluated the association of renal function and inotrope versus CF-LVAD support on posttransplant graft survival in status 1B patients. METHODS The Scientific Registry for Transplant Recipients database was analyzed for posttransplant survival in status 1B patients bridged with inotropes or CF-LVAD who underwent transplantation between 2003 and 2012. Pretransplant renal function was measured by estimating glomerular filtration rate (GFR) and was stratified as less than 45 mL · min(-1) · 1.73 m(-2), 45 to 59, and 60 or greater. Univariate Kaplan-Meier and multivariate Cox regression models were used to evaluate the main effects of GFR strata and inotropes versus CF-LVAD, and the interaction effect of GFR strata by CF-LVAD, on graft survival. RESULTS This study included 4,158 status 1B patients (74% male, aged 53 ± 12 years). Of those, 659 patients had a CF-LVAD (HeartMate-II [Thoratec, Pleasanton, CA], n = 638; HVAD [HeartWare, Framingham, MA], n = 21), and 3,530 were receiving inotropes (31 CF-LVAD patients were also receiving inotropes). Kaplan-Meier analyses demonstrated reduced graft survival (p = 0.022) in patients with pretransplant GFR less than 45 versus GFR 45 to 59 (p = 0.062) and versus GFR 60 or greater (p = 0.007), and no effect of inotrope versus CF-LVAD support on graft survival (p = 0.402). Multivariate analysis demonstrated that, after adjusting for the main effects of GFR stratum, CF-LVAD, and inotropes, status 1B patients bridged with a CF-LVAD and GFR in the lowest stratum had reduced graft survival (interaction effect p = 0.040). CONCLUSIONS Pretransplant renal insufficiency was associated with reduced posttransplant graft survival in status 1B patients. This risk is increased for patients bridged with a CF-LVAD (versus inotropes) who have GFR in the lowest stratum.
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Affiliation(s)
- Nicholas A Haglund
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Irene D Feurer
- Departments of Surgery and Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jamie P Dwyer
- Division of Nephrology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John M Stulak
- Division of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Thomas G DiSalvo
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mary E Keebler
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kelly H Schlendorf
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mark A Wigger
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Simon Maltais
- Division of Cardiovascular Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.
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Haglund NA, Cox ZL, Lee JT, Song Y, Keebler ME, DiSalvo TG, Maltais S, Lenihan DJ, Wigger MA. Are peripherally inserted central catheters associated with increased risk of adverse events in status 1B patients awaiting transplantation on continuous intravenous milrinone? J Card Fail 2014; 20:630-7. [PMID: 24954426 DOI: 10.1016/j.cardfail.2014.06.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 05/22/2014] [Accepted: 06/09/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Peripherally inserted central catheters (PICCs) are used to deliver continuous intravenous (IV) milrinone in stage D heart failure (HF) patients awaiting heart transplantation (HT). METHODS We retrospectively analyzed PICC adverse events (AEs) and associated cost in 129 status 1B patients from 2005 to 2012. End points were HT, left ventricular assist device (LVAD), and death. Regression analysis was used to identify AE risk factors. RESULTS Fifty-three PICC AEs occurred in 35 patients (27%), consisting of 48 infections, 4 thromboses, and 1 bleeding event. Median duration of PICC support was 63 (interquartile range [IQR] 34-131) days, and median time to first PICC infection was 44 (IQR 14-76) days. Among PICC infections, 9% required defibrillator removal and 30% were inactivated on the HT list for a mean of 23 ± 17 days. Rate of HT, LVAD, or death was similar between groups (P > .05). Regression analysis found that a double lumen PICC was associated with a shorter time to first PICC infection (hazard ratio 7.59, 95% CI 1.97-29.23; P = .003). Median cost per PICC infection was $10,704 (IQR $7,401-$26,083). CONCLUSIONS PICC infections were the most frequent AEs. PICCs with >1 lumen were associated with increased risk of infection. PICC AEs accounted for increased intensive care unit admissions, HT list inactivations, and overall cost.
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Affiliation(s)
- Nicholas A Haglund
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Zachary L Cox
- Pharmacy Practice, Lipscomb University College of Pharmacy, Nashville, Tennessee
| | - Jeff T Lee
- Pharmacy Practice, Lipscomb University College of Pharmacy, Nashville, Tennessee
| | - Yanna Song
- Department of Biostatistics, Vanderbilt University School of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mary E Keebler
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Thomas G DiSalvo
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Simon Maltais
- Cardiovascular Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Daniel J Lenihan
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mark A Wigger
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
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Haglund NA, Feurer ID, Ahmad RM, DiSalvo TG, Lenihan DJ, Keebler ME, Schlendorf KH, Stulak JM, Wigger MA, Maltais S. Institutional volume of heart transplantation with left ventricular assist device explantation influences graft survival. J Heart Lung Transplant 2014; 33:931-6. [PMID: 24925183 DOI: 10.1016/j.healun.2014.04.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2013] [Revised: 02/12/2014] [Accepted: 04/30/2014] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND There are increasing numbers of patients undergoing orthotopic heart transplantation (OHT) with left ventricular assist device (LVAD) explantation (LVAD explant-OHT). We hypothesized that LVAD explant-OHT is a more challenging surgical procedure compared to OHT without LVAD explantation and that institutional LVAD explant-OHT procedural volume would be associated with post-transplant graft survival. We sought to assess the impact of institutional volume of LVAD explant-OHT on post-transplant graft survival. METHODS This is a retrospective analysis of the Scientific Registry of Transplant Recipients for adult OHTs with long-term LVAD explantation. LVAD explant-OHT volume was characterized on the basis of the center's year-specific total OHT volume (OHTvol) and year-specific LVAD explant-OHT volume quartile (LVADvolQ). The effect of LVADvolQ on graft survival (death or re-transplantation) was analyzed. RESULTS From 2004 to 2011, 2,681 patients underwent OHT with LVAD explantation (740 with HeartMate XVE, 1,877 with HeartMate II and 64 with HeartWare devices). LVAD explant-OHT at centers falling in the lowest LVADvolQ was associated with reduced post-transplant graft survival (p = 0.022). After adjusting for annualized OHTvol (HR = 0.998, 95% CI 0.993 to 1.003, p = 0.515 and pulsatile XVE (HR = 0.842, 95% CI 0.688 to 1.032, p = 0.098), multivariate analysis confirmed a significantly (approximately 37%) increased risk of post-transplant graft failure among explant-OHT procedures occurring at centers in the lowest volume quartile (HR = 1.371, 95% CI 1.030 to 1.825, p = 0.030). CONCLUSION Graft survival is decreased when performed at centers falling in the lowest quartile of LVAD explant-OHT for a given year. This volume-survival relationship should be considered in the context of limited donor organ availability and the rapidly growing number of LVAD centers.
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Affiliation(s)
- Nicholas A Haglund
- Division of Cardiology, Vanderbilt University Medical Center, Nashville Tennessee
| | - Irene D Feurer
- Department of Surgery, Vanderbilt University Medical Center, Nashville Tennessee; Department of Biostatistics, Vanderbilt University Medical Center, Nashville Tennessee
| | - Rashid M Ahmad
- Division of Cardiovascular Surgery, Vanderbilt University Medical Center, Nashville Tennessee
| | - Thomas G DiSalvo
- Division of Cardiology, Vanderbilt University Medical Center, Nashville Tennessee
| | - Daniel J Lenihan
- Division of Cardiology, Vanderbilt University Medical Center, Nashville Tennessee
| | - Mary E Keebler
- Division of Cardiology, Vanderbilt University Medical Center, Nashville Tennessee
| | - Kelly H Schlendorf
- Division of Cardiology, Vanderbilt University Medical Center, Nashville Tennessee
| | - John M Stulak
- Division of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Mark A Wigger
- Division of Cardiology, Vanderbilt University Medical Center, Nashville Tennessee
| | - Simon Maltais
- Division of Cardiovascular Surgery, Vanderbilt University Medical Center, Nashville Tennessee.
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Maltais S, Jaik NP, Feurer ID, Wigger MA, DiSalvo TG, Schlendorf KH, Ahmad RM, Lenihan DJ, Stulak JM, Keebler ME. Mechanical circulatory support and heart transplantation: donor and recipient factors influencing graft survival. Ann Thorac Surg 2013; 96:1252-1258. [PMID: 23915592 DOI: 10.1016/j.athoracsur.2013.05.043] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Revised: 05/07/2013] [Accepted: 05/10/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Mechanical circulatory support is an accepted strategy to bridge patients to heart transplantation (HTx). Among mechanical circulatory support patients who go on to HTx, factors associated with improved graft survival have not been fully elucidated. METHODS Using the Scientific Registry for Transplant Recipients, we identified adults who were treated with a left ventricular assist device (LVAD) or total artificial heart (TAH) before HTx. Kaplan-Meier and multivariate Cox regression models were used to identify patient, donor, and device characteristics associated with graft survival. RESULTS Between January 1997 and February 2012, 2,785 adults underwent HTx. Before HTx, 2,674 patients were treated with a LVAD (HeartMate XVE, 724; HeartMate II, 1,882; HeartWare, 68), and 111 were treated with a TAH. Follow-up averaged 25 ± 24 months. Gender mismatch occurred in 23%. Graft survival did not differ between LVAD groups (all p > 0.168), but TAH was associated with reduced graft survival compared with LVADs (p < 0.001). After controlling for device type (LVAD vs TAH), lower recipient pulmonary vascular resistance, shorter ischemic time, younger donor age, donor-to-recipient gender match, and higher donor-to-recipient body mass index ratio were independent predictors of longer graft survival (all p < 0.05). CONCLUSIONS TAH was associated with reduced graft survival after transplant, and survival did not differ between the LVAD device groups. Additional variables that were independently associated with graft survival were donor age, recipient peripheral vascular resistance, ischemic time, gender match, and donor-to-recipient body mass index ratio. Recognition of these factors may inform decisions regarding device support and donor suitability.
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Affiliation(s)
- Simon Maltais
- Division of Cardiovascular Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Nikhil P Jaik
- Division of Cardiovascular Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Irene D Feurer
- Department of Surgery and Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mark A Wigger
- Department of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Thomas G DiSalvo
- Department of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kelly H Schlendorf
- Department of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rashid M Ahmad
- Division of Cardiovascular Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Daniel J Lenihan
- Department of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John M Stulak
- Division of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Mary E Keebler
- Department of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
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Maltais S, Jaik NP, Feurer I, Wigger MA. Donor-related Characteristics in Patients with Mechanical Circulatory Support Undergoing Heart Transplantation: Factors that Really Influence Survival. J Card Fail 2012. [DOI: 10.1016/j.cardfail.2012.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Umakanthan R, Hoff SJ, Solenkova N, Wigger MA, Keebler ME, Lenneman A, Leacche M, DiSalvo TG, Ooi H, Naftilan AJ, Byrne JG, Ahmad RM. Benefits of ambulatory axillary intra-aortic balloon pump for circulatory support as bridge to heart transplant. J Thorac Cardiovasc Surg 2012; 143:1193-7. [DOI: 10.1016/j.jtcvs.2012.02.009] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2011] [Revised: 01/13/2012] [Accepted: 02/03/2012] [Indexed: 11/30/2022]
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Nawar MA, Rashid A, Criswell R, Hoff S, DiSalvo TD, Wigger MA. BRIDGE TO A BRIDGE: INTERMEDIATE-TERM CIRCULATORY SUPPORT WITH THE AXILLARY INTRA-AORTIC BALLOON PUMP. J Am Coll Cardiol 2011. [DOI: 10.1016/s0735-1097(11)60317-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
The pharmacokinetics and effect of hemodialysis on the clearance of ganciclovir were evaluated in a patient with cytomegalovirus (CMV) retinitis and pneumonitis requiring dialytic support. A dose of 300 mg ganciclovir (5 mg/kg) was administered by intravenous infusion over a 60-minute period. Blood samples were obtained over the next 10 hours and used to assess plasma ganciclovir concentrations. The patient underwent hemodialysis the following day during which paired arterial and venous blood samples were obtained to determine dialyzer clearance of this antiviral agent. High-performance liquid chromatography was used to quantify ganciclovir plasma concentrations. Ganciclovir levels declined in a monoexponential manner following infusion and prior to dialysis. The patient's peak ganciclovir concentration was markedly elevated (20 micrograms/mL) compared with previously reported peak concentrations in patients with normal renal function. Similarly, the elimination half-life (t1/2) was increased (6.3 hours) in this patient compared with values reported in patients with normal renal function. The volume of distribution (0.21 L/kg) and total body clearance prior to hemodialysis (35.5 mL/min) were diminished in this patient. Hemodialysis reduced ganciclovir levels by approximately 62% with an extraction coefficient of 0.29 resulting in a dialyzer clearance of 48.3 mL/min. This supports supplementation of ganciclovir in patients receiving this antiviral agent when they are undergoing hemodialysis. Additionally, close monitoring of ganciclovir concentrations in patients with abnormal renal function is necessary in order to make appropriate dosage adjustments.
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Affiliation(s)
- S K Swan
- Division of Nephrology and Hypertension, Oregon Health Sciences University, Portland 97201
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