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Robert J Gajarski,
Elizabeth D Blume,
Simon Urschel,
Kenneth Schechtman,
Jie Zheng,
Lori J West,
Louis Altamirano,
Shelley Miyamoto,
David C Naftel,
James K Kirklin, Mary C Zamberlan,
Charles E Canter
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ABSTRACT: Variable rates of malignancy and early infection have previously been reported in heart transplant (HTx) recipients who received induction therapy. This study hypothesized that induced pediatric patients would have an increased risk of these events compared with non-induced patients.
Data from a prospective, multicenter event-driven registry of outcomes after HTx listing in patients aged < 18 years was used to analyze risks of infection and malignancy and their association with induction between January 1993 and December 2007.
Of 2,374 patients, 1,258 (53%) received induction and more frequently from 1999 to 2008 compared with 1993 to 1998 (70.8% vs 57.5%, p < 0.001). At HTx, induced patients were more likely to have congenital heart disease (56.9% vs 48.1%, p < 0.001) but no more likely to be positive for Epstein-Barr virus (50.3% vs 51.4%, p = 0.67). Post-transplant lymphoproliferative disease (PTLD) was the most common malignancy (n = 92) within 5 years of HTx. Patients who received induction had a lower risk for PTLD (hazard ratio [HR], 0.5; 95% confidence interval [CI], 0.3-0.84; p = 0.009) and early fungal infections (HR, 0.60; 91% CI, 0.40-0.91; p = 0.016). Among induction agents used, OKT3 was associated with lowest freedom from PTLD and fungal/cytomegalovirus infection.
Induction use has increased since 1999 and has not been associated with an increased risk of malignancy (predominantly PTLD) or overall infection. Because these adverse events occurred with higher rates in non-induced patients, it is likely that induction alone is not the primary risk determinant for PTLD and infection.
The Journal of heart and lung transplantation: the official publication of the International Society for Heart Transplantation 03/2011; 30(3):299-308. · 3.54 Impact Factor
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ABSTRACT: Transplant coronary artery disease (TCAD) is the limiting factor to long-term cardiac allograft survival; however, presymptomatic diagnosis remains challenging. To that concern, we evaluated the association of abnormal catheter-derived filling pressures with TCAD in pediatric heart transplant (HTx) recipients. DESIGN, PATIENTS, OUTCOME MEASURES: Data from 52 presymptomatic pediatric HTx patients were analyzed. Catheter-derived right ventricular end-diastolic pressure (RVEDP) and pulmonary capillary wedge pressure (PCWP) were recorded. Biopsies were collected to verify the absence of rejection.
TCAD was diagnosed an average of 8.3 years post-HTx in 20 (38%) patients, six of whom died and four of whom underwent retransplantation. Catheter-derived pressure measurements showed that RVEDP was elevated in TCAD compared with non-TCAD patients (9.5 ± 6.0 vs. 5.4 ± 4.7; P= .005), as was the PCWP (12.9 ± 5.7 vs. 9.1 ± 5.7; P= .012). Results from logistic regression analysis showed RVEDP > 10 mm Hg or PCWP > 12 mm Hg was associated with TCAD (OR = 5.2; P= .010).
In this series, elevated ventricular filling pressures measured during routine surveillance catheterizations were associated with angiographic TCAD. Recognizing the association between elevated RVEDP/PCWP and TCAD may prompt earlier diagnosis and treatment of this potentially lethal process.
Congenital Heart Disease 03/2011; 6(2):128-33. · 0.90 Impact Factor
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ABSTRACT: To determine the correlation between mycophenolate mofetil (MMF) dose and mycophenolic acid (MPA) level as well as its impact on rejection among young cardiac transplant recipients (OHT), trough concentrations of MPA and its metabolite, mycophenolic acid glucuronide (MPAG), were measured following MMF doses of 1200 mg/m2/d (max 3000 mg/d). Corresponding endomyocardial biopsy (EMB) grades and calcineurin inhibitor levels were recorded with simultaneous MPA/MPAG levels. Correlation coefficients were derived between MMF dose and MPA/MPAG levels. Contingency analysis evaluated the relation between MPA level and EMB score. Twenty-six patients (median age 15.4 years) had 120 MPA/MPAG levels measured. Average MMF dose was 1208.8 mg/m2/d with median MPA and MPAG concentrations: 2.1 (therapeutic: 1.0-3.5 microg/mL) and 48 microg/mL (reference range: 35-100 microg/mL), respectively. Only 50% of patients consistently achieved therapeutic levels with standard dosing. No correlation was found between MMF dose and MPA/MPAG levels. In the presence of therapeutic calcineurin inhibition, EMB grade > or = 2 occurred more with MPA concentrations < 2.5 microg/mL (p = 0.01). In young OHT patients, MMF dose does not correlate with MPA/MPAG levels, and standard MMF dosing fails to consistently achieve 'therapeutic' MPA concentrations. An MPA trough level < 2.5 microg/mL was more frequently associated with EMB grade > or = 2. Concentration rather than dose-driven management is a more prudent strategy when using MMF.
American Journal of Transplantation 10/2004; 4(9):1495-500. · 6.39 Impact Factor
