Outcome of patients surviving to heart transplantation after being mechanically bridged for more than 100 days.

OBJECTIVE: The effect of long-term mechanical support on subsequent heart transplantation is still debated. METHODS: We report the outcome of 41 patients (42 +/- 12 years) bridged with left ventricular assist devices (VAD; 28 Novacor, 9 HeartMate, 2 Thoratec, and 2 DeBakey) for >100 days (218 +/- 76 days) between April 1994 and March 2000). We compared follow-up with 146 patients (55 +/- 13 years) who underwent heart transplantation during the same time without prior long-term mechanical support. RESULTS: Thirty-two of the 41 patients (78%) underwent heart transplantation, 9 patients (22%) died of multi-organ (n = 5), cardiac (n = 2), or cerebral failure (n = 2). Thirty-day post-transplant mortality includes 5 cases (3 graft failures). Within the following 2 years, another 5 patients expired, 2 of cardiac failure/sudden death. Currently, 21 of 41 patients (51%) are still alive 10 to 77 months (41 +/- 22 months) after heart transplantation (1 patient was lost for follow-up). One-year and 5-year survival rates were compared with the control group (VAD vs control, 1-year survival was 75% vs 74% and 5-year survival was 60% vs 66%). Fifteen patients are doing well in New York Heart Association Class I), and 6 are NYHA Class II despite normal left ventricular ejection fraction. Episodes of moderate acute rejection (International Society for Heart and Lung Transplantation Grade 3) occurred in 10 patients (1.3 episodes per patient), not significantly different from that of the control group (1.2 episodes per patient). Scintigraphy showed regional myocardial ischemia/transplant vasculopathy in 4 patients, and coronary angiography detected the same in 2. One patient has undergone successful retransplantation. Two patients had increased right ventricular pressure. Six patients had impaired kidney function, and 3 had impaired liver function. Seven patients experienced cytomegalovirus infection. CONCLUSIONS: Our data indicate that patients who underwent heart transplantation after long-term mechanical support have a similar survival rate and comparable cardiac morbidity associated with acute rejection episodes.     

Early and midterm risk of coronary allograft vasculopathy in patients bridged to orthotopic heart transplantation with ventricular assist devices

BACKGROUND: Coronary transplant vasculopathy (CAV) has been associated with both immunologic and nonimmunologic factors. The impact of preoperative ventricular assist device (VAD) support on the development of CAV has not been studied. To examine this, we obtained posttransplant coronary angiograms from a group of patients bridged with VAD and compared them to post transplant coronary angiograms of a non-VAD cohort. METHODS: Adult patients undergoing orthotopic heart transplant between 1996-2000 were retrospectively studied and divided into VAD and non-VAD patients. Coronary angiograms were retrospectively reviewed and severity of coronary vasculopathy was categorized as trivial, mild, moderate, or severe. Other variables studied included recipient and donor demographics, cytotoxic panel reactive antibodies (PRA) against T-cell targets and flow cytometric crossmatching against donor T lymphocytes. RESULTS: There was no significant difference between groups regarding demographics. However, VAD patients had a sixfold greater chance of having a T-cell PRA >10% at the time of transplant (p < 0.05), and a fourfold greater chance of having a positive cross match when compared to non-VAD patients (p < 0.05). There was no significant difference in the degree of CAV between groups. Normal coronary anatomy was present in 76% of VAD patients and 64% of non-VAD patients (p = 0.37). These results were similar at 2- and 3-year follow-up (76 vs. 74% and 80 vs. 62%, respectively). CONCLUSION: Preoperative VAD use is associated with increased sensitization; however, these patients develop CAV at the same rate as those not bridged with a VAD.     

Risk factors for lymphoproliferative disorders after liver transplantation in adults: an analysis of 480 patients

BACKGROUND: Posttransplant lymphoproliferative disorder (PTLD) is a well-known complication of organ transplantation that leads to death in more than 50% of cases. The aim of this work was to identify specific risk factors for lymphoproliferative disorders after liver transplantation in adults. METHODS: A total of 480 consecutive patients who underwent transplantation between 1986 and 1997 were studied (323 men, 157 women; mean age: 49.8+/-10.4 years). Demographics, the indication for transplantation, the immunosuppressive regimens, the incidence of rejection episodes, and Epstein-Barr virus infection were analyzed. Univariate and multivariate analysis were used to identify factors predictive of PTLD. RESULTS: Sixteen cases of PTLD (3.3%) occurred at a median of 5.5 (range, 1-39) months after liver transplantation. All 16 cases occurred in patients with evidence of exposure to Epstein-Barr virus before transplantation. In multivariate analysis, the use of antilymphocyte antibodies (P=0.007, relative risk [RR]=4.2, 95% confidence interval [CI]=1.5-11.7), age older than 50 years (P=0.037, RR=3.5, 95% CI=0.95-13.0), liver transplantation for hepatitis C virus cirrhosis (P=0.015, RR=8.7, 95% CI=1-78.3), and liver transplantation for alcoholic cirrhosis (P=0.015, RR=9.6, 95% CI=1.2-77.2) were independently associated with the onset of PTLD. CONCLUSION: Liver transplantation for hepatitis C virus-related and alcoholic cirrhosis and age older than 50 years are three additional risk factors for lymphoproliferative disorder independent of the use of antilymphocyte antibodies. The use of antilymphocyte antibodies after liver transplantation should be avoided in these categories of patients, especially those older than 50 years.     

肝移植术后应用利奈唑胺对血小板的影响

目的分析肝移植术后应用利奈唑胺的不良反应及对患者预后的影响,评价其发生血小板减少的风险及治疗的有效性和安全性。方法选取2007年9月至2009年6月在本院肝移植中心行肝移植的患者85例,采取随机、对照的方法分为利奈唑胺组和万古霉素组,以治疗前、治疗后第3天、第5天、第7天、治疗结束以及治疗结束后第7天等6个时间点,分别从临床特征、血小板计数、发生血小板减少患者的累计发生率、临床疗效和细菌学检查结果等方面进行对比分析。结果随着用药时间的延长,两组患者平均血小板数量无减少的趋势,利奈唑胺组用药前及治疗结束后血小板计数分别为（71.25±11.01）×109/L和（86.74±11.60）×109/L;万古霉素组用药前及治疗结束后分别为（62.0±19.11）×109/L和（85.2±12.73）×109/L,两组差异无统计学意义;用药前后发生血小板减少的患者累计发生率两组的差异无统计学意义（利奈唑胺组2.3%,万古霉素组2.5%）,其中利奈唑胺组45%的患者血小板计数无明显变化或增加,万古霉素组47%的患者血小板计数无明显变化或增加。通过临床疗效及细菌学疗效对比,利奈唑胺组和万古霉素组的有效性差异也无统计学意义。其中临床疗效的有效率分别为90.9%和92.5%,细菌学疗效的有效率分别为91.8%和92.8%。结论与万古霉素相比,在肝移植术后发生革兰阳性球菌的患者中使用利奈唑胺并不会引起血小板的减少,其安全性及有效性与万古霉素相似。     

Risk of colorectal neoplasia in patients with solid organ transplantation

The incidence of colorectal adenomas and advanced neoplasia in the transplant population has not been well characterized. The aim of this study was to determine whether or not there was an increased incidence of colorectal adenomas and advanced neoplasia in solid organ transplantation (SOT) recipients compared with an average-risk population. We reviewed 360 patients with solid organ transplants who underwent colonoscopy between February 1995 and July 2008, and 360 age- and gender-matched patients in an average-risk population. The mean duration from transplantation to colonoscopy in the SOT group was 40.4 ± 34.0 months. Ninety-three (25.8%) adenomas were detected in the SOT group, while 98 (27.2%) adenomas were detected in the control group (p = 0.763). There was a statistically significant difference (p < 0.0001) in the number of patients with advanced neoplasia in the SOT group (24 patients [6.7%]) compared with the control group (3 patients [0.8%]). The independent risk factors of advanced neoplasia were old age (odds ratio [OR], 1.067; 95% CI, 1.019-1.118) and transplantation (OR, 6.069; 95% CI, 1.455-25.314). In summary, there was a significant increase in the incidence of advanced colorectal neoplasia in SOT recipients. The reason for this finding is unclear, and studies with a larger number of patients are needed to further evaluate this group.     

Risk factors for mortality in diabetic nephropathy patients accepted for transplantation

BACKGROUND: There is a high incidence of silent coronary artery disease (CAD) in patients with diabetes. We wanted to investigate risk factors for mortality, and especially CAD, in a well-defined cohort of diabetic nephropathy transplant candidates accepted for transplantation. METHODS: From 1999 through 2004, 155 patients underwent work up for living or deceased kidney (KA) or simultaneous pancreas-kidney (SPK) transplantation. The work up included coronary angiography for all patients and 136 were accepted. Mean (SD) age was 50 (12) years, 62% had type 1 diabetes, 73% were males, and 34% were on dialysis. Mean follow-up from time of acceptance for transplantation was 3.6 (1.9) years. RESULTS: Survival of KA transplanted patients was 97% at 1 year, 89% at 3 years, and 76% at 5 years, whereas in SPK patients 100%, 94%, and 90%, respectively (P=0.065). One- and 3- year survival was only 57% and 20% in those remaining wait-listed (P<0.001). In univariate analysis mortality was associated with KA transplantation (hazard ratio [HR]=0.30, P=0.011) and SPK transplantation (HR=0.10, P=0.001), and age (HR=1.04, P=0.014). In multivariable analysis, KA transplantation (HR=0.28, P=0.006), SPK transplantation (HR=0.09, P=0.001), age (HR=1.06, P=0.002), type 2 diabetes (HR=0.14, P=0.003), and duration of diabetes (HR=0.94, P=0.019) were parameters associated with mortality. CONCLUSIONS: The only modifiable risk factor was transplantation with risk reduction up to 90%. CAD was not a risk factor for mortality when medically treated and revascularized according to standard guidelines.     

肺移植术后中心气道狭窄危险因素分析

目的 探讨肺移植术后发生中心气道狭窄的危险因素.方法 回顾性分析2016年7月至2017年12月在南京医科大学附属无锡人民医院接受肺移植的155例受者的临床资料.根据术后中心气道狭窄的发生情况,将受者分为狭窄组(36例)和对照组(119例),总结肺移植术后中心气道狭窄的发生情况;采用单因素和多因素logistic回归分...     

Acute myocarditis supported by extracorporeal membrane oxygenation successfully bridged to transplantation: a giant cell myocarditis

Giant cell myocarditis is a rare and fatal heart disease in previously healthy young patients. We report the case of a 43-year-old patient presenting unstable acute congestive heart failure as a consequence of myocarditis who was supported for four days by an extracorporeal membrane oxygenation. While no cardiac recovery was observed and no viral and autoimmune causes of myocarditis were found, he underwent successful orthotopic heart transplantation in emergency. Giant cell myocarditis was diagnosed on the explanted heart. The patient has been on a triple-immunosuppression therapy with no signs of recurrence of the disease or rejection 16 months after surgery. This experience is compared with published cases and implication of diagnosis and treatment are discussed.     

Obesity in renal transplantation: analysis of 2691 patients

OBJECTIVE: Obesity is a cardiovascular risk factor in renal transplantation (RT). The objective of this study was to analyze the prevalence of post-RT obesity and risk factors associated with its development. PATIENTS AND METHODS: The study included all patients with a functioning renal transplant on December 31, 2003, who were residents of Catalonia, aged older than 14 years and who underwent transplantation between 1990 and 2003 (n = 2793); 102 patients (3.7%) were excluded due to lack of data for 1 or more study variables. Mean age was 53 +/- 14 years (range, 15-83) (61% men). Mean transplant duration was 63.0 +/- 44.5 months (range, 0-168). The chi-square test was used to compare proportions, analysis of variance (ANOVA) to compare mean values, and logistic regression to study risk factors for post-RT obesity. All data were taken from the Renal Registry of Catalonia (RMRC). RESULTS: Among RT patients, 38% were overweight (body mass index [BMI], 25-29.9 kg/m(2)) and 16% were obese (BMI >30). Prevalence of obesity was higher in women (21% vs 13%; P < .0001). Age was associated with obesity in RT patients aged 45-64 (20%) and 65-74 (18%) with respect to the group aged 15-44 years (9%) or >74 years (13%) (P < .0001). A total of 26% of patients who were normal weight before RT (BMI, 20-24.9) became overweight post-RT and 6% developed obesity (P < .0001). Among patients who were overweight pre-RT, 68% persisted with post-RT excess weight and 16% progressed to obesity (P < .0001). In the multivariate study, significant risk factors for developing post-RT obesity included the following: female (relative risk [RR], 2.46; P < .0001), age (45-64 years; RR, 2.36; P < .0001; and 65-74 years; RR, 2.23; P = .002), high blood pressure (RR, 1.44; P = .03), duration of transplant (RR, 1.06; P < .0001), cardiomyopathy (RR, 1.51; P = .007), and, particularly, the presence of excess weight (RR, 2.69; P < .0001) and pre-RT obesity (RR, 59.02; P < .0001). CONCLUSIONS: There is a high prevalence of post-RT excess weight and obesity. Adequate control of cardiovascular risk in renal transplant recipients should also include strict measures to prevent and treat obesity.