Orthotopic liver transplantation in patients 60 years of age and older

Cyclosporine appears to have abrogated age as a contraindication to kidney transplantation in the elderly, although it is unclear whether this is true for other types of solid organ transplantation. We performed a retrospective analysis of liver transplant recipients who were 60 years of age and older (n = 23) versus recipients of primary transplants who were 18 to 59 years of age (n = 84). Indications in recipients over 60 included alcoholism (6), postnecrotic cirrhosis (6), cancer (4), primary biliary cirrhosis (3), sclerosing cholangitis (2), and one patient with polycystic liver disease. There were no important differences in the initial transplant hospitalization or the incidence of infection and rejection between the two groups. No patient in the over-60 population required retransplantation. Actuarial patient survival is 83% at 2 years for recipients 60 years of age and above compared to 76% patient survival in adult recipients who are under the age of 60. Liver transplant recipients over the age of 60 years have excellent patient and graft survival and the same postoperative morbidity as recipients who are under 60 years of age. Therefore, advanced age does not appear to be a contraindication to orthotopic liver transplantation.     

Cadaveric renal transplantation with cyclosporine in patients more than 60 years of age

Advanced age has been a relative contraindication to kidney transplantation because of the likelihood of increased morbidity and mortality in the geriatric population. However, the introduction of cyclosporine has improved renal allograft survival rates dramatically, and higher-risk patients are now being successfully transplanted. With the introduction of cyclosporine in 1983, we have performed 36 cadaveric renal transplants in 34 recipients 60 years of age or older, including 34 primary and 2 retransplants. Most of the patients (88%) were on dialysis prior to transplantation and 29% had ASCVD. Three-year actuarial patient and allograft survival are 91% and 74%, respectively. Surgical complications were infrequent, and postoperative rejection episodes were less frequent than in younger patients but were more likely to lead to graft loss. Medical complications, especially infection, were common after transplantation but easily managed. Cadaveric renal transplantation with cyclosporine immunosuppression is a safe and effective therapeutic modality that is no longer contraindicated in elderly patients.     

Cardiac transplantation beyond 55 years of age

Abstract. Between January 1985 and December 1988, 20 patients over the age of 55 years (extremes 56–63 years; 15 men and 5 women) underwent cardiac transplantation. The cause of cardiopathy was ischemic in 70% of the cases. The immunosuppressive regimen consisted of cyclosporin A, corticoids, and azathioprine. Rejection episodes were monitored by endomyocardial biopsies and treated by pulses of corticoids or monoclonal antibodies (OKT3). The operative mortality was 10% ( n = 2). The 1-year survival rate was 70%. The 1-year incidence of infection and/or rejection episodes was 1 and 1. 53 episodes/patient, respectively. One patient was successfully retransplanted after 9 months because of intractable rejection. Age beyond 55 years is no longer a contraindication to cardiac transplantation. This change in recipient selection policy should lead to parallel changes in donor selection criteria.     

Renal transplantation for patients 60 years of older. A single-institution experience.

OBJECTIVE: The authors reviewed renal transplant outcomes in recipients 60 years of age or older. BACKGROUND: Before cyclosporine, patients older than 45 years of age were considered to be at high risk for transplantation. With cyclosporine, the age limits for transplantation have expanded. METHODS: The authors compared patient and graft survival, hospital stay, the incidence of rejection and rehospitalization, and the cause of graft loss for primary kidney recipients 60 years of age or older versus those 18 to 59 years of age. For those patients > or = 60 years transplanted since 1985, the authors analyzed pretransplant extrarenal disease and its impact on post-transplant outcome. In addition, all surviving recipients > or = 60 years completed a medical outcome survey (SF-36). RESULTS: Patient and graft survival for those > or = 60 years of age versus those 18 to 59 years of age were similar 3 years after transplant. Subsequently, mortality increased for the older recipients. Death-censored graft survival was identical in the two groups. There were no differences in the cause of graft loss. Those 60 years of age or older had a longer initial hospitalization, but had fewer rejection episodes and fewer rehospitalizations. Quality of life for recipients 60 years of age or older was similar to the age-matched U.S. population. CONCLUSION: Renal transplantation is successful for recipients 60 years of age or older. Most of them had extrarenal disease at the time of transplantation; however, extrarenal disease was not an important predictor of outcome and should not be used as an exclusion criterion. Post-transplant quality of life is excellent.     

A comparative analysis of outcome after heart transplantation in patients aged 60 years and older: the University of Alberta experience

BACKGROUND: The Registry of the International Society for Heart and Lung Transplantation (ISHLT) 2001 Annual Report indicated that the vast majority of heart transplant recipients are between 50 and 64 years of age. However, patient age beyond 60 years may have higher long-term mortality compared to younger patients. The purpose of this study was to compare short- and intermediate-term results including rates of acute rejection, transplant coronary artery disease, infections, malignancy, and mortality in cardiac transplant recipients 60 years or older with those below the age of 60 years. METHODS: We retrospectively analyzed the results of 50 patients aged 60 years and older who underwent heart transplantation at the University of Alberta from January 1990 to December 2000 and compared them with the results of 225 younger patients undergoing heart transplantation in the same time period. RESULTS: The older and younger groups had similar rates for treated acute rejection episodes (20.0% vs. 12.6%), transplant coronary artery disease (4.0% vs. 1.1%), and mortality (10.5% vs. 14.3%), respectively. No differences were noted with regards to quality and quantity of infection or malignancy rates. Five-year actuarial survival between the older and younger patients was also comparable at 89.5% vs.86.9% (p > 0.05). CONCLUSIONS: Heart transplantation in patients 60 years of age and older can be performed as successfully as in younger patients (< 60 years) with comparable morbidity and mortality, suggesting that patient age per se should not be an exclusion criterion for heart transplantation.     

Cadaveric renal transplantation with quadruple immunosuppression in patients with a positive antiglobulin crossmatch

The significance of the antiglobulin crossmatch in the cyclosporine era remains controversial. Over an 11-month period, 124 recipients of cadaveric renal allografts (109 primary, 15 nonprimary) were retrospectively crossmatched via the antiglobulin technique. Criteria for recipient selection for transplantation included a negative T lymphocytotoxic (CDC) crossmatch for current and historical sera. Fourteen patients (11.3%) underwent transplantation in the setting of a negative T and positive antiglobulin crossmatch. The patient group included 10 female and 4 male patients with a mean age of 43.8 years. All but one patient received a primary transplant, and current sera were positive in the antiglobulin crossmatch in all cases. The mean HLA-ABDR match was 1.4 (range 0-4). Preoperative PRA titers ranged from 0 to 80% (mean 18.3%). All patients underwent successful renal transplantation with quadruple immunosuppression consisting of prednisone, azathioprine, and the sequential use of MALG/cyclosporine. There were no episodes of hyperacute rejection. However, 10 patients (71.4%) experienced acute rejection, including 7 episodes within 4 days of transplant. Early rejection was significantly more common in patients with a positive antiglobulin test (50% vs. 20.9%, P less than 0.05). The mean one-month serum creatinine was 1.7 mg/dl. Actual patient and allograft survival are 92.9% and 85.7%, respectively. Risk factors for a positive antiglobulin crossmatch included female sex and prior sensitization as measured by PRA. Although these patients represent a high-risk group for early rejection, no adverse effect on patient or graft survival was noted with quadruple immunotherapy. In conclusion, a positive antiglobulin crossmatch is no longer a contraindication to renal transplantation with current immunosuppressive strategies.     

Pediatric heart transplantation 1990]

In this presentation the author updates the progress made in pediatric cardiac transplantation through a review of the results obtained at Ste-Justine Hospital (SJH) and of the recent literature. Of 56 children referred to SJH for cardiac transplantation, 27 met the selection criteria; 10 died before receiving a new heart and 2 are still awaiting transplantation. Fifteen children, aged 3 to 16 years, have received a transplant. Ten of them had 32 birth defects, all of which were repaired at the time of transplantation thanks to improved graft removal methods and innovative surgical techniques. This study demonstrates that birth defects are not a contraindication to cardiac transplantation in children. Triple-drug immunosuppression was used, and the cyclosporine blood levels were maintained in the range of 100 to 200 ng/mL. Survival at 2 years was 78%. Episodes of acute rejection occurred at a rate of 0.5 per patient, 85% of them within the first 3 months after transplantation. Adequate renal function was preserved (creatinine clearance between 89 and 102 mL/min.m-2). The use of low-dose cyclosporine might explain in part the lack of significant nephrotoxicity. Reversible high blood pressure was observed in 5 of 13 patients during the first 6 months postoperatively. Multifactorial analysis identified, as a likely cause, a higher dose of steroids and cyclosporine during this period. Annual coronary angiography did not reveal any lesion, and apart from the acute rejection episodes, cardiac function was normal at rest, and the transplanted children have maintained an excellent level of activity.(ABSTRACT TRUNCATED AT 250 WORDS)     

Cardiac transplantation beyond 55 years of age

Between January 1985 and December 1988, 20 pateints over the age of 55 years (extremes 56–63 years; 15 men and 5 women) underwent cardiac transplantation. The cause of cardiopathy was ischemic in 70% of the cases. The immunosuppressive regimen consisted of cyclosporin A, corticoids, and azathioprine. Rejection episodes were monitored by endomyocardial biopsies and treated by pulses of corticoids or monoclonal antibodies (OKT3). The operative mortality was 10% (n=2). The 1-year survival rate was 70%. The 1-year incidence of infection and/or rejection episodes was 1 and 1.53 episodes/patient, respectively. One patient was successfully retransplanted after 9 months because of intractable rejection. Age beyond 55 years is no longer a contraindication to cardiac transplantation. This change in recipient selection policy should lead to parallel changes in donor selection criteria.     

Renal transplantation outcomes: a comparative analysis between elderly and younger recipients

Renal transplantation is presently the best treatment for end-stage renal disease, although considered contraindicated for elderly patients. However, more investigation is needed due to higher life expectancy rates of the general population and the increasing number of over 60-yr-old patients with chronic renal failure dependent upon dialysis. This study aims to determine graft and patient survival rates of renal transplant patients 60 yr and older compared to a younger group (50-59 yr old). Relevant pre- and post-transplant clinical data related to graft and patient survival in both groups were also investigated. Three-hundred and twenty consecutive renal transplant patients were enrolled in this study and grouped based on age at the time of the transplantation: one-hundred and ten patients at or over 60 yr old (elderly group) and 210 patients ranging from 50 to 59 yr old (younger group). There were no statistical differences in either group regarding clinical characteristics and immunological risk factors. The incidence of acute rejection was higher in the younger group (37.6%) than in the elderly (22.7%) (p = 0.01). Censored to death graft survivals at five yr were respectively 86.7% for patients > or = 60 yr and 82.1% for patients 50-59 yr old (p = 0.49). Patient survival rates at five yr were respectively 76.2% for patients > or = 60 yr and 81.6% for patients 50-59 yr old (p = 0.33). Our data show that renal transplantation for elderly patients has similar results to those found in younger individuals, which does not make age, in and of itself, a contraindication for transplantation.     

Safety, tolerability and efficacy of cyclosporine microemulsion in heart transplant recipients: a randomized, multicenter, double-blind comparison with the oil based formulation of cyclosporine--results at six months after transplantation.

BACKGROUND: The introduction of cyclosporine has resulted in significant improvement in the survival of cardiac allograft recipients due to decreased mortality from infection and rejection. The original oil-based cyclosporine formulation exhibits variable and unpredictable bioavailability that correlates with an increased incidence of acute and chronic rejection in those patients in whom this is most pronounced. The primary objectives of this prospective, multicenter, randomized, double-blind study in cardiac transplant patients were: to compare the efficacy of cyclosporine microemulsion (CsA-NL) with oil-based cyclosporine (CsA-SM) as measured by cardiac allograft and recipient survival and the incidence and severity of acute rejection episodes; and to assess the safety and tolerability of CsA-NL compared with CsA-SM in this population. This report represents the analysis of results 6 months after transplantation. METHODS: A total of 380 patients undergoing their first cardiac transplant at 24 centers in the United States, Canada, and Europe were enrolled in this double-blind, randomized trial examining the safety and efficacy of CsA-NL versus CsA-SM. Rejection was diagnosed using endomyocardial biopsy and were graded according to standardized criteria of the International Society of Heart and Lung Transplantation (ISHLT). Clinical parameters were monitored during the study. Survival and freedom from were used for analysis as was Fisher's exact test for comparisons between groups. RESULTS: At 6 months after transplantation, allograft and patient survival were the same for both groups. The frequency of ISHLT grade 3A or greater episodes in the two groups was identical. Fewer CsA-NL patients (5.9%) required antilymphocyte antibody (ATG or OKT-3) therapy for rejection compared with the CsA-SM-treated patients (14.1%, P=0.01). Females with ISHLT rejection grade > or = 3A treated with CsA-NL had a 46% lower incidence of rejection compared with the CsA-SM-treated group (31.3% vs. 57.6%, P=0.032). Fewer infections were seen in the CsA-NL. With the exception of baseline and 1 week posttransplant creatinines which were higher in the CsA-NL group, the overall creatinine was not significantly different between the two groups. CONCLUSIONS: This multicenter, randomized study of cardiac transplant recipients documented less severe rejection (in particular those requiring antibody therapy) and a lower incidence of infection in CsA-NL-treated patients. Results from the female subgroup analysis suggest that the improved bioavailability of CsA-NL might reduce the frequency of rejection episodes in female patients. The use of CsA-NL was not associated with an increased risk of adverse events.     

Randomized prospective trial of OKT3 for early prophylaxis of rejection after liver transplantation

A group of 52 liver transplant patients was prospectively randomized to receive prophylactic immunosuppressive therapy consisting of either Orthoclone OKT3 for 14 days, azathioprine, and steroids (25 patients); or cyclosporine, azathioprine, and steroids (27 patients). The groups were similarly matched for age, diagnosis, and Child's classification. The patients were studied to determine the effect of these two regimens on the incidence of rejection, infection, renal dysfunction, and mortality. Seven rejection episodes, as determined by clinical and histological criteria, occurred in seven of 25 patients (28%) receiving OKT3 compared with 18 episodes in 27 patients (67%) receiving cyclosporine during the first 14 days after transplantation (P less than 0.02). In 20% of the OKT3 patients, CD3+ levels of greater than 10% developed during therapy, and 16% of the patients developed anti-OKT3 antibodies during OKT3 treatment. Five patients were retreated with OKT3 for steroid-resistant acute rejection episodes; all had resolution of the rejection episode. Infectious complications were similar in each group. Renal function, as measured by serum creatinine, was significantly better with OKT3 than with cyclosporine (P less than 0.003) at 14 days. We conclude that prophylactic OKT3 is effective in reducing the number of early rejection episodes after liver transplantation; after 14 days the incidence of rejection is similar; reuse of OKT3 has been successful in liver transplant patients; infectious complications are similar between OKT3 and cyclosporine; and OKT3 preserves renal function better than cyclosporine and is thus indicated in patients with compromised preoperative renal function.     

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.     

A successful cardiac transplantation program using combined university and community resources.

From August 1984 to August 1986, 75 patients with end-stage heart disease and cardiac failure were evaluated. Twenty-five patients received orthotopic cardiac transplants from donors as far away as 1300 miles with an ischemic time of less than 4 hours. Seventeen of 25 patients are alive 3-24 months after transplantation. Evidence of rejection was seen in each patient. Twelve patients had mild, easily controlled rejection; 13 patients had severe rejection averaging 3.1 episodes per patient. The initial immunosuppressive regimen included cyclosporine and prednisone. To decrease complications related to high dose steroids, azathioprine has recently been added to our maintenance regimen to lessen steroid requirements. Acute rejection episodes were treated with 500-1000 mg of methylprednisolone for 3 days; antithymocyte globulin or the murine monoclonal antibody, OKT3, was added for severe or resistant rejection episodes. Three patients died of rejection, and two patients died of infection. Seventeen of 18 survivors are New York Heart Association (NYHA) Class I; 15 patients have returned to employment or full activity. Because of new developments in support of transplant candidates and treatment of complications, as well as the introduction of cyclosporine, orthotopic cardiac transplantation has become an effective treatment for end-stage heart disease.     

老年患者的肝移植

目的探讨老年患者接受肝移植治疗的特点并分析其术后生存时间。方法2000年1月至2005年8月,共施行18岁以上成人首次肝脏移植1424例。将年龄≥60岁的211例受者分为老年组,其余的1213例受者为成年组。统计分析两组患者术前、术中指标及术后生存时间。结果单因素分析比较发现,老年组患者术前合并消化道出血的比例及术前血清胆红素总量、凝血酶原时间低于成年组,手术过程和无肝期时间较成年组略短。老年组术后急性排斥反应发生率(13.27%)和再次移植率(0.95%)低于成年组(19.37%,P=0.035;3.96%,P=0.028)。成年组术后6个月、1年、2年、3年、4年及5年累积生存率分别为88.67%、85.52%、77.53%、75.52%、73.77%和70.9%,老年组术后6个月、1年、2年及4年累积生存率分别为87.91%、83.42%、78.70%和40.14%,两组生存时间比较,差异无统计学意义(P=0.697)。对患者术后生存时间采用Cox比例风险模型进行多因素分析,影响肝移植术后生存时间的危险因素是:原发恶性肝病(P=0.000)、合并肝肾综合征(P =0.021)、供肝热缺血时间(P=0.046)以及术后发生感染(P=0.000)。结论高龄不再是肝移植的禁忌证,合理筛选适宜手术的老年受者可获得与成年受者相近的术后存活时间。     

Acyclovir plus CMV immunoglobulin prophylaxis and early therapy with ganciclovir are effective and safe in CMV high-risk renal transplant pediatric recipients

Cytomegalovirus (CMV) infection is still a major cause of morbidity in high-risk renal transplant recipients. In the present report, we have reviewed our records of renal transplant pediatric recipients (RTPR; mean age 14.1 ± 4.9 years) since 1991, when we started a policy of CMV prophylaxis constituting high-dose oral acyclovir plus CMV hyperimmune immunoglobulins (Hlg) followed by early i. v. ganciclovir therapy in high-risk patients (i. e., CMV donor + / recipient ?). Four patients received a kidney from a living relative (LR), 2 patients had one previous transplant, and 1 had a combined liver – kidney transplant. Thirty-three patients who were negative for CMV antibodies (ab) before transplantation received a kidney from CMV ab positive donors. The immunosuppressive regimen included cyclosporine A and steroids, with the addition of azathioprine in the 4 patients who received an LR kidney. Serial assessments for CMV antigenemia (pp 65) were routinely performed for 6 months after transplantation to define CMV infection. Among the 33 CMV seronegative recipients (R ?) who received the graft from a CMV seropositive donor (D +), 18 (54.5 %) experienced CMV infection, whereas among the 28 CMV R +, who received a graft from a CMV D +, 11 (39.3 %) experienced CMV infection. With regard to CMV ? related symptoms, only 2 patients suffered from a CMV syndrome (fever and leukopenia in 1 patient, fever and arthralgia in the other). In no case did the spectrum of CMV disease occur; only minor symptoms were present in 7 of the remaining CMV-infected patients (fever in 6 and leukopenia in 1). Rejection episodes and renal function did not differ between CMV-infected and non-CMV-infected patients. Our experiences support the use of prophylactic acyclovir plus CMV HIg followed by early therapy with i. v. ganciclovir to combat the risk of increased morbidity in high risk RTPR.     

Cardiac transplantation in the older recipient: excellent long-term survival based on pretransplant screening

BACKGROUND: Cardiac transplantation has become the established treatment of choice for eligible patients with end-stage congestive heart failure. Older recipients (over the age of 60) are sometimes regarded as too high risk for transplant. Because chronological age is frequently disparate from physiologic age, we hypothesized that with careful selection after a comprehensive screening evaluation we would be able to achieve comparable survival and quality of life in an older population. METHODS: Between January 1989 and December 2002, 240 de novo adult cardiac transplants were performed for 74 female and 176 male patients. Prior to listing for cardiac transplantation, the patients were evaluated to exclude significant comorbidities that would limit survival or functional capacity postsurgery. In patients over the age of 60, particularly rigorous testing was conducted to eliminate significant extracardiac disease. RESULTS: The patients are divided in this analysis into three groups based on age at transplant (age 18 to 45, 46 to 59, and 60 years or older). Older recipients experienced similar rates of moderately severe cellular rejection (ISHLT grade 3A/ B). Survival as derived by Kaplan-Meier analysis was equivalent for all groups by Mantel-Cox logrank test (P = NS). The survival for patients older than age 60 was 83.1%, 73.7%, 67.7%, 57.4%, and 43.1% at 1,3, 5, 7, and 10 years posttransplant, respectively. CONCLUSION: We conclude that chronological age over 60 years old should not exclude a patient from the potential long-term benefit of cardiac transplant, ensuring added longevity and excellent quality of life.     

Beneficial effects of cyclosporine compared with azathioprine in cadaveric renal transplantation

Recent reports have intimated that the use of antilymphocyte globulin in combination with azathioprine and steroids has ameliorated the beneficial affects of cyclosporine. We believe that even in the absence of significant statistical differences between patient survival rates and graft survival rates of cyclosporine-treated renal transplant patients compared with conventionally treated renal transplant patients, there are distinct advantages to cyclosporine use in renal transplantation. Twenty-three consecutive cadaveric renal transplant patients who received azathioprine, prednisone, and antilymphoblast globulin were compared with 23 cadaveric renal transplant patients who received cyclosporine and prednisone. Fewer statistically significant rejection episodes, multiple rejection episodes, and cytomegalovirus infections were demonstrated in those who received cyclosporine. Most notably, cyclosporine decreased the initial hospital stay, was associated with fewer readmissions, and therefore markedly reduced the initial cost of transplantation.     

Heart transplantation in females.

To confirm reports of a higher rate of rejection in female recipients of cardiac allografts and to determine whether infection rates and actuarial survival differ from that in males, we reviewed the results of 150 consecutive heart transplant procedures. Of these, 27 were in females and 123 were in males. Three different regimens were used over a 5-year period: group 1 (n = 37), cyclosporine and prednisolone; group 2 (n = 61), cyclosporine, azathioprine, and prednisolone; group 3 (n = 52), cyclosporine and azathioprine. All groups received a 7- to 10-day induction course with antithymocyte globulin. Female recipients had significantly more rejection episodes than male recipients to 3 months after transplantation (females 2.3 vs males 1.5 episodes/patient, p less than 0.01) and to 12 months (females 2.4 vs males 1.5 episodes/patient, p less than 0.02). These differences were largely caused by higher rates of rejection in females in both "double" therapy groups (groups 1 and 3). All surviving females in group 3 required the addition of maintenance steroids to control rejection. Gender mismatching of donors (male donor, female recipient) was identified as a factor associated with this requirement for conversion. Augmented treatment for rejection resulted in a higher rate of infection at 12 months in female recipients (females 1.5 vs males 0.7 episodes/patient, p less than 0.02), yet no female died of infection, and actuarial survival was comparable to that in male recipients. In view of the propensity of females to reject more frequently and earlier than males, triple therapy is currently the regimen of choice for female patients in the first 3 to 6 months after heart transplantation. Steroid withdrawal may be possible at a later time in those in whom this is indicated.     

Heart transplantation in diabetic recipients: a decade review of 161 patients at Columbia Presbyterian

OBJECTIVE: Diabetes is considered by some transplant centers to be a relative contraindication for cardiac transplantation because of concerns regarding decreased survival, as well as increased incidence of infection and transplant coronary artery disease. We evaluated our experience with diabetic recipients over the last 10 years. METHODS: From January 1992 through June 2002, 881 patients underwent cardiac transplantation at New York Presbyterian Hospital. Of these, 161 (18.3%) were diabetic patients. Diabetic recipients were compared with a control group of 161 nondiabetic recipients matched for age, sex, cause of heart failure, United Network for Organ Sharing status, and immunosuppression era. Outcome measures included posttransplantation survival, incidence of infection, rejection, and transplant coronary artery disease. RESULTS: There was no statistically significant difference in survival between diabetic and nondiabetic recipients, with actuarial survival at 1, 5, and 10 years of 89.3%, 66.9%, and 45.6%, respectively, for diabetic patients and 87.4%, 78.8%, and 59.1%, respectively, for nondiabetic patients (P =.168). There was no significant difference in freedom from infection, rejection, or transplant coronary artery disease between the groups. By using Cox proportional hazard models, development of infection, rejection, and transplant coronary artery disease were independent predictors of decreased survival (P <.001, P =.004, and P =.004, respectively). CONCLUSIONS: These results demonstrate similar short-term and long-term survivals, as well as similar risks for infection and transplant coronary artery disease, in diabetic and nondiabetic patients undergoing cardiac transplantation. The trend toward worse survival in the diabetic cohort, however, raises the possibility that if a greater number of diabetic patients were evaluated, a significant difference in survival might be observed, suggesting the need for a multicenter analysis to validate these outcomes.     

Long-term results of liver transplantation in older patients 60 years of age and older

BACKGROUND: Advances in perioperative care and immunosuppression have enabled clinicians to broaden the indications for organ transplantation. Advanced age is no longer considered a contraindication to transplantation at most centers. Although short-term studies of elderly liver transplant recipients have demonstrated that the incidence of complications and overall patient survival are similar to those of younger adults, transplant center-specific, long-term data are not available. METHODS: From August of 1984 to September of 1997, 91 patients 60 years of age or older received primary liver transplants at the University of Wisconsin, Madison. This group of patients was compared with a group of younger adults (n=387) ranging in age from 18 to 59 years who received primary liver transplants during the same period. The most common indications for transplantation in both groups were Laennec's cirrhosis, hepatitis C, primary biliary cirrhosis, primary sclerosing cholangitis, and cryptogenic cirrhosis. There was no difference in the preoperative severity of illness between the groups. Results. The length of hospitalization was the same for both groups, and there were no significant differences in the incidence of rejection, infection (surgical or opportunistic), repeat operation, readmission, or repeat transplantation between the groups. The only significant difference identified between the groups was long-term survival. Five-year patient survival was 52% in the older group and 75% in the younger group (P<0.05). Ten-year patient survival was 35% in the older group and 60% in the younger group (P<0.05). The most common cause of late mortality in elderly liver recipients was malignancy (35.0%), whereas most of the young adult deaths were the result of infectious complications (24.2%). CONCLUSION: Although older recipients at this center did as well as younger recipients in the early years after liver transplantation, long-term survival results were not as encouraging.