RESUMO
BACKGROUND: Organ transplant recipients with refractory rejection or intolerance to the prescribed immunosuppressant may respond to rescue therapy with tacrolimus. We sought to evaluate the clinical outcomes of children undergoing heart transplantation who required conversion from a cyclosporine-based, steroid-free therapy to a tacrolimus-based regimen. METHODS: We performed a prospective, observational, cohort study of 28 children who underwent conversion from cyclosporine-based, steroid-free therapy to a tacrolimus-based therapy for refractory or late rejection or intolerance to cyclosporine. RESULTS: There was complete resolution of refractory rejection episodes and adverse side effects in all patients. The incidence rate (×100) of rejection episodes before and after conversion was 7.98 and 2.11, respectively (P ≤ .0001). There was a 25% mortality rate in patients using tacrolimus after a mean period of 60 months after conversion. CONCLUSION: Tacrolimus is effective as rescue therapy for refractory rejection and is a therapeutic option for pediatric patients.
Assuntos
Ciclosporina/uso terapêutico , Rejeição de Enxerto/tratamento farmacológico , Transplante de Coração/imunologia , Imunossupressores/uso terapêutico , Tacrolimo/uso terapêutico , Fatores Etários , Criança , Pré-Escolar , Ciclosporina/efeitos adversos , Substituição de Medicamentos , Quimioterapia Combinada , Rejeição de Enxerto/imunologia , Rejeição de Enxerto/mortalidade , Transplante de Coração/mortalidade , Humanos , Imunossupressores/efeitos adversos , Incidência , Estimativa de Kaplan-Meier , Estudos Prospectivos , Terapia de Salvação , Tacrolimo/efeitos adversos , Fatores de Tempo , Resultado do TratamentoRESUMO
UNLABELLED: Candida spp. can lead to infections or even fungal sepsis particularly among immunocompromised individuals. OBJECTIVE: The aim of the present study was to analyze the presence of Candida spp. among patients subjected to orthotopic heart transplantation. MATERIAL AND METHODS: Oral rinses from 50 patients subjected to orthotopic heart transplantation, aged 13 to 70 years, 40 males and 10 females, were examined. Sex-age-oral conditions matched-control included 50 individuals who were not subjected to any kind of transplantation and were not immunocompromised for any other reason. Counts of yeasts were expressed as median values of logarithm of cfu/mL and were statistically compared by Mann-Whitney's test. The heart transplant and control groups were compared for the presence of Candida spp. by chi-square test (p<0.05). RESULTS: The results showed statistically significant difference (p=0.001) in the prevalence of Candida spp. between the transplantation and control groups. Counts of yeasts (cfu/mL) in the transplanted group were significantly higher than in the control group (p=0.005). Candida albicans was the most prevalent species isolated from both groups. CONCLUSIONS: It was concluded that Candida yeast counts were higher in the heart transplant recipients than in the controls. There was higher variation of Candida species among the heart transplant patients and the most frequently isolated samples were: Candida albicans, Candida glabrata and Candida tropicalis. Isolates of Candida dubliniensis was not found in either of the groups.
Assuntos
Candida/isolamento & purificação , Transplante de Coração/imunologia , Boca/microbiologia , Adolescente , Adulto , Idoso , Candida/classificação , Estudos de Casos e Controles , Contagem de Colônia Microbiana , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Reação em Cadeia da Polimerase , Estatísticas não Paramétricas , Leveduras , Adulto JovemRESUMO
Candida spp. can lead to infections or even fungal sepsis particularly among immunocompromized individuals. OBJECTIVE: The aim of the present study was to analyze the presence of Candida spp. among patients subjected to orthotopic heart transplantation. MATERIAL AND METHODS: Oral rinses from 50 patients subjected to orthotopic heart transplantation, aged 13 to 70 years, 40 males and 10 females, were examined. Sex-age-oral conditions matched-control included 50 individuals who were not subjected to any kind of transplantation and were not immunocompromized for any other reason. Counts of yeasts were expressed as median values of logarithm of cfu/mL and were statistically compared by Mann-Whitney's test. The heart transplant and control groups were compared for the presence of Candida spp. by chi-square test (p<0.05). RESULTS: The results showed statistically significant difference (p=0.001) in the prevalence of Candida spp. between the transplantation and control groups. Counts of yeasts (cfu/mL) in the transplanted group were significantly higher than in the control group (p=0.005). Candida albicans was the most prevalent species isolated from both groups. CONCLUSIONS: It was concluded that Candida yeast counts were higher in the heart transplant recipients than in the controls. There was higher variation of Candida species among the heart transplant patients and the most frequently isolated samples were: Candida albicans, Candida glabrata and Candida tropicalis. Isolates of Candida dubliniensis was not found in either of the groups.
Assuntos
Adolescente , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Adulto Jovem , Candida/isolamento & purificação , Transplante de Coração/imunologia , Boca/microbiologia , Estudos de Casos e Controles , Contagem de Colônia Microbiana , Candida/classificação , Reação em Cadeia da Polimerase , Estatísticas não Paramétricas , LevedurasRESUMO
Mycophenolate mofetil (MMF) is an immunosupressor agent frequently used in patients after bone marrow or solid organ transplants. The most common adverse reactions of the drug are gastrointestinal, specially diarrhea and vomiting. We report a 53-year-old male, that received a heart transplant receiving immunosuppression with cyclosporine, mycophenolate mofetil and prednisone. Six months after the transplant, the patient started with diarrhea, anorexia and weight loss. A duodenal biopsy showed villous atrophy. Celiac disease and the presence of parasites were discarded. Mycophenolate mofetil was discontinued and one week later, diarrhea subsided. Two months later the patient was asymptomatic and recovered weight. A new duodenal biopsy showed absence of villous atrophy.
Assuntos
Duodeno/patologia , Imunossupressores/efeitos adversos , Microvilosidades/patologia , Ácido Micofenólico/análogos & derivados , Atrofia , Biópsia , Transplante de Coração/imunologia , Humanos , Transplante de Rim/imunologia , Masculino , Pessoa de Meia-Idade , Ácido Micofenólico/efeitos adversosRESUMO
OBJECTIVE: The meaning of biopsy C4d detection in heart allografts without dysfunction or morphologic changes suggesting antibody-mediated rejection (AMR) is not clear. The aim of this study was to search for an association between C4d detection in allograft biopsies of well-functioning hearts without changes suggestive of AMR, and clinical outcomes. METHODS: Endomyocardial protocol biopsies from 44 heart transplant patients with well-functioning grafts and without changes suggesting AMR were performed at 1 month and 1 year after transplantation and analyze the presence of C4d deposition using immunohistochemistry. Two-year follow-up was based on clinical parameters and echocardiographic information. Heart graft function was categorized as good vs. poor. The presence of C4d, using diverse schemes to graduate the extension of the deposition, was correlated with clinical graft outcomes. RESULTS: C4d deposition was observed in the capillary walls of 33 biopsies (37.5%; n = 25 patients; 56.8%). No biopsy had diffuse (>50%) immunostaining. Six patients presented with multifocal capillary C4d immunostaining in at least 1 biopsy. Capillary positivity for C4d (if focal or multifocal) showed no statistical association with cellular rejection or graft function. Perimyocytic C4d detection was neither associated with rejection nor graft outcome. CONCLUSION: Our work failed to demonstrate an association between C4d detection in protocol biopsies of heart grafts and clinical outcomes. The clinical utility of C4d staining in solid organ transplantation may vary by organ. Our results suggest that C4d did not have clinical utility in surveillance biopsies of well-functioning heart grafts without morphological changes suggesting AMR.
Assuntos
Complemento C4b/análise , Rejeição de Enxerto/patologia , Transplante de Coração/imunologia , Fragmentos de Peptídeos/análise , Adolescente , Adulto , Biomarcadores/análise , Biópsia , Capilares/imunologia , Capilares/patologia , Criança , Pré-Escolar , Feminino , Rejeição de Enxerto/imunologia , Transplante de Coração/patologia , Humanos , Imuno-Histoquímica , Masculino , Pessoa de Meia-Idade , Transplante Homólogo/imunologia , Transplante Homólogo/patologia , Resultado do TratamentoRESUMO
Mycophenolate mofetil (MMF) is an immunosupressor agent frequently used in patients after bone marrow or solid organ transplants. The most common adverse reactions of the drug are gastrointestinal, specially diarrhea and vomiting. We report a 53-year-old male, that received a heart transplant receiving immunosuppression with cyclosporine, mycophenolate mofetil and prednisone. Six months after the transplant, the patient started with diarrhea, anorexia and weight loss. A duodenal biopsy showed villous atrophy. Celiac disease and the presence of parasites were discarded. Mycophenolate mofetil was discontinued and one week later, diarrhea subsided. Two months later the patient was asymptomatic and recovered weight. A new duodenal biopsy showed absence of villous atrophy.
Assuntos
Humanos , Masculino , Pessoa de Meia-Idade , Duodeno/patologia , Imunossupressores/efeitos adversos , Microvilosidades/patologia , Ácido Micofenólico/análogos & derivados , Atrofia , Biópsia , Transplante de Coração/imunologia , Transplante de Rim/imunologia , Ácido Micofenólico/efeitos adversosRESUMO
BACKGROUND: Renal failure is the most important comorbidity in patients with heart transplantation, it is associated with increased mortality. The major cause of renal dysfunction is the toxic effects of calcineurin inhibitors (CNI). Sirolimus, a proliferation signal inhibitor, is an imunossupressant recently introduced in cardiac transplantation. Its nonnephrotoxic properties make it an attractive immunosuppressive agent for patients with renal dysfunction. In this study, we evaluated the improvement in renal function after switching the CNI to sirolimus among patients with new-onset kidney dysfunction after heart transplantation. METHODS: The study included orthotopic cardiac transplant (OHT) patients who required discontinuation of CNI due to worsening renal function (creatinine clearance < 50 mL/min). We excluded subjects who had another indication for initiation of sirolimus, that is, rejection, malignancy, or allograft vasculopathy. The patients were followed for 6 months. The creatinine clearance (CrCl) was estimated according to the Cockcroft-Gault equation using the baseline weight and the serum creatinine at the time of introduction of sirolimus and 6 months there after. Nine patients were included, 7 (78%) were males and the overall mean age was 60.1 +/- 12.3 years and time since transplantation 8.7 +/- 6.1 years. The allograft was beyond 1 year in all patients. There was a significant improvement in the serum creatinine (2.98 +/- 0.9 to 1.69 +/- 0.5 mg/dL, P = .01) and CrCl (24.9 +/- 6.5 to 45.7 +/- 17.2 mL/min, P = .005) at 6 months follow-up. CONCLUSION: The replacement of CNI by sirolimus for imunosuppressive therapy for patients with renal failure after OHT was associated with a significant improvement in renal function after 6 months.
Assuntos
Transplante de Coração/fisiologia , Testes de Função Renal , Sirolimo/uso terapêutico , Idoso , Inibidores de Calcineurina , Creatinina/metabolismo , Feminino , Seguimentos , Transplante de Coração/efeitos adversos , Transplante de Coração/imunologia , Humanos , Imunossupressores/efeitos adversos , Imunossupressores/uso terapêutico , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Insuficiência Renal/epidemiologia , Insuficiência Renal/etiologia , Insuficiência Renal/prevenção & controle , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Sirolimo/efeitos adversos , Fatores de TempoRESUMO
The increasing number of heart transplant recipients receiving immunosuppression with mammalian target of rapamycin inhibitors prompted the implementation of a South American Transplant Physicians Group to register these patients in a database. Everolimus (EVL) is a signal proliferation inhibition that reduces graft vascular disease when used de novo. Recently, its administration has expanded to subjects with resistant rejection or with side effects due to other immunosuppressive drugs (calcineurin inhibitors and/or steroids), allowing for better regulation of the immunosuppressive regimen. Herein we have shown the data collected from patients receiving EVL in ten South American Heart Transplant Centers. We have concluded that the administration of EVL is a useful adjunctive therapy that allows the reduction or suspension of other immunosuppressive drugs that caused unwanted side effects, without a loss of immunosuppressive efficacy, with manageable side effects, and constituting a valuable therapeutic option.
Assuntos
Transplante de Coração/imunologia , Transplante de Coração/estatística & dados numéricos , Imunossupressores/uso terapêutico , Sistema de Registros/estatística & dados numéricos , Sirolimo/análogos & derivados , Adolescente , Corticosteroides/efeitos adversos , Corticosteroides/uso terapêutico , Adulto , Idoso , Criança , Ciclosporina/uso terapêutico , Everolimo , Feminino , Transplante de Coração/efeitos adversos , Humanos , Imunossupressores/efeitos adversos , Masculino , Pessoa de Meia-Idade , Sirolimo/uso terapêutico , América do Sul , Tacrolimo/uso terapêuticoRESUMO
BACKGROUND: Despite the high incidence of infections after heart transplantation, there is limited information about its epidemiology in patients from countries where Chagas' disease is endemic. METHODS: We analyzed the occurrence of infections in 126 patients aged older than 18 years who underwent transplantation from 1986 through 2007 at a Brazilian University Hospital and who survived at least 48 hours. RESULTS: Heart failure diagnoses before transplantation were idiopathic dilated cardiomyopathy (38.6%), Chagas' disease (34.9%), coronary artery disease (19.8%), and others (6.3%). The respiratory tract was the most common site of infections (40.9%), followed by surgical wound site (18.1%). Trypanosoma cruzi reactivations occurred in 38.8% of Chagas' disease patients: 47.0% had myocarditis, 23.5% had skin lesions, and 29.4% had both. New-onset ventricular dysfunction was observed in 47.0%, with complete response after specific treatment, and 41.0% were asymptomatic cases, diagnosed by routine endomyocardial biopsies. No patient died from such events. No differences in survival were found after 5 years of follow-up between recipients with and without Chagas' disease (p = 0.231). CONCLUSIONS: In a heart transplant population from a developing country, infectious complications occurred at a high rate. Tropical illnesses were uncommon, except for the high rate of Chagas' disease reactivations. Despite that, the overall outcome of these patients was similar to that of recipients with other cardiomyopathies.