Combined heart and kidney transplantation with allografts from the same donor (original) (raw)

Clinical results of steroid-free induction immunosuppression after heart transplantation

Annals of Thoracic Surgery, 1993

112 operative survivors of heart transplantation were initially immunosuppressed with cyclosporin A and azathioprine without prednisone. Eighty-eight patients (79%) remained on a regimen of double therapy for a mean follow-up of 25 f 15 months (range, 1 to 54 months), whereas 24 patients (21%) had oral prednisone, 5 mg/day, added to maintenance therapy for persistent or repeated rejection. There were 5 early deaths (4%) because of acute rejection (4 patients) or infection (1 patient). Only 1 patient died late after heart transplantation of chronic rejection. Actuarial survival was 95% f 2% and 94% f 3% at 12 and 48 months, respectively. Mean rate of acute rejection was 1.7 f 1.0 episodes per patient, with a 5% f 2% freedom he developments in immunosuppressive therapy T have resulted in improved survival and reduced morbidity after heart transplantation [l]. Although the clinical results obtained using cyclosporine, azathioprine, and steroids as maintenance immunosuppression have been extensively reported [l, 21, the definitive role of steroids continues to be questioned [3, 41. Much concern remains about the complications of long-term steroid administration in regard to the incidence of opportunistic infections, hypertension, diabetes, hyperlipidemia, obesity, osteoporosis, and retarded growth [3, 51. Further-For editorial comment, see page 1069. more, the role of steroids in the development of accelerated graft atherosclerosis is still uncertain [l, 61. The early and late advantages of corticosteroid withdrawal and of steroid-free maintenance immunosuppression have already been described [7]. However, the long-term results obtained after heart transplantation with a cyclosporineand azathioprine-based induction therapy have not been thoroughly assessed. For this purpose, we have retrospectively analyzed the clinical outcome of heart transplantation using a steroid-free induction immunosuppressive therapy.

Heart transplantation-An update

Clinical Cardiology, 1996

Cardiologists caring for heart transplant recipients must be familiar with the pharmacology, drug interactions, and drug toxicity of those agents used extensively in clinical practice (cyclosporine, prednisone, azathioprine, pol yclonal and monoclonal anti-T-cell agents) and the newer treatments [methotrexate, FK-506, rapamycin, mycophenolate mofetil (RS6 1443), deoxyspergualin, anti-CD4 monoclonal antibodies, total lymphoid irradiation, and photophoresis]. Another important aspect of medical follow-up is the detection, differential diagnosis, and treatment of allograft dysfunction. Hemodynamic abnormalities that occur as a result of rejection or a direct drug effect must be differentiated from physiologic changes. Cardiac allograft vasculopathy is the primary impediment to the long-term survival of heart transplant recipients. Immunopathogenesis, prevention, early detection, and treatment of allograft vasculopathy should be the major focus of heart transplantation research.

Simultaneous transplantation of the heart and kidney

Australian and New Zealand Journal of Medicine, 1994

Background: Multiple organ transplants have become frequent. Combined heart-and-kidney grafting has been reported recently and we have pursued this in selected cases. Aims: To devise a protocol for simultaneous heart-and-kidney transplantation, review our clinical experience with the procedure and the causes of cardiac and renal disease in this group. Methods: Seven patients with advanced cardiac failure (LV ejection fraction < 0.29 units; five with IDCM), and chronic renal failure (serum creatinine > 375 pmollL) due to a variety of causes, were accepted for combined heart-and-kidney transplantation. Four males, of mean age 33 years, underwent the procedure. Each received his organs from a single cadaveric donor with ABO blood group compatibility and a negative 'current' lymphocytotoxic cross-match, but without regard to HLA-antigen matching. Cardiac ischaemic time averaged 3 hours 40 minutes, the renal first warm time was 0 minutes in all cases, and renal cold and second warm ischaemic times averaged 5 hours 17 minutes and 52 minutes respectively. The heart was grafted first and the kidney second in a procedure which averaged seven hours. Immunosuppression was achieved by induction with antithymocyte globulin, thence steroids, azathioprine and cyclosporin A. Results: No patient required post-operative dialysis. One patient had early urological complications requiring operative correction, but no serious opportunistic infections were observed. Early cardiac rejection on biopsy (ISHT grade 3a) was seen in three patients at four-ten weeks and responded promptly to increased steroids, but severe steroid-resistant rejection of both heart and kidney contemporaneously occurred in one of these three at 19 months and required a course of muromonab-CD3. All four patients developed hypertension. Mean creatinine clearance was 1.23 0.22 mLlsecond (74 k 13 mL/minute) at last follow-up. All four recipients were alive, well and rehabilitated 5,20,28 and 35 months after grafting. Two patients died while waiting for the double procedure and another patient eventually died after being taken off the dual waiting list and receiving a renal transplant only. Conclusions: In experienced hands, combined heart-and-kidney transplantation is feasible and offers a compelling therapeutic solution in the treatment of advanced cardiac and renal failure. IDCM is a frequent cause of the heart failure in this group.

Cardiac Transplantation: The Stanford Experience In the Cyclosporine Era

The Journal of …, 1994

We analyzed our experience with 496 patients who underwent primary cardiac transplantation since the introduction of cyclosporine immunosuppression (Dec. 16, 1980, to Jan. 7, 1993). There were 388 male and 108 female patients. Mean recipient age was 40 ± 16 years (range 0.1 to 70 years, median 44 years). Recipient diagnoses included coronary disease in 188, idiopathic cardiomyopathy in 196, viral cardiomyopathy in 35, and congenital heart disease in 28 patients. Donor age was 25 ± 10 years (range 1 to 53 years, median 24 years). Graft ischemic time was 148 ± 57 minutes (range 38 to 495 minutes, median 149 minutes). Operative mortality (hospital death) rate was 7.9 % ± 1.3% (70% confidence intervals). Multivariate logistic regression analysis revealed that (higher) pulmonary vascular resistance and gender (female) were the only independent predictors of hospital death (p < 0.05). Actuarial survival estimates for aU patients at 1, 5, and 10 years are 82% ± 1.7% (83% ± 1.8% adult, 77% ± 5.2% pediatric), 61 % ± 2.5% (65% ± 2.5% adult, 64% ± 6.6% pediatric), and 41 % ± 3.7% (40% ± 4% adult, 54% ± 8.6% pediatric), respectively. For 232 patients treated with triple-drug immunosuppression and induction with OKT3 since 1987, survival estimates at 1 and 5 years are 82% ± 2.6% and 67% ± 3.7%, respectively. Causes of death for the entire group were rejection in 29 (14 % of deaths), infection in 69 (34%), graft coronary disease in 36 (18 %), nonspecific graft failure in 6 (3%), malignancy in 19 (10%), stroke in 6 (3%), pulmonary hypertension in 6 (3%), and other causes in 30 (15%) patients.