Nobuyuki Shiba

Analysis of survivors more than 10 years after heart transplantation in the cyclosporine era: Stanford experience

BACKGROUND Truly long term survival post heart transplantation has become increasingly frequent over the past two decades. METHODS We analyzed multiple clinical outcomes in the cohort of 140 patients in the Stanford database who underwent heart transplantation after the introduction of cyclosporine-based immunosuppression in 1980 and survived >10 years after transplantation. RESULTS We found generally excellent functional status in these patients, but a high incidence of hypertension, renal dysfunction, and graft CAD as well as malignancy. CONCLUSION With continued improvement in post-transplant survival rates, providing complex care for such long-term recipients as these will assume increasing clinical importance in the everyday practice of transplant medicine and these data highlight the problems to be anticipated.

Longer-term risks associated with 10-year survival after heart transplantation in the cyclosporine era.

BACKGROUND Long-term survival after heart transplantation is common in the cyclosporine era. However, there are few data documenting pre-transplant/peri-operative factors predictive of truly long-term survival (>10 years). The purpose of this study is to identify factors associated with 10-year survival after heart transplantation. METHODS Our study population included 197 adults who survived >6 months and died <10 years after heart transplant (medium-term group) and 140 adults who survived >10 years after heart transplant (long-term group) between December 1980 and May 2001. A comparison was done between the two groups and we used multivariate analysis to identify which factors predicted 10-year survival. RESULTS The long-term group had younger recipient and donor age, lower recipient body mass index at transplant, shorter waiting time and lower percentages of ischemic etiology/male recipient/non-white recipient. Kaplan-Meier plots of freedom from graft coronary artery disease and malignancy showed later onset patterns in the long-term group compared with the medium-term group. Multivariate analysis showed that white recipient, younger recipient and lower recipient body mass index at heart transplant were factors significantly associated with 10-year survival. CONCLUSIONS Several pre-transplant/peri-operative factors were associated with survival beyond 10 years after heart transplantation. Stratified/tailored strategies based on these factors may be helpful to attain longer-term survival of recipients with higher risks.

Post-operative conversion from cyclosporine to tacrolimus in heart transplantation: a single-center experience

BACKGROUND Tacrolimus is a potent calcineurin inhibitor that was introduced to heart transplantation in the early 1990s. The side-effect profile of tacrolimus is more favorable than that of cyclosporine and some reports have suggested an advantage of tacrolimus in the treatment of rejection. The present study was undertaken to determine whether a late conversion to tacrolimus affords these benefits to heart transplant recipients. METHODS Charts from 109 patients who underwent conversion from cyclosporine to tacrolimus for recurrent rejection or adverse effects were retrospectively reviewed. RESULTS During the year after conversion to tacrolimus, there was a significant decrease in treated rejection episodes. Conversion to tacrolimus rapidly resulted in an improved lipid profile. Two years after conversion blood pressure was significantly reduced. Apart from rejection, these benefits were found mainly among individuals converted to tacrolimus within 1 year of heart transplantation. CONCLUSIONS Conversion from cyclosporine to tacrolimus is safe and results in a more favorable risk factor profile. However, most of the benefits are seen in individuals converted within 1 year of transplantation.

Conversion of cyclosporine to tacrolimus in heart transplant patients: a single center experience

Background: Tacrolimus (TAC) is an alternative to cyclosporine (CSA) in heart transplant (HTX) patients. We sought to evaluate the use of TAC substituted for CSA in a single center. Methods: We analysed the outcome of HTX patients who were converted from CSA to TAC for refractory rejection or intolerance to CSA. The dose of TAC was adjusted to an initial level of 12 to 18 ng/mL for rejection or 8 to 12 ng/mL for CSA intolerance. Results: From to 1985 to 2001, 652 HTXs were performed at our center. Of these, 109 (16%) patients were converted to TAC, at 28 38 mths post-HTX (range 0.5 to 156). Age at time of HTX was 45 16 yr. Reasons for conversion were: rejection 58 (53.2%), gingival hyperplasia 9 (8.2%), CSA neurotoxicity 7 (6.4%), hirsutism 6 (5.5%), & other 29 (26.7%). At 6 mths after conversion, the TAC dose was 6.4 3.7 mg/d, and the level 10.8 5.0 ng/mL. Duration of follow-up after conversion was 34 17 mths. 10/109 (9%) patients had to stop TAC for renal insufficiency and/or tremor. For those 58 patients converted for rejection, the number of rejections fell from 1.2 1.0 to 0.3 0.5 per patient per yr (p 0.0001). 42/58 (72%) of patients were free from treated rejection during follow-up. For those converted for CSA side effects, 81% had partial or complete resolution. For the whole group (n 109), other data are as follows: