The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation
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J. Heart Lung Transplant. · Feb 2005
ReviewOverview of tacrolimus-based immunosuppression after heart or lung transplantation.
Transplantation has evolved into an accepted treatment for end-stage heart or lung disease. Acute rejection, complications related to immunosuppressive protocols, and the development of chronic rejection continue to challenge the long-term success of heart and lung transplantations. Wide acceptance of tacrolimus as an important immunosuppressant in renal and hepatic transplantations has led subsequently to its investigation as primary immunosuppression in heart and lung transplant recipients, either combined with azathioprine or with the newer agents mycophenolate mofetil or rapamycin. ⋯ Of importance, the enhanced immunosuppressive activity of tacrolimus is achieved without increased risk of infection or malignancy. Differences in tolerability profiles and side effects between tacrolimus and cyclosporine may be used in selecting the optimal immunotherapy after thoracic transplantation. In particular, the lesser propensity of tacrolimus to cause hypertension and hyperlipidemia potentially offers decreased cardiovascular risk for heart and lung transplant recipients.
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J. Heart Lung Transplant. · Feb 2005
Comparative StudyDiscordant utility of ideal body weight and body mass index as predictors of mortality in lung transplant recipients.
An upper limit of 130% predicted ideal body weight (PIBW) has been promulgated for assessing lung transplant (LTx) candidacy, but no data in the lung transplant population support this value. A prior study used body mass index (BMI) to suggest greater mortality risk in obese allograft recipients, but the number of studied patients was small. ⋯ Indices of pre-operative obesity did not predict long-term outcome in this large cohort of LTx recipients. The data suggest that BMI stratification may identify a group of patients at risk for increased short-term mortality, whereas PIBW is not a significant outcome predictor.
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J. Heart Lung Transplant. · Feb 2005
Case ReportsWhen death is the outcome of informed refusal: dilemma of rejecting ventricular assist device therapy.
Refusal of treatment can have fatal consequences for heart failure patients who could otherwise benefit from ventricular assist device therapy. Ethical dilemmas arise when treatment refusals seem based on unsound reasoning by patients. Using a clinical case from our medical center, we explored the complex ethical issues associated with patient refusal of ventricular assist device therapy due to the patient's perception of large device size as compared to other mechanical heart technologies. Early on, the medical team must assess a patient's refusal of therapy by reflecting on the decisionmaking capacity of the patient to determine whether such refusal is truly "informed," and all incidents of informed refusal should be clearly documented in the patient's chart.