Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil.
Arq Bras Cardiol. 2023 Oct;120(10):e20230133. doi: 10.36660/abc.20230133.
Chagas' disease (CD) is an important cause of heart transplantation (HT). The main obstacle is Chagas' disease reactivation (CDR), usually associated to high doses of immunosuppressants. Previous studies have suggested an association of mycophenolate mofetil with increased CDR. However, mortality predictors are unknown. To identify mortality risk factors in heart transplant patients with CD and the impact of antiproliferative regimen on survival. Retrospective study with CD patients who underwent HT between January 2004 and September 2020, under immunosuppression protocol that prioritized azathioprine and change to mycophenolate mofetil in case of rejection. We performed univariate regression to identify mortality predictors; and compared survival, rejection and evidence of CDR between who received azathioprine, mycophenolate mofetil and those who changed from azathioprine to mycophenolate mofetil after discharge ("Change" group). A p-value < 0.05 was considered statistically significant. Eighty-five patients were included, 54.1% men, median age 49 (39-57) years, and 91.8% were given priority in waiting list. Nineteen (22.4%) used azathioprine, 37 (43.5%) mycophenolate mofetil and 29 (34.1%) switched therapy; survival was not different between groups, 2.9 (1.6-5.0) x 2.9 (1.8-4.8) x 4.2 (2.0-5.0) years, respectively; p=0.4. There was no difference in rejection (42%, 73% and 59% respectively; p=0.08) or in CDR (T. cruzi positive by endomyocardial biopsy 5% x 11% x 7%; p=0.7; benznidazole use 58% x 65% x 69%; p=0.8; positive PCR for T. cruzi 20% x 68% x 42% respectively; p=0.1) rates. This retrospective study did not show difference in survival in heart transplant patients with CD receiving different antiproliferative regimens. Mycophenolate mofetil was not associated with statistically higher rates of CDR or graft rejection in this cohort. New randomized clinical trials are necessary to address this issue.
克氏锥虫病（CD）是心脏移植（HT）的重要原因。主要障碍是克氏锥虫病再激活（CDR），通常与免疫抑制剂的高剂量有关。先前的研究表明，霉酚酸酯与 CDR 增加有关。然而，尚不清楚死亡率的预测因素。确定 CD 合并 HT 患者的死亡风险因素以及抗增殖方案对生存的影响。这是一项回顾性研究，纳入了 2004 年 1 月至 2020 年 9 月期间接受 HT 的 CD 患者，他们接受的免疫抑制方案优先使用硫唑嘌呤，如果出现排斥反应则改为霉酚酸酯。我们进行了单变量回归以确定死亡率的预测因素；并比较了接受硫唑嘌呤、霉酚酸酯以及出院后从硫唑嘌呤改为霉酚酸酯的患者（“改变”组）之间的存活率、排斥反应和 CDR 的证据。p 值<0.05 被认为具有统计学意义。共纳入 85 例患者，其中 54.1%为男性，中位年龄 49（39-57）岁，91.8%在等待名单上优先。19 例（22.4%）使用硫唑嘌呤，37 例（43.5%）使用霉酚酸酯，29 例（34.1%）改变治疗方案；各组之间的存活率无差异，分别为 2.9（1.6-5.0）x 2.9（1.8-4.8）x 4.2（2.0-5.0）年，p=0.4。排斥反应无差异（分别为 42%、73%和 59%；p=0.08）或 CDR（心肌活检阳性的 T. cruzi 分别为 5%、11%和 7%；p=0.7；苯并咪唑使用分别为 58%、65%和 69%；p=0.8；T. cruzi 的阳性 PCR 分别为 20%、68%和 42%；p=0.1）率也无差异。这项回顾性研究表明，接受不同抗增殖方案的 CD 合并 HT 患者的存活率无差异。在本队列中，霉酚酸酯与 CDR 或移植物排斥反应的发生率增加无关。需要新的随机临床试验来解决这个问题。
