Patient selection for everolimus-based immunosuppression in de novo heart transplant recipients*.
All de novo heart transplant recipients except for those with special conditions and/or risks (see the following)
Checking all patients for possibility of everolimus therapy due to its potential to reduce CNI-related toxicity, CMV infection, and malignancy risk and CAV
Everolimus only with special care
Specific risks for renal impairment or creatinine increase
Reduceing CsA exposure to a minimum, monitoring urine electrophoresis and proteinuria, and stopping everolimus in the event of proteinuria > 1 g/day and/or signs of new glomerular damage on urine electrophoresis
Risks for wound healing disorders (diabetes mellitus, obese patients, high steroid exposure, and ventricular assist device)
Delay initiation of everolimus until completion of wound healing and resolution of any bacterial or fungal infection
Uncontrolled severe hyperlipidemia
Delay initiation of everolimus until serum lipids have been controlled Always administer everolimus in combination with lipid-lowering therapy for example, fluvastatin
Everolimus not appropriate
(i) Paracorporal biventricular assist device with immanent risk of infection (ii) Infected ventricular assist device (iii) LVAD in conjunction with specific risks such as combination of Thymoglobulin induction and infection
Avoid antilymphocyte antibodies for induction in patients with elevated risk for early postoperative infection Everolimus may be initiated after completion of wound healing and resolution of any bacterial or fungal infection
Latent bacterial or fungal infections
Everolimus may be unsuitable in individual cases based on benefit/risk assessment
High probability of reoperation or necessity for additional surgery in the initial phase
Considering late initiation of everolimus to avoid the need to switch immunosuppressive regimen during a critical period
GFR < 40 mL/min/1.73 m2 if slope shows an ongoing deterioration of renal function
Delay initiation of everolimus Everolimus may be initiated if CNI exposure requires marked reduction
Initiation within 72 hours after transplantation. CAV: cardiac allograft vasculopathy; CNI: calcineurin inhibitor; CsA: cyclosporine; GFR: glomerular filtration rate; LVAD: left ventricular assist device.
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