Effect of immunosuppressive agents on long-term survival of renal transplant recipients: focus on the cardiovascular risk

Conversion from cyclosporine to everolimus at 4.5 months posttransplant: 3-year results from the randomized ZEUS study

The long-term effect of conversion from calcineurin inhibitor (CNI) therapy to an mTOR inhibitor requires clarification. Following completion of the 12-month, open-label, multicenter ZEUS study, in which 300 kidney transplant recipients were randomized to continue cyclosporine (CsA) or convert to everolimus at 4.5 months posttransplant, outcomes were assessed at month 36 (n = 284; 94.7%). CNI therapy was reintroduced in 28.4% of everolimus patients by month 36. The primary efficacy endpoint, estimated glomerular filtration rate (Nankivell, ANCOVA) was significantly higher with everolimus versus the CsA group at month 24 (7.6 mL/min/1.73 m(2) , 95%CI 4.3, 11.0 mL/min/1.73 m(2) ; p < 0.001) and month 36 (7.5 mL/min/1.73 m(2) , 95%CI 3.6, 11.4 mL/min/1.73 m(2) ; p < 0.001). The incidence of biopsy-proven acute rejection from randomization to month 36 was 13.0% in the everolimus arm and 4.8% in the CsA arm (p = 0.015). Patient and graft survival, as well as incidences of malignancy, severe infections and hospitalization, were similar between groups. Kidney transplant patients who are converted from CsA to everolimus at month 4.5 and who remain on everolimus thereafter may achieve a significant improvement in renal function that is maintained to 3 years. There was a significantly higher rate of rejection in the everolimus arm but this did not exert a deleterious effect by 3 years posttransplant.

Steroid avoidance with early intensified dosing of enteric-coated mycophenolate sodium: a randomized multicentre trial in kidney transplant recipients

BACKGROUND

Short-term intensified dosing using enteric-coated mycophenolate sodium (EC-MPS) reduces rejection after kidney transplantation without compromising safety and may facilitate steroid avoidance.

METHODS

In a 6-month, multicentre open-label trial, 222 de novo kidney transplant recipients at low-immunological risk were randomized to steroid avoidance or maintenance steroids with interleukin (IL)-2 receptor antibody (IL-2RA) induction, EC-MPS (2160 mg/day to Week 6, 1440 mg/day thereafter) and cyclosporine.

RESULTS

The primary end point; treatment failure at Month 6 [biopsy-proven acute rejection (BPAR), graft loss, death or loss to follow-up], occurred in 17.9% (20/112) of steroid-avoidance patients and 14.5% (16/110) of controls (difference 3.4%, 95% confidence interval -6.3 to 13.1, P = 0.47 for superiority testing). BPAR occurred in 11.6 and 7.3% of patients in the steroid-avoidance and control arms, respectively (P = 0.27). Creatinine clearance was similar at Month 6 (steroid-avoidance 56 ± 18 mL/min/1.73 m(2), controls 60 ± 22 mL/min/1.73 m(2), P = 0.34). Cytomegalovirus infection, as reported by investigators, occurred in 12.5% of steroid-avoidance patients and 22.7% of controls (P = 0.045).

CONCLUSIONS

A regimen of early intensified EC-MPS dosing with calcineurin inhibitor and IL-2RA induction permits oral steroid avoidance in adult kidney transplant patients at low-immunological risk without compromising efficacy at 6 months' follow-up.

Clinical diagnosis of metabolic syndrome: predicting new-onset diabetes, coronary heart disease, and allograft failure late after kidney transplant

Metabolic syndrome is associated with coronary heart disease (CHD) and new-onset diabetes after kidney transplant (NODAT). Using data collected from transplant centers worldwide for the Patient Outcomes in Renal Transplantation study, we examined associations of metabolic syndrome (n = 2253 excluding recipients with diabetes pretransplant), CHD (n = 2253), and NODAT (n = 1840 further excluding recipients with diabetes in the first year post-transplant), with the primary outcome of allograft failure. We assessed risk factors associated with secondary outcomes of metabolic syndrome, NODAT, and CHD after adjusting for type of baseline immunosuppression and transplant center effects. Metabolic syndrome prevalence was 39.8% at 12-24 months post-transplant and 35.4% at 36-48 months. Metabolic syndrome was independently associated with NODAT (hazard ratio 3.46, 95% confidence interval 2.40-4.98, P < 0.0001), CHD (2.03, 1.16-3.52, P = 0.013), and allograft failure (1.36, 1.03-1.79, P = 0.028). Allograft failure occurred in 218 patients (14.6%). After adjustment for metabolic syndrome, NODAT (1.63, 1.18-2.24, P = 0.003) and CHD (5.48, 3.27-9.20, P < 0.0001) remained strongly associated with increased risk of allograft failure. Metabolic syndrome, NODAT, and CHD are risk factors for allograft failure. NODAT and CHD are risk factors for allograft failure, independent of metabolic syndrome.

Sustained renal response to mycophenolate mofetil and CNI taper promotes survival in liver transplant patients with CNI-related renal dysfunction

AIM

The aim of this trial was to evaluate the impact of conversion from a calcineurin-inhibitor (CNI)-based immunosuppressive regimen to mycophenolate mofetil (MMF) and reduced-dose CNI on long-term renal function and survival in a series of 63 liver transplant patients with CNI-induced renal dysfunction.

METHODS

CNI dosage was significantly tapered after introduction of 2,000 mg MMF per day. Renal function was assessed by determination of serum creatinine levels and calculated creatinine clearance (CCl). The impact of relevant clinical parameters on renal function and survival post-conversion was analyzed by univariate and multivariate analysis.

RESULTS

At 60 months post-conversion, mean creatinine level had significantly declined from 197.2±58.3 μmol/l at baseline to 160.0±76.5 μmol/l, and mean CCl has significantly increased from 38.4±13.4 ml/min at baseline to 47.9±21.1 ml/min (p<0.001), respectively. Forty-six patients (73.1%) demonstrated sustained renal response to modified immunosuppression. Full-dose MMF medication (p=0.006) and the early conversion (p=0.02) were identified as independent predictors of persistent renal function improvement. Sustained renal response to MMF plus reduced-dose CNI was identified as the most relevant independent promoter of long-term survival (hazard ratio 6.9). Five-year survival rate post-conversion was 93.9% in renal responders and 64.3% in renal non-responders (log rank<0.001).

CONCLUSIONS

Sustained renal response to MMF and CNI dose reduction promotes long-term survival in liver transplant patients with CNI-induced renal dysfunction.

Evaluation of the novel protein kinase C inhibitor sotrastaurin as immunosuppressive therapy after renal transplantation

IMPORTANCE OF THE FIELD

The prevalence of acute renal allograft rejection has decreased substantially in past decades due to new and more specific immunosuppressive compounds but improvements in long-term graft function have not been achieved. There is a large need for new immunosuppressive agents that lack toxicity of current agents such as calcineurin inhibitors but show high synergistic efficiency in preventing rejection processes.

AREAS COVERED IN THIS REVIEW

This review summarizes data concerning the pharmacokinetics, pharmacodynamics and clinical efficacy of the new PKC inhibitor sotrastaurin with a focus on renal transplantation. The article contains information that has been presented at international transplant meetings and congresses and that has been published between 2006 and 2010. Additionally, current ongoing trials are described in detail.

WHAT THE READER WILL GAIN

Immunosuppressive regimens after kidney transplantation consist of a combination of several agents in order to minimize drug toxicity. Therefore, the reader is presented with the most up-to-date/current developments in sotrastaurin applications in Phase I and II trials with emphasis on data maintained from studies that combined sotrastaurin with established agents such as mycophenolic acid and tacrolimus.

TAKE HOME MESSAGE

Several trials are ongoing and planned to determine the optimal immunosuppressive regimen to benefit from sotrastaurin's distinct mechanism of action.

A novel indole-3-propanamide exerts its immunosuppressive activity by inhibiting JAK3 in T cells

We previously identified an indole-3-propanamide derivative, 3-[1-(4-chlorobenzyl)indol-3-yl]-N-(pyridin-4-yl)propanamide (AD412), as a potential immunosuppressive agent. Here, we document that AD412 inhibited the proliferative response of CD3/CD28-stimulated human T cells without inhibiting their interleukin 2 (IL-2) production and also inhibited the proliferation of CTL-L2 cells in response to IL-2. These results prompted us to analyze the effect of our compound on the three main signaling pathways coupled to the IL-2 receptor. We provide evidence that AD412 inhibited the JAK1/3-dependent phosphorylations of Akt, STAT5a/b, and ERK1/2 in IL-2-stimulated CTL-L2 cells. In contrast, AD412 had little effect on the JAK1/2-dependent INF-gamma-induced phosphorylation of STAT1 in U266 cells. This suggested a preferential inhibition of JAK3 over JAK1 or JAK 2 activities by AD412 that was confirmed by in vitro kinase assays with purified JAK2 and JAK3 kinases. In addition, we provide evidence that the inhibition of IL-2 response by AD412 was not due to inhibition of IL-2Ralpha up-regulation because neither AD412 nor JAK3 inhibitors described previously [4-[(3-bromo-4-hydroxyphenyl)amino]-6,7-dimethoxyquinazoline (WHI-P154) and alpha-cyano-(3,4-dihydroxy)-N-benzylcinnamid (AG-490)] significantly inhibited IL-2-induced IL-2Ralpha overexpression. Finally, we further document the immunosuppressive activity of AD412 in vivo by showing that its administration per os significantly prolonged heart allograft graft survival. This molecule may thus represent an interesting lead compound to develop new immunosuppressive agents in the field of transplantation and autoimmune diseases.

Differential effects of immunosuppressive drugs on COX-2 activity in vitro and in kidney transplant patients in vivo

BACKGROUND

It was hypothesized that calcineurin inhibitors suppress vascular cyclooxygenase (COX)-2 and exert a reciprocal influence on in vivo prostacyclin and thromboxane. This could contribute to cardiovascular morbidity in transplanted patients.

METHODS

The ability of immunosuppressives to suppress vascular COX-2 expression in vitro was studied in cultured human vascular smooth muscle cells. Blood and urine samples were collected from 28 renal transplant patients before and 2, 4 and 6 h after intake of immunosuppressives and from 11 controls. ELISA was used to measure (1) plasma 6-keto-PGF1alpha and TxB2; (2) urine excretion of PGI-M and TxB(2); (3) 6-keto-PGF1alpha in the whole-blood COX-2 assay; and (4) TxB2 in the whole-blood COX-1 assay. Platelet aggregation was measured optically.

RESULTS

COX-2 in cultured vascular smooth muscle cells was suppressed by cyclosporine A (CsA); tacrolimus and rapamycin had no effect. Human renal arteries and vascular smooth muscle expressed calcineurin Abeta and Agamma isoforms. CsA had no effect on plasma 6-keto-PGF1alpha, whole-blood COX-2 activity or PGI-M urine excretion; after rapamycin intake, the former two increased. Plasma TxB2 did not change after drug intake. TxB2 in the COX-1 assay and urine excretion of TxB2 was significantly lower in tacrolimus- and rapamycin-treated patients compared to the CsA group. Platelet aggregation was increased significantly in the CsA group.

CONCLUSIONS

Although CsA suppressed COX-2 in cultured vascular smooth muscle cells, systemic prostacyclin was not suppressed by either CsA or tacrolimus in vivo. Rapamycin and tacrolimus may actively suppress platelet and renal thromboxane formation. Differential changes in prostanoids may have implications for long-term cardiovascular hazard in patients treated with immunosuppressives.

Mycophenolate mofetil (MMF) following penetrating high-risk keratoplasty: long-term results of a prospective, randomised, multicentre study

BACKGROUND

The purpose of this prospective, randomised, multicentre study was to prove the efficacy and safety of mycophenolate mofetil (MMF) in preventing graft rejection and in improving clear graft survival following high-risk keratoplasty.

METHODS

In all, 98 of 140 scheduled patients were included in this study (57 MMF, 41 control). Recruitment was stopped prematurely due to a statistically significant result. The patients in the MMF group received MMF orally 2 x 1 g daily for 6 months. All of the patients received fluocortolone 1 mg/kg/day tapered over 3 weeks and topical prednisolone acetate 5 x /day tapered over 5 months. Main criteria were immune reaction-free and clear graft survival, and the occurrence of side effects.

RESULTS

The mean follow-up time was 34.9+/-16.3 (mean+/-SD) months. Eleven patients withdrew from the study (nine patients due to protocol deviation, two because of side effects). Six reversible and two irreversible graft rejections occurred in the MMF group, and five reversible and seven irreversible rejections in the control group. The Kaplan-Meier analysis revealed an immune reaction-free graft survival after the mean follow-up time of 83% in the MMF group and 64.5% in the control group (P=0.044). Graft failure occurred in 10 MMF-treated patients (two due to rejection) and in nine patients in the control group (seven due to rejection). A total of 36 of 57 MMF-treated patients experienced mostly reversible adverse events.

CONCLUSIONS

Systemic immunosuppression with MMF over 6 months is relatively well tolerated and improves rejection-free graft survival following high-risk keratoplasty statistically significant, even in the long run.

The assessment of diastolic function in patients with rheumatoid arthritis

Introduction. Rheumatoid arthritis (RA) is a systemic inflammatory autoimmune chronic disease. In comparison with the overall population, mortality and morbidity of RA patients are increased due to cardiovascular diseases. There is increasing evidence that autoimmunity mechanisms are included in pathogenesis of cardiovascular diseases. Isolated disorder of diastolic function can, even with normal heart contractility, lead to heart failure. The aim of this study was to assess diastolic function in RA patients and determine factors causing diastolic dysfunction. Material and methods. The study included 88 patients with RA treated at Rheumatology Department, Clinical Hospital Centre, Zemun. All the patients were thoroughly examined (clinical findings, laboratory and echocardiographic examination). All parameters of diastolic function (mitral and pulmonary flow) were measured. Results. In RA patients 98,9% had diastolic function disorder. This parameter had been changed prior to clinical signs of heart failure and decrease of ejection fraction. Indicators of diastolic function, velocities E, A and their ratio VE/VA, as well as velocities S, D and their ratio VS/VD were lower in patients with positive rheumatoid factor. The patients' age (p<0.01), duration of the disease (p<0.05), high level of cholesterol (p<0.05), triglycerides (p<0.05) and arterial hypertension (p<0.05) were significant factors considerably affecting diastolic function. Conclusion. These findings suggest subclinical myocardial disorder in a great number of RA patients. Apart from early and aggressive treatment of the chronic inflammatory process, it is also necessary to prevent further heart complications by timely recognition and treatment of 'standard' risk factors for cardiovascular diseases.

Cardiovascular co-morbidity in rheumatic diseases

Patients with rheumatic disorders have an increased risk of cardiovascular disease (CVD). This excess co-morbidity is not fully explained by traditional risk factors. Disease severity is a major risk factor for CVD in patients with rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). Shared disease mechanisms in atherosclerosis and rheumatic disorders include immune dysregulation and inflammatory pathways, which are potential targets for therapy. Lessons from RA and SLE may have implications for future research on the pathogenesis of atherosclerotic vascular disease in general. Recent data indicate that suppression of inflammation reduces the risk of CVD morbidity and mortality in patients with severe RA. The modest, but clinically relevant, efficacy of atorvastatin treatment in RA adds to the evidence for important anti-inflammatory properties for statins. There is increased recognition of the need for structured preventive strategies to reduce the risk of CVD in patients with rheumatic disease. Such strategies should be based on insights into the role of inflammation in CVD, as well as optimal management of life style related risk factors. In this review, the research agenda for understanding and preventing CVD co-morbidity in patients with rheumatic disorders is discussed.

Cyclosporine A and Rapamycin induce in vitro cholesteryl ester transfer protein activity, and suppress lipoprotein lipase activity in human plasma

PURPOSE

Cyclosporine A (CsA), Rapamycin (RAPA), Tacrolimus (FK-506) and Mycophenolate mofetil (MMF) are immunosuppressants that are widely used in solid organ transplant patients. However, some of these drugs have been reported to cause dyslipidemia in patients. Our aim was to determine the effects of these drugs on in vitro cholesteryl ester transfer protein (CETP), hepatic lipase (HL) and lipoprotein lipase (LPL) activity within human plasma.

METHODS

We measured CETP activity in human normolipidemic plasma with and without drug treatment, by measuring the incorporation of labeled cholesteryl ester into lipoproteins. To further confirm the result, we also measured recombinant CETP (rCETP) activity with and without drug treatment. We measured HL and LPL activity in post-heparin normal human plasma in the presence and absence of the drugs by measuring the release of fatty acids from radiolabeled triolein.

RESULTS

We found an increase in CETP activity in human normolipidemic plasma and rCETP treated with CsA and RAPA. By contrast, CETP activity was not altered significantly in the presence of FK-506 and MMF. LPL activity in post-heparin normal human plasma was suppressed following the co-incubation with CsA, RAPA, FK-506 or MMF whereas HL activity remained unaffected.

CONCLUSIONS

The increase in CETP activity and suppression in LPL activity following CsA and RAPA treatment observed in the present study may be associated with elevated LDL cholesterol levels and hypertriglyceridemia seen in patients administered these drugs.

Therapy Insight: cardiovascular disease in pediatric systemic lupus erythematosus

In 15-20% of cases, systemic lupus erythematosus (SLE) presents before the age of 18 years, and such early-onset SLE seems to be particularly severe. SLE is an independent risk factor for premature atherosclerosis and death in young, premenopausal women with SLE, even after controlling for traditional cardiovascular risk factors. Children and adolescents with SLE are particularly susceptible to this long-term threat to their cardiovascular health because they have an increased disease severity and a lengthy disease burden. Factors that contribute to premature atherosclerosis include the inflammatory and immune abnormalities that are intrinsic to SLE, primary dyslipidemias, and the secondary effects of treatments such as corticosteroids. However, few rheumatologists provide appropriate preventive or management strategies for the increased atherosclerosis risk in this age-group. Screening should be performed on a regular basis, including evaluation of, and counseling for, traditional risk factors. Studies of treatment in pediatric patients are limited, and treatment strategies are often extrapolated from adult studies. Statins hold promise because they have both lipid-lowering and anti-inflammatory effects. There have been few studies of the use of statins in adults or adolescents with SLE; however, trials are currently underway to address the safety and efficacy of statin use in pediatric SLE.

Asymmetric dimethylarginine and adiponectin after renal transplantation: role of obesity

BACKGROUND

In obese renal transplant recipients, we assessed the course of selected proinflammatory factors liable to influence long-term outcomes of transplant patients and kidney grafts.

METHODS

In a prospective cohort study, we examined a total of 140 renal transplant recipients for a period of 12 months. Based on body mass index (BMI), patients were divided into Group I (BMI > or = 30 kg/m2, 68 patients) and Group II (BMI < or = 30 kg/m2, 72 patients).

RESULTS

Twelve months after renal transplantation, significant differences were found between Group I versus Group II in plasma levels of asymmetric dimethylarginine (ADMA) (3.65 [SD +/- 0.47 micromol/L] versus 2.01 [SD +/- 0.36 micromol/L], P < .01), adiponectin (ADPN) (15.4 [SD +/- 6.6 microg/mL] versus 22.3 [SD +/- 8.2 microg/mL], P < .01), leptin (51.3 [SD +/- 11.2 ng/L] versus 21.3 [SD +/- 9.2 ng/L], P < .01), soluble leptin receptor (24.6 [SD +/- 8.4 U/mL] versus 46.1 [SD +/- 11.4 U/mL], P < .01), resistin (20.8 [SD +/- 10.1 microg/mL] versus 14.6 [SD +/- 6.4 microg/mL], P < .025), and triglycerides (3.9 [SD +/- 1.6] versus mmol/L 2.8 [SD +/- 1.6 mmol/L], P < .01). There were significant correlations between ADMA and BMI (r = 0.520; P < .001), and ADPN and BMI (r = -0.570, P < .001). The correlation between ADMA and inulin clearance (Cin) was weak (r = -0.185, P < .05).

CONCLUSIONS

Obesity after renal transplantation is associated with increased ADMA and decreased ADPN in plasma, and this may represent a risk factor for renal transplant recipients.

Calcineurin inhibitors and post-transplant weight gain

AIM

Excessive weight gain that leads to obesity is quite common after kidney transplantation. This is often attributed to immunosuppression. The aim of this retrospective study was to assess the effect of calcineurin inhibitors on post-transplant weight gain.

METHODS

A total of 99 patients were studied. The patients were divided into cyclosporine A (CyA) and tacrolimus (Tac) groups and were evaluated for weight changes and risk factors related to weight gain.

RESULTS

The weights of patients in both groups significantly increased after the sixth month. The median weight gain at 12 months was 3.5 and 8.0 kg compared with pretransplant dry weight in the Tac and CyA groups, respectively. The increases in the CyA group were significant compared with those of the Tac group. The prevalences of obese and overweight patients in both groups did not differ during a 12-month follow-up. The frequencies of diabetes mellitus, hypertension and dyslipidemia were comparable in both groups. The decrease in systolic blood pressure (BP) of the Tac group was significant compared with the decrease in the CyA group at the 12th month. In the 12-month follow-up period, the increases in triglyceride, total- and low-density lipoprotein-cholesterol values of the CyA group were significantly higher than those of the Tac group. The weight change between 0 and 12 months was negatively correlated with pretransplant body mass index (BMI) and positively with cumulative corticosteroid doses, total-cholesterol and BP changes.

CONCLUSION

Only pretransplant BMI, creatinine clearance, CyA usage, being hypertensive and dyslipidemic were independent predictors of weight gain at the 12th month. Our results suggested that the type of immunosuppression may affect post-transplant weight gain.

Management of cardiovascular disease in renal transplant recipients

Cardiovascular disease is a major cause of graft loss and the leading cause of death in renal transplant recipients. Although there are robust data on the frequency of risk factors and their contributions to cardiovascular disease in this population, few trials have demonstrated the benefit of modifying these risk factors to reduce cardiovascular events. Nevertheless, it is widely accepted that the clinical acumen filtered through the best available studies in the general population be used to treat individual renal transplant recipients given their high cardiovascular mortality. Transplant task forces and the Kidney Disease Outcomes Quality Initiative have created guidelines for this purpose. This review examines the data available for prevention and treatment of major risk factors contributing to cardiovascular disease in renal transplant recipients. The contribution of immunosuppressive agents to each risk factor and the evidence to support lifestyle modification as well as drug therapy are examined. Reducing cardiovascular risk factors requires an integrative approach that is best accomplished by a team of health care professionals. It creates a significant challenge but one that must be met if allograft survival is to improve.

Management of dyslipidemia in children and adolescents with systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is an independent risk factor for atherosclerosis, placing children and adolescents with SLE at great risk for developing cardiovascular sequelae, including myocardial infarction, in adulthood. Dyslipidemia and other traditional cardiac risk factors occur frequently in pediatric SLE and are often under-recognized and under-treated. Two dyslipidemia patterns are evident in pediatric SLE. Active disease is characterized by elevated triglycerides (TG) and low high density lipoprotein (HDL). With SLE treatment HDL and TG often normalize, while total cholesterol and low density lipoprotein (LDL) rise. The complex pathophysiology of dyslipidemia in SLE involves cytokines, autoantibodies, disease activity, medications, diet, and physical activity level, as well as other factors. Routine screening for dyslipidemia with fasting lipid profiles is indicated for children and adolescents with SLE. If lipoprotein levels are abnormal, first line therapy involves diet and exercise interventions for a minimum of six months. For persistent dyslipidemia, several pharmacologic therapies are available. Hydroxychloroquine, a common treatment for SLE, can improve lipid profiles and should be considered for all patients with SLE. Statins and bile acid sequestrants are typically added first for dyslipidemia, while niacin and fibrates are reserved for refractory disease and optimally prescribed in a multidisciplinary lipid clinic. Future research is needed to further illuminate the mechanisms of dyslipidemia in pediatric SLE with well designed clinical trials to determine the safest and most effective interventions to correct lipid profiles and prevent atherosclerosis.

Clinical trial: switch to combined mycophenolate mofetil and minimal dose calcineurin inhibitor in stable liver transplant patients--assessment of renal and allograft function, cardiovascular risk factors and immune monitoring

BACKGROUND

Calcineurin inhibitor (CNI)-related nephrotoxicity significantly contributes to chronic renal failure after liver transplantation.

METHODS

In this prospective study, liver transplantation patients with renal dysfunction were randomized either to receive mycophenolate mofetil (MMF) followed by stepwise reduction of CNI with defined minimal CNI-trough levels (MMF group), or to continue their maintenance CNI dose (control group). Immune monitoring was performed in a subgroup of the patients.

RESULTS

In the MMF group (n = 50), renal function assessed by serum creatinine improved >10% in 62% of patients, was stable in 36% and deteriorated >10% in 2% after 12 months compared with baseline values. Mean serum creatinine levels (+/- s.d.) significantly decreased from 1.90 +/- 0.44 mg/dL to 1.61 +/- 0.39 mg/dL and the corresponding calculated glomerular filtration rate significantly increased from 38.8 +/- 9.6 mL/min/1.73 m(2) to 47.0 +/- 11.8 mL/min/1.73 m(2) over a 12-month follow-up period. Blood pressure and levels of liver enzymes significantly decreased. In the control group (n = 25), there were no significant changes with respect to the investigated parameters. The MMF group had significantly lower numbers of circulating cytotoxic T cells compared with the controls; whereas regulatory T cells significantly increased.

CONCLUSION

Combined MMF and minimal dose CNI therapy after liver transplantation is nephroprotective and may promote allograft tolerance.

Medicolegal reflections about a case of cardiac death after renal transplantation

Cardiovascular disease is the most common cause of death in patients with renal transplant. Acute coronary syndrome due to coronary artery disease, and left ventricular hypertrophy leading to chronic heart failure account for the majority of sudden arrhythmic deaths after transplantation. Furthermore death with functioning graft represents the main cause of graft loss, particularly after the first post-transplantation year. Although cardiovascular disease leads to morbidity and mortality in renal transplant recipients, its pathogenesis is poorly understood. The high incidence of cardiovascular disease in patients after renal transplant is chiefly due to high occurrence and accumulation of traditional risk factors before and after transplantation. Hypertension, post-transplant diabetes mellitus and hyperlipidemia increase the risk for cardiovascular events. Also 'non traditional' risk factors are associated with cardiovascular disease. Moreover several immunosuppressive drugs interfere with the cardiovascular system. The authors present a case of cardiac death following renal transplant in a patient with history of cardiovascular disease prior transplantation. Initially treated by hemodialysis, after 3 years he received a cadaveric renal transplant. The post-transplantation period was without surgery complications, immunological or infectious, except for a scarce control of blood pressure. A month after the operation, the patient developed thrombophlebitis, plus extra-peritoneal swelling. After ten days in hospital he suddenly died. The aim of the manuscript is to remark on the legal relevance of patient's consensus to transplant. It is necessary to well inform patients of an operation's risks and complications. Furthermore, the exceeding demand with respect to organ availability raises ethical issues about organ allocation.

Obesity and adiponectin after kidney transplantation

Obesity and hyperlipidaemia are found very frequently after kidney transplantation (Tx) and may represent independent risk factors for development of atherosclerosis and chronic allograft nephropathy. In a prospective metabolic study, we monitored, a total of 68 obese transplant patients [body mass index (BMI) > 30 kg/m2] with dyslipidaemia over a period of 24 months. We compared the findings of a new therapeutic regimen 1 year (start of the study) and 2 years after renal transplantation. Based on a Subjective Global Assessment Scoring Sheet, we started at the end of the first year with an individualized hypoenergic-hypolipidaemic diet (IHHD). Subsequently, after corticoid withdrawal, IHHD was supplemented regularly with statins (atorvastatin 10-20 mg/day)) and followed-up for 2 years. All patients were on a regimen of cyclosporin A or tacrolimus and mycophenolate mofetil. During the study period, there was a significant decrease in BMI (p < 0.025) and an increase of the adiponectin level (p < 0.01). Long-term therapy was associated with a significant decrease in serum leptin (p < 0.01) and lipid metabolism parameters (p < 0.01). Inulin clearance, mean systolic and diastolic blood pressure, proteinuria, lipoprotein(a) and apo-lipoprotein E isoforms did not differ significantly. Based on our results, we assume that obesity and hyperlipidaemia after renal transplantation can be treated effectively by modified immunosuppression (corticosteroid withdrawal), statins and long-term diet (IHHD). The increased level of adiponectin may be a marker of reducing atherosclerotic and chronic allograft nephropathy processes.

Synthetic N-pyridinyl(methyl)-indol-3-ylpropanamides as new potential immunosuppressive agents

Several N-pyridinyl(methyl)-indol-3-ylpropanamides were synthesized and pharmacological evaluations of their immunosuppressive potential were performed. Among thirteen compounds tested in vitro on murine T proliferation, three showed interesting inhibiting activity. For the most active compound (propanamide 18), immunosuppressive activity was documented both in vitro on human T lymphocytes proliferation and in vivo on mice delayed-type hypersensitivity. These experimental data demonstrated that these compounds hold potential as immunosuppressive agents.

Cardiovascular risk factors, fitness and physical activity in rheumatic diseases

PURPOSE OF REVIEW

There is increased recognition of an excess risk of cardiovascular disease in patients with rheumatic disorders. Physical inactivity is a frequent complication of arthritis, and also common in the general population. In this review, we highlight recent findings on risk factors for cardiovascular disease in patients with rheumatic diseases, and explore the role of physical activity for the prevention of cardiovascular disease.

RECENT FINDINGS

Inflammatory mechanisms are clearly involved in cardiovascular disease in patients with systemic lupus erythematosus and rheumatoid arthritis. In rheumatoid arthritis, disability is also a major predictor of cardiovascular disease. A sedentary lifestyle increases the risk of cardiovascular disease in the general population, and high physical activity prevents cardiovascular disease mortality and morbidity. Successful treatment of rheumatic disease with control of inflammation and improved functional capacity may also reduce the risk of cardiovascular disease.

SUMMARY

As part of the effort to prevent vascular comorbidity, regular exercise should be encouraged in patients with rheumatic diseases, and structured interventions to reduce adverse lifestyle factors scientifically evaluated.

Increased cardiovascular risk profile and mortality in kidney allograft recipients with post-transplant diabetes mellitus in Spain

BACKGROUND

Post-transplant diabetes mellitus (PTDM) is associated with poorer outcomes in kidney transplantation (KT) but little information exists about the evolution of traditional cardiovascular risk (CVR) factors under this disorder.

METHODS

We retrospectively analysed CVR factors at 3, 12 and 24 months of follow-up and mortality at three yr in 3365 KT performed in Spain during the years 1990, 1994 and 1998 with a functioning graft after the first year. Three groups were considered: (i) (PTDM, n, 251), (ii) diabetes mellitus as primary disease (DM, n = 156) and (iii) the remaining patients (controls, n = 2958).

RESULTS

Recipient age, weight and body mass index (BMI) were higher in PTDM than in the other groups (p < 0.0001), with a lower increase of body weight during follow-up (p < 0.003). PTDM patients showed higher total-cholesterol levels than controls at one (p < 0.01) and two yr (p < 0.0009), and higher triglyceride levels than the other groups during follow-up (p < 0.002). Compared with Controls, PTDM patients had significantly higher systolic blood pressure at one (p < 0.001) and two yr (p < 0.005). Diastolic blood pressure was higher in PTDM and controls (p < 0.001), while pulse pressure was higher in PTDM and DM patients (p < 0.0001) during follow-up. Using Cox proportional hazards analysis, PTDM correlated with total mortality (RR = 1.55; range 1.05-2.3; p < 0.02) but not with cardiovascular mortality.

CONCLUSIONS

In Spanish KT recipients with graft function after one yr, PTDM is associated with a worse traditional CVR profile and a higher overall mortality. Although short-term cardiovascular mortality remains similar, better control of CVR factors is mandatory to prevent long-term cardiovascular mortality inherent to this population.

Lipid Profile During Azathioprine or Mycophenolate Mofetil Combinations With Cyclosporine and Steroids

BACKGROUND

Immunosuppressive therapy is the major cause of hyperlipidemia after renal transplantation. We sought to compare the effects of an azathioprine (AZA) combination (n = 26) with corticosteroid and cyclosporine (CyA; group 1) with a mycophenolate mofetil (MMF) combination (n = 71; group 2) in the first year following renal transplantation.

METHODS

Ninety-seven renal transplant patients (71 men, 26 women; aged 34.7 +/- 13.1 years; renal transplantation duration, 44.9 +/- 12.9 months) underwent serum lipid profiles--total cholesterol, triglyceride, high-density lipoprotein (HDL); low-density lipoprotein (LDL), and very low-density lipoprotein (VLDL) at the initiation of as well as 3-month intervals after grafting for 1 year retrospectively. Serum creatinine for each patient was recorded at 12 months. We evaluated possible risk factors for hyperlipidemia.

RESULTS

For all patients, the prevalence of hypercholesterolemia (>200 mg/dL) was 36.1% during the pretransplant period, 60.8% at month 3, 50.5% at month 6, and 38.1% at month 12 after renal transplantation. Total cholesterol and triglyceride levels significantly increased in both groups in the first year (P = .001 and P = .02, respectively). Three-month values for total cholesterol were higher in group 2 than group 1 (P = .001). No significant difference was observed between the groups with respect to total cholesterol and triglyceride levels (P > .05). In both groups, HDL, LDL, and VLDL levels did not change during the 12-month study (P > .05 for all).

CONCLUSIONS

Independent of hyperlipidemia risk factors, serum total cholesterol and triglyceride levels tended to increase during CyA and steroid therapy among patients undergoing renal transplantation. Combination with MMF or AZA showed no advantage over one another regarding their effects on the lipid profile.

A comparison of the effects of C2-cyclosporine and C0-tacrolimus on renal function and cardiovascular risk factors in kidney transplant recipients

BACKGROUND

There are few data directly comparing the effects of two-hour postingestion monitored cyclosporine (C2-CsA) vs. trough-monitored tacrolimus (C0-Tac) on renal function and cardiovascular risk factors.

METHODS

We studied 378 (202 C2-CsA vs. 176 C0-Tac) incident kidney transplant recipients in Toronto, Canada, from August 1, 2000 and December 31, 2003. Outcomes included changes in estimated glomerular filtration rate (eGFR at 1 and 6 months by modification of diet in renal disease four-variable equation), mean arterial pressure (MAP), total cholesterol (TC), and new-onset diabetes mellitus (NODM) at six months posttransplant. The independent effect of treatment/monitoring strategies on continuous outcomes and time-to-NODM was modeled using linear and Cox regression, respectively.

RESULTS

Mean eGFR was 59.5 vs. 62.9 ml/min at one month and 50.6 vs. 61.2 ml/min at six months for C2-CsA vs. C0-Tac, respectively. Multiple linear regression revealed the slope of eGFR to be 0.93 ml/min/month lower in C2-CsA patients. This was equivalent to an adjusted average eGFR difference of 4.64 ml/min between months one and six posttransplant. There was no significant difference in average MAP and TC. In a stepwise multivariable Cox model and a propensity score analysis, there was no significant association between the type of treatment/monitoring strategy and time-to-NODM.

CONCLUSIONS

There was a greater decline in eGFR for patients on C2-CsA (vs. C0-Tac) between one and six months posttransplant. However, MAP, TC, and the risk of NODM were comparable in both treatment/monitoring groups. The long-term impact of short-term reductions in eGFR as a function of the type of treatment/monitoring strategy requires further study.

High Rejection Rate during Calcineurin Inhibitor-Free and Early Steroid Withdrawal Immunosuppression in Renal Transplantation

Morbidity and mortality due to cardiovascular disease are major problems after renal transplantation. The effects of three immunosuppressive protocols on cardiovascular end points were investigated in a single-center, randomized, parallel (1-1-1) group. Acute rejection was a secondary safety endpoint. Groups were as follows: group one, tacrolimus+sirolimus; group two, tacrolimus+mycophenolate mofetil (MMF); group three, sirolimus+MMF+daclizumab. All groups received two days methylprednisolone only. The Ethical Committee demanded an interim analysis when 50% of the patients were included. In this analysis, 54 patients with a median follow-up of 9.2 months were studied. The Kaplan-Meyer analysis showed a difference in rejection free survival between group one (82%) and group three (34%, P=0.03) and between groups one and two (tacrolimus-based, 76%) and group three (calcineurin-free, 34%, P=0.04). Calcineurin-free immunosuppression with two days of steroids only showed an unacceptable high incidence of acute rejection and re-rejection, and the study had to be stopped.

Perioperative management of immunosuppression

Current immunosuppressive regimens typically consist of two phases: induction phase (medications given at the time of the initial transplant) and maintenance therapy. Induction medications are given to decrease the occurrence of early acute rejection, avoid or minimise corticosteroids, and potentially induce long-term favourable immunoregulatory effects. As tolerance remains an elusive goal, life-long maintenance immunosuppression is required after all solid-organ transplantations. The various agents used in these two phases of immunosuppression are reviewed in this article. The similarities and differences between the agents within each class, with respect to efficacy and tolerability, are discussed.

Maintenance immunosuppression regimens: conversion, minimization, withdrawal, and avoidance

A wide choice of drug combinations is available to clinicians for immunosuppression regimens for their kidney transplant patients. Although many protocols have minimized early graft loss, the optimal long-term regimen is unknown. Recent studies clearly showed that cardiovascular death is now the leading cause of graft loss. Strategies must be developed that address this risk while keeping immunologic events low. Transplant physicians have focused on exploring regimens that minimize or avoid the use of corticosteroids. Studies also have started to explore protocols that minimize calcineurin inhibitor therapy.

Long-term patient survival: strategies to improve overall health

The use of potent immunosuppressant therapy has led to an increase in number of patients with successful long-term kidney transplants. These individuals come to kidney transplantation with varying levels of comorbidity associated with end-stage renal disease and are susceptible to immunologic and nonimmunologic comorbidities that arise late after transplantation, including cardiovascular disease, infection, malignancy, and bone disease, which negatively impact on patient and graft survival. In addition, nonadherence to immunosuppressant regimens increases with time after transplantation, which further augments the risk for late-term graft failure and mortality. Consistent and frequent follow-up of kidney transplant recipients beyond the first year permits early diagnosis and successful treatment of many posttransplantation comorbidities. Implementation of preventive practices and aggressive management of risk factors throughout the life of the transplant improves overall health and long-term outcomes. Establishment and maintenance of close relationships among transplant centers, physicians, patients, and their families improves patient adherence to medications and reduces the risk for morbidity and mortality.

Pharmacogenetic differences and drug-drug interactions in immunosuppressive therapy

With the advent of new immunosuppressants and formulations, the elucidation of molecular targets and the evolution of therapeutic drug monitoring, the field of organ transplantation has witnessed significant reductions in acute rejection rates, prolonged graft survival and improved patient outcome. Nonetheless, challenges persist in the use of immunosuppressive medications. Marked interindividual variability remains in drug concentrations and drug response. As medications with narrow therapeutic indices, variations in immunosuppressant concentrations can result in acute toxicity or transplant rejection. Recent studies have begun to identify factors that contribute to this variability with the promise of tailoring immunosuppressive regimens to the individual patient. These advances have uncovered differences in genetic composition in drug-metabolising enzymes, drug transporters and drug targets. This review focuses on commonly used maintenance immunosuppressants (including cyclosporin, mycophenolate mofetil, tacrolimus, sirolimus, everolimus, azathioprine and corticosteroids), examines current studies on pharmacogenetic differences in drug-metabolising enzymes, drug transporters and drug targets and addresses common drug-drug interactions with immunosuppressant therapies. The potential role of drug-metabolising enzymes in contributing to these drug-drug interactions is briefly considered.

Slowing the progression of chronic allograft nephropathy by conversion from cyclosporine to tacrolimus: a randomized controlled trial

BACKGROUND

Chronic allograft nephropathy (CAN) is a multifactorial process with immunologic and nonimmunologic factors. Because tacrolimus (Tac) has been ascribed a beneficial effect on some of these factors when compared to cyclosporine A (CyA), a randomized controlled trial was conducted to investigate whether conversion from CyA to Tac can ameliorate the progression of renal dysfunction in kidney transplant recipients (KTR) with CAN.

METHODS

Of the 46 patients with biopsy-proven CAN enrolled, 24 were converted from CyA to Tac, whereas 22 patients were maintained on CyA. Serum creatinine (SCrea), lipid profiles and an antihypertensive score (AHS) were determined after 3, 6 and 12 months. AHS is based on the total number and dosages of antihypertensive medications used. SCrea and AHS were additionally evaluated at 36 months.

RESULTS

SCrea was decreased in the Tac group (Tac(baseline): 297 +/- 67 micromol/L; Tac(6): 261+/- 70 micromol/L, P < 0.001; Tac(12): 254 +/- 55 micromol/L, P < 0.001; Tac(36): 255 +/- 78 micromol/L, P = 0.235), whereas a significant increase of SCrea was detected in the CyA group (CyA(baseline): 279 +/- 77 micromol/L, CyA(12): 333 +/- 98 micromol/L, P < 0.001; CyA(36): 317 +/- 89 micromol/L, P < 0.001). Compared to CyA therapy, SCrea in the Tac group declined after 12 and 36 months (P = 0.011 and 0.048, respectively) as well as AHS (Tac(12): 59 +/- 13, CyA(12): 83 +/- 14, P < 0.001; Tac(36): 60 +/- 12, CyA(36): 84 +/- 14, P < 0.001). LDL cholesterol was lower in the Tac group after 12 months (Tac(12): 2.5 +/- 0.5 mmol/L, CyA(12): 3.5 +/- 0.6 mmol/L, P < 0.001).

CONCLUSION

Conversion from CyA to Tac in KTR with CAN improves allograft function, lowers blood pressure, and reduces LDL cholesterol. This superior profile may translate into improved long-term graft survival.

Sudden cardiac death associates with a large right atrium thrombus in a late survivor of heart transplantation

A fatal circulatory collapse developed acutely in a patient six years after orthotopic heart transplantation. Autopsy revealed a large, fresh thrombus inside the right atrium which obstructed the orifice of the vena cava completely. The grafted coronary artery and pulmonary vessels were patent. There was no rejection or acute infarct in myocardium. Mildly immature organization was seen on the thrombus-adhered wall. Four chamber enlargement and a rapid decline of right ventricular hypokinesia were detected shortly before death although he did not show active cardiopulmonary symptom. Intracardiac thrombus formation is rather uncommon in late survivor. A synergic effect of atrial turbulence and ventricular hypokinesia in the right heart, superimposed by tissue organization, was proposed for thrombus formation. An empty cardiac output was favored for his mortality. These findings provide a strong evidence to suggest anticoagulation in case of complicated or highly risk of embolization such as turbulence or hypokinesia despite of an absence of active cardiopulmonary symptom.

Effect of cyclosporine a on glucose interstitial concentration in renal cortex and medulla from rats

AIM

To standardize microdialysis in rat kidneys and address cyclosporine A (CsA) effects on renal cortex and medulla interstitial glucose.

METHODS

Munich-Wistar rats were treated with vehicle or CsA (15 mg/kg/day) for 3 weeks. Glucose was assessed by spectrophotometry in dialysate samples from cortex, medulla and arterial plasma. Plasma insulin was measured by radioimmunoassay. Renal blood flow (RBF) was measured by Doppler ultrasound. Creatinine and urea were measured by spectrophotometry.

RESULTS

CsA significantly increased the plasma levels of urea and creatinine (1.5 +/- 0.20 vs. 0.73 +/- 0.03 mg/dl in controls, p < 0.05). Medullary glucose in control was 44% lower than arterial glucose (56 +/- 6 vs. 101 +/- 8 mg/dl, p < 0.05). At the same time, CsA increased arterial (163 +/- 35 vs. 101 +/- 8 mg/dl in controls, p < 0.05) and medullary interstitial glucose (100 +/- 18 vs. 56 +/- 6 mg/dl in controls, p < 0.05), but did not affect cortical glucose (114 +/- 21 vs. 90 +/- 11 mg/dl in controls). These changes occurred in the presence of a decreased plasma insulin level (2.7 +/- 0.2 vs. 9.3 +/- 0.4 microU/ml in controls, p < 0.05). The increment in medullary glucose in CsA group occurred despite a reduction in RBF (4.6 +/- 0.8 vs. 6.5 +/- 1.0 ml/min/kidney in controls, p < 0.05).

CONCLUSIONS

Microdialysis was an adequate tool to investigate in vivo regulation of renal glucose metabolism. Renal glucose uptake was dependent on medullary cells and CsA treatment induced diabetogenic effects on renal medulla in situ.

Lipoic acid supplementation prevents cyclosporine-induced hypertension and nephrotoxicity in spontaneously hypertensive rats

BACKGROUND

Cyclosporine (CsA) has significantly improved long-term survival after organ transplantations. Hypertension and nephrotoxicity are common side effects during CsA treatment and are aggravated by high salt intake.

OBJECTIVE

To examine whether lipoic acid (LA), a natural antioxidant that scavenges reactive oxygen species and regenerates/recycles endogenous antioxidants, could prevent CsA-induced hypertension and nephrotoxicity.

METHODS

Six-week-old spontaneously hypertensive rats (SHR) on a high-sodium diet (NaCl 6%) received CsA [5 mg/kg subcutaneously (s.c.)] alone or in combination with LA (0.5% w/w) for 6 weeks. Blood pressure, arterial functions, and tissue morphology were determined. Immunohistochemistry, quantitative reverse transcriptase-polymerase chain reaction (RT-PCR) and high-pressure liquid chromatography were used for kidney and heart samples.

RESULTS

CsA induced severe hypertension, cardiac hypertrophy, endothelial dysfunction, and pronounced albuminuria. Histologically, the kidneys showed severe thickening of the media of the afferent arteries with fibrinoid necrosis, perivascular monocyte/macrophage infiltration and nitrotyrosine overexpression. CsA induced the expression of fibrogenic connective tissue growth factor both in the heart and kidneys. The detrimental effects of CsA were associated with upregulation of myocardial atrial natriuretic peptide (ANP) mRNA expression, paradoxical activation of the renin-angiotensin system (RAS), induction of renal reduced nicotinamide-adenine dinucleotide phosphate (NADPH) oxidase, and overexpression of oxidative stress-induced transcription factor NRF2. LA lowered blood pressure, ameliorated cardiac hypertrophy and endothelial dysfunction, and totally normalized albuminuria. In LA-treated rats, renal and cardiac morphologies were indistinguishable from those of SHR controls. CsA-induced myocardial ANP and connective tissue growth factor (CTGF) mRNA overexpression, RAS activation, NADPH oxidase induction, and NRF2 overexpression were prevented by LA. LA induced the mRNA expression of gamma-glutamylcysteine ligase, the rate-limiting enzyme in glutathione synthesis, and markedly increased hepatic cysteine and glutathione concentrations.

CONCLUSIONS

Our findings suggest a salutary role for lipoic acid supplementation in the prevention of CsA-induced hypertension and nephrotoxicity, and underscore the importance of increased oxidative stress in the pathogenesis of CsA toxicity.

Recommendations for Outpatient Monitoring of Kidney Transplant Recipients

Clinical and laboratory outpatient monitoring is an important tool in the prevention and management of complications associated with kidney transplantation and immunosuppressive therapy. In the absence of standard protocols for outpatient surveillance of kidney transplant recipients, recommendations for frequency and type of monitoring are determined by the likelihood of problems that are unique to the individual transplant recipient and the particular posttransplantation period. In addition, it is imperative to maintain the transplant recipient's overall health by screening for conditions or diseases that can be linked to prior renal disease, immunosuppressive therapies, and general health maintenance.

Effect of apolipoprotein B polymorphism in kidney transplantation

INTRODUCTION

In kidney transplant recipients, dyslipidemia is a cardiovascular risk factor that also contributes to the development and progression of chronic allograft nephropathy. Apolipoprotein B (ApoB), present in low-density lipoproteins (LDL), is an important protein component of chylomicrons and very-low-density lipoproteins (VLDL). The del allele of the ApoB signal peptide polymorphism has been associated with elevated levels of total and LDL cholesterol and greater risk of coronary disease.

OBJECTIVE

The objective of this study was to assess the influence of ApoB polymorphism on allograft and patient survival among kidney transplant recipients.

METHODS

In this study, we analyzed 516 renal transplant recipients (38% were women, 62% were men), aged 46 +/- 15 years, with a minimum follow-up of 12 months (mean, 1854 +/- 806 days). The ApoB signal peptide was analyzed (insertion/deletion) using polymerase chain reaction (PCR) using genomic DNA. Clinical donor-recipient variables were assessed using a Cox multivariate model.

RESULTS

Polymorphism distribution was as follows: insertion/insertion (ins/ins) 51%, insertion/deletion (ins/del) 39%, and deletion/deletion (del/del) 9%, with no differences between the genders. Cholesterol levels at 12 months showed no differences between the ins/ins (217 +/- 46), ins/del (228 +/- 50), and del/del (227 +/- 54) groups. Presence of the ApoB signal peptide del/del or ins/del genotype was independently associated with lower patient survival in the group of men younger than 60 years (P < .05). Among the total deaths, cardiovascular causes predominated in the ins/del and del/del groups (50%) as compared with the ins/ins group (33%) (P < .01).

CONCLUSIONS

ApoB genetic polymorphism (del allele) seems to have an adverse effect on the long-term survival of kidney transplant recipients.

Apolipoprotein E genotypes as predictors of high-risk groups for developing hyperlipidemia in kidney transplant recipients undergoing sirolimus treatment

BACKGROUND

Hypercholesterolemia (HCHL) and hypertriglyceridemia (HTRG) have emerged as the most significant metabolic consequences of therapy with sirolimus. Lipid status can be exacerbated by a variety of factors in the posttransplant setting, including genetic factors. Apoliprotein E (Apo E) polymorphism is an established genetic risk factor for hyperlipidemia. We studied the association between Apo E gene polymorphisms and lipids after kidney transplantation in patients undergoing sirolimus treatment.

METHODS

We studied 98 kidney transplant patients (KTP) with stable renal allograft undergoing sirolimus treatment: 39 with HCHL and HTRG within 90 days postsirolimus treatment (PST) and 59 without hyperlipidemia PST. Apo E genotyping was performed using INNO-LiPA-ApoE.

RESULTS

The cholesterol and the triglyceride values between the groups were 323.3+/-71.6 vs. 180.9+/-31.2 mg/dL (P<0.001) and 318.9+/-97.2 vs. 159.7+/-38.7 mg/dL (P<0.001). There was a significant difference in the genotype distribution of the hyperlipidemia and normal groups (P=0.009) with the percentages in each group as follows: E2/2 and E3/2: 12.8 vs. 5.1%; E3/3: 69.2% vs. 86.4%; and E4/3 and E4/4: 18.0% vs. 8.5%. We observed a higher number of patients with the genotype E3/3 in the group without hyperlipidemia PST (P=0.039). E3/2 and E4/4 genotype frequencies were higher in patients with hyperlipidemia PST. LDL levels in the hyperlipidemia PST group was statistical significant higher (P<0.001) and we observed an association between Apo E allelic distribution and LDL (P=0.005).

CONCLUSIONS

Genetic factors, as Apo E genotypes, could allow the early identification of patients who are at a high risk for developing hyperlipidemia PST.