Sirolimus may reduce fertility in male renal transplant recipients

KDIGO clinical practice guideline for the care of kidney transplant recipients

The 2009 Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guideline on the monitoring, management, and treatment of kidney transplant recipients is intended to assist the practitioner caring for adults and children after kidney transplantation. The guideline development process followed an evidence-based approach, and management recommendations are based on systematic reviews of relevant treatment trials. Critical appraisal of the quality of the evidence and the strength of recommendations followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach. The guideline makes recommendations for immunosuppression, graft monitoring, as well as prevention and treatment of infection, cardiovascular disease, malignancy, and other complications that are common in kidney transplant recipients, including hematological and bone disorders. Limitations of the evidence, especially on the lack of definitive clinical outcome trials, are discussed and suggestions are provided for future research.

Gonadal dysfunction and infertility in kidney transplant patients receiving sirolimus

Sirolimus is an immunosupressor of the mammalian target of rapamycin inhibitors (mTOR-I) group. Recent studies have emphasized a potential impact of sirolimus on male gonadal function. We report our clinical experience with sirolimus-induced gonadal dysfunction and infertility in both male and female kidney transplant patients. Of the 170 kidney transplant patients, nine (5.3%) patients (six males and three females) were receiving sirolimus. Follow-up data for two male patients were not available. The one unmarried female patient developed amenorrhea post-transplantation and had resumption of her menstrual cycles after discontinuation of sirolimus. The remaining six married patients (four males and two females), who all had fathered or conceived children in the pre-transplantation period, developed gonadal dysfunction and infertility on average 5-12 months after transplantation. Sirolimus was discontinued in all four male patients with full recovery of the oligo/azospermia and restoration of fertility. Both married female patients developed amenorrhea post-transplantation. Sirolimus was discontinued in one female patient with resumption of her menstrual cycles. In this small population of patients treated with sirolimus, the prevalence rate of reversible gonadal dysfunction and infertility was significant in both males and females. Infertility secondary to sirolimus is under-diagnosed and should be studied further.

Kidney transplantation: the ideal immunosuppression regimen

Kidney transplantation today has excellent short-term outcomes, but long-term graft survival has not improved in a parallel fashion. The goal of immunosuppressive therapy is to balance the beneficial effects of reducing acute rejection while minimizing adverse effects from oversuppression including the development of infections, malignancy, and cardiovascular risk factors. In general, current immunosuppressive protocols use combinations of immunosuppressive agents with different mechanisms of action to maximize efficacy and minimize the toxicity of each drug. During the past decade, there has been a growing interest in identifying regimens that permit the minimization of calcineurin inhibitors or corticosteroids in an attempt to decrease nephrotoxicity and metabolic side effects. The emergence of new immunosuppressive agents and tolerance protocols appear promising as a means to deliver immunosuppression without long-term toxicity. Ultimately, the goal of prescribing immunosuppression is to transition from empiric therapy to one of individualized therapy.