Elective conversion of patients from cyclosporine to tacrolimus for hypertrichosis

Gout in renal transplant recipients

AIMS

The aims of the present audit were to determine the prevalence of gout in renal transplant recipients in Canterbury, New Zealand, to identify risk factors for gout, and to assess the range of treatments used, their efficacy and complications. In addition, the authors wished to assess the impact of post-renal transplant gout on the patient.

METHODS

Patients with post-transplantation gout were identified from the Christchurch Hospital Nephrology database. For each patient with gout a post-renal transplantation recipient without gout post transplant was found matched for age, sex and date of transplant. Case notes were audited and patients interviewed.

RESULTS

In total, 47/202 (23%) living renal transplant recipients had gout post transplant. Those patients with gout were more likely to be taking a loop diuretic (68%vs 34%, P < 0.001), to have a higher serum urate and impaired renal function and to have had gout prior to the transplant. Of those patients who developed gout post transplant 70% had an attack at least every 3 months. Of those who returned to work post transplant 48% required time off work because of gout.

CONCLUSION

out is an important problem in the post-transplant population causing significant morbidity and time off work. Diuretics, impaired renal function, gout prior to transplantation and hyperuricaemia are important risk factors. The need for diuretic therapy should be kept under review in these patients. Hypouricaemic therapy should be considered early in those who develop gout post renal transplantation. Further studies are required to determine whether treatment for asymptomatic hyperuricaemia is justified.

Preferred methods of excess hair removal in pediatric patients with lung transplantation

BACKGROUND

Hypertrichosis is common among recipients of lung transplantation taking cyclosporine and it poses a special psychosocial problem in children. Children and parents frequently inquire about methods of hair removal.

OBJECTIVE

We sought to determine preferred methods of hair removal in this population.

METHODS

We distributed a questionnaire to 104 pediatric recipients of lung transplantation. A total of 56 questionnaires (54%) were completed.

RESULTS

Of respondents, 91% (51 of 56) experienced hypertrichosis, 75% (38 of 51) of whom attempted treatment. Depilatory cream was the most common hair removal technique (79%, 30 of 38). Shaving, particularly with an electric razor, received the highest ratings of both satisfaction and likelihood of future use.

LIMITATIONS

Generalizability is limited by the response rate. Preferred methods according to different hair locations were not evaluated.

CONCLUSION

In our pediatric transplantation population, depilatory cream was the most commonly used treatment for hypertrichosis whereas electric shaving had the highest ratings of satisfaction and future use.

Gout in solid organ transplantation: a challenging clinical problem

Hyperuricaemia occurs in 5-84% and gout in 1.7-28% of recipients of solid organ transplants. Gout may be severe and crippling, and may hinder the improved quality of life gained through organ transplantation. Risk factors for gout in the general population include hyperuricaemia, obesity, weight gain, hypertension and diuretic use. In transplant recipients, therapy with ciclosporin (cyclosporin) is an additional risk factor. Hyperuricaemia is recognised as an independent risk factor for cardiovascular disease; however, whether anti-hyperuricaemic therapy reduces cardiovascular events remains to be determined. Dietary advice is important in the management of gout and patients should be educated to partake in a low-calorie diet with moderate carbohydrate restriction and increased proportional intake of protein and unsaturated fat. While gout is curable, its pharmacological management in transplant recipients is complicated by the risk of adverse effects and potentially severe interactions between immunosuppressive and hypouricaemic drugs. NSAIDs, colchicine and corticosteroids may be used to treat acute gouty attacks. NSAIDs have effects on renal haemodynamics, and must be used with caution and with close monitoring of renal function. Colchicine myotoxicty is of particular concern in transplant recipients with renal impairment or when used in combination with ciclosporin. Long-term urate-lowering therapy is required to promote dissolution of uric acid crystals, thereby preventing recurrent attacks of gout. Allopurinol should be used with caution because of its interaction with azathioprine, which results in bone marrow suppression. Substitution of mycophenylate mofetil for azathioprine avoids this interaction. Uricosuric agents, such as probenecid, are ineffective in patients with renal impairment. The exception is benzbromarone, which is effective in those with a creatinine clearance >25 mL/min. Benzbromarone is indicated in allopurinol-intolerant patients with renal failure, solid organ transplant or tophaceous/polyarticular gout. Monitoring for hepatotoxicty is essential for patients taking benzbromarone. Physicians should carefully consider therapeutic options for the management of hypertension and hyperlipidaemia, which are common in transplant recipients. While loop and thiazide diuretics increase serum urate, amlodipine and losartan have the same antihypertensive effect with the additional benefit of lowering serum urate. Atorvastatin, but not simvastatin, may lower uric acid, and while fenofibrate may reduce serum urate it has been associated with a decline in renal function. Gout in solid organ transplantation is an increasing and challenging clinical problem; it impacts adversely on patients' quality of life. Recognition and, if possible, alleviation of risk factors, prompt treatment of acute attacks and early introduction of hypouricaemic therapy with careful monitoring are the keys to successful management.

Hypertrichosis

Hypertrichosis is hair growth that is abnormal for the age, sex, or race of an individual, or for a particular area of the body. Recognized forms of hypertrichosis are reviewed. Hirsutism, which is male-pattern hair growth in a female or child, is not included in this review. Hypertrichosis is categorized as congenital or acquired, and regional or generalized. Methods of managing hypertrichosis are also briefly reviewed

The effect of conversion from cyclosporine to tacrolimus on gingival hyperplasia, hirsutism and cholesterol

The use of cyclosporine for immunosuppression in renal transplantation allograft recipients is associated with hypertrichosis, gingival hyperplasia, and hypercholesterolemia. Conversion of patients to tacrolimus may lead to an improvement in these effects with minimal risk of rejection or allograft dysfunction.

METHODS

Sixteen renal transplant recipients were prospectively converted from CsA to tacrolimus and followed for 1 year. Gingival hyperplasia index, total cholesterol, and blood pressure were recorded at the outset, 4-, 8-, and 12-month intervals. Glomerular filtration rate was checked before conversion and 1 year later. Photographs documenting hypertrichosis were taken before conversion and 1 year later. Adverse effects from tacrolimus were recorded at 4, 8, and 12 months.

RESULTS

Twelve patients with hypertrichosis noted rapid improvement. Mean gingival hyperplasia index decreased from 24 to 6; mean total cholesterol decreased from 237 to 195. Glomerular filtration rate was essentially unchanged (56 to 54). One episode of rejection occurred, three patients developed diarrhea, three noted headaches, and one had a tremor.

CONCLUSION

If carefully monitored, patients suffering adverse effects secondary to cyclosporine may be converted to tacrolimus with minimal risk of allograft dysfunction or rejection.