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Spiritos Z, Abdelmalek MF. Metabolic syndrome following liver transplantation in nonalcoholic steatohepatitis. Transl Gastroenterol Hepatol 2021; 6:13. [PMID: 33409407 DOI: 10.21037/tgh.2020.02.07] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 10/16/2019] [Indexed: 12/13/2022] Open
Abstract
Metabolic syndrome is a major clinical disorder involving metabolic dysregulation characterized clinically with features of central obesity, insulin resistance (IR), type 2 diabetes, hypertension, and dyslipidemia. Metabolic syndrome is strongly associated with the rising prevalence nonalcoholic steatohepatitis, a leading indication for orthotopic liver transplantation in the Western world. The presence or recurrence of metabolic syndrome following liver transplantation can contribute to the development and recurrence of nonalcoholic fatty liver disease (NAFLD) in the liver allograft. In this review, we discuss the endogenous and exogenous drivers of post-transplant metabolic syndrome, role of chronic immunosuppression, and the prevalence and clinical significant of post-transplant metabolic syndrome on nonalcoholic steatohepatitis.
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Affiliation(s)
- Zachary Spiritos
- Division of Gastroenterology and Hepatology, Duke University, Durham, NC, USA
| | - Manal F Abdelmalek
- Division of Gastroenterology and Hepatology, Duke University, Durham, NC, USA
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Effects of Statins on Lipid Profile of Kidney Transplant Recipients: A Meta-Analysis of Randomized Controlled Trials. BIOMED RESEARCH INTERNATIONAL 2020; 2020:9094543. [PMID: 32462035 PMCID: PMC7212277 DOI: 10.1155/2020/9094543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 03/21/2020] [Accepted: 04/07/2020] [Indexed: 11/17/2022]
Abstract
Objective To assess the benefits of statins on lipid profile in kidney transplant recipients via a meta-analysis. Methods We systematically identified peer-reviewed clinical trials, review articles, and treatment guidelines from PubMed, Embase, the Cochrane Library, Wanfang, Chinese National Knowledge Infrastructure (CNKI), SinoMed (CBM), and Chongqing VIP databases from inception to April 2019. In the analysis, only randomized controlled clinical trials performed in human were included. Results Eight articles were included in the analysis, involving 335 kidney transplant recipients who received statins and 350 kidney transplant patients as the control group. Results revealed that statins improved the lipid profile of kidney transplant recipients. Specifically, statin therapy significantly reduced total cholesterol and low-density lipoprotein cholesterol. However, it had no effects on high-density lipoprotein cholesterol and triglyceride levels. Conclusions The present study provides valuable knowledge on the potential benefits of statins in kidney transplant recipients. This meta-analysis shows that statin therapy modifies the lipid profile in this patient population.
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Han N, Han SH, Song YK, Kim MG, Kim YS, Kim IW, Oh JM. Statin therapy for preventing cardiovascular diseases in patients treated with tacrolimus after kidney transplantation. Ther Clin Risk Manag 2017; 13:1513-1520. [PMID: 29200861 PMCID: PMC5701562 DOI: 10.2147/tcrm.s147327] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background Lipid abnormalities are prevalent in tacrolimus-treated patients. The aim of the study was to evaluate the preventive effects of statin therapy on major adverse cardiovascular events (MACE) in patients treated with tacrolimus-based immunosuppression after kidney transplantation (KT), and to identify the risk factors. Methods This observational cohort study included adult patients who underwent KT and were treated with tacrolimus. Patients who received any lipid-lowering agents except statins, or had a history of immunosuppressant use before transplantation were excluded. The primary outcome was the adjusted risk of the first occurrence of MACE. The secondary outcomes included the risk of individual cardiovascular disease (CVD) and changes in cholesterol level. Subgroup analyses were performed in the statin-user group according to the dosage and/or type of statin. Results Compared with the control group (n=73), the statin-users (n=92) had a significantly reduced risk of MACE (adjusted HR, 0.31; 95% CI, 0.13–0.74). In the Cox regression analysis, old age, history of CVD, and comorbid hypertension were identified as independent factors associated with increased MACE. The total cholesterol levels were not significantly different between the two groups. Subjects with higher cumulative defined daily dose of statins had significantly lower risks of MACE. Conclusion Statin therapy in patients treated with tacrolimus after KT significantly lowered the risk of MACE. Long-term statin therapy is clearly indicated in older kidney transplant recipients for secondary prevention.
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Affiliation(s)
- Nayoung Han
- Research Institute of Pharmaceutical Sciences, College of Pharmacy, Seoul National University, Seoul
| | - Seung Hee Han
- Research Institute of Pharmaceutical Sciences, College of Pharmacy, Seoul National University, Seoul.,Department of Pharmacy, Asan Medical Center, Seoul
| | - Yun-Kyoung Song
- Research Institute of Pharmaceutical Sciences, College of Pharmacy, Seoul National University, Seoul
| | - Myeong Gyu Kim
- Research Institute of Pharmaceutical Sciences, College of Pharmacy, Seoul National University, Seoul
| | - Yon Su Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul.,College of Medicine, Seoul National University, Seoul, Republic of Korea
| | - In-Wha Kim
- Research Institute of Pharmaceutical Sciences, College of Pharmacy, Seoul National University, Seoul
| | - Jung Mi Oh
- Research Institute of Pharmaceutical Sciences, College of Pharmacy, Seoul National University, Seoul
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Abstract
There is a lack of studies assessing if race impacts the efficacy of 3-hydroxy-3-methyl-glutaryl-CoA reductase (HMGCR) inhibitor ("statin") therapy on renal transplantation (RTx) outcomes. We examined the association between statin therapy and RTx outcomes, while concurrently quantifying the effect modification African American (AA) race has on statin efficacy.This was a retrospective longitudinal cohort study of solitary adult RTx (n = 1176) between June 2005 and May 2013. The Cox proportional hazard model was used to examine the impact of statin therapy on graft loss, death, and acute rejection and determine if significant interactions exist between statin therapy and race. Models were adjusted for demographics, socioeconomic status, cardiovascular history, medication use, and transplant characteristics.AAs (n = 624) and non-African Americans (n = 552) were equally likely to receive statin therapy (P = 0.922). Mean LDL and TGs in AA were 94 mg/dL and 133 mg/dL compared to 90 mg/dL and 163 mg/dL in non-AA, respectively. After adjusting for confounders, high statin users had 52% lower risk of developing graft loss (HR 0.48, 95% CI 0.29-0.80) and a nonstatistically significant reduction in death (HR 0.50, 95% CI 0.23-1.06) compared to low statin users. Acute rejection was not significantly influenced by statin use (HR 0.77 95% CI 0.46-1.27). There was a significant interaction between race and statin therapy for death (P = 0.007), but not for graft loss (P = 0.121) or rejection (P = 0.605). After stratifying by race, high statin use reduced the risk of death in AAs (HR 0.43, 95% CI 0.20-0.94), but not in non-AAs (HR 1.09, 95% CI 0.49-2.44).High statin use reduces the risk of graft loss in RTx, with a mortality benefit in AAs compared to non-AA, despite similar LDL levels. These results suggest a compelling reason to optimize statin therapy in renal transplant recipients (RTR), especially in AAs.
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Affiliation(s)
- Mukoso N Ozieh
- From the Division of Nephrology, Medical University of South Carolina, Charleston, SC; Center for Health Disparities Research, Division of General Internal Medicine, Medical University of South Carolina, Charleston, SC (MNO); Division of Transplant Surgery, Medical University of South Carolina, Charleston, SC; Department of Pharmacy, Ralph H Johnson VAMC, Charleston, SC (DJT); Center for Health Disparities Research, Division of General Internal Medicine, Medical University of South Carolina, Charleston, SC; and Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson VAMC, Charleston, SC (LEE)
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5
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Palmer SC, Navaneethan SD, Craig JC, Perkovic V, Johnson DW, Nigwekar SU, Hegbrant J, Strippoli GFM. HMG CoA reductase inhibitors (statins) for kidney transplant recipients. Cochrane Database Syst Rev 2014; 2014:CD005019. [PMID: 24470059 PMCID: PMC8860132 DOI: 10.1002/14651858.cd005019.pub4] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND People with chronic kidney disease (CKD) have higher risks of cardiovascular disease compared to the general population. Specifically, cardiovascular deaths account most deaths in kidney transplant recipients. Statins are a potentially beneficial intervention for kidney transplant patients given their established benefits in patients at risk of cardiovascular disease in the general population. This is an update of a review first published in 2009. OBJECTIVES We aimed to evaluate the benefits (reductions in all-cause and cardiovascular mortality, major cardiovascular events, myocardial infarction and stroke, and progression of CKD to requiring dialysis) and harms (muscle or liver dysfunction, withdrawal, cancer) of statins compared to placebo, no treatment, standard care, or another statin in adults with CKD who have a functioning kidney transplant. SEARCH METHODS We searched the Cochrane Renal Group's Specialised Register to 29 February 2012 through contact with the Trials Search Co-ordinator using search terms relevant to this review. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs that compared the effects of statins with placebo, no treatment, standard care, or statins on mortality, cardiovascular events, kidney function and toxicity in kidney transplant recipients. DATA COLLECTION AND ANALYSIS Two authors independently extracted data and assessed risk of bias. Treatment effects were expressed as mean difference (MD) for continuous outcomes (lipids, glomerular filtration rate (GFR), proteinuria) and relative risk (RR) for dichotomous outcomes (major cardiovascular events, mortality, fatal or non-fatal myocardial infarction, fatal or non-fatal stroke, elevated muscle or liver enzymes, withdrawal due to adverse events, cancer, end-stage kidney disease (ESKD), acute allograft rejection) together with 95% confidence intervals (CI). MAIN RESULTS We identified 22 studies (3465 participants); 17 studies (3282 participants) compared statin with placebo or no treatment, and five studies (183 participants) compared two different statin regimens.From data generally derived from a single high-quality study, it was found that statins may reduce major cardiovascular events (1 study, 2102 participants: RR 0.84, CI 0.66 to 1.06), cardiovascular mortality (4 studies, 2322 participants: RR 0.68, CI 0.45 to 1.01), and fatal or non-fatal myocardial infarction (1 study, 2102 participants: RR 0.70, CI 0.48 to 1.01); although effect estimates lack precision and include the possibility of no effect.Statins had uncertain effects on all-cause mortality (6 studies, 2760 participants: RR 1.08, CI 0.63 to 1.83); fatal or non-fatal stroke (1 study, 2102 participants: RR 1.18, CI 0.85 to 1.63); creatine kinase elevation (3 studies, 2233 participants: RR 0.86, CI 0.39 to 1.89); liver enzyme elevation (4 studies, 608 participants: RR 0.62, CI 0.33 to 1.19); withdrawal due to adverse events (9 studies, 2810 participants: RR 0.89, CI 0.74 to 1.06); and cancer (1 study, 2094 participants: RR 0.94, CI 0.82 to 1.07).Statins significantly reduced serum total cholesterol (12 studies, 3070 participants: MD -42.43 mg/dL, CI -51.22 to -33.65); low-density lipoprotein cholesterol (11 studies, 3004 participants: MD -43.19 mg/dL, CI -52.59 to -33.78); serum triglycerides (11 studies, 3012 participants: MD -27.28 mg/dL, CI -34.29 to -20.27); and lowered high-density lipoprotein cholesterol (11 studies, 3005 participants: MD -5.69 mg/dL, CI -10.35 to -1.03).Statins had uncertain effects on kidney function: ESKD (6 studies, 2740 participants: RR 1.14, CI 0.94 to 1.37); proteinuria (2 studies, 136 participants: MD -0.04 g/24 h, CI -0.17 to 0.25); acute allograft rejection (4 studies, 582 participants: RR 0.88, CI 0.61 to 1.28); and GFR (1 study, 62 participants: MD -1.00 mL/min, CI -9.96 to 7.96).Due to heterogeneity in comparisons, data directly comparing differing statin regimens could not be meta-analysed. Evidence for statins in people who have had a kidney transplant were sparse and lower quality due to imprecise effect estimates and provided limited systematic evaluation of treatment harm. AUTHORS' CONCLUSIONS Statins may reduce cardiovascular events in kidney transplant recipients, although treatment effects are imprecise. Statin treatment has uncertain effects on overall mortality, stroke, kidney function, and toxicity outcomes in kidney transplant recipients. Additional studies would improve our confidence in the treatment benefits and harms of statins on cardiovascular events in this clinical setting.
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Affiliation(s)
- Suetonia C Palmer
- University of Otago ChristchurchDepartment of Medicine2 Riccarton AvePO Box 4345ChristchurchNew Zealand8140
| | - Sankar D Navaneethan
- Glickman Urological and Kidney Institute, Cleveland ClinicDepartment of Nephrology and HypertensionClevelandOHUSA44195
| | - Jonathan C Craig
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
- The Children's Hospital at WestmeadCochrane Renal Group, Centre for Kidney ResearchWestmeadNSWAustralia2145
| | - Vlado Perkovic
- The George Institute for International HealthRenal and Metabolic DivisionCamperdownNSWAustralia
| | - David W Johnson
- Princess Alexandra HospitalDepartment of NephrologyIpswich RdWoolloongabbaQueenslandAustralia4102
| | - Sagar U Nigwekar
- Harvard Medical SchoolBrigham and Women's Hospital, Massachusetts General Hospital, Scholars in Clinical Sciences ProgramBostonMAUSA
| | - Jorgen Hegbrant
- Diaverum Renal Services GroupMedical OfficePO Box 4167LundSwedenSE‐227 22
| | - Giovanni FM Strippoli
- The Children's Hospital at WestmeadCochrane Renal Group, Centre for Kidney ResearchWestmeadNSWAustralia2145
- Mario Negri Sud FoundationClinical Pharmacology and EpidemiologySanta Maria ImbaroItaly
- Amedeo Avogadro University of Eastern PiedmontNovaraItaly
- DiaverumMedical Scientific OfficeLundSweden
- Diaverum AcademyBariItaly
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Gillis KA, Patel RK, Jardine AG. Cardiovascular complications after transplantation: treatment options in solid organ recipients. Transplant Rev (Orlando) 2013; 28:47-55. [PMID: 24412041 DOI: 10.1016/j.trre.2013.12.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Accepted: 12/01/2013] [Indexed: 12/14/2022]
Abstract
Premature cardiovascular disease is the commonest cause of death in solid organ transplant recipients, with coronary artery disease, sudden cardiac death and heart failure being highly prevalent. There are unique factors leading to CV disease in organ transplant recipients that include underlying comorbidities, and metabolic effects of immunosuppression. As a consequence management strategies developed in the general population may have limited benefit. In this review, we will focus on renal transplantation, where most research has been carried out and, despite incomplete understanding of the disease process, the incidence of cardiovascular disease appears to be falling.
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Kaneko H, Yajima J, Oikawa Y, Tanaka S, Fukamachi D, Suzuki S, Sagara K, Otsuka T, Matsuno S, Funada R, Kano H, Uejima T, Koike A, Nagashima K, Kirigaya H, Sawada H, Aizawa T, Yamashita T. Effects of statin treatment in patients with coronary artery disease and chronic kidney disease. Heart Vessels 2013; 29:21-8. [PMID: 23430269 PMCID: PMC3890054 DOI: 10.1007/s00380-013-0325-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Accepted: 02/01/2013] [Indexed: 10/28/2022]
Abstract
Statins reduce cardiovascular morbidity and mortality from coronary artery disease (CAD). However, the effects of statin therapy in patients with CAD and chronic kidney disease (CKD) remain unclear. Within a single hospital-based cohort in the Shinken Database 2004-2010 comprising all patients (n = 15,227) who visited the Cardiovascular Institute, we followed patients with CKD and CAD after percutaneous coronary intervention (PCI). A major adverse cardiovascular and cerebrovascular event (MACCE) was defined by composite end points, including death, myocardial infarction, cerebral infarction, cerebral hemorrhage, and target lesion revascularization. A total of 391 patients were included in this study (median follow-up time 905 ± 679 days). Of these, 209 patients used statins. Patients with statin therapy were younger than those without. Obesity and dyslipidemia were more common, and the glomerular filtration rate (GFR) was significantly higher, in patients undergoing statin treatment. MACCE and cardiac death tended to be less common, and all-cause death was significantly less common, in patients taking statins. Multivariate analysis showed that low estimated GFR, poor left ventricular ejection fraction, and the absence of statin therapy were independent predictors for all-cause death of CKD patients after PCI. Statin therapy was associated with reduced all-cause mortality in patients with CKD and CAD after PCI.
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Affiliation(s)
- Hidehiro Kaneko
- Department of Cardiovascular Medicine, The Cardiovascular Institute, 3-2-19 Nishiazabu, Minato-ku, Tokyo, 106-0031, Japan,
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Assessment of Cardiovascular Risk Factors after Renal Transplantation: A Step towards Reducing Graft Failure. Transplant Proc 2012; 44:1270-4. [DOI: 10.1016/j.transproceed.2012.01.111] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Accepted: 01/21/2012] [Indexed: 11/23/2022]
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Jardine AG, Gaston RS, Fellstrom BC, Holdaas H. Prevention of cardiovascular disease in adult recipients of kidney transplants. Lancet 2011; 378:1419-27. [PMID: 22000138 DOI: 10.1016/s0140-6736(11)61334-2] [Citation(s) in RCA: 191] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Although advances in immunosuppression, tissue typing, surgery, and medical management have made transplantation a routine and preferred treatment for patients with irreversible renal failure, successful transplant recipients have a greatly increased risk of premature mortality because of cardiovascular disease and malignancy compared with the general population. Conventional cardiovascular risk factors such as hyperlipidaemia, hypertension, and diabetes are common in transplant recipients, partly because of the effects of immunosuppressive drugs, and are associated with adverse outcomes. However, the natural history of cardiovascular disease in such recipients differs from that in the general population, and only statin therapy has been studied in a large-scale interventional trial. Thus, the management of this disease and the balance between management of conventional risk factors and modification of immunosuppression is complex.
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Affiliation(s)
- Alan G Jardine
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.
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McQuarrie EP, Fellström BC, Holdaas H, Jardine AG. Cardiovascular disease in renal transplant recipients. J Ren Care 2010; 36 Suppl 1:136-45. [PMID: 20586909 DOI: 10.1111/j.1755-6686.2010.00160.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Renal transplant recipients have a markedly increased risk of premature cardiovascular disease (CVD) compared with the general population, although considerably lower than that of patients receiving maintenance haemodialysis. CVD in transplant recipients is poorly characterised and differs from the nonrenal population, with a much higher proportion of fatal to nonfatal cardiac events. In addition to traditional ischaemic heart disease risk factors such as age, gender, diabetes and smoking, there are additional factors to consider in this population such as the importance of hypertension, left ventricular hypertrophy and uraemic cardiomyopathy. There are factors specific to transplantation such immunosuppressive therapies and graft dysfunction which contribute to this altered risk profile. However, understanding and treatment is limited by the absence of large randomised intervention trials addressing risk factor modification, with the exception of the ALERT study. The approach to managing these patients should begin early and be multifactorial in nature.
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Vivek V, Bhandari S. Prevalence of modifiable cardiovascular risk factors in long-term renal transplant patients. Int J Nephrol Renovasc Dis 2010; 3:175-82. [PMID: 21694943 PMCID: PMC3108770 DOI: 10.2147/ijnrd.s13866] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2010] [Indexed: 12/14/2022] Open
Abstract
Background: Cardiovascular disease accounts for the majority of morbidity and mortality in renal transplant patients. This relates to a number of modifiable and nonmodifiable risk factors, including new onset diabetes after transplantation (NODAT). We examined the prevalence of these risk factors in a cohort of 126 renal transplant patients. Methods: A retrospective cross-sectional study of 94 nondiabetic post-transplant (ND) patients (mean age 45.7 ± 13.5 years) and 32 NODAT patients (55.2 ± 9.6 years) was performed. Univariate linear regression analysis was used to identify potential factors that affected cardiovascular events. Multivariable analysis was performed on those factors found to achieve a P value of less than 0.20 after univariate analysis to test for significance in relation to cardiovascular risk as the primary factor. Results: Mean serum creatinine levels were 131.1 ± 4.3 μmol/L and 135.2 ± 4.9 μmol/L at 96.9 ± 8.7 and 79.4 ± 14.1 months post-transplantation, respectively. Systolic pressure and pulse pressure were significantly higher in NODAT patients (P = 0.016 and P < 0.005). Adequate target blood pressures were obtained in 80% of patients. Low-density lipoprotein and high-density lipoprotein cholesterol were reduced in NODAT (P = 0.04 and P = 0.005). Homocysteine was similarly elevated in both groups (17.5 and 15.6 μmol/L, respectively). Coronary events and/or coronary disease were present in 19.1% of ND and 37.5% of NODAT patients (P < 0.05). Cardiac deaths were three-fold more common (25% versus 7.4%) in patients with NODAT. Univariate analysis revealed diabetes and age, and subsequent multivariable analysis revealed age only, as being significantly associated with cardiovascular outcomes. Conclusions: Cardiac events are more common in patients with NODAT. Age is an important determinant of cardiovascular risk.
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Affiliation(s)
- Vadamalai Vivek
- Department of Renal Medicine, Hull and East Yorkshire Hospitals NHS Trust and Hull York Medical School, East Yorkshire, UK
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Death with functioning kidney transplant: an obituarial analysis. Int Urol Nephrol 2010; 42:929-34. [PMID: 20521168 PMCID: PMC2995205 DOI: 10.1007/s11255-010-9721-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2009] [Accepted: 02/18/2010] [Indexed: 11/01/2022]
Abstract
BACKGROUND Death with a functioning kidney graft (DWFG) is now a major cause of graft loss after renal transplantation, occurring in up to 40% of cases. Its occurrence provides insight into the medical care of subjects with a functioning kidney transplant. In this study, we used the time to DWFG as an endpoint, to test whether improved medical care has contributed to better kidney transplant outcomes. METHODS We used single-center data from the Milwaukee Regional Medical Center and Froedtert Hospital, on kidney-only transplants from 1969 through 2005. A total of 3,157 kidney transplants were done at our center during this time. There were 714 deaths with functioning kidney. We also recorded the major causes of DWFG over the time period from 1969 through 2005 divided into 3 epochs. The data were analyzed as a serial collection of yearly obituaries. RESULTS The time to DWFG has increased to 10 years despite a 20-year increase in the mean age of transplant recipients over the same time period. CONCLUSIONS Better pre-transplant evaluation, improved treatments for hypertension and hyperlipidemia, improved management of acute myocardial infarction, superior immunosuppressive protocols and better prophylaxis and treatment of infectious diseases have all likely contributed to this trend.
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Statin therapy ameliorates renal allograft function. Transplant Proc 2010; 41:4178-80. [PMID: 20005363 DOI: 10.1016/j.transproceed.2009.08.075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2008] [Revised: 07/20/2009] [Accepted: 08/17/2009] [Indexed: 11/24/2022]
Abstract
BACKGROUND Statins have proven ability as antilipidemic agents and benefit cardiovascular survival in transplant recipients. The pleiotropic effects of statins on renal function in renal allograft recipients are still undetermined. METHODS Statin therapy was initiated according to guidelines for cardiovascular protection. Serum creatinine concentration and estimated glomerular filtration rate (eGFR) were analyzed before and after introduction of statins. The 73 patients who were retrospectively studied included those who were dialysis-dependent. Mean changes in eGFR and lipid profile were compared before and after commencing statins using chi(2) tests. RESULTS Mean serum creatinine concentration 18 months before starting statin therapy was 160.13 mumol/L, and 24 months after starting statin therapy was 172.22 mumol/L. Mean eGFR was 53.40 mL/min 18 months before starting statin therapy, and decreased to 49.43 mL/min after starting statin therapy. This represented a decline in renal function of 0.22 mL/min/mo over 18 months. The eGFR at 12 months after beginning statin therapy was 52.67 mL/min, and at 24 months was 49.06 mL/min. The rate of decline of eGFR after starting statin therapy was significantly lower: 0.02 mL/min/mo over 24 months (P < .001). Total cholesterol and low-density lipoprotein cholesterol concentrations were significantly decreased after starting statin therapy (P < .001). Four of 73 patients developed graft failure within 24 months. CONCLUSION Statin therapy in our setting was associated with a lower rate of decline in renal function in renal allograft recipients within 2 years of starting treatment.
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Younas N, Wu CM, Shapiro R, McCauley J, Johnston J, Tan H, Basu A, Schaefer H, Smetanka C, Winkelmayer WC, Unruh M. HMG-CoA reductase inhibitors in kidney transplant recipients receiving tacrolimus: statins not associated with improved patient or graft survival. BMC Nephrol 2010; 11:5. [PMID: 20359353 PMCID: PMC2855559 DOI: 10.1186/1471-2369-11-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2009] [Accepted: 04/01/2010] [Indexed: 11/21/2022] Open
Abstract
Background The beneficial effects of early statin use in kidney transplant recipients, especially those on tacrolimus-based immunosuppression, are not well established. We evaluated the predictors of statin use following kidney transplantation and examined its association with patient and allograft survival. Methods We examined 615 consecutive patients who underwent kidney transplant at our institution between January 1998 and January 2002. Statin use was assessed at baseline and 3, 6, 9, and 12 months following kidney transplant. Patients were followed for allograft and patient survival. Results 36% of the 615 kidney transplant recipients were treated with statin treatment. Statin use increased over the course of the study period. Older age, elevated body mass index, higher triglyceride levels, hypercholesterolemia, diabetes, history of myocardial infarction were associated with higher rates of statin use; elevated alkaline phosphatase levels and CMV IgG seropositivity were associated with less statin use. Older age, elevated BMI and hypercholesterolemia remained significant predictors of increased statin use after accounting for covariates using multiple regression. The early use of statins was not associated with improvements in unadjusted patient survival [HR 0.99; 95%CI 0.72-1.37] or graft survival [HR 0.97; 95% CI 0.76-1.24]. The risks of death and graft survival were not consistently reduced with exposure to statin using either adjusted models or propensity scores in Cox Proportional Hazards models. Conclusions In a kidney transplant population primarily receiving tacrolimus-based immunosuppression, early statin use was not associated with significantly improved graft or patient survival.
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Affiliation(s)
- Nizar Younas
- Department of Medicine, Renal-Electrolyte Division, University of Pittsburgh, Pittsburgh, PA, USA
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Díaz JM, Gich I, Bonfill X, Solà R, Guirado L, Facundo C, Sainz Z, Puig T, Silva I, Ballarín J. Prevalence evolution and impact of cardiovascular risk factors on allograft and renal transplant patient survival. Transplant Proc 2010; 41:2151-5. [PMID: 19715859 DOI: 10.1016/j.transproceed.2009.06.134] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The prevalence of traditional cardiovascular risk factors in renal transplantation is high. Studying the evolution of cardiovascular risk factors over time may help us to design better strategies to control them. The relative impact of traditional cardiovascular risk factors on allograft survival and mortality in transplant recipients is not clear. This study was performed to determine the incidence and risk factors for allograft survival and mortality among renal transplant patients. PATIENTS AND METHODS We enrolled 250 patients who had undergone transplantation between 1980 and 2004. They were followed for various periods, and we analyzed the impact of traditional and nontraditional risk factors on renal allograft survival. RESULTS The prevalence of hypertension was >80% during all the follow-up periods. Blood pressure diminished, antihypertensive drug prescription increased, and 15% of patients had adequate blood pressure control during follow-up. The prevalence of pretransplant diabetes mellitus was 6.8%; the incidence of posttransplant diabetes mellitus (PTDM) was 14.2%. The prevalence of PTDM increased over the course of patient evolution. The prevalence of dyslipidemia was in all cases >70%; total cholesterol and low-density lipoprotein (LDL)-cholesterol decreased; prescription of statins increased; and the percentage of patients with good lipid control also increased. The 25% prevalence of active smoking at the time of transplantation decreased to 13.6% at 10 years posttransplantation. The mean patient follow-up was 8 +/- 4.6 years. Sixty-five patients (26%) lost their grafts and 40 (16%) died during follow-up. Donor age, exercise, diastolic blood pressure, renal function, and albumin levels were independent risk factors for graft loss. Charlson comorbidity index at transplantation, recipient and donor ages, exercise, diastolic blood pressure, and LDL-cholesterol posttransplantation were independent risk factors for mortality among renal transplant recipients. CONCLUSION Blood pressure and lipid control improved during follow-up, however, insufficiently among renal transplant patients. The prevalence of diabetes gradually increased, and the incidence of smoking cessation was low. Diastolic blood pressure, exercise, and albuminemia were the most significant modifiable cardiovascular risk factors for renal allograft survival. Diastolic blood pressure, LDL-cholesterol level, and exercise were the most relevant modifiable cardiovascular risk factors for the survival of renal transplant patients.
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Affiliation(s)
- J M Díaz
- Department of Nephrology, Fundació Puigvert, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain.
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Nacasch N, Korzets Z. Worsening of hyperglycemia due to atorvastatin in a renal transplant patient. Clin Kidney J 2009; 2:392-4. [PMID: 25949354 PMCID: PMC4421381 DOI: 10.1093/ndtplus/sfp058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2009] [Accepted: 04/27/2009] [Indexed: 11/26/2022] Open
Abstract
New-onset diabetes mellitus post-renal transplantation [post-transplantation diabetes mellitus (PTDM)] and impaired glucose tolerance are among the most serious adverse metabolic disturbances of kidney transplants. We report a renal transplant patient whose mild post-transplant hyperglycaemia considerably worsened upon substituting atorvastatin for pravastatin. The patient was a 58-years-old Caucasian man who underwent living, non-related kidney transplantation. The mean blood sugar level (BSL) following transplantation was 113.8 mg/dl. In an attempt to reduce LDL cholesterol, atorvastatin 40 mg/day was substituted for pravastatin. Soon after commencement of atorvastatin, polydipsia and polyuria appeared. Both fasting and 2-h post-prandial BSL values increased, while there was no change in the patient's medications, dietary habits and renal function. Upon reverting back to pravastatin, BSL promptly declined to the previously mentioned baseline values. Since PTDM is a strong independent factor of graft failure, cardiovascular events and mortality, physicians should be made aware of this possible adverse effect of atorvastatin on glucose tolerance.
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Affiliation(s)
- Naomi Nacasch
- Department of Nephrology and Hypertension, Sapir Medical Center, Kfar-Saba
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Hurst FP, Neff RT, Jindal RM, Roberts JR, Lentine KL, Agodoa LY, Abbott KC. Incidence, predictors and associated outcomes of rhabdomyolysis after kidney transplantation. Nephrol Dial Transplant 2009; 24:3861-6. [PMID: 19729463 DOI: 10.1093/ndt/gfp416] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND There are several case reports of rhabdomyolysis (RM) in renal transplant recipients, but the actual incidence of this complication is not known. Most of the reported cases have been attributed to drug-drug interactions with calcineurin inhibitors, with the majority of interactions reported between cyclosporine and 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors (statins). Pharmacokinetic studies have demonstrated that cyclosporine increases statin drug levels, presumably via competitive inhibition of cytochrome P450 3A4. METHODS In a retrospective cohort of 20 366 adult Medicare primary renal transplant recipients in the USRDS database transplanted from 1 January 2003 to 31 July 2005 and followed through 31 December 2005, we assessed Medicare claims for RM and dyslipidaemia (HPL), which was used as a surrogate for statin use. RESULTS The incidence rate of RM post-transplant for the study period was 1.4 (95% CI 1.1-1.8) per 1000 person-years. By Cox regression analysis, cyclosporine (versus tacrolimus) use [AHR 2.36 (95% CI 1.23-4.35); P = 0.006] and black race [AHR 2.33 (95% CI 1.30-4.17); P = 0.005] were associated with RM. By Cox non-proportional hazards regression, RM was associated with graft loss (including death) [AHR 2.84 (95% CI 1.70-4.72); P < 0.001]. CONCLUSIONS RM is a rare complication after renal transplantation and is significantly associated with allograft loss (including death). RM is significantly more likely to occur with cyclosporine (versus tacrolimus)-based immunosuppression and possibly in persons of black race. Increased surveillance for RM is warranted in these at-risk patients.
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Affiliation(s)
- Frank P Hurst
- Nephrology Service, Walter Reed Army Medical Center, Washington, DC, USA.
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Abstract
Lipid abnormalities are a common complication of kidney transplantation, occurring in up to 60% of patients. In fact, impairment of lipid metabolism is often present before renal transplantation due to the uremic state. After transplantation and recovery of renal function, lipid disturbances usually persist but show a different profile due to the various effects of immunosuppressive drugs on lipid metabolism. Actually, steroids, calcineurin inhibitors, and mammalian target of rapamycin inhibitors usually lead to quantitative and qualitative abnormalities of very low-density, low-density, and high-density lipoproteins. As cardiovascular diseases remain the leading cause of death in renal transplant recipients, management of dyslipidemia and other traditional risk factors, such as smoking, arterial hypertension, diabetes mellitus, and obesity, is of great importance to prevent cardiovascular complications and chronic allograft dysfunction. This review addresses the causes of dyslipidemia, the role of immunosuppressive drugs, and current recommendations to manage lipid disorders in renal transplant recipients.
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Haller H, Richter N, Bröcker V, Gwinner W, Gueler F, Schwarz A. [Current problems of kidney transplantation]. Internist (Berl) 2009; 50:523-35. [PMID: 19396413 DOI: 10.1007/s00108-008-2269-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The long-term problems after kidney transplantation have changed considerably in recent years. While formerly immunosuppression and prevention of acute rejection were of prime concern, now attention focuses on chronic alterations of the transplanted organ and long-term survival of the patients. The transplantation procedure itself has evolved into a standardized technique with a high level of surgical quality. Problems involving organ preservation and ischemia/reperfusion damage also play a role, especially in view of chronic aspects. Monitoring of long-term complications should follow a program for the transplanted organ as well as a program for the patient. Monitoring kidney function should address the organ more precisely than has previously been the case. Serum creatinine level and proteinuria alone provide insufficient information and only change long after cellular deterioration has begun. Hence it is imperative that new testing methods be developed. One possibility is offered by protocol biopsies that allow histological and molecular analysis of the kidney at regular intervals. The patient programs concentrate on diagnostics and treatment of the cardiovascular diseases. Furthermore, the patients must be screened for occurrence of neoplasia. There are no prospective studies covering all cardiovascular risk factors after kidney transplantation. This pertains particularly to the subject of hypertension.
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Affiliation(s)
- H Haller
- Klinik für Nieren- und Hochdruckerkrankungen, Medizinische Hochschule Hannover, Hannover.
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Navaneethan SD, Perkovic V, Johnson DW, Nigwekar SU, Craig JC, Strippoli GFM. HMG CoA reductase inhibitors (statins) for kidney transplant recipients. Cochrane Database Syst Rev 2009:CD005019. [PMID: 19370615 DOI: 10.1002/14651858.cd005019.pub3] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Cardiovascular deaths account for the majority of deaths in kidney transplant recipients and dyslipidaemia contributes significantly to their cardiovascular disease. Statins are widely used in kidney transplant patients given their established benefits in the general population, however evidence favouring their use is lacking. OBJECTIVES To assess the benefits and harms of statin therapy on mortality and renal outcomes in kidney transplant recipients. SEARCH STRATEGY We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), and hand searched reference lists of articles and scientific proceedings. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs comparing statins with placebo, no treatment or other statins in kidney transplant recipients. DATA COLLECTION AND ANALYSIS Two authors independently assessed study quality and extracted data. Statistical analyses were performed using the random effects model after testing for heterogeneity. Results were expressed as mean difference (MD) for continuous outcomes (lipid parameters) and risk ratio (RR) for dichotomous outcomes (mortality, allograft rejection, liver enzymes, occurrence of rhabdomyolysis and study withdrawal) with 95% confidence intervals (CI). MAIN RESULTS Sixteen studies (3229 patients) comparing statins versus placebo (15) or another statin (1) were included. Compared to placebo, statins did not decrease all-cause mortality (14 studies: RR 1.30, 95% CI 0.54 to 3.12). Point estimates favoured statins in terms of cardiovascular mortality (13 studies: RR 0.68, 95% CI 0.46 to 1.03) and non-fatal cardiovascular events (1 study: RR 0.70, 95% CI 0.48 to 1.01), however the results were not statistically significant. Compared to placebo, the use of statins was associated with a significantly lower end of treatment average total cholesterol (10 studies: MD -42.33 mg/dL (1.26 mmol/L), 95% CI -53.02 to -31.64), LDL cholesterol (10 studies: MD -46.15 mg/dL (1.19 mmol/L), 95% CI -55.97 to -36.33) and triglycerides (10 studies: MD -25.46 mg/dL (0.26 mmol/L), 95% CI -33.95 to 16.9). There was no significant difference in the risk of acute rejection (5 studies: RR 0.61; 95% C.I.0.32 to 1.16.) No data on chronic rejection was available and no major toxicity was noted. AUTHORS' CONCLUSIONS Statins significantly reduced hyperlipidaemia and tended to reduce cardiovascular events in kidney transplant recipients, but no effect has yet been demonstrated for mortality outcomes. Most of the data was derived from one large long-term study. Considering the significant impact of statins on all-cause and cardiovascular mortality in the general and predialysis populations, more studies are needed in kidney transplant patients.
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Affiliation(s)
- Sankar D Navaneethan
- Department of Nephrology and Hypertension, Glickman Urological and Kidney institute, Cleveland Clinic, Cleveland, OH 44195, USA.
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Mulay AV, van Walraven C, Knoll GA. Impact of immunosuppressive medication on the risk of renal allograft failure due to recurrent glomerulonephritis. Am J Transplant 2009; 9:804-11. [PMID: 19353768 DOI: 10.1111/j.1600-6143.2009.02554.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Recurrent glomerulonephritis is a major problem in kidney transplantation but the role of immunosuppression in preventing this complication is not known. We used data from the United States Renal Data System to examine the effect of immunosuppressive medication on allograft failure due to recurrent glomerulonephritis for 41,272 patients undergoing kidney transplantation from 1990 to 2003. Ten-year incidence of graft loss due to recurrent glomerulonephritis was 2.6% (95% confidence interval [CI]: 2.3-2.8%). After adjusting for important covariates, the use of cyclosporine, tacrolimus, azathioprine, mycophenolate mofetil, sirolimus or prednisone was not associated with graft failure due to recurrent glomerulonephritis. There was no difference between cyclosporine and tacrolimus or between azathioprine and mycophenolate mofetil in the risk of graft failure due to recurrent glomerulonephritis. However, any change in immunosuppression during follow-up was independently associated with graft loss due to recurrence (adjusted hazard ratio 1.30, 95% CI: 1.06-1.58, p = 0.01). In patients with a pretransplant diagnosis of glomerulonephritis, the risk of graft loss due to recurrence was not associated with any specific immunosuppressive medication. The selection of immunosuppression for kidney transplant recipients should not be made with the goal of reducing graft failure due to recurrent glomerulonephritis.
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Affiliation(s)
- A V Mulay
- Division of Nephrology, Kidney Research Centre, University of Ottawa, Ottawa, Ontario, Canada
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Wiesbauer F, Heinze G, Mitterbauer C, Harnoncourt F, Hörl WH, Oberbauer R. Statin use is associated with prolonged survival of renal transplant recipients. J Am Soc Nephrol 2008; 19:2211-8. [PMID: 18650477 DOI: 10.1681/asn.2008010101] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
The efficacy of statins for the prevention of cardiovascular events is well established in the general population but remains unknown in renal transplant recipients. In this study, the association of statin use with patient and graft survival was investigated in a cohort of 2041 first-time recipients of renal allografts between 1990 and 2003. Multivariable Cox regression demonstrated that statin use was independently associated with lower mortality rates. Twelve-year survival rates were 73% for statin users and 64% for nonusers (P = 0.055). The adjusted hazard ratio for all-cause mortality associated with statin use was 0.64 (95% confidence interval 0.48 to 0.86). Graft survival rates during the same time period were 76% for statin users and 70% for nonusers (P = 0.055). The adjusted hazard ratio for graft survival associated with statin use was 0.76 (95% confidence interval 0.55 to 1.04). Results from marginal structural models were virtually identical. In summary, statin use was associated with prolonged patient survival, but no difference in graft survival was detected. Although these results are encouraging, a definitive causal relationship can be determined only from randomized clinical trials.
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Affiliation(s)
- Franz Wiesbauer
- Department of Cardiology, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
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Risk Profile for Cardiovascular Morbidity and Mortality After Lung Transplantation. Nurs Clin North Am 2008; 43:37-53; vi. [DOI: 10.1016/j.cnur.2007.10.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Marcén R, Morales JM, Arias M, Fernández-Juárez G, Fernández-Fresnedo G, Andrés A, Rodrigo E, Pascual J, Domínguez B, Ortuño J. Ischemic heart disease after renal transplantation in patients on cyclosporine in Spain. J Am Soc Nephrol 2007; 17:S286-90. [PMID: 17130276 DOI: 10.1681/asn.2006080928] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Ischemic heart disease (IHD), more common among transplant recipients than in the general population, accounts for approximately 50% of cardiovascular deaths. Despite its importance, only a few publications have addressed the prevalence of and risk factors for this complication. This was a retrospective cohort study in 2382 cadaver renal transplant recipients who were treated with cyclosporine as initial immunosuppression. Two groups were formed. The first group consisted of 163 patients with IHD, and the second group consisted of 326 patients without IHD. The prevalence of IHD was 6.8%, and the incidence was 15.7/1000 patient-years. Cardiac events presented during the first year in 62 (38%) patients. Multivariate analysis showed that the risk factors for IHD were age at transplant in years (relative risk [RR] 1.054; 95% confidence interval [CI] 1.033 to 1.075; P = 0.000), male gender (RR 1.940; 95% CI 1.221 to 3.081; P = 0.005), body weight at transplant in kg (RR 1.020; 95% CI 1.007 to 1.033; P = 0.002), pretransplantation cardiovascular disease (RR 2.150; 95% CI 1.733 to 3.359; P = 0.001), and a history of pretransplantation hypercholesterolemia (RR 2.032; 95% CI 1.378 to 2.998; P = 0.000). When only ischemic events that occurred 12 mo after transplantation were taken into consideration, the risk factors were age, male gender, body weight, smoking, and pretransplantation and posttransplantation hypercholesterolemia, whereas pretransplantation cardiovascular disease disappeared from the model. IHD affected nearly 7% of transplant recipients. Smoking, hypertension, and hypercholesterolemia constituted the treatable risk factors for IHD in this population. Emphasis should be placed on the need to stop smoking and to control hypertension and pre- and posttransplantation levels of serum cholesterol.
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Chisholm MA, Spivey CA, Mulloy LL. Effects of a medication assistance program with medication therapy management on the health of renal transplant recipients. Am J Health Syst Pharm 2007; 64:1506-12. [PMID: 17617501 DOI: 10.2146/ajhp060634] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The effects of a medication assistance program with medication therapy management (MTM) on the clinical outcomes and health-related quality of life (HQOL) of renal transplant recipients were studied. METHODS All renal transplant recipients who were enrolled in the Medication Access Program at the Medical College of Georgia for at least one year were included in the study. Patients' demographics, number of graft rejections (for one year pre-enrollment and one year post-enrollment), and diagnoses of hypertension, diabetes, and dyslipidemia were recorded and confirmed by medical and pharmacy records. The use of antihypertensive, antidiabetic, antilipemic, and immunosuppressant agents and laboratory values for fasting blood glucose, glycosylated hemoglobin (HbA(1c)), blood pressure, low-density-lipoprotein (LDL) cholesterol, total cholesterol, triglycerides, and serum immunosuppressant concentrations were identified for one year pre-enrollment and one year post-enrollment. HQOL was measured at the time of enrollment and one year post-enrollment. RESULTS Thirty-six adult renal transplant recipients were included in the study. All patients had hypertension, 72% had dyslipidemia, and 42% had diabetes. Patients received significantly more antihypertensive agents post-enrollment versus pre-enrollment (p < 0.001) and significantly more antidiabetic agents (p = 0.004) and antilipemics (p = 0.001). Measures of fasting blood glucose, glycosylated hemoglobin, LDL cholesterol, total cholesterol, triglycerides, blood pressure, and number of graft rejections decreased from pre-enrollment levels (p < 0.01). A significantly greater number of patients reached target serum cyclosporine levels post-enrollment versus pre-enrollment (p = 0.008). HQOL was significantly increased one year post-enrollment (p < 0.01). CONCLUSION A medication assistance program that included MTM services improved medication access, clinical outcomes, and HQOL in renal transplant recipients.
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Affiliation(s)
- Marie A Chisholm
- Pharmacy Practice and Science, The University of Arizona College of Pharmacy, Tucson, AZ 85750, USA.
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Bignelli AT, Barberato SH, Aveles P, Abensur H, Pecoits-Filho R. The Impact of Living Donor Kidney Transplantation on Markers of Cardiovascular Risk in Chronic Kidney Disease Patients. Blood Purif 2007; 25:233-41. [PMID: 17377377 DOI: 10.1159/000101028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2006] [Accepted: 01/17/2007] [Indexed: 12/28/2022]
Abstract
BACKGROUND Kidney transplant (Tx) patients present a reduced cardiovascular (CV) mortality in comparison to the dialysis population, but in comparison to the general population, it is still several-fold higher. METHODS We studied risk factors for CV disease in a group of 38 patients (50% males, median age 36 years) who underwent a living donor Tx at the baseline and after 3 +/- 1 and 9 +/- 2 months. RESULTS The prevalence of overweight increased from 26 to 54% after Tx (p < 0.001). The mean systolic blood pressure decreased significantly after the Tx (148 +/- 27.6 vs. 126 +/- 12.7 mm Hg). There was a significant increase in LDL (97 +/- 30 vs. 114 +/- 35) and hematocrit (33.8 +/- 4.4 to 42 +/- 5.7%) levels and a significant reduction in fibrinogen levels (394 +/- 91 vs. 366 +/- 100 mg/dl) after 9 months as compared to the baseline. Obesity and dislipidemia were significantly correlated with inflammation. Significant changes in left ventricle mass index (293 +/- 116 vs. 241 +/- 96) were observed after the Tx. Patients with a low glomerular filtration rate (GFR) in the follow-up evaluation presented higher LDL (128 +/- 7 vs. 99 +/- 7 mg/dl; p < 0.05) and higher fibrinogen levels (399 +/- 21 vs. 332 +/- 22 mg/dl; p < 0.05) compared to patients with a high GFR. CONCLUSION Most of the risk factors analyzed (particularly the uremia-related) improved after the renal Tx, which could justify the positive impact of Tx on the development of CV disease. Inflammation and dyslipidemia were related to renal dysfunction after the Tx, suggesting that complete restoration of renal function may have an impact on reducing CV mortality in CKD patients treated with renal Tx.
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Affiliation(s)
- Alexandre T Bignelli
- Center for Health and Biological Sciences, Pontifícia Universidade Católica do Paraná, Curitiba, Brazil
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Wang J, Zou H, Li Q, Wang Y, Xu Q. The expression of monocyte chemoattractant protein-1 and C–C chemokine receptor 2 in post-kidney transplant patients and the influence of simvastatin treatment. Clin Chim Acta 2006; 373:44-8. [PMID: 16781696 DOI: 10.1016/j.cca.2006.04.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2005] [Revised: 04/26/2006] [Accepted: 04/26/2006] [Indexed: 11/23/2022]
Abstract
BACKGROUND Inflammation is involved in the pathogenesis of chronic allograft nephropathy (CAN) and cardiovascular disease (CVD) in post-kidney transplantation. METHODS Sixty patients, selected from 167 renal transplant patients, were divided into 2 groups: Group A (normal lipidemia group, n=30) and Group B (hyperlipidemia group, n=30). In addition, Control Group came from 30 healthy volunteers. In Group B, the patients were treated with simvastatin for 3 months. The mRNA expressions of MCP-1 and CCR2 were detected with reverse transcription-polymerase chain reaction (RT-PCR). RESULTS The mRNA expressions of MCP-1 and CCR2 of all post-kidney transplant patients were significantly higher than controls. Compare Group A with Group B and the mRNA expressions of MCP-1 and CCR2 in Group B were much higher than Group A. After simvastatin treatment, the mRNA expressions of MCP-1 and CCR2 were significantly reduced in one and a half months and decreased to the lowest levels in three months. CONCLUSIONS Simvastatin decreased the expressions of MCP-1 and CCR2 in post-kidney transplant patients with hyperlipidemia.
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Affiliation(s)
- Jun Wang
- Department of Nephrology, the Fifth Affiliated Hospital of Sun Yat-sen University, 52 Meihua Dong Road, Zhuhai 519000, Guangdong, PR China
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Abstract
By the time of renal transplantation, end-stage renal disease patients have a huge burden of cardiovascular disease (CVD) and are heavily saturated with atherosclerotic risk factors. Worsening of preexisting risk factors or new CVD risk factors may develop in the posttransplant period consequent in part to the diabetogenic and atherogenic potential of immunosuppressive drugs. The annual risk of a fatal or non-fatal CVD event of 3.5 to 5% in kidney transplant recipients is 50-fold higher than the general population. Renal allograft dysfunction, proteinuria, anemia, moderate hyperhomocysteinemia and elevated serum C-reactive protein concentrations, each dependently confer greater risk of CVD morbidity and mortality in the posttransplant period. Long-term care of renal transplant recipients should programmatically incorporate the recommendations of the National Kidney Foundation Working Groups and European Best Practice Guidelines Expert Group on Renal Transplantations into the management of hypertension, dyslipidemia, smoking, and posttransplant diabetes mellitus. Timely utilization of coronary revascularization procedures should be undertaken as these treatments are equally effective in the kidney transplant population.
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Djamali A, Samaniego M, Muth B, Muehrer R, Hofmann RM, Pirsch J, Howard A, Mourad G, Becker BN. Medical Care of Kidney Transplant Recipients after the First Posttransplant Year. Clin J Am Soc Nephrol 2006; 1:623-40. [PMID: 17699268 DOI: 10.2215/cjn.01371005] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Kidney transplantation is the treatment of choice for patients with ESRD. Despite improvements in short-term patient and graft outcomes, there has been no major improvement in long-term outcomes. The use of kidney allografts from expanded-criteria donors, polyoma virus nephropathy, underimmunosuppression, and incomplete functional recovery after rejection episodes may play a role in the lack of improvement in long-term outcomes. Other factors, including cardiovascular disease, infections, and malignancies, also shorten patient survival and therefore reduce the functional life of an allograft. There is a need for interventions that improve long-term outcomes in kidney transplant recipients. These patients are a unique subset of patients with chronic kidney disease. Therefore, interventions need to address disease progression, comorbid conditions, and patient mortality through a multifaceted approach. The Kidney Disease Outcomes Quality Initiative from the National Kidney Foundation, the European Best Practice Guidelines, and the forthcoming Kidney Disease: Improving Global Outcomes clinical practice guidelines can serve as a cornerstone of this approach. The unique aspects of chronic kidney disease in the transplant recipient require the integration of specific transplant-oriented problems into this care schema and a concrete partnership among transplant centers, community nephrologists, and primary care physicians. This article reviews the contemporary aspects of care for these patients.
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Affiliation(s)
- Arjang Djamali
- Department of Medicine, Nephrology Section, University of Wisconsin Madison, School of Medicine, 3034 Fish Hatchery Road, Suite B, Madison, WI 53713, USA.
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Buemi M, Nostro L, Crascì E, Barillà A, Cosentini V, Aloisi C, Sofi T, Campo S, Frisina N. Statins in nephrotic syndrome: a new weapon against tissue injury. Med Res Rev 2006; 25:587-609. [PMID: 16075407 DOI: 10.1002/med.20040] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The nephrotic syndrome is characterized by metabolic disorders leading to an increase in circulating lipoproteins levels. Hypertriglyceridemia and hypercholesterolemia in this case may depend on a reduction in triglyceride-rich lipoproteins catabolism and on an increase in hepatic synthesis of Apo B-containing lipoproteins. These alterations are the starting point of a self-maintaining mechanism, which can accelerate the progression of chronic renal failure. Indeed, hyperlipidemia can affect renal function, increase proteinuria and speed glomerulosclerosis, thus determining a higher risk of progression to dialysis. 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase is the rate-limiting enzyme in cholesterol synthesis from mevalonate and its inhibitors, or statins, can therefore interfere with the above-mentioned consequences of hyperlipidemia. Statins are already well known for their effectiveness on primary cardiovascular prevention, which cannot be explained only through their hypolipemic effect. As far as kidney diseases are concerned, statin therapy has been shown to prevent creatinine clearance decline and to slow renal function loss, particularly in case of proteinuria, and its favorable effect may depend only partially on the attenuation of hyperlipidemia. Statins may therefore confer tissue protection through lipid-independent mechanisms, which can be triggered by other mediators, such as angiotensin receptor blockers. Possible pathways for the protective action of statins, other than any hypocholesterolemic effect, are: cellular apoptosis/proliferation balance, inflammatory cytokines production, and signal transduction regulation. Statins also play a role in the regulation of the inflammatory and immune response, coagulation process, bone turnover, neovascularization, vascular tone, and arterial pressure. In this study, we would like to provide scientific evidences for the pleiotropic effects of statins, which could be the starting point for the development of new therapeutical strategies in different clinical areas.
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Affiliation(s)
- Michele Buemi
- Department of Internal Medicine, University of Messina, Messina, Italy.
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Hindler K, Eltzschig HK, Fox AA, Body SC, Shernan SK, Collard CD. Influence of statins on perioperative outcomes. J Cardiothorac Vasc Anesth 2006; 20:251-8. [PMID: 16616673 DOI: 10.1053/j.jvca.2005.12.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2005] [Indexed: 11/11/2022]
Affiliation(s)
- Katja Hindler
- Division of Cardiovascular Anesthesia, Texas Heart Institute at Saint Luke's Episcopal Hospital, Houston, TX 77030, USA
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Abstract
BACKGROUND Chronic kidney disease (CKD) is extremely common in adults, although often undiagnosed and thus untreated. Cardiovascular disease is the leading cause of death among patients with CKD and reducing its risk in this population is an important priority. Dyslipidemia is almost always present when proteinuria is above 3 gr/24 hours. Roughly two thirds of all patients with end-stage renal failure and kidney transplants suffer from dyslipidemia and should receive lipid-lowering therapy, as suggested by recent Afssaps (French drug agency) and NKF-K/DOQI (National Kidney Foundation-Kidney Disease Outcomes Quality Initiative) guidelines. We reviewed recent studies on efficacy, tolerability and prescription recommendations of statins in CKD and renal transplant patients. METHODS We searched Medline, the international medical database, to conduct a systematic review of the literature on the efficacy and tolerability of statins in CKD and renal transplant patients and on specific recommendations for dosage adjustments in this population. RESULTS The efficacy of statins in decreasing total cholesterol and LDL-cholesterol levels in dialysis and renal transplant patients is similar to that in the general population. On the other hand, large-scale randomized clinical trials among CKD (4D) and renal transplant (ALERT) patients do not demonstrate that statins significantly decrease rates of cardiovascular disease. They have a beneficial effect on proteinuria and lower the rate of kidney function deterioration in patients with dyslipidemia. Early introduction of a statin in transplant patients did not lead to improved kidney function or prevent loss of the graft. Although most statins are not excreted by the kidneys, the dosage of some must be adapted in CKD patients because of pharmacokinetic modifications induced by renal impairment. CONCLUSION Statins at appropriately adapted doses have the same efficacy in CKD patients as in subjects with normal kidney function, and tolerance is not a problem. Their effectiveness in cardiovascular prevention in this population has not been demonstrated to date. Results about statin-induced kidney protection are encouraging but further and more specific studies are needed.
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Affiliation(s)
- Svetlana Karie
- Service de néphrologie, Hôpital Pitié-Salpêtrière, Paris
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Spinelli GA, Felipe CR, Machado PG, Garcia R, Casarini DE, Moreira SR, Park SI, Tedesco-Silva H, Medina-Pestana JO. Relationship of cyclosporin and sirolimus blood concentrations regarding the incidence and severity of hyperlipidemia after kidney transplantation. Braz J Med Biol Res 2006; 39:19-30. [PMID: 16400461 DOI: 10.1590/s0100-879x2006000100003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The influence of drug concentrations on the development of persistent posttransplant hyperlipidemia was investigated in 82 patients who received cyclosporin A (CsA) and prednisone plus sirolimus (SRL) (52) or azathioprine (AZA) (30) during the first year after transplantation. Blood levels of CsA and SRL, daily doses of AZA and prednisone, and cholesterol, triglyceride, and glucose concentrations were determined during each visit (pretransplant and 30, 60, 90, 120, 180, and 360 days posttransplant). Persistent hyperlipidemia was defined as one-year average steady-state cholesterol (CavCHOL) or triglyceride (CavTG) concentrations above 240 and 200 mg/dL, respectively. Mean cholesterol and triglyceride concentrations increased after transplantation (P < 0.01) and were higher in patients receiving SRL compared to AZA (P < 0.001). Patients receiving SRL showed a significantly higher number of cholesterol (> 229 or > 274 mg/dL) and triglyceride (> 198 or > 282 mg/dL) determinations in the upper interquartile ranges. CsA and SRL interquartile ranges correlated with cholesterol concentrations (P = 0.001) whereas only SRL interquartile ranges correlated with triglyceride concentrations (P < 0.0001). Only pretransplant cholesterol concentration > 205 mg/dL was independently associated with development of persistent hypercholesterolemia (CavCHOL > 240 mg/dL, relative risk (RR) = 20, CI 3.8-104.6, P = 0.0004) whereas pretransplant triglyceride concentration > 150 mg/dL (RR = 7.2, CI 1.6-32.4, P = 0.01) or > 211 mg/dL (RR = 19.8, CI 3.6-107.9, P = 0.0006) and use of SRL (RR = 3, CI 1.0-8.8, P = 0.0049) were independently associated with development of persistent hypertriglyceridemia (CavTG > 200 mg/dL). Persistent hypercholesterolemia was more frequent among patients with higher pretransplant cholesterol concentrations and was dependent on both CsA and SRL concentrations. Persistent hypertriglyceridemia was more frequent among patients with higher pretransplant triglyceride concentrations and was dependent on SRL concentrations.
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Affiliation(s)
- G A Spinelli
- Divisão de Nefrologia, Hospital do Rim e Hipertensão, Universidade Federal de São Paulo, São Paulo, SP, Brazil
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35
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Kohnle M, Pietruck F, Kribben A, Philipp T, Heemann U, Witzke O. Ezetimibe for the treatment of uncontrolled hypercholesterolemia in patients with high-dose statin therapy after renal transplantation. Am J Transplant 2006; 6:205-8. [PMID: 16433776 DOI: 10.1111/j.1600-6143.2005.01132.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We investigated prospectively the efficacy of ezetimibe in addition to statin therapy in stable renal transplant patients in whom hypercholesterolemia was not sufficiently treated. Eighteen renal transplant patients received 10 mg ezetimibe once daily in addition to high-dose statin therapy for uncontrolled hypercholesterolemia. Total cholesterol, LDL-cholesterol, HDL-cholesterol, triglycerides, Tacrolimus (Tac)- and Cyclosporine A (CsA) blood levels, creatinine, urea, liver enzymes, electrolytes and creatinkinase (CK) were measured before initiation of ezetimibe therapy, after 7 days, 6 weeks and 3 months. Cholesterol concentrations decreased significantly (p < 0.005) from 264 +/- 46 mg/dL at baseline to 205 +/- 48 mg/dL after 1 week to 202 +/- 48 mg/dL after 6 weeks and 212 +/- 40 mg/dL after 3 months (reduction after 3 months 21 +/- 10%). LDL-concentrations decreased significantly (p < 0.005) from 178 +/- 41 mg/dL at baseline to 129 +/- 35 mg/dL after 1 week to 123 +/- 25 after 6 weeks and to 117 +/- 40 mg/dL after 3 months (reduction after 3 months 37 +/- 14%). Two patients stopped ezetimibe therapy due to nausea and muscle pain without CK elevation. Significant changes of CsA and Tac blood levels, liver and muscle enzymes were not observed. Ezetimibe seems to be an effective therapy for uncontrolled hypercholesterolemia in renal transplant patients when combined with high-dose statin therapy.
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Affiliation(s)
- M Kohnle
- Department of Nephrology, School of Medicine, University of Duisburg-Essen, Hufelandstrasse 55, 45122 Essen, Germany
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Davidson M. Considerations in the treatment of dyslipidemia associated with chronic kidney failure and renal transplantation. ACTA ACUST UNITED AC 2005; 8:244-9. [PMID: 16230879 DOI: 10.1111/j.0197-3118.2005.04078.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
In comparison to the general population, individuals with chronic kidney failure experience an increased risk for atherosclerotic cardiovascular disease attributed predominantly to pronounced abnormalities in lipid metabolism. The emerging consensus is that patients with chronic kidney failure should be treated aggressively for dyslipidemia. Statins reduce the risk of cardiovascular disease in a range of at-risk patients; this class of lipid-lowering drugs should be considered first-line treatment of dyslipidemia observed in renal disease patients. Although the statins share a common lipid-lowering effect, there are differences within this class of drugs. The statins differ in their pharmacokinetic effects, drug interaction profiles, and risk of myotoxicity. This article characterizes the dyslipidemia observed in the renal failure setting and reviews the therapeutic considerations involved in selecting among the statins. Lovastatin, simvastatin, pravastatin, fluvastatin, atorvastatin, and rosuvastatin are the available statins in the United States.
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Affiliation(s)
- Michael Davidson
- Department of Preventive Cardiology, Rush University Medical Center, 1725 West Harrison Street, Chicago, IL 60612, USA.
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37
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Morales JM. Does time of onset of therapy alter the protective cardiovascular effect of fluvastatin after renal transplantation? ACTA ACUST UNITED AC 2005; 1:78-9. [PMID: 16932372 DOI: 10.1038/ncpneph0050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2005] [Accepted: 09/28/2005] [Indexed: 11/08/2022]
Affiliation(s)
- Jose M Morales
- Hospital 12 de Octubre Renal Transplant Unit Nephrology Department, Madrid 28001, Spain.
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38
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Abstract
Managing the failing allograft juxtaposes immunosuppressive management and routine chronic kidney disease care. The complications of immunosuppression can be more pronounced in those with renal failure (infection, anemia, bone disease). The withdrawal of immunosuppression may be associated with acute allograft rejection, arthralgias, and the development of antidonor antibodies. Likewise depression is prevalent. Improving well-being and overall survival necessitates proper titration of immunosuppressive medications and control of blood pressure, anemia, lipids, and glucose along with attention to treatment of depression.
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Affiliation(s)
- Elizabeth A Kendrick
- Department of Medicine, Division of Nephrology, University of Washington School of Medicine, Seattle, Washington, USA
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39
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Stallone G, Infante B, Schena A, Battaglia M, Ditonno P, Loverre A, Gesualdo L, Schena FP, Grandaliano G. Rapamycin for treatment of chronic allograft nephropathy in renal transplant patients. J Am Soc Nephrol 2005; 16:3755-62. [PMID: 16236802 DOI: 10.1681/asn.2005060635] [Citation(s) in RCA: 102] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Chronic allograft nephropathy (CAN) represents the main cause of renal allograft loss after 1 yr of transplantation. Calcineurin inhibitor (CNI) use is associated with increased graft expression of profibrotic cytokines, whereas rapamycin inhibits fibroblast proliferation. The aim of this randomized, prospective, open-label, single-center study was to evaluate the histologic and clinical effect of rapamycin on biopsy-proven CAN. Eighty-four consecutive patients who had biopsy-proven CAN and received a transplant were randomized to receive either a 40% CNI reduction plus mycophenolate mofetil (group 1; 50 patients) or immediate CNI withdrawal and rapamycin introduction with a loading dose of 0.1 mg/kg per d and a maintaining dose aiming at through levels of 6 to 10 ng/ml (group 2; 34 patients). The follow-up period was 24 mo. At the end of follow-up, 25 patients (group 1, 10 patients; group 2, 15 patients) underwent a second biopsy. CAN lesions were graded according to Banff criteria. alpha-Smooth muscle actin (alpha-SMA) protein expression was evaluated in all biopsies as a marker of fibroblast activation. Graft function and Banff grading were superimposable at randomization. Graft survival was significantly better in group 2 (P = 0.0376, chi2 = 4.323). CAN grading worsened significantly in group 1, whereas it remained stable in group 2. After 24 mo, all group 1 biopsies showed an increase of alpha-SMA expression at the interstitial and vascular levels (P < 0.001); on the contrary, alpha-SMA expression was dramatically reduced in group 2 biopsies (P = 0.005). This study demonstrates that rapamycin introduction/CNI withdrawal improves graft survival and reduces interstitial and vascular alpha-SMA expression, slowing down the progression of allograft injury in patients with CAN.
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Affiliation(s)
- Giovanni Stallone
- Department of Biomedical Sciences, Division of Nephrology, University of Foggia, Foggia, Italy
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40
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Belliard G, Coupel S, Charreau B. Effet de la fluvastatine sur l'expression du CMH de classe I par les cellules endothéliales humaines. Nephrol Ther 2005; 1:221-7. [PMID: 16895688 DOI: 10.1016/j.nephro.2005.06.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2005] [Revised: 05/17/2005] [Accepted: 06/06/2005] [Indexed: 11/15/2022]
Abstract
Originally designed to target elevated lipids, the "traditional" cause of atherosclerosis, statins might also confer vascular benefit by directly or indirectly modulating both the inflammatory and immune responses. Statins have been shown to downregulate MHC class II and CD40 expression on activated endothelial cells (EC). In this study, we investigate the potential effect of statins on MHC class I expression and regulation in response to IFNgamma. Primary cultures of human ECs have been treated with increasing doses of fluvastatin (0.01; 0.1 and 1 microM) with or without IFNgamma for 48 hours. Surface expression of MHC class I and class II has been analyzed by flow cytometry. Our data indicate that fluvastatin increases MHC class I expression on quiescent ECs by a dose-dependent effect. Furthermore, fluvastatin potentiates the MHC class I upregulation but prevents MHC class II induction triggered by IFNgamma. These effects are reversed by mevalonate. In conclusion, our results suggest that while decreasing MHC class II expression, fluvastatin (at 0.1 and 1 microM) upregulates MHC class I expression on ECs. Functional consequences of statin-mediated modulation of MHC on ECs have still to be elucidated in vitro and in vivo.
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Affiliation(s)
- Guillaume Belliard
- Institut national de la santé et de la recherche médicale, UMR 643, Immunointervention en allo et xénotransplantation, et institut de transplantation et de recherche en transplantation, CHU Hôtel-Dieu, 44093 Nantes cedex 01, France
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41
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Wilkinson A, Davidson J, Dotta F, Home PD, Keown P, Kiberd B, Jardine A, Levitt N, Marchetti P, Markell M, Naicker S, O'Connell P, Schnitzler M, Standl E, Torregosa JV, Uchida K, Valantine H, Villamil F, Vincenti F, Wissing M. Guidelines for the treatment and management of new-onset diabetes after transplantation. Clin Transplant 2005; 19:291-8. [PMID: 15877787 DOI: 10.1111/j.1399-0012.2005.00359.x] [Citation(s) in RCA: 194] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Although graft and patient survival after solid organ transplantation have improved markedly in recent years, transplant recipients continue to experience an increased prevalence of cardiovascular disease (CVD) compared with the general population. A number of factors are known to impact on the increased risk of CVD in this population, including hypertension, dyslipidemia and diabetes mellitus. Of these factors, new-onset diabetes after transplantation has been identified as one of the most important, being associated with reduced graft function and patient survival, and increased risk of graft loss. In 2003, International Consensus Guidelines on New-onset Diabetes after Transplantation were published, which aimed to establish a precise definition and diagnosis of the condition and recommend management strategies to reduce its occurrence and impact. These updated 2004 guidelines, developed in consultation with the International Diabetes Federation (IDF), extend the recommendations of the previous guidelines and encompass new-onset diabetes after kidney, liver and heart transplantation. It is hoped that adoption of these management approaches pre- and post-transplant will reduce individuals' risk of developing new-onset diabetes after transplantation as well as ameliorating the long-term impact of this serious complication.
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Affiliation(s)
- Alan Wilkinson
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Lemahieu WPD, Hermann M, Asberg A, Verbeke K, Holdaas H, Vanrenterghem Y, Maes BD. Combined therapy with atorvastatin and calcineurin inhibitors: no interactions with tacrolimus. Am J Transplant 2005; 5:2236-43. [PMID: 16095503 DOI: 10.1111/j.1600-6143.2005.01005.x] [Citation(s) in RCA: 105] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Increased systemic exposure to statins and consequent risk for complications has been reported in patients concomitantly treated with cyclosporin A (CsA). This has been ascribed to inhibition of drug catabolism by cytochrome P450 3A4 (CYP3A4) or drug transport by P-glycoprotein (PGP) and organic anion transporting polypeptide (OATP1B1). It is not known whether the combination of statins and tacrolimus (Tac) also suffers from this drawback. Therefore, a pharmacokinetic study of atorvastatin and its metabolites was performed in 13 healthy volunteers after 4 days' treatment, and after short (12 h) concomitant exposure to CsA and Tac. A complementary assessment of overall CYP, and hepatic and intestinal CYP3A4+PGP activity was performed after each treatment episode and compared to baseline (no drugs). Systemic exposure to atorvastatin acid and its metabolites was significantly increased when administered with CsA. In contrast, intake of Tac did not have any impact on atorvastatin pharmacokinetics. Concomitantly, a profound decrease of hepatic and intestinal PGP and an increase of intestinal CYP3A4 were noted with CsA, whereas no effect was seen after atorvastatin therapy with or without Tac. Based on these findings treatment with Tac appears a safer option for patients needing a combination of statins and calcineurin inhibitors.
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Affiliation(s)
- W P D Lemahieu
- Department of Medicine, Division of Nephrology and Laboratory of Gastrointestinal Research, University Hospitals Gasthuisberg, Leuven, Belgium
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43
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Jardine AG. Assessing the relative risk of cardiovascular disease among renal transplant patients receiving tacrolimus or cyclosporine. Transpl Int 2005; 18:379-84. [PMID: 15773954 DOI: 10.1111/j.1432-2277.2005.00080.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Calcineurin inhibitors potentially contribute to risk of cardiovascular events through the development of new-onset diabetes mellitus, hypertension and hyperlipidemia. The exact extent to which calcineurin inhibitors affect these risk factors is difficult to establish since pre-existing renal disease and concomitant immunosuppressive agents (such as steroids or TOR inhibitors) also exert an effect. Clinical trials have consistently shown a higher incidence of new-onset diabetes mellitus with tacrolimus, which has been borne out in large-scale registry analyses. However, the risk of hypertension is approximately 5% higher with cyclosporine than tacrolimus, as is the risk of hyperlipidemia. Statin therapy is effective in treating dyslipidemia and has significant benefits in renal transplant patients. An individualized approach to choice of calcineurin inhibitor, by which cyclosporine or tacrolimus are selected based on the patient's particular risk profile, may thus help to reduce the toll of cardiovascular mortality among renal transplant recipients in the future.
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Affiliation(s)
- Alan G Jardine
- University of Glasgow, Gardiner Institute, Western Infirmary, UK.
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44
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Holdaas H, Fellström B, Jardine AG, Nyberg G, Grönhagen-Riska C, Madsen S, Neumayer HH, Cole E, Maes B, Ambühl P, Logan JO, Staffler B, Gimpelewicz C. Beneficial effect of early initiation of lipid-lowering therapy following renal transplantation. Nephrol Dial Transplant 2005; 20:974-80. [PMID: 15784644 DOI: 10.1093/ndt/gfh735] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Renal transplant recipients have a significantly reduced life expectancy, largely due to premature cardiovascular disease. The aim of the current analysis was to investigate the importance of time of initiation of therapy after transplantation, on the benefits of statin therapy. METHODS 2102 renal transplant recipients with total cholesterol levels of 4.0-9.0 mmol/l were randomly assigned to treatment with fluvastatin (n = 1050) or placebo (n = 1052) and followed for a mean time of 5.1 years. The end-points were major cardiac events. The average median time from transplantation to randomization was 4.5 years (range: 0.5-29 years). RESULTS In patients starting treatment with fluvastatin <4.5 years after renal transplantation, the incidence of cardiac events was 4.6% over 5.1 years vs 9.2% in those on placebo (P = 0.007). Fluvastatin significantly reduced the risk of cardiac death and non-fatal myocardial infarction by 56% [risk ratio (RR): 0.44; 95% confidence interval (95% CI): 0.26-0.74; P = 0.002]. In a more detailed analysis patients were grouped into 2-year intervals (since the last transplantation). The frequency of cardiac death and non-fatal myocardial infarction was reduced by 3.2%, 5.1%, 9.6% and 8.2% with fluvastatin treatment as compared to 6%, 10.4%, 13.4% and 9.6% with placebo when treatment was initiated at 0-2, 2-4, 4-6 and >6 years, respectively. The risk reduction for patients initiating therapy with fluvastatin at years 0-2 (compared with >6 years) following transplantation was 59% (RR: 0.41; 95% CI: 0.18-0.92; P = 0.0328). This is also reflected in total time on renal replacement therapy: in patients in the first quartile (<47 months) fluvastatin use was associated with a risk reduction of 64% compared with 19% for patients in the fourth quartile (>120 months) (P = 0.033). CONCLUSIONS Our data support an early introduction of fluvastatin therapy in a population of transplant recipients at high risk of premature coronary heart disease.
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Holdaas H. Preventing cardiovascular outcome in patients with renal impairment: is there a role for lipid-lowering therapy? Am J Cardiovasc Drugs 2005; 5:255-69. [PMID: 15984908 DOI: 10.2165/00129784-200505040-00005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Patients with chronic kidney disease (CKD), ranging from modest renal impairment to dialysis and transplant, have an increased risk for cardiovascular disease (CVD). Patients with CKD have both traditional and non-traditional risk factors for CVD. The role of lipids as risk factors for CVD in these populations has not been firmly established. In a recent prospective controlled trial, it was established that atherogenic lipids are indeed strong risk factors for CVD in renal transplant recipients, and that treatment with a HMG-CoA reductase inhibitor reduced the incidence of cardiac death and myocardial infarction. For patients receiving dialysis, the association between serum lipid levels and cardiovascular outcome is uncertain and there is no evidence from controlled trials that lipid-lowering therapy does have a beneficial effect on cardiovascular outcome in these patients. Atherogenic lipids are probably a risk factor for patients with mild or moderate CKD, and five subgroup analyses have indicated a favorable effect of lipid-lowering therapy on cardiovascular outcome, although we still lack prospective controlled trials in these patients. CVD in patients with CKD has been a neglected area of research.
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Affiliation(s)
- Hallvard Holdaas
- Medical Department, National Hospital, University of Oslo, Oslo, Norway.
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46
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Inman SR, Davis NA, Mazzone ME, Olson KM, Lukaszek VA, Yoder KN. Simvastatin and l-Arginine Preserve Renal Function after Ischemia/Reperfusion Injury. Am J Med Sci 2005; 329:13-7. [PMID: 15654174 DOI: 10.1097/00000441-200501000-00003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND HMG-CoA reductase inhibitors have been shown to have beneficial renal hemodynamic effects by increasing renal blood flow, independent of their lipid-lowering properties. Currently in organ transplantation, the calcineurin inhibitor cyclosporine A (CyA) is the immunosuppressant of choice. However, its use is limited by its nephrotoxic effects, namely its renal vasoconstrictor properties. The purpose of this study was to determine the effect of an HMG-CoA reductase inhibitor, simvastatin (Zocor), on renal function in rats and on urinary nitrite/nitrate production following ischemia/reperfusion injury (I/R) with concomitant cyclosporine treatment. In addition, L-NAME (N(G)-nitro-L-arginine methyl ester) and L-arginine were administered with CyA to the rats to test the hypothesis that simvastatin's beneficial effects were due to nitric oxide. METHODS Male Wistar rats (250 g) were anesthetized and the supra-aorta clamped for 40 minutes. The right kidney was removed. After recovery, the rats were divided into five groups: 1) controls, no ischemia, no treatment (CTRL, n = 8); 2) ischemia (ISCH) plus cyclosporine A only (CyA, 5 mg/kg/day i.p., n = 8); 3) ischemia plus CyA and simvastatin (SIM, 10 mg/kg/day, gavage, n = 8); 4) ischemia plus simvastatin plus L-NAME plus CyA (10 mg/kg/day, gavage, n = 8), and 5) ischemia plus simvastatin plus L-arginine (2% in drinking water, n = 7) plus CyA. Five to 7 days after I/R injury, the glomerular filtration rate (GFR) was determined using urinary iohexol clearance. Urinary nitrite/nitrate production was determined using nitrate reductase and the Greiss reaction. Data are expressed as mean +/- SEM, and intergroup comparisons were made using one-way analysis of variance. RESULTS The GFR values (mL/min) for all five groups are as follows: 1) CTRL = 1.25 +/- 0.10; 2) ISCH plus CyA only = 0.45 +/- 0.06 (P < 0.05 versus CTRL, ISCH only and simvastatin and cyclosporine and simvastatin plus L-arginine and cyclosporine); 3) CyA and SIM = 0.78 +/- 0.09, CyA and L-NAME = 0.62 +/- 0.12, and CyA and L-arginine and SIM = 1.57 +/- 0.12. Results in the control were significantly different from results in the ischemic only and the L-NAME groups (P < 0.05). The L-arginine plus cyclosporine and simvastatin group was significantly higher than the ischemic only group, ischemic plus simvastatin and cyclosporine and the L-NAME plus cyclosporine group (P < 0.05). No significant differences could be detected in the urinary nitric oxide concentrations. CONCLUSIONS : After I/R injury and cyclosporine treatment, simvastatin and L-arginine preserved renal function, compared with cyclosporine treatment alone, because simvastatin and L-arginine may not have a direct vasoconstrictor effect on the renal microcirculation. They may be suppressing endothelin or increasing other vasodilator mediators such as the vasodilator prostaglandins and/or nitric oxide.
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Affiliation(s)
- Sharon R Inman
- Department of Biomedical Sciences, Ohio University College of Osteopathic Medicine, Athens, Ohio 45701, USA.
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47
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Boots JMM, Christiaans MHL, van Hooff JP. Effect of immunosuppressive agents on long-term survival of renal transplant recipients: focus on the cardiovascular risk. Drugs 2004; 64:2047-73. [PMID: 15341497 DOI: 10.2165/00003495-200464180-00004] [Citation(s) in RCA: 112] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In the control of acute rejection, attention is being focused more and more on the long-term adverse effects of the immunosuppressive agents used. Since cardiovascular disease is the main cause of death in renal transplant recipients, optimal control of cardiovascular risk factors is essential in the long-term management of these patients. Unfortunately, several commonly used immunosuppressive drugs interfere with the cardiovascular system. In this review, the cardiovascular adverse effects of the immunosuppressive agents currently used for maintenance immunosuppression are thoroughly discussed. Optimising immunosuppression means finding a balance between efficacy and safety. Corticosteroids induce endothelial dysfunction, hypertension, hyperlipidaemia and diabetes mellitus, and impair fibrinolysis. The use of corticosteroids in transplant recipients is undesirable, not only because of their cardiovascular effects, but also because they induce such adverse effects as osteoporosis, obesity, and atrophy of the skin and vessel wall. Calcineurin inhibitors are the most powerful agents for maintenance immunosuppression. The calcineurin inhibitor ciclosporin (cyclosporine) not only induces these same adverse effects as corticosteroids but is also nephrotoxic. Tacrolimus has a more favourable cardiovascular risk profile than ciclosporin and is also less nephrotoxic. It has little or no effect on blood pressure and serum lipids; however, its diabetogenic effect is more prominent in the period immediately following transplantation, although at maintenance dosages, the diabetogenic effect appears to be comparable to that of ciclosporin. The diabetogenic effect of tacrolimus can be managed by reducing the dose of tacrolimus and early corticosteroid withdrawal. The effect of tacrolimus on endothelial function has not been completely elucidated. The proliferation inhibitors azathioprine and mycophenolate mofetil (MMF) have little effect on the cardiovascular system. Yet, indirectly, by inducing anaemia, they may lead to left ventricular hypertrophy. MMF is an attractive alternative to azathioprine because of its higher potency and possibly lower risk of malignancies. Sirolimus also induces anaemia, but may be promising because of its antiproliferative features. Whether the hyperlipidaemia induced by sirolimus counteracts its beneficial effects is, as yet, unknown. It may be combined with MMF, however, initial attempts resulted in severe mouth ulcers.
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Affiliation(s)
- Johannes M M Boots
- Department of Nephrology, University Hospital Maastricht, Maastricht, The Netherlands.
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48
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Abstract
Kidney transplantation is the treatment of choice for patients with end stage renal disease. Kidney transplantation not only improves the quality of life but also prolongs life. Over the last decade, the short-term allograft survival rate has been improved dramatically. Chronic allograft nephropathy and death from cardiovascular diseases become predominant causes of later graft loss. Prevention and treatment of these disease processes require a comprehensive approach. The ever-increasing shortage of organ supply becomes the greatest challenge for the transplant community and modern medicine. More and more patients are waiting for organs; many of them are dying while waiting. Xenotransplantation and organ engineering and cloning are promising techniques and can potentially provide organs for transplantation in the future.
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Affiliation(s)
- Rubin Zhang
- Department of Medicine, Louisiana State University Health Sciences Center, New Orleans, USA
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49
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Prasad GVR, Kim SJ, Huang M, Nash MM, Zaltzman JS, Fenton SSA, Cattran DC, Cole EH, Cardella CJ. Reduced incidence of new-onset diabetes mellitus after renal transplantation with 3-hydroxy-3-methylglutaryl-coenzyme a reductase inhibitors (statins). Am J Transplant 2004; 4:1897-903. [PMID: 15476492 DOI: 10.1046/j.1600-6143.2004.00598.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Statins have anti-inflammatory effects, modify endothelial function and improve peripheral insulin resistance. We hypothesized that statins influence the development of new-onset diabetes mellitus in renal transplant recipients. The records of all previously non-diabetic adults who received an allograft in Toronto between January 1, 1999 and December 31, 2001 were reviewed with follow-up through December 31, 2002. All patients receiving cyclosporine or tacrolimus, mycophenolate mofetil and prednisone were included. New-onset diabetes was diagnosed by the Canadian Diabetic Association criteria: fasting plasma glucose > or =7.0 mmol/L or 2-h postprandial glucose > or =11.1 mmol/L on more than two occasions. Statin use prior to diabetes development was recorded along with other variables. Cox proportional hazards models analyzing statin use as a time-dependent covariate were performed. Three hundred fourteen recipients met study criteria, of whom 129 received statins. New-onset diabetes incidence was 16% (n = 49). Statins (p = 0.0004, HR 0.238[0.109-0.524]) and ACE inhibitors/ARB (p = 0.01, HR 0.309[0.127-0.750]) were associated with decreased risk. Prednisone dose (p = 0.0001, HR 1.007[1.003-1.010] per 1 mg/d at 3 months), weight at transplant (p = 0.02, HR 1.022[1.003-1.042] per 1 kg), black ethnicity (p = 0.02, HR 1.230[1.023-1.480]) and age > or =45 years (p = 0.01, HR 2.226[1.162-4.261]) were associated with increased diabetes. Statin use is associated with reduced new-onset diabetes development after renal transplantation.
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Affiliation(s)
- G V Ramesh Prasad
- Division of Nephrology, Department of Medicine, University of Toronto, 61 Queen Street East, 9th Floor, Toronto, ON M5C 2T2, Canada.
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50
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Meier-Kriesche HU, Schold JD, Srinivas TR, Reed A, Kaplan B. Kidney transplantation halts cardiovascular disease progression in patients with end-stage renal disease. Am J Transplant 2004; 4:1662-8. [PMID: 15367222 DOI: 10.1111/j.1600-6143.2004.00573.x] [Citation(s) in RCA: 241] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Morbidity and mortality from cardiovascular disease have a devastating impact on patients with chronic kidney disease (CKD) and end-stage renal disease. Renal function decline in itself is thought to be a strong risk factor for cardiovascular disease (CVD). In this study, we investigated the hypothesis that the elevated CV mortality in kidney transplant patients is due to the preexisting CVD burden and that restoring renal function by a kidney transplant might over time lower the risk for CVD. We analyzed 60,141 first-kidney-transplant patients registered in the USRDS from 1995 to 2000 for the primary endpoint of cardiac death by transplant vintage and compared these rates to all 66813 adult kidney wait listed patients by wait listing vintage, covering the same time period. The CVD rates peaked during the first 3 months following transplantation and decreased subsequently by transplant vintage when censoring for transplant loss. This trend could be shown in living and deceased donor transplants and even in patients with end-stage renal disease secondary to diabetes. In contrast, the CVD rates on the transplant waiting list increased sharply and progressively by wait listing vintage. Despite the many mechanisms that may be in play, the enduring theme underlying rapid progression of atherosclerosis and cardiovascular disease in renal failure is the loss of renal function. The data presented in this paper thus suggest that the development or progression of these lesions could be ameliorated by restoring renal function with a transplant.
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Affiliation(s)
- Herwig-Ulf Meier-Kriesche
- Kidney Transplant Program, Division of Nephrology, University of Florida College of Medicine, 1600 SW Archer Rd, RM CG-98, Gainesville, FL, USA.
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