Hyperlipidemia in adult, pediatric and diabetic renal transplant recipients

Lipoprotein profile changes in children after renal transplantation in the modern immunosuppression era

There are little data on prevalence of dyslipidemia in pediatric kidney TX recipients in the modern IS era. LP profiles of 38 TX recipients receiving triple IS with MMF, prednisone, and tacrolimus were compared with those of 11 children on HD using mixed model multiple linear regression analysis of repeated measures after adjusting for age, sex, ethnicity, duration of ESRD, and BMI. TC and LDL levels were significantly higher in TX compared with HD, whereas there was no difference in the HDL, VLDL, and TG levels. TC and LDL in TX children had no association with age, sex, ethnicity, and duration of ESRD, stage of chronic kidney disease, DM, BMI percentile, and gain in percentage IBW. Five children treated with atrovastatin had a significant reduction in TC, LDL, VLDL, and TG at 3-6 months post-treatment compared with pretreatment levels, whereas there was no difference in HDL or tacrolimus levels after treatment. No side effects of therapy were observed. Although dyslipidemia remains a significant problem in pediatric renal TX recipients in the modern era, the prevalence may have decreased with use of newer IS drugs.

Assessment of risk factors for cardiovasuclar disease in pediatric renal transplant patients

Pediatric renal TP recipients are at risk for CVD. We performed a cross-sectional study of the prevalence of RF for CVD in 45 long-term pediatric renal TP patients. The time since TP was 42 months. The GFR was 87.8 +/- 3.4 mL/min/1.73 m(2); 25/45 (56%) had Stage 2-4 CKD. A total of 33% had elevated SBP and 24% had high DBP; 57% had elevated SBP or DBP. A total of 20% had elevated serum CHOL levels, while 45% had high serum TG levels. A total of 42% had high HCY levels and 50% had low HCT levels. The vast majority (66.7%) had at least two RF for CVD. A total of 18.2% had abnormal post-TP echocardiography results. There was a negative correlation between GFR and SBP, DBP, serum CHOL, HCY, and BMI. There was a positive correlation between GFR and HCT. Serum CHOL was significantly lower and SBP and DBP trended lower in patients on a SF immunosuppression regimen. Similarly, SBP and DBP trended higher and CHOL was significantly higher in patients receiving SRL vs. mycophenolate mofetil. We conclude that the majority of pediatric renal TP patients exhibit multiple CVD RF.

Apolipoprotein a polymorphism predicts lipoprotein a concentration in renal transplant recipients

Increased serum lipoprotein(a) is an independent risk factor for atherosclerosis in renal transplant recipients. Higher levels may be due to genetic factors, for example, apolipoprotein A isoforms and/or environmental states such as drugs and diets. We evaluated 75 renal transplant recipients including 30 men and 45 women of overall mean age of 30 +/- 7 years and transplantation duration of 57 +/- 10 months as well as 30 healthy controls for apolipoprotein A isoforms, lipoprotein(a) concentrations, serum triglycerides, serum cholesterol, serum creatinine, and serum homocysteine concentrations. High- and low-molecular-weight apolipoprotein A isoforms (>35 and <35 kringle 4) were observed in 71% and 29% of renal transplant recipients and 83% and 17% of controls. Average lipoprotein(a) concentration ratios between high- and low-molecular-weight apolipoprotein A isoenzymes were significantly greater in renal transplant recipients than in controls. Lipoprotein A and cholesterol concentrations that did not correlate with each other were not higher among the eight renal transplant recipients with creatinine levels greater than 1.8 mg/dL. Absolute levels in renal transplant recipients with failed grafts also were not different regarding the various apolipoprotein A phenotypes. Homocysteine levels were significantly higher with high-molecular-weight apolipoprotein A isoenzymes. A relationship existed between lipoprotein(a) and triglycerides, but not cholesterol: higher triglyceride levels were associated more with high-molecular-weight isoforms of apolipoprotein A (P = .027). Lipoprotein(a) concentrations are higher in low-molecular-weight isoforms of apolipoprotein but triglyceride levels and homocysteine concentrations are higher among the high-molecular-weight isoforms of apolipoprotein A. This finding could be used as a guideline to select the most appropriate drug for different apolipoprotein A isoforms.

Results of one-year follow-up of steroid-free immunosuppression in pediatric renal transplant patients

Renal transplantation in children has traditionally required immunosuppression with multiple medications including glucocorticoids. Data collected over almost 30 yr suggest that although glucocorticoids are efficacious as part of a regimen to minimize the incidence of acute rejection episodes, their use is associated with increased risk for post-transplant hypertension, hyperlipidemia, and reduced growth rates. We desired to reduce these complications and thus used an immunosuppressive protocol including daclizumab, tacrolimus, and mycophenolate mofetil and study the efficacy of this protocol in a population with a high percentage of African-American recipients. No patient received glucocorticoids at any time post-transplant. Our results show that at 1 yr post-transplant, glomerular filtration rate, serum glucose, calcium and phosphorous metabolism, serum magnesium, and serum lipids were similar in patients receiving steroid-free and those receiving steroid-based immunosuppression. The incidence of acute rejection was similar in the two groups. Hematocrit and white blood count levels were lower 1 month after transplant in the steroid-free patients but these levels increased within several months. Systolic blood pressure was similar in the two groups, although this was achieved, in part, in the patients who received steroids by the administration of medications to lower blood pressure. Finally, tacrolimus levels were similar in the two groups, but patients receiving steroids required higher doses of tacrolimus at several time points studied during the first post-transplant year. Taken together, our data suggests that at one-year follow-up, steroid-free immunosuppression is safe, and efficacious in pediatric renal transplant recipients.

Glucocorticoid use and serum lipid levels in US adults: The third national health and nutrition examination survey

OBJECTIVE

It has been generally perceived that glucocorticoids adversely affect serum lipid levels, although results of prospective studies have suggested the contrary. In this study, we sought to examine the relationship between glucocorticoid use and lipid profiles in a nationally representative sample of subjects.

METHODS

Using data from 15,004 participants ages 20 years and older in The Third National Health and Nutrition Examination Survey (1988-1994), we examined the relationship between glucocorticoid use and serum lipid profiles. Glucocorticoid use was determined from the household interview regarding prescription medication use. We used multivariate linear regression to adjust for age, sex, race or ethnicity, education, smoking status, body mass index, physical activity, alcohol consumption, energy fraction from protein and carbohydrates, and total energy intake.

RESULTS

Glucocorticoid use was associated with a higher serum high-density lipoprotein (HDL) cholesterol level and a lower ratio of total cholesterol-to-HDL cholesterol among subjects ages 60 years or older (multivariate difference 9.0 mg/dl [95% confidence interval (95% CI) 3.9, 14.1] and -0.6 mg/dl [95% CI -0.9, -0.3], respectively) but not among those younger than age 60 years (multivariate difference -1.5 mg/dl [95% CI -5.4, 2.5] and 0.1 mg/dl [95% CI -0.3, 0.5], respectively). Correspondingly, glucocorticoid use was associated with a higher serum apolipoprotein A-I (Apo A-I) level and a lower Apo A-I:Apo B ratio (multivariate difference 12.1 mg/dl [95% CI 2.9, 21.3] and 0.16 mg/dl [95% CI 0.03, 0.29], respectively) only among subjects ages 60 years or older. Inhalation/intranasal glucocorticoid use was also associated with a higher serum HDL cholesterol level (multivariate difference 4.9 mg/dl [95% CI 0.3, 9.5]) only among subjects ages 60 years or older.

CONCLUSION

Our results suggest that glucocorticoid use is not associated with an adverse lipid profile in the US population and may be associated with a favorable lipid profile among persons ages 60 years or older, in concordance with previous prospective studies.

Risk factors for cardiovascular disease in pediatric renal transplant recipients

About 1,000 children develop end-stage renal disease (ESRD) each year in the United States and about 5,000 children are currently receiving dialysis. Children who develop ESRD are eligible to receive renal replacement therapy, including renal transplantation. There are inherent risks associated with transplantation, including renal insufficiency, infections, post-transplant lymphoproliferative disorder, and cardiovascular disease (CVD). Potential risk factors for CVD in pediatric renal transplant recipients include renal insufficiency, hyperlipidemia, hyperhomocysteinemia, inflammation, malnutrition, anemia, and hyperglycemia/insulin resistance. Despite evidence that many children may possess various risk factors for CVD post-renal transplantation, there are very few studies that have attempted to assess the link between these risk factors and CVD in pediatric renal transplant recipients.

Hypercholesterolemia is common after pediatric heart transplantation: initial experience with pravastatin

BACKGROUND

Coronary allograft vasculopathy (CAV) is a progressive complication after cardiac transplantation and limits survival. Hyperlipidemia is a known risk factor for CAV, and pravastatin is effective in decreasing cholesterol levels in adults after transplantation. However, few data exist regarding lipid profiles and statin use after pediatric heart transplantation. We evaluated the prevalence of hyperlipidemia in pediatric heart transplant recipients and assessed the efficacy and safety of pravastatin therapy.

METHODS

We performed a retrospective chart review of lipid profiles > or =1 year after surgery in 50 pediatric cardiac transplant recipients to assess the incidence of hyperlipidemia. Twenty of these patients received pravastatin for hypercholesterolemia. Their primary immunosuppression therapy was cyclosporine/prednisone plus either azathioprine or mycophenolate mofetil. We reviewed serial lipid profiles, creatinine phosphokinase, and liver enzymes.

RESULTS

Overall, 36% of the patients (n = 50) had total cholesterol (TC) concentrations > 200 mg/dl and 52% had low-density lipoprotein (LDL) >110 mg/dL beyond 1 year after transplantation. Of the 20 treated with pravastatin, TC (236 +/- 51 vs 174 +/- 33 mg/dl) and LDL levels (151 +/- 32 vs 99 +/- 21 mg/dl) decreased significantly with therapy (p <.0001). We found no symptoms; however, 1 patient had increased creatinine phosphokinase. Liver enzyme concentrations remained normal in all.

CONCLUSIONS

Hypercholesterolemia is prevalent in pediatric cardiac transplant recipients. Pravastatin therapy is effective in decreasing TC and LDL levels, seems to be safe, and is tolerated well. Further studies are necessary to determine whether pravastatin treatment is beneficial in decreasing CAV.

Hyperlipidemia in pediatric kidney transplant recipients treated with cyclosporine

Hyperlipidemia is a risk factor for cardiovascular disease in adult kidney transplant (Tx) recipients. We sought to determine the prevalence of, and the risk factors associated with, hyperlipidemia in pediatric kidney Tx recipients on cyclosporine (CsA). We identified 59 patients (mean age 8.2+/-5.7 years) transplanted between 1 January 1991 and 31 December 1993. Pre Tx, 34% had elevated total cholesterol [TC >200 mg/dl (5.17 mmol/l)]; 54% had elevated triglycerides [TG >200 mg/dl (2.26 mmol/L)]. Mean TG was higher pre Tx in dialysis (versus nondialysis) patients: 306 mg/dl (3.46 mmol/l) versus 228 mg/dl (2.58 mmol/l) ( P=0.04). Mean TC was higher in peritoneal dialysis than hemodialysis patients: 222 mg/dl (5.74 mmol/l) versus 169 mg/dl (4.37 mmol/l) ( P=0.03). Pre Tx and 3-year values correlated (TC, r=0.49, P=0.0008; TG, r=0.41, P=0.001); 3- and 5-year TC values correlated ( r=0.57, P=0.003). At 5 years post Tx, 41% of the recipients had elevated TC; 14% had elevated TG. Recipients with elevated TC had higher mean CsA concentrations at 1 year post Tx ( P=0.03). Recipients with elevated TG tended to receive more prednisone ( P=0.06). At 5 years post Tx, recipients had a high prevalence of hyperlipidemia. The identification and treatment of hyperlipidemia should be included in pediatric kidney Tx protocols.

Atorvastatin treatment for hyperlipidemia in pediatric renal transplant recipients

The objective of this prospective study was to determine the prevalence of hyperlipidemia in our pediatric renal transplant patients and to treat those with persistently elevated cholesterol and/or low-density lipoprotein (LDL) levels. All patients with a functioning renal allograft for greater than 6 months were studied (n = 18). Patients with cholesterol and/or LDL levels greater than the 95th percentile (n = 9) were commenced on an HMG-CoA reductase inhibitor, Atorvastatin and monitoring was performed for efficacy and adverse effects. Total serum cholesterol was elevated in 11 of 18 (61%) and triglyceride (TG) was elevated in 12 of 18 (67%) patients. Atorvastatin treatment was effective with a mean percentage reduction of total cholesterol of 41 +/- 10% (p < 0.01 vs. before treatment), LDL 57 +/- 7% (p < 0.01 vs. before treatment) and TG 44 +/-25% (p = 0.05 vs. before treatment). No adverse effects on allograft function or cyclosporin levels were experienced. Hyperlipidemia is a common problem and Atorvastatin is a safe and effective treatment in pediatric renal transplant recipients.

Tacrolimus conversion improves hyperlipidemic states in stable liver transplant recipients

With improvements in surgical technique and the advent of new and more effective immunosuppressive agents, survival rates in liver transplant recipients have dramatically improved. However, hyperlipidemia frequently develops in patients administered cyclosporine-based immunosuppression long-term, although it appears to occur less often with newer, tacrolimus-based regimens. We sought to determine whether an isolated change in the baseline immunosuppressive regimen (cyclosporine to tacrolimus) would improve hyperlipidemic states in these patients. Twenty-one long-term stable liver transplant recipients with hyperlipidemia, manifested by elevated cholesterol and/or triglyceride levels, were offered conversion to tacrolimus from cyclosporine A therapy. Lipid profiles were monitored at baseline (while on cyclosporine therapy) and at 1 and 3 months after conversion to tacrolimus therapy. There were no other medication manipulations. After conversion to tacrolimus therapy, mean cholesterol levels decreased from 251 to 202 mg/dL at 1 month (P <.001) and 194 mg/dL at 3 months (P <.001). Similarly, triglyceride levels decreased from 300 to 207 mg/dL by 1 month (P =.011) and 203 mg/dL by 3 months (P <.001). There was also a statistically significant decrease for very low-density lipoprotein levels at 3 months (P =.005) and low-density lipoprotein levels at 1 and 3 months (P =.013 and P =.014, respectively). High-density lipoprotein levels did not significantly change after conversion to tacrolimus therapy. Conversion was not accompanied by adverse side effects, and patients tolerated the change well. In conclusion, simple conversion from cyclosporine to tacrolimus-based immunosuppression therapy is safe and improves posttransplantation hyperlipidemia in a subgroup of liver transplant recipients.

Double-blind comparison of two corticosteroid regimens plus mycophenolate mofetil and cyclosporine for prevention of acute renal allograft rejection

BACKGROUND

Renal transplant recipients experience adverse events attributed to corticosteroid therapy.

METHODS

This was a multicenter, randomized, double-blind, 6-month, controlled steroid dose-reduction study in renal transplant recipients with an unblinded 6-month follow-up. In the low/stop arm, corticoste. roids were given at half the dosage of control for 3 months from the date of transplantation, and then withdrawn. Both arms received mycophenolate mofetil and cyclosporine. The primary endpoint was the incidence of biopsy-proven acute rejection at 6 months posttransplantation.

RESULTS

There were 248 patients in the control group and 252 in the low/stop group. At 6 months the low/stop group had more biopsy-proven acute rejection episodes than the control (23% vs. 14%; P=0.008). At 12 months this increased to 25% vs. 15%. Most rejections were Banff grade I. Twelve-month graft loss was 5% in the low/stop group vs. 4% in the control. At 6 and 12 months serum cholesterol (P<0.01, P<0.01), triglycer. ides (P<0.01, P<0.01), and systolic blood pressure (P<0.001, P<0.001) were lower in the low/stop group. Diastolic pressure was lower (P<0.01) and lumbar spine bone density was greater (P<0.01) in the low/ stop group at 12 months.

CONCLUSIONS

In renal transplant recipients treated with mycophenolate mofetil and cyclosporine, reduction and early withdrawal of the prophylactic corticosteroid dose is feasible without an unacceptable increase in serious rejection episodes. This is accompanied by a significant reduction of steroid-related adverse events.

Lack of effect of gemfibrozil on cyclosporine blood concentrations in kidney-transplanted patients

Forty kidney-transplanted patients with hypertriglyceridemia, under treatment with cyclosporine alone or associated with other immunosuppressive drugs, were treated with gemfibrozil. This drug, for a long-term treatment (ranging from 4 to 6 months), was able to decrease hypertriglyceridemia and did not modify either polyclonal (P) and monoclonal (M) cyclosporine blood levels or P/M ratio. These data seem to exclude an effect of gemfibrozil on cyclosporine blood concentrations. Therefore, the use of gemfibrozil in kidney-transplanted patients does not require modifications of cyclosporine dose.

Does immunosuppressive regimen influence the lipid disturbances in kidney recipients?

Though it is said that some immunosuppressive agents are implicated in the development of hyperlipidemia in kidney recipients, this subject is still controversial. Main plasma lipid parameters, as well as apolipoproteins A1 and B were measured periodically in 39 kidney first cadaveric, nondiabetic recipients during 24 months of clinic follow-up after transplantation. Standard triple immunosuppressive therapy: prednisone + cyclosporine + azathioprine was administrated from the beginning. After the second year of kidney transplantation, a significant reduction refers to values of TC, LDL, apo A1 and apo B. In the group with antirejection - methylprednisolone therapy, and without it only TG in the 24th month and apo B in the 1st month were statistically lower in the latter group (both p < 0.05). In the multiple regression test, a linear coincidence was observed between apo A1, apo B and prednisone cumulative dosage after the 1st month, TG and cyclosporine in the 6th month and LDL and cyclosporine in the 12th month after transplantation. It appears that steroids had an impact on lipids directly after transplantation, while cyclosporine did so thereafter.

Effects of simvastatin and pravastatin on hyperlipidemia and cyclosporin blood levels in renal transplant recipients

Thirty-one renal transplant recipients, submitted to treatment with cyclosporin in association with other immunosuppressive agents, were also treated for 9 months with two hydroxymethylglutaryl coenzyme A reductase inhibitors, simvastatin (10 mg/day) or pravastatin (20 mg/day), for concomitant hypercholesterolemia and hypertriglyceridemia. Both drugs significantly decreased total cholesterol and triglyceride serum levels, but they did not modify whole-blood trough concentrations of polyclonal and monoclonal cyclosporin or polyclonal/monoclonal cyclosporin ratio. No alterations of the clinical and laboratory parameters investigated were found. The results of this study show the efficacy and safety of hydroxymethylglutaryl coenzyme A reductase inhibitors in the treatment of hyperlipidemia in kidney transplant patients.

Body composition in renal transplant patients: bioimpedance analysis compared to isotope dilution, dual energy X-ray absorptiometry, and anthropometry

Whether multifrequency bioelectrical impedance analysis (MF-BIA), a relatively new method for measuring body composition, is also applicable for accurate body composition measurements in renal transplant (RTx) patients is not known. Therefore, the use of MF-BIA is validated in 77 RTx patients with a stable renal function at least 2 yr posttransplantation. MF-BIA is compared to isotope dilution techniques for measurement of body water compartments, and to dual energy x-ray absorptiometry (DEXA) and anthropometry for measurement of fat and fat free mass. Finally, DEXA and anthropometry are compared to each other. Method agreement is assessed by intraclass correlation coefficients (ICC) and plotted by Bland and Altman analysis. MF-BIA significantly underestimates total body water (TBW, 0.7+/-2.1 L) and overestimates the extracellular water (ECW, 3.3+/-1.8 L) compared to isotope dilution; the ICC between both techniques is 0.943 for TBW and 0.846 for ECW. The percentage body fat (BF) measured by MF-BIA is significantly higher than both BF measured by DEXA (3.4+/-4.7%) or by anthropometry (5.5+/-5.2%). The ICC between MF-BIA and DEXA is 0.887 and between MF-BIA and anthropometry 0.856. BF measured by DEXA is significantly higher than BF measured by anthropometry (2.1+/-4.4%); their ICC is 0.913. In conclusion, MF-BIA seems to be suitable for measurement of TBW in RTx patients; however, method agreement between isotope dilution and MF-BIA for the measurement of ECW is not satisfactory. In the assessment of fat and fat free mass, the reliability of MF-BIA appears to be questionable. Method agreement between DEXA and anthropometry seems to be slightly better.

Apo(a) phenotypes and lp(a) concentrations in renal transplant patients

Plasma lipoprotein (a) (LP(a)) concentrations are increased in patients with end-stage renal disease. Considering the influence of the apolipoprotein (a) (Apo(a)) polymorphism and the mode of dialysis in this prospective longitudinal study, we compared Lp(a) concentrations before and after the first 6 months of a successful kidney transplantation in 125 recipient patients. Apo(a) phenotyping was performed by using SDS-PAGE and SDS-agarose, isoforms were classified into high molecular weight (HMW) and low molecular weight (LMW). Before the graft, the Lp(a) concentrations were significantly higher in CAPD than in hemodialysis patients (p = 0.021). Six months after transplantation, Lp(a) fell in both treatment groups. This decrease occurred within both LMW and HMW but to a different extent: median relative variations were -35 and -50%, respectively (p = 0. 048). Among patients with Lp(a) concentration >30 mg/dl 6 months after transplantation, 74% had LMW Apo(a) isoform while the remaining 26% had HMW isoform. Successful renal transplantation leads rapidly to a correction of Lp(a) concentrations, especially in patients treated with CAPD who have higher Lp(a) levels. The most important factor seems to be the LMW status corresponding to high Lp(a) levels.

Effect of therapy with deflazacort on dyslipoproteinemia after pediatric renal transplantation

Deflazacort is an oxazolone compound derived from prednisolone, with similar immunosuppressive action but fewer side effects. Kidney function, weight/height ratio, serum triglycerides, cholesterol, high-density lipoprotein (HDL) cholesterol, very-low-density lipoprotein cholesterol, low-density lipoprotein (LDL) cholesterol, apolipoprotein A, apolipoprotein B, and lipoprotein (a) were studied before and 6 months after substitution of deflazacort (mean +/- SEM, 0.3 +/- 0.1 mg/kg per day) for methylprednisone (0.2 +/- 0.1 mg/kg per day) in 14 patients treated with cyclosporine, aged 3.1 to 20.3 years, 3 years after renal transplantation. Serum creatinine and calculated creatinine clearance did not change significantly, and weight/height ratio decreased from 20.0% +/- 7.1% to 12.5% +/- 6.5% (P < .005) during deflazacort therapy. Total cholesterol was reduced by 15.9% (from 233 +/- 15 mg/dL to 196 +/- 13 mg/dL, P < .01), LDL cholesterol by 25.5% (from 153 +/- 14 mg/dL to 114 +/- 12 mg/dL, P < .01), and TC/HDL cholesterol ratio by 28.3% (from 5.3 +/- 0.4 to 3.8 +/- 0.4, P < .01), whereas HDL cholesterol increased 18% (from 45 +/- 2 mg/dL to 53 +/- 2 mg/dL) and apolipoprotein A by 8.3% (from 122 +/- 5 mg/dL to 132 +/- 5 mg/dL, P < .05) during deflazacort therapy. Our data suggest that substituting deflazacort for maintenance methylprednisone therapy leads to an improvement in the lipoprotein profile of children after renal transplantation.

Effects of tacrolimus on hyperlipidemia after successful renal transplantation: a Southeastern Organ Procurement Foundation multicenter clinical study

BACKGROUND

Tacrolimus has been shown to have a less adverse effect on the lipid profiles of transplant patients when the drug is started as induction therapy. In order to determine the effect tacrolimus has on lipid profiles in stable cyclosporine-treated renal transplant patients with established hyperlipidemia, a randomized prospective study was undertaken by the Southeastern Organ Procurement Foundation.

METHODS

Patients of the 13 transplant centers, with cholesterol of 240 mg/dl or greater, who were at least 1 year posttransplant with stable renal function, were randomly assigned to remain on cyclosporine (control) or converted to tacrolimus. Patients converted to tacrolimus were maintained at a level of 5-15 ng/ml, and control patients remained at their previous levels of cyclosporine. Concurrent immunosuppressants were not changed. Levels of total cholesterol, triglycerides, total high-density lipoprotein, low-density lipoprotein (LDL), very-low-density lipoprotein, and apoproteins A and B were monitored before conversion and at months 1, 3, and 6. Renal function and glucose control were evaluated at the beginning and end of the study (month 6).

RESULTS

A total of 65 patients were enrolled; 12 patients failed to complete the study. None were removed as a result of acute rejection or graft failure. Fifty-three patients were available for analysis (27 in the tacrolimus group and 26 controls). Demographics were not different between groups. In patients converted to tacrolimus treatment, there was a -55 mg/dl (-16%) (P=0.0031) change in cholesterol, a -48 mg/dl (-25%) (P=0.0014) change in LDL cholesterol, and a -36 mg/dl (-23%) (P=0.034) change in apolipoprotein B. There was no change in renal function, glycemic control, or incidence of new onset diabetes mellitus in the tacrolimus group.

CONCLUSION

Conversion from cyclosporine to tacrolimus can be safely done after successful transplantation. Introduction of tacrolimus to a stable renal patient does not effect renal function or glycemic control. Tacrolimus can lower cholesterol, LDL, and apolipoprotein B. Conversion to tacrolimus from cyclosporine should be considered in the treatment of posttransplant hyperlipidemia.

Risk factors for premature coronary heart disease after successful liver transplantation in adults

As solid-organ transplantation has evolved into a highly effective treatment for end-stage organ disease, the long-term health implications of chronic exposure of recipients to immunosuppressants and other pharmacological agents are becoming more apparent. Coronary heart disease has long been known to plague kidney transplant recipients and more recently has been found to affect heart transplant recipients disproportionately. Coronary heart disease after liver transplantation, however, is less well known. The purpose of this study was to examine risk factors for premature coronary heart disease in asymptomatic adult recipients of liver transplants. Nutrition-related risk factors for coronary heart disease (obesity and hyperlipidemia) were measured in 29 patients before and after liver transplantation. Changes with respect to primary immunosuppression protocol (cyclosporine plus corticosteroid vs tacrolimus plus corticosteroid) were compared. Risk factors that had not been present before transplantation were apparent in both groups by 6 months after transplantation. Although obesity and hyperlipidemia were not found to be independent risk factors for coronary heart disease, they were clinically important when considered in combination. Cyclosporine was associated with significantly higher serum lipid concentrations than was tacrolimus.

Posttransplant hyperlipidemia: the treatment dilemma

Hyperlipidemia occurs in the majority of renal transplant recipients and may play an important role in the development of posttransplant cardiovascular disease. Although many clinical factors are associated with posttransplant hyperlipidemia, corticosteroids and cyclosporine clearly play key pathogenetic roles. Aside from cautious reduction of immunosuppression and appropriate dietary restrictions, therapeutic strategies for the management of posttransplant hyperlipidemia are limited, in part, due to special pharmacologic considerations in transplant recipients receiving cyclosporine. Based on recent studies suggesting that low doses of 3-hydroxy-3-methylglutaryl coenzyme A (HMGCoA) reductase inhibitors are safe and effective, these agents have emerged as the drugs of first choice in the pharmacologic treatment of posttransplant hypercholesterolemia. Considering the increasing importance of cardiovascular disorders as major causes of posttransplant morbidity and mortality, additional studies are warranted to delineate the relationship between posttransplant hyperlipidemia and posttransplant cardiovascular disease, and to find safe and effective strategies for reducing lipid levels after renal transplantation.

Managing nutrition problems in transplant patients

Patients who undergo organ transplantation receive immunosuppressive drugs in the posttrans-plant period. All of these drugs influence host metabolic response or alter nutrient intake. One of the most prominent aspects of the posttransplant period is the occurrence of hyperlipidemia, which may require dietary or pharmacologic control. Dietary recommendations for this patient population include limiting carbohydrate intake, restricting caloric intake to maintain ideal body weight, and maintaining a low cholesterol/saturated fat diet.

Lipid and apolipoprotein changes after orthotopic liver transplantation for end-stage liver diseases

Orthotopic liver transplantation was performed in 37 patients with different endstage liver diseases. Changes in lipid and apolipoprotein concentrations were followed daily from day 1 to 20 after surgery and regularly thereafter until 12 months. When the acute effects of surgery had cleared away, there was a sharp drop in HDL-C, apo A-I and A-II from day 1 to 5, a stabilization at their lowest values from day 5 to 15 and then a progressive rise. Contrasting with this drop, triglycerides, apo B, C-II and C-III increased from day 1 to 5 with variable concentrations thereafter. Apo SAA considerably increased early after surgery and remained significantly higher than normal in most patients after 12 months. All other parameters returned to normal from 3 to 6 months after transplant. The mechanism leading to these lipid and apolipoprotein changes are discussed with respect to the distant effect of infusions, re-alimentation, immunosuppressive therapy and lipoprotein metabolism. The apolipoprotein concentrations appear very useful indicators of functional liver recovery.

Lipoprotein-apolipoprotein changes in renal transplant recipients: a 2-year follow-up

Renal transplantation modifies the dyslipidemia characteristic of chronic renal failure (CRF). The change in lipoprotein and lipid values of 51 transplant recipients, on cyclosporine and corticosteroid treatment, was studied during 2 years after transplantation to examine the short- and medium-term variations of lipid metabolism. Compared with control values of (all in mg/dL) triglycerides (Tg) 111 +/- 44, very-low-density lipoprotein (VLDL) Tg 69 +/- 18, total cholesterol (Chol) 201 +/- 32, VLDL-Chol 32 +/- 9, low-density lipoprotein (LDL) Chol 118 +/- 28, and high-density lipoprotein (HDL) Chol 50 +/- 10, uremic patients pretransplantation exhibited values of Tg 200 +/- 82 (P less than .001), VLDL-Tg 133 +/- 70 (P less than .001), Chol 193 +/- 51 (NS), VLDL-Chol 52 +/- 16 (P less than .001), LDL-Chol 100 +/- 37 (P less than .007), HDL-Chol 40 +/- 16 (P less than .001), which changed to Tg 118 +/- 18 (P less than .001), VLDL-Tg 64 +/- 45 (P less than .001), Chol 223 +/- 48 (P less than .006), VLDL-Chol 26 +/- 33 (P less than .001), LDL-Chol 134 +/- 43 (P less than .001), at HDL-Chol 63 +/- 21 (P less than .001) at 3 months and Tg 135 +/- 76, VLDL-Tg 81 +/- 62, Chol 218 +/- 55, VLDL-Chol 22 +/- 20, LDL-Chol 139 +/- 46, and HDL-Chol 58 +/- 18 at 24 months without evidence of a significative variations in the 3- to 24-month posttransplant period.(ABSTRACT TRUNCATED AT 250 WORDS)

Independent effects of cyclosporine and prednisone on posttransplant hypercholesterolemia

To clarify the relative influences of cyclosporine (CsA) therapy, corticosteroid therapy, and other clinical variables on posttransplant hypercholesterolemia, total serum cholesterol levels were measured in 107 renal transplant recipients receiving one of three immunosuppression regimens: CsA and azathioprine (AZA) (group I); CsA, AZA, and prednisone (group II); or AZA and prednisone (group III). Multivariate analysis demonstrated that prednisone therapy, CsA therapy, patient age, and pretransplant cholesterol levels correlated independently with posttransplant cholesterol levels at last follow-up (ranging from 13 to 84 months after transplantation). In 32 patients successfully withdrawn from corticosteroid therapy and maintained on AZA and stable doses of CsA, serum cholesterol decreased from 6.55 +/- 1.1 mmol/L (253.5 +/- 43.1 mg/dL) to 5.27 +/- 1.2 mmol/L (203.9 +/- 45.6 mg/dL). Results of this analysis indicate that prednisone and CsA are independent factors in the pathogenesis of posttransplant hypercholesterolemia. Complete withdrawal of corticosteroids partially corrects hypercholesterolemia in CsA-treated renal transplant recipients.

The adverse impact of cyclosporine on serum lipids in renal transplant recipients

The extent to which cyclosporine (CsA) directly, or indirectly, influences serum lipid levels in renal transplant patients treated with multiple-drug immunosuppression protocols is unclear. Indeed, patients treated with CsA have reduced corticosteroid requirements, fewer acute rejection episodes, and other differences from patients receiving conventional immunosuppression that may reduce serum lipid levels. We studied patients treated with low-dose CsA, corticosteroids, azathioprine, and Minnesota antilymphocyte globulin ([ALG] n = 205) versus conventional (three-drug) immunosuppression (n = 368) and evaluated the impact of CsA, acute rejection episodes, and other clinical parameters on serum lipids. Fasting serum lipid levels from stable patients transplanted between 1976 to 1989 were studied at 3 (n = 573), 12 (n = 565), 26 (n = 55), and 52 (n = 521) weeks posttransplant using multivariate, linear regression analysis. The incidence of acute rejection episodes was reduced by CsA, but patients with fewer acute rejection episodes in the early posttransplant period had higher serum total cholesterol (increased by .33 +/- .12 mmol/L [13 +/- 5 mg/dL] and .27 +/- .12 mmol/L [10 +/- 5 mg/dL], P less than 0.05, at 3 and 12 weeks, respectively) and low-density lipoprotein (LDL) (increased by .23 +/- .11 mmol/L [9 +/- 4 mg/dL] and .23 +/- .11 mmol/L [9 +/- 4 mg/dL], P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Impact of long-term immunosuppression with cyclosporin A on serum lipids in stable renal transplant recipients

To determine the impact of long-term immunosuppression on serum lipids in stable renal graft recipients we measured serum lipids and apolipoprotein B concentrations in 20 patients receiving therapy with cyclosporin (CsA) and low-dose prednisolone (CsA/P) and in 18 patients on therapy with azathioprine and maintenance steroids (Aza/P). The patients were matched for age, body mass index, primary renal disease and dose of prednisolone, but not for the duration in transplantation and serum creatinine concentration. Triglyceride concentrations were significantly higher in the CsA/P group than in Aza/P-treated patients: 2.62 +/- 0.35 vs 1.62 +/- 0.23 mmol/l (P less than 0.05). Similarly, total cholesterol (C) levels were significantly more elevated in the CsA/P recipients than in the other group: 7.44 +/- 0.32 vs 5.84 +/- 0.25 (P less than 0.02). CsA/P patients had higher serum levels of LDL-C (4.79 +/- 0.20 vs 3.43 +/- 0.19 mmol/l (P less than 0.001) and apolipoprotein B concentrations (191 +/- 13 vs 128 +/- 9 mg/dl: P less than 0.001). CsA/P and Aza/P recipients had similar concentrations of HDL-C (1.73 +/- 0.13 vs 1.52 +/- 0.09 mmol/l: NS). We conclude that in stable renal graft recipients with good transplant function long-term immunosuppression with CsA/P is associated with a more atherogenic lipid status than therapy with Aza/P.

Outcome of renal transplantation in patients with a functioning graft for 20 years or more

In the present study long-term morbidity, quality of life and over-all rehabilitation were assessed in 14 patients with a functioning renal allograft for 20 years or longer. Followup ranged from 20 to 27 years (mean 22.5 years). All patients enjoyed excellent and stable renal function, and the mean serum creatinine level at 20 years was 1.3 mg. per dl. Complications related to long-term immunosuppressive therapy comprised infection in 8 patients (57%), malignancy in 7 (50%), cardiovascular disease in 6 (43%), cataracts in 3 (21%) and avascular necrosis of the hip in 2 (14%). Over-all quality of life was excellent in 13 patients who were able to return to work, participate in pre-illness levels of activity and enjoy sexual activity. While successful renal transplantation allows patients with end stage renal failure to resume relatively normal lives, these patients remain prone to complications resulting from long-term immunosuppressive therapy.

Endocrine and metabolic abnormalities following kidney transplantation

Various endocrine and metabolic disturbances associated with long standing uremia persist after kidney transplantation or arise from the use of immunosuppressive drugs. Hyperlipidemia for long time being implicated as the cause of corticosteroids is also observed in renal transplant recipients treated with cyclosporin A monotherapy. After conversion from cyclosporin to azathioprine serum cholesterol and triglyceride concentration fall, and elevation of LDL-cholesterol may also be reversed. There is a tendency for higher HDL-cholesterol in azathioprine and prednisolone treated transplant patients. Those patients who are at risk for clinically significant cholesterol elevations can be predicted by their pretransplant lipid levels, specifically the LDL-fraction. Risk-benefit ratio of conversion and of treatment with lipid-lowering drugs, especially with lovastatin, should be carefully examined, also in view of glucose intolerance. Higher incidence of diabetes mellitus requiring insulin therapy in cyclosporin treated transplant recipients has been reported. Cyclosporin may cause toxic effects on pancreatic beta-cells resulting in inhibition of insulin secretion. High doses of cyclosporin induce inhibition of glycogen synthesis in rat liver. Glucose intolerance is reversible after reduction of cyclosporin dose or conversion to azathioprine. Therefore glucose metabolism in kidney transplant recipients treated with cyclosporin should be carefully followed. Immunosuppressive therapy may affect reproductive function, arachidonate metabolism and renin-angiotensin-aldosterone system as well as posttransplant calcium and phosphate metabolism. Endocrine and metabolic abnormalities are associated with long standing uremia. After successful kidney transplantation several observations are normalized but further complications arise from the use of immunosuppressive drugs. The present paper reviews various endocrine and metabolic disturbances described following renal transplantation.

Plasma lipoproteins and adrenocortical hormones in men--positive association of low density lipoprotein cholesterol with plasma cortisol concentration

The associations of plasma lipoprotein lipids with the plasma concentrations of two adrenocortical hormones (sampled at 09.00-11.00 h) have been investigated in a random sample of 70 men aged 52-67 yr (mean, 59 yr). Plasma low density lipoprotein (LDL) cholesterol concentration was found to be positively correlated with plasma cortisol, independently of the concentrations of plasma triglyceride, high density lipoprotein cholesterol and androstenedione. After adjusting for covariates, plasma cortisol explained approximately twelve per cent of the variance in LDL cholesterol. These results suggest that plasma cortisol may significantly influence the metabolism of LDL in healthy humans.

Frequency of hypercholesterolemia after cardiac transplantation

Cardiac transplant patients are prone to accelerated coronary atherosclerosis. The mechanism by which this process occurs is not yet known, although immunologically mediated arterial injury is thought to play a primary role in its pathogenesis. Despite immunosuppressive potency, patients treated with cyclosporin A remain at significant risk for the development of accelerated atherosclerosis. It is hypothesized that cyclosporin A's hepatotoxic effects might contribute to the atherosclerotic process by impairing low density lipoprotein hepatic clearance in transplant patients, which would be reflected in a more atherogenic lipoprotein profile. To test this hypothesis, serum cholesterol levels were analyzed after transplantation. Significant and progressive increases in total cholesterol and in the total-to-high density lipoprotein cholesterol ratio were found. This atherogenic lipoprotein profile may contribute to accelerated atherosclerosis in cardiac transplant patients treated with cyclosporin A.

Efficacy and long-term adverse effect pattern of lovastatin

The efficacy of lovastatin, a potent inhibitor of HMG CoA reductase, has been established by numerous studies. At doses of 40 mg administered twice daily, lovastatin produces a mean reduction in total plasma cholesterol of 33%, attributable to a reduction in low-density lipoprotein cholesterol of 41%. The drug also produces a mean increase in high-density lipoprotein cholesterol of 9%, and a reduction in the high- and low-density lipoprotein cholesterol ratio of 44%. The serious reported adverse effects of lovastatin are myopathy (0.5%) and asymptomatic but marked and persistent increases in transaminases (1.9%). Both are reversible when therapy is discontinued. Myopathy has occurred mainly in patients with complicated histories who were receiving concomitant therapy with immunosuppressive drugs, gemfibrozil or niacin. In an ongoing long-term safety study, 744 patients have received lovastatin for an average duration of 2.5 years up to March 1988. Fifteen patients (2.0%) have been withdrawn because of drug-attributable adverse events: raised transaminases (9), skin rash (2), gastrointestinal symptoms (2), myopathy (1) and insomnia (1). No effect of the drug on the human lens has been observed up to the date mentioned above. Lovastatin has been available in the United States since September 1987. By March 1988, the drug had been prescribed for approximately 250,000 patients. This clinical experience has confirmed the tolerability observed in clinical trials. The good adverse-effect profile of lovastatin is thus now supported both by a substantial body of data in patients treated for over 2 years in clinical trials, and by experience in clinical use with a large number of patients since the drug has been available for prescription.