Cardiovascular risk profile in kidney transplant recipients treated with two immunosuppressive regimens: tacrolimus and mycophenolate mofetil versus everolimus and low-dose cyclosporine

Immunosuppressive Therapy-Related Cardiovascular Risk Factors in Renal Transplantation: A Narrative Review

BACKGROUND

Kidney transplantation is the best treatment for patients with chronic renal failure, capable of improving life expectancy and the risk of death from all causes, which, however, remains higher than in the general population. The leading cause of death in transplant patients is cardiovascular events, burdened by a significant impact brought about by anti-rejection therapy. Experimental and clinical studies to date show that in kidney transplant recipients, traditional cardiovascular risk factors (hypertension, diabetes, dyslipidemia, obesity, tobacco, etc.) may be exacerbated or worsened by the dysmetabolic effects of immunosuppressive drugs, which may also result in additional risk factors such as proteinuria, anemia, and arterial stiffness. The aim of this review was to provide an in-depth evaluation of the effect of immunosuppressive treatments on cardiovascular risk factors.

SUMMARY

We have investigated and described the main cardiovascular risk factors related to immunosuppressive drugs. We searched for relevant scientific articles in medicine, transplant, cardiologic, and nephrological journals in major medical science libraries.

KEY MESSAGES

Immunosuppressive drugs allow graft survival and successful bunking of the transplant; however, they are not without significant side effects and should always be prescribed weighing the risk/benefit ratio and the individual patient's therapeutic needs.

Comparison of Kidney Transplant Function, Lipid Metabolism Disorders, and Glucose and Hemoglobin Concentration in Transplant Patients Treated With Proliferation Signal Inhibitor (Everolimus) or Calcineurin Inhibitor (Tacrolimus)

INTRODUCTION

After kidney transplantation (KTx) in patients with diagnosed cancers, calcineurin inhibitor tacrolimus (TAC) is replaced by sirolimus or everolimus (EV).

OBJECTIVE

The objective of the study was to compare the lipid metabolism parameters, KTx function, and glucose and hemoglobin (Hgb) levels in patients treated with EV to those on TAC.

MATERIAL AND METHODS

The retrospective study included 114 patients: 54 (17 women and 37 men) aged 57.6 years (18-77 years) treated with EV and 60 (18 women and 42 men) aged 49.6 years (20-77 years) treated with TAC as a control group. Their total cholesterol (TC), triglycerides (TG), fasting glucose (FG), serum creatinine (SCr), Hgb, and estimated glomerular filtration rate (eGFR) were assessed. In the patients treated with EV, the above values were evaluated before conversion, as well as 12 and 24 months following the switch and were evaluated once in the group treated with TAC.

RESULTS

In the EV-treated group, the mean preconversion values after 12 and 24 months were as follows: TC 5.06, 6.59, and 5.98 mmol/L; TG 1.90, 2.48, and 2.20 mmol/L; FG 94.95, 97.85, and 104.05 mg/dL; SCr 1.46, 1.44, and 1.56 mg/dL; Hgb 12.46, 12.83, and 13.36 g/dL; and eGFR 50.3, 50.6, and 50.5 mL/min/1.73 m². In the patients on TAC, the authors obtained the following values: TC 4.6 mmol/L; TG 1.87 mmol/L; glucose 104.13 mg/dL; SCr 1.51 mg/dL; Hgb 13.96 g/dL; and eGFR 56.6 mL/min/1.73 m².

CONCLUSIONS

After conversion from TAC to EV, increased values of TC and TG were observed after 1 year, while the increased values of TC, TG, SCr, Hgb, and FG were observed after 2 years.

Cardiovascular Parameters to 2 years After Kidney Transplantation Following Early Switch to Everolimus Without Calcineurin Inhibitor Therapy: An Analysis of the Randomized ELEVATE Study

BACKGROUND

Mammalian target of rapamycin inhibitors may confer cardioprotective advantages, but clinical data are limited.

METHODS

In the open-label ELEVATE trial, kidney transplant patients were randomized at 10 to 14 weeks after transplant to convert from calcineurin inhibitor (CNI) to everolimus or remain on standard CNI therapy. Prespecified end points included left ventricular mass index and, in a subpopulation of patients, arterial stiffness as measured by pulse wave velocity.

RESULTS

The mean change in left ventricular mass index from randomization was similar with everolimus versus CNI (month 24, -4.37 g/m versus -5.26 g/m; mean difference, 0.89 [p = 0.392]). At month 24, left ventricular hypertrophy was present in 41.7% versus 37.7% of everolimus and CNI patients, respectively. Mean pulse wave velocity remained stable with both everolimus (mean change from randomization to month 12, -0.24 m/s; month 24, -0.03 m/s) and CNI (month 12, 0.11 m/s; month 24, 0.16 m/s). The change in mean ambulatory nighttime blood pressure from randomization showed a benefit for diastolic pressure at month 12 (P = 0.039) but not at month 24. Major adverse cardiac events occurred in 1.1% and 4.2% of everolimus-treated and CNI-treated patients, respectively, by month 12 (P = 0.018) and 2.3% (8/353) and 4.5% by month 24 (P = 0.145).

CONCLUSIONS

Overall, these data do not suggest a clinically relevant effect on cardiac end points after early conversion from CNI to a CNI-free everolimus-based regimen.

Calcineurin Inhibitor Minimization, Conversion, Withdrawal, and Avoidance Strategies in Renal Transplantation: A Systematic Review and Meta-Analysis

Despite their clinical efficacy, concerns about calcineurin inhibitor (CNI) toxicity make alternative regimens that reduce CNI exposure attractive for renal transplant recipients. In this systematic review and meta-analysis, we assessed four CNI immunosuppression strategies (minimization, conversion, withdrawal, and avoidance) designed to reduce CNI exposure and assessed the impact of each on patient and allograft survival, acute rejection and renal function. We evaluated 92 comparisons from 88 randomized controlled trials and found moderate- to high-strength evidence suggesting that minimization strategies result in better clinical outcomes compared with standard-dose regimens; moderate-strength evidence indicating that conversion to a mammalian target of rapamycin inhibitor or belatacept was associated with improved renal function but increased rejection risk; and moderate- to high-strength evidence suggesting planned CNI withdrawal could result in improved renal function despite an association with increased rejection risk. The evidence base for avoidance studies was insufficient to draw meaningful conclusions. The applicability of the review is limited by the large number of studies examining cyclosporine-based strategies and low-risk populations. Additional research is needed with tacrolimus-based regimens and higher risk populations. Moreover, research is necessary to clarify the effect of induction and adjunctive agents in alternative immunosuppression strategies and should include more comprehensive and consistent reporting of patient-centered outcomes.

Why are kids with lupus at an increased risk of cardiovascular disease?

Juvenile-onset systemic lupus erythematosus (SLE) is an aggressive multisystem autoimmune disease. Despite improvements in outcomes for adult patients, children with SLE continue to have a lower life expectancy than adults with SLE, with more aggressive disease, a higher incidence of lupus nephritis and there is an emerging awareness of their increased risk of cardiovascular disease (CVD). In this review, we discuss the evidence for an increased risk of CVD in SLE, its pathogenesis, and the clinical approach to its management.

Changes in lipid and carbohydrate metabolism under mTOR- and calcineurin-based immunosuppressive regimen in adult patients after liver transplantation

BACKGROUND

Cardiovascular disease is a leading cause of long-term mortality after liver transplantation (LT). Life long immunosuppression harbors the risk of metabolic alterations. We aimed to analyze the impact of calcineurin (CNI)-only containing regimen (group A) compared to mTOR-containing regimen (group B) on lipid and carbohydrate metabolism.

PATIENTS/METHODS

92 adult patients after LT, University of Mainz (group A-78 patients, group B-14 patients; 65 M/27 F; mean age 59+/-10.2years; mean time from LT 5.8+/-5years). Clinical data, comorbidities, and medication were assessed. Fasting lipid profile including small dense LDLs (sdLDL) and oral glucose tolerance tests were performed.

RESULTS

Group B had significantly higher levels of total cholesterol (TC), LDL-cholesterol (LDL-C), triglycerides (TG) and sdLDL, with persistence of higher TC, TG, sdLDLs (mg/dl) after exclusion of patients under lipid lowering medication. Concentrations above the upper limits of normal were found: for LDL-C in 9% of group A/35.7% of group B (p=0.016); for TG: in 32.1% of group A/92.9% in group B (p=0.0001). A positive correlation between time since LT (years) and sdLDL (mg/dl) was found in group B (p=0.018). In patients without previously known diabetes, NODAT and impaired glucose tolerance developed in 27.9% of group A/44.4% of group B (n.s.).

CONCLUSION

Patients under mTOR-containing regimen are at higher risk to develop dyslipidemia with increased atherogenic sdLDLs compared to patients under CNI-only-containing regimen and display more frequently a dysglycemic status, with uncertain relevance for long-term cardiovascular risk. A careful monitoring after LT is needed to identify early metabolic risk and manage this appropriately.

Leptin, insulin resistance, and metabolic changes 5 years after renal transplantation

OBJECTIVE

To evaluate leptin, insulin resistance (IR), and changes in body composition and lipid profile within 5 years after renal transplantation.

DESIGN

Longitudinal study.

SETTING

Hospital de Clínicas de Porto Alegre/RS, Brazil.

SUBJECTS

Thirty-two renal transplant recipients were followed up for 5 years after transplantation.

METHODS

Data were collected at transplantation time (T₁) and after 3 months (T₂), 1 year (T₃), and 5 years (T₄). Leptin serum levels, IR assessed by homeostasis model assessment (HOMA) index, lipid profile, and anthropometric measurements were analyzed. Data were compared with a control group at baseline.

RESULTS

At T₁, pretransplant patients had leptin levels (ng/mL) (11.9 [9.2 to 25.2]) higher than the control group (7.7 [5.2 to 9.9]; P < .0001). After transplantation, levels decreased at T₂ and T₃, but increased at T₄ to values similar to those seen at T₁ (T₄: 9.2 [5.7 to 21]; P = 1). HOMA also decreased at T₂, but increased at T₄ to identical levels (T₁: 2.1 [1.63 to 2.23], T₄: 2.1 [1.6 to 2.85]; P = 1). No significant changes in body fat percentage (BF%) were observed; however, the arm muscle circumference increased significantly at T₄ (P < .0001). At T₂, total cholesterol, triglycerides, and low-density lipoprotein cholesterol increased, whereas at T₄, lipid profile moved toward T₁ levels. By linear regression analysis, gender, BF%, and HOMA were independent predictors of leptin levels. A trend toward higher body mass index was observed in woman who also presented higher leptin and lower HOMA levels.

CONCLUSION

Leptin levels and HOMA decrease in the immediate posttransplant period and remain reduced for at least 1 year. Five years post transplantation, leptin, IR, BF%, and lipids have a profile similar to those in the pretransplant period. This metabolic profile is possibly associated with the elevated incidence of cardiovascular diseases observed in the late posttransplant period.