Conversion from cyclosporine to tacrolimus in renal transplant recipients with gum hyperplasia

Connective Tissue Metabolism and Gingival Overgrowth

Gingival overgrowth occurs mainly as a result of certain anti-seizure, immunosuppressive, or antihypertensive drug therapies. Excess gingival tissues impede oral function and are disfiguring. Effective oral hygiene is compromised in the presence of gingival overgrowth, and it is now recognized that this may have negative implications for the systemic health of affected patients. Recent studies indicate that cytokine balances are abnormal in drug-induced forms of gingival overgrowth. Data supporting molecular and cellular characteristics that distinguish different forms of gingival overgrowth are summarized, and aspects of gingival fibroblast extracellular matrix metabolism that are unique to gingival tissues and cells are reviewed. Abnormal cytokine balances derived principally from lymphocytes and macrophages, and unique aspects of gingival extracellular matrix metabolism, are elements of a working model presented to facilitate our gaining a better understanding of mechanisms and of the tissue specificity of gingival overgrowth.

Drug-Induced Gingival Hyperplasia in Transplant Recipients

Gingival hyperplasia is a common occurrence in transplant recipients who are taking cyclosporine. This condition can be complicated when calcium channel blockers or phenytoin are added to the armamentarium of medications; it can be painful and may interfere with eating, speech, and appearance. Multiple mechanisms exist for gingival overgrowth. Prevention with appropriate oral hygiene appears important in controlling the inflammatory component and decreasing the severity of the overgrowth. Patients must be aware of the potential for the development of gingival hyperplasia and must follow up with regular professional cleanings. If the overgrowth persists, treatment options should be discussed between patients and their physician. Conversion from cyclosporine to tacrolimus, treatment with antibiotic therapy, and surgical excision or laser therapy are all potential therapies to consider.

Complete response to tacrolimus in a child with severe aplastic anemia resistant to cyclosporin A

Aplastic anemia (AA) is a rare disorder in children, usually treated with immunosuppressive therapy (IST) including antithymocyte globulin (ATG) and cyclosporin A. There are no current widely used alternative therapies with comparable efficacy. We describe a child with severe aplastic anemia (SAA), who developed severe gingival hyperplasia secondary to cyclosporin A, unresponsive to intensive dental intervention. When IST was changed to tacrolimus there was a significant improvement in the gingival hyperplasia, but equally important, he achieved complete response of his AA within several months. The use of tacrolimus in children with AA may be a potential modality of treatment.

Transforming growth factor-beta1 gene expression and cyclosporine A-induced gingival overgrowth: a pilot study

AIMS

The relationship between gingival overgrowth (GO) induced by cyclosporine A (CsA) and transforming growth factor-beta1 (TGF-beta1) remains unclear. The aims of the present study were to evaluate TGF-beta1 gene expression under different immunosuppressive treatments and its association with TGF-beta1 gene functional polymorphism and GO in renal transplant recipients.

MATERIAL AND METHODS

The study included 98 CsA-treated renal transplant recipients (with and without GO) and 44 tacrolimus-treated transplant patients (without GO). TGF-beta1 mRNA expression was measured using a real-time quantitative polymerase chain reaction assay. The levels were correlated with TGF-beta1 gene polymorphisms at codons 10 and 25, with different immunosuppressive treatment and GO.

RESULTS

The level of TGF-beta1 gene expression was insignificantly lower in the CsA-treated group compared with the tacrolimus group, and significantly lower in the group with GO compared with patients without GO. In tacrolimus- and CsA-treated patients, but not in patients with GO, the level of TGF-beta1 gene expression was associated with functional phenotypes of TGF-beta1. The incidence, degree and extent of GO were higher in recipients with lower TGF-beta1 gene expression.

CONCLUSIONS

Lower level TGF-beta1 gene expression, not functional polymorphism, in patients treated with CsA may be considered to be a risk factor for GO.

Maintenance immunosuppression regimens: conversion, minimization, withdrawal, and avoidance

A wide choice of drug combinations is available to clinicians for immunosuppression regimens for their kidney transplant patients. Although many protocols have minimized early graft loss, the optimal long-term regimen is unknown. Recent studies clearly showed that cardiovascular death is now the leading cause of graft loss. Strategies must be developed that address this risk while keeping immunologic events low. Transplant physicians have focused on exploring regimens that minimize or avoid the use of corticosteroids. Studies also have started to explore protocols that minimize calcineurin inhibitor therapy.

Current and evolving immunosuppressive regimens in kidney transplantation

The advent of novel immunosuppressive agents with increased potency now offers multiple treatment options for transplant physicians. However, variable efficacy, drug-drug interactions, and adverse effects associated with long-term immunosuppression continue to complicate the clinical management of kidney transplant recipients. Currently, investigators are challenged to develop regimens that take into account not only efficacy, but also dosing, monitoring, safety, and patient quality of life. Recent research has focused on evaluating new combinations of approved agents that seek to improve outcomes by improving control of immunologic events with fewer complications. This article reviews current practice and recent studies to give all health care providers who manage kidney transplant recipients a better understanding of current regimens and general trends in immunosuppressive therapy.

The Relationship of Transforming Growth Factor-β1 Gene Polymorphism, Its Plasma Level, and Gingival Overgrowth in Renal Transplant Recipients Receiving Different Immunosuppressive Regimens

BACKGROUND

Cyclosporin A (CsA) induces gingival overgrowth (GO) in patients who seem to be prone to this disorder. It is still impossible to determine which patients will develop GO. Patients treated with the new immunosuppressive drug tacrolimus seem not to have GO. The aims of this study were to investigate transforming growth factor-beta1 (TGF-beta1) gene polymorphisms in renal transplant recipients treated with CsA or tacrolimus and to establish an association between these polymorphisms and TGF-beta1 plasma concentration and the incidence of GO.

METHODS

The examined group consisted of 134 renal transplant recipients. Ninety-two underwent CsA treatment (50 with and 42 without GO), and 42 underwent tacrolimus treatment. Age, gender, time after transplantation, calcineurin inhibitor total dosage, number of teeth, and sulcus bleeding index were analyzed. TGF-beta1 plasma levels were estimated in 60 CsA- and 30 tacrolimus-treated patients. Two biallelic polymorphisms of the TGF-beta1 gene were studied at codon 10 (at position +869) and at codon 25 (at position +915) in patients from the examined group and in 108 healthy volunteers (the control group).

RESULTS

The distribution of the high, intermediate, and low TGF-beta1 producer phenotypes was comparable in all the studied groups and in the healthy controls. The high producer phenotype was more frequent in patients with GO. TGF-beta1 levels in the CsA group showed correlation with the phenotypes. The lowest incidence of GO was observed in the 10C/C genotype, whereas the highest was observed in the 10T/C genotype.

CONCLUSION

High and intermediate TGF-beta1 producer phenotypes and heterozygous genotype 10T/C might be considered risk factors for GO in patients treated with CsA.

Posttransplantation Quality of Life: More Than Graft Function

Whereas newer immunosuppressive therapies have increased patient and graft survival, long-term treatment with these drugs has been linked to medical and physical complications that may impact on posttransplantation quality of life. Immunosuppression-related physical side effects that can alter appearance--including hirsutism, gingival hyperplasia, weight gain, cushingoid facies, hand tremors, alopecia, and skin disorders--are among the most bothersome to patients and may have serious psychosocial implications. In addition, physical side effects may influence patient adherence to their prescribed treatment regimens and result in more serious complications, such as acute rejection, graft loss, rehospitalization, and even mortality. Therefore, strategies for minimizing side effects of immunosuppressive therapy and improving medication adherence are integral to better long-term transplant recipient management.

Diffuse gingival enlargement

Diffuse gingival enlargement is defined as an excessive growth of periodontal tissue. It can be considered a relatively common finding, as thousands of patients have been described in the literature. Patients may seek medical attention because of pain, tenderness, interference with speech and/or mastication, halitosis, or unsightly appearance, or gingival enlargement may be an unexpected finding on routine physical examination. Diffuse gingival enlargement has numerous causes, including poor dental hygiene, medications, serious systemic illnesses, genetic conditions, other specific physiologic states, or it may be idiopathic. Given the large number of possible underlying conditions, the work-up of a patient presenting with diffuse gingival enlargement may seem daunting. We present a systemic review of diffuse gingival enlargement, including an algorithm that can be used to direct the work-up of patients presenting with this condition.

Open prospective multicenter study of conversion to tacrolimus therapy in renal transplant patients experiencing ciclosporin-related side-effects

The hyperlipidemic and hypertensive effects of ciclosporin constitute a cardiovascular risk. Cosmetic side-effects are known to reduce patients' quality of life. This was a 6-month, open, prospective, multicentre study in 296 adult kidney transplant patients to evaluate the conversion from ciclosporin to a tacrolimus-based regimen. Primary indications for conversion were hyperlipidemia (n =77), hypertension (n = 72), hypertrichosis (n = 32) and gingival hyperplasia (n = 115). At month 6, hyperlipidemia and hypertension were at least moderately improved in 59.1% and 63.5% of patients, and strongly or completely resolved in 29% and 25%. Gingival hyperplasia and hypertrichosis were strongly or completely resolved in 73% and 72% of patients. Mean total cholesterol was reduced from 255 to 218 mg/dl. Mean systolic blood pressure (SBP) was reduced from 152.9 to 137.5 mmHg and mean diastolic blood pressure (DBP) from 90.7 to 85.8 mmHg. Ciclosporin-related side-effects resolved or improved after conversion to tacrolimus.

Conversion from Cyclosporin A to Tacrolimus as a Non-Surgical Alternative to Reduce Gingival Enlargement: A Preliminary Case Series

BACKGROUND

Gingival enlargement (GE) is a frequent side effect that occurs in organ transplant recipients (OTR) after the administration of cyclosporin A (CsA). The availability of new drugs used to suppress graft rejection in OTR offers an opportunity to manage GE non-surgically. This preliminary case series aimed to analyze the effect of CsA withdrawal and its substitution by another immunosuppressant in OTR with severe GE.

METHODS

Four organ transplant recipients who had received a liver or renal allograft were recruited for this study. All OTR had developed clinically severe CsA-induced GE. GE scores were assessed for each patient at baseline and at weeks 2, 4, 8, 12, 16, and 54 following conversion to tacrolimus. Scaling and root planing were initially performed and repeated monthly during the first 6 months. Careful polishing of the teeth was carried out once every 2 weeks until month 6 and then monthly until month 12. Hygiene instructions and reinforcement to optimize oral hygiene were maintained throughout the study.

RESULTS

The four patients showed a rapid decrease in their gingival symptoms and in the size of the gingivae. This change was clinically evident 8 weeks after conversion to tacrolimus. One year later, all the patients experienced GE regression, although some anatomic irregularities persisted in the interdental papillae of one of the patients. No adverse effects from tacrolimus were observed during the study except in one patient who presented headaches.

CONCLUSION

It seems that CsA withdrawal and its conversion to tacrolimus in organ transplant recipients who develop severe gingival enlargement, together with an extensive plaque control program, provide an effective means to control/eliminate gingival hyperplasia, with minimal risk of graft dysfunction.

Drug-induced gingival hyperplasia in transplant recipients

Gingival hyperplasia is a common occurrence in transplant recipients who are taking cyclosporine. This condition can be complicated when calcium channel blockers or phenytoin are added to the armamentarium of medications; it can be painful and may interfere with eating, speech, and appearance. Multiple mechanisms exist for gingival overgrowth. Prevention with appropriate oral hygiene appears important in controlling the inflammatory component and decreasing the severity of the overgrowth. Patients must be aware of the potential for the development of gingival hyperplasia and must follow up with regular professional cleanings. If the overgrowth persists, treatment options should be discussed between patients and their physician. Conversion from cyclosporine to tacrolimus, treatment with antibiotic therapy, and surgical excision or laser therapy are all potential therapies to consider.

Tacrolimus: a further update of its pharmacology and therapeutic use in the management of organ transplantation

Tacrolimus (FK-506) is an immunosuppressant agent that acts by a variety of different mechanisms which include inhibition of calcineurin. It is used as a therapeutic alternative to cyclosporin, and therefore represents a cornerstone of immunosuppressive therapy in organ transplant recipients. Tacrolimus is now well established for primary immunosuppression in liver and kidney transplantation, and experience with its use in other types of solid organ transplantation, including heart, lung, pancreas and intestinal, as well as its use for the prevention of graft-versus-host disease in allogeneic bone marrow transplantation (BMT), is rapidly accumulating. Large randomised nonblind multicentre studies conducted in the US and Europe in both liver and kidney transplantation showed similar patient and graft survival rates between treatment groups (although rates were numerically higher with tacrolimus- versus cyclosporin-based immunosuppression in adults with liver transplants), and a consistent statistically significant advantage for tacrolimus with respect to acute rejection rate. Chronic rejection rates were also significantly lower with tacrolimus in a large randomised liver transplantation trial, and a trend towards a lower rate of chronic rejection was noted with tacrolimus in a large multicentre renal transplantation study. In general, a similar trend in overall efficacy has been demonstrated in a number of additional clinical trials comparing tacrolimus- with cyclosporin-based immunosuppression in various types of transplantation. One notable exception is in BMT, where a large randomised trial showed significantly better 2-year patient survival with cyclosporin over tacrolimus, which was primarily attributed to patients with advanced haematological malignancies at the time of (matched sibling donor) BMT. These survival results in BMT require further elucidation. Tacrolimus has also demonstrated efficacy in various types of transplantation as rescue therapy in patients who experience persistent acute rejection (or significant adverse effect's) with cyclosporin-based therapy, whereas cyclosporin has not demonstrated a similar capacity to reverse refractory acute rejection. A corticosteroid-sparing effect has been demonstrated in several studies with tacrolimus, which may be a particularly useful consideration in children receiving transplants. The differences in the tolerability profiles of tacrolimus and cyclosporin may well be an influential factor in selecting the optimal treatment for patients undergoing organ transplantation. Although both drugs have a similar degree of nephrotoxicity, cyclosporin has a higher incidence of significant hypertension, hypercholesterolaemia, hirsutism and gingival hyperplasia, while tacrolimus has a higher incidence of diabetes mellitus, some types of neurotoxicity (e.g. tremor, paraesthesia), diarrhoea and alopecia.

CONCLUSION

Tacrolimus is an important therapeutic option for the optimal individualisation of immunosuppressive therapy in transplant recipients.