Organ transplantation in the twenty-first century

Teratogen update: azathioprine and 6-mercaptopurine

BACKGROUND

Cyclosporine (CsA) therapy must often be continued during pregnancy to maintain maternal health in such conditions as organ transplantation and autoimmune disease. This meta-analysis was performed to determine whether CsA exposure during pregnancy is associated with an increased risk of congenital malformations, preterm delivery, or low birthweight.

METHODS

Various health science databases were searched to identify relevant articles. Articles selected for inclusion in the study were required to be free of any apparent selection bias and report outcomes in at least 10 newborns exposed to CsA in utero, specifically commenting on the presence or absence of congenital malformations. Article selection and data extraction were performed by two independent reviewers, with adjudication in cases of disagreement. To assess risks of CsA exposure, a summary odds ratio was calculated. Prevalence of malformations was calculated as a rate for all cyclosporine-exposed live births and for the subgroups identified. Ninety-five percent confidence intervals were constructed for both the odds ratio and prevalence rates.

RESULTS

Fifteen studies (6 with control groups of transplant without use of cyclosporine; total patients: 410) met the inclusion criteria for major malformations, 10 for preterm delivery (4 with control groups; total patients: 379) and 5 for low birth weight (1 with control groups; total number of patients: 314). The calculated odds ratio of 3.83 for malformations did not achieve statistical significance (CI 0.75-19.6). The overall prevalence of major malformations in the study population (4.1%) also did not vary substantially from that reported in the general population. OR for prematurity [1.52 (CI 1.00-2.32)] did not reach statistical significance although the overall prevalence rate was 56.3%. The OR for low birth weight [1.5 (CI 0.95-2.44 based on 1 study)].

CONCLUSIONS

CsA does not appear to be a major human teratogen. It may be associated with increased rates of prematurity. More research is needed to evaluate whether cyclosporine increases teratogenic risk.

Impact of changing societal trends on the spread of infections in American and Canadian homes

Infectious diseases continue to exert a heavy toll on human health even in industrialized countries. Recent data from the World Health Organization suggests that infectious diseases are the leading cause of death in the world. Many changing trends in our society have a known or potential impact on infectious disease spread and may have an impact on the normal routine of home hygiene. Important amongst these societal trends are increasing population and life expectancy, changes in urbanization, grouping of susceptibles, increased ambulatory and home care, increased immunosuppression, increased and faster travel, changes in technology, increasing antibiotic resistance as a result of misuse of antibiotics, changes in food and water consumption, and changes in personal cleaning, washing, and laundry practices. This review will highlight these factors and their impact on home hygiene and steps that may be needed to reduce the risk from infections.

Oscillopsia and pseudonystagmus in kidney transplant patients

PURPOSE

Modern immunosuppressants have improved the success of kidney transplantation for renal failure patients. They also may induce neurotoxic effects including tremor. We report two cases of pseudonystagmus and oscillopsia in transplant patients caused by immunosuppressant-induced head tremor and gentamicin-induced vestibulotoxicity.

METHODS

Case reports. Head tremor, static visual acuity, and dynamic visual acuity were measured. Vestibular function was evaluated with ice water calorics.

RESULTS

Both patients had significant head tremor and pseudonystagmus. Head stabilization improved static visual acuity. Dynamic visual acuity revealed a 4-line and 10-line loss of visual acuity, respectively.

CONCLUSIONS

These findings of pseudonystagmus and oscillopsia are likely to become more prevalent as more renal failure patients receive transplants. Improvement may be seen with reduction of immunosuppressant, reduction of stimulant intake, use of medications to reduce head tremor, and vestibular rehabilitation.