Drugs causing dyslipoproteinemia

2024 KSoLA consensus on secondary dyslipidemia

Elevated blood cholesterol and triglyceride levels induced by secondary causes are frequently observed. The identification and appropriate handling of these causes are essential for secondary dyslipidemia treatment. Major secondary causes of hypercholesterolemia and hypertriglyceridemia include an unhealthy diet, diseases and metabolic conditions affecting lipid levels, and therapeutic side effects. It is imperative to correct secondary causes prior to initiating conventional lipid-lowering therapy. Guideline-based lipid therapy can then be administered based on the subsequent lipid levels.

Secondary hypertriglyceridemia

Secondary hypertriglyceridemia (HTG) are the most common cause of excess triglyceride rich particles in plasma. Faced with HTG, the first thing to do is rule out if there is a secondary cause since it can interact with genetic susceptibility and further aggravate the HTG. The most common causes are diet with high fat and high glycemic index, obesity, diabetes mellitus, alcohol consumption, renal disease like nephrotic syndrome, hepatic disorders and medications. The most important medications that can influence in HTG are oestrogen, isotretinoin, immunosuppressant therapy, L-asparaginase and with less effect thiazides, beta blockers, atypical antipsychotics and glucocorticoids. Other causes less frequent are endocrinological diseases such as Cushing's syndrome, acromegaly, hypothyroidism; pregnancy, lipodystrophies and autoimmune diseases. Lastly, the identifications and treatment or correction of secondary causes is a corner stone in the treatment of this disease.

Secondary dyslipidemia: its treatments and association with atherosclerosis

Dyslipidemia is classified into primary and secondary types. Primary dyslipidemia is basically inherited and caused by single or multiple gene mutations that result in either overproduction or defective clearance of triglycerides and cholesterol. Secondary dyslipidemia is caused by unhealthy lifestyle factors and acquired medical conditions, including underlying diseases and applied drugs. Secondary dyslipidemia accounts for approximately 30-40% of all dyslipidemia. Secondary dyslipidemia should be treated by finding and addressing its causative diseases or drugs. For example, treatment of secondary dyslipidemia, such as hyperlipidemia due to hypothyroidism, by using statin without controlling hypothyroidism, may lead to myopathy and serious adverse events such as rhabdomyolysis. Differential diagnosis of secondary dyslipidemia is very important for safe and effective treatment. Here, we describe an overview about diseases and drugs that interfere with lipid metabolism leading to secondary dyslipidemia. Further, we show the association of each secondary dyslipidemia with atherosclerosis and the treatments for such dyslipidemia.

The prevalence of dyslipoproteinemia in Thai patients with systemic lupus erythematosus

Fasting blood samples taken from 93 pairs of outpatient systemic lupus erythematosus (SLE) women and matched controls were assessed for total cholesterol (TC), triglyceride (TG), high-density lipoprotein (HDL)- and low-density lipoprotein (LDL)-cholesterol. The demographic data, clinical manifestations, Mexican-SLE Disease Activity Index (MEX-SLEDAI), Systemic Lupus International Collaborating Clinics/American College of Rheumatology (SLICC/ACR) damage index and medication prescribed in the SLE patients were reviewed. A significant elevation of TG levels was observed in the SLE patients compared to controls (mean ±SD 113.3 ±59.5 versus 77.7 ±45.7 mg/dL, P < 0.001). The HDL-c level was also significantly lower in SLE patients than controls (mean ±SD 49.7 ±12.7 versus 65.0 ±14.8 mg/dL, P < 0.001). The percentage of samples with low HDL-c (<35 mg/dL) was higher in the SLE group (9.7%) than controls (0%; P = 0.002). The LDL-c and TC levels were comparable in both groups. The use of antimalarial drugs was negatively associated with TC (OR 0.22, 95%CI 0.08-0.61) and LDL-c levels (OR 0.27, 95%CI 0.09-0.80). The increased prevalence of dyslipoproteinemia in SLE patients in this report has confirmed the results of previous studies and emphasized the importance of controlling this modifiable cardiovascular risk factor by the combination of lifestyle modification and medical treatments.

Corticosteroids in Solid Organ Transplantation: Update and Review of the Literature

Corticosteroids have been a constant in immunosuppressive regimens since the beginning of solid organ transplantation. Although the use of corticosteroids allowed the advancement of transplantation in the early years, this came at the price of numerous adverse events for patients. As the survival of transplanted organs has risen over the past several years, increasing attention has been focused on the management of long-term complications. Many of these long-term complications are directly related to the toxicities of immunosuppressive agents. Due to these toxicities, we have seen a resurgence in immunosuppressive protocols that utilize regimens designed to minimize these long-term complications. This has been accomplished by avoiding, reducing or withdrawing one or more medications from the multi-drug regimens. Corticosteroids, with their plethora of side affects, have been of major interest to the transplant community in terms of minimizing side affects by limiting exposure.

Hypertriglyceridemia: a too long unfairly neglected major cardiovascular risk factor

The existence of an independent association between elevated triglyceride (TG) levels, cardiovascular (CV) risk and mortality has been largely controversial. The main difficulty in isolating the effect of hypertriglyceridemia on CV risk is the fact that elevated triglyceride levels are commonly associated with concomitant changes in high density lipoprotein (HDL), low density lipoprotein (LDL) and other lipoproteins. As a result of this problem and in disregard of the real biological role of TG, its significance as a plausible therapeutic target was unfoundedly underestimated for many years. However, taking epidemiological data together, both moderate and severe hypertriglyceridaemia are associated with a substantially increased long term total mortality and CV risk. Plasma TG levels partially reflect the concentration of the triglyceride-carrying lipoproteins (TRL): very low density lipoprotein (VLDL), chylomicrons and their remnants. Furthermore, hypertriglyceridemia commonly leads to reduction in HDL and increase in atherogenic small dense LDL levels. TG may also stimulate atherogenesis by mechanisms, such excessive free fatty acids (FFA) release, production of proinflammatory cytokines, fibrinogen, coagulation factors and impairment of fibrinolysis. Genetic studies strongly support hypertriglyceridemia and high concentrations of TRL as causal risk factors for CV disease. The most common forms of hypertriglyceridemia are related to overweight and sedentary life style, which in turn lead to insulin resistance, metabolic syndrome (MS) and type 2 diabetes mellitus (T2DM). Intensive lifestyle therapy is the main initial treatment of hypertriglyceridemia. Statins are a cornerstone of the modern lipids-modifying therapy. If the primary goal is to lower TG levels, fibrates (bezafibrate and fenofibrate for monotherapy, and in combination with statin; gemfibrozil only for monotherapy) could be the preferable drugs. Also ezetimibe has mild positive effects in lowering TG. Initial experience with en ezetimibe/fibrates combination seems promising. The recently released IMPROVE-IT Trial is the first to prove that adding a non-statin drug (ezetimibe) to a statin lowers the risk of future CV events. In conclusion, the classical clinical paradigm of lipids-modifying treatment should be changed and high TG should be recognized as an important target for therapy in their own right. Hypertriglyceridemia should be treated.

Hypertension following kidney transplantation

The majority of patients become hypertensive following kidney transplantation. Its occurrence is associated not only with increased fatal and nonfatal cardiovascular events but also with decreased allograft survival. This review summarizes the current knowledge of the epidemiology, etiology, pathophysiology, and management of post-transplant hypertension.

The impact of functioning pancreas-kidney transplantation and pancreas alone transplantation on the lipid metabolism of statin-naïve diabetic patients

OBJECTIVE

To compare the lipid profile (total cholesterol - TC, triglycerides - TG, high density lipoprotein cholesterol - HDL-c, low density lipoprotein cholesterol - LDL-c and non-HDL cholesterol - NHDL-c) of patients with functioning pancreas-kidney transplantation (PKT) or pancreas transplantation alone (PTA) after one (T1) and two yr (T2) following their pre-transplantation data (T0).

METHODS

Fifty-three type 1 diabetic patients underwent pancreas transplantation (42 PKT and 11 PTA) remaining euglycemic after transplantation were evaluated before and one and two yr after the procedures. They were using predominantly tacrolimus-mycophenolate mofetil-based immunosuppression and low glucocorticoid dose with systemic venous drainage of the pancreatic graft. None of them used hypolipidemic agents for economical reasons. Lipids were reported as means +/- standard error of the mean. Data obtained in T0 were compared with T1 and T2 using ANOVA followed by Student's t-test.

RESULTS

TC, LDL-c, NHDL-c and TG were lower in T1 and T2 when compared with T0 (p < 0.05) in PKT, while no change was observed for HDL-c (p > 0.05). PTA group showed no significant changes in lipids.

CONCLUSION

In spite of the known side effects of tacrolimus-based immunosuppression to lipids, our study with a statin-naïve sample showed improvements (PKT) or stabilization (PTA) in the serum lipid profile after pancreas transplantation.

Disturbed lipids, lipoproteins and triglyceride-rich lipoproteins as well as fasting and nonfasting non-high-density lipoprotein cholesterol in post-renal transplant patients

Serum levels of lipids and lipoproteins were determined in 98 post-renal transplant fasting patients, and lipids and non-high density lipoprotein-cholesterol (non-HDL-C) and lipid ratios in the same post-renal transplant non-fasting patients were compared. The reference group was 87 healthy subjects. All patients were divided into two groups: patients with dyslipidemia (n = 69) and patients with normolipidemic (n = 29). The post-renal transplant patients (TX) with dyslipidemia had a significantly increased concentration of triglyceride (TG), low-density lipoprotein-cholesterol (LDL-C), non-HDL-C, apoB, and TRL and lipid ratios, and decreased HDL-C level and lipoprotein ratios. The lipids, lipoproteins, and lipoprotein ratios were significantly beneficial in TX patients with normolipidemic than in those with dyslipidemia. However, TRL concentration and lipid ratios were significantly increased and apoAI/apoCIII significantly decreased as compared to the reference group. The TX patients with dyslipidemia showed a significant correlation between TG and apoB:CIII (r = 0.562, p < 0.001) and apoCIII (r = 0.380, p < 0.004), but those with normolipidemic showed a significant correlation only between TG and apoCIII (r = 0.564, p < 0.008). Regression and Bland-Altman analyses showed excellent correlation between fasting and nonfasting non-HDL-C levels (r = 0.987, R(2) + 0.987) in TX patients both with dyslipidemia and normolipidemic. We think the finding that nonfasting labs that are reliable for non-HDL-C as well as total cholesterol is important, as fasting labs are not always available. Disturbances of lipids, lipoproteins, and TRLs depend not only on the kind of treatment, but due to multiple factors can accelerate cardiovascular complications in post-renal transplant patients with dyslipidemia and also with normolipidemic. Further studies concerning this problem should be completed.

Comparison of sirolimus and everolimus in their effects on blood lipid profiles and haematological parameters in heart transplant recipients

The mTOR (mammalian target of rapamycin) inhibitors sirolimus (SRL) and everolimus (EVL) are potent immunosuppressive agents, which allow reducing the dose of the nephrotoxic calcineurin inhibitors cyclosporin and tacrolimus (TAC) in solid organ transplant recipients. However, there is evidence that mTOR inhibitors may lead to myelosuppression and dyslipidemia/hyperlipidemia. We therefore performed a retrospective analysis in heart transplant recipients with renal insufficiency, who received 3.0 mg/d SRL (SRL group; n = 28) or 1.5 mg/d EVL (EVL group; n = 27) each in combination with a reduced TAC dose for at least one yr. Fewer cardiac rejections, but a similar rate of infections occurred in the EVL group compared with the SRL group indicating that the administered EVL dose resulted in a potent immunosuppression. Serum triglyceride and total cholesterol concentrations rose significantly in the SRL group but not in the EVL group. In the SRL group only, the frequency of statin use increased significantly during follow-up. The EVL group showed a significant rise in HDL cholesterol levels during follow-up. There was a slight transient fall in haemoglobin concentrations in the SRL group but not in the EVL group. Leucocyte counts fell significantly in both study groups. However, no cases of leucopenia and also no cases of thrombopenia occurred. In summary, we could demonstrate that in heart transplant recipients with renal insufficiency the introduction of 1.5 mg/d EVL in combination with a reduced TAC dose is effective in preventing cardiac rejections and has less adverse effects on lipid metabolism than the usually prescribed SRL dose, whereas both therapy regimens are not associated with major haematological side-effects.

The effect of montelukast and low-dose theophylline on cardiovascular disease risk factors in asthmatics

BACKGROUND

Recent studies have implicated the 5-lipoxygenase/leukotriene (LT) pathway in cardiovascular disease (CVD), which may have important implications for asthmatics because several drugs that target this pathway are currently used to treat asthma. We sought to determine whether montelukast, a cysteinyl LT antagonist, and low-dose theophylline affected serum inflammatory and lipid CVD risk factors in a recently completed clinical trial in asthmatic patients.

METHODS

Patients were randomized to receive either montelukast (10 mg/d), theophylline (300 mg/d), or placebo. A baseline run-in period of 7 to 14 days was followed by treatment for 6 months. Serum levels of C-reactive protein (CRP), interleukin-6, total cholesterol, triglycerides, low-density lipoprotein cholesterol, and high-density cholesterol (HDL-C) were measured 1 month and 6 months after treatment.

RESULTS

Patients with moderate-to-severe asthma receiving montelukast (n = 60) had significantly lower serum CRP compared to placebo (n = 73) after 1 month (1.7 mg/L vs 3.2 mg/L, respectively; p < 0.006) and 6 months of treatment (2.3 mg/L vs 3.5 mg/L, respectively; p < 0.04). At both time points, serum levels of all lipids were also significantly lower in the montelukast and theophylline groups compared to placebo, but these effects were primarily observed in individuals who were also receiving inhaled corticosteroids as monotherapy for asthma.

CONCLUSIONS

Asthmatic patients receiving montelukast and, to some extent, low-dose theophylline have lower levels of CVD-associated inflammatory biomarkers and lipid levels. These observations suggest these asthma medications may have some beneficial value in asthmatics with respect to CVD risk, although the effects on HDL-C levels should also be taken into consideration.

Familial dyslipidaemias: an overview of genetics, pathophysiology and management

Plasma lipid disorders can occur either as a primary event or secondary to an underlying disease or use of medications. Familial dyslipidaemias are traditionally classified according to the electrophoretic profile of lipoproteins. In more recent texts, this phenotypic classification has been replaced with an aetiological classification. Familial dyslipidaemias are generally grouped into disorders leading to hypercholesterolaemia, hypertriglyceridaemia, a combination of hyper-cholesterolaemia and hypertriglyceridaemia, or abnormal high-density lipoprotein-cholesterol (HDL-C) levels. The management of these disorders requires an understanding of plasma lipid and lipoprotein metabolism. Lipid transport and metabolism involves three general pathways: (i) the exogenous pathway, whereby chylomicrons are synthesised by the small intestine, and dietary triglycerides (TGs) and cholesterol are transported to various cells of the body; (ii) the endogenous pathway, whereby very low-density lipoprotein-cholesterol (VLDL-C) and TGs are synthesised by the liver for transport to various tissues; and (iii) the reverse cholesterol transport, whereby HDL cholesteryl ester is exchanged for TGs in low-density lipoptrotein (LDL) and VLDL particles through cholesteryl ester transfer protein in a series of steps to remove cholesterol from the peripheral tissues for delivery to the liver and steroidogenic organs. The plasma lipid profile can provide a framework to guide the selection of appropriate diet and drug treatment. Many patients with hyperlipoproteinaemia can be treated effectively with diet. However, dietary regimens are often insufficient to bring lipoprotein levels to within acceptable limits. In this article, we review lipid transport and metabolism, discuss the more common lipid disorders and suggest some management guidelines. The choice of a particular agent depends on the baseline lipid profile achieved after 6-12 weeks of intense lifestyle changes and possible use of dietry supplements such as stanols and plant sterols. If the predominant lipid abnormality is hypertriglyceridaemia, omega-3 fatty acids, a fibric acid derivative (fibrate) or nicotinic acid would be considered as the first choice of therapy. In subsequent follow-up, when LDL-C is >130 mg/dL (3.36 mmol/L) then an HMG-CoA reductase inhibitor (statin) should be added as a combination therapy. If the serum TG levels are <500 mg/dL (2.26 mmol/L) and the LDL-C values are over 130 mg/dL (3.36 mmol/L) then a statin would be the first drug of choice. The statin dose can be titrated up to achieve the therapeutic goal or, alternatively, ezetimibe can be added. A bile acid binding agent is an option if the serum TG levels do not exceed 200 mg/dL (5.65 mmol/L), otherwise a fibrate or nicotinic acid should be considered. The decision to treat a particular person has to be individualised.

A long-term study of dyslipidemia and dyslipoproteinemia in stable post-renal transplant patients

BACKGROUND

Dyslipidemia is a major risk factor for atherosclerotic disease in renal transplant patients.

METHODS

The serum levels of lipids and lipoproteins were determined in the same 12 post-renal transplant patients (TX) 10-29 and 73-122 months after transplantation. Thirteen healthy subjects--i.e., without diabetes, endocrine disease, liver disease, active inflammatory disease, glucose intolerance, malignancy, obesity, and urinary protein--were used as a reference group. TX patients had stable renal function. Twelve patients received cyclosporine A and prednisone, six received lovastatin, and one received rapa and prednisone. Lipids and lipoprotein (apo)AI and B were determined using Roche kits. An anti-apoB antibody was used to separate apoB-containing apoCIII and apoE lipoproteins as triglyceride-rich lipoproteins (TRLs) in the non-HDL fraction from apoCIIInonB and apoEnonB in the HDL fraction.

RESULTS

In both groups of post-renal transplant patients, a statistically significant increase of TG, TC, and non-HDL-C levels was observed. Moreover, statistically significant changes were shown in total apoCIII and apoCIIInonB, as well as in TG/HDL-C and apoAI/apoCIII ratios, as compared to the reference group. On the other hand, in TX patients 73-122 months after transplantation, significantly higher concentrations of TC, LDL-C, and especially non-HDL-C were observed. It was shown that apoCIII, apoCIIInonB, apoB:CIII, and lipid and lipoprotein ratios as risk factors of atherosclerosis and renal risk factors were higher in these patients 73-122 months after transplantation.

CONCLUSION

TX patients in a long-term study showed that they had disturbed lipoprotein composition, and its consequence was hyperlipidemia, perhaps partly due to the increased use of immunosuppressants and steroids.

Hypertension in Kidney Transplantation

Arterial hypertension in renal transplant patients plays a major role in the progression to chronic allograft failure, and in morbidity and mortality associated with cardiovascular disease. Its cause is diverse, with contributions not only from donor and/or recipient factors, but it also is influenced strongly by the type of immunosuppressive regimen. Despite increased awareness of the adverse effects of hypertension in both graft and patient survival, long-term studies have shown that arterial hypertension in the transplant population has not been controlled adequately. Ambulatory blood pressure measurements provide the advantage of a better assessment of the diurnal blood pressure variation, a predictor of target organ damage and cardiovascular morbidity and mortality events. Although the available data do not support the recommendation of any class of antihypertensive medication as preferred agents for blood pressure management in the transplant population, angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers have shown beneficial effects beyond their antihypertensive effects. Clinical data in transplant recipients are emerging that suggest that applying interventions proven to be effective in reducing cardiovascular morbidity and mortality in the general population may be effective for the transplant population.

Features of the Metabolic Syndrome of “Hypertriglyceridemic Waist” and Transplant Coronary Artery Disease

BACKGROUND

This study evaluated the prevalence of the atherogenic metabolic triad and the hypothesis that waist circumference and fasting triglyceride concentrations could be used as screening tools for identification of the atherogenic metabolic triad in a population of heart transplant men. It also evaluated the relationship between the atherogenic metabolic triad and coronary artery disease (CAD).

METHODS

In the study group of 83 consecutive male heart transplant patients having their routine annual coronarography, 23 patients (28%) were characterized by the atherogenic metabolic triad defined by the presence of elevated fasting insulin and apolipoprotein B concentrations and by small low-density lipoprotein (LDL) particles.

RESULTS

Seventy-seven per cent of patients with waist circumference values >/= 90 cm and with elevated triglyceride levels (>/=2.0 mmol/liter) were characterized by this atherogenic metabolic triad. Patients with the atherogenic metabolic triad were at markedly increased risk of CAD (odds ratio of 25.3, 95% CI: 1.11-577.3, p < 0.04) compared to heart transplant patients without the atherogenic metabolic triad.

CONCLUSIONS

About 30% of heart transplant patients showed the features of the atherogenic metabolic triad. Measurement and interpretation of waist circumference and fasting triglycerides could be used among heart transplant patients to early identify men characterized by the presence of elevated fasting insulin and apolipoprotein B concentrations and small LDL particles. The presence of the atherogenic metabolic triad identified patients at high risk of CAD even in the heart transplant population.

Effect of different immunosuppressive therapies on the lipid pattern in kidney-transplanted rats

We analyzed the effect of oral administration of cyclosporine-methylprednisone (CsA-MP) and sirolimus (SRL) on the lipid pattern of kidney-transplanted rats after a 7-day survival. A significant increase in plasma cholesterol in CsA-MP group (control: 26 +/- 3 mg/dl vs. 59 +/- 8 mg/dl, P < 0.05) and in triglyceride levels in SRL group (control: 53 +/- 4 mg/dl vs. 114 +/- 3 mg/dl, P < 0.05), was shown. Kidney microsomal membranes from both treated groups showed that cholesterol and triglyceride values and the relative percentage of arachidonic acid in the total amount of n-6 fatty acids decreased. A diminution of linoleic acid occurred in testis (control: 9.4 +/- 0.1 mg/dl vs. CsA-MP: 6.0 +/- 0.3 mg/dl and vs. SRL: 6.8 +/- 0.2 mg/dl, P < 0.05), liver (control: 17.7 +/- 0.6 mg/dl vs. CsA-MP: 15.1 +/- 0.6 mg/dl and SRL: 13.5 +/- 0.8 mg/dl, P < 0.05) and erythrocyte membranes (control:11.7 +/- 0.1% vs. CsA-MP: 10.6 +/- 0.2% and SRL: 10.0 +/- 0.4%, P < 0.01). The immunosuppressive therapies improved the rejection rate of the graft, fact that was remarkable in the SRL-treated group. However, lipid abnormalities still remain in spite of immunosuppressive therapies (150).

A DECADE OF PROGRESS IN KIDNEY TRANSPLANTATION

Kidney transplantation has become the treatment of choice for patients with end-stage renal disease because of better surgical techniques and the availability of more powerful immunosuppressive drugs. Regimens of immunosuppression should combine both short-term outcomes and predictors of long-term safety and survival. The value of tacrolimus for immunosuppression protocols lies in its ability to reduce the immunologic risk to the allograft and its excellent safety profile. Outcomes for kidney-transplant recipients can be further optimized by individualizing therapy to address each patient's risk profile.

A comparison of the effectiveness of soy protein isolate and fish oil for reducing the severity of retinoid-induced hypertriglyceridemia

The effectiveness of soy protein isolate (SPI) to reduce the severity of retinoid-induced hypertriglyceridemia has been demonstrated in the rat, but not in human subjects. Because fish oil has been demonstrated to be effective at lowering serum triglyceride concentration in human subjects undergoing retinoid therapy, a study was conducted to compare the ability of SPI with that of fish oil to reduce the severity of retinoid-induced hypertriglyceridemia in the rat. Male Fischer 344 rats, n=8/group, were fed one of four isonitrogenous, isoenergetic diets, consisting of a control diet containing 24% casein +20% corn oil (C), and three 13-cis retinoic acid (13cRA)-supplemented diets containing 24% casein +20% corn oil (R), 24% SPI +20% corn oil (SR), and 24% casein +15% fish oil and 5% corn oil (FR). There was no effect of diet on food intake or final body weight. Serum triglyceride concentration for group R was higher (P<0.001) than for groups C, SR, and FR (7.20 vs. 2.50, 2.84, and 2.02 mmol/L, respectively); values for groups SR and FR did not differ for this parameter. The serum concentration of 13cRA for group R did not differ from that for groups SR and FR. Thus, SPI was as effective as fish oil in reducing the severity of retinoid-induced hypertriglyceridemia in an animal model, suggesting that it may be effective for this purpose in human subjects.

The importance of clinical factors in parenteral nutrition-associated hypertriglyceridemia

AIMS

The purpose of this study was to establish the relevance of several clinical factors associated with parenteral nutrition (PN) hypertriglyceridemia and to construct a predictive model for this complication.

METHOD

This multicenter study included all patients with initial serum triglyceridemia <3 mmol and receiving a minimum of 7 days' PN therapy. The study ended for each patient when hypertriglyceridemia developed or PN was terminated. Two multivariate models were constructed, one to study the clinical factors and the second to predict plasma triglyceridemia. A total of 22 clinical factors studied as independent variables were included in the multiple-step regression models only when they showed a P-value over 0.1. Statistical significance was determined by the confidence interval of the odds ratio (OR) and the partial regression coefficient (b).

RESULTS

The study included 260 patients from 14 hospitals. Lipid administration was 0.83+/-0.37 g/kg/day. Among the total, 68 patients (26.2%) showed hypertriglyceridemia. Variables included in both models were serum glucose (OR, 2.63; b, 0.06), renal failure (OR, 10.56; b, 1.70), corticoid administration >0.5 mg/kg (OR, 7.98; b, 0.97), pancreatitis (OR, 4.38; b, 0.64), sepsis (OR, 4.48; b, 0.24), lipids infused (OR, 3.03; b, 0.24) and heparin administration >3 mg/kg/day (OR, 0.11; b, -1.21).

CONCLUSION

Although the rate of lipid infusion was low, certain clinical factors modified triglyceridemia. Nevertheless, relatively fast plasma clearance of lipids infused indicates that a reduction in lipid supply could be a quick, effective measure for controlling hypertriglyceridemia. Thus, careful monitoring of patients with clinical factors predicting risk in the model studied, with adjustment of lipid perfusion rates accordingly, is suggested to avoid hypertriglyceridemia.

Calcineurin inhibitors and post-transplant hyperlipidaemias

Cardiovascular disease is now the leading cause of death in transplant recipients. This is due, in part, to the vulnerability of these patients to a complicated set of conditions including hypertension, diabetes mellitus, and post-transplant hyperlipidaemia (PTHL). PTHL is characterised by persistent elevations in total serum cholesterol, low density lipoprotein cholesterol and triglyceride levels. The causes of PTHL are complex and not fully understood, however several classes of immunosuppressants including the corticosteroids, rapamycins and calcineurin inhibitors, appear to play a role. PTHL has been observed in most studies in which patients received calcineurin inhibitor-based regimens, and has been observed with both tacrolimus and cyclosporin. Comparing these calcineurin inhibitors with regard to the relative incidence or severity of PTHL occurring during treatment is difficult because of the use of higher doses of corticosteroids in cyclosporin-based regimens, as compared with tacrolimus-based regimens. However, current expert opinion suggests that the discrepancies in the relative incidence and severity of PTHL are largely accounted for by this difference in corticosteroid dose. At this point in time, evidence for potential differences is scant and inconclusive. Further study is needed, not only to investigate differences in lipid profile, but also of the relative effects of these immunosuppressants on long term graft function as well as on cardiovascular morbidity and mortality. PTHL can be successfully managed with a combination of dietary management, reduction and, if appropriate, withdrawal of corticosteroids, and the administration of lipid-lowering drugs. With this combination of therapeutic options, the threats to long term health posed by PTHL may be effectively addressed.

Routine renin-angiotensin system blockade in renal transplantation?

There is ample evidence to support the recommendation of renin-angiotensin system blockade therapy as the standard of care for strategies aimed at preserving renal function in chronic renal disease. Nevertheless, despite the well established antihypertensive effects of these drugs, the use of renin-angiotensin system blockers in renal transplantation has been quite limited so far, nephrologists being afraid of the possibility of inducing renal insufficiency in patients with a single kidney transplant. However, current knowledge of the ability of these agents to control blood pressure and urinary protein excretion, as well as post-transplant erythrocytosis, effectively in kidney transplant recipients suggests that it is now time to apply renin-angiotensin system blockers to the field of renal transplantation.

Risk factors for and management of post-transplantation cardiovascular disease

The mortality rates due to cardiovascular disease (CVD) in transplant recipients are greater than in the general population. CVD is a major cause of both graft loss and patient death in renal transplant recipients, and improving cardiovascular health in transplant recipients will presumably help to extend both patient and graft survival. Further studies are needed to better evaluate the effectiveness of risk modification on subsequent CVD morbidity and mortality. There is no reason to consider risk factors for CVD such as hyperlipidaemia, hypertension and diabetes mellitus in transplant recipients differently from in the general population. In addition, there are specific transplantation risk factors such as acute rejection episodes and the use of immunosuppressive drugs. It is obvious that several of the immunosuppressive agents used today have disadvantageous influences on risk factors for CVD such as hyperlipidaemia, hypertension and post-transplantation diabetes mellitus (PTDM), but the relative importance of immunosuppressant-induced increases in these risk factors is basically unknown. This may be a strong argument for the selective use and individual tailoring of immunosuppressive agents based upon the risk factor profile of the patient, without jeopardising the function of the graft. Hyperlipidaemia is common after transplantation, and immunosuppression with corticosteroids, cyclosporin, or sirolimus (rapamycin) causes different types of post-transplantation hyperlipidaemia. However, to date, no studies have demonstrated that lipid lowering strategies significantly reduce CVD morbidity or mortality and improve allograft survival in transplant recipients. Several studies using preventive or interventional approaches are ongoing and will be reported in the near future. Post-transplantation hypertension appears to be a major risk factor determining graft and patient survival, and immunosuppressive agents have different effects on hypertension. Controlled studies support the opinion that post-transplantation hypertension must be treated as strictly as in a population with essential hypertension, diabetes mellitus, or chronic renal failure. As increasing numbers of immunosuppressive agents become available for use, we may be in a better position to tailor immunosuppressive therapy to the individual patient, avoiding the use of diabetogenic drugs, drug combinations, or inappropriate doses in patients susceptible to PTDM. Multiple acute rejection episodes have also been demonstrated to be a risk factor for CVD - a strong argument for the use of immunosuppressive drugs to reduce acute rejection. Until we have a better understanding from ongoing landmark studies on the management of CVD, presently available therapy to reduce risk factors needs to be used together with individual tailoring of immunosuppressive therapy with the aim of reducing CVD in these patients.

Short-term effects of statin therapy in patients with hyperlipoproteinemia after liver transplantation: results of a randomized cross-over trial

BACKGROUND/AIMS

Hyperlipoproteinemia is frequent following liver transplantation and may lead to atherosclerosis. Lipid-lowering agents may be useful, but could interfere with the function of the transplanted organ and with immunosuppression. We therefore evaluated in a prospective, randomized, open-labeled cross-over trial the effect of two frequently used 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (pravastatin 10 mg d(-1) and cerivastatin 0.1 mg d(-1)) in hyperlipoproteinemic patients after liver transplantation.

METHODS

Sixteen patients (6.3 +/- 2.0 years post-transplantation, cyclosporine n = 11, tacrolimus n = 5) with hyperlipoproteinemia (cholesterol 246 +/- 42, triglycerides 191 +/- 87, low-density lipoprotein (LDL)-cholesterol 161 +/- 35, high-density lipoprotein (HDL)-cholesterol 44 +/- 11 mg d(-1)) were included. Treatment periods of 6 weeks were separated by a 4-week washout period.

RESULTS

Both medications were tolerated well, no effects on serum concentrations of liver enzymes or immunosuppressive agents were observed. Cerivastatin and pravastatin decreased (P < 0.001) cholesterol by 21 +/- 10% and 15 +/- 10%, LDL-cholesterol by 27 +/- 14% and 17 +/- 15%, respectively, while triglyceride and HDL-cholesterol concentrations did not change significantly. LDL/HDL-cholesterol markedly improved (P < 0.001) by 29 +/- 16% (cerivastatin) and 16 +/- 16% (pravastatin). Cerivastatin was more potent than pravastatin in patients receiving cyclosporine A, while there was no significant difference in patients receiving tacrolimus.

CONCLUSIONS

Low-dose cerivastatin and pravastatin significantly improve lipid profiles following liver transplantation without affecting liver function or immunosuppression.

Nutritional and medical therapy for dyslipidemia in patients with cardiovascular disease

Dyslipidemia is a significant risk factor for the progression of cardiovascular disease, particularly when associated with other risk factors. An understanding of the pathophysiology and risks for patients with atherosclerotic diseases of undertreated dyslipidemia is essential for the healthcare provider. In this article, a review of epidemiologic data regarding the role of lipid levels in cardiovascular disease prognosis is presented. A familiarity with current dietary and drug treatment of lipid disorders is at the core of an evidence-based approach to dyslipidemia management in the patient with established cardiovascular diseases.

Update on systemic glucocorticosteroids in dermatology

Although dermatology now has the most extensive group of systemic medications available for the treatment of skin diseases at any time, GCSs remain the most important agents for managing inflammatory disorders. It is important that the dermatologist have a broad knowledge of guidelines for clinical use, pharmacology, and adverse effects of these drugs. Acute and chronic side reactions should be well recognized. An understanding of the HPA axis and reasons for administering GCSs in different ways is of great value. A good medical history should be taken on any patient treated with GCSs, including knowledge of conditions that would make GCSs inadvisable and other concomitant systemic medications that might produce drug interactions. During the course of therapy, physical examination should include all systems pertinent to side effects caused by these agents, including frequent evaluations of weight and blood pressure. Blood chemistries should be performed on a regular basis, including glucose, electrolytes, and serum lipids. Osteoporosis is one of the most significant adverse affects to be evaluated, with bone mineral density studies recommended on an annual basis for persons continuing on GCS therapy. If hip or other joint pain develops, MR imaging is the most specific and sensitive radiologic examination for evaluating the possibility of osteonecrosis. An ophthalmology examination should be performed every 6 to 12 months to detect early cataract or glaucoma development. Any early signs of infection should be evaluated by appropriate smears, wet preparations, and cultures. Many other studies, including gastrointestinal and pulmonary examinations, may be dictated by specific acute situations. It is important to begin early prevention of the bone loss that occurs with GCS-induced osteoporosis. The 1996 guidelines of the American College of Rheumatology, including adequate calcium and vitamin D intake, should be followed. Hormonal replacement, a bisphosphonate, calcitonin, or a thiazide diuretic may be indicated. Restriction of sodium in the diet is important, as well as adequate potassium intake. The diet should be low in saturated fat and calories and should be high in vegetable protein. Because osteoporosis is so prevalent with GCSs, keeping the patient as active as possible with mild-to-moderate exercise is important. Whenever possible, exposure to persons with infectious processes should be avoided, and proper treatment should be instituted at the initial signs of systemic or cutaneous infection. Oral doses of GCSs are best taken with food to prevent gastrointestinal irritation, and agents for gastric acidity occasionally may be indicated. Significant trauma should be prevented, as should severe exposure to the sun. Many situations may call for consultation with other medical or surgical subspecialists. The patient must be aware of the importance of regular physician evaluations and reporting of any adverse effects while on long-term GCSs. A good relationship and understanding between the patient and physician are vital in minimizing potential problems from these agents. If the dermatologist maintains the proper guidelines of care, patients on GCSs have the highest benefits and lowest risks possible.

Management of hypercholesterolemia

Benefit from the treatment of hyperlipidemia has now been conclusively documented, and this article has focused on the clinical trial data supporting diet and drug therapy in adult patients with different lipoprotein disorders and discussed therapeutic approaches with a focus on reducing plasma concentrations of LDL cholesterol. National guidelines for the use of hypolipidemic drugs are strongly supported by the clinical trials and have appropriately set lower target concentrations of LDL cholesterol for patients with established atherosclerosis or diabetic patients as compared with patients with more than two cardiovascular risk factors or, the lowest risk group, patients without evidence of atherosclerosis and fewer than two known cardiovascular risk factors. The goals of therapy in patients with established atherosclerosis are to prevent further progression and potentially induce regression, whereas in high-risk patients (e.g., those with heterozygous familial hypercholesterolemia) without evidence of atherosclerosis, the aims of therapy are to reduce LDL cholesterol to a concentration at which subclinical atherosclerosis and xanthomas regress and the patient does not develop premature cardiovascular disease. Evidence-based medicine strongly supports clinical benefit from the treatment of hypercholesterolemia in men and women with and without known coronary artery disease, and the main goal should be ensure that patients who could benefit from lipid-lowering therapy are effectively treated and followed to ensure long-term compliance, efficacy, and safety.