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Rostaing L, Jouve T, Terrec F, Malvezzi P, Noble J. Adverse Drug Events after Kidney Transplantation. J Pers Med 2023; 13:1706. [PMID: 38138933 PMCID: PMC10744736 DOI: 10.3390/jpm13121706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 12/04/2023] [Accepted: 12/09/2023] [Indexed: 12/24/2023] Open
Abstract
Introduction: Kidney transplantation stands out as the optimal treatment for patients with end-stage kidney disease, provided they meet specific criteria for a secure outcome. With the exception of identical twin donor-recipient pairs, lifelong immunosuppression becomes imperative. Unfortunately, immunosuppressant drugs, particularly calcineurin inhibitors like tacrolimus, bring about adverse effects, including nephrotoxicity, diabetes mellitus, hypertension, infections, malignancy, leukopenia, anemia, thrombocytopenia, mouth ulcers, dyslipidemia, and wound complications. Since achieving tolerance is not feasible, patients are compelled to adhere to lifelong immunosuppressive therapies, often involving calcineurin inhibitors, alongside mycophenolic acid or mTOR inhibitors, with or without steroids. Area covered: Notably, these drugs, especially calcineurin inhibitors, possess narrow therapeutic windows, resulting in numerous drug-related side effects. This review focuses on the prevalent immunosuppressive drug-related side effects encountered in kidney transplant recipients, namely nephrotoxicity, post-transplant diabetes mellitus, leukopenia, anemia, dyslipidemia, mouth ulcers, hypertension, and viral reactivations (cytomegalovirus and BK virus). Additionally, other post-kidney-transplantation drugs such as valganciclovir may also contribute to adverse events such as leukopenia. For each side effect, we propose preventive measures and outline appropriate treatment strategies.
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Affiliation(s)
- Lionel Rostaing
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38043 Grenoble, France; (T.J.); (F.T.); (P.M.); (J.N.)
- Institute for Advanced Biosciences (IAB), INSERM U 1209, CNRS UMR 5309, Université Grenoble Alpes, 38043 Grenoble, France
- Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Thomas Jouve
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38043 Grenoble, France; (T.J.); (F.T.); (P.M.); (J.N.)
- Institute for Advanced Biosciences (IAB), INSERM U 1209, CNRS UMR 5309, Université Grenoble Alpes, 38043 Grenoble, France
| | - Florian Terrec
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38043 Grenoble, France; (T.J.); (F.T.); (P.M.); (J.N.)
| | - Paolo Malvezzi
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38043 Grenoble, France; (T.J.); (F.T.); (P.M.); (J.N.)
| | - Johan Noble
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38043 Grenoble, France; (T.J.); (F.T.); (P.M.); (J.N.)
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Lin IH, Van Duong T, Nien SW, Tseng IH, Wu YM, Chiang YJ, Wang HH, Chiang CY, Wang MH, Chiu CH, Lin YT, Wong TC. High diet quality indices associated with lower risk of lipid profile abnormalities in Taiwanese kidney transplant recipients. Sci Rep 2023; 13:19662. [PMID: 37952063 PMCID: PMC10640642 DOI: 10.1038/s41598-023-46736-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 11/04/2023] [Indexed: 11/14/2023] Open
Abstract
Cardiovascular disease (CVD) and its risk factors seem to be linked with deteriorated graft function and persists as the major cause of mortality in kidney transplant recipients (KTRs). Diet quality is associated with CVD prevention in the healthy population, however, less study focuses on KTRs. The study aimed to determine the association between diet quality indices and lipid profile abnormalities as risk factors for CVD in KTRs. This prospective study enrolled 106 KTRs who had functioning allografts from September 2016. Lipid profiles included low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), total cholesterol (TC), and triglyceride (TG) and were based on the National Cholesterol Education Program Adult Treatment Panel III recommendations. Three-day dietary data were collected by a well-trained registered dietitian. The Alternative Healthy Eating Index-Taiwan (AHEI-Taiwan), Alternative Healthy Eating Index-2010 (AHEI-2010), and Healthy Eating Index-2015 (HEI-2015) scores were calculated and divided into quartiles and compared accordingly. KTRs' mean LDL-C, HDL-C, TC, and TG levels were 119.8 ± 36.6 mg/dL, 52.0 ± 17.9 mg/dL, 205.8 ± 43.9 mg/dL, and 160.2 ± 121.6 mg/dL, respectively. Compared with the lowest quartile, only the highest quartile of AHEI-Taiwan had lower TC and LDL-C levels. After adjustment for age, gender, energy, Charlson comorbidity index, transplant duration, and dialysis duration, logistic regression analysis revealed that the highest quartile of AHEI-Taiwan had 82% (odds ratio [OR], 0.18; 95% confidence interval [CI] 0.04-0.72, p < 0.05) lower odds of high TC and 88% (OR 0.12; 95% CI 0.03-0.58, p < 0.05) lower odds of high LDL-C, and the highest quartile of HEI-2015 had 77% (OR 0.23; 95% CI 0.05-0.95, p < 0.05) lower odds of high LDL-C. Higher adherence to a healthy diet as per AHEI-Taiwan and HEI-2015 guidelines associated with lower risk of lipid profile abnormalities in KTRs.
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Affiliation(s)
- I-Hsin Lin
- Department of Medical Nutrition Therapy, Linkou Chang Gung Memorial Hospital, Taoyüan, Taiwan, ROC
| | - Tuyen Van Duong
- School of Nutrition and Health Sciences, College of Nutrition, Taipei Medical University, Taipei, Taiwan, ROC
| | - Shih-Wei Nien
- Department of Medical Nutrition Therapy, Linkou Chang Gung Memorial Hospital, Taoyüan, Taiwan, ROC
| | - I-Hsin Tseng
- Department of Medical Nutrition Therapy, Linkou Chang Gung Memorial Hospital, Taoyüan, Taiwan, ROC
| | - Yi-Ming Wu
- Department of Medical Nutrition Therapy, Linkou Chang Gung Memorial Hospital, Taoyüan, Taiwan, ROC
| | - Yang-Jen Chiang
- Department of Urology, Linkou Chang Gung Memorial Hospital, Taoyüan, Taiwan, ROC
- Department of Medicine, Chang Gung University, Taoyüan, Taiwan, ROC
| | - Hsu-Han Wang
- Department of Urology, Linkou Chang Gung Memorial Hospital, Taoyüan, Taiwan, ROC
- Department of Medicine, Chang Gung University, Taoyüan, Taiwan, ROC
| | - Chia-Yu Chiang
- Department of Business Administration, College of Management, National Changhua University of Education, Changhua, Taiwan, ROC
| | - Ming-Hsu Wang
- Center for General Education, Taipei Medical University, Taipei, Taiwan, ROC
| | - Chia-Hui Chiu
- Center for General Education, Taipei Medical University, Taipei, Taiwan, ROC
| | - Ying-Tsen Lin
- Department of Health Promotion and Health Education, National Taiwan Normal University, Taipei, Taiwan, ROC
| | - Te-Chih Wong
- Department of Nutrition and Health Sciences, Chinese Culture University, Taipei, Taiwan, ROC.
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Zhang X, Xu H, Yu J, Cui J, Chen Z, Li Y, Niu Y, Wang S, Ran S, Zou Y, Wu J, Xia J. Immune Regulation of the Liver Through the PCSK9/CD36 Pathway During Heart Transplant Rejection. Circulation 2023; 148:336-353. [PMID: 37232170 DOI: 10.1161/circulationaha.123.062788] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 05/05/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND PCSK9 (proprotein convertase subtilisin/kexin 9), which is mainly secreted by the liver, is not only a therapeutic target for hyperlipidemia and cardiovascular disease, but also has been implicated in the immune regulation of infections and tumors. However, the role of PCSK9 and the liver in heart transplant rejection (HTR) and the underlying mechanisms remain unclear. METHODS We assessed serum PCSK9 expression in both murine and human recipients during HTR and investigated the effect of PCSK9 ablation on HTR by using global knockout mice and a neutralizing antibody. Moreover, we performed multiorgan histological and transcriptome analyses, and multiomics and single-cell RNA-sequencing studies of the liver during HTR, as well. We further used hepatocyte-specific Pcsk9 knockout mice to investigate whether the liver regulated HTR through PCSK9. Last, we explored the regulatory effect of the PCSK9/CD36 pathway on the phenotype and function of macrophages in vitro and in vivo. RESULTS Here, we report that murine and human recipients have high serum PCSK9 levels during HTR. PCSK9 ablation prolonged cardiac allograft survival and attenuated the infiltration of inflammatory cells in the graft and the expansion of alloreactive T cells in the spleen. Next, we demonstrated that PCSK9 was mainly produced and significantly upregulated in the recipient liver, which also showed a series of signaling changes, including changes in the TNF-α (tumor necrosis factor α) and IFN-γ (interferon γ) signaling pathways and the bile acid and fatty acid metabolism pathways. We found mechanistically that TNF-α and IFN-γ synergistically promoted PCSK9 expression in hepatocytes through the transcription factor SREBP2 (sterol regulatory element binding protein 2). Moreover, in vitro and in vivo studies indicated that PCSK9 inhibited CD36 expression and fatty acid uptake by macrophages and strengthened the proinflammatory phenotype, which facilitated their ability to promote proliferation and IFN-γ production by donor-reactive T cells. Last, we found that the protective effect of PCSK9 ablation against HTR is dependent on the CD36 pathway in the recipient. CONCLUSIONS This study reveals a novel mechanism for immune regulation by the liver through the PCSK9/CD36 pathway during HTR, which influences the phenotype and function of macrophages and suggests that the modulation of this pathway may be a potential therapeutic target to prevent HTR.
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Affiliation(s)
- Xi Zhang
- Department of Cardiovascular Surgery (X.Z., H.X., J.Y., J.C., Z.C., Y.L., Y.N., S.W., S.R., Y.Z., J.W., J.X.), Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Center for Translational Medicine (X.Z., J.Y., Z.C., Y.L., Y.N., S.W., S.R., J.W., J.X.), Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Heng Xu
- Department of Cardiovascular Surgery (X.Z., H.X., J.Y., J.C., Z.C., Y.L., Y.N., S.W., S.R., Y.Z., J.W., J.X.), Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jizhang Yu
- Department of Cardiovascular Surgery (X.Z., H.X., J.Y., J.C., Z.C., Y.L., Y.N., S.W., S.R., Y.Z., J.W., J.X.), Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Center for Translational Medicine (X.Z., J.Y., Z.C., Y.L., Y.N., S.W., S.R., J.W., J.X.), Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jikai Cui
- Department of Cardiovascular Surgery (X.Z., H.X., J.Y., J.C., Z.C., Y.L., Y.N., S.W., S.R., Y.Z., J.W., J.X.), Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhang Chen
- Department of Cardiovascular Surgery (X.Z., H.X., J.Y., J.C., Z.C., Y.L., Y.N., S.W., S.R., Y.Z., J.W., J.X.), Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Center for Translational Medicine (X.Z., J.Y., Z.C., Y.L., Y.N., S.W., S.R., J.W., J.X.), Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yuan Li
- Department of Cardiovascular Surgery (X.Z., H.X., J.Y., J.C., Z.C., Y.L., Y.N., S.W., S.R., Y.Z., J.W., J.X.), Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Center for Translational Medicine (X.Z., J.Y., Z.C., Y.L., Y.N., S.W., S.R., J.W., J.X.), Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yuqing Niu
- Department of Cardiovascular Surgery (X.Z., H.X., J.Y., J.C., Z.C., Y.L., Y.N., S.W., S.R., Y.Z., J.W., J.X.), Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Center for Translational Medicine (X.Z., J.Y., Z.C., Y.L., Y.N., S.W., S.R., J.W., J.X.), Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Song Wang
- Department of Cardiovascular Surgery (X.Z., H.X., J.Y., J.C., Z.C., Y.L., Y.N., S.W., S.R., Y.Z., J.W., J.X.), Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Center for Translational Medicine (X.Z., J.Y., Z.C., Y.L., Y.N., S.W., S.R., J.W., J.X.), Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Institute of Translational Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (S.W., S.R., J.W., J.X.)
| | - Shuan Ran
- Department of Cardiovascular Surgery (X.Z., H.X., J.Y., J.C., Z.C., Y.L., Y.N., S.W., S.R., Y.Z., J.W., J.X.), Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Center for Translational Medicine (X.Z., J.Y., Z.C., Y.L., Y.N., S.W., S.R., J.W., J.X.), Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Institute of Translational Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (S.W., S.R., J.W., J.X.)
| | - Yanqiang Zou
- Department of Cardiovascular Surgery (X.Z., H.X., J.Y., J.C., Z.C., Y.L., Y.N., S.W., S.R., Y.Z., J.W., J.X.), Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jie Wu
- Department of Cardiovascular Surgery (X.Z., H.X., J.Y., J.C., Z.C., Y.L., Y.N., S.W., S.R., Y.Z., J.W., J.X.), Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Center for Translational Medicine (X.Z., J.Y., Z.C., Y.L., Y.N., S.W., S.R., J.W., J.X.), Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Key Laboratory of Organ Transplantation, Ministry of Education, NHC Key Laboratory of Organ Transplantation, Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan (J.W.)
- Institute of Translational Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (S.W., S.R., J.W., J.X.)
| | - Jiahong Xia
- Department of Cardiovascular Surgery (X.Z., H.X., J.Y., J.C., Z.C., Y.L., Y.N., S.W., S.R., Y.Z., J.W., J.X.), Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Center for Translational Medicine (X.Z., J.Y., Z.C., Y.L., Y.N., S.W., S.R., J.W., J.X.), Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Institute of Translational Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China (S.W., S.R., J.W., J.X.)
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Bae S, Ahn JB, Joseph C, Whisler R, Schnitzler MA, Lentine KL, Kadosh BS, Segev DL, McAdams-DeMarco MA. Incidence of Statin-Associated Adverse Events in Kidney Transplant Recipients. Clin J Am Soc Nephrol 2023; 18:626-633. [PMID: 36800538 PMCID: PMC10278779 DOI: 10.2215/cjn.0000000000000124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 02/07/2023] [Indexed: 02/19/2023]
Abstract
BACKGROUND Statins are the third most prescribed drug class in kidney transplant recipients as cardiovascular disease is the leading cause of death in this population. However, statins' safety profile remains unclear in kidney transplant recipients who are uniquely burdened by concomitant immunosuppression and comorbidities. We conducted a national study to characterize the association of statin use with adverse events in kidney transplant recipients. METHODS We studied adult (18 years or older) single-organ kidney transplant recipients in 2006-2016 with Medicare as primary payer ( n =57,699). We used prescription drug claims to capture statin use and International Classification of Diseases 9/10 diagnosis codes to capture statin-related adverse events (post-transplant diabetes mellitus, hemorrhagic stroke, cataract, liver injury, and rhabdomyolysis). We conducted multivariable Cox regression for each outcome with statin use as a time-varying exposure. RESULTS Post-transplant diabetes mellitus was the most common outcome (5-year Kaplan-Meier incidence; 43% in statin users versus 35% in nonusers), followed by cataract (22% versus 12%), liver injury (2% versus 3%), hemorrhagic stroke (1.9% versus 1.4%), and rhabdomyolysis (1.5% versus 0.9%). In our multivariable analysis, statin use was associated with higher hazard of post-transplant diabetes mellitus (adjust hazard ratio [aHR], 1.12; 95% confidence interval [95% CI], 1.07 to 1.18), cataract (aHR, 1.22; 95% CI, 1.14 to 1.31), and rhabdomyolysis (aHR, 1.37; 95% CI, 1.10 to 1.71) but lower hazard of liver injury (aHR, 0.82; 95% CI, 0.71 to 0.95). Statin use was not associated with hemorrhagic stroke (aHR, 1.04; 95% CI, 0.86 to 1.26). CONCLUSIONS Statins seem to be generally well tolerated in kidney transplant recipients. However, statin use might be associated with slightly higher risk of post-transplant diabetes mellitus, cataract, and rhabdomyolysis.
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Affiliation(s)
- Sunjae Bae
- Department of Surgery, NYU Grossman School of Medicine, New York, New York
- Department of Population Health, NYU Grossman School of Medicine, New York, New York
| | - JiYoon B. Ahn
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Corey Joseph
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Ryan Whisler
- Department of Pharmacy, Johns Hopkins Medicine, Baltimore, Maryland
| | | | - Krista L. Lentine
- Department of Internal Medicine, Saint Louis University, St. Louis, Missouri
| | - Bernard S. Kadosh
- Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | - Dorry L. Segev
- Department of Surgery, NYU Grossman School of Medicine, New York, New York
- Department of Population Health, NYU Grossman School of Medicine, New York, New York
| | - Mara A. McAdams-DeMarco
- Department of Surgery, NYU Grossman School of Medicine, New York, New York
- Department of Population Health, NYU Grossman School of Medicine, New York, New York
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Lv P, Li Y, Wu L, Weng H, Chen M, Ding W, Li J. PCSK9 inhibitors in a renal transplant patient complicated with hepatitis B: A case report and literature review. Front Cardiovasc Med 2022; 9:937474. [PMID: 36419496 PMCID: PMC9676271 DOI: 10.3389/fcvm.2022.937474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 10/13/2022] [Indexed: 11/09/2022] Open
Abstract
Lipid metabolism disorders are recognized to be one of the most frequent complications of renal transplantation, while dyslipidemia and chronic kidney disease (CKD) are strong risk factors for arteriosclerotic cardiovascular disease (ASCVD). Proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) are novel lipid-lowering drugs, the safety and efficacy of which are yet to be confirmed in transplanted patients. There have been several small-sample studies using PCSK9i in patients after heart transplantation, while fewer cases use PCSK9i after kidney transplantation. We report a case of a renal transplant recipient complicated with hepatitis B treated with PCSK9i, which achieved a remarkable lipid-lowering efficacy, and no significant adverse effects were found during the follow-up.
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Ponticelli C, Citterio F. Non-Immunologic Causes of Late Death-Censored Kidney Graft Failure: A Personalized Approach. J Pers Med 2022; 12:1271. [PMID: 36013220 PMCID: PMC9410103 DOI: 10.3390/jpm12081271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 07/28/2022] [Accepted: 07/28/2022] [Indexed: 11/29/2022] Open
Abstract
Despite continuous advances in surgical and immunosuppressive protocols, the long-term survival of transplanted kidneys is still far from being satisfactory. Antibody-mediated rejection, recurrent autoimmune diseases, and death with functioning graft are the most frequent causes of late-kidney allograft failure. However, in addition to these complications, a number of other non-immunologic events may impair the function of transplanted kidneys and directly or indirectly lead to their failure. In this narrative review, we will list and discuss the most important nonimmune causes of late death-censored kidney graft failure, including quality of the donated kidney, adherence to prescriptions, drug toxicities, arterial hypertension, dyslipidemia, new onset diabetes mellitus, hyperuricemia, and lifestyle of the renal transplant recipient. For each of these risk factors, we will report the etiopathogenesis and the potential consequences on graft function, keeping in mind that in many cases, two or more risk factors may negatively interact together.
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Affiliation(s)
| | - Franco Citterio
- Renal Transplant Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Università Cattolica Sacro Cuore, 00168 Roma, Italy
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Cardiovascular Risk after Kidney Transplantation: Causes and Current Approaches to a Relevant Burden. J Pers Med 2022; 12:jpm12081200. [PMID: 35893294 PMCID: PMC9329988 DOI: 10.3390/jpm12081200] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 07/11/2022] [Accepted: 07/20/2022] [Indexed: 11/17/2022] Open
Abstract
Background. Cardiovascular disease is a frequent complication after kidney transplantation and represents the leading cause of mortality in this population. Material and Methods. We searched for the relevant articles in the National Institutes of Health library of medicine, transplant, cardiologic and nephrological journals. Results. The pathogenesis of cardiovascular disease in kidney transplant is multifactorial. Apart from non-modifiable risk factors, such as age, gender, genetic predisposition and ethnicity, several traditional and non-traditional modifiable risk factors contribute to its development. Traditional factors, such as diabetes, hypertension and dyslipidemia, may be present before and may worsen after transplantation. Immunosuppressants and impaired graft function may strongly influence the exacerbation of these comorbidities. However, in the last years, several studies showed that many other cardiovascular risk factors may be involved in kidney transplantation, including hyperuricemia, inflammation, low klotho and elevated Fibroblast Growth Factor 23 levels, deficient levels of vitamin D, vascular calcifications, anemia and poor physical activity and quality of life. Conclusions. The timely and effective treatment of time-honored and recently discovered modifiable risk factors represent the basis of the prevention of cardiovascular complications in kidney transplantation. Reduction of cardiovascular risk can improve the life expectancy, the quality of life and the allograft function and survival.
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Dyslipidemia in Transplant Patients: Which Therapy? J Clin Med 2022; 11:jcm11144080. [PMID: 35887846 PMCID: PMC9318180 DOI: 10.3390/jcm11144080] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 07/11/2022] [Accepted: 07/11/2022] [Indexed: 12/17/2022] Open
Abstract
Cardiovascular disease is the most important cause of death worldwide in recent years; an increasing trend is also shown in organ transplant patients subjected to immunosuppressive therapies, in which cardiovascular diseases represent one of the most frequent causes of long-term mortality. This is also linked to immunosuppressant-induced dyslipidemia, which occurs in 27 to 71% of organ transplant recipients. The aim of this review is to clarify the pathophysiological mechanisms underlying dyslipidemia in patients treated with immunosuppressants to identify immunosuppressive therapies which do not cause dyslipidemia or therapeutic pathways effective in reducing hypercholesterolemia, hypertriglyceridemia, or both, without further adverse events.
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Dyslipidemia in Renal Transplant Recipients. TRANSPLANTOLOGY 2022. [DOI: 10.3390/transplantology3020020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Dyslipidemia is a frequent complication after kidney transplantation (KT) and is an important risk factor for cardiovascular disease (CVD). Renal transplant recipients (RTRs) are considered at high, or very high, risk of CVD, which is a leading cause of death in this patient group. Despite many factors of post-transplant dyslipidemia, the immunosuppressive treatment has the biggest influence on a lipid profile. There are no strict dyslipidemia treatment guidelines for RTRs, but the ones proposing an individual approach regarding CVD risk seem most suitable. Proper diet and physical activity are the main general measures to manage dyslipidemia and should be introduced initially in every patient after KT. In the case of an insufficient correction of lipemia, statins are the basis for hypolipidemic treatment. Statins should be introduced with caution to avoid serious side-effects (e.g., myopathy) or drug-drug interactions, especially with immunosuppressants. To lower the incidence of adverse effects, and improve medication adherence, ezetimibe in combination with statins is recommended. Fibrates and bile sequestrants are not recommended due to their side-effects and variable efficacy. However, several new lipid-lowering drugs like Proprotein convertase subtilisin/Kexin type9 (PCSK9) inhibitors may have promising effects in RTRs, but further research assessing efficacy and safety is yet to be carried out.
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Documento de información y consenso para la detección y manejo de la enfermedad renal crónica. Nefrologia 2022. [DOI: 10.1016/j.nefro.2021.07.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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García-Maset R, Bover J, Segura de la Morena J, Goicoechea Diezhandino M, Cebollada Del Hoyo J, Escalada San Martin J, Fácila Rubio L, Gamarra Ortiz J, García-Donaire JA, García-Matarín L, Gràcia Garcia S, Isabel Gutiérrez Pérez M, Hernández Moreno J, Mazón Ramos P, Montañés Bermudez R, Muñoz Torres M, de Pablos-Velasco P, Pérez-Maraver M, Suárez Fernández C, Tranche Iparraguirre S, Luis Górriz J. Information and consensus document for the detection and management of chronic kidney disease. Nefrologia 2022; 42:233-264. [PMID: 36210616 DOI: 10.1016/j.nefroe.2022.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 07/20/2021] [Indexed: 06/16/2023] Open
Abstract
Chronic kidney disease (CKD) is a major public health problem worldwide that affects more than 10% of the Spanish population. CKD is associated with high comorbidity rates, poor prognosis and major consumption of health system resources. Since the publication of the last consensus document on CKD seven years ago, little evidence has emerged and few clinical trials on new diagnostic and treatment strategies in CKD have been conducted, apart from new trials in diabetic kidney disease. Therefore, CKD international guidelines have not been recently updated. The rigidity and conservative attitude of the guidelines should not prevent the publication of updates in knowledge about certain matters that may be key in detecting CKD and managing patients with this disease. This document, also prepared by 10 scientific associations, provides an update on concepts, clarifications, diagnostic criteria, remission strategies and new treatment options. The evidence and the main studies published on these aspects of CKD have been reviewed. This should be considered more as an information document on CKD. It includes an update on CKD detection, risk factors and screening; a definition of renal progression; an update of remission criteria with new suggestions in the older population; CKD monitoring and prevention strategies; management of associated comorbidities, particularly in diabetes mellitus; roles of the Primary Care physician in CKD management; and what not to do in Nephrology. The aim of the document is to serve as an aid in the multidisciplinary management of the patient with CKD based on current recommendations and knowledge.
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Affiliation(s)
| | | | - Julián Segura de la Morena
- Sociedad Española de Hipertensión-Liga Española para la Lucha contra la Hipertensión Arterial (SEH-LELHA)
| | | | | | | | | | | | - Jose A García-Donaire
- Sociedad Española de Hipertensión-Liga Española para la Lucha contra la Hipertensión Arterial (SEH-LELHA)
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Ponticelli C, Reggiani F, Moroni G. Old and New Calcineurin Inhibitors in Lupus Nephritis. J Clin Med 2021; 10:jcm10214832. [PMID: 34768354 PMCID: PMC8584552 DOI: 10.3390/jcm10214832] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 10/11/2021] [Accepted: 10/19/2021] [Indexed: 12/27/2022] Open
Abstract
Calcineurin inhibitors (CNIs) are drugs that inhibit calcineurin, a key phosphatase that dephosphorylates a transcription factor called the nuclear factor of activated T cells (NFAT), allowing its translocation into the nucleus of quiescent T cells. In the nucleus, NFAT activates interleukin 2, which stimulates the proliferation and differentiation of T-cells. CNIs can also stabilize the actin cytoskeleton of podocytes reducing proteinuria. Thanks to these characteristics, CNIs have been often used in the treatment of autoimmune diseases. However, the therapeutic index of CNIs is narrow, and their interactions with other drugs can increase toxicity or reduce efficacy. In lupus nephritis, cyclosporine and tacrolimus have been used both in induction and maintenance therapies. Observational studies and randomized controlled trials showed that both cyclosporine and tacrolimus can increase efficacy. Tolerance is satisfactory if low doses are used and the patient is carefully monitored. More recently, a new CNI, called voclosporin (VCS), has been approved by the Food and Drug Administration for use in lupus nephritis. VCS offers potential advantages over other CNIs. In two large multiethnic trials, VCS was not associated with adverse renal and metabolic events and obtained positive results despite a novel and rapid corticosteroid tapering regime.
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Affiliation(s)
- Claudio Ponticelli
- Nephrology Division, Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Correspondence:
| | - Francesco Reggiani
- Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089 Milan, Italy; (F.R.); (G.M.)
| | - Gabriella Moroni
- Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089 Milan, Italy; (F.R.); (G.M.)
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Chen Z, Cheng X, Zhang L, Tang L, Fang Y, Chen H, Zhang L, Shen A. The impact of IL-10 and CYP3A5 gene polymorphisms on dose-adjusted trough blood tacrolimus concentrations in early post-renal transplant recipients. Pharmacol Rep 2021; 73:1418-1426. [PMID: 34089513 DOI: 10.1007/s43440-021-00288-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 05/22/2021] [Accepted: 05/26/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The strong inter-individual pharmacokinetic variability and the narrow therapeutic window of tacrolimus (TAC) have hampered the clinical application. Gene polymorphisms play an important role in TAC pharmacokinetics. Here, we investigate the influence of genotypes of IL-10, CYP3A5, CYP2C8, and ABCB1 on dose-adjusted trough blood concentrations (the C0/D ratio) of TAC to reveal unclear genetic factors that may affect TAC dose requirements for renal transplant recipients. METHODS Genetic polymorphisms of IL-10, CYP3A5, CYP2C8, and ABCB1 in 188 renal transplant recipients were determined using Kompetitive Allele Specific PCR (KASP). Statistical analysis was applied to examine the effect of genetic variation on the TAC C0/D at 5, 10, 15, and 30 days after transplantation. RESULTS Recipients carrying the IL-10 -819C > T TT genotype showed a significantly higher TAC C0/D than those with the TC/CC genotype (p < 0.05). Additionally, the TAC C0/D values of recipients with the capacity for low IL-10 activity (-819 TT) engrafted with CYP3A5 non-expressers were higher compared to the intermediate/high activity of IL-10 -819C > T TC or CC carrying CYP3A5 expressers, and the difference was statistically significant at different time points (p < 0.05). CONCLUSIONS Genetic polymorphisms of IL-10 -819C > T and CYP3A5 6986A > G influence the TAC C0/D, which may contribute to variation in TAC dose requirements during the early post-transplantation period. Detecting IL-10 -819C > T and CYP3A5 6986A > G polymorphisms may allow determination of individualized tacrolimus dosage regimens for renal transplant recipients during the early post-transplantation period.
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Affiliation(s)
- Zhaolin Chen
- Division of Life Sciences and Medicine, Department of Pharmacy, The First Affiliated Hospital of USTC, Anhui Provincial Hospital, University of Science and Technology of China, Hefei, Anhui, 230001, People's Republic of China
| | - Xi Cheng
- Division of Life Sciences and Medicine, Department of Pharmacy, The First Affiliated Hospital of USTC, Anhui Provincial Hospital, University of Science and Technology of China, Hefei, Anhui, 230001, People's Republic of China
| | - Liwen Zhang
- Department of Data & Analytics, WuXi Diagnostics Limited Corporation, Shanghai, 200131, People's Republic of China
| | - Liqin Tang
- Division of Life Sciences and Medicine, Department of Pharmacy, The First Affiliated Hospital of USTC, Anhui Provincial Hospital, University of Science and Technology of China, Hefei, Anhui, 230001, People's Republic of China
| | - Yan Fang
- Division of Life Sciences and Medicine, Department of Pharmacy, The First Affiliated Hospital of USTC, Anhui Provincial Hospital, University of Science and Technology of China, Hefei, Anhui, 230001, People's Republic of China
| | - Hongxiao Chen
- Division of Life Sciences and Medicine, Department of Pharmacy, The First Affiliated Hospital of USTC, Anhui Provincial Hospital, University of Science and Technology of China, Hefei, Anhui, 230001, People's Republic of China
| | - Lei Zhang
- Division of Life Sciences and Medicine, Department of Pharmacy, The First Affiliated Hospital of USTC, Anhui Provincial Hospital, University of Science and Technology of China, Hefei, Anhui, 230001, People's Republic of China.
| | - Aizong Shen
- Division of Life Sciences and Medicine, Department of Pharmacy, The First Affiliated Hospital of USTC, Anhui Provincial Hospital, University of Science and Technology of China, Hefei, Anhui, 230001, People's Republic of China.
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Update on Treatment of Hypertension After Renal Transplantation. Curr Hypertens Rep 2021; 23:25. [PMID: 33961145 DOI: 10.1007/s11906-021-01151-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE OF REVIEW To incorporate novel findings on pathophysiology and treatment of posttransplant hypertension. RECENT FINDINGS (1) The sodium retaining effects of CNIs are mediated by stimulation of the thiazide-sensitive sodium chloride co-transporter in the distal convoluted tubule and in this regard chlorthalidone was proven to be an effective antihypertensive drug in renal transplantation. (2) Local and not systemic activation of the renin-angiotensin-aldosterone system plays a crucial role in the pathogenesis of posttransplant hypertension. (3) Recent randomized controlled trials failed to prove the presumed superiority of renin-angiotensin blockers in kidney transplantation. (4) Steroid-free and mammalian target of rapamycin-based immunosuppressive drug combinations did not show favorable effects on blood pressure control. (5) In a recent report the risk of non-melanoma skin cancer was higher with thiazide diuretics. But the increased cancer risk in transplant recipients is mainly attributed to comorbidities, such as diabetes and hypertension and of course to the transplantation condition itself or the obligatory application of immunosuppression, and has little to do with the antihypertensive medication Actual recommendations about BP targets in adult renal transplant recipients are coming from a post hoc analysis of a large randomized trial with another primary endpoint. Unless convincing studies on treatment of hypertension after renal transplantation are available, the ESC/ESH Guidelines 2018 should apply for these patients.
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Chevallier E, Jouve T, Rostaing L, Malvezzi P, Noble J. pre-existing diabetes and PTDM in kidney transplant recipients: how to handle immunosuppression. Expert Rev Clin Pharmacol 2020; 14:55-66. [PMID: 33196346 DOI: 10.1080/17512433.2021.1851596] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Preexisting diabetes (PD) and post-transplant diabetes mellitus (PTDM) are common and severe comorbidities posttransplantation. The immunosuppressive regimens are modifiable risk factors. AREAS COVERED We reviewed Pubmed and Cochrane database and we summarize the mechanisms and impacts of available immunosuppressive treatments on the risk of PD and PTDM. We also assess the possible management of these drugs to improve glycemic parameters while considering risks inherent in transplantation. EXPERT OPINION PD i) increases the risk of sepsis, ii) is an independent risk factor for infection-related mortality, and iii) increases acute rejection risk. Regarding PTDM development i) immunosuppressive strategies without corticosteroids significantly reduce the risk but the price may be a higher incidence of rejection; ii) minimization or rapid withdrawal of steroids are two valuable approaches; iii) the diabetogenic role of calcineurin inhibitors(CNIs) is also well-described and is more important for tacrolimus than for cyclosporine. Reducing tacrolimus-exposure may improve glycemic parameters but also has a higher risk of rejection. PTDM risk is higher in patients that receive sirolimus compared to mycophenolate mofetil. Finally, conversion from CNIs to belatacept may offer the best benefits to PTDM-recipients in terms of glycemic parameters, graft and patient-outcomes.
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Affiliation(s)
- Eloi Chevallier
- Service De Néphrologie, Hémodialyse, Aphérèses Et Transplantation Rénale, CHU Grenoble-Alpes , Grenoble, France
| | - Thomas Jouve
- Service De Néphrologie, Hémodialyse, Aphérèses Et Transplantation Rénale, CHU Grenoble-Alpes , Grenoble, France.,Université Grenoble Alpes , Grenoble, France
| | - Lionel Rostaing
- Service De Néphrologie, Hémodialyse, Aphérèses Et Transplantation Rénale, CHU Grenoble-Alpes , Grenoble, France.,Université Grenoble Alpes , Grenoble, France
| | - Paolo Malvezzi
- Service De Néphrologie, Hémodialyse, Aphérèses Et Transplantation Rénale, CHU Grenoble-Alpes , Grenoble, France
| | - Johan Noble
- Service De Néphrologie, Hémodialyse, Aphérèses Et Transplantation Rénale, CHU Grenoble-Alpes , Grenoble, France
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