Ezetimibe in Renal Transplant Patients with Hyperlipidemia Resistant to HMG-CoA Reductase Inhibitors

Cardiovascular Risk after Kidney Transplantation: Causes and Current Approaches to a Relevant Burden

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.

Management of dyslipidemia in adult solid organ transplant recipients

Solid organ transplantation (SOT) has revolutionized treatment of end-stage disease. Improvements in the SOT continuum of care have unmasked a significant burden of cardiovascular disease, manifesting as a leading cause of morbidity and mortality. Although several risk factors for development of post-transplant cardiovascular disease exist, dyslipidemia remains one of the most frequent and modifiable risks. An important contributor to dyslipidemia in SOT recipients is the off-target metabolic effects of immunosuppressive medications, which may alter lipoproteins and their metabolism. Dyslipidemia management is paramount as lipid-lowering therapy with statins has demonstrated reductions in graft vasculopathy, decreased rejection rates, and improved survival. Several nonstatin medication options are available, but data supporting their benefit in the SOT population are minimal, typically extrapolated from studies in the general population. Further compounding dyslipidemia management is the complex interplay of drug interactions between lipid-lowering and immunosuppressant medications, which can result in serious toxicity and/or therapeutic failure.

An observational study of ezetimibe in cardiac transplant recipients receiving calcineurin inhibitors

BACKGROUND

Cardiac transplant patients are at risk for developing cardiac allograft vasculopathy, and dyslipidemia in this patient population has been associated with increased risk. Data evaluating the efficacy and safety of ezetimibe in this population are minimal.

OBJECTIVES

The purpose of this study was to assess the effects of ezetimibe, alone or in combination with other lipid-lowering agents, in cardiac transplant recipients receiving calcineurin inhibitors (CNIs).

METHODS

This study was a single-center retrospective chart review. Data on demographics, medications prescribed for dyslipidemia and prevention of transplant rejection, results of lipid panels, CNI blood concentrations, and adverse effects were extracted from medical records of cardiac transplant recipients who were prescribed ezetimibe, either alone or in combination with other lipid-lowering agents, and seen at least once in a 12-month period at a cardiac transplantation clinic of an 800-bed teaching hospital.

RESULTS

There were 71 patients prescribed ezetimibe in whom a safety analysis was performed. Approximately 49% (n = 35) were included in the analysis for lipid lowering. Ezetimibe significantly decreased low-density lipoprotein cholesterol (LDL-C; 129 mg/dL vs 94 mg/dL, P < .0001), non-high-density lipoprotein cholesterol (non-HDL-C; 170 mg/dL vs 127.5 mg/dL, P = .0058), and total cholesterol (236 mg/dL vs 200 mg/dL, P < .0001). There was no significant change in HDL-C and triglycerides as compared with baseline. The proportion of patients achieving goal LDL-C < 100 mg/dL significantly increased from 11.5% at baseline to 60.5% after the addition of ezetimibe (P < .0001). Ezetimibe had no measurable effect on blood CNI concentrations or doses. Adverse effects were reported by 15.5% of patients (n = 11), with 4% (n = 3) of patients discontinuing therapy. The most common complaints were gastrointestinal intolerance and myalgia.

CONCLUSIONS

Ezetimibe was associated with lower LDL-C in cardiac transplant recipients either as combination therapy in patients with elevated LDL-C or as monotherapy, with a low frequency of adverse effects.

Medical management of the liver transplant recipient

Long-term survival of liver transplant recipients has become the rule rather than the exception. As a result, the medical complications of long-term survival, including atherosclerotic cardiovascular disease, metabolic bone disease, and de novo malignancy, have accounted for an increasing proportion of late morbidity and mortality. Risk factors for these complications begin before transplant and are potentially modifiable but are exacerbated by the requirement for immunosuppressive medications after transplantation. Surveillance and early intervention programs administered by transplant hepatologists and other medical subspecialists may improve long-term outcomes in liver transplant recipients by ameliorating risk factors for atherosclerosis, bone fractures, and cancer.

The efficacy and safety of the 3-hydroxy-3-methylglutaryl-CoA reductase inhibitors in chronic kidney disease, dialysis, and transplant patients

Coronary heart disease (CHD) is the leading cause of death in Western civilizations, in particular in chronic kidney disease (CKD) patients. Serum total cholesterol and LDL have been linked to the development of atherosclerosis and progression to CHD in the general population. However, the reductions of total and LDL cholesterol in the dialysis population have not demonstrated the ability to reduce the morbidity, mortality, and cost burden associated with CHD. The patients at greatest risk include those with pre-existing CHD, a CHD-risk equivalent, or multiple risk factors. However, data in the dialysis population are much less impressive, and the relationship between plasma cholesterol, cholesterol reduction, use of 3-hydroxy-3-methylglutaryl-CoA (HMG-CoA) reductase, and reduction in incidence of CHD or effect on progression of renal disease have not been proven. Adverse event information from published trials indicates that agents within this class share similar tolerability and adverse event profiles. Hepatic transaminase elevations may occur in 1 to 2% of patients and is dose related. Myalgia, myopathy, and rhabodmyolysis occur infrequently and are more common in kidney transplant patients and patients with CKD. This effect appears to be dose related and may be precipitated by administration with agents that inhibit cytochrome P-450 isoenzymes. Caution should be exercised when coadministering any statin with drugs that metabolize through cytochrome P-450 IIIA-4 in particular fibrates, cyclosporine, and azole antifungals. Elderly patients with CKD are at greater risk of adverse drug reactions, and therefore the lowest possible dose of statins should be used for the treatment of hyperlipidemia.

Primary care of the renal transplant patient

There has been a remarkable rise in the number of kidney transplant recipients (KTR) in the US over the last decade. Increasing use of potent immunosuppressants, which are also potentially diabetogenic and atherogenic, can result in worsening of pre-existing medical conditions as well as development of post-transplant disease. This, coupled with improving long-term survival, is putting tremendous pressure on transplant centers that were not designed to deliver primary care to KTR. Thus, increasing numbers of KTR will present to their primary care physicians (PCP) post-transplant for routine medical care. Similar to native chronic kidney disease patients, KTRs are vulnerable to cardiovascular disease as well as a host of other problems including bone disease, infections and malignancies. Deaths related to complications of cardiovascular disease and malignancies account for 60-65% of long-term mortality among KTRs. Guidelines from the National Kidney Foundation and the European Best Practice Guidelines Expert Group on the management of hypertension, dyslipidemia, smoking, diabetes and bone disease should be incorporated into the long-term care plan of the KTR to improve outcomes. A number of transplant centers do not supply PCPs with protocols and guidelines, making the task of the PCP more difficult. Despite this, PCPs are expected to continue to provide general preventive medicine, vaccinations and management of chronic medical problems. In this narrative review, we examine the common medical problems seen in KTR from the PCP's perspective. Medical management issues related to immunosuppressive medications are also briefly discussed.

Extended-release doxazosin for treatment of renal transplant recipients with benign prostatic hyperplasia

We studied living-related donor renal transplant recipients with benign prostatic hyperplasia (BPH). No prisoners were used in the study either as donors or recipients. We sought to assess the effectiveness and safety of extended-release doxazosin for treatment of renal transplant recipients with BPH.

METHODS

Forty-six recipients were diagnosed with BPH. Their transplanted kidney functions were stable. They received 4 or 8 mg/d of extended-release doxazosin orally. After 2, 4, 12, and 24 weeks, changes in the International Prostate Symptom Score (IPSS), quality of life (QoL), peak urinary flow rate (Q(max)), residual urine, blood pressure, renal graft function, and trough immunosuppressant concentrations were analyzed by a prospective, self-calibrated method.

RESULTS

The effectiveness rate of extended-release doxazosin in renal transplant recipients with BPH was 63.04% (29/46). Compared with their status before they took doxazosin, IPSS and residual urine decreased significantly, whereas Q(max) and QoL increased significantly at 2, 4, 12, and 24 weeks after treatment (P < .01). In 15 renal transplant recipients with hypertension, systolic blood pressure (SBP) and diastolic blood pressure (DBP) significantly decreased at 2, 4, 12, and 24 weeks after treatment (P < .01); blood pressure became normal in 10 patients (66.67%). The differences in renal graft function and trough concentration of immunosuppressants before versus after treatment were not significant.

CONCLUSION

Extended-release doxazosin treatment was effective and safe in renal transplant recipients with BPH. The drug not only had no influence on renal graft function and trough concentrations of immunosuppressant, but improved hypertension in these patients.

The efficacy and safety of ezetimibe and low-dose simvastatin as a primary treatment for dyslipidemia in renal transplant recipients

BACKGROUND/AIMS

The efficacy and safety of a combination of ezetimibe and low-dose statin as primary treatment for dyslipidemia in renal transplant patients were evaluated prospectively.

METHODS

The study enrolled 77 renal transplant recipients with dyslipidemia. They were given ezetimibe (10 mg) and simvastatin (10 mg) for 6 months as the initial treatment for dyslipidemia. Efficacy and safety were evaluated using lipid profiles, trough calcineurin inhibitor levels, allograft function, and adverse effects. The effects on proteinuria and high sensitivity C-reactive protein (hsCRP) levels were also evaluated.

RESULTS

Ezetimibe and low-dose simvastatin significantly decreased the levels of total cholesterol (34.6%), triglyceride (16.0%), and low-density lipoprotein cholesterol (LDL-C) (47.6%), and 82.5% of the patients reached the target LDL-C level of <100 mg/dL. No significant change in the trough calcineurin inhibitor levels or allograft function occurred, and no serious adverse effects were observed. Fourteen patients (18.2%) discontinued treatment; eight patients (11.7%) developed muscle pain or weakness without an increase in creatinine kinase levels, and two patients (2.6%) developed elevated liver transaminase levels. The proteinuria and hsCRP levels did not change significantly.

CONCLUSIONS

Ezetimibe and low-dose statin treatment is safe and effective as a primary treatment for dyslipidemia in renal transplant patients.

Impact of ezetimibe on cholesterol subfractions in dyslipidemic cardiac transplant recipients receiving statin therapy

BACKGROUND

Ezetimibe decreases cholesterol in cardiac transplant recipients intolerant to statins therapy. The effects of ezetimibe in addition to statins therapy and its relationship with the magnitude of dyslipidemia and statins utilization have not been studied in cardiac transplant recipients.

METHODS

The design of this investigation was a retrospective case control study. Twenty-two patients receiving the combination of therapy of statins plus ezetimibe were compared with 43 patients treated with statins only. The endpoints were assessed after three months of follow-up.

RESULTS

The addition of ezetimibe decreased low density lipoprotein-cholesterol by 25% compared with a 4% increase in patients receiving statins only. The impact of ezetimibe was similar regardless of the magnitude of dyslipidemia or statins dosage. Ezetimibe increase high density lipoprotein (HDL)-cholesterol only in patients with baseline HDL-cholesterol above 1.3 mM/L (p < 0.05). There was an asymptomatic, but significant increase in creatinine kinase level [+31.4 +/- 8.1 (ezetimibe) vs. + 1.5 +/- 5.0 mM/L (placebo); p = 0.005].

CONCLUSION

Ezetimibe therapy provides a significant reduction in most cholesterol subfractions regardless of the magnitude of dyslipidemia and statins dosage.

The efficacy and safety of ezetimibe for treatment of dyslipidemia after heart transplantation

INTRODUCTION

Statins, although the treatment of choice for dyslipidemia after heart transplantation (HT), are not always well tolerated or effective. In such cases, administration of ezetimibe may be useful.

AIM

The aim of this study was to assess the efficacy and safety of ezetimibe, with or without statins, after HT.

METHOD

Thirty-six HT patients, 97% of whom were males of overall mean age of 57 +/- 13 years, were all unable to reach target lipid levels with statins alone and/or were intolerant of statins. They were prescribed ezetimibe, with or without a statin. Efficacy and safety were evaluated after 1, 3, 6, and 12 months.

RESULTS

Thirty-four patients were evaluated at 1 month and 12 months. Ezetimibe was prescribed to 27 patients (75%) because of statin inefficacy, and to 9 patients (25%) because of statin intolerance, manifested by myalgia in 4 cases (11%), hepatotoxicity in 2 cases (6%), and rhabdomyolysis in 3 cases (8%). Lipid levels (mg/dL; baseline vs 1 year) were as follows: cholesterol, 235 +/- 49 versus 167 +/- 32 (P = .013); LDL cholesterol, 137 +/- 47 versus 89 +/- 29 (P = .001); HDL cholesterol, 54 +/- 13 versus 51 +/- 10 (P = .235); and triglycerides, 243 +/- 187 versus 143 +/- 72 (P = .022). There were no cases of liver toxicity, renal dysfunction, or significant alteration of immunosuppressive pharmacokinetics. Ezetimibe was withdrawn from 2 patients because of hand edema or asymptomatic recurrence of rhabdomyolysis first caused by statins.

CONCLUSIONS

With or without a statin, ezetimibe was generally well tolerated, reducing total cholesterol, LDL cholesterol, and triglyceride levels with no long-term alteration of HDL cholesterol levels. CPK surveillance is recommended because of a slight continued risk of adverse effects. Further studies should evaluate the benefit for survival.

Ezetimibe reduces low-density lipoprotein cholesterol (LDL-C) in renal transplant patients resistant to HMG-CoA reductase inhibitors

Hyperlipidemia is common after renal transplantation. On the basis of current lipid guidelines, the majority of renal transplant recipients should have plasma low-density lipoprotein cholesterol (LDL-C) levels <100 mg/dL. Even with statin (HMG-CoA [3-hydroxy-3-methylglutaryl CoA] reductase inhibitor) therapy, a significant number of renal transplant recipients have LDL-C levels >100 mg/dL. We report that ezetimibe, a novel inhibitor of intestinal cholesterol absorption, was well tolerated and effectively reduced the LDL-C level to <100 mg/dL in our cohort of renal transplant recipients with persistently elevated LDL-C levels during treatment with maximally tolerated statin medications.

Effect of ezetimibe in patients who cannot tolerate statins or cannot get to the low density lipoprotein cholesterol target despite taking a statin

BACKGROUND

Recent guidelines underline the need for high-risk patients to reach strict low density lipoprotein cholesterol (LDL-C) targets (1.8-2.6 mmol/L; 70-100 mg/dL), and specifically mention the possible use of combination therapy (e.g.statin + ezetimibe) to achieve these goals.

METHODS

A retrospective case-note audit was carried out to assess the response to administering ezetimibe in patients unable to tolerate statins (Group 1), or high dose of statins (Group 2) and patients who cannot achieve the LDL-C target (2.6 mmol/L; 100 mg/dL) despite taking a statin (Group 3).

RESULTS

Ezetimibe lowered LDL-C levels by 20-29% across the 3 patient groups after 2-3 months of treatment. High density lipoprotein cholesterol (HDL-C) levels tended to remain unchanged, although there was a consistent trend for a fall if baseline values were 'high'. However, the LDL-C/HDL-C ratio changed significantly and favourably in all groups. The fall in fasting triglyceride levels in all groups was greater (reaching 19-25%) when baseline levels were > or = 1.5 or 1.7 mmol/L (136-150 mg/dL). There were no marked abnormalities in liver function tests or creatine kinase activity. In Group 3 there was a significant trend for a fall in serum creatinine levels across the tertiles of baseline creatinine values. Limitations of the present study include the small sample size (especially in Groups 1 and 2), its short-term duration and the absence of event-based end-points. Therefore, the results are hypothesis-generating rather than conclusive.

CONCLUSIONS

When used alone or added to a statin, ezetimibe favourably altered the LDL-C/HDL-C ratio and lowered triglyceride levels. Ezetimibe was well tolerated in patients with statin intolerance and was associated with a 26% fall in LDL-C. An additional action may be some degree of improved renal function. Further studies are needed to confirm these findings.

Reducing the risks of cardiovascular disease in liver allograft recipients

Liver allograft recipients are at increased risk of death from cerebrovascular and cardiovascular disease. We propose the following strategy of risk-reduction, based on currently available literature. Lifestyle: standard advice should be given (avoidance of smoking, excess alcohol and obesity, adequate exercise, reduction of excess sodium intake). Hypertension: target blood pressure should be 140/90 mmHg or lower, but for those with diabetes or renal disease, 130/80 mmHg or lower. For patients without proteinuria, antihypertensive therapy should be initiated with a calcium channel blocker and for those with proteinuria, an angiotensin-converting enzyme (ACE) inhibitor or angiotensin II receptor blocker. If monotherapy fails to achieve adequate response, calcium channel blockers and ACE-inhibitors or angiotensin II receptor blockers should be combined. If hypertension remains uncontrolled, an alpha-blocker may be added. Consideration should be given to changing immunosuppression and avoiding use of calcineurin inhibitors. Diabetes: recipients should be regularly screened for diabetes. For patients with new-onset diabetes after transplant, stepwise therapy should be guided by HbA1c concentrations, as with type II diabetes mellitus. Hyperlipidemia: annual screening of lipid profile should be undertaken, with treatment thresholds and targets based on those advocated for the high risk general population. Dietary intervention is appropriate for all patients. A statin should be considered as the first line treatment to achieve specified targets. In patients receiving a calcineurin inhibitor, Pravastatin should be commenced at a dose of 10 mg/day. In patients receiving other forms of immunosuppression, pravastatin may be commenced at a dose of 20 mg/day. Liver tests should be monitored and patients warned to report myalgia. If monotherapy is inadequate, ezetimibe or a fibrate may be added. Consideration may be given to change in immunosuppression if combination lipid-lowering therapy proves inadequate.

The unique character of cardiovascular disease in chronic kidney disease and its implications for treatment with lipid-lowering drugs

Although the risk for cardiovascular disease (CVD) is high in individuals with chronic kidney disease (CKD), there are very limited data to guide the use of lipid-lowering drugs (LLDs) in this population because the major trials of LLDs in the general population have included very few individuals with CKD. The pathophysiologic and epidemiologic differences of CVD in the CKD population suggest that the study findings derived in the general population may not be directly applicable to those with CKD, and the few trials that have been directed at patients with kidney disease have not shown clear clinical benefits of LLDs. The National Kidney Foundation Kidney Disease Outcomes Quality Initiative (K/DOQI) Work Group has provided consensus-based guidelines for managing dyslipidemias in individuals with CKD and after renal transplantation. Since the publication of these statements, further data have emerged and multiple studies are ongoing to define better the role of LLDs in patients with CKD. In this article, the data that are pertinent to the CKD population are reviewed, and updated recommendations for use of LLD in the CKD population are provided.

Treatment of Hypercholesterolemia With Ezetimibe in Cardiac Transplant Recipients

The purpose of this study was to examine the efficacy and tolerability of ezetimibe in cardiac transplant recipients who were intolerant of 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) or unable to reach target lipid levels with statin therapy. After treatment with ezetimibe (n = 16), mean total and low-density lipoprotein cholesterol levels decreased significantly (228 +/- 40 mg/dl to 197 +/- 48 mg/dl, p = 0.003; and 149 +/- 34 mg/dl to 117 +/- 39 mg/dl, p < 0.001, respectively). One patient required a reduction in ezetimibe dose owing to myalgias; no other adverse events occurred. This initial experience indicates that ezetimibe is well tolerated in cardiac transplant recipients and is effective in reducing total and low-density lipoprotein cholesterol levels.

Review article: medical management of the liver transplant recipient - a primer for non-transplant doctors

BACKGROUND

Survival 10 years after orthotopic liver transplantation now approaches 65%. Consequently, community doctors must manage the metabolic and neoplastic complications of orthotopic liver transplantation in an ageing population.

AIMS

To review common sources of morbidity and mortality in long-term orthotopic liver transplantation recipients, and to make evidence-based recommendations regarding their management.

METHODS

Pertinent studies and reviews were identified by literature search through PubMed. Where evidence-based recommendations could not be gleaned from the literature, expert opinion was obtained from syllabi of national meetings.

RESULTS

The two most common causes of morbidity and mortality in orthotopic liver transplantation recipients are atherosclerotic vascular disease and de novo malignancy. The pathogenesis of many complications begins before orthotopic liver transplantation, and many are potentially modifiable. Most complications, however, can be directly ascribed to immunosuppressive agents. Despite improvements in our understanding of the pathogenesis and epidemiology of the metabolic and neoplastic complications of orthotopic liver transplantation, remarkably few randomized-controlled studies exist to define their optimal management.

CONCLUSIONS

Orthotopic liver transplantation recipients experience and succumb to the same afflictions of old age as non-transplant patients, but with greater frequency and at an earlier age. Most recommendations regarding surveillance for, and treatment of, medical complications of orthotopic liver transplantation remain based upon expert opinion rather than evidence-based medicine.

Non-low-density lipoprotein cholesterol-associated actions of ezetimibe: an overview

Ezetimibe, an intestinal cholesterol absorption inhibitor, lowers circulating low-density lipoprotein cholesterol (LDL-C) levels both when administered as monotherapy and in combination with other hypolipidaemic drugs, mostly statins. This review focuses on the effects of ezetimibe on non-LDL-C-associated variables. In most studies, ezetimibe effectively reduced triglyceride and increased high density lipoprotein cholesterol levels. The authors also consider the effect of ezetimibe on other variables such as C-reactive protein levels, insulin sensitivity and endothelial function. Ezetimibe is useful in patients with sitosterolaemia (a rare inherited disorder) as it significantly reduces plasma phytosterol concentrations. Ezetimibe fulfils two of the three essential characteristics of any drug (efficacy and safety). However, clinical studies are required to provide evidence of its ability to reduce vascular events.