Treatment of dyslipidemia in kidney transplantation

ABSTRACT

Introduction: Lipid disorders are frequent after kidney transplantation (KT) and KT recipients are considered at high- or very-high cardiovascular risk. Among many concurring factors, a major role is played by immunosuppressants.

Areas covered: General measures to manage lipid disorders first include physical activity and diet counseling. Modulating the doses of immunosuppressants also improves dyslipidemia. When lipid-lowering drugs are necessary to control elevated plasma cholesterol and/or triglycerides, statins are the cornerstone for managing hypercholesterolemia. However, side-effects (e.g. myopathy, new-onset diabetes, and kidney graft dysfunction) may occur. In these cases, ezetimibe (which does not affect kidney function) alone or on top of statins for the severe cases, is suggested by the most recent Guidelines. Proprotein convertase subtilisin/kexin type9 inhibitors are promising but expensive and their use in KT is still limited.

Expert opinion: In KT recipients, statins should be used cautiously. Rather than using high-dose statin in difficult patients, an association with ezetimibe is suggested. While fibrates, niacin, and resins do not play a relevant role due to their erratic efficacy and common side-effects, new lipid-lowering drugs are emerging but their safety and efficacy in KT patients still need to be assessed.

KEYWORDS:

• Dyslipidemia
• kidney transplantation
• cardiovascular disease
• statins

Article Highlights

• Dyslipidemia is a frequent complication of KT and may concur in increasing the risk of CVD, the main cause of death in transplant population.

• The physiopathology of posttransplant dyslipidemia is multifactorial, but a main role is played by some immunosuppressive drugs, such as CNI (particularly cyclosporine), mTOR inhibitors, and glucocorticoids.

• Preventive measures include regular physical activity and a normo/hypocaloric diet with the preferential use of vegetables, fruits, whole grains, legumes, healthy protein sources, nontropical vegetable oils. In the presence of severe hypercholesterolemia, the use of cyclosporine, mTOR inhibitors and/or glucocorticoids should be limited, if possible, or the dosage reduced.

• Current treatment of hypercholesterolemia is based on statins. These drugs are usually well tolerated but their simultaneous administration with cyclosporine and mTOR inhibitors may alter the pharmacokinetics of either drugs.

• Little information is available about the use of new lipid-lowering drugs in KT.

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Declaration of interest

A Corsini has received honoraria from Novartis, Amgen, Sanofi, Merck, AstraZeneca, Recordati and Daiichi Sankyo. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.