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Over the past few years, multiple immunosuppressant agents have become available. This means that the transplant physician is now able to tailor the transplant recipient's medication regimen according to his or her unique characteristics or other ongoing illnesses.

One of the reasons for customizing transplant medication regimens is the risk of some long-term complications related to the immunosuppressive agents. We've all heard the concerns about gaining too much weight and eating too much cholesterol. This is especially concerning for transplant recipients since the long-term complications that can occur include post-transplant obesity and hyperlipidemia. Hyperlipidemia, or increased cholesterol and/or triglycerides in the blood, over time, can lead to cardiovascular disease. Heart disease is the primary cause of death in stable organ transplant recipients. In other words, organ preservation, surgical technique, post-operative care and the immunosuppressants available today are improving the life of the transplanted organ. But, recipients are primarily succumbing to cardiovascular illness.

Hyperlipidemia can occur early after the transplant procedure. Heart and kidney transplant patients may have had hyperlipidemia prior to their transplant as part of their overall illness, as is often the case with diabetes or heart failure syndrome. Therefore, the receipt of a new heart or kidney may not prevent the continued presence of the increased lipids. It simply gives the recipient a new heart or kidney that has not been exposed to hyperlipidemia. In addition, numerous transplant medications may worsen the already present hyperlipidemia.

Coronary artery disease (CAD), when the arteries supplying the heart become blocked with fatty substances, is the most worrisome effect of hyperlipidemia. A long-term consequence of CAD is the need for heart surgery, such as a coronary artery bypass graft (CABG); replacing the diseased coronary arteries with less diseased ones. Some risk factors for the development of hyperlipidemia include an increase in lipid levels before surgery, older age, diet, increased blood sugars, weight gain, steroid use, worsening kidney function and cyclosporine (Neoral®, Sandimmune®, Gengraf®). Some studies have suggested that a tacrolimus-based (Prograf®) regimen has been associated with lower cholesterol levels than a cyclosporine-based one. The most notable and significant side effect of the new immunosuppressant, sirolimus (Rapamune®) is hyperlipidemia. This effect of sirolimus may add to the already present hyperlipidemic effect of cyclosporine and/or steroids.

In addition to some immunosuppressants, other medications that transplant recipients are often prescribed have been known to cause or worsen hyperlipidemia. These include certain high blood pressure medications such as the thiazide diuretics (hydrochlorothiazide, etc.) and the beta-blocking agents (propranolol, metoprolol, etc.). Lipid levels may start to improve in three to six months following transplantation as the doses of prednisone and cyclosporine are reduced. However, the majority of patients will require some type of intervention.

Exercise is an important part of lifestyle modification. Physical activity reduces the so-called "bad" cholesterol, LDL and VLDL, and improves the levels of the "good" cholesterol, or HDL. Not only is exercise beneficial on the lipid profile, but also reduces total body weight, strengthens muscle tone and improves cardiovascular performance. In addition to exercise, treatment of hyperlipidemia usually requires dietary changes and medication. Transplant recipients who are at risk, may be encouraged to follow the guidelines established by the National Cholesterol Education Program. This program consists of specific guidelines for diet and medication usage. The cornerstone of this program stresses the need for a reduction in dietary intake of total fat, saturated fat, and cholesterol. Reducing saturated fat in the diet appears to have the most effect in the overall reduction of cholesterol. For patients whose hyperlipidemia is not controlled by at least three months of dietary therapy, treatment with medications should be considered.

Many transplant centers have had a growing interest in the use of the class of drugs called "statins" for the treatment of hypercholesterolemia. Technically, these drugs are also referred to as HMG-CoA reductase inhibitors. They primarily block the production of cholesterol. Because of their potency, the statins are often considered first-line therapy in the treatment of hyperlipidemia. Some examples of these drugs include atorvastatin (Lipitor®), pravastatin (Pravachol®) and simvastatin (Zocor®). In addition to being very effective at lowering cholesterol levels, there is increasing evidence that this class of drugs may also improve the survival of the transplanted organ. The statins are relatively safe medications; however, they may cause muscle soreness, pain or weakness.

One primary concern with muscle weakness and the use of statins is a condition known as rhabdomyolysis. Rhabdomyolysis is a breakdown of the skeletol muscle tissue with the inability to clear the breakdown products through the kidney. Left untreated, rhabdomyolysis can lead to kidney failure, so it's important to contact your transplant team if you experience any changes with your muscle strength. To minimize the chance of these side effects occurring, your transplant team may monitor for this as part of your routine blood tests. Other lipid-lowering drugs are also used; however, they may have potential complications such as drug interactions or increased side effects. The vitamin, niacin, is very effective in lowering lipids in the nontransplant patient, but its use in the transplant population may require strict monitoring of liver function tests, particularly in the case of a liver transplant. This applies to the agent gemfibrozil (Lopid®) as well. Gemfibrozil, if given in combination with a statin agent can also increase the risk for developing rhabdomyolosis. The bile acid-binding agents, cholestyramine and colestipol, are also effective in cholesterol reduction. When used with cyclosporine, however, the administration of either drug should be spaced out appropriately to minimize an important drug interaction. The absorption of cyclosporine into the bloodstream is hindered by the presence of cholestyramine or colestipol.

Hyperlipidemia is very common in transplant recipients. If left untreated, it can cause significant problems with your cardiovascular and overall health and well-being. Your transplant team can work with you on the appropriate management of this condition, including lifestyle and dietary changes, as well as medication. With the variety of transplant medications available today, your transplant physician may also tailor your regimen according to your specific needs. As with any medication that you may be prescribed, in addition to your immunosuppressants, it is important that you discuss any issues you may have with your physician or pharmacist.

Information in this Web site is intended to supplement, not replace, the medical advice you receive from your healthcare providers. If you have a question regarding any information contained in this Web site and how it pertains to your personal condition, please consult your physician.

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