Dislipidemia post-trapianto

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Pubblicato il 10 novembre 2016

Dyslipidemia in Kidney transplant recipients

Dislipidemia post-trapianto

Dyslipidemia in Kidney transplant recipients

Giovanni Mosconi, Camilla Gambaretto, Loretta Zambianchi, Maria Francesca Lifrieri, Marco De Fabritiis, Stefania Cristino, Claudio Americo, Maria Laura Angelini

Unità Operativa di Nefrologia e Dialisi - Ospedale Morgagni Pierantoni Forlì

Corrispondenza a: Giovanni Mosconi; Tel: +39 0543735300, +39 0543735312; E-mail: giovanni.mosconi@auslromagna.it

Abstract

La popolazione con trapianto di rene presenta marcate alterazioni dell’assetto lipidico con ipercolesterolemia (totale, LDL, VLDL), normali valori di HDL, ipertrigliceridemia. Molteplici fattori concorrono allo sviluppo di dislipidemia favorita anche dalla terapia immunosoppressiva; l’impatto sugli effetti cardiovascolari risulta meno definito rispetto alla popolazione generale. Il lavoro si ripropone una rivalutazione della gestione clinica della dislipidemia alla luce della letteratura e delle più recenti Linee Guida. L’impiego di statine nella popolazione trapiantata adulta (eventualmente associate ad ezetimibe) risulta sicuro e costituisce un approccio con buon rapporto costo/benefici. Altri farmaci ipolipemizzanti non sono solitamente consigliati per l’elevata incidenza di effetti collaterali (miopatia, alterazioni epatiche). Sempre maggior rilevanza assume il ruolo di adeguati stili di vita che nella popolazione pediatrica costituiscono il solo approccio terapeutico consigliato.

Abstract

The kidney transplant recipients' population shows pronounced alterations of the lipidic profile, with hypercholesterolemia (total cholesterol, LDL, VLDL), normal HDL and hypertriglyceridemia. Multiple factors contribute to the development of dyslipidemia, towards these, immunosuppressive therapy plays an important role. The impact on cardiovascular outcomes is less well defined than in general population. This work is a revaluation of the clinical approach to dyslipidemia in kidney transplant based on the more recent Guide Lines and literature. The use of statins in an adult transplanted population (eventually associated with ezetimibe) is safe and is a good compromise in terms of a cost/benefit analysis. Other hypolipidemic drugs are not usually suggested for the high incidence of side effects. Lifestyle changes are taking more and more relevance, and in the pediatric population is the only therapeutic act suggested.

Tabella 1. Principali effetti dei farmaci immunosoppressivi sull’assetto lipidico

Farmaco	Col totale	Col LDL	Col HDL	Trigliceridi
Ciclosporina	aumento moderato	aumento moderato	riduzione	aumento moderato
Tacrolimus	aumento lieve	aumento lieve	riduzione	aumento lieve
Sirolimus/Everolimus	aumento moderato	aumento moderato	riduzione	aumento severo
MMF/Azatioprina	non influenzato	non influenzato	non influenzato	non influenzato
Prednisone	aumento lieve	aumento lieve	aumento lieve	aumento lieve
Deflazacort	aumento lieve	aumento lieve	aumento moderato	aumento lieve

(adattata da Badiou et al)

Tabella 2. Gestione della dislipidemia in pazienti con trapianto di rene

Grado di evidenza		Raccomandazioni
1C non valutato 1C	Valutazione stato lipidico (adulti e pediatrici) Follow-up (pz adulti) Follow-up (pz pediatrici)	Valutazione basale del profilo lipidico (colesterolo totale, LDL, HDL, trigliceridi) Follow-up laboratoristico non richiesto per la maggior parte dei pazienti Annuale
2A 2C	Trattamento ipercolesterolemia (pz adulti) Trattamento ipercolesterolemia (pz pediatrici)	Statine (possibilità di impiego di ezetimibe in associazione o meno con statine) Non suggerito utilizzo di statine o ezetimibe
2D	Trattamento dell’ipertrigliceridemia (pz adulti, pz pediatrici)	Cambiamenti dello stile di vita (nella popolazione adulta possibilità di impiego di statine)

Grado di evidenza

Raccomandazioni

non valutato

Valutazione stato lipidico (adulti e pediatrici)

Follow-up (pz adulti)

Follow-up (pz pediatrici)

Valutazione basale del profilo lipidico (colesterolo totale, LDL, HDL, trigliceridi)

Follow-up laboratoristico non richiesto per la maggior parte dei pazienti

Annuale

Trattamento ipercolesterolemia (pz adulti)

Trattamento ipercolesterolemia (pz pediatrici)

Statine (possibilità di impiego di ezetimibe in associazione o meno con statine)

Non suggerito utilizzo di statine o ezetimibe

Trattamento dell’ipertrigliceridemia (pz adulti, pz pediatrici)

Cambiamenti dello stile di vita (nella popolazione adulta possibilità di impiego di statine)

(KDIGO, adattata da Wanner et al)

Tabella 3. Impiego di statine in soggetti adulti con eGFR G3a-G5, inclusi trapiantati renali

Farmaco	mg/die
Lovastatina	Non studiata
Fluvastatina	80
Atorvastatina	20
Rosuvastatina	10
Simvastatina/Ezetimibe	20/10
Pravastatina	40
Simvastatina	40
Pitavasattina	2

(adattata da Tonelli et al)

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Contenuti articolo

release 1
pubblicata il 10 novembre 2016
Da

Giovanni Mosconi, Camilla Gambaretto, Loretta Zambianchi, Maria Francesca Lifrieri, Marco De Fabritiis, Stefania Cristino, Claudio Americo, Maria Laura Angelini

Unità Operativa di Nefrologia e Dialisi - Ospedale Morgagni Pierantoni Forlì

Corrispondenza a: Giovanni Mosconi; Tel: +39 0543735300, +39 0543735312; E-mail: giovanni.mosconi@auslromagna.it

Parole chiave: colesterolo, dislipidemia, statine, terapia, terapia immunosoppressiva, trapianto, trigliceridi

Key words: cholesterol, dyslipidemia, immunosuppressive therapy, statins, transplant, triglycerides

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