Sunday, August 16, 2009

Post Transplant Watch: High Blood Pressure

After a kidney transplant, there are a number of health issues that doctors will ask you to watch out for. Often, most of the kidney related problems that appeared when you had kidney disease go away after having a kidney transplant. There are some, however, that will remain even after a successful kidney transplant.

This is a part of a series that I call Post Transplant Watch, where we will look at the different issues that may linger after kidney transplantation and steps doctors often take to treat them.

We begin with the most common problem and main cause of transplant (graft) loss-- cardiovascular disease or heart disease. Because there are many things that lead to cardiovascular disease, we will go through them one at a time, beginning with high blood pressure.

You will notice a number of levels listed below. Beginning with level 1, we start to solve the problem, in this case hypertension. If that doesn't work, we move on to the next level to see if that works better, and so on. These are the steps I've noticed doctors take in dealing with particular issues.

I hope this can be a guide for you so you will have an idea about what your doctor doing. Remember, this is meant to give you an idea of what to expect and is not a substitute to your doctor's advice. Only your doctor will be able to tell you what to do because they know your medical history.

Here goes.

Level 1: Target BP: less than 130/85

How? Weight loss if overweight, limit salt in diet or low sodium diet, reduce alcohol intake, increase exercise.

This is the best way to do it, without any drugs or medication. All natural. Your doc will probably want to have your BP at 120/80 or 110/70.

If these aren't able to control blood pressure, we proceed to level 2.
Level 2: Calcium channel blockers
What? Calcium channel blockers (CCBs) are blood pressure medications. Often the first line of defense used by doctors for high blood pressure in kidney transplant patients.

Research has shown that they help improve renal function by controlling blood pressure. The also protect you from the hypertensive effects of CNIs like cyclosporine and tacrolimus. Examples are amlodipine and lercanidipine.
Level 3: ACE Inhibitors and ARBs
What? These are 2 different classes of blood pressure medication. ACE inhibitors and ARBs work differently to achieve the same goal — lower blood pressure. Often you will be told to take one or the other with most doctors favoring the use of ACE inhibitors first before trying ARBs if the ACE inhibitors don't work well enough or produce side effects.

There are times that either ACE-I and ARBs aren't able to achieve the desired results on their own. In this case, the some doctors will use a combination of an ACE inhibitor and ARB.

The reason why CCBs are tried before ACE-I or ARBs is because the latter two have more side effects. One very known side effect is coughing. Increase in creatinine level and anemia in some patients also happen.

There is one instance though, where your doctor may opt to use an ACE inhibitor or ARB over a CCB. This is when there is protein in your urine. ACE-I and ARBs are known to have anti-proteinuric effects. And by lessening the amount of protein spilled in the urine, it protects the kidney.

Examples of ACE inhibitors are lisinopril and ramapril, while valsartan, losartan and candesartan are some known ARBs.
Level 4: Beta-Blockers
What? Beta blockers are yet another type of blood pressure drug. They work differently from those mentioned above and are known to be used for coronary heart disease.

They should be avoided for people with asthma. One example of a beta blocker is atenolol.
Level 5: Immunosuppressive medication adjustments
Why? Some doctors may actually try this before level 2. The reason I place this here is that adjusting medication is risky and often more troublesome. Having your kidney transplant medication adjusted may cause possible rejection if you become under suppressed. It also means that you'll probably be having labs done more often in the coming weeks to monitor if everything is okay with the change.

That said, lowering steroid doses helps in bringing down blood pressure. Another well known anti-rejection drug that causes hypertension are CNIs, like cyclosporine (Neoral) and tacrolimus (Prograf), so keeping it within therapeutic range will be helpful.
One thing to remember is that not everyone will have to deal with these issues. At times, these issues are caused by kidney transplant medications themselves. If you do happen to notice them make sure to inform your doctor so they can treat it accordingly.

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1 comment:

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