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. Read more...

The Issue of Generic Cellcept

Earlier this year, the generic version of Cellcept came into the market after Roche's patent on Cellcept expired in May of this year. This was and is still a much discussed topic. On the issue of kidney transplant medication or immunosuppressive medication as a whole, the issue of generics is a very touchy subject.

There are actually two main causes of this, on one side, is cost. Transplant medications are very expensive. Depending on what doses and which drugs you are on, costs may range from high to exorbitant. Not to mention that, more often than not, you have additional drugs and supplements aside from the anti-rejection pills.

At the other end, is drug efficacy. How well does the generic drug, in this case Cellcept, stack up against the branded one. Patients who have had their transplants have been on the Cellcept brand for a while and are now facing the choice between the cheaper generic and costlier but proven brand.

The sad fact of the matter is, as much talk as there is, transplant patients may not really have a choice. Most patients have their transplant medications covered by some sort of health insurance. In most cases, it has been the insurance agency that is prompting the move to generic. For those who pay out of their own pockets, depending on where you source your immunosuppressive drugs, the cost difference between Cellcept and its generic may vary from 10% to more than 50%.

Doctors, on the other hand, are more hesitant. Given the option, they prefer that patients take the branded product. As a whole, they seem to agree that the difference in efficacy matters. Some say there is a 10% variance, others say the effects may be +15% or -15% the effect of the branded product depending on the person taking it.

Another thing they seem to agree is that though they prefer that we use the brand name, and should you shift to generic, to make sure to inform them so that they may monitor your progress and the cellcept blood levels closely during the initial conversion period.

So what has happened since?

Some transplant patients have avoided the generic because their doctors and clinics forbid it. Their doctors have provided branded scripts that explicitly state “no substitutions”, “use branded name”, “no substitutes,” “original as written” and the like.

Others have opted to add to their co-pays or pay for the extra cost it takes to have the branded name.

One creative method I've heard from few was they were asked to switch to Myfortic because the insurance didn't want the branded Cellcept.

There are also quite a number of transplants who have moved and are now using the generic. Some clinics have given it the go signal for their patients.

Generally, the generic seems to be working okay. Some have said they have no problems with it, others say it is less troublesome for their stomachs. Then again, I've also heard a few problems like stomach issues and skin problems, proving once again that everyone reacts differently to medication.

Luckily, my being on Myfortic allowed me to sidestep this issue. But whichever way you look at it, this is a learning lesson for all of us. It has happened before, with cyclosporine (Gengraf) and now Cellcept, and it will happen again.

Soon, Prograf will have a generic then all our other drugs will go past their patent. At least next time, we'll be better prepared.

Read more...

FDA warning on Cellcept and Anemia

The Wall Street Journal has reported that the U.S. Food and Drug Administration (FDA) is is warning doctors that organ transplant drug Cellcept, may cause a type of severe anemia. Recently, the FDA has asked Roche, the maker of Cellcept, to make stricter warning labels regarding the risks involved in using Cellcept.

The U.S. Food and Drug Administration on Friday warned doctors about a certain type of anemia in patients being treated with the Roche (ROG.VX) kidney-transplant drug Cellcept.

[...]

Last month, the FDA said it was requiring Roche and other manufacturers of certain drugs used to prevent the rejection of transplanted kidneys to warn of certain serious infections.

The drugs, including Cellcept, Myfortic by Novartis AG (NVS) and Wyeth's (WYE) Rapamune, already carry the agency's toughest boxed warning discussing their various risks.

The FDA said the drug labels must discuss an increased risk of "opportunistic infections," including activation of latent viral infections such as one caused by the BK virus.

The anemia the FDA is speaking of is PRCA or Pure Red Cell Aplasia. It is a severe form of anemia wherein the bone marrow ceases produce red blood cells because PRCA affects the production process of red blood cells within the bone marrow.

Like many other transplant medications, Cellcept carries a number of risks and produces a number of side effects. It is a very good drug in warding off rejection and is being used by close to 90% of transplant centers in the U.S.

As in many instances, with kidney transplants or organ transplants as a whole, the need for weighing the good against the bad and hopefully coming up with a harmonious balance is the key.

Read more...

EPO: Erythropoietin for Anemia

EPO, or erythropoietin, is a drug many kidney patients are familiar with. Just about everyone on dialysis has used one form or another of erythropoietin.

So what is it? And why is it important?

Erythropoietin is pronounced as e-ryth-row-po-e-tin. I actually had difficulty pronouncing it correctly in the when I first started using it. I spelled it out as it should be pronounced so you won't end up like me mumbling some funny word that made the doc scratch his head whenever I tried to say it.

Anyways, going back to our topic of discussion... let's rewind back to the functions of our kidneys, remember how the kidney produces erythropoietin in order to stimulate our bone marrow to produce red blood cells or blood? The problem with kidney disease is it causes the levels of erythropoietin produced by our kidney to go down, resulting in us becoming anemic.

One way medical science has learned to treat this is through the use of a synthetic (man-made) version of erythropoietin. And By injecting the synthetic erythropoietin, we supplement or replace that which isn't being made by our kidneys.

You will see doctors adjust your dosage on a weekly basis until they get the proper level that will allow you to maintain a healthy red blood level. So in case you were thinking, yes, this isn't a one-shot thing. It will likely be continuous until your kidneys can reproduce enough erythropoietin, which does happen for some after a kidney transplant.

The thing about erythropoietin is that it isn't fast acting. Often, it takes a around 2 weeks before you see improvement. Though I have seen cases where the docs pumped in a good amount of it that the hemoglobin values shot up within 3 days and kept going up.

So if it is slow acting, why not opt for blood transfusions instead, where the effects are immediate?

Whenever possible, you will notice that doctors will defer blood transfusions and opt to use EPO to boost red blood levels. This is because the risks that transfusions bring with them, which we mentioned here, are far heavier than those of EPO.

The exception to this rule is when your hemoglobin levels drop below 7, necessitating an immediate need to increase it.

Just for your information, there are three major types of erythropoietin currently available.

- epoetin alpha brand names Eprex®, Epogen® and Procrit®
- epoetin beta, under NeoRecormon® and Mircera®
- darbepoetin, branded as Aranesp®

We'll go through their differences in a later post so you can get a better grasp on the available options.

Read more...