Post-transplant dyslipidemia: Mechanisms, diagnosis and management

Table 1 Factors associated with lipid abnormalities after transplantation

Hypercholesterolemia	Hypertriglyceridemia
Genetic predisposition	Genetic predisposition
Age	Excessive dietary intake of carbohydrates, cholesterol, and saturated fat
Excessive dietary intake of cholesterol and saturated fats	Obesity
Obesity	Proteinuria
Proteinuria	Renal insufficiency
Anti-hypertensive agents, e.g., diuretics, beta-blockers	Corticosteroids
Corticosteroids	Mammalian target-of-rapamycin inhibitors (sirolimus)
Calcineurin-inhibitors (cyclosporine, possibly tacrolimus)
Mammalian target-of-rapamycin inhibitors (sirolimus, everolimus)

Table 2 A suggested approach to managing post-transplant dyslipidemia

Initial post-transplant period	Manage acute graft-related concerns
	Optimize immunosuppressive medication to graft function
2-3 mo post-transplant	Measure 8-12 h fasting lipid profile
If LDL cholesterol and/or triglyceride level above target1	Dietician consult
2-3 mo post-dietary intervention	Measure 8-12 h fasting lipid profile
If LDL cholesterol and/or triglyceride level still above target1	Initiate statin therapy, e.g., atorvastatin 10 mg/d or rosuvastatin 5 mg/d
	Assess for potential drug interactions
	Monitor creatine kinase and liver transaminase levels
2-3 mo post-statin initiation	Measure 8-12 h fasting lipid profile
If LDL cholesterol and/or triglyceride level still above target1	Repeat all of the above until targets are achieved. Increase statin dose as tolerated to a maximum acceptable dose with each measurement not at target. If targets are not achieved then consider adding a supplemental agent, e.g., ezetimibe 10 mg/d
If LDL cholesterol and/or triglyceride level still above target1	Consider consultation with lipid specialist
LDL and triglyceride target levels achieved	Annual monitoring of lipid levels. Consider more frequent monitoring for side effects
At all times post-transplant	Gauge overall cardiovascular risk

¹See text for relevant targets but also consult relevant local transplant and lipid society guidelines. LDL: Low density lipoprotein.