The Impact of Total Gastrectomy on Pharmacokinetics in Kidney Transplant Immunosuppressive Drug Regimes: A Case Study.

BACKGROUND: Ensuring reliable gastrointestinal drug absorption of orally administered immunosuppressive medications posttransplant is critical to ensuring graft survival. METHODS: A 66-year-old man of East Asian origin with a previous total gastrectomy was evaluated for living donor kidney transplantation. Pretransplant pharmacokinetic testing was performed to determine the most appropriate posttransplant medication strategy. The Gastrointestinal Quality of Life Index and Gastrointestinal Rating Scale questionnaires were administered to gauge immunosuppressive medication-related side effects in the absence of a stomach. RESULTS: The patient's ability to absorb cyclosporin, tacrolimus (Tac), enteric-coated mycophenolate sodium (EC-MPS) and sirolimus (SRL) in oral dosage forms was well-preserved. Compared to nongastrectomy reference populations, the rate and extent of absorption of SRL and mycophenolic acid from EC-MPS were similar. The absorption of Tac and cyclosporin was greater than expected. Mycophenolate mofetil did not provide mycophenolic acid absorption as well as EC-MPS. The patient had worsened gastrointestinal symptoms with mycophenolate mofetil or EC-MPS in combination with Tac and cyclosporin, but this was not seen with isolated SRL. CONCLUSIONS: This case demonstrates that commonly used postkidney transplantation immunosuppressive regimes may be prescribed after total gastrectomy as long as their limitations are noted.

Rapid risk stratification for obstructive sleep apnea, based on snoring severity and body mass index.

OBJECTIVE: It is unclear whether all snoring patients require polysomnography, and there are no highly sensitive clinical predictors of sleep apnea. Our objective was to develop a simple clinical screening test for OSA in snoring patients. STUDY DESIGN: Prospective, IRB-approved study at a university sleep disorders center. SUBJECTS AND METHODS: In 211 patients undergoing polysomnography, snoring severity, Epworth sleepiness scale, body mass index, demographic, and sleep study data were collected. Receiver operating characteristic (ROC) analysis and Pearson correlation were used to develop a sensitive screening test for OSA. RESULTS: Snoring severity score (SSS) and BMI were the two most accurate predictors of OSA on the ROC curve. A bipartite threshold of SSS = 4 or BMI = 26 carried sensitivity of 97.4%, specificity of 40%, positive predictive value of 82.3%, and negative predictive value of 84.2% for moderate/severe OSA. Patients at high risk were those with BMI > or =32 (89% PPV) or SSS > or =7 (92% PPV). CONCLUSIONS: The statistic most predictive of OSA was snoring severity. Combining this with BMI yielded a highly sensitive screening test for moderate/severe OSA. This clinical assessment may be useful in risk-stratifying patients for polysomnography and therapy, facilitating deferred work-up in low-risk patients and expedited therapy in high-risk patients.