Complementary and integrative medicine in kidney transplantation.

PURPOSE OF REVIEW: Complementary and integrative medicine (CIM) use is widely prevalent in kidney transplant recipients but studies of efficacy or potential harm are sparse. This review examines prevalence of use of CIM and discusses potential beneficial and harmful aspects of CIM in renal transplant recipients. RECENT FINDINGS: The prevalence of CIM use in kidney transplant patients varies from 12 to 45%. There is a knowledge gap regarding CIM modalities among healthcare professionals that may contribute to reluctance to discuss CIM use with patients. Patients often do not spontaneously disclose its use, and those that use it may be more likely to be nonadherent to allopathic therapies. Herbal supplements may be nephrotoxic or interact with pharmaceutical agents, including calcineurin inhibitors. More data are needed to assess the potential benefits of other modalities of CIM, including yoga, Tai Chi or meditation, as these modalities have been beneficial for people with diabetes or hypertension, both of which are common in the posttransplant period. SUMMARY: Despite a high prevalence of CIM use in kidney transplant recipients, data are limited regarding risks and benefits. Education of healthcare providers who care for kidney transplant recipients should be encouraged. Intervention studies should be designed to investigate the CIM modalities, including yoga, meditation and Tai Chi that have been shown to be beneficial in other chronic diseases.

Complementary Medicine Use, Symptom Burden and Non-Adherence in Kidney Transplant Recipients.

BACKGROUND: Complementary Medicine (CAM) is often used by patients with chronic illness and may not be disclosed to health care providers without prompting. In other populations, patients who use CAM were more likely to alter medications without discussing it with their provider. This study examined the relationship between self-reported use of CAM, attitudes toward care, and adherence to medical therapy in a population of inner-City kidney transplant recipients. METHODS: Cross-sectional observational analysis in a random convenience sample from the outpatient transplant clinic. Data were obtained via face-to-face structured closed-ended interview using validated survey instruments. RESULTS: 45% of patients reported using CAM. Of the study participants who used CAM, 39.1% reported non-adherence to immunosuppressant medications within the past three months, while among the non-CAM users, 17.9% reported non-adherence (p value=0.084). Adherence to hypoglycemic medication was significantly lower CAM users,(p=0.029). Patients who reported having somatic symptoms were more likely to use CAM. Symptom sum was significantly associated with CAM use, p=0.030, with 47.8% CAM users reporting skin problems vs. 10.7% non-CAM users,p=0.003 and 17.4% CAM users noting loss of appetite, compared to 3.5% of non-CAM users,p=0.002 In a random subgroup of 26 patients, 15% who did not use CAM reported medication side effects, while 53% of CAM users reported them, p =0.039. CONCLUSIONS: Use of CAM was common in our kidney transplant population. Patients who use CAM reported more somatic symptoms, more medication side effects and were more likely to be non-adherent to non-immunosuppressant medications. Positive response to questions about CAM use may be a surrogate marker for high symptom burden and risk of non-adherence to non-immunosuppresion medications in kidney transplant recipients.

Potential benefits of complementary medicine modalities in patients with chronic kidney disease.

Use of complementary and alternative medicine (CAM) by the general population is common, and, although potential for harm exists, evidence is accumulating that several modalities, including acupuncture, massage, relaxation response/guided or integrative imagery, meditation, and herbal supplements, have actions that are beneficial for patients with chronic illness. Potential areas in which CAM might benefit patients with kidney disease include prolonging time of progression to kidney failure as well as treatment of concomitant problems, including arthritides, pruritus, cardiovascular risk factors, anxiety, depression, and fatigue, as well as hepatoprotection and treatment of uremic bruising. Although no systematic survey of prevalence of use has been performed in patients with chronic kidney disease and much research remains to be done so that safety and efficacy issues can be resolved, it is likely that many patients are using the services of CAM providers without the knowledge of their nephrologists. Thus, it behooves us to become conversant in these therapies so that we may hold open dialogues with our patients, discouraging potentially harmful treatments, suggesting potentially helpful ones, and monitoring them for effects, both beneficial and harmful.

Management of the well renal transplant recipient: outpatient surveillance and treatment recommendations.

Although renal transplantation offers survival and quality of life advantages as a renal replacement therapy, a substantial proportion of transplant recipients develop worsening of preexisting medical diseases or new complications, including sequelae of rejection, new onset diabetes after transplantation (NODAT), hyperlipidemia, opportunistic infections, cancer, and other systemic diseases secondary to immunosuppression. Management of these problems can be a complex endeavor due to medication interactions that often affect immunosuppression levels. However, successful management of the chronic medical problems associated with renal transplantation can prolong the life span of the graft and the patient.

Allograft diabetic nephropathy may progress to end-stage renal disease.

Mesangial expansion and glomerular basement membrane thickening characteristic of diabetic nephropathy recur in diabetic recipients of renal allografts from non-diabetic donors but progression to renal failure is minimally documented. Three female renal allograft recipients (aged 40, 62 and 73 yr), who developed end-stage renal disease (ESRD) due to recurrent diabetic nephropathy (two patients) and de novo diabetes (one patient) are reported. Onset of proteinuria, uncontrolled hypertension, azotemia, renal allograft pathologic findings and the need for hemodialysis were analyzed. None of the kidney donors (one cadaver, two living related) had known diabetes or perturbed glucose metabolism pre-transplantation. The three patients presented had different varieties of diabetes; type 1, type 2 and new onset diabetes after transplantation (NODAT). In each subject, proteinuria was detected by dipstick at a mean of 8.3 yr (range 8-9) post-transplantation and increased to the nephrotic range (3.7-4.8 g/day) inducing hypoalbuminemia and azotemia. A histopathologic diagnosis of allograft diabetic nephropathy was made in a mean of 11.7 yr (range 10-14), based on glomerular basement membrane thickening, nodular and diffuse intercapillary glomerulosclerosis, arteriolosclerosis, and tubular atrophy with marked tubular basement membrane thickening characteristic of advanced diabetic nephropathy. All three patients manifested uremia and resumed hemodialysis. Two patients died from sepsis within 2 months and one patient died 2.5 yr later after resumption of maintenance hemodialysis. We infer that recurrent or de novo diabetic nephropathy in renal allografts follows a clinical decade-long course irrespective of diabetes. Reports of ESRD due to allograft diabetic nephropathy (ADN) have been limited because of shorter survival of diabetic transplant recipients and few kidney biopsies performed in patients with chronic allograft dysfunction. The occurrence of allograft diabetic nephropathy in some, but not all patients, however, suggests that individual genetic variability modulates disease expression.