Safety of statin therapy after liver transplantation

Purpose: Cardiovascular disease (CVD) remains a leading cause of long-term mortality in transplant patients. A risk factor for CVD is hyperlipidemia, where the treatment is statin therapy. The use of statins in liver transplant (LT) may be challenging because of drug interactions with immunosuppression and concerns over elevations in liver enzymes. There are insufficient data assessing the safety of statin therapy in LT. The objective of this study was to assess the incidence of transaminase elevation and safety of statin use after LT. Methods: A retrospective chart review of LT recipients at an academic medical center from January 2013 to December 2014 was performed. All LT recipients with ICD-9/10 codes of hyperlipidemia were eligible. Primary endpoint was an increase of greater than 2 times the baseline liver enzymes in patients on statin therapy compared to no statin. Secondary endpoints included adverse effects, rejection, and patient or graft survival. Bivariate analysis was performed. Results: Out of the 170 liver transplants completed, 123 patients had a diagnosis of hyperlipidemia. One hundred-four patients met inclusion criteria with 37 patients receiving statin therapy. Median time to statin initiation was 6 months post-transplant. There was no difference in the incidence of transaminase elevations in the statin arm compared to non-statin arm (51.4% vs. 35.8%; p=0.14). Adverse reactions were reported in 5.4% of patients on a statin. One patient on atorvastatin 40 mg complained of myalgias, but subsequently tolerated pravastatin 20 mg. The other patient on simvastatin 40 mg experienced elevations in transaminases and was discontinued, but was restarted 5 months later without effect on liver enzymes. Thirty-one patients receiving calcineurin inhibitors were on a statin compared to 6 patients on mammalian target of rapamycin inhibitors. Majority of patients on statin therapy received a moderate intensity statin (59.5%) per ACC/AHA guideline. Only 8.1% (n=3) patients in the statin arm had an episode of rejection compared to 29.9% (n=20) in the non-statin (p=0.01). There was no difference in graft or patient survival. Conclusion: In this study, the use of statin therapy after LT did not cause significant elevations in liver enzymes. Although there was no difference in patient or graft survival, the statin arm had significantly less episodes of rejection. Further investigation is needed to determine if statin use decreases the incidence of rejection. With monitoring, statins appear safe to use in LT recipients