Transplant Digest - Fall 2010, Issue No. 9 - St. Michael's Hospital

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Smoking and kidney transplantation: Don’t let your kidney go up in smoke! Csaba Ambrus, M.D., Ph.D Cigarette smoking is an addiction that affects many people worldwide. Unfortunately, many patients with advanced kidney disease or already on dialysis and awaiting kidney transplant are smokers as well as a significant proportion, around 20% of kidney transplant recipients smoke regularly. The relationships of smoking with hypertension, cardiovascular disease and cancer are well known in the general population. Because of this evidence, smoking is usually highly discouraged by every health professional. If you happen to be a smoker who is awaiting a kidney transplant or already a lucky recipient with a working graft, or even if you are not affected but just curious, you might want to know: Are there any special considerations with cigarette smoking in kidney transplant patients Certainly, there are. According to a study of 4000 kidney recipients in the US, patients who smoked cigarettes had a 51% increased relative risk of graft failure, a 45% increased risk of mortality, and a 24% increased risk of acute rejection compared to non-smoker recipients. Increased risk of cardiovascular disease and death You might have heard about it, that if you have severe kidney insufficiency or are already on dialysis, your risk of cardiovascular disease is much higher (even 10-50-fold higher!) compared to others without kidney disease. Although somewhat less, your risk is still high as a kidney transplant recipient. There is no doubt about the association between smoking and cardiovascular events in the general population. This relationship is more pronounced in kidney transplant recipients and the already very high risk of any cardiac or cerebral event is amplified by smoking. A study of elderly kidney recipients in Quebec showed that smoking was the greatest modifiable risk factor of death after transplantation. These findings were later confirmed for younger recipients as well. The likelihood of an acute cardiac event within the first two years after transplantation was 3.5-fold higher in smokers compared to non-smokers. Not only cardiac events but also peripheral vascular disease is more common and more severe in smokers. Increased the risk of early rejection If you are a smoker awaiting transplantation, unfortunately, your risk of acute rejection early after transplantation is higher. Smokers had poor early transplant function and worse graft function one year after transplantation. The mechanism how smoking impacts the risk of acute rejection is not clear, but a few studies suggest that it might directly affect the immune system leading to rejection. Smoking accelerates loss of graft function It has been shown that smoking is a risk factor of worsening renal function in different renal diseases, such as diabetes, lupus, IgA nephropathy or polycystic kidney disease. After transplantation, smoking is a risk factor for progressive loss of graft function regardless of your original kidney disease. According to an earlier study, patients who smoked before transplantation had 2.3 fold higher risk of losing the kidney graft compared to non-smokers. In another report, patients who were smokers at the time of transplantation had inferior graft survival rates to patients who were nonsmokers: 65% at 5 years and only 48% at 10 years had functioning graft whereas those numbers were 78% and 62% in non-smokers, respectively. “patients who smoked cigarettes had a 51% increased relative risk of graft failure, a 45% increased risk of mortality, and a 24% increased risk of acute rejection compared to non-smoker recipients” The good news is that there seems to be a benefit to quitting, since patients who no longer smoke at the time of transplantation do better than current smokers: an earlier study showed that patients who quit smoking were not at higher risk of transplant loss compared to whose who never smoked. I should mention that donors’ smoking history also may affect graft function and survival. How does smoking affect the kidney Graft loss over the long term is a result of chronic changes in the kidney due to both immunological and non-immune factors. Those processes partly lead to changes of the blood vessels, resulting in stiffer and narrower blood vessels in the transplanted kidney. Similar damage to the blood vessels is caused by smoking and it clearly accelerates the process and contributes to the earlier decline of graft function. In addition, many other structures in the kidney changes in regular smokers. There are several other mechanisms underlying the adverse effects of smoking and the mechanisms are not yet fully understood. More than 4000 chemicals have been identified in smoke in the form of particles or gases; many of those can accumulate in the kidney (such as lead, cadmium, mercury, and silica) and those are toxic even in small quantities. In addition, nicotine has a great effect on the circulation increasing blood pressure and the resistance of peripheral blood vessels. It also has the ability to blunt the beneficial effect of certain blood pressure medication, even in the very short term after smoking only one cigarette. The blood flow inside the kidney is also greatly impacted by nicotine, letting it exposed to higher blood pressure and blood flow that can be detrimental over the long term. Increased risk of malignancy, infection and other consequences Cancer is a well known complication of transplantation, the risk of malignancy is 3-5 fold higher compared to the general population and cancers are usually 6
more aggressive. Age, sun exposure and smoking history are the most important predictors of cancer development. Various cancer types have been associated with smoking after transplantation, especially lung and lip cancer. Smoking will damage lung structure and also inhibit the natural clearance mechanisms of the airways. As a consequence, it puts you at greater risk for lung infections, bronchitis and pneumonia. Smoking also increases the acid production in your stomach and this will delay the healing any ulcers you may develop. It also impairs the ability of red cells to carry oxygen, so less oxygen will reach the tissues in the body and this decreases the ability to heal. All these effects are more severe if you take immunosuppressive medications. Furthermore, there are studies suggesting that smoking is also a risk factor for development of diabetes after transplantation. Is it worth quitting even if someone has been smoking for many years We do not have much evidence about the effect of smoking cessation on kidney function. However, as studies showed in the general population, the risk of any event related to smoking will decrease after quitting. As I earlier mentioned, patient who quit few years before transplantation had better graft function and their graft last longer compared to those who continued smoking. So it is never late to quit! How can I get help to quit smoking Weaning from smoking is a difficult process that needs the cooperation of both patient and health personal. It requires regular counselling and often drug support such as nicotine patch or other medication. Ask your doctor for help! I can give you few tips to help you quit: • Avoid beverages that contain caffeine! Caffeine, found in coffee, tea, and many soft drinks, can stimulate your urge to smoke again. • Drink more liquids and eat fruits during the first three non-smoking days, provided your kidney function allows you to do so (!!). Body fluids of smokers have high concentrations of nicotine; as these concentrations decrease nicotine cravings increase. Extra liquid can act as an alternative to cigarettes and help nicotine pass out of your body. • Use deep breathing! When the craving to smoke strikes, you should take slow, deep breaths. This will help you relax long enough to consciously decide not to smoke. It will also help supply your brain and the rest of the body with oxygen. Take in a deep breath with your mouth wide open, bend at the waist, and breathe out; repeat two or three times. Stop if you begin to feel dizzy. • Take your vitamins! Taking a B vitamin may help diminish the nervousness and mood swings that can occur when one tries to stop smoking. Take vitamin C if you are unable to eat fruit. Remember to consult your doctor before taking vitamins. • Exercise regularly! An aerobic workout, such as walking briskly, can improve lung capacity and vascular tone, and help prevent depression. Consult with your doctor or physiotherapist before beginning any exercise program. • Join a smoking cessation group! These groups can be helpful for discussing feelings and learning from others in the same situation. Check the Yellow Pages or your local heart, lung, or cancer society chapter to find a convenient group. It is not easy to give up smoking. You may become anxious or irritable. You may develop headaches, nervousness, dizziness, muscle cramps, fatigue, sleepiness, increased sweating, as well as difficulty focusing your attention, a loss of appetite, increased craving for food, or an intense craving to smoke. However, if you stick to your decision not to smoke, you will be breaking a habit that is harming your health and, in time, the “withdrawal” symptoms will diminish and you’ll feel better than ever before. Your ability to choose not to smoke grows stronger each time you repeat the choice. Instead of thinking about how much you want to smoke, remind yourself of smoking’s harmful effects and the health benefits that will be yours without smoking. References 1.Tips to quit smoking were taken from the homepage of the Columbia University, with minor modifications and without the author’s permission: http://www.cumc.columbia.edu/dept/cs/pat/kidneypancreastx/life.html 2.Cosio, F. G., Falkenhain, M. E., Pesavento, T. E., Yim, S., Alamir, a., Henry, M. L., et al. (1999). Patient survival after renal transplantation: II. The impact of smoking. Clinical transplantation, 13(4), 336-41. 3.Dantal, J., & Pohanka, E. (2007). Malignancies in renal transplantation: an unmet medical need. NDT, 22 Suppl 1, i4-10. 4.Gallagher, M. P., Kelly, P. J., Jardine, M., Perkovic, V., Cass, A., Craig, J. C., et al. (2010). Long-term cancer risk of immunosuppressive regimens after kidney transplantation. JASN, 21(5), 852-8. 5.Kasiske, B. L., & Klinger, D. (2000). Cigarette smoking in renal transplant recipients. JASN, 11(4), 753-9. 6.Nogueira, J. M., Haririan, A., Jacobs, S. C., Cooper, M., & Weir, M. R. (2010). Cigarette smoking, kidney function, and mortality after live donor kidney transplant. AJKD, 55(5), 907-15. 7.Orth, S. R., & Hallan, S. I. (2008). Smoking: a risk factor for progression of chronic kidney disease and for cardiovascular morbidity and mortality in renal patients--absence of evidence or evidence of absence CJASN, 3(1), 226-36. 8.Sezer, S., Bilgic, a., Uyar, M., Arat, Z., Ozdemir, F. N., Haberal, M., et al. (2006). Risk factors for development of posttransplant diabetes mellitus in renal transplant recipients. Transplantation proceedings, 38(2), 529-32. 9.Sung, R. S., Althoen, M., Howell, T. a., Ojo, a. O., & Merion, R. M. (2001). Excess risk of renal allograft loss associated with cigarette smoking. Transplantation, 71(12), 1752-7. 10.van Leeuwen, M. T., Grulich, A. E., McDonald, S. P., McCredie, M. R., Amin, J., Stewart, J. H., et al. (2009). Immunosuppression and other risk factors for lip cancer after kidney transplantation. Cancer epidemiology, biomarkers & prevention, 18(2), 561-9. 11.van Walraven, C., Austin, P. C., & Knoll, G. (2010). Predicting potential survival benefit of renal transplantation in patients with chronic kidney disease. CMAJ, 182(7), 666-72. 12.Yavuz, a., Tuncer, M., Gürkan, a., Demirbas, a., Süleymanlar, G., Ersoy, F., et al. (2004). Cigarette smoking in renal transplant recipients. Transplantation proceedings, 36(1), 108-10. 7
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Transplant Digest - Fall 2010, Issue No. 9 - St. Michael's Hospital

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