Cardiovascular morbidity and mortality after kidney transplantation

Abstract

Summary Kidney transplantation is the optimal treatment for patients with end stage renal disease (ESRD) who would otherwise require dialysis. Patients with ESRD are at dramatically increased cardiovascular (CV) risk compared with the general population. As well as improving quality of life, successful transplantation accords major benefits by reducing CV risk in these patients. Worldwide, cardiovascular disease remains the leading cause of death with a functioning graft and therefore is a leading cause of graft failure. This review focuses on the mechanisms underpinning excess CV morbidity and mortality and current evidence for improving CV risk in kidney transplant recipients. Conventional CV risk factors such as hypertension, diabetes mellitus, dyslipidaemia and pre‐existing ischaemic heart disease are all highly prevalent in this group. In addition, kidney transplant recipients exhibit a number of risk factors associated with pre‐existing renal disease. Furthermore, complications specific to transplantation may ensue including reduced graft function, side effects of immunosuppression and post‐transplantation diabetes mellitus. Strategies to improve CV outcomes post‐transplantation may include pharmacological intervention including lipid‐lowering or antihypertensive therapy, optimization of graft function, lifestyle intervention and personalizing immunosuppression to the individual patients risk profile.

Rola aktywności fizycznej w leczeniu pacjentów z przewlekłą chorobą nerek

“…Ryzyko roczne wystąpienia zdarzenia sercowo--naczyniowego zakończonego zgonem wynosi 3,5-5% i jest 50-krotnie większe niż w populacji ogólnej [10]. Do najczęściej stwierdzanych zaburzeń kardiologicznych u pacjentów po zabiegu transplantacji zalicza się: przerost lewej komory serca, kardiomiopatię, zastoinową niewydolność serca, chorobę niedokrwienną serca, nadciśnienie tętnicze czy cukrzycę potransplantacyjną [11,12]. Obserwowany wzrost liczby chorych oczekujących na transplantację powoduje, iż w najbliż-szym czasie tendencja ta nie ulegnie zmianie.…”

Practical Recommendations for Long-term Management of Modifiable Risks in Kidney and Liver Transplant Recipients

“…291 Compared with the nondialysis general population, age-, race-, and sex-matched kidney transplant recipients (25-55 years) have a significantly higher CVD mortality. 292 Metabolic disorders, such as diabetes, hyperlipidemia, arterial hypertension and proteinuria are widely observed in liver and kidney transplant recipients, [293][294][295] and are risk factors for CVEs. Marked increases in these disorders are evident after both liver and kidney transplantation.…”

“…Registry data show that CVD accounts for 18% to 30% of premature deaths among kidney transplant recipients, 292 and almost 40% of kidney transplant recipients experience a CVE in the first 3 years posttransplant. 301 In a UK registry study, cardiovascular and cerebrovascular events, combined, were the leading cause of death (22.9%) in the first year postkidney transplantation, accounting for more deaths than infection (21.6%).…”

“…Pretransplant risk factors for CVEs include conventional demographic (and nonmodifiable) factors, such as age (young age in kidney transplantation and older age in liver transplantation), sex, race, preexisting conditions, such as diabetes, ischemic heart disease, duration of dialysis for kidney transplant recipients, smoking and general patient health (Figure 12). 289,292,313,314 Posttransplant risk factors for CVEs include NODAT, hypertension, impaired glucose tolerance, 288,289,292,315 impaired kidney function 295,316 and posttransplant hyperglycemia (Table 11 and Figure 12). 317,318 In clinical trials and registry studies in kidney transplantation, hypertension shows a strong association with major adverse cardiovascular event (MACE), as well as graft failure and mortality 289 ; increased systolic and pulse pressuremarkers of vascular stiffness-are specifically associated with cardiac death and stroke.…”

“…289 Furthermore, CNIs and steroids play a major role in the development of hypertension in kidney transplant patients; therefore, modifications of immunosuppressive regimen may be considered for lowering BP in these patients. 292,352 The changes in immunosuppressive drugs include CNI minimization, conversion from cyclosporine to tacrolimus, the use of CNI-free immunosuppressive regimens and avoiding steroids. 289 Although, BP control is particularly challenging in kidney transplant patients 292 ; in practice modification of immunosuppression is rarely done because of the potential risks of acute rejection and development of DSA.…”