Evaluation and Management of Pulmonary Hypertension in Kidney Transplant Candidates and Recipients

Abstract

Although cardiac evaluation before kidney transplantation commonly focuses on coronary artery disease, a comprehensive pretransplant cardiac evaluation must consider other prognostically important cardiac conditions including functional and structural heart disease. Pulmonary hypertension (PH) is increasingly recognized among patients with kidney failure and may be driven by left heart failure, high cardiac output from arteriovenous fistula, hypoxic lung diseases, and metabolic derangements associated with renal disease. In this article, we examine several key concepts and controversies relevant to optimizing the assessment and management of PH in kidney transplant candidates and recipients. First, categorizing PH according to underlying pathophysiologies, hemodynamic characteristics, and treatment responses as currently defined by the World Health Organization can be challenging in this population, but should be pursued to direct appropriate management. Second, echocardiographic PH (based on variable definitions) has been reported in 13% to 50% of selected pretransplant cohorts, but use of more precise diagnostic methods is needed to better define epidemiology and underlying etiologies. Third, although measures of PH have been associated with adverse patient and graft outcomes after kidney transplantation, pilot data suggest that PH may improve with successful transplantation. Fourth, recent advances in PH treatment in the general population focus on World Health Organization group 1 pulmonary arterial hypertension, and the efficacy of management strategies for any PH type in patients with renal failure is largely unproven. Broader prospective data, including attention to the impact of transplantation, are needed to advance understanding of the frequency, causes, and optimal management of PH in kidney transplant candidates and recipients.

Diagnosis and Management of Cardiovascular Disease in Advanced and End‐Stage Renal Disease

“…It is essential to dialyze patients to their dry weights to prevent chronic volume overload and reduce the risk of development of PH, which is frequently observed in this patient population. 120,121 Compression of AVF for 1 minute has been shown to decrease cardiac output and pulmonary arterial pressure and may be a useful diagnostic maneuver to determine the reversibility of PH. 122 Given the massive capacitance of the pulmonary vasculature, increased cardiac output alone might not be the only driving force for the development of PH in patients on dialysis.…”

“…119,122 Treatment of PH Development of PH is associated with significant morbidity and mortality. [121][122][123][124][125] Patients on dialysis with PH have significantly lower survival rates than their counterparts without PH, with respective survival rates of 78.6% versus 96.5% at 1 year, 42.9% versus 78.8% at 3 years, and 25.5% versus 66.4% at 5 years. 126 Thus, patients with ESRD and severe PH should be referred to a PH specialist for PH-specific therapies.…”

“…Surgical reduction of AVF should be considered in patients with very high cardiac output in whom improvements in cardiac output and PH by temporary AVF closure has been shown. 121,122,126,127 An AVF flow rate ≥2 L/min and cardiac output of ≥8 L/min place patients at high risk of high-output cardiac failure. 128,129 The definitive treatment for PH in this population is renal transplantation if the etiology is secondary to high cardiac output from AVF.…”

“…20,125 Consultation with a PH specialist should also be considered early because therapy with phosphodiesterase type 5 inhibitors or endothelin receptor antagonists may be needed to facilitate renal transplantation in patients with refractory PH not secondary to AVF-dependent high cardiac output. 121 During surgery, systemic hypotension or abrupt increases in pulmonary artery pressures can cause right ventricular overload and lead to right ventricular systolic dysfunction and decreased cardiac output. Therefore, intraoperative invasive hemodynamic monitoring of pulmonary circulation should be considered.…”

Does diabetes impact therapeutic immunomodulation therapy decisions for kidney transplant recipients? Data from the Folic Acid for Vascular Outcome Reduction in Transplant (FAVORIT) trial

“…17 Although a reasonably low-risk group of patients with diabetes and renal disease can be identified and treated with successful renal transplant, recipients with diabetes demonstrated an excess risk for both cardiovascular and infectious events when compared to non-diabetic populations. [18][19][20][21] Successful prediction of subsequent cardiovascular events (SCVE) from a history of PCVE has been demonstrated for diabetic patients with impaired renal function. 22 In a small study of diabetic patients on long-term dialysis, we were unable to demonstrate this predictability; however, the populations were quite different.…”