FP730ARTERIAL Hypertension as a Risk Factor for Renal Disease in Living Kidney Donors (original) (raw)
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International Journal of Nephrology and Renovascular Disease, 2013
Background: For suitable patients with end-stage renal disease, kidney transplantation (KT) is the best renal replacement therapy, resulting in lower morbidity and mortality rates and improved quality of life. Preemptive kidney transplantation (PKT) is defined as transplantation performed before initiation of maintenance dialysis and reported to be associated with superior outcomes of graft and patient survival. In our study, we aimed to compare the 5-year outcomes of PKT and nonpreemptive kidney transplantation (NPKT) patients who received KT in our center, to define the differences according to complications, comorbidities, adverse effects, clinical symptoms, periodical laboratory parameters, rejection episodes, graft, and patient survival. Methods: One hundred kidney transplantation (37 PKT, 63 NPKT) recipients were included in our study. All patients were evaluated for adverse effects, complications, comorbidities, clinical symptoms, monthly laboratory parameters, acute rejection episodes, graft, and patient survival. Results: Acute rejection episodes were found to be significantly correlated with graft loss in both groups (P = 0.02 and P = 0.01, respectively). Hypertension after transplantation was diagnosed by ambulatory blood pressure measurement in 74 of 100 patients. Twenty-five of 37 (67.6%) of Group 1 (PKT) recipients had hypertension while 54 of 63 (85.4%) of Group 2 (NPKT) had hypertension. The incidence of hypertension between two groups was statistically significant (P = 0.03), but this finding was not correlated to graft survival (P = 0.07). Some patients had serious infections, requiring hospitalization, and were treated immediately. Infection rates between the two groups were 10.8% for Group 1 patients and 31.7% for Group 2 patients and were statistically significant (P = 0.02). Infection, requiring hospitalization, was found to be statistically correlated to graft loss in only NPKT patients (P = 0.00). Conclusion: While the comparison of PKT and graft and patient survival with NPKT is poorer than we expected, lower morbidity rates of hypertension and infection are similar with recent data. Avoidance of dialysis-associated comorbidities, diminished immune response, and cardiovascular complications are the main benefits of PKT.
Pre-Operative Cardiovascular Testing and Post-Renal Transplant Clinical Outcomes
Cardiovascular Revascularization Medicine, 2019
Background Cardiovascular disease, a major contributor to morbidity and mortality in chronic kidney disease and kidney transplant patients, is closely evaluated before kidney transplant. We aimed to characterize pre-transplant cardiac testing practices and post-transplant cardiac outcomes at a single academic center. Methods This was a retrospective, single-center analysis of consecutive adults receiving first renal transplant from 1/1/2016 to 6/31/2017. Data included demographics, medical history, and medications. Pre-transplant workup included echocardiograms, cardiac stress testing, coronary computed tomography, left heart catheterization (LHC), and any revascularization. Outcomes included all-cause mortality, cardiac mortality, myocardial infarction (MI), and myocardial injury. Results Our analysis included 235 patients with mean follow-up of 1.6 ± 0.53 years. Of these, 219 (93%) patients had non-invasive functional testing before transplant, with 198 normal and 21 abnormal. The most common modalities were dobutamine stress echocardiogram (88) and pharmacological myocardial perfusion imaging (60). Twenty-four (10%) patients had an LHC, including 14 abnormal studies, and 10 who subsequently underwent successful revascularization. There were 3 deaths, 2 that were cardiac-specific. There were no ST-elevation MIs and 1 Type I non-STelevation MI (NSTEMI), occurring 2 days after transplant. Of those patients with a 30-day postoperative troponin, 30 (13%) patients had an elevation due to a type II NSTEMI or myocardial injury.
Detection and treatment of coronary artery disease in renal transplantation candidates
Transplantation Proceedings, 2002
D URING THE PAST three decades, despite the gradual but significant increase in the number of diabetics, elderly, and sick patients as renal transplant (Tx) recipients, the mortality rate following renal Tx has markedly decreased. Meanwhile, the main cause of death has changed from infection to cardiovascular disease (CVD). According to US Renal Data System, CVD is the most common cause of death in renal Tx recipients. 1 This finding is due to high prevalence of coronary artery disease (CAD) in this population. The risk is significantly higher among diabetic recipients. Reports from European Dialysis and Transplantation Association (EDTA) registry have also repeatedly emphasized the importance of CVD as the leading cause of death in both dialysis patients and renal Tx recipients, the incidence being higher than infectious causes. As almost all Tx recipients who die with CVD have a functioning graft, their death not only decreases the rate of patient survival but also graft survival. In a study from Scandinavia, Lindholm et al reported 49% graft loss due to patient death versus 41% due to rejection during the 2-to 5-year follow-up period of 1347 renal Tx recipients. 3 Fiftythree percent of deaths with a functioning graft were due to ischemic heart disease (IHD) and 10% due to other vascular events. Thus, more grafts were lost with patient mortality, secondary to cardiac death than due to graft rejection. So it is expected that in future further advances to increase long-term patient and graft survival rates will be dependent on prevention and treatment of CVD rather than on prevention and treatment of infections or immunosuppressive therapies. High prevalence of CAD (40%), left ventricular hypertrophy (LVH) (75%), and congestive heart failure (CHF) (40%) before Tx is the most important cause of increased cardiovascular mortality in renal Tx recipients. CAD and LVH are precursors of cardiovascular death and CHF is an independent predictor of cardiovascular mortality. 5 The traditional risk factors of CVD, such as hypertension, diabetes, hyperlipidemia, and hyperhomocysteinemia, are also very common before and after renal transplantation. Nonatherosclerotic cardiovascular structural changes specific to renal failure or uremic vasculopathy characterized by reduced capillary density, arteriolar wall thickening, and interstitial fibrosis of the heart has been shown in these patients. The high prevalence of traditional risk factors of CVD not only does not decrease after transplantation but also becomes exacerbated by immunosuppressive drugs, such as cyclosporine, tacrolimus, sirolimus, and steroids.
Hypertension, 2003
Guidelines for the detection of coronary artery disease (CAD) and assess of risk in renal transplant candidates are based on the results of noninvasive testing, according to data originated in the nonuremic population. We evaluated prospectively the accuracy of 2 noninvasive tests and risk stratification in detecting CAD (Ն70% obstruction) and assessing cardiac risk by using coronary angiography (CA). One hundred twenty-six renal transplant candidates who were classified as at moderate (Ն50 years) or high (diabetes, extracardiac atherosclerosis, or clinical coronary artery disease) coronary risk underwent myocardial scintigraphy (SPECT), dobutamine stress echocardiography, and CA and were followed for 6 to 48 months. The prevalence of CAD was 42%. The sensitivities and negative predictive values for the 2 noninvasive tests and risk stratification were Ͻ75%. After 6 to 48 months, there were 18 cardiac events, 9 fatal. Risk stratification (Pϭ0.007) and CA (Pϭ0.0002) predicted the crude probability of surviving free of cardiac events. The probability of event-free survival at 6, 12, 24, 36, and 48 months were 98%, 98%, 94%, 94%, and 94% in patients with Ͻ70% stenosis on CA and 97%, 87%, 61%, 56%, and 54% in patients with Ն70% stenosis. Multivariate analysis showed that the sole predictor of cardiac events was critical coronary lesions (Pϭ0.003). Coronary angiography may still be necessary for detecting CAD and determining cardiac risk in renal transplant candidates. The data suggest that current algorithms based on noninvasive testing in this population should be revised. (Hypertension. 2003;42:263-268.)
American Journal of Kidney Diseases, 2010
Cardiovascular disease is the most common cause of death after kidney transplant. However, uncertainties regarding the optimal assessment of cardiovascular risk in potential transplant candidates have produced controversy and inconsistency in pretransplant cardiac evaluation practices. In this review, we consider the evidence supporting cardiac evaluation in kidney transplant candidates, generally focused on coronary artery disease, according to the World Health Organization principles for screening. The importance of pretransplant cardiac evaluation is supported by the high prevalence of coronary artery disease and by the incidence and adverse consequences of acute coronary syndromes in this population. Testing for coronary artery disease may be performed noninvasively by modalities including nuclear myocardial perfusion studies and dobutamine stress echocardiography. These tests have prognostic value for mortality but imperfect sensitivity and specificity for detecting angiographically-defined coronary artery disease in end-stage renal disease patients. Associations of angiographically-defined coronary artery disease with subsequent survival are also inconsistent, likely because plaque instability is more critical for infarction risk than angiographic stenosis. The efficacy and best methods of myocardial revascularization have not been examined in large, contemporary clinical trials among end-stage renal disease patients. Biomarkers such as cardiac troponin have prognostic value in end-stage renal disease but require further study to determine clinical applications in directing more expensive and invasive cardiac evaluation.
International Journal of Cardiology, 2011
Background: Coronary artery disease is a major cause of morbidity and mortality in renal transplant recipients, but there is no agreed screening protocol. The value of myocardial perfusion imaging (MPI) and coronary angiography (CA) in predicting future cardiovascular events and mortality in unselected dialysis patients was studied. Methods: Forty seven patients (mean age 51 ± 14 years, 37 males), underwent both CA and MPI as part of prerenal transplant assessment between 1995 and 1999. Follow-up period was 75 ± 132 (range 3 to 143) months. Results: Twenty-two (46.8%) patients had N 50% stenosis of at least one major coronary artery (CAD), only 10 patients had abnormal MPI. Positive CA was found in all patients with angina and in 80% of diabetics. During follow-up 18 (38.3%) patients received a transplant and 28 (59.6%) patients died, of which 16 were proven or suspected cardiac deaths. Survival was significantly longer in patients with negative MPI or CA (92 and 96 versus 29 and 54 months for positive studies, respectively). CA had PPV of 95.7% and NPV of 54.2% for predicting the combined outcome of death and cardiovascular events whereas for MPI and MUGA, PPVs were 90.9% and 73.3% and NPVs 37.8% and 30%, respectively. Conclusions: Although MPI had a high specificity for CAD detection, its sensitivity appears limited in dialysis patients. The study suggests that those with angina and/or diabetes should undergo CA because of the high incidence of CAD in these groups, but MPI was at least as important as CA in overall mortality prediction over a long follow-up.
Arquivos Brasileiros de Cardiologia, 2010
Background: Coronary artery disease (CAD) is the major cause of death among chronic renal failure (CRF) patients. Traditional, non-invasive exams to detect CAD and to predict events have shown insufficient results in this group. CT Scan evaluation of Coronary Calcium Score (CCS) has proven to be of prognostic value for the population reporting no renal condition. Objective: To investigate CCS accuracy in detecting obstructive CAD and in predicting cardiovascular events in candidates to renal transplant as compared to quantitative invasive coronary angiography (ICA). Methods: Ninety-seven (97) CRF patients aged ≥ 35 were evaluated. Obstructive CAD was considered as ≥50% or ≥70% stenosis on ICA. Descriptive data, concordance, diagnostic tests, Kaplan-Meier, and multivariate analysis were used. Results: Agatston mean score was 580.6 ± 1102.2. Minimum and maximum values were 0 and 7994, with median at 176. Only 14 patients had zero calcium score. No differences were reported in regard to ethnicity. Highest regional calcium was associated to the highest probability of coronary stenosis in the same segment. Agatston calcium score showed high accuracy for the diagnosis of ≥50% and ≥70% stenosis, with area under ROC curve (AUC) of 0.75 and 0.70, respectively. At the threshold of 400, calcium score identified a subgroup with a higher rate of cardiovascular events at an average follow-up time of 29±11.0 months. Conclusion: CCS proved to have good diagnostic and prognostic performance for cardiovascular events evaluation in CRF patients. (Arq Bras Cardiol 2010;94(2): 236-243