Detection and treatment of coronary artery disease in renal transplantation candidates (original) (raw)

2002, Transplantation Proceedings

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.