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Panisset V, Girerd N, Bozec E, Lamiral Z, d'Hervé Q, Frimat L, Huttin O, Girerd S. Long-term changes in cardiac remodelling in prevalent kidney graft recipients. Int J Cardiol 2024; 403:131852. [PMID: 38360102 DOI: 10.1016/j.ijcard.2024.131852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 01/26/2024] [Accepted: 02/10/2024] [Indexed: 02/17/2024]
Abstract
BACKGROUND Approximately 15% of kidney transplant (KT) recipients develop de novo heart failure after KT. There are scarce data reporting the long-term changes in cardiac structure and function among KT recipients. Despite the improvement in renal function, transplant-related complications as well as immunosuppressive therapy could have an impact on cardiac remodelling during follow-up. We aimed to describe the long-term changes in echocardiographic parameters in prevalent KT recipients and identify the clinical and laboratory factors associated with these changes. METHODS A centralised blinded review of two echocardiographic examinations after KT (on average after 17 and 39 months post-KT respectively) was performed among 80 patients (age 50.4 ± 16.2, diabetes 13.8% pre-KT), followed by linear regression to identify clinico-biological factors related to echocardiographic changes. RESULTS Left atrial volume index (LAVI) increased significantly (34.2 ± 10.8 mL/m2vs. 37.6 ± 15.0 mL/m2, annualised delta 3.1 ± 11.4 mL/m2/year; p = 0.034) while left ventricular ejection fraction (LVEF) decreased (62.1 ± 9.0% vs. 59.7 ± 9.9%, annualised delta -2.7 ± 13.6%/year; p = 0.04). Male sex (β = 8.112 ± 2.747; p < 0.01), pre-KT hypertension (β = 9.725 ± 4.156; p < 0.05), graft from expanded criteria donor (β = 3.791 ± 3.587; p < 0.05), and induction by anti-thymocyte globulin (β = 7.920 ± 2.974; p = 0.01) were associated with an increase in LAVI during follow-up. Higher haemoglobin (>12.9 g/dL) at the time of the first echocardiography (β = 6.029 ± 2.967; p < 0.05) and ACEi/ARB therapy (β = 8.306 ± 3.161; p < 0.05) were associated with an increase in LVEF during follow-up. CONCLUSION This study confirms the existence of long-term cardiac remodelling after KT despite dialysis cessation, characterised by an increase in LAVI and a decrease in LVEF. A better management of anaemia and using ACEi/ARB therapy may prevent such remodelling.
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Affiliation(s)
- Valentin Panisset
- Nephrology Department, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
| | - Nicolas Girerd
- Université de Lorraine, Inserm, Centre d'Investigations Cliniques-1433, and Inserm U1116; CHRU Nancy; F-CRIN INI-CRCT, Vandoeuvre-lès-Nancy, France
| | - Erwan Bozec
- Université de Lorraine, Inserm, Centre d'Investigations Cliniques-1433, and Inserm U1116; CHRU Nancy; F-CRIN INI-CRCT, Vandoeuvre-lès-Nancy, France
| | - Zohra Lamiral
- Université de Lorraine, Inserm, Centre d'Investigations Cliniques-1433, and Inserm U1116; CHRU Nancy; F-CRIN INI-CRCT, Vandoeuvre-lès-Nancy, France
| | - Quentin d'Hervé
- Nephrology Department, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
| | - Luc Frimat
- Nephrology Department, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
| | - Olivier Huttin
- Cardiology Department, University Hospital of Nancy, Vandoeuvre-lès- Nancy, France
| | - Sophie Girerd
- Nephrology Department, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France; Université de Lorraine, Inserm, Centre d'Investigations Cliniques-1433, and Inserm U1116; CHRU Nancy; F-CRIN INI-CRCT, Vandoeuvre-lès-Nancy, France.
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2
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David-Neto E, Filho MPM, de Sá ÍJAS, Agena F, de Andrade JL, de Paula FJ. The impact of mTOR inhibitors in the regression of left ventricular hypertrophy in elderly kidney transplant recipients. Clin Transplant 2022; 36:e14742. [PMID: 35678134 DOI: 10.1111/ctr.14742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 05/24/2022] [Accepted: 06/02/2022] [Indexed: 11/27/2022]
Abstract
End-stage kidney disease is frequently associated with left ventricular hypertrophy (LVH), a condition more prevalent in the elderly, that may increase mortality after renal transplantation (RTx). Previous studies suggested that mTOR inhibitors (mTORi) can improve LVH, but this has never been tested in elderly kidney transplant recipients. In this prospective randomized clinical trial, we analyzed the impact of Everolimus (EVL) on the reversal of LVH after RTx in elderly recipients (≥60 years) submitted to different immunosuppressive regimens: EVL/lowTacrolimus (EVL group, n = 53) or mycophenolate sodium/regularTacrolimus (MPS group, n = 47). Patients performed echocardiograms (Echo) up to 3 months after RTx and then annually. At baseline, mean age was 65±3 years in both groups and LVH was observed in 63.6% of patients in EVL group and in 61.8% of MPS group. Last Echo was performed at mean time of 47 and 49 months after RTx in EVL and MPS groups, respectively (P = .34). LVH regression was observed in 23.8% (EVL group) and 19% (MPS group) of patients (P = 1.00). Mean eGFR, blood pressure, and use of RAS blockers were similar between groups throughout follow-up. EVL did not improve LVH in this cohort, and this lack of benefit may be attributed to concomitant use of TAC, senescence, or both.
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Affiliation(s)
- Elias David-Neto
- Kidney Transplant Service, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Marcelo Paes Menezes Filho
- Kidney Transplant Service, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | | | - Fabiana Agena
- Kidney Transplant Service, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - José Lázaro de Andrade
- Echochardiographic Service of the Image and Radiology Institute, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Flávio Jota de Paula
- Kidney Transplant Service, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
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3
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Meucci MC, Reinders MEJ, Groeneweg KE, Bezstarosti S, Ajmone Marsan N, Bax JJ, De Fijter JW, Delgado V. Cardiovascular Effects of Autologous Bone Marrow-Derived Mesenchymal Stromal Cell Therapy With Early Tacrolimus Withdrawal in Renal Transplant Recipients: An Analysis of the Randomized TRITON Study. J Am Heart Assoc 2021; 10:e023300. [PMID: 34913362 PMCID: PMC9075245 DOI: 10.1161/jaha.121.023300] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background After renal transplantation, there is a need of immunosuppressive regimens that effectively prevent allograft rejection while minimizing cardiovascular complications. This substudy of the TRITON trial evaluated the cardiovascular effects of autologous bone marrow-derived mesenchymal stromal cells (MSCs) in renal transplant recipients. Methods and Results Renal transplant recipients were randomized to MSC therapy, infused at weeks 6 and 7 after transplantation, with withdrawal at week 8 of tacrolimus or standard tacrolimus dose. Fifty-four patients (MSC group=27; control group=27) underwent transthoracic echocardiography at weeks 4 and 24 after transplantation and were included in this substudy. Changes in clinical and echocardiographic variables were compared. The MSC group showed a benefit in blood pressure control, assessed by a significant interaction between changes in diastolic blood pressure and the treatment group (P=0.005), and a higher proportion of patients achieving the predefined blood pressure target of <140/90 mm Hg compared with the control group (59.3% versus 29.6%, P=0.03). A significant reduction in left ventricular mass index was observed in the MSC group, whereas there were no changes in the control group (P=0.002). The proportion of patients with left ventricular hypertrophy decreased at 24 weeks in the MSC group (33.3% versus 70.4%, P=0.006), whereas no changes were noted in the control group (63.0% versus 48.1%, P=0.29). Additionally, MSC therapy prevented progressive left ventricular diastolic dysfunction, as demonstrated by changes in mitral deceleration time and tricuspid regurgitant jet velocity. Conclusions MSC strategy is associated with improved blood pressure control, regression of left ventricular hypertrophy, and prevention of progressive diastolic dysfunction at 24 weeks after transplantation. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03398681.
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Affiliation(s)
- Maria Chiara Meucci
- Department of Cardiology Leiden University Medical Center Leiden the Netherlands.,Department of Cardiovascular and Thoracic Sciences Fondazione Policlinico Universitario A. Gemelli IRCCSCatholic University of the Sacred Heart Rome Italy
| | - Marlies E J Reinders
- Department of Internal Medicine (Nephrology) Leiden University Medical Center Leiden the Netherlands
| | - Koen E Groeneweg
- Department of Internal Medicine (Nephrology) Leiden University Medical Center Leiden the Netherlands
| | - Suzanne Bezstarosti
- Department of Internal Medicine (Nephrology) Leiden University Medical Center Leiden the Netherlands.,Department of Immunology Leiden University Medical Center Leiden the Netherlands
| | - Nina Ajmone Marsan
- Department of Cardiology Leiden University Medical Center Leiden the Netherlands
| | - Jeroen J Bax
- Department of Cardiology Leiden University Medical Center Leiden the Netherlands.,Heart Center University of Turku and Turku University Hospital Turku Finland
| | - Johan W De Fijter
- Department of Internal Medicine (Nephrology) Leiden University Medical Center Leiden the Netherlands
| | - Victoria Delgado
- Department of Cardiology Leiden University Medical Center Leiden the Netherlands
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4
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Bussalino E, Panaro L, Marsano L, Bellino D, Ravera M, Paoletti E. Prevalence and clinical correlates of hyperkalemia in stable kidney transplant recipients. Intern Emerg Med 2021; 16:1787-1792. [PMID: 33544373 DOI: 10.1007/s11739-021-02649-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 01/19/2021] [Indexed: 12/28/2022]
Abstract
Although hyperkalemia (HK) is often associated with adverse clinical outcomes in renal patients, few studies are available in the setting of kidney transplantation. Therefore, we evaluated prevalence and clinical correlates of HK in stable kidney transplant recipients (KTRs) on standard of care immunosuppressive therapy. We studied 160 stable KTRs (post-transplant vintage 46.6 ± 16.6 months), most of whom (96.2%) on calcineurin inhibitor (CNI)-based immunosuppressive therapy. HK was defined as plasma potassium levels above 5 mEq/L, confirmed in two consecutive samples. Office blood pressure was measured, and renal graft function was expressed by estimated glomerular filtration rate (eGFR), calculated according to the CKD-EPI formula. HK prevalence was 8.8%, and plasma K above 5.5 mEq/L was found in 2.5% of all KTRs. In the univariate logistic regression analysis HK was significantly associated with serum urea concentration (OR 1.03, 95% CI 1.01-1.05 for each 1 mg/dL increase), tCO2 (OR 0.77, 95% CI 0.66-0.90 for each 1 mmol/L increase), the presence of arterial hypertension (OR 4.01, 95% CI 1.3-12.64), the use of RAAS inhibitors (OR 5.26, 95% CI 1.6-17.7), and eGFR less than 30 ml/min/1.73 m2 (OR 7.51, 95% CI 2.37-23.77). By multivariable backward stepwise regression analysis, the presence of metabolic acidosis (OR 0.83, 95% CI 0.69-0.99, P = 0.04), arterial hypertension (OR 4.65 95% CI 1.01-17.46 P = 0.03), and to be administered RAAS inhibitors (OR 6.11, 95% CI 1.03-25.96 P = 0.03) remained significantly associated with HK. We conclude that in stable KTRs the prevalence of HK is about 9%, slightly lower than previously reported. Moreover, it is not associated with eGFR, but with metabolic acidosis, arterial hypertension, and the use of RAAS inhibitors.
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Affiliation(s)
- Elisabetta Bussalino
- Nephrology, Dialysis, and Transplantation, University of Genoa, and Policlinico San Martino, Largo R. Benzi 10, 16132, Genova, Italy
| | - Laura Panaro
- Nephrology, Dialysis, and Transplantation, University of Genoa, and Policlinico San Martino, Largo R. Benzi 10, 16132, Genova, Italy
| | - Luigina Marsano
- Nephrology, Dialysis, and Transplantation, University of Genoa, and Policlinico San Martino, Largo R. Benzi 10, 16132, Genova, Italy
| | - Diego Bellino
- Nephrology, Dialysis, and Transplantation, University of Genoa, and Policlinico San Martino, Largo R. Benzi 10, 16132, Genova, Italy
| | - Maura Ravera
- Nephrology, Dialysis, and Transplantation, University of Genoa, and Policlinico San Martino, Largo R. Benzi 10, 16132, Genova, Italy
| | - Ernesto Paoletti
- Nephrology, Dialysis, and Transplantation, University of Genoa, and Policlinico San Martino, Largo R. Benzi 10, 16132, Genova, Italy.
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5
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Update on Treatment of Hypertension After Renal Transplantation. Curr Hypertens Rep 2021; 23:25. [PMID: 33961145 DOI: 10.1007/s11906-021-01151-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE OF REVIEW To incorporate novel findings on pathophysiology and treatment of posttransplant hypertension. RECENT FINDINGS (1) The sodium retaining effects of CNIs are mediated by stimulation of the thiazide-sensitive sodium chloride co-transporter in the distal convoluted tubule and in this regard chlorthalidone was proven to be an effective antihypertensive drug in renal transplantation. (2) Local and not systemic activation of the renin-angiotensin-aldosterone system plays a crucial role in the pathogenesis of posttransplant hypertension. (3) Recent randomized controlled trials failed to prove the presumed superiority of renin-angiotensin blockers in kidney transplantation. (4) Steroid-free and mammalian target of rapamycin-based immunosuppressive drug combinations did not show favorable effects on blood pressure control. (5) In a recent report the risk of non-melanoma skin cancer was higher with thiazide diuretics. But the increased cancer risk in transplant recipients is mainly attributed to comorbidities, such as diabetes and hypertension and of course to the transplantation condition itself or the obligatory application of immunosuppression, and has little to do with the antihypertensive medication Actual recommendations about BP targets in adult renal transplant recipients are coming from a post hoc analysis of a large randomized trial with another primary endpoint. Unless convincing studies on treatment of hypertension after renal transplantation are available, the ESC/ESH Guidelines 2018 should apply for these patients.
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Cheung AK, Chang TI, Cushman WC, Furth SL, Hou FF, Ix JH, Knoll GA, Muntner P, Pecoits-Filho R, Sarnak MJ, Tobe SW, Tomson CR, Mann JF. KDIGO 2021 Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease. Kidney Int 2021; 99:S1-S87. [PMID: 33637192 DOI: 10.1016/j.kint.2020.11.003] [Citation(s) in RCA: 385] [Impact Index Per Article: 128.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 11/02/2020] [Indexed: 12/19/2022]
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7
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Basic-Jukic N, Juric I, Furic-Cunko V. Cardiorenal Syndrome in Renal Transplant Recipients: Prevalence, Clinical Presentation, Treatment, and Outcome. Cardiorenal Med 2020; 10:333-339. [PMID: 32629448 DOI: 10.1159/000507728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 03/31/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Data on the cardiorenal syndrome (CRS) in renal transplant recipients (RTR) are scarce. We investigated the prevalence, clinical presentation, treatment, and outcomes of patients with CRS in our renal transplant cohort. METHODS Charts and medical records of adult RTR were investigated to identify patients with renal allograft dysfunction and heart failure (HF) with reduced (HFrEF) or preserved (HFpEF) ejection fraction. RESULTS From December 2009 to December 2019, a total of 1,610 patients received a kidney allograft at our institution. CRS was diagnosed in 9 patients (0.56%) a median of 11 years after transplantation (4-20 years). Seven of the patients were male, and 2 were female. The median age when CRS was diagnosed was 71 years (64-80 years). The major presenting symptom was dyspnea. Five patients had HFrEF, and 4 had HFpEF. The patient's median basal creatinine clearance was 37 mL/min (range 29-77 mL/min). At hospitalization, it was decreased to 24 mL/min (range 13-45 mL/min). The patients were treated with diuretics, but 5 of them required extracorporeal fluid removal. At the 16-month follow-up (median), all patients with HFpEF were alive and had returned to initial levels of creatinine clearance. Two of the 5 HFrEF had died, and 2 needed permanent extracorporeal water removal. CONCLUSION CRS after renal transplantation was rare (<1.0%), but CRS in HFreF patients was associated with a poor outcome.
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Affiliation(s)
- Nikolina Basic-Jukic
- Department of Nephrology, Arterial Hypertension, Dialysis, and Transplantation, University Hospital Center Zagreb, Faculty of Medicine, University of Zagreb, Zagreb, Croatia, .,Faculty of Medicine, University of Osijek, Osijek, Croatia,
| | - Ivana Juric
- Department of Nephrology, Arterial Hypertension, Dialysis, and Transplantation, University Hospital Center Zagreb, Faculty of Medicine, University of Zagreb, Zagreb, Croatia.,Faculty of Medicine, University of Osijek, Osijek, Croatia
| | - Vesna Furic-Cunko
- Department of Nephrology, Arterial Hypertension, Dialysis, and Transplantation, University Hospital Center Zagreb, Faculty of Medicine, University of Zagreb, Zagreb, Croatia.,Faculty of Medicine, University of Osijek, Osijek, Croatia
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8
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Lunney M, Ruospo M, Natale P, Quinn RR, Ronksley PE, Konstantinidis I, Palmer SC, Tonelli M, Strippoli GFM, Ravani P. Pharmacological interventions for heart failure in people with chronic kidney disease. Cochrane Database Syst Rev 2020; 2:CD012466. [PMID: 32103487 PMCID: PMC7044419 DOI: 10.1002/14651858.cd012466.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Approximately half of people with heart failure have chronic kidney disease (CKD). Pharmacological interventions for heart failure in people with CKD have the potential to reduce death (any cause) or hospitalisations for decompensated heart failure. However, these interventions are of uncertain benefit and may increase the risk of harm, such as hypotension and electrolyte abnormalities, in those with CKD. OBJECTIVES This review aims to look at the benefits and harms of pharmacological interventions for HF (i.e., antihypertensive agents, inotropes, and agents that may improve the heart performance indirectly) in people with HF and CKD. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies through 12 September 2019 in consultation with an Information Specialist and using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA We included randomised controlled trials of any pharmacological intervention for acute or chronic heart failure, among people of any age with chronic kidney disease of at least three months duration. DATA COLLECTION AND ANALYSIS Two authors independently screened the records to identify eligible studies and extracted data on the following dichotomous outcomes: death, hospitalisations, worsening heart failure, worsening kidney function, hyperkalaemia, and hypotension. We used random effects meta-analysis to estimate treatment effects, which we expressed as a risk ratio (RR) with 95% confidence intervals (CI). We assessed the risk of bias using the Cochrane tool. We applied the GRADE methodology to rate the certainty of evidence. MAIN RESULTS One hundred and twelve studies met our selection criteria: 15 were studies of adults with CKD; 16 studies were conducted in the general population but provided subgroup data for people with CKD; and 81 studies included individuals with CKD, however, data for this subgroup were not provided. The risk of bias in all 112 studies was frequently high or unclear. Of the 31 studies (23,762 participants) with data on CKD patients, follow-up ranged from three months to five years, and study size ranged from 16 to 2916 participants. In total, 26 studies (19,612 participants) reported disaggregated and extractable data on at least one outcome of interest for our review and were included in our meta-analyses. In acute heart failure, the effects of adenosine A1-receptor antagonists, dopamine, nesiritide, or serelaxin on death, hospitalisations, worsening heart failure or kidney function, hyperkalaemia, hypotension or quality of life were uncertain due to sparse data or were not reported. In chronic heart failure, the effects of angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB) (4 studies, 5003 participants: RR 0.85, 95% CI 0.70 to 1.02; I2 = 78%; low certainty evidence), aldosterone antagonists (2 studies, 34 participants: RR 0.61 95% CI 0.06 to 6.59; very low certainty evidence), and vasopressin receptor antagonists (RR 1.26, 95% CI 0.55 to 2.89; 2 studies, 1840 participants; low certainty evidence) on death (any cause) were uncertain. Treatment with beta-blockers may reduce the risk of death (any cause) (4 studies, 3136 participants: RR 0.69, 95% CI 0.60 to 0.79; I2 = 0%; moderate certainty evidence). Treatment with ACEi or ARB (2 studies, 1368 participants: RR 0.90, 95% CI 0.43 to 1.90; I2 = 97%; very low certainty evidence) had uncertain effects on hospitalisation for heart failure, as treatment estimates were consistent with either benefit or harm. Treatment with beta-blockers may decrease hospitalisation for heart failure (3 studies, 2287 participants: RR 0.67, 95% CI 0.43 to 1.05; I2 = 87%; low certainty evidence). Aldosterone antagonists may increase the risk of hyperkalaemia compared to placebo or no treatment (3 studies, 826 participants: RR 2.91, 95% CI 2.03 to 4.17; I2 = 0%; low certainty evidence). Renin inhibitors had uncertain risks of hyperkalaemia (2 studies, 142 participants: RR 0.86, 95% CI 0.49 to 1.49; I2 = 0%; very low certainty). We were unable to estimate whether treatment with sinus node inhibitors affects the risk of hyperkalaemia, as there were few studies and meta-analysis was not possible. Hyperkalaemia was not reported for the CKD subgroup in studies investigating other therapies. The effects of ACEi or ARB, or aldosterone antagonists on worsening heart failure or kidney function, hypotension, or quality of life were uncertain due to sparse data or were not reported. Effects of anti-arrhythmic agents, digoxin, phosphodiesterase inhibitors, renin inhibitors, sinus node inhibitors, vasodilators, and vasopressin receptor antagonists were very uncertain due to the paucity of studies. AUTHORS' CONCLUSIONS The effects of pharmacological interventions for heart failure in people with CKD are uncertain and there is insufficient evidence to inform clinical practice. Study data for treatment outcomes in patients with heart failure and CKD are sparse despite the potential impact of kidney impairment on the benefits and harms of treatment. Future research aimed at analysing existing data in general population HF studies to explore the effect in subgroups of patients with CKD, considering stage of disease, may yield valuable insights for the management of people with HF and CKD.
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Affiliation(s)
- Meaghan Lunney
- University of CalgaryDepartment of Community Health Sciences3330 Hospital Drive NWCalgaryAlbertaCanadaT2N 4N1
| | - Marinella Ruospo
- The University of SydneySydney School of Public HealthSydneyAustralia
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
| | - Patrizia Natale
- The University of SydneySydney School of Public HealthSydneyAustralia
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
| | - Robert R Quinn
- University of CalgaryDepartment of Community Health Sciences3330 Hospital Drive NWCalgaryAlbertaCanadaT2N 4N1
- Cumming School of Medicine, University of CalgaryDepartment of MedicineCalgaryCanada
| | - Paul E Ronksley
- University of CalgaryDepartment of Community Health Sciences3330 Hospital Drive NWCalgaryAlbertaCanadaT2N 4N1
| | - Ioannis Konstantinidis
- University of Pittsburgh Medical CenterDepartment of Medicine3459 Fifth AvenuePittsburghPAUSA15213
| | - Suetonia C Palmer
- Christchurch Hospital, University of OtagoDepartment of Medicine, NephrologistChristchurchNew Zealand
| | - Marcello Tonelli
- Cumming School of Medicine, University of CalgaryDepartment of MedicineCalgaryCanada
| | - Giovanni FM Strippoli
- The University of SydneySydney School of Public HealthSydneyAustralia
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
| | - Pietro Ravani
- University of CalgaryDepartment of Community Health Sciences3330 Hospital Drive NWCalgaryAlbertaCanadaT2N 4N1
- Cumming School of Medicine, University of CalgaryDepartment of MedicineCalgaryCanada
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9
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Zuziela MA, Vidal J, Knorr JP. Evaluating Factors Associated With Blood Pressure Control in the Early Post-Kidney Transplant Period. Hosp Pharm 2020; 56:359-367. [PMID: 34381275 DOI: 10.1177/0018578720906614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Shortened allograft survival, and cardiovascular morbidity and mortality are consequences of inadequate control of hypertension for kidney transplant recipients (KTRs). Literature suggests the risk is multifactorial, although few studies have evaluated risk factors in relation to guideline recommended blood pressure (BP) goals in the early post-kidney transplant period. This study will elucidate factors associated with controlled BP in KTRs. Methods: Adult KTRs who were transplanted between January 1, 2013, and October 31, 2018, were evaluated. Coprimary outcomes included the proportion of patients who had controlled BP at postoperative day (POD) 30 and identification of the covariates associated with controlled BP at POD 30. Additional outcomes included the proportion of patients who had controlled BP at POD 60 and 90; the difference in the average number of antihypertensive medications taken pretransplant vs POD 30, 60, and 90 for patients with controlled BP at POD 30; antihypertensive use rates pretransplant vs POD 30 and 90; and class of antihypertensive used pretransplant vs POD 30 and 90. Results: At POD 30, 44% (100/226) of patients had controlled BP. The proportion of patients with controlled BP at POD 60 and 90 were 37% (82/220) and 40% (79/196), respectively. In bivariate analyses, lack of recipient hypertension (75% vs 42.5%, P = .04); fewer days on dialysis (1684 vs 2189 days, P = .005); absence of delayed graft function (51.2% vs 35.6%, P = .02); younger donor age (30 vs 40 years, P < .001); absence of donor hypertension (46.9% vs 29.3%, P = .004); and a lower median kidney donor profile index (29% vs 40%, P = .03) were associated with controlled BP at POD 30. In a multivariate analysis, donor age was independently associated with controlled BP at POD 30 (P = .03). Conclusions: This study suggests that younger donor age is associated with controlled BP, and conversely, older donor age is associated with uncontrolled BP in KTRs in the early post-kidney transplant period. Patients receiving a graft from older donors should have their BP closely monitored.
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10
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House AA, Wanner C, Sarnak MJ, Piña IL, McIntyre CW, Komenda P, Kasiske BL, Deswal A, deFilippi CR, Cleland JGF, Anker SD, Herzog CA, Cheung M, Wheeler DC, Winkelmayer WC, McCullough PA. Heart failure in chronic kidney disease: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2019; 95:1304-1317. [PMID: 31053387 DOI: 10.1016/j.kint.2019.02.022] [Citation(s) in RCA: 202] [Impact Index Per Article: 40.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 02/13/2019] [Accepted: 02/21/2019] [Indexed: 12/24/2022]
Abstract
The incidence and prevalence of heart failure (HF) and chronic kidney disease (CKD) are increasing, and as such a better understanding of the interface between both conditions is imperative for developing optimal strategies for their detection, prevention, diagnosis, and management. To this end, Kidney Disease: Improving Global Outcomes (KDIGO) convened an international, multidisciplinary Controversies Conference titled Heart Failure in CKD. Breakout group discussions included (i) HF with preserved ejection fraction (HFpEF) and nondialysis CKD, (ii) HF with reduced ejection fraction (HFrEF) and nondialysis CKD, (iii) HFpEF and dialysis-dependent CKD, (iv) HFrEF and dialysis-dependent CKD, and (v) HF in kidney transplant patients. The questions that formed the basis of discussions are available on the KDIGO website http://kdigo.org/conferences/heart-failure-in-ckd/, and the deliberations from the conference are summarized here.
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Affiliation(s)
- Andrew A House
- Division of Nephrology, Department of Medicine, Western University and London Health Sciences Centre, London, Ontario, Canada.
| | - Christoph Wanner
- Department of Medicine, Division of Nephrology, University Hospital of Würzburg, Würzburg, Germany
| | - Mark J Sarnak
- Department of Medicine, Division of Nephrology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Ileana L Piña
- Division of Cardiology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Christopher W McIntyre
- Division of Nephrology, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Paul Komenda
- Department of Internal Medicine, Section of Nephrology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Medicine, Seven Oaks General Hospital, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Community Health Sciences, Seven Oaks General Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Anita Deswal
- Section of Cardiology, Michael E. DeBakey Veteran Affairs Medical Center, Houston, Texas, USA; Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | | | - John G F Cleland
- Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow, UK; National Heart and Lung Institute, Imperial College, London, UK
| | - Stefan D Anker
- Division of Cardiology and Metabolism, Department of Cardiology (CVK), Charité - Universitätsmedizin Berlin, Berlin, Germany; Berlin-Brandenburg Center for Regenerative Therapies (BCRT), Charité - Universitätsmedizin Berlin, Berlin, Germany; Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK, German Centre for Cardiovascular Research), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Charles A Herzog
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota, USA; Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota, USA
| | | | | | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Peter A McCullough
- Department of Internal Medicine, Division of Cardiology, Baylor University Medical Center, Dallas, Texas, USA; Department of Internal Medicine, Division of Cardiology, Baylor Heart and Vascular Institute, Dallas, Texas, USA.
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11
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Sadat‐Ebrahimi S, Parnianfard N, Vahed N, Babaei H, Ghojazadeh M, Tang S, Azarpazhooh A. An evidence-based systematic review of the off-label uses of lisinopril. Br J Clin Pharmacol 2018; 84:2502-2521. [PMID: 29971804 PMCID: PMC6177695 DOI: 10.1111/bcp.13705] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 06/14/2018] [Accepted: 06/19/2018] [Indexed: 12/13/2022] Open
Abstract
AIMS Lisinopril is an angiotensin-converting-enzyme inhibitor that is largely administered for off-label uses. This study aims to provide a comprehensive review of off-label uses of lisinopril to aid physicians to make evidence-based decisions. METHODS The following bibliographic databases were searched from inception up to 30 March 2017: PubMed, EMBASE, the Cochrane Library, Cochrane Central Register of Controlled Trials, Scopus, Ovid and Proquest. This systematic review sought all randomized trials conducted on adult individuals comparing lisinopril on its off-label uses with alternative drugs or placebos and reported direct or alternative clinical outcomes. Risk of bias assessment by using the Cochrane Collaboration risk-of-bias tool and quality evaluation took place. RESULTS Included studies demonstrated significant positive effects of lisinopril on proteinuric kidney disease; however, lisinopril caused a slight reduction of glomerular filtration rate (GFR) especially for patients with GFR < 90 ml min-1 . Lisinopril offered better outcomes in comparison to other standard treatments of diabetic nephropathy. Other studies showed positive effects of lisinopril for migraine, prevention of diabetes, myocardial fibrosis, mitral valve regurgitation, cardiomyopathy in patients with Duchenne muscular dystrophy, oligospermia and infertility, and diabetic retinopathy. Conversely, the studies reported that lisinopril was ineffective for five other off-label uses. CONCLUSIONS The identified studies showed that lisinopril was highly effective for proteinuric kidney disease with a minor but inconsiderable decrease in GFR. Positive effects of lisinopril were demonstrated in seven other off-label uses; however, lisinopril cannot be recommended as the first choice for these until further clinical trials confirm these positive effects.
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Affiliation(s)
- Seyyed‐Reza Sadat‐Ebrahimi
- Research Center for Evidence‐Based Medicine, Health Management and Safety Promotion Research InstituteTabriz University of Medical SciencesTabrizIran
- Iranian EBM Center: A Joanna Briggs Institute Affiliated Group
- Drug Applied Research CenterTabriz University of Medical SciencesTabrizIran
| | - Neda Parnianfard
- Research Center for Evidence‐Based Medicine, Health Management and Safety Promotion Research InstituteTabriz University of Medical SciencesTabrizIran
- Iranian EBM Center: A Joanna Briggs Institute Affiliated Group
| | - Nafiseh Vahed
- Research Center for Evidence‐Based Medicine, Health Management and Safety Promotion Research InstituteTabriz University of Medical SciencesTabrizIran
- Iranian EBM Center: A Joanna Briggs Institute Affiliated Group
| | - Hossein Babaei
- Drug Applied Research CenterTabriz University of Medical SciencesTabrizIran
- Faculty of PharmacologyTabriz University of Medical SciencesTabrizIran
| | - Morteza Ghojazadeh
- Research Development & Coordination Center, Faculty of MedicineTabriz University of Medical SciencesTabrizIran
| | - Sydney Tang
- Division of Nephrology, Department of MedicineUniversity of Hong Kong, Queen Mary HospitalHong Kong
| | - Amir Azarpazhooh
- Mount Sinai Hospital, Sinai Health SystemTorontoCanada
- Faculty of DentistryUniversity of TorontoTorontoCanada
- Clinical Epidemiology & Health Care Research, Institute of Health Policy, Management and Evaluation, Faculty of MedicineUniversity of TorontoTorontoCanada
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12
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Cakir U, Alis G, Erturk T, Karayagiz AH, Karabulut U, Berber I. Role of Everolimus on Cardiac Functions in Kidney Transplant Recipients. Transplant Proc 2017; 49:497-500. [PMID: 28340820 DOI: 10.1016/j.transproceed.2017.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Kidney transplantation is known to increase the survival of dialysis patients by ameloriating cardiac status, including both systolic and diastolic functions. We aimed to evaluate the role of immunosuppressive drug regimens on cardiac functions of kidney transplant recipients (KTRs). METHODS We prospectively evaluated 120 KTRs immediately before and 1 year after the kidney transplantation, using tissue Doppler echocardiography. A triple immunosuppressive therapy including tacrolimus, mycophenoloic acid (MPA), and prednisolone was started for all patients. After 3 to 6 months, the tacrolimus dose was lowered to achieve target serum levels of 5 to 8 ng/mL in both groups. MPA was switched to everolimus, with target levels of 4 to 6 ng/mL, in group 1 (n = 58), whereas group 2 (n = 62) continued with MPA. RESULTS No differences in age, sex, or dialysis duration existed between the groups. The prevalence of diabetic or hypertensive nephropathy as the etiology of chronic kidney disease was similar. Blood pressure was strictly controlled. The number of acute rejection episodes was not different in both groups, and no graft loss was observed in either group. Improvement in cardiac parameters including ejection fraction, left ventricular diastolic diameter, posterior wall thickness, and left ventricular hypertrophy was significantly better before and 1 year after transplantation. Interestingly, when compared with group 2, ameloriation of all of the parameters mentioned above was even better in group 1 patients (P = .02, P = .03, P = .04, and P = .04, respectively). Multivariate analysis of the significant variables determined by univariate analysis identified albumin (relative risk [RR] = 1.05, P = .02) and everolimus (RR = 1.07, P = .01) as two independent factors of improving cardiovascular function. CONCLUSIONS Better ameloriation of cardiovascular functions with everolimus may favor the choice of this drug in KTRs.
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Affiliation(s)
- U Cakir
- Transplant Center, Acibadem International Hospital, Acibadem University, Istanbul, Turkey.
| | - G Alis
- Transplant Center, Acibadem International Hospital, Acibadem University, Istanbul, Turkey
| | - T Erturk
- Transplant Center, Acibadem International Hospital, Acibadem University, Istanbul, Turkey
| | - A H Karayagiz
- Transplant Center, Acibadem International Hospital, Acibadem University, Istanbul, Turkey
| | - U Karabulut
- Cardiology Department, Acibadem Healthcare Group, Istanbul, Turkey
| | - I Berber
- Transplant Center, Acibadem International Hospital, Acibadem University, Istanbul, Turkey
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13
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Liao RX, Lyu XF, Tang WJ, Gao K. Short- and long-term outcomes with renin-angiotensin-aldosterone inhibitors in renal transplant recipients: A meta-analysis of randomized controlled trials. Clin Transplant 2017; 31. [PMID: 28186357 DOI: 10.1111/ctr.12917] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2017] [Indexed: 02/05/2023]
Affiliation(s)
- Ruo-xi Liao
- Department of Nephrology; West China Hospital; Sichuan University; Chengdu China
| | - Xia-fei Lyu
- Department of Radiology; West China Hospital; Sichuan University; Chengdu China
| | - Wen-jiao Tang
- Department of Hematology; West China Hospital; Sichuan University; Chengdu China
| | - Kai Gao
- Department of Computer Science and Technology; Tsinghua University; Beijing China
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14
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Cruzado JM, Pascual J, Sánchez‐Fructuoso A, Serón D, Díaz JM, Rengel M, Oppenheimer F, Hernández D, Paravisini A, Saval N, Morales JM. Controlled randomized study comparing the cardiovascular profile of everolimus with tacrolimus in renal transplantation. Transpl Int 2016; 29:1317-1328. [DOI: 10.1111/tri.12862] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 05/03/2016] [Accepted: 09/16/2016] [Indexed: 01/06/2023]
Affiliation(s)
- Josep M. Cruzado
- Nephrology Department IDIBELL Hospital de Bellvitge Barcelona Spain
| | - Julio Pascual
- Nephrology Department Hospital del Mar Barcelona Spain
| | | | - Daniel Serón
- Nephrology Department Hospital Vall Hebron Barcelona Spain
| | - Joan M. Díaz
- Nephrology Department Fundació Puigvert Barcelona Spain
| | - Manuel Rengel
- Nephrology Department Hospital Gregorio Marañón Madrid Spain
| | - Federico Oppenheimer
- Kidney Transplant Department Hospital Clínic i Provincial de Barcelona Barcelona Spain
| | | | | | - Núria Saval
- Medical Department Novartis Farmacéutica Barcelona Spain
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15
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Chatzikyrkou C, Eichler J, Karch A, Clajus C, Scurt FG, Ramackers W, Lehner F, Menne J, Haller H, Mertens PR, Schiffer M. Short- and long-term effects of the use of RAAS blockers immediately after renal transplantation. Blood Press 2016; 26:30-38. [DOI: 10.1080/08037051.2016.1182856] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Christos Chatzikyrkou
- Division of Nephrology and Hypertension, Department of Medicine, Hannover Medical School, Hannover, Germany
- Division of Nephrology and Hypertension, Diabetology and Endocrinology, University Hospital of Magedburg, Magedburg, Germany
| | - Jenny Eichler
- Division of Nephrology and Hypertension, Department of Medicine, Hannover Medical School, Hannover, Germany
| | - Annika Karch
- Institute for Biostatistics, Hannover Medical School, Hannover, Germany
| | - Christian Clajus
- Division of Nephrology and Hypertension, Department of Medicine, Hannover Medical School, Hannover, Germany
| | - Florian Gunnar Scurt
- Division of Nephrology and Hypertension, Diabetology and Endocrinology, University Hospital of Magedburg, Magedburg, Germany
| | - Wolf Ramackers
- Department of General, Visceral and Transplantation Surgery, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Frank Lehner
- Department of General, Visceral and Transplantation Surgery, Integrated Research and Treatment Center Transplantation (IFB-Tx), Hannover Medical School, Hannover, Germany
| | - Jan Menne
- Division of Nephrology and Hypertension, Department of Medicine, Hannover Medical School, Hannover, Germany
| | - Hermann Haller
- Division of Nephrology and Hypertension, Department of Medicine, Hannover Medical School, Hannover, Germany
| | - Peter R. Mertens
- Division of Nephrology and Hypertension, Diabetology and Endocrinology, University Hospital of Magedburg, Magedburg, Germany
| | - Mario Schiffer
- Division of Nephrology and Hypertension, Department of Medicine, Hannover Medical School, Hannover, Germany
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16
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Abstract
Solid organ transplantation is an effective treatment for patients with end-stage organ disease. The prevalence of cardiovascular diseases (CVD) has increased in recipients. CVD remains a leading cause of mortality among recipients with functioning grafts. The pathophysiology of CVD recipients is a complex interplay between preexisting risk factors, metabolic sequelae of immunosuppressive agents, infection, and rejection. Risk modification must be weighed against the risk of mortality owing to rejection or infection. Aggressive risk stratification and modification before and after transplantation and tailoring immunosuppressive regimens are essential to prevent complications and improve short-term and long-term mortality and graft survival.
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Affiliation(s)
- Mrudula R Munagala
- Department of Cardiology, Newark Beth Israel Medical Center, 201 Lyons Avenue, Suite # L4, Newark, NJ 07112, USA.
| | - Anita Phancao
- Integris Baptist Medical Center, 3400 Northwest Expressway, Building C, Suite 200, Oklahoma City, OK 73112, USA
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17
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Knoll GA, Fergusson D, Chassé M, Hebert P, Wells G, Tibbles LA, Treleaven D, Holland D, White C, Muirhead N, Cantarovich M, Paquet M, Kiberd B, Gourishankar S, Shapiro J, Prasad R, Cole E, Pilmore H, Cronin V, Hogan D, Ramsay T, Gill J. Ramipril versus placebo in kidney transplant patients with proteinuria: a multicentre, double-blind, randomised controlled trial. Lancet Diabetes Endocrinol 2016; 4:318-26. [PMID: 26608067 DOI: 10.1016/s2213-8587(15)00368-x] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Revised: 09/14/2015] [Accepted: 09/15/2015] [Indexed: 01/13/2023]
Abstract
BACKGROUND Angiotensin-converting enzyme inhibitors have been shown to reduce the risk of end-stage renal disease and death in non-transplant patients with proteinuria. We examined whether ramipril would have a similar beneficial effect on important clinical outcomes in kidney transplant recipients with proteinuria. METHODS In this double-blind, placebo-controlled, randomised trial, conducted at 14 centres in Canada and New Zealand, we enrolled adult renal transplant recipients at least 3-months post-transplant with an estimated glomerular filtration rate (GFR) of 20 mL/min/1·73m(2) or greater and proteinuria 0·2 g per day or greater and randomly assigned them to receive either ramipril (5 mg orally twice daily) or placebo for up to 4 years. Patients completing the final 4-year study visit were invited to participate in a trial extension phase. Treatment was assigned by centrally generated randomisation with permuted variable blocks of 2 and 4, stratified by centre and estimated GFR (above or below 40 mL/min/1·73 m(2)). The primary outcome was a composite consisting of doubling of serum creatinine, end-stage renal disease, or death in the intention-to-treat population. The principal secondary outcome was the change in measured GFR. We ascertained whether any component of the primary outcome had occurred at each study visit (1 month and 6 months post-randomisation, then every 6 months thereafter). This trial is registered with ISRCTN, number 78129473. FINDINGS Between Aug 23, 2006, and March 28, 2012, 213 patients were randomised. 109 were allocated to placebo and 104 were allocated to ramipril, of whom 109 patients in the placebo group and 103 patients in the ramipril group were analysed and the trial is now complete. The intention to treat population (placebo n=109, ramipril n=103) was used for the primary analysis and the trial extension phase analysis. The primary outcome occurred in 19 (17%) of 109 patients in the placebo group and 14 (14%) of 103 patients in the ramipril group (hazard ratio [HR] 0·76 [95% CI 0·38-1·51]; absolute risk difference -3·8% [95% CI -13·6 to 6·1]). With extended follow-up (mean 48 months), the primary outcome occurred in 27 patients (25%) in the placebo group and 25 (24%) patients in the ramipril group (HR 0·96 [95% CI 0·55-1·65]); absolute risk difference: -0·5% (95% CI -12·0 to 11·1). There was no significant difference in the rate of measured GFR decline between the two groups (mean difference per 6-month interval: -0·16 mL/min/1·73m(2) (SE 0·24); p=0·49). 14 (14%) of patients died in the ramipril group and 11 (10%) in the placebo group, but the difference between groups was not statistically significant (HR 1·45 [95% CI 0·66 to 3·21]). Adverse events were more common in the ramipril group (39 [38%]) than in the placebo group (24 [22%]; p=0·02). INTERPRETATION Treatment with ramipril compared with placebo did not lead to a significant reduction in doubling of serum creatinine, end-stage renal disease, or death in kidney transplant recipients with proteinuria. These results do not support the use of angiotensin-converting enzyme inhibitors with the goal of improving clinical outcomes in this population. FUNDING Canadian Institutes of Health Research.
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Affiliation(s)
- Greg A Knoll
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute and Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON, Canada; Kidney Research Centre, Ottawa Hospital Research Institute and University of Ottawa, Ottawa, ON, Canada.
| | - Dean Fergusson
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute and Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Michaël Chassé
- Clinical Epidemiology Program, Ottawa Hospital Research Institute and Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Paul Hebert
- Centre de Recherche, Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - George Wells
- Clinical Epidemiology Program, Ottawa Hospital Research Institute and Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Lee Anne Tibbles
- Division of Nephrology, Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Darin Treleaven
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - David Holland
- Division of Nephrology, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Christine White
- Division of Nephrology, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Norman Muirhead
- Division of Nephrology, Department of Medicine, Western University, London, ON, Canada
| | - Marcelo Cantarovich
- Division of Nephrology, Department of Medicine, McGill University, Montreal, QC, Canada
| | - Michel Paquet
- Division of Nephrology, Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Bryce Kiberd
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Sita Gourishankar
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Jean Shapiro
- Division of Nephrology, Department of Medicine, Vancouver General Hospital, Vancouver, BC, Canada
| | - Ramesh Prasad
- Division of Nephrology, Department of Medicine, St Michael's Hospital, Toronto, ON, Canada
| | - Edward Cole
- Division of Nephrology, Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Helen Pilmore
- Department of Renal Medicine, Auckland City Hospital and Department of Medicine, Auckland University, Auckland, New Zealand
| | - Valerie Cronin
- Kidney Research Centre, Ottawa Hospital Research Institute and University of Ottawa, Ottawa, ON, Canada
| | - Debora Hogan
- Clinical Epidemiology Program, Ottawa Hospital Research Institute and Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Tim Ramsay
- Clinical Epidemiology Program, Ottawa Hospital Research Institute and Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON, Canada
| | - John Gill
- Division of Nephrology, Department of Medicine, St Paul's Hospital, Vancouver, BC, Canada
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18
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Pecoits-Filho R, Calice-Silva V. Unchain the heart: impact of left ventricular myocardial hypertrophy regression in kidney transplant outcomes. Nephrol Dial Transplant 2016; 31:1025-6. [PMID: 26797262 DOI: 10.1093/ndt/gfv424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 11/17/2015] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Viviane Calice-Silva
- School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, Brazil
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19
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Neale J, Smith AC. Cardiovascular risk factors following renal transplant. World J Transplant 2015; 5:183-95. [PMID: 26722646 PMCID: PMC4689929 DOI: 10.5500/wjt.v5.i4.183] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 08/19/2015] [Accepted: 09/25/2015] [Indexed: 02/05/2023] Open
Abstract
Kidney transplantation is the gold-standard treatment for many patients with end-stage renal disease. Renal transplant recipients (RTRs) remain at an increased risk of fatal and non-fatal cardiovascular (CV) events compared to the general population, although rates are lower than those patients on maintenance haemodialysis. Death with a functioning graft is most commonly due to cardiovascular disease (CVD) and therefore this remains an important therapeutic target to prevent graft failure. Conventional CV risk factors such as diabetes, hypertension and renal dysfunction remain a major influence on CVD in RTRs. However it is now recognised that the morbidity and mortality from CVD are not entirely accounted for by these traditional risk-factors. Immunosuppression medications exert a deleterious effect on many of these well-recognised contributors to CVD and are known to exacerbate the probability of developing diabetes, graft dysfunction and hypertension which can all lead on to CVD. Non-traditional CV risk factors such as inflammation and anaemia have been strongly linked to increased CV events in RTRs and should be considered alongside those which are classified as conventional. This review summarises what is known about risk-factors for CVD in RTRs and how, through identification of those which are modifiable, outcomes can be improved. The overall CV risk in RTRs is likely to be multifactorial and a complex interaction between the multiple traditional and non-traditional factors; further studies are required to determine how these may be modified to enhance survival and quality of life in this unique population.
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Paoletti E, Bellino D, Signori A, Pieracci L, Marsano L, Russo R, Massarino F, Ravera M, Fontana I, Carta A, Cassottana P, Garibotto G. Regression of asymptomatic cardiomyopathy and clinical outcome of renal transplant recipients: a long-term prospective cohort study. Nephrol Dial Transplant 2015; 31:1168-74. [PMID: 26472820 DOI: 10.1093/ndt/gfv354] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 09/14/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Asymptomatic left ventricular hypertrophy (LVH) is highly prevalent and associated with an adverse outcome in renal transplant recipients (RTRs). Nonetheless, there are currently no available studies analyzing the effect of LVH regression on solid clinical endpoints in these patients. METHODS This study is the prospective observational extension of two randomized controlled trials aimed at assessing the effect of active intervention on post-transplant LVH in RTRs. We evaluated the incidence of a composite of death and any cardiovascular (CV) or renal event in 60 RTRs in whom LVH regression was observed and in 40 whose LVH remained unchanged or worsened. RESULTS During an 8.4 ± 3.5-year follow-up, 8 deaths, 18 CV events and 6 renal events occurred in the entire cohort. Multivariable analysis showed that age [hazard ratio (HR) 1.07, 95% confidence interval (CI) 1.03-1.12 each 1 year, P = 0.002] and LVH regression (HR 0.42, 95% CI 0.22-0.87, P = 0.019) were significant predictors of the composite endpoint. Kaplan-Meier estimates showed better survival rates in patients in whom actual LVH regression was achieved (P < 0.001, log-rank test). Age (HR 1.09, 95% CI 1.03-1.15 each 1 year, P = 0.004), better graft function (HR 0.95, 95% CI 0.91-0.99 each 1 mL/min/1.73 m(2) increase in estimated glomerular filtration rate, P = 0.03) and LVH regression (HR 0.41, 95% CI 0.22-0.79, P = 0.01) were significant predictors of the CV endpoint. Patients with a left ventricular mass index decrease also showed better cardiac event-free survival (P = 0.0022, log-rank test). CONCLUSIONS This is the first study to demonstrate that LVH regression, regardless of the therapeutic strategy adopted to achieve it, portends better long-term clinical outcome in RTRs.
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Affiliation(s)
- Ernesto Paoletti
- Division of Nephrology, Dialysis, and Transplantation, University of Genoa, IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Genoa, Italy
| | - Diego Bellino
- Division of Nephrology, Dialysis, and Transplantation, University of Genoa, IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Genoa, Italy
| | - Alessio Signori
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Laura Pieracci
- Division of Nephrology, Dialysis, and Transplantation, University of Genoa, IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Genoa, Italy
| | - Luigina Marsano
- Division of Nephrology, Dialysis, and Transplantation, University of Genoa, IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Genoa, Italy
| | - Rodolfo Russo
- Division of Nephrology, Dialysis, and Transplantation, University of Genoa, IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Genoa, Italy
| | - Fabio Massarino
- Division of Nephrology, Dialysis, and Transplantation, University of Genoa, IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Genoa, Italy
| | - Maura Ravera
- Division of Nephrology, Dialysis, and Transplantation, University of Genoa, IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Genoa, Italy
| | - Iris Fontana
- Kidney Transplant Unit, IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Genoa, Italy
| | - Annalisa Carta
- Division of Nephrology, Dialysis, and Transplantation, University of Genoa, IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Genoa, Italy
| | - Paolo Cassottana
- Division of Cardiology, IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Genoa, Italy
| | - Giacomo Garibotto
- Division of Nephrology, Dialysis, and Transplantation, University of Genoa, IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Genoa, Italy
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21
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Stoumpos S, Jardine AG, Mark PB. Cardiovascular morbidity and mortality after kidney transplantation. Transpl Int 2014; 28:10-21. [PMID: 25081992 DOI: 10.1111/tri.12413] [Citation(s) in RCA: 143] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 07/28/2014] [Indexed: 12/14/2022]
Abstract
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.
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Salerno MP, Rossi E, Favi E, Pedroso JA, Spagnoletti G, Romagnoli J, Citterio F. The reduction of left ventricular hypertrophy after renal transplantation is not influenced by the immunosuppressive regimen. Transplant Proc 2014; 45:2660-2. [PMID: 24034017 DOI: 10.1016/j.transproceed.2013.07.045] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Cardiovascular (CV) disease is the first cause of death after kidney transplantation. Left ventricular hypertrophy (LVH) is one of the main CV risk factors. It has been reported that the antiproliferative properties of everolimus (EVE) treatment may decrease left ventricular mass. The aim of this study was to evaluate the evolution of LVH in two groups of kidney transplant recipients receiving immunosuppressive treatment with low-dose calcineurin inhibitor (CNI) + EVE or CNI + mycophenolate mofetil (MMF). METHODS We evaluated 104 patients of mean age 47.5 ± 13.1 years who underwent kidney transplantation between January 2006 and December 2009 pretransplant by echocardiography, which was repeated every year for 3 years during which all patients continued the initial therapy. Over the 3-year period 76 subjects were treated with MMF, and 28 with EVE. We recorded left ventricular end-diastolic diameter (LVEDD), interventricular septum thickness in diastole (IVSTD), left ventricular posterior wall thickness in diastole (LVPWD), left ventricular end-diastolic volume and end-systolic volume during the follow-up echocardiographic evaluations. RESULTS No differences in the evolution of the echocardiographic parameters were observed between the two groups-MMF versus EVE group: LVEDD, 50.3 ± 5.1 versus 51.2 ± 6.7 mm; IVSTD, 11.2 ± 1.9 versus 11.3 ± 2 mm; LVPWD, 10.2 ± 1.9 versus 10.5 ± 1.7 mm; relative wall thickness, 0.041 ± 0.08 versus 0.42 ± 0.08; ejection fraction, 63 ± 6% versus 61 ± 5%; and left ventricular mass index, 113 ± 28.9 versus 121.9 ± 39.4 g/m(2), respectively. Compared with pretransplant echocardiographic evaluations, similar reductions in left ventricular mass index were noted in both groups after transplantation. CONCLUSIONS We observed that after renal transplantation there was a reduction of the LVH respect to the pretransplant dialytic status. The two immunosuppressive regimen did not influence the evolution of post-transplant LVH.
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Affiliation(s)
- M P Salerno
- Department of Surgical Science, Renal Transplant Unit, Catholic University, Rome, Italy
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Regression of cardiac growth in kidney transplant recipients using anti-m-TOR drugs plus RAS blockers: a controlled longitudinal study. BMC Nephrol 2014; 15:65. [PMID: 24755192 PMCID: PMC4005821 DOI: 10.1186/1471-2369-15-65] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 04/16/2014] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Left ventricular hypertrophy (LVH) is common in kidney transplant (KT) recipients. LVH is associated with a worse outcome, though m-TOR therapy may help to revert this complication. We therefore conducted a longitudinal study to assess morphological and functional echocardiographic changes after conversion from CNI to m-TOR inhibitor drugs in nondiabetic KT patients who had previously received RAS blockers during the follow-up. METHODS We undertook a 1-year nonrandomized controlled study in 30 non-diabetic KT patients who were converted from calcineurin inhibitor (CNI) to m-TOR therapy. A control group received immunosuppressive therapy based on CNIs. Two echocardiograms were done during the follow-up. RESULTS Nineteen patients were switched to SRL and 11 to EVL. The m-TOR group showed a significant reduction in LVMi after 1 year (from 62 ± 22 to 55 ± 20 g/m2.7; P=0.003, paired t-test). A higher proportion of patients showing LVMi reduction was observed in the m-TOR group (53.3 versus 29.3%, P=0.048) at the study end. In addition, only 56% of the m-TOR patients had LVH at the study end compared to 77% of the control group (P=0.047). A significant change from baseline in deceleration time in early diastole was observed in the m-TOR group compared with the control group (P=0.019). CONCLUSIONS Switching from CNI to m-TOR therapy in non-diabetic KT patients may regress LVH, independently of blood pressure changes and follow-up time. This suggests a direct non-hemodynamic effect of m-TOR drugs on cardiac mass.
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Vogelzang JL, Heestermans LWAA, van Stralen KJ, Jager KJ, Groothoff JW. Simultaneous reversal of risk factors for cardiac death and intensified therapy in long-term survivors of paediatric end-stage renal disease over the last 10 years. Nephrol Dial Transplant 2013; 28:2545-52. [DOI: 10.1093/ndt/gft257] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Blanca L, Jiménez T, Cabello M, Sola E, Gutierrez C, Burgos D, Lopez V, Hernandez D. Cardiovascular risk in recipients with kidney transplants from expanded criteria donors. Transplant Proc 2013; 44:2579-81. [PMID: 23146460 DOI: 10.1016/j.transproceed.2012.09.086] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Posttransplant cardiovascular disease (CVD) is the leading cause of death in renal transplant (RT) recipients and is more evident in recipients with transplants from expanded criteria donors (ECD). OBJECTIVES We analyzed the evolution of cardiovascular risk factors and their association with patient mortality. MATERIALS AND METHODS We undertook a single-center, prospective study of RT patients (n = 360) between 1999 and 2006. These were 180 recipients with transplants from ECD and 180 controls. We analyzed the baseline characteristics and the cardiovascular risk factors: hypertension, diabetes, dyslipidemia, CVD, and anemia. Posttransplant analyses included the evolution of cardiovascular risk factors and causes of death. RESULTS The mean age of the ECD was 63.5 ± 5.4 versus 32.0 ± 13.2 years in the non-ECD (P < .001) and the recipient ages were 58.4 ± 8.7 versus 40.8 ± 13.3 years, respectively (P < .001). The median interquartile range [IQR] dialysis time was 25 months (15-39) versus 20 months (12-44; P = .017). The pretransplant body mass index was 26.89 ± 3.91 versus 25.43 ± 4.72 kg/m(2) (P = .002); the median (IQR) number of antihypertensive drugs was two (1-2) versus two (1-2.75; P = .015); dyslipidemia was present in 32.5% versus 21.6% (P = .024), diabetes in 10.6% versus 5.6% (P = .087), and CVD in 13.3% versus 7.8% (P = .086). Treatment with erythropoiesis-stimulating agents (ESA) was received by 84.9% versus 83.9% (P = .857). Concerning transplantation, the mean follow-up was 64.3 ± 33.7 months. Hypertension was present at 3 and 5 years in 85.6% versus 69.5% (P = .001) and 87.9% versus 72.8% (P = .009), respiratory. Treatment with angiotensin-converting enzyme inhibitors/angiotensin-II receptor blockers at 3 and 5 years was 79.8% versus 64.5% and 85.6% versus 65%. Dyslipidemia was present at 5 years in 63.1% versus 58.0% (P = .482). De novo diabetes occurred in 16.7% versus 11.1% (P = .128), and CVD in 13.5% versus 4.5% (P = .003). Univariate and multivariate Cox regression proportional hazards models were constructed to analyze the factors associated with patient death. CONCLUSIONS CVD is the most common cause of death in recipients of ECD, RT, 40% in the ECD group versus 28.6% in the control group. Tight control of cardiovascular risk factors and a good pretransplant patient selection contributed to the good results obtained.
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Affiliation(s)
- L Blanca
- Nephrology and Pathology Departments, H.U. Carlos Haya, Malaga, Spain.
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Salari A, Monfared A, Fahim S, Khosravi M, Lebadi M, Mokhtari G, Pourreza F, Shakiba M. The Survey of Diastolic Function Changes in End-Stage Renal Disease Patients Before and 3 and 6 Months After Kidney Transplantation. Transplant Proc 2012. [DOI: 10.1016/j.transproceed.2012.03.060] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Effect of everolimus on left ventricular hypertrophy of de novo kidney transplant recipients: a 1 year, randomized, controlled trial. Transplantation 2012; 93:503-8. [PMID: 22318246 DOI: 10.1097/tp.0b013e318242be28] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Although conversion from calcineurin inhibitors to mammalian target of rapamycin inhibitors proved to be effective in regressing left ventricular hypertrophy (LVH) in renal transplant recipients (RTRs) with chronic allograft dysfunction, there are currently no reports of randomized trials on this issue involving de novo RTRs administered everolimus (EVL). METHODS This randomized, open-label, controlled trial evaluated the effect of EVL on the left ventricular mass index (LVMi) of 30 nondiabetic RTRs (21 men; age 28-65 years). Ten were allocated to EVL plus reduced-exposure cyclosporine A (CsA), and 20 to standard dose CsA. LVMi was assessed by echocardiography both at baseline and 1 year later. Blood pressure (BP), hemoglobin, serum creatinine, lipids, trough levels of immunosuppressive drugs, and daily proteinuria were also evaluated twice monthly. Antihypertensive therapy that did not include renin-angiotensin system blockers was administered to achieve BP less than or equal to 130/80 mm Hg. RESULTS Changes in BP were similar in the two groups (between group difference 1.2 ± 5.7 mm Hg, P=0.84 for systolic, and -1.5 ± 3.7, P=0.69, for diastolic BP), whereas LVMi significantly decreased in the EVL group alone (between group difference 9.2 ± 3.1 g/m(2.7), P=0.005), due to a reduction in both the interventricular septum and the left ventricular posterior wall thickness. EVL therapy together with baseline LVMi were the only significant predictors of LVH regression according to a multivariate model that explained 49% of the total LVMi variance (P=0.0015). CONCLUSIONS An immunosuppressive regimen consisting of EVL plus reduced exposure CsA proved to be effective in regressing LVH in RTRs regardless of BP, mainly by reducing left ventricular wall thickness.
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Paoletti E, Cannella G. Regression of left ventricular hypertrophy in kidney transplant recipients: the potential role for inhibition of mammalian target of rapamycin. Transplant Proc 2011; 42:S41-3. [PMID: 21095451 DOI: 10.1016/j.transproceed.2010.07.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Left ventricular hypertrophy (LVH) contributes to elevated cardiac mortality with graft function in renal transplant recipients. Antihypertensive therapy, and especially angiotensin-converting enzyme (ACE) inhibitors, proved to be effective in regressing the LVH of renal transplant recipients, at least in part by interacting with immunosuppressive agents, thus raising the possibility that immunosuppressive therapy might affect changes in the left ventricular mass (LVM) of recipients. This review mainly focuses on the potential role of mammalian target of rapamycin (mTOR) inhibition to regress cardiac hypertrophy in both experimental models and in the clinical setting. We comment on the results of experimental studies conducted on animal models, which showed regression of cardiac hypertrophy by sirolimus (SRL). We also discuss clinical studies that show that conversion from calcineurin inhibitors to SRL is effective to achieve regression of LVH in both kidney and cardiac transplant recipients, mainly by reducing the true left ventricular wall hypertrophy.
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Affiliation(s)
- E Paoletti
- Divisione di Nefrologia, Dialisi e Trapianto, Azienda Ospedaliera Universitaria San Martino, Genova, Italy.
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Büscher R, Nagel D, Finkelberg I, Büscher AK, Wingen AM, Kranz B, Vester U, Hoyer PF. Donor and recipient ACE I/D genotype are associated with loss of renal function in children following renal transplantation. Pediatr Transplant 2011; 15:214-20. [PMID: 21309964 DOI: 10.1111/j.1399-3046.2010.01449.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Genetic polymorphisms of the RAS correlate with allograft function. We therefore analyzed common RAS polymorphisms in kidney donors and in children following RTx to determine the relationship between genotype and decline in GFR, blood pressure, and LVM. A total of 107 children who underwent RTx were included: 70 male, 37 female, mean age 8.8±4.9 yr, mean follow up 5.4 yr. The following RAS polymorphisms were studied in all 107 recipients, 48 donors, and 120 healthy controls: Renin (Renin Mbol 18G/A), ACE I/D; angiotensinogen (AGT M235T), and angiotensin II receptor type-1 (AT1R A1166C). Only patients homozygous for the ACE D allele had a significantly steeper decline in GFR compared with homozygous carriers of the ACE I allele (slope DD: -4.3±0.8 vs. II: -1.3±1.1 mL/min/1.73 m2 per yr; p=0.035). In four cases, a DD recipient received a kidney from a DD donor, and these patients showed a more pronounced decline in GFR (-5.2±0.5 mL/min/1.73 m2 per yr; p=0.002). MABP was not different before vs. after RTx and was independent of ACE I/D genotype. LVMI increased significantly in the majority of patients (36.6±13.9 g/m2.7 six months before RTx vs. 46.4±15.3 g/m2.7 12 months after RTx, p=0.015). However, this difference disappeared after stratification by ACE I/D genotype. The ACE DD genotype is a potential marker for identifying patients at high risk of poor allograft outcome.
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Affiliation(s)
- Rainer Büscher
- University of Duisburg-Essen, Children's Hospital, Pediatrics II, Essen, Germany.
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Arnol M, Knap B, Oblak M, Buturović-Ponikvar J, Bren A, Kandus A. Subclinical Left Ventricular Echocardiographic Abnormalities 1 Year after Kidney Transplantation Are Associated with Graft Function and Future Cardiovascular Events. Transplant Proc 2010; 42:4064-8. [DOI: 10.1016/j.transproceed.2010.09.044] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2010] [Accepted: 09/09/2010] [Indexed: 10/18/2022]
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White CA, Siegal D, Akbari A, Knoll GA. Use of kidney function end points in kidney transplant trials: a systematic review. Am J Kidney Dis 2010; 56:1140-57. [PMID: 21036442 DOI: 10.1053/j.ajkd.2010.08.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2010] [Accepted: 08/06/2010] [Indexed: 12/30/2022]
Abstract
BACKGROUND Clinical trials in kidney transplantation are beginning to include markers of kidney function as end points now that traditional outcomes, such as acute rejection, become increasingly rare events. The frequency and type of kidney function end points used are unknown. STUDY DESIGN Systematic review. SETTING & POPULATION Randomized controlled trials in adult kidney transplant recipients reported in 5 major general medical journals and 5 major subspecialty journals in nephrology and transplantation between January 2003 and November 2008. SELECTION CRITERIA Inclusion of at least one kidney function end point at least 1 month posttransplant. RESULTS 133 (79%) of 169 randomized trials identified used a kidney function end point. Of these, 37 (28%) used one or more measures of kidney function as the primary end point, and 81 (61%), as a secondary end point. For the primary end point, 21 (57%) trials used a creatinine-based estimated glomerular filtration rate (eGFR), 18 (49%) used serum creatinine level, and 7 (19%) used measured GFR. Overall, eGFR was an end point in 81 (61%) trials, and measured GFR, in 12 (9%) trials. LIMITATIONS This review is limited by the poor quality of the included trials, with many not defining either primary or secondary end points. CONCLUSIONS Measures of kidney function are used commonly as surrogate end points in kidney transplant trials, with eGFR becoming more frequently used over time. Further data are needed to properly validate these surrogate end points and fully understand their limitations when designing and interpreting randomized trials.
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Affiliation(s)
- Christine A White
- Division of Nephrology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
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Does Blockade of the Renin-Angiotensin-Aldosterone System Slow Progression of All Forms of Kidney Disease? Curr Hypertens Rep 2010; 12:369-77. [DOI: 10.1007/s11906-010-0142-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Hypertension in the kidney transplant recipient. Transplant Rev (Orlando) 2010; 24:105-20. [DOI: 10.1016/j.trre.2010.02.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2010] [Accepted: 02/02/2010] [Indexed: 12/31/2022]
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Morath C, Schmied B, Mehrabi A, Weitz J, Schmidt J, Werner J, Buchler M, Morcos M, Nawroth P, Schwenger V, Doehler B, Opelz G, Zeier M. Angiotensin-converting enzyme inhibitors and angiotensin II type 1 receptor blockers after renal transplantation. Clin Transplant 2009; 23 Suppl 21:33-6. [DOI: 10.1111/j.1399-0012.2009.01107.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Abstract
The 2009 Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guideline on the monitoring, management, and treatment of kidney transplant recipients is intended to assist the practitioner caring for adults and children after kidney transplantation. The guideline development process followed an evidence-based approach, and management recommendations are based on systematic reviews of relevant treatment trials. Critical appraisal of the quality of the evidence and the strength of recommendations followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach. The guideline makes recommendations for immunosuppression, graft monitoring, as well as prevention and treatment of infection, cardiovascular disease, malignancy, and other complications that are common in kidney transplant recipients, including hematological and bone disorders. Limitations of the evidence, especially on the lack of definitive clinical outcome trials, are discussed and suggestions are provided for future research.
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Association and prognostic impact of persistent left ventricular hypertrophy after live-donor kidney transplantation: a prospective study. Clin Exp Nephrol 2009; 14:68-74. [PMID: 19876703 DOI: 10.1007/s10157-009-0231-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2009] [Accepted: 09/14/2009] [Indexed: 12/31/2022]
Abstract
AIM Persistent or de novo left ventricular hypertrophy (LVH) is a risk factor for cardiovascular diseases and congestive heart failure following renal transplantation (RT). Our aim was to determine the associations and impact of persistent LVH on RT outcome. MATERIALS AND METHODS We included 72 live-donor renal allograft recipients with mean age of 28.5 years who had evidence of LVH at time of transplantation and had stable functioning grafts 1 year after transplantation. Cardiac status of all recipients was assessed before transplantation and at 1 year after transplantation by echocardiography. Recipients were subdivided into two groups according to persistence or regression of LVH 1 year after transplantation. The first group included 33 patients who had persistent LVH. The second group included 39 patients in whom LVH had regressed (control group). Both groups were closely followed for 10 years. RESULTS Univariate analysis showed that persistent LVH 1 year after RT was significantly associated with high serum creatinine, higher incidence of medical infection, and acute and chronic rejection. Chronic rejection and infection were the only valid associations on multivariate logistic regression analysis. Patient and graft survival were significantly lower in the persistent LVH group (P = 0.012). CONCLUSION Persistent LVH may be associated with higher incidence of medical infection and chronic rejection that worsen the prognosis for renal transplant recipients.
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Cross NB, Webster AC, Masson P, O'connell PJ, Craig JC. Antihypertensives for kidney transplant recipients: systematic review and meta-analysis of randomized controlled trials. Transplantation 2009; 88:7-18. [PMID: 19584673 DOI: 10.1097/tp.0b013e3181a9e960] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In nontransplant populations, effects of different antihypertensive drug classes vary. Relative effects in kidney transplant recipients are uncertain. We performed a systematic review including random effects meta-analysis of randomized controlled trials, using Cochrane Collaboration methodology. We identified 60 trials, enrolling 3802 recipients. Twenty-nine trials (2262 patients) compared calcium channel blockers (CCB) with placebo or no treatment, 10 trials (445 patients) compared angiotensin-converting enzyme inhibitors (ACEi) with placebo or no treatment, and seven studies (405 patients) compared CCB with ACEi. CCB compared with placebo or no treatment (plus additional agents in either arm as required) reduced graft loss (risk ratio [RR] 0.75, 95% confidence intervals [CI] 0.57-0.99) and improved glomerular filtration rate (GFR; mean difference [MD] 4.5 mL/min, 95% CI 2.2-6.7). Data on ACEi versus placebo or no treatment were inconclusive for GFR (MD -8.1 mL/min, 95% CI -18.6-2.4) and inconsistent for graft loss, precluding meta-analysis. In direct comparison with CCB, ACEi decreased GFR (MD 11.5 mL/min, 95% CI 7.2-15.8), proteinuria (MD 0.28 g/day, 95% CI 0.10-0.47), hemoglobin (MD 11.5 g/L, 95% CI 7.2-15.8), and increased hyperkalemia (RR 3.7, 95% CI 1.9-7.7). Graft loss data were inconclusive (RR 7.4, 95% CI 0.4-140). These data suggest that CCB may be preferred as first-line agents for hypertensive kidney transplant recipients.
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Affiliation(s)
- Nicholas B Cross
- Centre for Kidney Research, Children's Hospital at Westmead, Westmead, NSW, Australia.
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Reducing the risk of left ventricular hypertrophy in kidney transplant recipients: the potential role of mammalian target of rapamycin. Transplant Proc 2009; 41:S3-5. [PMID: 19651293 DOI: 10.1016/j.transproceed.2009.06.091] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Persistence of left ventricular hypertrophy (LVH) following renal transplantation is associated with unfavorable outcomes in renal transplant recipients. This review presents clinical data on LVH after renal transplantation and the role of antihypertensive therapy, especially ACE inhibitors, to reduce left ventricular mass, as well as the effects of interactions between antihypertensive medications acting on the renin-angiotensin system and immunosuppressive agents to regress LVH among renal transplant recipients. The effectiveness of sirolimus (SRL) to reduce posttransplantation LVH is also discussed in light of both animal model studies and 2 clinical trials in transplant recipients that showed the efficacy of this immunosuppressive agent to treat LVH in both kidney and heart transplant recipients.
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Cross NB, Webster AC, Masson P, O'Connell PJ, Craig JC. Antihypertensive treatment for kidney transplant recipients. Cochrane Database Syst Rev 2009; 2009:CD003598. [PMID: 19588343 PMCID: PMC7163284 DOI: 10.1002/14651858.cd003598.pub2] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND In some nontransplant populations, effects of different antihypertensive drug classes vary. Relative effects in kidney transplant recipients are uncertain. OBJECTIVES To assess comparative effects of different classes of antihypertensive agents in kidney transplant recipients. SEARCH STRATEGY MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, conference proceedings and reference lists of identified studies were searched. SELECTION CRITERIA Randomised controlled trials of any antihypertensive agent applied to kidney transplant recipients for at least two weeks were included. DATA COLLECTION AND ANALYSIS Data was extracted by two investigators independently. Study quality, transplant outcomes and other patient centred outcomes were assessed using random effects meta-analysis. Risk ratios (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes, both with 95% confidence intervals (CI) were calculated. Stratified analyses and meta-regression were used to investigate heterogeneity. MAIN RESULTS We identified 60 studies, enrolling 3802 recipients. Twenty-nine studies (2262 participants) compared calcium channel blockers (CCB) to placebo/no treatment, 10 studies (445 participants) compared angiotensin converting enzyme inhibitors (ACEi) to placebo/no treatment and seven studies (405 participants) compared CCB to ACEi. CCB compared to placebo/no treatment (plus additional agents in either arm as required) reduced graft loss (RR 0.75, 95% CI 0.57 to 0.99) and improved glomerular filtration rate (GFR), (MD, 4.45 mL/min, 95% CI 2.22 to 6.68). Data on ACEi versus placebo/no treatment were inconclusive for GFR (MD -8.07 mL/min, 95% CI -18.57 to 2.43), and variable for graft loss, precluding meta-analysis. In direct comparison with CCB, ACEi decreased GFR (MD -11.48 mL/min, 95% CI -5.75 to -7.21), proteinuria (MD -0.28 g/24 h, 95% CI -0.47 to -0.10), haemoglobin (MD -12.96 g/L, 95% CI -5.72 to -10.21) and increased hyperkalaemia (RR 3.74, 95% CI 1.89 to 7.43). Graft loss data were inconclusive (RR 7.37, 95% CI 0.39 to 140.35). Other drug comparisons were compared in small numbers of participants and studies. AUTHORS' CONCLUSIONS These data suggest that CCB may be preferred as first line agents for hypertensive kidney transplant recipients. ACEi have some detrimental effects in kidney transplant recipients. More high quality studies reporting patient centred outcomes are required.
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Affiliation(s)
- Nicholas B Cross
- Christchurch Public HospitalDepartment of NephrologyPrivate Bag 4710ChristchurchNew Zealand
| | - Angela C Webster
- (c) School of Public Health, University of Sydney(a) Cochrane Renal Group, Centre for Kidney Research, The Children's Hospital at Westmead, (b) Centre for Transplant and Renal Research, Westmead Millennium Institute, University of Sydney at Westmead HospitalEdward Ford Building A27SydneyNSWAustralia2006
| | - Philip Masson
- Royal Infirmary of EdinburghDepartment of Renal MedicineEdinburghScotlandUK
| | - Philip J O'Connell
- University of Sydney at Westmead HospitalCentre for Transplant and Renal Research, Westmead Millennium InstituteWestmeadNSWAustralia2145
| | - Jonathan C Craig
- (b) School of Public Health, The University of Sydney(a) Cochrane Renal Group, Centre for Kidney Research, The Children's Hospital at WestmeadLocked Bag 4001WestmeadNSWAustralia2145
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Cardiac dysfunction after renal transplantation; incomplete resolution in pediatric population. Transplantation 2009; 87:1737-43. [PMID: 19502969 DOI: 10.1097/tp.0b013e3181a63f2f] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Long-term data of cardiac function after renal transplantation (RT) are limited, especially in children. Thus, we evaluated the status of left ventricular hypertrophy and various indices of left ventricular (LV) function in pediatric RT patients. METHODS Blood pressure, serum biochemical profiles, electrocardiogram, and echocardiogram of 32 pediatric patients (mean age, 15.5+/-4.4 years) who underwent RT 5.1+/-2.5 years before and 29 body surface area-matched control subjects were studied. RESULTS Repolarization abnormalities shown on electrocardiogram of pre-RT patients improved significantly after RT (QTc dispersion 50.8+/-37.3 to 37.4+/-11.9 msec, P=0.009). Left ventricular hypertrophy with increased LV mass index of pre-RT patients regressed remarkably after RT (LV mass index 120.9+/-40.5 to 69.2+/-14.5 g/m2, P<0.001); still, LV mass was significantly higher in RT patients than the controls (54.0+/-9.6 g/m2, P<0.001). Compared with the controls, the RT patients showed diastolic dysfunction (lower E/A ratio and higher isovolumic relaxation time) and lower myocardial performance (higher LV Tei index and weaker strain pattern). Patients who had shorter duration of non-RT renal replacement therapy showed better LV function (lower LV Tei index and stronger strain pattern) in the long-term follow-up. CONCLUSIONS Because cardiac dysfunction did not resolve after RT in pediatric population, regular evaluation for cardiovascular function after RT is required. Early RT may also be beneficial to global LV performance after RT.
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Improved left ventricular mass index in children after renal transplantation. Pediatr Nephrol 2008; 23:1545-50. [PMID: 18548286 DOI: 10.1007/s00467-008-0855-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2008] [Revised: 03/24/2008] [Accepted: 04/02/2008] [Indexed: 11/27/2022]
Abstract
Left ventricular hypertrophy (LVH) is a risk factor for cardiovascular disease, and it is prevalent in children with end-stage renal disease (ESRD) and after renal transplantation (RTx) on cross-sectional studies. Our aim was to compare prospectively left ventricular mass index (LVMI) in children with ESRD, before and after RTx. Thirteen patients aged 1.5-15 years underwent echocardiogram prior to and at least 3 months after RTx, and again in the second year after transplantation. A control group consisted of children with ESRD who remained on dialysis. Systolic and diastolic blood pressure index decreased significantly over the study period only in the children who had undergone RTx. Mean LVMI in children with ESRD decreased from 45.4 +/- 12.6 g/m(2.7) to 34.9 +/- 10.4 g/m(2.7) after RTx (P = 0.001), but it remained unchanged in patients who remained on dialysis. The prevalence of LVH decreased from 54% to 8% (P = 0.03) after RTx. Systolic and diastolic blood pressure index were correlated with LVMI. Mean body mass index increased during the study period from 17.3 +/- 2.5 to 20 +/- 4.6 (P = 0.05); however, no correlation was found with LVMI. LVH in children with ESRD is potentially reversible after RTx, especially with good control of hypertension.
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Paoletti E, Amidone M, Cassottana P, Gherzi M, Marsano L, Cannella G. Effect of sirolimus on left ventricular hypertrophy in kidney transplant recipients: a 1-year nonrandomized controlled trial. Am J Kidney Dis 2008; 52:324-30. [PMID: 18585837 DOI: 10.1053/j.ajkd.2008.04.018] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2008] [Accepted: 04/23/2008] [Indexed: 12/13/2022]
Abstract
BACKGROUND Left ventricular hypertrophy (LVH) after renal transplantation may be affected by immunosuppressive therapy. STUDY DESIGN Nonrandomized controlled trial evaluating the effect of sirolimus (SRL) on LVH of renal transplant recipients (RTRs). SETTING & PARTICIPANTS 13 RTRs without diabetes who had received a single-kidney transplant from a deceased donor with chronic allograft dysfunction and biopsy-proven allograft nephropathy who were converted from calcineurin-inhibitor (CNI) to SRL treatment; 26 controls matched for age and year of transplantation who were not converted from CNI to SRL treatment. INTERVENTION Conversion from CNI to SRL therapy. OUTCOMES & MEASUREMENTS Left ventricular mass determination by using echocardiography at baseline and again 1 year later. Blood pressure (BP), hemoglobin level, serum creatinine level, uric acid level, lipid levels, trough levels of immunosuppressive drugs, and daily proteinuria were assessed at least twice monthly. Conventional antihypertensive therapy was used to achieve BP of 130/80 mm Hg or less. RESULTS The study population included 26 men and 13 women (age, 25 to 66 years). Changes in BP were similar in the 2 groups (between-group difference, -4 +/- 5 mm Hg; P = 0.5 for systolic BP; -2 +/- 3; P = 0.6 for diastolic BP), whereas left ventricular mass significantly decreased in the SRL group alone (between-group difference, 8.6 +/- 2.4 g/m(2.7); P < 0.001) because of a decrease in both the interventricular septum and left ventricular posterior wall. LVH regressed in 12 of 13 patients on SRL therapy and 10 of 26 controls (P = 0.002). LIMITATIONS Nonrandomized design. Single-center study with small sample size. CONCLUSIONS Conversion from CNI to SRL therapy may regress LVH in RTRs regardless of BP changes, mainly by decreasing left ventricular wall thickness, thus suggesting nonhemodynamic-effect mechanisms of SRL on left ventricular mass.
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Affiliation(s)
- Ernesto Paoletti
- Divisione di Nefrologia, Dialisi, e Trapianto, Azienda Ospedaliera Universitaria S Martino, Genova, Italy.
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Cruzado JM, Rico J, Grinyó JM. The renin angiotensin system blockade in kidney transplantation: pros and cons. Transpl Int 2008; 21:304-13. [DOI: 10.1111/j.1432-2277.2008.00638.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Sterling J. Recent Publications on Medications and Pharmacy. Hosp Pharm 2007. [DOI: 10.1310/hpj4209-866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Hospital Pharmacy presents this feature to keep pharmacists abreast of new publications in the medical/pharmacy literature. Articles of interest will be abstracted monthly regarding a broad scope of topics.
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