1
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Tian Z, Bergmann K, Kaufeld J, Schmidt-Ott K, Melk A, Schmidt BM. Left Ventricular Hypertrophy After Renal Transplantation: Systematic Review and Meta-analysis. Transplant Direct 2024; 10:e1647. [PMID: 38769973 PMCID: PMC11104731 DOI: 10.1097/txd.0000000000001647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 03/14/2024] [Indexed: 05/22/2024] Open
Abstract
Background Left ventricular hypertrophy (LVH) in patients with end stage renal disease undergoing renal replacement is linked to an increased risk for cardiovascular diseases. Dialysis does not completely prevent or correct this abnormality, and the evidence for kidney transplantation (KT) varies. This analysis aims to explore the relationship between KT and LVH. Methods MEDLINE and Scopus were systematically searched in October 2023. All cross-sectional and longitudinal studies that fulfilled our inclusion criteria were included. Outcome was left ventricular mass index (LVMI) changes. We conducted a meta-analysis using a random effects model. Meta-regression was applied to examine the LVMI changes dependent on various covariates. Sensitivity analysis was used to handle outlying or influential studies and address publication bias. Results From 7416 records, 46 studies met the inclusion criteria with 4122 included participants in total. Longitudinal studies demonstrated an improvement of LVMI after KT -0.44 g/m2 (-0.60 to -0.28). Blood pressure was identified as a predictor of LVMI change. A younger age at the time of KT and well-controlled anemia were also associated with regression of LVH. In studies longitudinally comparing patients on dialysis and renal transplant recipients, no difference was detected -0.09 g/m2 (-0.33 to 0.16). Meta-regression using changes of systolic blood pressure as a covariate showed an association between higher blood pressure and an increase in LVMI, regardless of the modality of renal replacement treatment. Conclusions In conclusion, our results indicated a potential cardiovascular benefit, defined as the regression of LVH, after KT. This benefit was primarily attributed to improved blood pressure control rather than the transplantation itself.
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Affiliation(s)
- Zhejia Tian
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Kai Bergmann
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Jessica Kaufeld
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Kai Schmidt-Ott
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Anette Melk
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Bernhard M.W. Schmidt
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
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2
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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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3
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Should ACE inhibitors or calcium channel blockers be used for post-transplant hypertension? Pediatr Nephrol 2021; 36:539-549. [PMID: 32060819 DOI: 10.1007/s00467-020-04485-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 01/14/2020] [Accepted: 01/17/2020] [Indexed: 10/25/2022]
Abstract
Arterial hypertension in renal transplant recipients warrants antihypertensive treatment. The preferable choice of antihypertensives that should be used in patients after kidney transplantation remains a matter of debate; however, calcium channel blockers (CCB) and angiotensin-converting enzyme inhibitors (ACEI) are currently the most commonly used antihypertensives. This educational review summarizes the current evidence about the effects of these two classes of medications in transplant recipients. Several studies have demonstrated that both classes of drugs can reduce blood pressure (BP) to similar extents. Meta-analyses of adult randomized controlled trials have shown that graft survival is improved in patients treated with ACEIs and CCBs, and that CCBs increase, yet ACEIs decrease, graft function. Proteinuria is usually decreased by ACEIs but remains unchanged with CCBs. In children, no randomized controlled study has ever been performed to compare BP or graft survival between CCBs and ACEIs. Post-transplant proteinuria could be reduced in children along with BP by ACEIs. The results of the most current meta-analyses recommend that due to their positive effects on graft function and survival, along with their lack of negative effects on serum potassium, CCBs could be the preferred first-line antihypertensive agent in renal transplant recipients. However, antihypertensive therapy should be individually tailored based on other factors, such as time after transplantation, presence of proteinuria/albuminuria, or hyperkalemia. Furthermore, due to the difficulty in controlling hypertension, combination therapy containing both CCBs and ACEIs could be a reasonable first-step therapy in treating children with severe post-transplantation hypertension.
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4
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Tantisattamo E, Molnar MZ, Ho BT, Reddy UG, Dafoe DC, Ichii H, Ferrey AJ, Hanna RM, Kalantar-Zadeh K, Amin A. Approach and Management of Hypertension After Kidney Transplantation. Front Med (Lausanne) 2020; 7:229. [PMID: 32613001 PMCID: PMC7310511 DOI: 10.3389/fmed.2020.00229] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 05/04/2020] [Indexed: 12/14/2022] Open
Abstract
Hypertension is one of the most common cardiovascular co-morbidities after successful kidney transplantation. It commonly occurs in patients with other metabolic diseases, such as diabetes mellitus, hyperlipidemia, and obesity. The pathogenesis of post-transplant hypertension is complex and is a result of the interplay between immunological and non-immunological factors. Post-transplant hypertension can be divided into immediate, early, and late post-transplant periods. This classification can help clinicians determine the etiology and provide the appropriate management for these complex patients. Volume overload from intravenous fluid administration is common during the immediate post-transplant period and commonly contributes to hypertension seen early after transplantation. Immunosuppressive medications and donor kidneys are associated with post-transplant hypertension occurring at any time point after transplantation. Transplant renal artery stenosis (TRAS) and obstructive sleep apnea (OSA) are recognized but common and treatable causes of resistant hypertension post-transplantation. During late post-transplant period, chronic renal allograft dysfunction becomes an additional cause of hypertension. As these patients develop more substantial chronic kidney disease affecting their allografts, fibroblast growth factor 23 (FGF23) increases and is associated with increased cardiovascular and all-cause mortality in kidney transplant recipients. The exact relationship between increased FGF23 and post-transplant hypertension remains poorly understood. Blood pressure (BP) targets and management involve both non-pharmacologic and pharmacologic treatment and should be individualized. Until strong evidence in the kidney transplant population exists, a BP of <130/80 mmHg is a reasonable target. Similar to complete renal denervation in non-transplant patients, bilateral native nephrectomy is another treatment option for resistant post-transplant hypertension. Native renal denervation offers promising outcomes for controlling resistant hypertension with no significant procedure-related complications. This review addresses the epidemiology, pathogenesis, and specific etiologies of post-transplant hypertension including TRAS, calcineurin inhibitor effects, OSA, and failed native kidney. The cardiovascular and survival outcomes related to post-transplant hypertension and the utility of 24-h blood pressure monitoring will be briefly discussed. Antihypertensive medications and their mechanism of actions relevant to kidney transplantation will be highlighted. A summary of guidelines from different professional societies for BP targets and antihypertensive medications as well as non-pharmacological interventions, including bilateral native nephrectomy and native renal denervation, will be reviewed.
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Affiliation(s)
- Ekamol Tantisattamo
- Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA, United States.,Nephrology Section, Department of Medicine, Tibor Rubin Veterans Affairs Medical Center, VA Long Beach Healthcare System, Long Beach, CA, United States.,Section of Nephrology, Department of Internal Medicine, Multi-Organ Transplant Center, William Beaumont Hospital, Oakland University William Beaumont School of Medicine, Royal Oak, MI, United States
| | - Miklos Z Molnar
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, United States.,Methodist University Hospital Transplant Institute, Memphis, TN, United States.,Division of Transplant Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Bing T Ho
- Division of Nephrology and Hypertension, Department of Medicine, Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Uttam G Reddy
- Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA, United States.,Nephrology Section, Department of Medicine, Tibor Rubin Veterans Affairs Medical Center, VA Long Beach Healthcare System, Long Beach, CA, United States
| | - Donald C Dafoe
- Division of Transplantation, Department of Surgery, University of California Irvine School of Medicine, Orange, CA, United States
| | - Hirohito Ichii
- Division of Transplantation, Department of Surgery, University of California Irvine School of Medicine, Orange, CA, United States
| | - Antoney J Ferrey
- Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA, United States.,Nephrology Section, Department of Medicine, Tibor Rubin Veterans Affairs Medical Center, VA Long Beach Healthcare System, Long Beach, CA, United States
| | - Ramy M Hanna
- Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA, United States
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, Harold Simmons Center for Kidney Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA, United States.,Nephrology Section, Department of Medicine, Tibor Rubin Veterans Affairs Medical Center, VA Long Beach Healthcare System, Long Beach, CA, United States
| | - Alpesh Amin
- Department of Medicine, University of California Irvine School of Medicine, Orange, CA, United States
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5
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Devine PA, Courtney AE, Maxwell AP. Cardiovascular risk in renal transplant recipients. J Nephrol 2019; 32:389-399. [PMID: 30406606 PMCID: PMC6482292 DOI: 10.1007/s40620-018-0549-4] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 10/30/2018] [Indexed: 02/07/2023]
Abstract
Successful kidney transplantation offers patients with end-stage renal disease the greatest likelihood of survival. However, cardiovascular disease poses a major threat to both graft and patient survival in this cohort. Transplant recipients are unique in their accumulation of a wide range of traditional and non-traditional cardiovascular risk factors. Hypertension, diabetes, dyslipidaemia and obesity are highly prevalent in patients with end-stage renal disease. These risk factors persist following transplantation and are often exacerbated by the drugs used for immunosuppression in organ transplantation. Additional transplant-specific factors such as poor graft function and proteinuria are also associated with increased cardiovascular risk. However, these transplant-related factors remain unaccounted for in current cardiovascular risk prediction models, making it challenging to identify transplant recipients with highest risk. With few interventional trials in this area specific to transplant recipients, strategies to reduce cardiovascular risk are largely extrapolated from other populations. Aggressive management of traditional cardiovascular risk factors remains the cornerstone of prevention, though there is also a potential role for selecting immunosuppression regimens to minimise additional cardiovascular injury.
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Affiliation(s)
- Paul A Devine
- Regional Nephrology and Transplant Unit, Belfast City Hospital Northern Ireland, Belfast, BT9 7AB, UK.
- Centre for Public Health, Queen's University Belfast, Belfast, UK.
| | - Aisling E Courtney
- Regional Nephrology and Transplant Unit, Belfast City Hospital Northern Ireland, Belfast, BT9 7AB, UK
| | - Alexander P Maxwell
- Regional Nephrology and Transplant Unit, Belfast City Hospital Northern Ireland, Belfast, BT9 7AB, UK
- Centre for Public Health, Queen's University Belfast, Belfast, UK
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6
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Seeman T, Vondrák K, Dušek J. Effects of the strict control of blood pressure in pediatric renal transplant recipients-ESCORT trial. Pediatr Transplant 2019; 23:e13329. [PMID: 30537138 DOI: 10.1111/petr.13329] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 10/26/2018] [Accepted: 11/02/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Strict BP control can retard progression of CKD in children. This prospective 3-year randomized controlled trial is aimed to investigate whether strict BP control can retard progression of chronic allograft dysfunction. METHODS Twenty-three pediatric patients were randomly selected to the standard BP group (STAND, target 24-hour MAP 50-95th percentile, n = 11) or the intensified BP group (INTENS, target 24-hour MAP <50th percentile, n = 12). The primary endpoint was an annual reduction in eGFR (Schwartz formula, mL/min/1.73 m2 /y), secondary graft survival, BP, proteinuria, and safety. RESULTS A total of 21 children (age at entry 11.2 (range 6.2-16.8) years) completed the study, with 73% of children in INTENS and 70% of children in STAND group reached their goal BP. Ambulatory indexed 24-hour MAP decreased significantly in INTENS group (from 0.94 (range 0.86-1.17) to 0.85 (range 0.79-1.01, P < 0.01)) but not in STAND group (from 0.93 (range 0.85-1.07) to 0.90 (range 0.84-1.01)). Proteinuria did not change significantly in either group (22.1 mg/mmol creatinine to 15.3 in STAND group vs 25.7 to 11.8 in INTENS group). The annual reduction in eGFR did not differ between the INTENS and STAND groups (-1.9 mL/min/1.73 m2 /y (range +6.4 to -14.3) vs -0.9 (range +4.0 to -8.5)). CONCLUSION This first randomized controlled trial on strict BP control has demonstrated that strict BP control is feasible in 73% of children but the strict BP control does not lead to retardation of graft function decline in comparison with standard BP control. However, the results need to be interpreted with caution keeping the major limitation of the study, that is, small sample size in mind.
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Affiliation(s)
- Tomáš Seeman
- Department of Pediatrics and Transplantation Center, University Hospital Motol, 2nd Medical Faculty Prague, Charles University Prague, Prague, Czech Republic.,Biomedical Centre, Faculty of Medicine in Plzen, Plzen, Czech Republic
| | - Karel Vondrák
- Department of Pediatrics and Transplantation Center, University Hospital Motol, 2nd Medical Faculty Prague, Charles University Prague, Prague, Czech Republic
| | - Jiří Dušek
- Department of Pediatrics and Transplantation Center, University Hospital Motol, 2nd Medical Faculty Prague, Charles University Prague, Prague, Czech Republic
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7
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Sen A, Callisen H, Libricz S, Patel B. Complications of Solid Organ Transplantation: Cardiovascular, Neurologic, Renal, and Gastrointestinal. Crit Care Clin 2018; 35:169-186. [PMID: 30447778 DOI: 10.1016/j.ccc.2018.08.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Despite improvements in overall graft function and patient survival rates after solid organ transplantation, complications can lead to significant morbidity and mortality. Cardiovascular complications include heart failure, arrhythmias leading to sudden death, hypertension, left ventricular hypertrophy, and allograft vasculopathy in heart transplantation. Neurologic complications include stroke, posterior reversible encephalopathy syndrome, infections, neuromuscular disease, seizure disorders, and neoplastic disease. Acute kidney injury occurs from immunosuppression with calcineurin inhibitors or as a result of graft failure after kidney transplantation. Gastrointestinal complications include infections, malignancy, mucosal ulceration, perforation, biliary tract disease, pancreatitis, and diverticular disease. Immunosuppression can predispose to infections and malignancy.
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Affiliation(s)
- Ayan Sen
- Department of Critical Care Medicine, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA.
| | - Hannelisa Callisen
- Department of Critical Care Medicine, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Stacy Libricz
- Department of Critical Care Medicine, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Bhavesh Patel
- Department of Critical Care Medicine, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
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8
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Changes in left ventricular geometry during antihypertensive treatment. Pharmacol Res 2018; 134:193-199. [DOI: 10.1016/j.phrs.2018.06.026] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Revised: 03/22/2018] [Accepted: 06/25/2018] [Indexed: 11/22/2022]
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9
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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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10
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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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11
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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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12
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Soliman EZ, Byington RP, Bigger JT, Evans G, Okin PM, Goff DC, Chen H. Effect of Intensive Blood Pressure Lowering on Left Ventricular Hypertrophy in Patients With Diabetes Mellitus: Action to Control Cardiovascular Risk in Diabetes Blood Pressure Trial. Hypertension 2015; 66:1123-9. [PMID: 26459421 PMCID: PMC4644090 DOI: 10.1161/hypertensionaha.115.06236] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 09/04/2015] [Indexed: 02/06/2023]
Abstract
UNLABELLED Left ventricular hypertrophy (LVH), a marker of cardiac end-organ damage, is a common complication of hypertension. Regression of LVH is achievable by sustained lowering of systolic blood pressure (BP). However, it is unknown whether a strategy aimed at lowering BP beyond that recommended would lower the risk of LVH. We examined the effect of intensive (systolic BP<120 mm Hg), compared with standard (systolic BP<140 mm Hg), BP lowering on the risk of LVH in 4331 patients with diabetes mellitus from the Action to Control Cardiovascular Risk in Diabetes (ACCORD) BP trial, a randomized controlled trial. The outcome measures were electrocardiographic LVH defined by Cornell voltage (binary variable) and mean Cornell index (continuous variable). The baseline prevalence of LVH (5.3% versus 5.4%; P=0.91) and the mean Cornell index (1456 versus 1470 µV; P=0.45) were similar in the intensive (n=2154) and standard (n=2177) BP-lowering arms, respectively. However, after median follow-up of 4.4 years, intensive, compared with standard, BP lowering was associated with a 39% lower risk of LVH (odds ratio [95% confidence interval], 0.61[0.43, 0.88]; P=0.008) and a significantly lower adjusted mean Cornell index (1352 versus 1447 µV; P<0.001). The lower risk of LVH associated with intensive BP lowering during follow-up was because of more regression of baseline LVH and lower rate of developing new LVH, compared with standard BP lowering. No interactions by age, sex, or race were observed. These results provide evidence that targeting a systolic BP of <120 mm Hg when compared with <140 mm Hg in patients with hypertension and diabetes mellitus produces a greater reduction in LVH. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00000620.
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Affiliation(s)
- Elsayed Z Soliman
- From the Division of Public Health Sciences, Epidemiological Cardiology Research Center (EPICARE) (E.Z.S.); Section of Cardiology, Department of Medicine (E.Z.S.), Division of Public Health Sciences, Department of Epidemiology (E.Z.S., R.P.B), and Division of Public Health Sciences, Department of Biostatistical Sciences (G.E., H.C.), Wake Forest School of Medicine, Winston-Salem, NC; Division of Cardiology, Department of Medicine, Columbia University, New York, NY (J.T.B.); Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York, NY (P.M.O.); and Colorado School of Public Health, Aurora (D.C.G.).
| | - Robert P Byington
- From the Division of Public Health Sciences, Epidemiological Cardiology Research Center (EPICARE) (E.Z.S.); Section of Cardiology, Department of Medicine (E.Z.S.), Division of Public Health Sciences, Department of Epidemiology (E.Z.S., R.P.B), and Division of Public Health Sciences, Department of Biostatistical Sciences (G.E., H.C.), Wake Forest School of Medicine, Winston-Salem, NC; Division of Cardiology, Department of Medicine, Columbia University, New York, NY (J.T.B.); Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York, NY (P.M.O.); and Colorado School of Public Health, Aurora (D.C.G.)
| | - J Thomas Bigger
- From the Division of Public Health Sciences, Epidemiological Cardiology Research Center (EPICARE) (E.Z.S.); Section of Cardiology, Department of Medicine (E.Z.S.), Division of Public Health Sciences, Department of Epidemiology (E.Z.S., R.P.B), and Division of Public Health Sciences, Department of Biostatistical Sciences (G.E., H.C.), Wake Forest School of Medicine, Winston-Salem, NC; Division of Cardiology, Department of Medicine, Columbia University, New York, NY (J.T.B.); Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York, NY (P.M.O.); and Colorado School of Public Health, Aurora (D.C.G.)
| | - Gregory Evans
- From the Division of Public Health Sciences, Epidemiological Cardiology Research Center (EPICARE) (E.Z.S.); Section of Cardiology, Department of Medicine (E.Z.S.), Division of Public Health Sciences, Department of Epidemiology (E.Z.S., R.P.B), and Division of Public Health Sciences, Department of Biostatistical Sciences (G.E., H.C.), Wake Forest School of Medicine, Winston-Salem, NC; Division of Cardiology, Department of Medicine, Columbia University, New York, NY (J.T.B.); Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York, NY (P.M.O.); and Colorado School of Public Health, Aurora (D.C.G.)
| | - Peter M Okin
- From the Division of Public Health Sciences, Epidemiological Cardiology Research Center (EPICARE) (E.Z.S.); Section of Cardiology, Department of Medicine (E.Z.S.), Division of Public Health Sciences, Department of Epidemiology (E.Z.S., R.P.B), and Division of Public Health Sciences, Department of Biostatistical Sciences (G.E., H.C.), Wake Forest School of Medicine, Winston-Salem, NC; Division of Cardiology, Department of Medicine, Columbia University, New York, NY (J.T.B.); Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York, NY (P.M.O.); and Colorado School of Public Health, Aurora (D.C.G.)
| | - David C Goff
- From the Division of Public Health Sciences, Epidemiological Cardiology Research Center (EPICARE) (E.Z.S.); Section of Cardiology, Department of Medicine (E.Z.S.), Division of Public Health Sciences, Department of Epidemiology (E.Z.S., R.P.B), and Division of Public Health Sciences, Department of Biostatistical Sciences (G.E., H.C.), Wake Forest School of Medicine, Winston-Salem, NC; Division of Cardiology, Department of Medicine, Columbia University, New York, NY (J.T.B.); Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York, NY (P.M.O.); and Colorado School of Public Health, Aurora (D.C.G.)
| | - Haiying Chen
- From the Division of Public Health Sciences, Epidemiological Cardiology Research Center (EPICARE) (E.Z.S.); Section of Cardiology, Department of Medicine (E.Z.S.), Division of Public Health Sciences, Department of Epidemiology (E.Z.S., R.P.B), and Division of Public Health Sciences, Department of Biostatistical Sciences (G.E., H.C.), Wake Forest School of Medicine, Winston-Salem, NC; Division of Cardiology, Department of Medicine, Columbia University, New York, NY (J.T.B.); Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York, NY (P.M.O.); and Colorado School of Public Health, Aurora (D.C.G.)
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13
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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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14
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Murbraech K, Massey R, Undset LH, Midtvedt K, Holdaas H, Aakhus S. Cardiac response to early conversion from calcineurin inhibitor to everolimus in renal transplant recipients--a three-yr serial echocardiographic substudy of the randomized controlled CENTRAL trial. Clin Transplant 2015; 29:678-84. [PMID: 25982053 DOI: 10.1111/ctr.12565] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2015] [Indexed: 12/31/2022]
Abstract
BACKGROUND In transplant recipients, calcineurin inhibitors (CNIs) are associated with adverse cardiac effects while mTOR inhibitors have been reported to be beneficial. We performed a randomized controlled trial (RCT) in de novo renal transplant recipients examining cardiac responses of everolimus vs. CNI. METHODS This was a substudy of the three-yr CENTRAL study, an RCT on safety and efficacy of early (week 7 post-engraftment) conversion from cyclosporine A (CsA) to everolimus vs. continued CsA. Thirty-nine recipients [median age 64 yr, (range 31-81)] completed echocardiographic evaluations at baseline, one, and three yr. RESULTS After three yr, there was no difference between groups in left ventricle (LV) diastolic function, LV systolic function, LV morphology, and blood pressure response. We observed a relevant decrease in LV mass (CsA; 9.6%, p = 0.008, vs. everolimus; 7.0% reduction, p = 0.15), stabilized LV diastolic function, and a trend toward lower systolic blood pressure with 6 mmHg decrease in both arms (CsA, p = 0.08; everolimus, p = 0.14). Diastolic blood pressure was significantly reduced (8 mmHg decrease, p = 0.002) only in everolimus patients. CONCLUSIONS After three-yr follow-up, no clinically relevant effect on cardiac function of an early conversion from CsA to an everolimus-based immunosuppressive regimen was detected in de novo renal transplant recipients.
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Affiliation(s)
- Klaus Murbraech
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Norway
| | - Richard Massey
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Norway
| | - Liv H Undset
- Department of Medicine, Baerum County Hospital, Baerum, Norway
| | - Karsten Midtvedt
- Department of Nephrology, Department of Transplant Medicine, Oslo University Hospital, Rikshospitalet, Norway
| | - Hallvard Holdaas
- Department of Nephrology, Department of Transplant Medicine, Oslo University Hospital, Rikshospitalet, Norway
| | - Svend Aakhus
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Norway
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15
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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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16
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Thomas B, Taber DJ, Srinivas TR. Hypertension after kidney transplantation: a pathophysiologic approach. Curr Hypertens Rep 2014; 15:458-69. [PMID: 23933793 DOI: 10.1007/s11906-013-0381-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Post-transplant hypertension is associated with decreased graft and patient survival and cardiovascular morbidity. Unfortunately, post-transplant hypertension is often poorly controlled. Important risk factors include immunosuppressive medications, complications of the transplant surgery, delayed graft function, rejection, and donor and recipient risk factors. The effects of immunosuppressive medications are multifactorial including increased vascular and sympathetic tone and salt and fluid retention. The immunosuppressive agents most commonly associated with hypertension are glucocorticoids and calcineurin inhibitors. Drug therapy for hypertension should be based on the comorbidities and pathophysiology. Evidence-based approaches to defining and treating hypertension in renal transplant recipients are predominantly extrapolated from large-scale studies performed in the general population. Thus, there continues to be a need for larger studies examining the pathophysiology, diagnosis and treatment of hypertension in renal transplant recipients.
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Affiliation(s)
- Beje Thomas
- Division of Nephrology, Medical University of South Carolina, 96 Jonathan Lucas Street CSB 829, Charleston, SC, 29425, USA,
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17
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Holdaas H, Jardine AG. BP targets in renal transplant recipients: too high or too low? J Am Soc Nephrol 2014; 25:1371-3. [PMID: 24627350 DOI: 10.1681/asn.2014020177] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Affiliation(s)
- Hallvard Holdaas
- Department of Transplant Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway; and
| | - Alan G Jardine
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
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18
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Gillis KA, Patel RK, Jardine AG. Cardiovascular complications after transplantation: treatment options in solid organ recipients. Transplant Rev (Orlando) 2013; 28:47-55. [PMID: 24412041 DOI: 10.1016/j.trre.2013.12.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Accepted: 12/01/2013] [Indexed: 12/14/2022]
Abstract
Premature cardiovascular disease is the commonest cause of death in solid organ transplant recipients, with coronary artery disease, sudden cardiac death and heart failure being highly prevalent. There are unique factors leading to CV disease in organ transplant recipients that include underlying comorbidities, and metabolic effects of immunosuppression. As a consequence management strategies developed in the general population may have limited benefit. In this review, we will focus on renal transplantation, where most research has been carried out and, despite incomplete understanding of the disease process, the incidence of cardiovascular disease appears to be falling.
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19
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Holdaas H, Midtvedt K, Åsberg A. A drug safety evaluation of everolimus in kidney transplantation. Expert Opin Drug Saf 2012; 11:1013-22. [PMID: 22954349 DOI: 10.1517/14740338.2012.722993] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Calcineurin inhibitors (CNI) have greatly reduced the rate of acute rejection and improved short-term graft survival after organ transplantation, however, long-term survival has hardly changed since their introduction. CNIs are believed to contribute to graft fibrosis, have side effects that adversely affect cardiovascular risk, and are associated with an increased rate of post-transplant malignancies. Everolimus, a mammalian target of rapamycin (mTOR) inhibitor, is not associated with graft fibrosis, has a superior cardiovascular risk profile to CNI therapy and has shown potential for the prevention and treatment of diverse forms of cancer. AREAS COVERED This review summarizes key aspects of everolimus, including its mechanism of action, pharmacokinetics, pharmacodynamics, drug-drug interactions and pivotal clinical studies with a focus on safety and efficacy. EXPERT OPINION Everolimus is effective in improving graft function in selected kidney transplant patients. Most adverse events are present for a short time after the introduction of everolimus, and are manageable. Everolimus has the potential to become an important agent in de novo and maintenance immunotherapy in kidney transplant recipients.
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Affiliation(s)
- Hallvard Holdaas
- Oslo University Hospital, Department of Transplant Medicine, Section of Nephrology, Rikshospitalet, Postbox 4950 Nydalen, N-0424 Oslo, Norway.
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20
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Jardine AG, Gaston RS, Fellstrom BC, Holdaas H. Prevention of cardiovascular disease in adult recipients of kidney transplants. Lancet 2011; 378:1419-27. [PMID: 22000138 DOI: 10.1016/s0140-6736(11)61334-2] [Citation(s) in RCA: 191] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Although advances in immunosuppression, tissue typing, surgery, and medical management have made transplantation a routine and preferred treatment for patients with irreversible renal failure, successful transplant recipients have a greatly increased risk of premature mortality because of cardiovascular disease and malignancy compared with the general population. Conventional cardiovascular risk factors such as hyperlipidaemia, hypertension, and diabetes are common in transplant recipients, partly because of the effects of immunosuppressive drugs, and are associated with adverse outcomes. However, the natural history of cardiovascular disease in such recipients differs from that in the general population, and only statin therapy has been studied in a large-scale interventional trial. Thus, the management of this disease and the balance between management of conventional risk factors and modification of immunosuppression is complex.
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Affiliation(s)
- Alan G Jardine
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.
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21
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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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22
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Mangray M, Vella JP. Hypertension after kidney transplant. Am J Kidney Dis 2011; 57:331-41. [PMID: 21251543 DOI: 10.1053/j.ajkd.2010.10.048] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2010] [Accepted: 10/27/2010] [Indexed: 12/13/2022]
Abstract
Hypertension in kidney transplant recipients is a major "traditional" risk factor for atherosclerotic cardiovascular disease. Importantly, atherosclerotic cardiovascular disease is the leading cause of premature death and a major factor in death-censored graft failure in transplant recipients. The blood pressure achieved after transplant is related inversely to postoperative glomerular filtration rate (GFR), with many patients experiencing a significant improvement in blood pressure control with fewer medications within months of surgery. However, the benefits of improved GFR and fluid status may be affected by the immunosuppression regimen. Immunosuppressive agents affect hypertension through a variety of mechanisms, including catechol- and endothelin-induced vasoconstriction, abrogation of nitric oxide-induced vasodilatation, and sodium retention. Most notable is the role of calcineurin inhibitors in promoting hypertension, cyclosporine more so than tacrolimus. Additionally, the combination of calcineurin- and mammalian target of rapamycin (mTOR)-inhibitor therapy is synergistically nephrotoxic and promotes hypertension, whereas steroid withdrawal and minimization strategies seem to have little or no impact on hypertension. Other important causes of hypertension after transplant, beyond a progressive decrease in GFR, include transplant renal artery stenosis and sequelae of antibody-mediated rejection. Calcium channel blockers may be the most useful medication for mitigating calcineurin inhibitor-induced vasoconstriction, and use of such agents may be associated with improvements in GFR. Use of inhibitors of the renin-angiotensin system, such as angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, remains an attractive strategy for many transplant recipients, although some recipients may have significant adverse effects associated with these medications, including decreased GFR, hyperkalemia, and anemia. In conclusion, hypertension control affects both patient and long-term transplant survival, and its best management requires careful analysis of causes and close monitoring of therapies.
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23
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McQuarrie EP, Fellström BC, Holdaas H, Jardine AG. Cardiovascular disease in renal transplant recipients. J Ren Care 2010; 36 Suppl 1:136-45. [PMID: 20586909 DOI: 10.1111/j.1755-6686.2010.00160.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Renal transplant recipients have a markedly increased risk of premature cardiovascular disease (CVD) compared with the general population, although considerably lower than that of patients receiving maintenance haemodialysis. CVD in transplant recipients is poorly characterised and differs from the nonrenal population, with a much higher proportion of fatal to nonfatal cardiac events. In addition to traditional ischaemic heart disease risk factors such as age, gender, diabetes and smoking, there are additional factors to consider in this population such as the importance of hypertension, left ventricular hypertrophy and uraemic cardiomyopathy. There are factors specific to transplantation such immunosuppressive therapies and graft dysfunction which contribute to this altered risk profile. However, understanding and treatment is limited by the absence of large randomised intervention trials addressing risk factor modification, with the exception of the ALERT study. The approach to managing these patients should begin early and be multifactorial in nature.
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24
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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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25
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Hasley PB, Arnold RM. Primary care of the transplant patient. Am J Med 2010; 123:205-12. [PMID: 20193824 DOI: 10.1016/j.amjmed.2009.06.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2009] [Revised: 06/12/2009] [Accepted: 06/18/2009] [Indexed: 01/06/2023]
Abstract
A total of 153,245 patients are living with a solid organ transplant in the US. In addition, patients are experiencing high 5-year survival rates after transplantation. Thus, primary care physicians will be caring for transplanted patients. The aim of this review is to update primary care physicians on chronic diseases, screening for malignancy, immunizations, and contraception in the transplant patient. Several studies on the treatment of hypertension and hyperlipidemia demonstrate that most agents used to treat the general population also can be used to treat transplant recipients. Little information exists on the medical management of diabetes in the transplant population, but experts in the area believe that the treatment of diabetes should be similar. Transplant recipients are at increased risk for all malignancies. Aggressive screening should be employed for all cancers with a proven screening benefit. Killed immunizations are safe for the transplant population, but live virus vaccines should be avoided. Women of childbearing age should be counseled about the impact of immunosuppressants on the efficacy and side effects of contraception.
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Affiliation(s)
- Peggy B Hasley
- University of Pittsburgh School of Medicine, PA 15213, USA.
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26
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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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27
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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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28
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Abstract
Hypertension is a common and serious complication after renal transplantation. It is an important risk factor for graft loss and morbidity and mortality of transplanted children. The etiology of posttransplant hypertension is multifactorial: native kidneys, immunosuppressive therapy, renal-graft artery stenosis, and chronic allograft nephropathy are the most common causes. Blood pressure (BP) in transplanted children should be measured not only by casual BP (CBP) measurement but also regularly by ambulatory BP monitoring (ABPM). The prevalence of posttransplant hypertension ranges between 60% and 90% depending on the method of BP measurement and definition. Left ventricular hypertrophy is a frequent type of end-organ damage in hypertensive children after transplantation (50-80%). All classes of antihypertensive drugs can be used in the treatment of posttransplant hypertension. Hypertension control in transplanted children is poor; only 20-50% of treated children reach normal BP. The reason for this poor control seems to be inadequate antihypertensive therapy, which can be improved by increasing the number of antihypertensive drugs. Improved hypertension control leads to improved long-term graft and patient survival in adults. In children, there is a great potential for antihypertensive treatment that could also result in improved graft and patient survival.
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Affiliation(s)
- Tomáš Seeman
- Department of Pediatrics and Transplantation Center University, University Hospital Motol, Charles University Prague, Second School of Medicine, V Úvalu 84, 15006 Prague, Czech Republic
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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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Use of cardiac allografts with mild and moderate left ventricular hypertrophy can be safely used in heart transplantation to expand the donor pool. J Am Coll Cardiol 2008; 51:1214-20. [PMID: 18355661 DOI: 10.1016/j.jacc.2007.11.052] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2007] [Revised: 10/26/2007] [Accepted: 11/12/2007] [Indexed: 11/22/2022]
Abstract
OBJECTIVES The purpose of this study was to evaluate outcomes of heart transplantation (HTx) and changes in left ventricular wall thickness (LVWT) post-HTx using donors with left ventricular hypertrophy (LVH). BACKGROUND Limited data are available on use of donor hearts with LVH in HTx. METHODS We reviewed 427 patients who underwent HTx: 62 received hearts with LVH (interventricular septum [IVS] or posterior wall [PW] thickness >or=1.2 cm) by echocardiography, and 365 received hearts without LVH. The median follow-up was 3.8 years (range 0 to 16.2 years). RESULTS Recipient age was 56 +/- 11 years and donor age was 30 +/- 12 years. Baseline recipient characteristics were similar in both groups. Donors with LVH were older (35 +/- 12 years vs. 29 +/- 12 years, p = 0.001) and had higher rates of intracranial hemorrhage (38% vs. 15%, p = 0.001). The LVWT was increased in the LVH group compared with LVWT in the non-LVH group (IVS: 1.28 +/- 0.18 cm vs. 0.85 +/- 0.19 cm, PW: 1.27 +/- 0.19 cm vs. 0.85 +/- 0.20 cm, p = 0.0001 for both groups). Mild LVH (1.2 to 1.3 cm) was found in 42%, moderate (>1.3 to 1.7 cm) in 53%, and severe (>1.7 cm) in 5% of donors with LVH. Left ventricular wall thickness regression occurred in both IVS and PW (1.28 +/- 0.18 cm vs. 1.10 +/- 0.13 cm vs. 1.13 +/- 0.14 cm, and 1.27 +/- 0.19 cm vs. 1.11 +/- 0.11 cm vs. 1.13 +/- 0.14 cm, at baseline, 1 year, and 5 years, respectively; p < 0.001 for change from baseline to 1 and 5 years for both locations). Patients with or without donor LVH had similar 1-year (3.5% vs. 9.5%, p = 0.2) and 5-year survival rates (84 +/- 5.9% vs. 70 +/- 2.7%, p = 0.07). CONCLUSIONS Short- and long-term survival rates and rates of LVH at follow-up were similar in both groups, suggesting that donor hearts with mild and moderate LVH can be safely used in HTx.
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Studies on left ventricular hypertrophy regression in arterial hypertension: a clear message for the clinician? Am J Hypertens 2008; 21:458-63. [PMID: 18369363 DOI: 10.1038/ajh.2007.85] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Evidence-based medicine should provide clear and unbiased information to clinicians. We conducted an analysis on published randomized trials evaluating the effects of antihypertensive therapy on left ventricular (LV) morphology assessed by echocardiography to investigate (i) the consistency of criteria used for definition of LV hypertrophy (LVH) and (ii) the consistency of the way LVH regression and blood pressure (BP) control were reported. METHODS Studies identified by a PubMed search were eligible for inclusion in the analysis, if they fulfilled the following criteria: (i) publication in a peer-reviewed journal within the last 12 years; (ii) double blind, randomized, controlled, parallel-group design; (iii) numerosity of at least 50 adult hypertensive subjects; (iv) follow-up duration of at least 6 months; (v) comparison between single-drugs or association regimens; (vi) LV mass (LVM) or wall thickness measured by echocardiography. RESULTS Thirty-nine trials, including 9,162 hypertensive subjects of both genders in 78 active treatment arms or in 6 placebo arms were identified. Definition of LVH was provided by 34 studies (87.1%) according to 19 different criteria. All trials evaluated LVH regression as the absolute or relative changes of continuous variables such as LVM index (LVMI) or LV wall thickness. Data concerning prevalence rates of LVM normalization were reported in 12 studies (30.7%). The percentage of patients reaching BP target (<140/90 mm Hg) was reported in 11 studies (28.2%). CONCLUSIONS Our findings indicate that (i) definition of hypertensive LVH phenotype is extremely variable, and (ii) no precise information on LVH regression rates or changes in LV geometrical patterns, as well as on target BP, is provided by the majority of papers.
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Shirali AC, Bia MJ. Management of cardiovascular disease in renal transplant recipients. Clin J Am Soc Nephrol 2008; 3:491-504. [PMID: 18287250 DOI: 10.2215/cjn.05081107] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Cardiovascular disease is a major cause of graft loss and the leading cause of death in renal transplant recipients. Although there are robust data on the frequency of risk factors and their contributions to cardiovascular disease in this population, few trials have demonstrated the benefit of modifying these risk factors to reduce cardiovascular events. Nevertheless, it is widely accepted that the clinical acumen filtered through the best available studies in the general population be used to treat individual renal transplant recipients given their high cardiovascular mortality. Transplant task forces and the Kidney Disease Outcomes Quality Initiative have created guidelines for this purpose. This review examines the data available for prevention and treatment of major risk factors contributing to cardiovascular disease in renal transplant recipients. The contribution of immunosuppressive agents to each risk factor and the evidence to support lifestyle modification as well as drug therapy are examined. Reducing cardiovascular risk factors requires an integrative approach that is best accomplished by a team of health care professionals. It creates a significant challenge but one that must be met if allograft survival is to improve.
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Affiliation(s)
- Anushree C Shirali
- Division of Nephrology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT 06520, USA
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Shilliday IR, Sherif M. Calcium channel blockers for preventing acute tubular necrosis in kidney transplant recipients. Cochrane Database Syst Rev 2007; 2007:CD003421. [PMID: 17943790 PMCID: PMC7017635 DOI: 10.1002/14651858.cd003421.pub4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The incidence of delayed graft function in cadaveric grafts has increased over the last few years due in part to the large demand for cadaveric kidneys necessitating the use of kidneys from marginal donors. Calcium channel blockers have the potential to reduce the incidence of post-transplant acute tubular necrosis (ATN) if given in the peri-operative period. However, there is controversy surrounding their use in this situation with no consensus as to their efficacy. OBJECTIVES To evaluate the benefits and harms of using calcium channel blockers in the peri-transplant period in patients at risk of ATN following cadaveric kidney transplantation. SEARCH STRATEGY We searched the Cochrane Renal Group's specialised register, the Cochrane Central Register of Controlled Trials (CENTRAL, in The Cochrane Library) MEDLINE (from 1966) and EMBASE (from 1980). The Trials Search Coordinator was contacted to develop the search strategy. Date of last search: January 2007 SELECTION CRITERIA Randomised controlled trials comparing calcium channel blockers given in the peri-transplant period with controls were included. Quasi-randomised trials were excluded. DATA COLLECTION AND ANALYSIS Data was extracted and quality assessed independently by two reviewers, with differences resolved by discussion. Dichotomous outcomes are reported as relative risk (RR) and measurements on continuous scales are reported as mean differences (WMD) with 95% confidence intervals (CI). MAIN RESULTS Thirteen trials (724 participants) were suitable for inclusion. Treatment with calcium channel blockers in the peri-transplant period was associated with a significant decrease in the incidence of post-transplant ATN (RR 0.62, 95% CI 0.46 to 0.85) and delayed graft function (RR 0.55, 95% CI 0.42 to 0.73). There was no difference between control and treatment groups in graft loss, mortality, requirement for haemodialysis. There was insufficient information to comment on adverse events. AUTHORS' CONCLUSIONS These results suggest that calcium channel blockers given in the peri-operative period may reduce the incidence of ATN post-transplantation. The result should be treated with caution due to the heterogeneity of the trials which made comparison of studies and pooling of data difficult.
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Affiliation(s)
- I R Shilliday
- Monklands Hospital, Renal Unit, Monkscourt Avenue, Airdrie, UK, ML6 0JS.
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ACE inhibitors and persistent left ventricular hypertrophy after renal transplantation: a randomized clinical trial. Am J Kidney Dis 2007; 50:133-42. [PMID: 17591533 DOI: 10.1053/j.ajkd.2007.04.013] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2006] [Accepted: 04/13/2007] [Indexed: 12/13/2022]
Abstract
BACKGROUND Interventional studies of left ventricular hypertrophy (LVH) in renal transplant recipients are scarce and to date evaluated only patients immediately after renal transplantation. STUDY DESIGN Randomized controlled trial that assessed the effectiveness of angiotensin-converting enzyme (ACE) inhibitors in regressing persistent LVH after successful transplantation. SETTING & PARTICIPANTS 70 renal transplant recipients (47 men; age, 30 to 68 years) without diabetes previously randomly assigned to either cyclosporine or tacrolimus therapy, with LVH persisting 3 to 6 months after transplantation. INTERVENTION Subjects were randomly assigned to either lisinopril (ACE-inhibitor group; 36 patients) or no therapy (control group; 34 subjects). OUTCOMES Main outcome was change in left ventricular mass index (LVMi) at month 18. RESULTS A consistent decrease in both systolic (SBP) and diastolic blood pressure (DBP) was observed in both groups (between-group differences, -1.7 +/- 3.3 mm Hg; 95% confidence interval [CI], -4.8 to 8.2; P = 0.6 for SBP; 0.3 +/- 2.2 mm Hg; 95% CI, -4.8 to 4.1; P = 0.9 for DBP), whereas LVMi regressed more in the ACE-inhibitor group (between-group difference, 10.1 +/- 16.3 g/m(2.7); 95% CI, 4.2 to 16.1; P < 0.01). A significant interaction of ACE inhibitors with cyclosporine in affecting LVMi change was shown by means of post hoc multiple regression analysis (P < 0.01; differences between cyclosporine and tacrolimus group, 13.3 +/- 3.9 g/m(2.7); 95% CI, 5.3 to 21.2; P < 0.01 in the ACE-inhibitor group; 3.7 +/- 4.2 g/m(2.7); 95% CI, -4.7 to 12.2; P = 0.4 in the control group). LIMITATIONS Single-center study with small sample size. Interaction of ACE inhibitors with cyclosporine treatment emerged from post hoc analysis. CONCLUSION A prolonged course of ACE-inhibitor therapy is effective in regressing the persistent LVH of renal transplant recipients by mechanisms independent of effects on BP. This regression seems to be at least in part the effect of an interaction between ACE inhibitors and cyclosporine.
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Taler SJ. Transplant Hypertension. Hypertension 2007. [DOI: 10.1016/b978-1-4160-3053-9.50036-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Croom KF, Wellington K. Modified-release nifedipine: a review of the use of modified-release formulations in the treatment of hypertension and angina pectoris. Drugs 2006; 66:497-528. [PMID: 16597165 DOI: 10.2165/00003495-200666040-00007] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Nifedipine is a dihydropyridine calcium channel antagonist with predominantly vasodilatory activity. Modified-release formulations of nifedipine are effective antihypertensive and antianginal therapies and are generally well tolerated. Among the available formulations, those that produce a gradual increase in plasma nifedipine concentration, which is then sustained over a 24-hour period, are preferred, as they cause a gradual onset of vasodilatation and avoid baroreflex sympathetic activation (for example, nifedipine gastrointestinal therapeutic system [GITS] and a Japanese controlled-release formulation). Modified-release nifedipine had beneficial effects on a number of markers of vascular function, and nifedipine GITS reduced the need for coronary procedures in patients with coronary artery disease. In patients with hypertension, nifedipine GITS and nifedipine retard had beneficial effects on the overall incidence of major cardiovascular events, as did nifedipine retard in patients with concurrent hypertension and coronary artery disease.
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Rigatto C, Parfrey P. Therapy Insight: management of cardiovascular disease in the renal transplant recipient. ACTA ACUST UNITED AC 2006; 2:514-26. [PMID: 16941044 DOI: 10.1038/ncpneph0253] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2005] [Accepted: 02/27/2006] [Indexed: 12/28/2022]
Abstract
Cardiovascular disease causes the deaths of up to 50% of renal transplant recipients who have a functioning graft. As in other states of chronic kidney disease, both overload cardiomyopathy (chronic heart failure and left ventricular hypertrophy) and ischemic heart disease are evident; age and gender are important risk factors for both of these disorders. Potentially treatable risk factors include smoking, hyperlipidemia, diabetes and hypertension for ischemic heart disease, and anemia, hypertension and diabetes for cardiomyopathy. Although definitive evidence on the effectiveness of interventions is lacking, it seems reasonable to treat renal transplant recipients as patients at the highest risk of cardiovascular disease. Aggressive targeting of lifestyle factors, blood pressure, cholesterol and sugar regulation is likely to have a major impact on patient and graft survival and should be initiated well before transplantation. Maintenance of hemoglobin with erythropoietic agents is controversial but might improve quality of life. Although immunosuppressive agents have distinct effects on cardiovascular risk factors, the impact on outcomes is impossible to predict on the basis of current data, and no firm recommendations can be made.
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Affiliation(s)
- Claudio Rigatto
- Section of Nephrology, St Boniface General Hospital, University of Manitoba, Winnipeg, Manitoba, Canada.
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Ersoy A. Current and future antihypertensive drugs in post-transplant hypertension and related patents. Expert Opin Ther Pat 2006. [DOI: 10.1517/13543776.16.8.1093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Hjelmesaeth J, Ueland T, Flyvbjerg A, Bollerslev J, Leivestad T, Jenssen T, Hansen TK, Thiel S, Sagedal S, Røislien J, Hartmann A. Early posttransplant serum osteoprotegerin levels predict long-term (8-year) patient survival and cardiovascular death in renal transplant patients. J Am Soc Nephrol 2006; 17:1746-54. [PMID: 16687626 DOI: 10.1681/asn.2005121368] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
The primary objectives of this analysis were to examine the effects of early posttransplantation (10 wk) serum levels of osteoprotegerin (OPG), mannose-binding lectin (MBL), and MBL-associated serine proteases (MASP; MASP-2 and MASP-3) on long-term (8-yr) patient survival, graft survival, and cardiovascular (CV) death. During a period of 16 mo (1995 to 1996), a total of 173 consecutive renal transplant recipients without diabetes before transplantation were included in a prospective study that was designed to address the impact of metabolic CV risk factors on survival and CV end points. Baseline sera from 172 patients were available for analysis. Follow-up data until January 1, 2004, were obtained from a national renal registry. Patients with high (fourth quartile) serum levels of OPG had significantly higher all-cause mortality (hazard ratio [HR] 6.3; 95% confidence interval [CI] 3.3 to 11.8; P<0.001) and CV death (HR 10.8; 95% CI 3.8 to 30.4; P<0.001) than patients with lower OPG concentrations. After multiple Cox regression analysis, high serum levels of OPG remained an independent predictor of all-cause mortality (HR 6.0; 95% CI 3.1 to 11.6, P<0.001) and CV death (HR 8.2; 95% CI 2.5 to 26.4; P<0.001). Multiple linear regression analysis revealed that age, creatinine clearance, and high-sensitivity C-reactive protein all were independently associated with OPG (R2=0.42). No significant association between OPG and death-censored graft loss was revealed. Serum levels of MBL, MASP-2, and MASP-3 were not significantly associated with patient survival, CV death, or graft loss. Early measured posttransplantation serum OPG is a highly significant independent predictor of death from any cause or CV death in white renal transplant recipients.
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Affiliation(s)
- Jøran Hjelmesaeth
- Department of Medicine, Rikshospitalet University Hospital, University of Oslo, Norway.
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Aasebø W, Midtvedt K, Hartmann A, Stavem K. Predictors of health-related quality of life in hypertensive recipients following renal transplantation. Clin Transplant 2006; 19:756-62. [PMID: 16313321 DOI: 10.1111/j.1399-0012.2005.00416.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Health-related quality of life (HRQoL) improves after renal transplantation. However, it is unclear which variables are the strongest determinants of HRQoL following renal transplantation. In this study, we wanted to assess whether antihypertensive medication, donor type, human leukocyte antigen (HLA)-compatibility or other variables could predict HRQoL 6-12 months after transplantation. METHODS The study was a follow up of 124 patients recruited to a single center, randomized, double-blind clinical trial, comparing the effects of lisinopril and nifedipine in hypertensive renal transplant recipients. HRQoL was assessed with the Short Form 36 (SF-36) questionnaire. Bivariate and multiple linear regression analysis were used to assess the relationship between potential predictors and the physical component summary (PCS) and mental component summary (MCS) scales of the SF-36. RESULTS Average scores 6-12 months after transplantation did not differ between patients randomized to lisinopril or nifedipine, or between cadaveric and living donor recipients on any of the eight SF-36 scales, or the two summary scales. In multivariate analyses, recipient age (p = 0.01) and cold ischemia time >14.5 h (p = 0.04) were independent predictors of the PCS score. Recipient age (p = 0.05), 2-4 HLA-AB mismatches (p = 0.05) and donor age (p = 0.03) were independent predictors of the MCS score. CONCLUSIONS There was no evidence of differences in HRQoL according to lisinopril or nifedipine, or living vs. cadaveric donor transplantation. HRQoL was significantly reduced with longer cold ischemia time and more than one HLA-AB mismatches, after adjusting for age. These donor kidneys related issues need confirmation.
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Affiliation(s)
- Willy Aasebø
- Medical Department, Akershus University Hospital, Nordbyhagen, Norway.
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Sabharwal NK, Swinburn J, Lahiri A, Senior R. Effect of Imidapril and Nifedipine on??Left Ventricular Hypertrophy in??Untreated Hypertension. Clin Drug Investig 2005; 25:367-75. [PMID: 17532677 DOI: 10.2165/00044011-200525060-00002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
OBJECTIVE Imidapril is an ACE inhibitor that is licensed for use in the treatment of hypertension. Studies assessing regression of left ventricular hypertrophy are limited, especially those comparing imidapril with other antihypertensive agents. DESIGN AND SETTING Single-centre, randomised, double-blind, double-dummy, parallel-group study carried out in a district general hospital. METHODS Eighty-six patients with untreated hypertension and left ventricular hypertrophy were included in the study. The mean age of the study population was 54 years and 70% were male. Patients were randomised to treatment with either imidapril or sustained-release nifedipine over a 24-week period. MAIN OUTCOME MEASURE AND RESULTS Efficacy was assessed using clinic cuff blood pressure (BP) measurement, ambulatory BP measurement and serial transthoracic echocardiography. In the nifedipine and imidapril groups, respectively, there were significant reductions in clinic BP (16.8mm Hg [20.1, 13.4] vs 11.8mm Hg [15.3, 8.4] drop in mean [95% CI] arterial pressure), ambulatory BP (9.0mm Hg [13.2, 4.9] vs 9.7mm Hg [13.8, 5.7]) and left ventricular mass index (26.4 g/m(2) [36.3, 16.5] vs 20.8 g/m(2)[27.4, 4.1]). No significant differences in effects on these parameters were noted between the nifedipine and imidapril treatment groups (p = ns). There were no significant changes in left ventricular end-diastolic volume, left ventricular end-systolic volume, or stroke volume. Patients on imidapril were more likely to complete the study and experienced fewer adverse effects. CONCLUSIONS Imidapril is a well tolerated ACE inhibitor that has been shown to be as efficacious as sustained-release nifedipine in the treatment of hypertension and left ventricular hypertrophy in patients with previously untreated hypertension.
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Abstract
The prevalence of hypertension in pediatric patients with renal transplant (Tx) has not changed for the last three decades, remaining at 50-80%. Long-standing and uncontrolled hypertension is associated with the development of end-organ damage including allograft dysfunction, early cardiomyopathy and premature atherosclerosis. Aggressive treatment of elevated BP is an essential part of Tx care with the goal to delay graft failure and prevent the development of symptomatic cardiovascular disease in young recipients of renal Tx.
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Affiliation(s)
- Mark M Mitsnefes
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229-9039, USA.
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Satyan S, Rocher LL. Impact of kidney transplantation on the progression of cardiovascular disease. Adv Chronic Kidney Dis 2004; 11:274-93. [PMID: 15241742 DOI: 10.1053/j.arrt.2004.04.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Kidney transplantation, of all the treatment modalities for end-stage renal disease, affords the greatest potential for prolonged survival and improved quality of life. Great strides in immunosuppressant therapy have improved graft survival and forced clinicians to consider other health-care needs of kidney transplant recipients. Chief among these needs is the prevention and treatment of cardiovascular disease. Cardiovascular disease is the most common cause of death among patients with a working renal allograft. Because therapies for primary and secondary prevention are successful in the general population, transplant clinicians are increasingly focused on preventing or limiting the progression of cardiovascular disease. Initiation of aggressive management of conventional atherosclerotic risk factors and uremia-related risk factors, ideally during the early stages of chronic kidney disease (CKD) or after kidney transplantation, and efforts to delay the progression of kidney disease will hopefully reduce the cardiovascular burden in transplant recipients.
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Affiliation(s)
- Sangeetha Satyan
- Department of Medicine, Division of Nephrology, William Beaumont Hospital, Royal Oak, MI 48073, USA
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References. Am J Kidney Dis 2004. [DOI: 10.1053/j.ajkd.2004.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Hernández D. Experience with cyclosporine in the Canary Islands. Transplant Proc 2004; 36:120S-124S. [PMID: 15041320 DOI: 10.1016/j.transproceed.2003.12.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Cyclosporine (CsA) is currently the basis of most immunosuppressive protocols after solid organ transplantation. The introduction of Neoral, a new microemulsion formulation of CsA, and more recently a range of adjunctive immunosuppressants have further enhanced short-term efficacy and tolerability of CsA-based immunosuppression. In addition, Neoral C2 monitoring has been shown to have advantages not only in the early posttransplant period, but also for maintenance transplant patients. The major long-term disadvantage associated with CsA is the development of nephrotoxicity and chronic allograft nephropathy (CAN), which is the second major cause of graft failure. Thus, strategies to reduce the risk of CAN include CsA-sparing protocols, use of C2 level monitoring, introduction of non-nephrotoxic adjunctive immunosuppressants, and optimal management of additional risk factors. Other important side effects related to CsA-based immunosuppression include hypertension, diabetes, and hyperlipidemia. Optimal management of these conditions may lead to significant reduction of cardiovascular-related morbidity and mortality following solid organ transplantation.
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Affiliation(s)
- D Hernández
- Nephrology Section, Hospital Universitario de Canarias, Tenerife, Spain.
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Covic A, Goldsmith DJA, Gusbeth-Tatomir P, Buhaescu I, Covic M. Successful renal transplantation decreases aortic stiffness and increases vascular reactivity in dialysis patients. Transplantation 2003; 76:1573-7. [PMID: 14702526 DOI: 10.1097/01.tp.0000086343.32903.a8] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients with end-stage renal disease on dialysis have among the highest cardiovascular event rates documented. Abnormal nitric oxide (NO)-dependent endothelial reactivity and increased arterial stiffness are commonly described in hemodialysis (HD) patients. Measures of aortic stiffness--aortic pulse wave velocity (PWV) and augmentation index (AGI)--have been shown to be powerful predictors of survival on hemodialysis. It is not known how these parameters interfere with successful renal transplantation. METHODS PWV and aortic AGI (difference between the first and second systolic peak on the aortic pressure waveform divided by the pulse wave height) were determined from contour analysis of arterial waveforms recorded by applanation tonometry using a SphygmoCor device in 41 HD patients (20 men; age, 41.8 years) and in a control group of 20 patients with essential hypertension (HTA) (10 men; age, 43.6 years). Twenty of the HD patients (10 men; age, 39.7 years) received live-related renal transplants (RTx) and were restudied (3 months after RTx, normal serum creatinine). NO-dependent and NO-independent vascular reactivity were assessed by changes in AGI after challenges with inhaled salbutamol (SAL) and sublingual nitroglycerin (NTG), respectively. RESULTS AGI values were significantly lower in RTx patients compared with subjects on hemodialysis (15.9 +/- 13.9% vs. 27.9 +/- 11.9%, P<0.05), but similar to essential HTA controls (16.5 +/- 17%). Serial AGI measurements showed that successful renal transplantation is associated with a decrease in AGI in all cases, from a mean of 25.1 +/- 7.8% while on dialysis to 15.9 +/- 7.0% 3 months after transplantation (P<0.0001). The responsiveness to both endothelium-dependent stimuli (inhaled SAL) and endothelium-independent stimuli (sublingual NTG) was greater in transplant patients than in hemodialysis patients (SAL-induced decrease in AGI -82.3 +/- 65.7% vs. 45 +/- 72.3%, P<0.01; and NTG-induced decrease in AGI 197 +/- 108 vs. -129.0 +/- 215.5%, P<0.01). PWV values in dialysis patients (7.19 +/- 1.88 m/sec) were significantly higher than those measured in essential HTA patients (6.34 +/- 1.32 m/sec, P<0.05) with normal renal function (despite similar blood pressure levels). PWV after RTx was 6.59 +/- 1.62 m/sec, significantly different from pretransplantation (dialysis) values (P<0.05 for comparison) but similar to the control group of essential HTA patients. CONCLUSIONS Renal transplantation is associated with marked improvements in vascular structure and function to a profile comparable to essential HTA patients.
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Affiliation(s)
- A Covic
- C I Parhon University Hospital, Dialysis and Transplantation Center, Iasi, Romania.
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Baroletti SA, Gabardi S, Magee CC, Milford EL. Calcium channel blockers as the treatment of choice for hypertension in renal transplant recipients: fact or fiction. Pharmacotherapy 2003; 23:788-801. [PMID: 12820820 DOI: 10.1592/phco.23.6.788.32180] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Posttransplantation hypertension has been identified as an independent risk factor for chronic allograft dysfunction and loss. Based on available morbidity and mortality data, posttransplantation hypertension must be identified and managed appropriately. During the past decade, calcium channel blockers have been recommended by some as the antihypertensive agents of choice in this population, because it was theorized that their vasodilatory effects would counteract the vasoconstrictive effects of the calcineurin inhibitors. With increasing data becoming available, reexamining the use of traditional antihypertensive agents, including diuretics and beta-blockers, or the newer agents, angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers, may be beneficial. Transplant clinicians must choose antihypertensive agents that will provide their patients with maximum benefit, from both a renal and a cardiovascular perspective. Beta-blockers, diuretics, and ACE inhibitors have all demonstrated significant benefit on morbidity and mortality in patients with cardiovascular disease. Calcium channel blockers have been shown to possess the ability to counteract cyclosporine-induced nephrotoxicity. When compared with beta-blockers, diuretics, and ACE inhibitors, however, the relative risk of cardiovascular events is increased with calcium channel blockers. With the long-term benefits of calcium channel blockers on the kidney unknown and a negative cardiovascular profile, these agents are best reserved as adjunctive therapy to beta-blockers, diuretics, and ACE inhibitors.
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Affiliation(s)
- Steven A Baroletti
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA.
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Zhang R, Leslie B, Boudreaux JP, Frey D, Reisin E. Hypertension after kidney transplantation: impact, pathogenesis and therapy. Am J Med Sci 2003; 325:202-8. [PMID: 12695725 DOI: 10.1097/00000441-200304000-00006] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Hypertension (HTN) contributes to the high incidence of cardiovascular disease mortality as well as chronic allograft nephropathy (CAN) and late graft failure in renal transplant recipients. The mechanisms are complex and may involve pathogenic factors attributable to the host, allograft, and immunosuppressive drugs. Calcium channel blockers should be used to ameliorate the nephrotoxicity of calcineurin inhibitors in the early years after transplantation. Angiotensin-converting enzyme inhibitors and angiotensin-2 type-1 receptor blockers are safe and effective, have antiproteinuric effects, slow the progression of CAN, and may provide survival benefits. Diuretics and/or beta-adrenergic receptor blockers are frequently added in combination regimen. Appropriate adjustment of the immunosuppressive drugs should also be considered for the long-term care of kidney recipients with HTN.
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Affiliation(s)
- Rubin Zhang
- Section of Nephrology, Department of Medicine, Louisianna State University Health Sciences Center, New Orleans 70112-2822, USA
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Foley RN. Clinical epidemiology of cardiac disease in dialysis patients: left ventricular hypertrophy, ischemic heart disease, and cardiac failure. Semin Dial 2003; 16:111-7. [PMID: 12641874 DOI: 10.1046/j.1525-139x.2003.160271.x] [Citation(s) in RCA: 127] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Patients with end-stage renal disease (ESRD) are at extreme cardiovascular risk. At least half of all patients starting dialysis therapy have overt cardiovascular disease (CVD). In addition, recent studies suggest annual incidence rates for new-onset cardiac failure, peripheral vascular disease, ischemic heart disease (IHD), and stroke of approximately 7%, 7%, 5%, and 1%, respectively. High-level exposure to traditional risk factors, such as smoking and dyslipidemia, hemodynamic overload factors, such as anemia and hypertension, and a myriad of metabolic factors related to uremia are all likely to play a role. There has been explosive growth in observational studies and a heartening, if less dramatic, increase in risk factor intervention trials, suggesting that risk factor modification can lead to meaningful benefit.
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Affiliation(s)
- Robert N Foley
- Nephrology Analytical Services, Hennepin County Medical Center, Minneapolis, Minnesota 55404, USA.
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Abstract
Individuals with chronic kidney disease (CKD) are at increased risk for the development and progression of cardiovascular disease (CVD). The increased risk is due to a higher prevalence of both traditional risk factors as well as nontraditional risk factors. In this review we focus on individuals at all stages of CKD and discuss modifiable traditional risk factors, namely hypertension, dyslipidemia, diabetes mellitus and poor glycemic control, smoking, and physical inactivity. The prevalence of each risk factor and its relationship with CVD is described. Treatment recommendations are provided using evidence available from populations with CKD or evidence extrapolated from the general population when there are insufficient data on individuals with CKD.
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Affiliation(s)
- Katrin Uhlig
- Division of Nephrology, Department of Medicine, Tufts New England Medical Center, Boston, Massachusetts 02111, USA
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