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Yuan S, Li S, Ruan J, Liu H, Jiang T, Dai H. Chronic kidney disease and pulmonary hypertension: Progress in diagnosis and treatment. Transl Res 2024; 273:16-22. [PMID: 38960282 DOI: 10.1016/j.trsl.2024.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 06/13/2024] [Accepted: 06/18/2024] [Indexed: 07/05/2024]
Abstract
Pulmonary hypertension (PH) is a medical condition characterized by elevated pulmonary vascular resistance and pressure, resulting from different diseases. Due to their high occurrence of PH, intricate hemodynamic classification, and frequently multifactorial cause and mechanism, individuals suffering from chronic kidney disease (CKD) are categorized as the fifth primary group of PH. Based on both domestic and international research, this article provides information on the epidemiology, risk factors, pathogenesis, and targeted drug treatment of PH associated with CKD.
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Affiliation(s)
- Shanshan Yuan
- Department of Cardiology, Qingdao Municipal Hospital, Qingdao 266011, PR China
| | - Shicheng Li
- Department of Cardiology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, PR China
| | - Jiangwen Ruan
- Department of Cardiology, The People's Hospital of Guangxi Zhuang Autonomous Region, Institute of Cardiovascular Sciences, Guangxi Academy of Medical Sciences, Nanning 530021, PR China
| | - Hui Liu
- Division of Biology and Chemistry, Paul Scherrer Institut, 5232, Villigen, Switzerland; Department of Health Sciences and Technology, ETH Zurich, 8092, Zurich, Switzerland
| | - Tongmeng Jiang
- Key Laboratory of Emergency and Trauma of Ministry of Education, Key Laboratory of Haikou Trauma, Key Laboratory of Hainan Trauma and Disaster Rescue, The First Affiliated Hospital, Hainan Medical University, Haikou 571199, PR China; Engineering Research Center for Hainan Bio-Smart Materials and Bio-Medical Devices, Key Laboratory of Hainan Functional Materials and Molecular Imaging, College of Emergency and Trauma, Hainan Academy of Medical Sciences, Hainan Medical University, Haikou 571199, PR China.
| | - Hongyan Dai
- Department of Cardiology, Qingdao Municipal Hospital, Qingdao 266011, PR China.
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Kumar D, Raju N, Prajapati B, Moinuddin I, Tripathi S, Grinnan D, Thomas D, Gupta G. Management and Outcomes of Kidney Transplant Candidates With Severe Pulmonary Hypertension: A Single-center Strategy and Experience. Transplant Direct 2024; 10:e1640. [PMID: 38769978 PMCID: PMC11104714 DOI: 10.1097/txd.0000000000001640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 03/14/2024] [Indexed: 05/22/2024] Open
Abstract
Background Severe pulmonary hypertension (PH) is associated with high mortality posttransplant and thus is considered a contraindication to kidney transplantation. In this study, we describe the pretransplant management and posttransplant outcomes in patients with severe PH using a multidisciplinary approach. Methods Between 11 of 2013 and 8 of 2022, we identified all patients with severe PH on initial pretransplant workup who underwent ultrafiltration (UF) or medical therapy for PH before transplant. Posttransplant we evaluated the perioperative course, renal function, graft, and patient survival. We compared survival to those who remained waitlisted or were delisted. Results Three-two patients (mean age = 55.03 ± 10.22 y) diagnosed with severe PH on pretransplant screening echocardiogram. Thirty patients (94%) were subjected to a median of 4 (range, 3-8) UF sessions with an average weight loss of 4.33 ± 2.6 kg. Repeat assessment of PH revealed a decline in mean pulmonary artery systolic pressure from 67 ± 12 mm Hg to 43 ± 13 mm Hg (P < 0.0001). Seventeen patients (53%) received a kidney transplant. The mean estimated Glomerular Filtration Rate at 3, 6, 9, and 12 mo was 72 ± 27, 72 ± 28, 75 ± 29, and 75 ± 29 mL/min/1.73 m2. Among, those who underwent transplantation both graft and patient survival was 100% at 1-y posttransplant. Overall, since the UF intervention, at a median follow-up of 88 ± 12 mo those transplanted had a patient survival of 88% while those who remained on dialysis had a survival of 53% (P = 0.0003). Conclusion In this single-center study, we report postcapillary PH can be a significant contributor to elevations in pulmonary artery systolic pressure. Using a multidisciplinary approach, PH can improve with volume removal and phosphodiesterase 5 inhibitors therapy leading to a successful posttransplant outcome.
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Affiliation(s)
- Dhiren Kumar
- Virginia Commonwealth University, Internal Medicine, Richmond, VA
| | - Nihar Raju
- Virginia Commonwealth University, Internal Medicine, Richmond, VA
| | | | - Irfan Moinuddin
- Virginia Commonwealth University, Internal Medicine, Richmond, VA
| | | | - Daniel Grinnan
- Virginia Commonwealth University, Internal Medicine, Richmond, VA
| | - Deepak Thomas
- Virginia Commonwealth University, Internal Medicine, Richmond, VA
| | - Gaurav Gupta
- Virginia Commonwealth University, Internal Medicine, Richmond, VA
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Brinza C, Covic A, Stefan AE, Floria M, Popa IV, Scripcariu DV, Burlacu A. Pulmonary Arterial Hypertension and Adverse Outcomes after Kidney Transplantation: A Systematic Review and Meta-Analysis. J Clin Med 2022; 11:1944. [PMID: 35407552 PMCID: PMC8999673 DOI: 10.3390/jcm11071944] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/18/2022] [Accepted: 03/28/2022] [Indexed: 12/10/2022] Open
Abstract
Pulmonary arterial hypertension (PH) has a high prevalence in chronic kidney disease (CKD) patients, especially those undergoing kidney transplantation (KT). We aimed to systematically review and calculate the pooled effect size of the literature evaluating the association between pre-existing PH documented by transthoracic echocardiography (TTE) or invasively and adverse outcomes following KT. The primary composite outcome extracted from the included studies was represented by the mortality from any cause following KT and delayed graft function (DGF), graft dysfunction, or graft failure. The secondary outcomes were represented by individual components of the primary composite outcome. Twelve studies meeting the inclusion criteria were selected. The main finding is that pre-existing PH was associated with increased mortality and a higher rate of DGF, kidney graft dysfunction, or failure in KT recipients. The effect remained significant for all outcomes irrespective of PH evaluation, invasively or using TTE. Consequently, patients with PH defined only by TTE were at higher risk of death, DGF, or graft failure. Our findings support the routine assessment of PH in patients on the KT waitlist. PH might represent an extensively available and valuable tool for risk stratification in KT patients. These data should be confirmed in large prospective clinical trials.
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Affiliation(s)
- Crischentian Brinza
- Institute of Cardiovascular Diseases, 700503 Iasi, Romania;
- Faculty of Medicine, University of Medicine and Pharmacy Grigore T Popa, 700115 Iasi, Romania; (A.C.); (M.F.); (I.V.P.)
| | - Adrian Covic
- Faculty of Medicine, University of Medicine and Pharmacy Grigore T Popa, 700115 Iasi, Romania; (A.C.); (M.F.); (I.V.P.)
- Nephrology Clinic, Dialysis and Renal Transplant Center—Constantin Ion Parhon University Hospital, 700503 Iasi, Romania;
| | - Anca Elena Stefan
- Nephrology Clinic, Dialysis and Renal Transplant Center—Constantin Ion Parhon University Hospital, 700503 Iasi, Romania;
| | - Mariana Floria
- Faculty of Medicine, University of Medicine and Pharmacy Grigore T Popa, 700115 Iasi, Romania; (A.C.); (M.F.); (I.V.P.)
- Doctor Iacob Czihac Military Emergency Clinical Hospital, 700483 Iasi, Romania
| | - Iolanda Valentina Popa
- Faculty of Medicine, University of Medicine and Pharmacy Grigore T Popa, 700115 Iasi, Romania; (A.C.); (M.F.); (I.V.P.)
| | - Dragos-Viorel Scripcariu
- Faculty of Medicine, University of Medicine and Pharmacy Grigore T Popa, 700115 Iasi, Romania; (A.C.); (M.F.); (I.V.P.)
| | - Alexandru Burlacu
- Institute of Cardiovascular Diseases, 700503 Iasi, Romania;
- Faculty of Medicine, University of Medicine and Pharmacy Grigore T Popa, 700115 Iasi, Romania; (A.C.); (M.F.); (I.V.P.)
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Incidence, Clinical Correlates, and Outcomes of Pulmonary Hypertension After Kidney Transplantation: Analysis of Linked US Registry and Medicare Billing Claims. Transplantation 2022; 106:666-675. [PMID: 33859148 DOI: 10.1097/tp.0000000000003783] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The incidence, risks, and outcomes associated with pulmonary hypertension (P-HTN) in the kidney transplant (KTx) population are not well described. METHODS We linked US transplant registry data with Medicare claims (2006-2016) to investigate P-HTN diagnoses among Medicare-insured KTx recipients (N = 35 512) using billing claims. Cox regression was applied to identify independent correlates and outcomes of P-HTN (adjusted hazard ratio [aHR] 95%LCLaHR95%UCL) and to examine P-HTN diagnoses as time-dependent mortality predictors. RESULTS Overall, 8.2% of recipients had a diagnostic code for P-HTN within 2 y preceding transplant. By 3 y posttransplant, P-HTN was diagnosed in 10.310.6%11.0 of the study cohort. After adjustment, posttransplant P-HTN was more likely in KTx recipients who were older (age ≥60 versus 18-30 y a HR, 1.912.403.01) or female (aHR, 1.151.241.34), who had pretransplant P-HTN (aHR, 4.384.795.24), coronary artery disease (aHR, 1.051.151.27), valvular heart disease (aHR, 1.221.321.43), peripheral vascular disease (aHR, 1.051.181.33), chronic pulmonary disease (aHR, 1.201.311.43), obstructive sleep apnea (aHR, 1.151.281.43), longer dialysis duration, pretransplant hemodialysis (aHR, 1.171.371.59), or who underwent transplant in the more recent era (2012-2016 versus 2006-2011: aHR, 1.291.391.51). Posttransplant P-HTN was associated with >2.5-fold increased risk of mortality (aHR, 2.572.843.14) and all-cause graft failure (aHR, 2.422.642.88) within 3 y posttransplant. Outcome associations of newly diagnosed posttransplant P-HTN were similar. CONCLUSIONS Posttransplant P-HTN is diagnosed in 1 in 10 KTx recipients and is associated with an increased risk of death and graft failure. Future research is needed to refine diagnostic, classification, and management strategies to improve outcomes in KTx recipients who develop P-HTN.
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Rabih F, Holden RL, Vasanth P, Pastan SO, Fisher MR, Trammell AW. Effect of pulmonary hypertension on 5‐year outcome of kidney transplantation. Pulm Circ 2022; 12:e12010. [PMID: 35506090 PMCID: PMC9052965 DOI: 10.1002/pul2.12010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 11/08/2021] [Accepted: 11/23/2021] [Indexed: 12/19/2022] Open
Affiliation(s)
- Fadi Rabih
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine Emory University School of Medicine Atlanta Georgia USA
| | - Rhiannon L. Holden
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine Emory University School of Medicine Atlanta Georgia USA
| | - Payaswini Vasanth
- Department of Medicine, Division of Renal Medicine Emory University School of Medicine Atlanta Georgia USA
- Emory Transplant Center, Emory Healthcare Atlanta Georgia USA
| | - Stephen O. Pastan
- Department of Medicine, Division of Renal Medicine Emory University School of Medicine Atlanta Georgia USA
- Emory Transplant Center, Emory Healthcare Atlanta Georgia USA
| | - Micah R. Fisher
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine Emory University School of Medicine Atlanta Georgia USA
| | - Aaron W. Trammell
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine Emory University School of Medicine Atlanta Georgia USA
- Atlanta VA Medical Center, Office of Research Decatur Georgia USA
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Frost AE, Moore LW, Valdivia e Alvarado M, Obi C, Graviss EA, Nguyen DT, Gaber AO, Suki WN. The echocardiographic course of pretransplant pulmonary hypertension following kidney transplantation and associated outcomes. Pulm Circ 2021; 12:e12030. [PMID: 35506107 PMCID: PMC9052995 DOI: 10.1002/pul2.12030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 11/17/2021] [Accepted: 12/17/2021] [Indexed: 11/14/2022] Open
Abstract
The post 3 kidney transplant course of pretransplant echocardiographically‐defined pulmonary hypertension (PH) was reviewed in 115 patients. Of these 61 patients (the largest cohort reported to date), underwent 160 “for indication” echocardiograms posttransplant (mean echocardiograms per patient: 2.6 ± 2.3). Patients undergoing posttransplant echocardiograms demonstrated greater risks for worse outcomes than those without posttransplant echocardiograms; however, there was no difference in mortality, death‐censored graft failure or the composite of death or graft failure between these two groups. Of patients tested, 36 (59%) showed resolution of PH at a median of 37.5 months. Six patients (16.7%) in whom PH resolved (at a median of 29 months), experienced recurrence of PH after an interval of 48 months. No pretransplant demographic or echocardiographic characteristics distinguished those in whom PH persisted versus resolved. Though there was no difference in the risk for mortality or death‐censored graft loss between the two groups at 3 and 5 years, there was a higher risk for the composite of mortality or graft loss at three but not at five years in the group with persistent PH. In conclusion, echocardiographically defined PH resolved in 59% of patients following kidney transplantation; but irrespective of resolution there was no clear association with worse outcome.
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Affiliation(s)
- Adaani E Frost
- Houston Methodist Academic Institute Houston Texas
- Houston Methodist Research Institute Houston Texas
| | - Linda W Moore
- Houston Methodist Research Institute Houston Texas
- Dept of Surgery Houston Methodist Hospital Houston Texas
| | | | - Chizoba Obi
- Dept. of Medicine Houston Methodist Hospital Houston Texas
| | - Edward A Graviss
- Houston Methodist Research Institute Houston Texas
- Dept of Surgery Houston Methodist Hospital Houston Texas
| | - Duc T Nguyen
- Houston Methodist Research Institute Houston Texas
| | - A Osama Gaber
- Houston Methodist Research Institute Houston Texas
- Dept of Surgery Houston Methodist Hospital Houston Texas
| | - Wadi N Suki
- Houston Methodist Academic Institute Houston Texas
- Dept. of Medicine Houston Methodist Hospital Houston Texas
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van de Wouw J, Steenhorst JJ, Sorop O, van Drie RWA, Wielopolski PA, Kleinjan A, Hirsch A, Duncker DJ, Merkus D. Impaired pulmonary vasomotor control in exercising swine with multiple comorbidities. Basic Res Cardiol 2021; 116:51. [PMID: 34510273 PMCID: PMC8435524 DOI: 10.1007/s00395-021-00891-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 07/29/2021] [Indexed: 12/15/2022]
Abstract
Pulmonary hypertension is common in heart failure with preserved ejection fraction (HFpEF). Here, we tested the hypothesis that comorbidities [diabetes mellitus (DM, streptozotocin), hypercholesterolemia (HC, high-fat diet) and chronic kidney disease (CKD, renal microembolization)] directly impair pulmonary vasomotor control in a DM + HC + CKD swine model. 6 months after induction of DM + HC + CKD, pulmonary arterial pressure was similar in chronically instrumented female DM + HC + CKD (n = 19) and Healthy swine (n = 18). However, cardiac output was lower both at rest and during exercise, implying an elevated pulmonary vascular resistance (PVR) in DM + HC + CKD swine (153 ± 10 vs. 122 ± 9 mmHg∙L-1∙min∙kg). Phosphodiesterase 5 inhibition and endothelin receptor antagonism decreased PVR in DM + HC + CKD (- 12 ± 12 and - 22 ± 7 mmHg∙L-1∙min∙kg) but not in Healthy swine (- 1 ± 12 and 2 ± 14 mmHg∙L-1∙min∙kg), indicating increased vasoconstrictor influences of phosphodiesterase 5 and endothelin. Inhibition of nitric oxide synthase produced pulmonary vasoconstriction that was similar in Healthy and DM + HC + CKD swine, but unmasked a pulmonary vasodilator effect of endothelin receptor antagonism in Healthy (- 56 ± 26 mmHg∙L-1∙min∙kg), whereas it failed to significantly decrease PVR in DM + HC + CKD, indicating loss of nitric oxide mediated inhibition of endothelin in DM + HC + CKD. Scavenging of reactive oxygen species (ROS) had no effect on PVR in either Healthy or DM + HC + CKD swine. Cardiovascular magnetic resonance imaging, under anesthesia, showed no right ventricular changes. Finally, despite an increased contribution of endogenous nitric oxide to vasomotor tone regulation in the systemic vasculature, systemic vascular resistance at rest was higher in DM + HC + CKD compared to Healthy swine (824 ± 41 vs. 698 ± 35 mmHg∙L-1∙min∙kg). ROS scavenging induced systemic vasodilation in DM + HC + CKD, but not Healthy swine. In conclusion, common comorbidities directly alter pulmonary vascular control, by enhanced PDE5 and endothelin-mediated vasoconstrictor influences, well before overt left ventricular backward failure or pulmonary hypertension develop.
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Affiliation(s)
- Jens van de Wouw
- Division of Experimental Cardiology, Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Jarno J Steenhorst
- Division of Experimental Cardiology, Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Oana Sorop
- Division of Experimental Cardiology, Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Ruben W A van Drie
- Division of Experimental Cardiology, Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Piotr A Wielopolski
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Alex Kleinjan
- Department of Pulmonary Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Alexander Hirsch
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Dirk J Duncker
- Division of Experimental Cardiology, Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Daphne Merkus
- Division of Experimental Cardiology, Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000 CA, Rotterdam, The Netherlands.
- Institute for Surgical Research, Walter Brendel Center of Experimental Medicine (WBex), University Clinic Munich, LMU Munich, Munich, Germany.
- German Center for Cardiovascular Research, Partner Site Munich, Munich Heart Alliance, Munich, Germany.
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Puttarajappa CM, Schinstock CA, Wu CM, Leca N, Kumar V, Vasudev BS, Hariharan S. KDOQI US Commentary on the 2020 KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation. Am J Kidney Dis 2021; 77:833-856. [PMID: 33745779 DOI: 10.1053/j.ajkd.2020.11.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 11/17/2020] [Indexed: 12/14/2022]
Abstract
Evaluation of patients for kidney transplant candidacy is a comprehensive process that involves a detailed assessment of medical and surgical issues, psychosocial factors, and patients' physical and cognitive abilities with an aim of balancing the benefits of transplantation and potential risks of surgery and long-term immunosuppression. There is considerable variability among transplant centers in their approach to evaluation and decision-making regarding transplant candidacy. The 2020 KDIGO (Kidney Disease: Improving Guidelines Outcome) clinical practice guideline on the evaluation and management of candidates for kidney transplantation provides practice recommendations that can serve as a useful reference guide to transplant professionals. The guideline, covering a broad range of topics, was developed by an international group of experts from transplant and nephrology through a review of literature published until May 2019. A work group of US transplant nephrologists convened by NKF-KDOQI (National Kidney Foundation-Kidney Disease Quality Initiative) chose key topics for this commentary with a goal of presenting a broad discussion to the US transplant community. Each section of this article has a summary of the key KDIGO guideline recommendations, followed by a brief commentary on the recommendations, their clinical utility, and potential implementation challenges. The KDOQI work group agrees broadly with the KDIGO recommendations but also recognizes and highlights the decision-making challenges that arise from lack of high-quality evidence and the need to balance equity with utility of organ transplantation.
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Affiliation(s)
- Chethan M Puttarajappa
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Carrie A Schinstock
- Division of Nephrology & Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Christine M Wu
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Nicolae Leca
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA
| | - Vineeta Kumar
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Brahm S Vasudev
- Division of Nephrology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Sundaram Hariharan
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA.
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