1
|
Zeder K, Siew ED, Kovacs G, Brittain EL, Maron BA. Pulmonary hypertension and chronic kidney disease: prevalence, pathophysiology and outcomes. Nat Rev Nephrol 2024:10.1038/s41581-024-00857-7. [PMID: 38890546 DOI: 10.1038/s41581-024-00857-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2024] [Indexed: 06/20/2024]
Abstract
Pulmonary hypertension (PH) is common in patients with chronic kidney disease (CKD) or kidney failure, with an estimated prevalence of up to 78% in those referred for right-heart catheterization. PH is independently associated with adverse outcomes in CKD, raising the possibility that early detection and appropriate management of PH might improve outcomes in at-risk patients. Among patients with PH, the prevalence of CKD stages 3 and 4 is estimated to be as high as 36%, and CKD is also independently associated with adverse outcomes. However, the complex, heterogenous pathophysiology and clinical profile of CKD-PH requires further characterization. CKD is often associated with elevated left ventricular filling pressure and volume overload, which presumably leads to pulmonary vascular stiffening and post-capillary PH. By contrast, a distinct subgroup of patients at high risk is characterized by elevated pulmonary vascular resistance and right ventricular dysfunction in the absence of pulmonary venous hypertension, which may represent a right-sided cardiorenal syndrome defined in principle by hypervolaemia, salt avidity, low cardiac output and normal left ventricular function. Current understanding of CKD-PH is limited, despite its potentially important ramifications for clinical decision making. In particular, whether PH should be considered when determining the suitability and timing of kidney replacement therapy or kidney transplantation is unclear. More research is urgently needed to address these knowledge gaps and improve the outcomes of patients with or at risk of CKD-PH.
Collapse
Affiliation(s)
- Katarina Zeder
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
- Division of Cardiovascular Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
- Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- The University of Maryland-Institute for Health Computing, Bethesda, MD, USA
| | - Edward D Siew
- Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease and Integrated Program for Acute Kidney Injury, Nashville, TN, USA
| | - Gabor Kovacs
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
- Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Evan L Brittain
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Bradley A Maron
- Division of Cardiovascular Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.
- The University of Maryland-Institute for Health Computing, Bethesda, MD, USA.
| |
Collapse
|
2
|
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.
Collapse
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
| |
Collapse
|
3
|
Rajnochova Bloudickova S, Janek B, Machackova K, Hruba P. Standardized risk-stratified cardiac assessment and early posttransplant cardiovascular complications in kidney transplant recipients. Front Cardiovasc Med 2024; 11:1322176. [PMID: 38327495 PMCID: PMC10847279 DOI: 10.3389/fcvm.2024.1322176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 01/11/2024] [Indexed: 02/09/2024] Open
Abstract
Introduction Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in kidney transplant recipient (KTR). There is a dearth of standardized guidelines on optimal cardiovascular evaluation of transplant candidates. Methods This single-center cohort study aims to determine the effectiveness of our standardized risk-stratified pretransplant cardiovascular screening protocol, which includes coronary angiography (CAG), in identifying advanced CVD, the proper pretransplant management of which could lead to a reduction in the incidence of major cardiac events (MACE) in the early posttransplant period. Results Out of the total 776 KTR transplanted between 2017 and 2019, CAG was performed on 541 patients (69.7%), of whom 22.4% were found to have obstructive coronary artery disease (CAD). Asymptomatic obstructive CAD was observed in 70.2% of cases. In 73.6% of cases, CAG findings resulted in myocardial revascularization. MACE occurred in 5.6% (N = 44) of the 23 KTR with pretransplant CVD and 21 without pretransplant CVD. KTR with posttransplant MACE occurrence had significantly worse kidney graft function at the first year posttransplant (p = 0.00048) and worse patient survival rates (p = 0.0063) during the 3-year follow-up period compared with KTR without MACE. After adjustment, the independent significant factors for MACE were arrhythmia (HR 2.511, p = 0.02, 95% CI 1.158-5.444), pretransplant history of acute myocardial infarction (HR 0.201, p = 0.046, 95% CI 0.042-0.970), and pretransplant myocardial revascularization (HR 0.225, p = 0.045, 95% CI 0.052-0.939). Conclusion Asymptomatic CVD is largely prevalent in KTR. Posttransplant MACE has a negative effect on grafts and patient outcomes. Further research is needed to assess the benefits of pretransplant myocardial revascularization in asymptomatic kidney transplant candidates.
Collapse
Affiliation(s)
| | - Bronislav Janek
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Karolina Machackova
- Department of Nephrology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Petra Hruba
- Transplant Laboratory, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| |
Collapse
|
4
|
Mahalwar G, Mathew RO, Rangaswami J. Sodium-glucose cotransporter 2 inhibitors and cardiorenal outcomes in kidney transplantation. Curr Opin Nephrol Hypertens 2024; 33:53-60. [PMID: 38014999 DOI: 10.1097/mnh.0000000000000948] [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: 11/29/2023]
Abstract
PURPOSE OF REVIEW This review aims to explore the current evidence regarding cardiovascular and kidney outcomes in patients who undergo treatment with sodium-glucose cotransporter 2 inhibitors (SGLT2i) post kidney transplantation. RECENT FINDINGS Summary findings from individual studies included in this review showed largely favorable results in the kidney transplant recipients (KTRs) being treated with SGLT2i.These outcomes included parameters such as allograft function, glycemic control, proteinuria, blood pressure, weight loss and safety profile, among others. Almost all the studies reported an initial 'dip' in eGFR, followed by recovery, after the initiation of SGLT2i treatment. None of the studies reported significant interaction of SGLT2i with immunosuppressive medications. The most common adverse effects noted in these studies were infection-related including UTI and genital mycosis. None of the studies reported acute graft rejection attributable to SGLT2i therapy. SUMMARY SGLT2i can play a significant role in improving health outcomes in KTRs. However, clinical trials with larger representation of KTRs longer follow-up period are needed to draw more substantial conclusions.
Collapse
Affiliation(s)
- Gauranga Mahalwar
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Roy O Mathew
- Department of Nephrology, Loma Linda VA Healthcare System, Loma Linda
- Loma Linda University School of Medicine, Loma Linda, California
| | - Janani Rangaswami
- Department of Nephrology, Washington DC Veterans Affairs Medical Center
- George Washington University School of Medicine and Health Sciences, Washington DC, USA
| |
Collapse
|
5
|
Jha AK, Jha N, Malik V. Perioperative Decision-Making in Pulmonary Hypertension. Heart Lung Circ 2023; 32:454-466. [PMID: 36841637 DOI: 10.1016/j.hlc.2023.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 11/03/2022] [Accepted: 01/03/2023] [Indexed: 02/27/2023]
Abstract
Pulmonary hypertension (PH) is a haemodynamic manifestation of cardiorespiratory and non-cardiorespiratory pathologies. Cardiorespiratory pathologies account for nearly three-fourths of patients with PH. It is now increasingly being recognised due to routine requests for transthoracic echocardiographic examination in the perioperative setting in patients undergoing intermediate- to high-risk non-cardiac surgery. The increased risks of perioperative morbidity and mortality attributed to PH have been widely acknowledged in the literature. The importance of PH in perioperative decision-making and postoperative outcomes has had little mention in all the guidelines. Understanding the complexity of the pathophysiology of PH may help in anaesthetic and surgical decision-making. Preoperative evaluation and risk assessment are guided by the nature, extent, invasiveness, and duration of surgery. Surgical decision-making and anaesthetic management involve preoperative risk stratification, understanding the interactions between surgical procedures and PH, and understanding the interactions between anaesthetic procedures, PH, and cardiopulmonary interactions. Intraoperative and postoperative monitoring is crucial for maintaining the haemodynamic parameters and helps titrate anaesthetic agents and medication. This narrative review focusses on all issues related to anaesthetic and surgical challenges in patients with PH. This review aimed to suggest a preoperative evaluation plan, surgical decision-making, anaesthetic plan, and anaesthetic management based on the evidence available in the literature.
Collapse
Affiliation(s)
- Ajay Kumar Jha
- Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India.
| | - Nivedita Jha
- Department of Obstetrics and Gynaecology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - Vishwas Malik
- Department of Cardiac Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
6
|
Earasi K, Mihaltses J, Kennedy JLW, Rao S, Holsten L, Mazimba S, Doyle A, Mihalek AD. Intensive ultrafiltration strategy restores kidney transplant candidacy for patients with echocardiographic evidence of pulmonary hypertension. Clin Transplant 2022; 36:e14799. [PMID: 36029145 PMCID: PMC10078392 DOI: 10.1111/ctr.14799] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 05/12/2022] [Accepted: 08/10/2022] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Pulmonary hypertension (PH) is prevalent in those with end-stage kidney disease (ESKD) and poses a barrier to kidney transplant due to its association with poor outcomes. Studies examining these adverse outcomes are limited and often utilize echocardiographic measurements of pulmonary artery systolic pressure (PASP) instead of the gold standard right heart catheterization (RHC). We hypothesized that in ESKD patients deemed ineligible for kidney transplant because of an echocardiographic diagnosis of PH the predominant cause of PH is hypervolemia and is potentially reversible. METHODS We conducted a prospective study of 16 patients with ESKD who were denied transplant candidacy. Prior echocardiograms and RHCs were reviewed for confirmation of PH. Patients were admitted for daily sessions of ultrafiltration for volume removal and repeat RHCs were performed following intervention. RHC parameters and body weight were compared before and after intervention. Statistical analysis was performed using PRISM GraphPad software. A p-value <.05 was considered statistically significant. RESULTS Following intervention, the mean pulmonary artery pressure (mPAP) and pulmonary arterial wedge pressure decreased from 45.0 ± 3.06 to 29.1 ± 7.77 mmHg (p < .0001) and 22.2 ± 5.06 to 13.1 ± 7.25 mmHg (p = .003), respectively. The pulmonary vascular resistance decreased from 4.73 ± 1.99 to 4.28 ± 2.07 WU (p = .30). Eleven patients from the initial cohort underwent successful kidney transplantation post-intervention with 100% survival at 1-year. CONCLUSIONS In ESKD patients, diagnoses of PH made by echocardiography may be largely due to hypervolemia and may be optimized using an intensive ultrafiltration strategy to restore transplant candidacy.
Collapse
Affiliation(s)
- Kranthikiran Earasi
- Department of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - John Mihaltses
- Eastern Nephrology Associates, Wilmington, North Carolina, USA
| | | | - Swati Rao
- Department of Medicine, University of Virginia, Charlottesville, Virginia, USA.,Division of Nephrology, University of Virginia, Charlottesville, Virginia, USA
| | - Laura Holsten
- Department of Medicine, University of Virginia, Charlottesville, Virginia, USA.,Division of Nephrology, University of Virginia, Charlottesville, Virginia, USA
| | - Sula Mazimba
- Department of Medicine, University of Virginia, Charlottesville, Virginia, USA.,Division of Cardiovascular Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Alden Doyle
- Department of Medicine, University of Virginia, Charlottesville, Virginia, USA.,Division of Nephrology, University of Virginia, Charlottesville, Virginia, USA
| | - Andrew D Mihalek
- Department of Medicine, University of Virginia, Charlottesville, Virginia, USA.,Division of Pulmonary and Critical Care Medicine, University of Virginia, Charlottesville, Virginia, USA
| |
Collapse
|
7
|
McGlothlin D, Granton J, Klepetko W, Beghetti M, Rosenzweig EB, Corris P, Horn E, Kanwar M, McRae K, Roman A, Tedford R, Badagliacca R, Bartolome S, Benza R, Caccamo M, Cogswell R, Dewachter C, Donahoe L, Fadel E, Farber HW, Feinstein J, Franco V, Frantz R, Gatzoulis M, Hwa (Anne) Goh C, Guazzi M, Hansmann G, Hastings S, Heerdt P, Hemnes A, Herpain A, Hsu CH, Kerr K, Kolaitis N, Kukreja J, Madani M, McCluskey S, McCulloch M, Moser B, Navaratnam M, Radegran G, Reimer C, Savale L, Shlobin O, Svetlichnaya J, Swetz K, Tashjian J, Thenappan T, Vizza CD, West S, Zuckerman W, Zuckermann A, De Marco T. ISHLT CONSENSUS STATEMENT: Peri-operative Management of Patients with Pulmonary Hypertension and Right Heart Failure Undergoing Surgery. J Heart Lung Transplant 2022; 41:1135-1194. [DOI: 10.1016/j.healun.2022.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 06/13/2022] [Indexed: 10/17/2022] Open
|
8
|
Aziz F, Jorgenson M, Garg N, Parajuli S, Mohamed M, Raza F, Mandelbrot D, Djamali A, Dhingra R. New Approaches to Cardiovascular Disease and Its Management in Kidney Transplant Recipients. Transplantation 2022; 106:1143-1158. [PMID: 34856598 DOI: 10.1097/tp.0000000000003990] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Cardiovascular events, including ischemic heart disease, heart failure, and arrhythmia, are common complications after kidney transplantation and continue to be leading causes of graft loss. Kidney transplant recipients have both traditional and transplant-specific risk factors for cardiovascular disease. In the general population, modification of cardiovascular risk factors is the best strategy to reduce cardiovascular events; however, studies evaluating the impact of risk modification strategies on cardiovascular outcomes among kidney transplant recipients are limited. Furthermore, there is only minimal guidance on appropriate cardiovascular screening and monitoring in this unique patient population. This review focuses on the limited scientific evidence that addresses cardiovascular events in kidney transplant recipients. Additionally, we focus on clinical management of specific cardiovascular entities that are more prevalent among kidney transplant recipients (ie, pulmonary hypertension, valvular diseases, diastolic dysfunction) and the use of newer evolving drug classes for treatment of heart failure within this cohort of patients. We note that there are no consensus documents describing optimal diagnostic, monitoring, or management strategies to reduce cardiovascular events after kidney transplantation; however, we outline quality initiatives and research recommendations for the assessment and management of cardiovascular-specific risk factors that could improve outcomes.
Collapse
Affiliation(s)
- Fahad Aziz
- Division of Nephrology, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Margaret Jorgenson
- Department of Pharmacology, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Neetika Garg
- Division of Nephrology, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Sandesh Parajuli
- Division of Nephrology, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Maha Mohamed
- Division of Nephrology, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Farhan Raza
- Cardiovascular Division, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Didier Mandelbrot
- Division of Nephrology, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Arjang Djamali
- Division of Nephrology, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
- Division of Transplantation, Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Ravi Dhingra
- Cardiovascular Division, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, University of Wisconsin Hospital and Clinics, Madison, WI
| |
Collapse
|
9
|
Alıcı G, Waberi MM, Mohamud MA, Bashir AM, Genç Ö. Pulmonary hypertension among maintenance hemodialysis patients in Somalia: a hospital-based observational study. Egypt Heart J 2022; 74:24. [PMID: 35394597 PMCID: PMC8993991 DOI: 10.1186/s43044-022-00261-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 03/24/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study aims to examine the prevalence and related factors of pulmonary hypertension (PHT) in patients on hemodialysis (HD) at the only referral institution in Somalia. A total of one hundred and forty-three patients who had received regular HD therapy for at least three months and underwent transthoracic echocardiography (TTE) were included in the study. Patients with a systolic pulmonary artery pressure (sPAP) value > 35 mmHg at rest on TTE were considered having PHT. The relationship of TTE parameters, demographic, and clinic characteristics of participants with PHT were evaluated. RESULTS The number of patients with PHT was 73 (51%). The mean age was 54.2 ± 18.4 years. The majority of patients were 65 years of age or older. (n: 46, 32.2%) and 65 (45.5%) were male. Median sPAP was found to be 35 mmHg. Systolic pulmonary artery pressure was positively correlated with right atrium (RA) diameter (r: 0.6, p < 0.001) and negatively correlated with left ventricular ejection fraction (LVEF) (r: - 0.4, p < 0.001). In addition, LVEF, RA diameter, presence of pericardial effusion (PE) were found to be independent predictors of PHT. CONCLUSIONS Pulmonary hypertension has a relatively high prevalence in end-stage renal disease (ESRD) patients on regular HD. Besides, the presence of PE and certain right and left heart parameters were independently associated with PHT.
Collapse
Affiliation(s)
- Gökhan Alıcı
- Department of Cardiology, Turkey Recep Tayyip Erdogan, Somalia Mogadishu Training and Research Hospital, Mogadishu, Somalia.
| | - Mohamud Mire Waberi
- Department of Cardiology, Turkey Recep Tayyip Erdogan, Somalia Mogadishu Training and Research Hospital, Mogadishu, Somalia
| | - Mohamed Abdullahi Mohamud
- Department of Cardiology, Turkey Recep Tayyip Erdogan, Somalia Mogadishu Training and Research Hospital, Mogadishu, Somalia
| | - Ahmed Muhammad Bashir
- Department of Cardiology, Turkey Recep Tayyip Erdogan, Somalia Mogadishu Training and Research Hospital, Mogadishu, Somalia
| | - Ömer Genç
- Department of Cardiology, Agri Training and Research Hospital, Agri, Turkey
| |
Collapse
|
10
|
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.
Collapse
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.)
| |
Collapse
|
11
|
Ramadan SM, Hadeel AM, Nashwa AAM, Heba AM. Left Ventricular Mass and Functions in Egyptian Children with Chronic Kidney Disease in Comparison to Normal Subjects. SAUDI JOURNAL OF KIDNEY DISEASES AND TRANSPLANTATION 2022; 33:296-306. [PMID: 37417182 DOI: 10.4103/1319-2442.379028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2023] Open
Abstract
Left ventricular hypertrophy (LVH) and cardiac fibrosis are common accompaniments of chronic kidney disease (CKD). They can be rather easily assessed by conventional cardiac imaging modalities, most practically by M-mode or two-dimensional (2D) echocardiography, with adequate recognition of pitfalls. This study uncovers the impact of impaired renal function on left ventricular mass (LVM) and LVM index (LVMI) in children with CKD on regular hemodialysis (HD) attending the Zagazig University Hospital for Children. A total of 80 Egyptian children, out of which 40 subjects having a mean age of 11.2 ± 3.12 years were cases with CKD in stage 5 on regular HD and the other 40 healthy subjects as controls, with a mean age of 12.2 ± 2.54 years, were included in the study and assessed for LVH and LVMI by 2D echocardiography. HD children had a significantly higher mean LVMI (102.3 ± 19.1 vs. 49.6 ± 4.11 g/m2, P <0.001) than controls. Relative wall thickness was significantly higher in the patients with CKD patients on HD compared with controls (P <0.001) with a mean value of 0.46 indicating concentric LVH in renal patients. Comparing mitral inflow velocities between both the groups revealed that the patient group had a significant decrease in mitral E-wave velocity (0.88 ± 0.2 vs. 1.1 ± 0.1 m/sec, P <0.001) and E/A velocity ratio (1.3 ± 0.3 vs. 1.7 ± 0.3, P <0.001) in comparison with the control group, but there was no statistically significant difference in A-wave velocity. This indicates early diastolic dysfunction in CKD patients. LV mass changes in CKD children were strongly related to hypocalcemia and Vitamin D deficiency. Children with CKD are prone to the development of cardiac diastolic dysfunction and LVH, so early and regular echocardiographic studies of all children with CKD are recommended to detect early cardiac changes and institute interventions.
Collapse
Affiliation(s)
| | - Abdelrahman M Hadeel
- Department of Pediatrics Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Al Azizizi M Nashwa
- Department of Clinical Pathology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Abouzeid M Heba
- Department of Pediatrics Faculty of Medicine, Zagazig University, Zagazig, Egypt
| |
Collapse
|
12
|
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: 2] [Impact Index Per Article: 1.0] [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.
Collapse
|
13
|
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
| |
Collapse
|
14
|
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.
Collapse
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
| |
Collapse
|
15
|
Arevalo C, White RJ, Le T, Lachant D. Vasodilator use in precapillary pulmonary hypertension with end stage kidney disease: A single center experience. Respir Med 2021; 188:106596. [PMID: 34509135 DOI: 10.1016/j.rmed.2021.106596] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/31/2021] [Accepted: 08/27/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND OBJECTIVES Pulmonary hypertension is commonly seen in end stage kidney disease and is most commonly due to elevated left heart pressures. There is limited data about vasodilator use during the management of Group 1 pulmonary arterial hypertension in the context of those who also have or later developed end stage kidney disease. The objective of this study was to determine safety and efficacy of vasodilator therapy in precapillary pulmonary hypertension requiring renal replacement therapy. DESIGN This was a single-center retrospective case series. Patients were identified from our Pulmonary Hypertension Clinic using a historical roster from 2012 to 2020. Patients were included if they >18 years of age, had Group 1 or Group 4 (precapillary) pulmonary hypertension on right heart catheterization, and also had end stage kidney disease requiring either intermittent hemodialysis or peritoneal dialysis. RESULTS 18 patients were identified with invasively confirmed Group 1 or Group 4 pulmonary hypertension and end stage kidney disease on renal replacement therapy. Scleroderma was the most common etiology for renal failure. 17 patients were treated with vasodilator therapy. Fifteen patients had paired right heart catheterizations that showed a significant decrease in mean pulmonary artery pressure and pulmonary vascular resistance. Therapy was relatively well tolerated but hypotension was common and midodrine was often helpful. Two patients had successful renal transplantation after starting vasodilator therapy. CONCLUSION We found vasodilator therapy was reasonably well tolerated and associated with a drop in mean pressure and pulmonary vascular resistance in patients with end stage kidney disease on dialysis.
Collapse
Affiliation(s)
- Carlo Arevalo
- Department of Internal Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - R James White
- Division of Pulmonary and Critical Care Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Thu Le
- Division of Nephrology, University of Rochester Medical Center, Rochester, NY, USA
| | - Daniel Lachant
- Division of Pulmonary and Critical Care Medicine, University of Rochester Medical Center, Rochester, NY, USA.
| |
Collapse
|
16
|
Abstract
There is a high prevalence of pulmonary hypertension in chronic kidney disease (CKD), with rates increasing as glomerular filtration rate declines. Pulmonary hypertension is associated with a higher risk of cardiovascular events and mortality in non-dialysis-dependent CKD stages 3 to 5, dialysis-dependent CKD, as well as kidney transplant recipients. The pathophysiology of pulmonary hypertension in CKD is multifactorial and includes higher pulmonary capillary wedge pressure caused by ischemic heart disease and cardiomyopathy, higher cardiac output caused by anemia and arteriovenous access used for hemodialysis, as well as potentially higher pulmonary vascular resistance. Treatment should focus on the underlying cause.
Collapse
Affiliation(s)
- Alison Travers
- Department of Medicine, Tufts Medical Center, 800 Washington Street, Boston, MA 02111, USA
| | - Harrison W Farber
- Department of Medicine, Tufts Medical Center, 800 Washington Street, Boston, MA 02111, USA; Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, MA, USA
| | - Mark J Sarnak
- Department of Medicine, Tufts Medical Center, 800 Washington Street, Boston, MA 02111, USA; Division of Nephrology, Tufts Medical Center, Box 257, 800 Washington Street, Boston, MA 02111, USA.
| |
Collapse
|
17
|
Nguyen MC, Po-Yu Chiang T, Massie AB, Bae S, Motter JD, Brennan DC, Desai NM, Segev DL, Garonzik-Wang JM. Kidney Transplantation Confers Survival Benefit for Candidates With Pulmonary Hypertension. Transplant Direct 2021; 7:e738. [PMID: 35836668 PMCID: PMC9276173 DOI: 10.1097/txd.0000000000001191] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 05/23/2021] [Indexed: 02/03/2023] Open
Abstract
Kidney transplantation (KT) is controversial in patients with pretransplant pulmonary hypertension (PtPH). We aimed to quantify post-KT graft and patient survival as well as survival benefit in recipients with PtPH. Methods Using UR Renal Data System (2000-2018), we studied 90 819 adult KT recipients. Delayed graft function, death-censored graft failure, and mortality were compared between recipients with and without PtPH using inverse probability weighted logistic and Cox regression. Survival benefit of KT was determined using stochastic matching and stabilized inverse probability treatment Cox regression. Results Among 90 819 KT recipients, 2641 (2.9%) had PtPH. PtPH was associated with higher risk of delayed graft function (odds ratio, 1.23; 95% CI, 1.10-1.36; P < 0.01), death-censored graft failure (hazard ratio [HR], 1.23; 95% CI, 1.11-1.38; P < 0.01), and mortality (HR, 1.56; 95% CI, 1.44-1.69; P < 0.01). However, patients with PtPH who received a KT had a 46% reduction in mortality (HR, 0.54; 95% CI, 0.48-0.61; P < 0.01) compared with those who remained on the waitlist. Conclusions Although PtPH is associated with inferior post-KT outcomes, KT is associated with better survival compared with remaining on the waitlist. Therefore, KT is a viable treatment modality for appropriately selected patients with PtPH.
Collapse
Affiliation(s)
- Michelle C. Nguyen
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Teresa Po-Yu Chiang
- Department of Epidemiology, Johns Hopkins University School of Public Health, Baltimore, MD
| | - Allan B. Massie
- Department of Epidemiology, Johns Hopkins University School of Public Health, Baltimore, MD
| | - Sunjae Bae
- Department of Epidemiology, Johns Hopkins University School of Public Health, Baltimore, MD
| | - Jennifer D. Motter
- Department of Epidemiology, Johns Hopkins University School of Public Health, Baltimore, MD
| | - Daniel C. Brennan
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Niraj M. Desai
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins University School of Public Health, Baltimore, MD
| | - Jacqueline M. Garonzik-Wang
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins University School of Public Health, Baltimore, MD
| |
Collapse
|
18
|
Joseph MS, Tinney F, Naik A, Parasuraman R, Samaniego-Picota M, Bhave NM. Right Ventricular Dysfunction and Adverse Outcomes after Renal Transplantation. Cardiorenal Med 2021; 11:109-118. [PMID: 33853060 DOI: 10.1159/000515124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 11/16/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Pulmonary hypertension is common among patients with end-stage renal disease, although data regarding the impact of right ventricular (RV) failure on postoperative outcomes remain limited. We hypothesized that echocardiographic findings of RV dilation and dysfunction are associated with adverse clinical outcomes after renal transplant. METHODS A retrospective review of adult renal transplant recipients at a single institution from January 2008 to June 2010 was conducted. Patients with transthoracic echocardiograms (TTEs) within 1 year leading up to transplant were included. The primary end point was a composite of delayed graft function, graft failure, and all-cause mortality. RESULTS Eighty patients were included. Mean follow-up time was 9.4 ± 0.8 years. Eight patients (100%) with qualitative RV dysfunction met the primary end point, while 39/65 patients (60.0%) without RV dysfunction met the end point (p = 0.026). Qualitative RV dilation was associated with a significantly shorter time to all-cause graft failure (p = 0.03) and death (p = 0.048). RV systolic pressure was not measurable in 45/80 patients (56%) and was not associated with outcomes in the remaining patients. CONCLUSION RV dilation and dysfunction are associated with adverse outcomes after renal transplant. TTE assessment of RV size and function should be a standard part of the pre-kidney transplant cardiovascular risk assessment.
Collapse
Affiliation(s)
- Megan S Joseph
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Medical School and Michigan Medicine, Ann Arbor, Michigan, USA
| | - Francis Tinney
- Department of Surgery, Henry Ford Health System, Detroit, Michigan, USA
| | - Abhijit Naik
- Division of Nephrology, Department of Internal Medicine, University of Michigan Medical School and Michigan Medicine, Ann Arbor, Michigan, USA
| | - Raviprasenna Parasuraman
- Division of Nephrology, Department of Internal Medicine, University of Michigan Medical School and Michigan Medicine, Ann Arbor, Michigan, USA
| | - Milagros Samaniego-Picota
- Division of Nephrology, Department of Internal Medicine, Henry Ford Health System, Detroit, Michigan, USA
| | - Nicole M Bhave
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Medical School and Michigan Medicine, Ann Arbor, Michigan, USA
| |
Collapse
|
19
|
Al-Qadi M, LeVarge B, Ford HJ. Epidemiology, Pathogenesis, and Clinical Approach in Group 5 Pulmonary Hypertension. Front Med (Lausanne) 2021; 7:616720. [PMID: 33842491 PMCID: PMC8026868 DOI: 10.3389/fmed.2020.616720] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 12/17/2020] [Indexed: 01/19/2023] Open
Abstract
Pulmonary hypertension (PH) is recognized to be associated with a number of comorbid conditions. Based on these associations, PH is classified into 5 groups, considering common pathophysiologic drivers of disease, histopathologic features, clinical manifestations and course, and response to PH therapy. However, in some of these associated conditions, these characteristics are less well-understood. These include, among others, conditions commonly encountered in clinical practice such as sarcoidosis, sickle cell disease, myeloproliferative disorders, and chronic kidney disease/end stage renal disease. PH in these contexts presents a significant challenge to clinicians with respect to disease management. The most recent updated clinical classification schemata from the 6th World Symposium on PH classifies such entities in Group 5, highlighting the often unclear and/or multifactorial nature of PH. An in-depth review of the state of the science of Group 5 PH with respect to epidemiology, pathogenesis, and management is provided. Where applicable, future directions with respect to research needed to enhance understanding of the clinical course of these entities is also discussed.
Collapse
Affiliation(s)
- Mazen Al-Qadi
- Division of Pulmonary and Critical Care Medicine, Pulmonary Hypertension Program, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Barbara LeVarge
- Division of Pulmonary and Critical Care Medicine, Pulmonary Hypertension Program, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - H James Ford
- Division of Pulmonary and Critical Care Medicine, Pulmonary Hypertension Program, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| |
Collapse
|
20
|
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.
Collapse
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.
| |
Collapse
|
21
|
Sadat B, Tirunagari D, Karthikeyan V, Patel A, Van Harn M, Saleem MM, Ananthasubramaniam K. Clinical impact of pre-kidney transplant pulmonary hypertension on post-transplant outcomes. Int J Cardiovasc Imaging 2021; 37:1979-1986. [PMID: 33616784 DOI: 10.1007/s10554-021-02182-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 01/30/2021] [Indexed: 11/25/2022]
Abstract
Outcomes of kidney transplant (KT) patients with pre-transplant pulmonary hypertension (PH) are poorly understood. PH patients are often considered high risk and excluded from KT. We investigated the association of pre-transplant PH with KT recipient's outcomes. A single-center, retrospective study that reviewed all patients transplanted from 2010 to 2016, who had a transthoracic echocardiogram (TTE) before KT and at least one TTE post-KT. The TTE closest to the KT was used for analyses. PH is defined as pulmonary artery systolic pressure (PASP) ≥ 40 mm Hg. Of 204 patients, 61 had PASP ≥ 40 mm Hg (with PH) and 143 had PASP < 40 mm Hg (without PH) prior to KT. No statistically significant differences existed between the two groups in baseline demographics, renal failure etiologies, dialysis access type, and cardiovascular risk factors. The mean difference in pre-KT PASP was 18.1 ± 7 mm Hg (P < 0.001). Patients with PH had a statistically significant decrease in PASP post-KT compared to the patients without PH with a mean change of -7.03 ± 12.28 mm Hg vs. + 3.96 ± 11.98 mm Hg (p < 0.001), respectively. Moderate mitral and moderate-severe tricuspid regurgitation were the only factors found to be independently associated with PH (p = 0.001) on multivariable analysis. No statistically significant difference was notable in patient survival, graft function, and creatinine post-KT in both groups. PH pre-KT particularly mild-moderate PH did not adversely affect intermediate (90-day) and long-term allograft and patient survival. Patients with mild-moderate PH should not be excluded from KT.
Collapse
Affiliation(s)
- Besher Sadat
- Department of Hospital Medicine, Henry Ford Hospital, Detroit, MI, USA
| | - Deepthi Tirunagari
- Department of Cardiology, St. Joseph Mercy Oakland Hospital, Pontiac, MI, USA
| | | | - Anita Patel
- Department of Nephrology, Henry Ford Hospital, Detroit, MI, USA
| | - Meredith Van Harn
- Department of Public Health Sciences, Henry Ford Health System, Detroit, MI, USA
| | - M Mariam Saleem
- Department of Hospital Medicine, Henry Ford Hospital, Detroit, MI, USA
| | | |
Collapse
|
22
|
Jha AK, Lata S. Kidney transplantation in valvular heart disease and pulmonary hypertension: Consensus in waiting. Clin Transplant 2020; 35:e14116. [PMID: 33048408 DOI: 10.1111/ctr.14116] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 09/24/2020] [Accepted: 10/01/2020] [Indexed: 11/29/2022]
Abstract
Kidney transplantation induces a lesser anesthetic, surgical, and physiological alterations than other solid organ transplantation. Concomitant valvular pathologies expose these patients to poor postoperative outcome. There is a critical gap in knowledge and lack of coherence in the guidelines related to the management in patients with end-stage renal disease with valvular heart disease. The individualized diagnostic and management plan should be based on the assessment of perioperative outcomes. Similarly, pulmonary hypertension in end-stage renal disease poses a unique challenge, it can manifest in isolation or may be associated with other cardiac lesions, namely left-sided valvular heart disease and left ventricular systolic and diastolic dysfunction. Quantification and stratification according to etiology are needed in pulmonary hypertension to ensure an adequate management plan to minimize the adverse perioperative outcomes. Lack of randomized controlled trials has imposed hindrance in proposing a unified approach to clinical decision-making in these scenarios. In this review, we have described the magnitude of the problems, pathophysiologic interactions, impact on clinical outcomes and have also proposed a management algorithm for both the scenarios.
Collapse
Affiliation(s)
- Ajay Kumar Jha
- Department of Anesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Suman Lata
- Department of Anesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| |
Collapse
|
23
|
Engole YM, Lepira FB, Nlandu YM, Lubenga YS, Longo AL, Nkodila A, Makulo JRR, Mokoli VM, Bukabau JB, Mboliasa MFI, Kadima EM, Ilunga CK, Mvunzi TS, Nseka NM, Sumaili EK. Prevalence and factors associated with pulmonary arterial hypertension on maintenance hemodialysis patients in Kinshasa, Democratic Republic of Congo: a cross-sectional study. BMC Nephrol 2020; 21:460. [PMID: 33148221 PMCID: PMC7640388 DOI: 10.1186/s12882-020-02131-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 10/27/2020] [Indexed: 11/11/2022] Open
Abstract
Background Although cardiovascular diseases in particular Pulmonary Arterial Hypertension (PAH) is associated with, high morbid-mortality in chronic hemodialysis, but its magnitude remains paradoxically unknown in sub-Saharan Africa. The aim of this study was to evaluate the prevalence of PAH and associated factors in chronic hemodialysis in Sub-Saharan African population. Method In a cross-sectional study, patients treated with HD for at least 6 months in 4 hemodialysis centers were examined. PAH was defined as estimated systolic pulmonary arterial pressure (sPAP) ≥ 35 mmHg using transthoracic Doppler echocardiography performed 24 h after the HD session. Results Eighty-five HD patients were included; their average age was 52.6 ± 15.9 years. Fifty-seven patients (67.1%) were male. Mean duration of HD was 13.3 ± 11 months. With reference to vascular access, 12 (14.1%), 29 (34.1%) and 44 (51.8%) patients had AVF, tunneled cuff and temporary catheter, respectively. The underlying cause of ESRD was diabetes in 30 patients (35.3%). The prevalence of PAH was 29.4%. Patients with PAH had more hyponatremia (11 (44%) vs 10 (16.7%), p = 0.010). In multivariate analysis, unsecured healthcare funding (aOR 4, 95% CI [1.18–6.018]), arrhythmia (aOR 3, 95% CI [1.29–7.34]), vascular access change (aOR 4, 95% CI [1.18–7.51]) and diastolic dysfunction (aOR 5, 95% CI [1.35–9.57] were independently associated with PAH. Conclusion One third of hemodialysis patients exhibit PAH, which is independently associated with low socioeconomic status (unsecured funding, vascular access change) and cardiovascular complications (arrhythmia, diastolic dysfunction).
Collapse
Affiliation(s)
- Yannick Mompango Engole
- Nephrology Unit, University Hospital of Kinshasa, Kinshasa, Democratic Republic of the Congo.
| | - François Bompeka Lepira
- Nephrology Unit, University Hospital of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Yannick Mayamba Nlandu
- Nephrology Unit, University Hospital of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Yves Simbi Lubenga
- Cardiology Unit, University Hospital of Kinshasa, BP: 123, Kinshasa, XI, Democratic Republic of the Congo
| | | | - Aliocha Nkodila
- Nephrology Unit, University Hospital of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | | | - Vieux Momeme Mokoli
- Nephrology Unit, University Hospital of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Justine Busanga Bukabau
- Nephrology Unit, University Hospital of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | | | - Evariste Mukendi Kadima
- Nephrology Unit, University Hospital of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Cedric Kabemba Ilunga
- Nephrology Unit, University Hospital of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Tresor Swambulu Mvunzi
- Cardiology Unit, University Hospital of Kinshasa, BP: 123, Kinshasa, XI, Democratic Republic of the Congo
| | - Nazaire Mangani Nseka
- Nephrology Unit, University Hospital of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Ernest Kiswaya Sumaili
- Nephrology Unit, University Hospital of Kinshasa, Kinshasa, Democratic Republic of the Congo
| |
Collapse
|
24
|
A Man with End-Stage Renal Disease, Dyspnea, and an Abnormal Echocardiogram. Ann Am Thorac Soc 2020; 16:1577-1581. [PMID: 31774325 DOI: 10.1513/annalsats.201904-300cc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
25
|
The Association of Pretransplant Pulmonary Hypertension With Patient and Graft Survival After Kidney Transplantation: A Retrospective Cohort Study. Transplant Proc 2020; 52:3023-3032. [PMID: 32665088 DOI: 10.1016/j.transproceed.2020.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 05/06/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Pulmonary hypertension (PH) has been well characterized in end-stage kidney disease and carries a grave prognosis. Its relationship to kidney transplantation outcomes is uncertain. The purpose of the present study was to characterize PH in kidney transplant candidates and to evaluate the relationship of PH to post-transplantation outcomes. METHODS A retrospective review of medical records and echocardiographic findings in all patients listed and transplanted at a large urban academic medical center from 2010 to 2015 was undertaken. PH (defined as echocardiographic evidence of pulmonary artery systolic pressure ≥ 35 mm Hg) was assessed along with demographics, and comorbidities for its relationship to patient, and graft survival by univariable and multivariable analysis. RESULTS Of 733 patients, 15.6% (115) had PH. PH in this population was primarily due to left ventricular (LV) diastolic dysfunction. Patient survival (78.3% vs 89.6%, P = .02) and the composite of patient and graft survival (70.7% vs 85.0%, P = .04) was reduced at 5 years in patients with PH as compared to patients with No PH, respectively. However, multivariable analysis suggested that age at presentation, race, and left ventricular systolic function but not PH were significantly associated with patient mortality or graft loss. CONCLUSION Reduced patient and graft survival seen in patients with pulmonary hypertension appears to be related to risk factors other than the pulmonary hypertension itself; therefore, pretransplant PH should not be considered as a barrier to kidney transplantation.
Collapse
|
26
|
Nithiya N, Indhumathi E, Jagadeswaran D, Jayaprakash V, Jayakumar M. Pulmonary hypertension - prevalence, risk factors, and its association with vascular calcification in chronic kidney disease and hemodialysis patients. SAUDI JOURNAL OF KIDNEY DISEASES AND TRANSPLANTATION 2020; 31:380-387. [PMID: 32394910 DOI: 10.4103/1319-2442.284012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Pulmonary hypertension (PHTN) is a recently recognized complication in dialysis and it is associated with a poor outcome. We estimated the prevalence of PHTN and its association with vascular calcification in chronic kidney disease (CKD) and hemodialysis (HD) patients. One hundred and thirteen adult CKD patients were included in this study, of which 56 (49.6%) were on conservative treatment (nondialysis group) and 57 (50.4%) were on maintenance HD (dialysis group). Demographic, clinical, and biochemical parameters were collected and compared between the groups. Thirty-nine (69.6%) and 33 (57.8%) males were included in nondialysis and dialysis group, respectively. Mean age was 47.5 ± 13.7 in nondialysis group and 52.8 ± 13.9 in the dialysis group. PHTN was estimated using Doppler echocardiography and peripheral vascular calcification by lateral lumbar X-ray with aortic calcification scoring. Patients with and without PHTN and vascular calcification in dialysis and nondialysis group were compared. PHTN was found in 55 patients (48.7%) and it was high in patients on dialysis compared to nondialysis(59.6% vs. 37.5%, P <0.019). Abdominal aortic calcification was present in 35 patients (30.9%), dialysis versus nondialysis group was 22.8% and 39.3%. Increased left atrial diameter was significantly associated with PHTN (P <0.003), whereas peripheral artery calcification was not related to PHT (P = 0.248). The prevalence of PHTN in CKD was 48.7% which was higher in dialysis group than non dialysis group. Increased left atrial (LA) diameter was associated with PHTN but not peripheral arterial calcification.
Collapse
Affiliation(s)
- N Nithiya
- Department of Nephrology, Sri Ramachandra Institute of Higher Education and Research (Deemed to be University), Chennai, Tamil Nadu, India
| | - Elayaperumal Indhumathi
- Department of Nephrology, Sri Ramachandra Institute of Higher Education and Research (Deemed to be University), Chennai, Tamil Nadu, India
| | - Dhakshinamoorty Jagadeswaran
- Department of Nephrology, Sri Ramachandra Institute of Higher Education and Research (Deemed to be University), Chennai, Tamil Nadu, India
| | - Varadharajan Jayaprakash
- Department of Nephrology, Sri Ramachandra Institute of Higher Education and Research (Deemed to be University), Chennai, Tamil Nadu, India
| | - Matcha Jayakumar
- Department of Nephrology, Sri Ramachandra Institute of Higher Education and Research (Deemed to be University), Chennai, Tamil Nadu, India
| |
Collapse
|
27
|
Schoenberg NC, Argula RG, Klings ES, Wilson KC, Farber HW. Prevalence and Mortality of Pulmonary Hypertension in ESRD: A Systematic Review and Meta-analysis. Lung 2020; 198:535-545. [DOI: 10.1007/s00408-020-00355-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 04/20/2020] [Indexed: 01/08/2023]
|
28
|
Rangaswami J, Mathew RO, Parasuraman R, Tantisattamo E, Lubetzky M, Rao S, Yaqub MS, Birdwell KA, Bennett W, Dalal P, Kapoor R, Lerma EV, Lerman M, McCormick N, Bangalore S, McCullough PA, Dadhania DM. Cardiovascular disease in the kidney transplant recipient: epidemiology, diagnosis and management strategies. Nephrol Dial Transplant 2020; 34:760-773. [PMID: 30984976 DOI: 10.1093/ndt/gfz053] [Citation(s) in RCA: 104] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Indexed: 12/19/2022] Open
Abstract
Kidney transplantation (KT) is the optimal therapy for end-stage kidney disease (ESKD), resulting in significant improvement in survival as well as quality of life when compared with maintenance dialysis. The burden of cardiovascular disease (CVD) in ESKD is reduced after KT; however, it still remains the leading cause of premature patient and allograft loss, as well as a source of significant morbidity and healthcare costs. All major phenotypes of CVD including coronary artery disease, heart failure, valvular heart disease, arrhythmias and pulmonary hypertension are represented in the KT recipient population. Pre-existing risk factors for CVD in the KT recipient are amplified by superimposed cardio-metabolic derangements after transplantation such as the metabolic effects of immunosuppressive regimens, obesity, posttransplant diabetes, hypertension, dyslipidemia and allograft dysfunction. This review summarizes the major risk factors for CVD in KT recipients and describes the individual phenotypes of overt CVD in this population. It highlights gaps in the existing literature to emphasize the need for future studies in those areas and optimize cardiovascular outcomes after KT. Finally, it outlines the need for a joint 'cardio-nephrology' clinical care model to ensure continuity, multidisciplinary collaboration and implementation of best clinical practices toward reducing CVD after KT.
Collapse
Affiliation(s)
- Janani Rangaswami
- Einstein Medical Center, Philadelphia, PA, USA.,Sidney Kimmel College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Roy O Mathew
- Columbia Veterans Affairs Health Care System, Columbia, SC, USA
| | | | | | - Michelle Lubetzky
- Weill Cornell Medicine-New York Presbyterian Hospital, New York, NY, USA
| | - Swati Rao
- University of Virginia, Charlottesville, VA, USA
| | | | | | | | | | - Rajan Kapoor
- Augusta University Medical Center, Augusta, GA, USA
| | - Edgar V Lerma
- UIC/Advocate Christ Medical Center, Oak Lawn, IL, USA
| | - Mark Lerman
- Medical City Dallas Hospital, Dallas, TX, USA
| | | | | | | | | |
Collapse
|
29
|
Cardiovascular Risk Assessment in Renal and Liver Transplant Candidates: A Multidisciplinary Institutional Standardized Approach. Cardiol Rev 2020; 27:286-292. [PMID: 31584469 DOI: 10.1097/crd.0000000000000282] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In the modern era, renal and liver transplant candidates present with a greater medical complexity driven in part by a higher prevalence of cardiovascular conditions, including coronary artery disease, valvular heart disease, and cardiomyopathies. In fact, cardiovascular disease is the most common cause of death after kidney transplantation worldwide. Similarly, an increase in the number of patients being listed with end-stage liver disease from nonalcoholic steatohepatitis and a rising model for end-stage liver disease scores at the time of liver transplant in the United States parallel an increasing cardiovascular disease risk profile for liver transplant candidates. A large degree of variation exists among clinical practice guidelines and transplant center practice patterns regarding patient selection for routine cardiac testing and the choice of testing modalities. Here, we review the clinical practice guidelines established at our center by a multidisciplinary group, including transplant nephrology, hepatology, and surgery, as well as general and interventional cardiology, with the goal of improving patient selection and reducing adverse cardiac events posttransplant.
Collapse
|
30
|
Rangaswami J, Bhalla V, Blair JEA, Chang TI, Costa S, Lentine KL, Lerma EV, Mezue K, Molitch M, Mullens W, Ronco C, Tang WHW, McCullough PA. Cardiorenal Syndrome: Classification, Pathophysiology, Diagnosis, and Treatment Strategies: A Scientific Statement From the American Heart Association. Circulation 2020; 139:e840-e878. [PMID: 30852913 DOI: 10.1161/cir.0000000000000664] [Citation(s) in RCA: 555] [Impact Index Per Article: 138.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Cardiorenal syndrome encompasses a spectrum of disorders involving both the heart and kidneys in which acute or chronic dysfunction in 1 organ may induce acute or chronic dysfunction in the other organ. It represents the confluence of heart-kidney interactions across several interfaces. These include the hemodynamic cross-talk between the failing heart and the response of the kidneys and vice versa, as well as alterations in neurohormonal markers and inflammatory molecular signatures characteristic of its clinical phenotypes. The mission of this scientific statement is to describe the epidemiology and pathogenesis of cardiorenal syndrome in the context of the continuously evolving nature of its clinicopathological description over the past decade. It also describes diagnostic and therapeutic strategies applicable to cardiorenal syndrome, summarizes cardiac-kidney interactions in special populations such as patients with diabetes mellitus and kidney transplant recipients, and emphasizes the role of palliative care in patients with cardiorenal syndrome. Finally, it outlines the need for a cardiorenal education track that will guide future cardiorenal trials and integrate the clinical and research needs of this important field in the future.
Collapse
|
31
|
Perioperative considerations for kidney and pancreas-kidney transplantation. Best Pract Res Clin Anaesthesiol 2020; 34:3-14. [PMID: 32334785 DOI: 10.1016/j.bpa.2020.01.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 12/16/2019] [Accepted: 01/06/2020] [Indexed: 01/28/2023]
Abstract
Kidney transplantation is the treatment of choice in patients with end-stage renal disease, as it improves survival and quality of life. Living donor kidney transplant prior to pancreas transplantation, or simultaneous pancreas and kidney transplantation are discussed. Patients usually present comorbidities and extensive preoperative workups are recommended, especially cardiac assessment, though type and frequency of surveillance is not established. Nephroprotective strategies include adequate fluid status and goal-directed therapy. The conventional use of diuretics has not demonstrated a real nephroprotective effect at follow-up. Thromboprophylaxis regimes, especially for the pancreatic graft outcome, are of importance. Notably, transplantation in the obese population has increased in recent decades. Strict preoperative evaluation and pulmonary considerations must be kept in mind. Finally, robotic kidney transplant is a recent approach that presents anesthetic challenges, mainly related to steep Trendelenburg position and fluid restriction.
Collapse
|
32
|
Pulmonary Hypertension and Mortality in Patients Awaiting Kidney Transplant: Cause for Concern and Potential Opportunity. Transplantation 2020; 104:2001-2002. [PMID: 31929417 DOI: 10.1097/tp.0000000000003069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
33
|
Hernández D, Alonso-Titos J, Armas-Padrón AM, Lopez V, Cabello M, Sola E, Fuentes L, Gutierrez E, Vazquez T, Jimenez T, Ruiz-Esteban P, Gonzalez-Molina M. Waiting List and Kidney Transplant Vascular Risk: An Ongoing Unmet Concern. Kidney Blood Press Res 2019; 45:1-27. [PMID: 31801144 DOI: 10.1159/000504546] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 11/01/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is an important independent risk factor for adverse cardiovascular events in patients waitlisted for kidney transplantation (KT). Although KT reduces cardiovascular risk, these patients still have a higher all-cause and cardiovascular mortality than the general population. This concerning situation is due to a high burden of traditional and nontraditional risk factors as well as uremia-related factors and transplant-specific factors, leading to 2 differentiated processes under the framework of CKD, atherosclerosis and arteriosclerosis. These can be initiated by insults to the vascular endothelial endothelium, leading to vascular calcification (VC) of the tunica media or the tunica intima, which may coexist. Several pathogenic mechanisms such as inflammation-related endothelial dysfunction, mineral metabolism disorders, activation of the renin-angiotensin system, reduction of nitric oxide, lipid disorders, and the fibroblast growth factor 23-klotho axis are involved in the pathogenesis of atherosclerosis and arteriosclerosis, including VC. SUMMARY This review focuses on the current understanding of atherosclerosis and arteriosclerosis, both in patients on the waiting list as well as in kidney transplant recipients, emphasizing the cardiovascular risk factors in both populations and the inflammation-related pathogenic mechanisms. Key Message: The importance of cardiovascular risk factors and the pathogenic mechanisms related to inflammation in patients waitlisted for KT and kidney transplant recipients.
Collapse
Affiliation(s)
- Domingo Hernández
- Department of Nephrology, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain,
| | - Juana Alonso-Titos
- Department of Nephrology, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | | | - Veronica Lopez
- Department of Nephrology, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - Mercedes Cabello
- Department of Nephrology, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - Eugenia Sola
- Department of Nephrology, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - Laura Fuentes
- Department of Nephrology, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - Elena Gutierrez
- Department of Nephrology, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - Teresa Vazquez
- Department of Nephrology, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - Tamara Jimenez
- Department of Nephrology, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - Pedro Ruiz-Esteban
- Department of Nephrology, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - Miguel Gonzalez-Molina
- Department of Nephrology, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| |
Collapse
|
34
|
Baman JR, Knapper J, Raval Z, Harinstein ME, Friedewald JJ, Maganti K, Cuttica MJ, Abecassis MI, Ali ZA, Gheorghiade M, Flaherty JD. Preoperative Noncoronary Cardiovascular Assessment and Management of Kidney Transplant Candidates. Clin J Am Soc Nephrol 2019; 14:1670-1676. [PMID: 31554619 PMCID: PMC6832054 DOI: 10.2215/cjn.03640319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The pretransplant risk assessment for patients with ESKD who are undergoing evaluation for kidney transplant is complex and multifaceted. When considering cardiovascular disease in particular, many factors should be considered. Given the increasing incidence of kidney transplantation and the growing body of evidence addressing ESKD-specific cardiovascular risk profiles, there is an important need for a consolidated, evidence-based model that considers the unique cardiovascular challenges that these patients face. Cardiovascular physiology is altered in these patients by abrupt shifts in volume status, altered calcium-phosphate metabolism, high-output states (in the setting of arteriovenous fistulization), and adverse geometric and electrical remodeling, to name a few. Here, we present a contemporary review by addressing cardiomyopathy/heart failure, pulmonary hypertension, valvular dysfunction, and arrhythmia/sudden cardiac death within the ESKD population.
Collapse
Affiliation(s)
| | | | - Zankhana Raval
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York Presbyterian Hospital, New York, New York; and
| | - Matthew E Harinstein
- Division of Cardiology, Cardiovascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - John J Friedewald
- Division of Nephrology, Department of Medicine.,Division of Transplantation, Department of Surgery, and
| | | | - Michael J Cuttica
- Division of Pulmonary and Critical Care, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Ziad A Ali
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York Presbyterian Hospital, New York, New York; and
| | | | | |
Collapse
|
35
|
Relationship between volume status and possibility of pulmonary hypertension in dialysis naive CKD5 patients. PLoS One 2019; 14:e0221970. [PMID: 31479489 PMCID: PMC6719868 DOI: 10.1371/journal.pone.0221970] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 08/19/2019] [Indexed: 12/18/2022] Open
Abstract
Background Chronic fluid overload is common in patients with chronic kidney disease (CKD) and can with time lead to poor prognosis regarding to the cardiovascular events. Serum NT-proBNP and OH/ECW might reflect fluid status of the patients, and the maximal tricuspid regurgitation velocity (TRVmax) could reflect systolic pulmonary artery pressure (SPAP). We investigated the relationship between markers of volume status and marker of pulmonary hypertension (PH) in non-dialysis CKD5 (CKD5-ND) patients. Methods Bioimpedance spectroscopy (BIS), echocardiography, and measurement of serum NT-proBNP were performed in 137 consecutive patients on the same day. TRVmax greater than or equal to 2.9 m/s, corresponding to SPAP of approximately 36 mmHg, was used as a definition of the possibility of PH in the absence of left heart disease and chronic respiratory disease (PH group). Results Patients with possibility of PH (TRVmax ≥ 2.9 m/s) was found in 27 (19.70%) patients. Among the values obtained from BIS, those reflecting the fluid balance (OH, OH/ECW, and E/I ratio) were significantly higher in the PH group. The OH/ECW in patients with PH were significantly higher than those patients without (26.76 ± 15.07 vs. 13.09 ± 15.05, P < 0.001). NT-proBNP was also significantly higher in PH group compared to the non-PH group (median = 10,112 pg/ml, IQR = 30,847 pg/ml vs. median = 1,973 pg/ml, IQR = 7,093 pg/ml, P < 0.001). OH/ECW was positively associated with TRVmax (r = 0.235, P = 0.006). Multivariate logistic regression revealed that increased OH/ECW and serum NT-proBNP were significantly associated with an increased risk of PH. Conclusions A significant number of patients showed increased TRVmax, which was closely related to volume status in CKD5-ND patients. Echocardiography and BIS could be important players in a high possibility of PH detection and treatment in asymptomatic CKD patients. Therefore, these measures could be helpful to improve the cardiac outcomes after initiating renal replacement therapy. Further research may be needed to validate the consistency of this association across other stages of CKD.
Collapse
|
36
|
Mehta KS, Shirkande AK, Bhurke SP, Pajai AE, Swami RS, Jadhav SN. Pulmonary Hypertension in Various Stages of Chronic Kidney Disease in Indian Patients. Indian J Nephrol 2019; 29:95-101. [PMID: 30983749 PMCID: PMC6440332 DOI: 10.4103/ijn.ijn_407_17] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The prevalence of pulmonary hypertension (PH) in chronic kidney disease (CKD) in Indian patients has been evaluated in this study. In addition, association of PH with CKD etiology, its prevalence in various CKD stages, correlation between the severity of PH with CKD duration, various related biochemical parameters, and their relation to PH in CKD patients were analyzed. This cross-sectional and prospective study included 200 CKD patients. Detailed history and clinical examination were recorded. Hemoglobin, blood urea nitrogen (BUN), serum creatinine, albumin, and calcium-phosphorus product were recorded. Pulmonary function test was evaluated and two-dimensional echo was done 4 hours post dialysis. The prevalence of PH in CKD patients was 60.5%, with mean pulmonary artery systolic pressure (PASP) of 38.52 ± 7.32 mmHg. The mean age of those with PH was 47.85 ± 13.09 years. PH was more common in males (p = 0.03). The prevalence of PH increased as CKD stage advanced (p < 0.001). Diabetes and hypertension had a strong association with PH (p < 0.001). The prevalence (p = 0.003) and severity (p = 0.011) of PH increased with increase in CKD duration. In patients on hemodialysis (HD), the prevalence (p < 0.001) and severity (p = 0.022) of PH was significant compared to those on conservative treatment. The prevalence (p < 0.001) and severity (p < 0.001) of PH significantly increased as duration of HD increased. The prevalence of PH was significantly higher in patients with arteriovenous fistula (p = 0.002). Serum creatinine (p = 0.02) and serum calcium-phosphorus product (p < 0.001) were significantly higher in patients with PH. The prevalence of PH in CKD patients was 60.5%. There was a positive correlation between PH and duration of CKD, duration of HD, BUN, serum creatinine, and serum calcium-phosphorus product.
Collapse
Affiliation(s)
- Kalpana S Mehta
- Department of Nephrology, Topiwala National Medical College and B.Y.L. Nair Charitable Hospital, Mumbai, Maharashtra, India
| | - Abhishek K Shirkande
- Department of Nephrology, Topiwala National Medical College and B.Y.L. Nair Charitable Hospital, Mumbai, Maharashtra, India
| | - Sandip P Bhurke
- Department of Nephrology, Topiwala National Medical College and B.Y.L. Nair Charitable Hospital, Mumbai, Maharashtra, India
| | - Atim E Pajai
- Department of Nephrology, Topiwala National Medical College and B.Y.L. Nair Charitable Hospital, Mumbai, Maharashtra, India
| | - Rudramani S Swami
- Department of Nephrology, Topiwala National Medical College and B.Y.L. Nair Charitable Hospital, Mumbai, Maharashtra, India
| | - Swapnil N Jadhav
- Department of Nephrology, Topiwala National Medical College and B.Y.L. Nair Charitable Hospital, Mumbai, Maharashtra, India
| |
Collapse
|
37
|
Naranjo M, Lo KB, Mezue K, Rangaswami J. Effects of Pulmonary Hypertension and Right Ventricular Function in Short and Long-Term Kidney Function. Curr Cardiol Rev 2019; 15:3-11. [PMID: 30306876 PMCID: PMC6367698 DOI: 10.2174/1573403x14666181008154215] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 09/22/2018] [Accepted: 09/30/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Pulmonary hypertension is not uncommon in patients with renal disease and vice versa; therefore, it influences treatments and outcomes. There is a large body of literature on pulmonary hypertension in patients with kidney disease, its prognostic implications, economic burden, and management strategies. However, the converse, namely the hemodynamic effects of pulmonary hypertension on kidney function (acute and chronic kidney injury) is less studied and described. There is also increasing interest in the effects of pulmonary hypertension on kidney transplant outcomes. The relationship is a complex phenomenon and multiple body systems and mechanisms are involved in its pathophysiology. Although the definition of pulmonary hypertension has evolved over time with the understanding of multiple interplays between the heart, lungs, kidneys, etc; there is limited evidence to provide a specific treatment strategy when kidneys and lungs are affected at the same time. Nevertheless, available evidence appears to support new therapeutics and highlights the importance of individualized approach. There is sufficient research showing that the morbidity and mortality from PH are driven by the influence of the pulmonary hemodynamic dysfunction on the kidneys. CONCLUSION This concise review focuses on the effects of pulmonary hypertension on the kidneys, including, the patho-physiological effects of pulmonary hypertension on acute kidney injury, progression of CKD, effects on kidney transplant outcomes, progression of kidney disease in situations such as post LVAD implantation and novel diagnostic indices. We believe a review of this nature will fill in an important gap in understanding the prognostic implication of pulmonary hypertension on renal disease, and help highlight this important component of the cardio-reno-pulmonary axis.
Collapse
Affiliation(s)
- Mario Naranjo
- Department of Medicine, Albert Einstein Medical Center, Philadelphia, PA, United States
| | - Kevin Bryan Lo
- Department of Medicine, Albert Einstein Medical Center, Philadelphia, PA, United States
| | - Kenechukwu Mezue
- Department of Medicine, Albert Einstein Medical Center, Philadelphia, PA, United States
| | - Janani Rangaswami
- Department of Medicine, Albert Einstein Medical Center, Philadelphia, PA, United States.,Sidney Kimmel College of Thomas Jefferson University, Philadelphia, PA, United States
| |
Collapse
|
38
|
Bolignano D, Pisano A, Coppolino G, Tripepi GL, D'Arrigo G. Pulmonary Hypertension Predicts Adverse Outcomes in Renal Patients: A Systematic Review and Meta‐Analysis. Ther Apher Dial 2019; 23:369-384. [DOI: 10.1111/1744-9987.12777] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 10/26/2018] [Accepted: 11/19/2018] [Indexed: 01/09/2023]
Affiliation(s)
| | - Anna Pisano
- CNR ‐ Institute of Clinical Physiology Reggio Calabria Italy
| | - Giuseppe Coppolino
- Nephrology and Dialysis Unit“Pugliese‐Ciaccio” Hospital of Catanzaro Catanzaro Italy
| | | | | |
Collapse
|
39
|
Jarmi T, Doumit E, Makdisi G, Mhaskar R, Miladinovic B, Wadei H, Rumbak M, Aslam S. Pulmonary Artery Systolic Pressure Measured Intraoperatively by Right Heart Catheterization Is a Predictor of Kidney Transplant Recipient Survival. Ann Transplant 2018; 23:867-873. [PMID: 30559336 PMCID: PMC6319438 DOI: 10.12659/aot.911176] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The effect of pulmonary artery systolic pressure (PASP) measured by Swan-Ganz right heart catheter (SG-RHC) on kidney transplant recipient survival has not been previously studied. The objective of this study was to assess the relationships between PASP measured via SG-RHC, done intraoperatively at the time of initiating anesthesia at the beginning of kidney transplant surgery, and patient survival. Multiple comorbidities, time on dialysis before the transplantation, and graft function were also analyzed in our study. MATERIAL AND METHODS This was a retrospective cohort study using data from all consecutive patients undergoing kidney transplant between January 1, 2005 and December 31, 2009 at Tampa General Hospital. Kidney transplant recipients were divided into 2 groups: Group 1 with PASP <35 mmHg and group 2 with PASP ≥35 mmHg. Patients and graft survival data, time on dialysis before transplant, and comorbidities were compared between the 2 groups. RESULTS Only 363 patients were found to have a documented PASP measurement at the time of anesthesia induction for the transplant surgery, and were included in the specific analysis of our study. Patients with PASP ≥35 mmHg showed a significant decrease in survival in comparison to patients having PASP values <35 mmHg (HR 1.88; 95% CI 1.012 to 3.47, P=0.04). There was a significant positive correlation between time on dialysis and PASP (rho 0.20; 95% CI 0.09 to 0.30, p<0.001), as well as a significant difference in median time on dialysis between PASP <35 vs. PASP ≥35 (22 vs. 29 months, p=0.004). There were no significant differences in graft failure between the 2 PASP groups (HR 0.34; 95% CI 0.12 to 1.01, P=0.05). CONCLUSIONS Patients with PASP ≥35 mmHg, measured intraoperatively by SG-RHC, showed significantly shorter survival in comparison to patients having PASP values <35 mmHg. This result suggests the need for a randomized controlled trial to address the importance of post-transplant pulmonary hypertension management in patient survival.
Collapse
Affiliation(s)
- Tambi Jarmi
- Division of Nephrology, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Elias Doumit
- Division of Nephrology, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - George Makdisi
- Department of Surgery, Division of Thoracic and Cardiovascular, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Rahul Mhaskar
- Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Branko Miladinovic
- Program for Comparative Effectiveness Research and Evidence-Based Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Hani Wadei
- Transplant Center, Mayo Clinic, Jacksonville Campus, Jacksonville, FL, USA
| | - Mark Rumbak
- Department of Pulmonary Critical Care and Sleep Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Sadaf Aslam
- Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| |
Collapse
|
40
|
Lo K, Mezue K, Ram P, Goyal A, Shah M, Krishnamoorthy P, Gupta S, Pressman G, Rangaswami J. Echocardiographic and Hemodynamic Parameters Associated with Diminishing Renal Filtration among Patients with Heart Failure with Preserved Ejection Fraction. Cardiorenal Med 2018; 9:83-91. [DOI: 10.1159/000494089] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 09/27/2018] [Indexed: 11/19/2022] Open
Abstract
Background: Renal dysfunction is an important predictor of poor outcomes in patients with heart failure with preserved ejection fraction (HFpEF). Right ventricular (RV) dysfunction is implicated as one of the explanations for worsening renal function in cardiorenal syndrome. Novel right heart catheterization (RHC) parameters such as pulmonary artery pulsatility index (PAPi) and right atrial to pulmonary capillary wedge pressure ratio (RA:PCWP) have been found as predictors of RV dysfunction. However, most studies investigating these parameters have been done in the setting of myocardial infarction or left ventricular assist device implantation, with limited data on these metrics in patients with HFpEF. Objective: The purpose of this study was to determine whether novel RHC parameters such as RA:PCWP and PAPi correlate with long-term renal outcomes among patients with HFpEF. Methods: A retrospective single-center study of adult patients with a documented diagnosis of heart failure who had RHC was performed between January 2006 and December 2010 at Einstein Med ical Center Philadelphia. Selected patients also had a serum B-type natriuretic peptide level ≥100 pg/mL and a PCWP ≥15 mm Hg. Patients with an ejection fraction < 50%, including those with recovered ejection fraction, and end-stage renal disease were excluded. Results: A total of 81 patients with a clinical diagnosis of HFpEF were identified who met the inclusion criteria. On multivariate analysis, after adjusting for age, sex, race, diabetes, hypertension, and cardiac index, PAPi was associated with long-term estimated glomerular filtration rate (eGFR) (β = 3.43, 95% CI = 0.635–6.23, p = 0.017), and RA:PCWP showed a trend towards significance (β = 14.81, 95% CI = –0.096–29.73, p = 0.051). The results were unchanged after further adjustment for eGFR at the time of RHC. Conclusion: Novel hemodynamic indices obtained by RHC may have predictive value for long-term renal dysfunction in patients with HFpEF.
Collapse
|
41
|
Goyal A, Chatterjee K, Mathew R, Sidhu M, Bangalore S, McCullough P, Rangaswami J. In-Hospital Mortality and Major Adverse Cardiovascular Events after Kidney Transplantation in the United States. Cardiorenal Med 2018; 9:51-60. [DOI: 10.1159/000492731] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 08/03/2018] [Indexed: 11/19/2022] Open
Abstract
Background: Kidney transplantation (KT) is the treatment of choice for end-stage kidney disease. Cardiovascular disease is a major determinant of morbidity and mortality in patients with KT. Temporal trends in perioperative cardiovascular outcomes after KT are understudied, especially in light of an aging KT waitlist population. Methods: We performed a retrospective observational cohort study using the National Inpatient Sample for the years 2004–2013. All adult patients undergoing KT were identified using the appropriate International Classification of Diseases, 9th Revision, Clinical Modification codes. Demographic and hospital characteristics, discharge disposition, payer status, and major adverse cardiovascular events (MACEs) were summarized using summary statistics. Multivariate logistic regression was used to identify predictors of MACEs in the perioperative period of KT. Results: A total of 147,431 KTs were performed between 2004 and 2013. The mean age at KT went up from 48.1 to 51.8 years from 2004 to 2013. Medicare was the primary payer for 59.6% of the KTs. Overall average perioperative mortality was 0.5%, median length of stay was 5 days, and 6.5% of patients experienced an MACE, 78% of which were heart failures (HFs). Important predictors of perioperative MACEs were age ≥65 years (OR = 2.14), Medicare as primary payer (OR = 1.51), diabetes (OR = 1.46), recreational drug use (OR = 1.72), pulmonary circulation disorders (OR = 3.28), and malnutrition (OR = 1.91). Conclusion: Despite increases in age at the time of KT, the absolute risk of perioperative MACEs has remained stable from 2004 to 2013. HF is a major component of postoperative MACEs in KT. Malnutrition and pulmonary hypertension are major nontraditional predictors of perioperative MACE outcomes.
Collapse
|
42
|
Peter ID, Asani MO, Aliyu I, Obiagwu PN. Elevated Mean Pulmonary Artery Pressure and Right Ventricular Dysfunction in Children with Chronic Kidney Disease. J Cardiovasc Echogr 2018; 28:109-113. [PMID: 29911007 PMCID: PMC5989541 DOI: 10.4103/jcecho.jcecho_56_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Elevated mean pulmonary artery pressure (mPAP) and right heart failure increase mortality in patients with chronic kidney disease (CKD). Objectives The objective of this study is to determine the prevalence of elevated mPAP in children with CKD compared with matched controls and to ascertain the relationship between elevated mPAP with right ventricular dysfunction and history of hemodialysis. Materials and Methods A cross-sectional comparative study of mPAP and tricuspid annular plane systolic excursion of 21 children with CKD and age- and sex-matched controls asymptomatic for cardiac disease was conducted. Results Median mPAP was 27.69 (18.3-36.1) mmHg in CKD patients compared with 14.55 (13.5-17.1) mmHg in controls (P = 0.002). Elevated mPAP was present in 42.9% of CKD group and 0% in controls (P < 0.001). The prevalence of right ventricle (RV) dysfunction in CKD was 9.5% and 0% in controls (P = 0.49). Right ventricular dysfunction was significantly more common in patients with elevated mPAP compared with those with normal mPAP (P < 0.001). Children with CKD who had a history of having been dialyzed were less likely to have elevated mPAP (P < 0.001). Conclusion Elevated mPAP is significantly more common in children with CKD compared with controls. CKD population with mPAP elevation is more likely to have impaired RV function. The occurrence of elevated mPAP was more common in those who were never dialyzed.
Collapse
Affiliation(s)
- Igoche D Peter
- Paediatric Cardiology Unit, Aminu Kano Teaching Hospital, Bayero University Kano, Nigeria
| | - Mustafa O Asani
- Paediatric Cardiology Unit, Aminu Kano Teaching Hospital, Bayero University Kano, Nigeria
| | - Ibrahim Aliyu
- Paediatric Cardiology Unit, Aminu Kano Teaching Hospital, Bayero University Kano, Nigeria
| | - Patience N Obiagwu
- Department of Paediatrics, Paediatric Nephrology Unit, Aminu Kano Teaching Hospital, Bayero University Kano, Nigeria
| |
Collapse
|
43
|
Wolfe JD, Hickey GW, Althouse AD, Sharbaugh MS, Kliner DE, Mathier MA, Wu CM, Tevar AD, Soman P. Pulmonary vascular resistance determines mortality in end-stage renal disease patients with pulmonary hypertension. Clin Transplant 2018; 32:e13270. [PMID: 29697854 DOI: 10.1111/ctr.13270] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2018] [Indexed: 12/11/2022]
Abstract
The multifactorial etiology of pulmonary hypertension (PH) in end-stage renal disease (ESRD) includes patients with and without elevated pulmonary vascular resistance (PVR). We explored the prognostic implication of this distinction by evaluating pretransplant ESRD patients who underwent right heart catheterization and echocardiography. Demographics, clinical data, and test results were analyzed. All-cause mortality data were obtained. Median follow-up was 4 years. Of the 150 patients evaluated, echocardiography identified 99 patients (66%) with estimated pulmonary artery (PA) systolic pressure > 36 mm Hg, which correlated poorly with mortality (HR = 1.28, 95% CI 0.72-2.27, P = .387). Right heart catheterization identified 88 (59%) patients with mean PA pressure ≥ 25 mm Hg. Of these, 70 had PVR ≤ 3 Wood units and 18 had PVR > 3 Wood units. Survival analysis demonstrated a significant prognostic effect of an elevated PVR in patients with high mean PA pressures (HR = 2.26, 95% CI 1.07-4.77, P = .03), while patients with high mean PA pressure and normal PVR had equivalent survival to those with normal PA pressure. Despite the high prevalence of PH in ESRD patients, elevated PVR is uncommon and is a determinant of prognosis in patients with PH. Patients with normal PVR had survival equivalent to those with normal PA pressures.
Collapse
Affiliation(s)
- Jonathan D Wolfe
- Heart and Vascular Institute, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Gavin W Hickey
- Heart and Vascular Institute, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Andrew D Althouse
- Heart and Vascular Institute, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael S Sharbaugh
- Heart and Vascular Institute, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Dustin E Kliner
- Heart and Vascular Institute, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael A Mathier
- Heart and Vascular Institute, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Christine M Wu
- Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Amit D Tevar
- Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Prem Soman
- Heart and Vascular Institute, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| |
Collapse
|
44
|
Shang W, Li Y, Ren Y, Li W, Wei H, Dong J. Prevalence of pulmonary hypertension in patients with chronic kidney disease without dialysis: a meta-analysis. Int Urol Nephrol 2018; 50:1497-1504. [PMID: 29582339 DOI: 10.1007/s11255-018-1853-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Accepted: 03/21/2018] [Indexed: 01/11/2023]
Abstract
PURPOSE Recent epidemiological evidence attempts to demonstrate the risk of pulmonary hypertension (PH) among patients with chronic kidney disease (CKD) without dialysis, but prevalence estimates of PH in CKD without dialysis vary widely in the existing studies. This meta-analysis was to summarize the point prevalence of PH in adults with CKD without dialysis. METHODS PubMed, EMBASE, the Cochrane Collaboration, and the reference lists of relevant articles were searched to identify eligible studies. We used a random-effect meta-analysis model to estimate the prevalence of PH. Associations were tested in subgroups and meta-regression analyses. We also performed sensitivity analyses and assessments of publishing bias. RESULTS Twenty-one observational studies (n = 8012 participants) were included in this meta-analysis. The result of analysis in random-effect model showed that the pooled prevalence was 32% (95% CI 23-42%), with significant heterogeneity between these studies (I2 = 98%, P < 0.01). Stratified analyses found that the study design, region, sample size, year of publication, and definition of PH based on PASP ≥ 35 mmHg may explain the variation between studies. Sensitivity analysis further demonstrated the results to be robust. There was no evidence of publication bias. CONCLUSIONS PH is highly prevalent in patients with CKD without dialysis. Owing to the high heterogeneity, future well-designed and large prospective studies are encouraged to confirm the findings and definitively clarify the potential biological mechanisms.
Collapse
Affiliation(s)
- Weifeng Shang
- Department of Nephrology and Rheumatology, The Forth Hospital of Wuhan Affiliated with Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, People's Republic of China
| | - Yuanyuan Li
- Department of Respiratory Medicine, The Forth Hospital of Wuhan Affiliated with Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, People's Republic of China
| | - Yali Ren
- Department of Medical Affaires, Liyuan Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, People's Republic of China
| | - Wei Li
- Department of Nephrology and Rheumatology, The Forth Hospital of Wuhan Affiliated with Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, People's Republic of China
| | - HongLan Wei
- Department of Nephrology and Rheumatology, The Forth Hospital of Wuhan Affiliated with Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, People's Republic of China
| | - Junwu Dong
- Department of Nephrology and Rheumatology, The Forth Hospital of Wuhan Affiliated with Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, People's Republic of China.
| |
Collapse
|
45
|
Tang M, Batty JA, Lin C, Fan X, Chan KE, Kalim S. Pulmonary Hypertension, Mortality, and Cardiovascular Disease in CKD and ESRD Patients: A Systematic Review and Meta-analysis. Am J Kidney Dis 2018; 72:75-83. [PMID: 29429751 DOI: 10.1053/j.ajkd.2017.11.018] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 11/21/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pulmonary hypertension is common in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) and may be associated with poor outcomes. The magnitude of the association between pulmonary hypertension and mortality is uncertain due to the small size and variable findings of observational studies. STUDY DESIGN Systematic review and meta-analysis of observational studies using subgroup analyses and metaregression. SETTING & POPULATION Patients with ESRD or earlier stages of CKD. SELECTION CRITERIA FOR STUDIES Observational studies reporting clinical outcomes in patients with co-existing pulmonary hypertension and CKD or ESRD identified using a systematic search of PubMed and Embase. PREDICTOR Pulmonary hypertension diagnosed by Doppler echocardiography. OUTCOMES All-cause mortality, cardiovascular mortality, and cardiovascular events. RESULTS 16 studies, with 7,112 patients with an overall pulmonary hypertension prevalence of 23%, were included. Pulmonary hypertension was associated with increased risk for all-cause mortality among patients with CKD (relative risk [RR], 1.44; 95% CI, 1.17-1.76), with ESRD receiving maintenance dialysis (RR, 2.32; 95% CI, 1.91-2.83), and with a functioning kidney transplant (RR, 2.08; 95% CI, 1.35-3.20). Pulmonary hypertension was associated with increased risk for cardiovascular events in patients with CKD (RR, 1.67; 95% CI, 1.07-2.60) and ESRD receiving dialysis (RR, 2.33; 95% CI, 1.76-3.08). There was an association between pulmonary hypertension and increased risk for cardiovascular mortality in patients with CKD or ESRD (RR, 2.20; 95% CI, 1.53-3.15). LIMITATIONS Heterogeneity of included studies, possibility of residual confounding, unavailability of individual patient-level data, and possibility of outcome reporting bias. CONCLUSIONS Pulmonary hypertension is associated with a substantially increased risk for death and cardiovascular events in patients with CKD and ESRD. Risk is higher in patients with ESRD receiving dialysis compared with patients with CKD stages 1 to 5. Understanding the effect of interventions to lower pulmonary artery pressure on the survival of these patents awaits their evaluation in randomized controlled trials.
Collapse
Affiliation(s)
- Mengyao Tang
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA.
| | - Jonathan A Batty
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Chiayu Lin
- Zhejiang University School of Medicine, Hangzhou
| | - Xiaohong Fan
- Division of Nephrology, Department of Internal Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Kevin E Chan
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston; Fresenius Medical Care NA, Waltham, MA
| | - Sahir Kalim
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston
| |
Collapse
|
46
|
Kim J, Schulman-Marcus J, Watkins AC, Feldman DN, Swaminathan R, Lee JB, Muthukumar T, Serur D, Kim L, Hartono C. In-Hospital Cardiovascular Complications After Pancreas Transplantation in the United States from 2003 to 2012. Am J Cardiol 2017; 120:682-687. [PMID: 28683901 DOI: 10.1016/j.amjcard.2017.05.038] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 05/03/2017] [Accepted: 05/03/2017] [Indexed: 11/30/2022]
Abstract
Large database studies detailing the risk of perioperative cardiovascular complications after pancreas transplant has been limited, perhaps because these outcomes are not captured by transplant registries. Greater data on the incidence and risks of such outcomes could provide additional insight for referring physicians and inform potential recipients of their risk. We performed a serial, cross-sectional analysis of the National Inpatient Sample, the largest publicly available inpatient database in the United States, to assess for the risk of cardiovascular complications after pancreas transplants in the United States from 2003 to 2012 (n = 13,399). Using multivariable logistic regression models, the risk of cardiovascular outcomes after simultaneous pancreas-kidney transplants (SPK) was compared with solitary pancreas transplants (pancreas after kidney and pancreas transplant alone [PAK + PTA]). The unadjusted prevalence of in-hospital cardiovascular complications was higher in SPK than PAK + PTA (5.5% vs 3.7%, p <0.001). After multivariable adjustment, SPK remained associated with significantly higher odds of any cardiovascular complication (odds ratio [OR] 1.48, 95% confidence interval [CI] 1.21 to 1.80, p = 0.01), and particularly stroke (OR 13.41, 95% CI 4.78 to 37.63, p <0.001), compared with PAK + PTA. However, there was no difference in perioperative mortality (OR 0.78, 95% CI 0.54 to 1.12, p = 0.18). In conclusion, these findings highlight the association between uremia and stroke in pancreas transplant patients, as well as the need for improved preoperative cardiac risk assessment and perioperative management, especially in those who underwent SPK.
Collapse
Affiliation(s)
- Jim Kim
- Division of Transplant Surgery, Weill Cornell Medicine, New York, New York.
| | - Joshua Schulman-Marcus
- Division of Cardiology, Albany Medical Center, Albany, New York; Division of Cardiology, Weill Cornell Medicine, New York, New York
| | - Anthony C Watkins
- Division of Transplant Surgery, Weill Cornell Medicine, New York, New York
| | | | - Rajesh Swaminathan
- Division of Cardiology, Weill Cornell Medicine, New York, New York; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Jun B Lee
- Division of Nephrology and Hypertension, Weill Cornell Medicine, New York, New York; The Rogosin Institute, New York, New York
| | | | - David Serur
- Division of Nephrology and Hypertension, Weill Cornell Medicine, New York, New York; The Rogosin Institute, New York, New York
| | - Luke Kim
- Division of Cardiology, Weill Cornell Medicine, New York, New York
| | - Choli Hartono
- Division of Nephrology and Hypertension, Weill Cornell Medicine, New York, New York; The Rogosin Institute, New York, New York
| |
Collapse
|
47
|
Selvaraj S, Shah SJ, Ommerborn MJ, Clark CR, Hall ME, Mentz RJ, Qazi S, Robbins JM, Skelton TN, Chen J, Gaziano JM, Djoussé L. Pulmonary Hypertension Is Associated With a Higher Risk of Heart Failure Hospitalization and Mortality in Patients With Chronic Kidney Disease: The Jackson Heart Study. Circ Heart Fail 2017; 10:CIRCHEARTFAILURE.116.003940. [PMID: 28611127 DOI: 10.1161/circheartfailure.116.003940] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 05/15/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND African Americans develop chronic kidney disease and pulmonary hypertension (PH) at disproportionately high rates. Little is known whether PH heightens the risk of heart failure (HF) admission or mortality among chronic kidney disease patients, including patients with non-end-stage renal disease. METHODS AND RESULTS We analyzed African Americans participants with chronic kidney disease (estimated glomerular filtration rate <60 mL/min per 1.73 m2 or urine albumin/creatinine >30 mg/g) and available echocardiogram-derived pulmonary artery systolic pressure (PASP) from the Jackson Heart Study (N=408). We used Cox models to assess whether PH (PASP>35 mm Hg) was associated with higher rates of HF hospitalization and mortality. In a secondary, cross-sectional analysis, we examined the relationship between cystatin C (a marker of renal function) and PASP and potential mediators, including BNP (B-type natriuretic peptide) and endothelin-1. In our cohort, the mean age was 63±13 years, 70% were female, 78% had hypertension, and 22% had PH. Eighty-five percent of the participants had an estimated glomerular filtration rate >30 mL/min per 1.73 m2. During follow-up, 13% were hospitalized for HF and 27% died. After adjusting for potential confounders, including BNP, PH was found to be associated with HF hospitalization (hazard ratio, 2.37; 95% confidence interval, 1.15-4.86) and the combined outcome of HF hospitalization or mortality (hazard ratio, 1.84; confidence interval, 1.09-3.10). Log cystatin C was directly associated with PASP (adjusted β =2.5 [95% confidence interval, 0.8-4.1] per standard deviation change in cystatin C). Mediation analysis showed that BNP and endothelin-1 explained 56% and 40%, respectively, of the indirect effects between cystatin C and PASP. CONCLUSIONS Among African Americans with chronic kidney disease, PH, which is likely pulmonary venous hypertension, was associated with a higher risk of HF admission and mortality.
Collapse
Affiliation(s)
- Senthil Selvaraj
- From the Department of Medicine, VA Boston Healthcare System, MA (S.S., S.Q.); Division of Aging, Department of Medicine (S.S., S.Q., J.C., J.M.G., L.D.) and Center for Community Health and Health Equity and Department of Medicine (M.J.O., C.R.C.), Brigham and Women's Hospital, Boston, MA; Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.); Division of Cardiology, Department of Medicine, University of Mississippi Medical Center, Jackson (M.E.H., T.N.S.); Duke Clinical Research Institute, Durham, NC (R.J.M.); Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (J.M.R.); and Massachusetts Veterans Epidemiology and Research Information Center (MAVERIC), VA Boston Healthcare System (J.M.G., L.D.).
| | - Sanjiv J Shah
- From the Department of Medicine, VA Boston Healthcare System, MA (S.S., S.Q.); Division of Aging, Department of Medicine (S.S., S.Q., J.C., J.M.G., L.D.) and Center for Community Health and Health Equity and Department of Medicine (M.J.O., C.R.C.), Brigham and Women's Hospital, Boston, MA; Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.); Division of Cardiology, Department of Medicine, University of Mississippi Medical Center, Jackson (M.E.H., T.N.S.); Duke Clinical Research Institute, Durham, NC (R.J.M.); Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (J.M.R.); and Massachusetts Veterans Epidemiology and Research Information Center (MAVERIC), VA Boston Healthcare System (J.M.G., L.D.)
| | - Mark J Ommerborn
- From the Department of Medicine, VA Boston Healthcare System, MA (S.S., S.Q.); Division of Aging, Department of Medicine (S.S., S.Q., J.C., J.M.G., L.D.) and Center for Community Health and Health Equity and Department of Medicine (M.J.O., C.R.C.), Brigham and Women's Hospital, Boston, MA; Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.); Division of Cardiology, Department of Medicine, University of Mississippi Medical Center, Jackson (M.E.H., T.N.S.); Duke Clinical Research Institute, Durham, NC (R.J.M.); Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (J.M.R.); and Massachusetts Veterans Epidemiology and Research Information Center (MAVERIC), VA Boston Healthcare System (J.M.G., L.D.)
| | - Cheryl R Clark
- From the Department of Medicine, VA Boston Healthcare System, MA (S.S., S.Q.); Division of Aging, Department of Medicine (S.S., S.Q., J.C., J.M.G., L.D.) and Center for Community Health and Health Equity and Department of Medicine (M.J.O., C.R.C.), Brigham and Women's Hospital, Boston, MA; Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.); Division of Cardiology, Department of Medicine, University of Mississippi Medical Center, Jackson (M.E.H., T.N.S.); Duke Clinical Research Institute, Durham, NC (R.J.M.); Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (J.M.R.); and Massachusetts Veterans Epidemiology and Research Information Center (MAVERIC), VA Boston Healthcare System (J.M.G., L.D.)
| | - Michael E Hall
- From the Department of Medicine, VA Boston Healthcare System, MA (S.S., S.Q.); Division of Aging, Department of Medicine (S.S., S.Q., J.C., J.M.G., L.D.) and Center for Community Health and Health Equity and Department of Medicine (M.J.O., C.R.C.), Brigham and Women's Hospital, Boston, MA; Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.); Division of Cardiology, Department of Medicine, University of Mississippi Medical Center, Jackson (M.E.H., T.N.S.); Duke Clinical Research Institute, Durham, NC (R.J.M.); Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (J.M.R.); and Massachusetts Veterans Epidemiology and Research Information Center (MAVERIC), VA Boston Healthcare System (J.M.G., L.D.)
| | - Robert J Mentz
- From the Department of Medicine, VA Boston Healthcare System, MA (S.S., S.Q.); Division of Aging, Department of Medicine (S.S., S.Q., J.C., J.M.G., L.D.) and Center for Community Health and Health Equity and Department of Medicine (M.J.O., C.R.C.), Brigham and Women's Hospital, Boston, MA; Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.); Division of Cardiology, Department of Medicine, University of Mississippi Medical Center, Jackson (M.E.H., T.N.S.); Duke Clinical Research Institute, Durham, NC (R.J.M.); Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (J.M.R.); and Massachusetts Veterans Epidemiology and Research Information Center (MAVERIC), VA Boston Healthcare System (J.M.G., L.D.)
| | - Saadia Qazi
- From the Department of Medicine, VA Boston Healthcare System, MA (S.S., S.Q.); Division of Aging, Department of Medicine (S.S., S.Q., J.C., J.M.G., L.D.) and Center for Community Health and Health Equity and Department of Medicine (M.J.O., C.R.C.), Brigham and Women's Hospital, Boston, MA; Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.); Division of Cardiology, Department of Medicine, University of Mississippi Medical Center, Jackson (M.E.H., T.N.S.); Duke Clinical Research Institute, Durham, NC (R.J.M.); Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (J.M.R.); and Massachusetts Veterans Epidemiology and Research Information Center (MAVERIC), VA Boston Healthcare System (J.M.G., L.D.)
| | - Jeremy M Robbins
- From the Department of Medicine, VA Boston Healthcare System, MA (S.S., S.Q.); Division of Aging, Department of Medicine (S.S., S.Q., J.C., J.M.G., L.D.) and Center for Community Health and Health Equity and Department of Medicine (M.J.O., C.R.C.), Brigham and Women's Hospital, Boston, MA; Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.); Division of Cardiology, Department of Medicine, University of Mississippi Medical Center, Jackson (M.E.H., T.N.S.); Duke Clinical Research Institute, Durham, NC (R.J.M.); Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (J.M.R.); and Massachusetts Veterans Epidemiology and Research Information Center (MAVERIC), VA Boston Healthcare System (J.M.G., L.D.)
| | - Thomas N Skelton
- From the Department of Medicine, VA Boston Healthcare System, MA (S.S., S.Q.); Division of Aging, Department of Medicine (S.S., S.Q., J.C., J.M.G., L.D.) and Center for Community Health and Health Equity and Department of Medicine (M.J.O., C.R.C.), Brigham and Women's Hospital, Boston, MA; Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.); Division of Cardiology, Department of Medicine, University of Mississippi Medical Center, Jackson (M.E.H., T.N.S.); Duke Clinical Research Institute, Durham, NC (R.J.M.); Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (J.M.R.); and Massachusetts Veterans Epidemiology and Research Information Center (MAVERIC), VA Boston Healthcare System (J.M.G., L.D.)
| | - Jiaying Chen
- From the Department of Medicine, VA Boston Healthcare System, MA (S.S., S.Q.); Division of Aging, Department of Medicine (S.S., S.Q., J.C., J.M.G., L.D.) and Center for Community Health and Health Equity and Department of Medicine (M.J.O., C.R.C.), Brigham and Women's Hospital, Boston, MA; Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.); Division of Cardiology, Department of Medicine, University of Mississippi Medical Center, Jackson (M.E.H., T.N.S.); Duke Clinical Research Institute, Durham, NC (R.J.M.); Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (J.M.R.); and Massachusetts Veterans Epidemiology and Research Information Center (MAVERIC), VA Boston Healthcare System (J.M.G., L.D.)
| | - J Michael Gaziano
- From the Department of Medicine, VA Boston Healthcare System, MA (S.S., S.Q.); Division of Aging, Department of Medicine (S.S., S.Q., J.C., J.M.G., L.D.) and Center for Community Health and Health Equity and Department of Medicine (M.J.O., C.R.C.), Brigham and Women's Hospital, Boston, MA; Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.); Division of Cardiology, Department of Medicine, University of Mississippi Medical Center, Jackson (M.E.H., T.N.S.); Duke Clinical Research Institute, Durham, NC (R.J.M.); Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (J.M.R.); and Massachusetts Veterans Epidemiology and Research Information Center (MAVERIC), VA Boston Healthcare System (J.M.G., L.D.)
| | - Luc Djoussé
- From the Department of Medicine, VA Boston Healthcare System, MA (S.S., S.Q.); Division of Aging, Department of Medicine (S.S., S.Q., J.C., J.M.G., L.D.) and Center for Community Health and Health Equity and Department of Medicine (M.J.O., C.R.C.), Brigham and Women's Hospital, Boston, MA; Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.); Division of Cardiology, Department of Medicine, University of Mississippi Medical Center, Jackson (M.E.H., T.N.S.); Duke Clinical Research Institute, Durham, NC (R.J.M.); Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (J.M.R.); and Massachusetts Veterans Epidemiology and Research Information Center (MAVERIC), VA Boston Healthcare System (J.M.G., L.D.)
| |
Collapse
|
48
|
Foderaro AE, Baird GL, Bazargan-Lari A, Morrissey PE, Gohh RY, Poppas A, Klinger JR, Ventetuolo CE. Echocardiographic Pulmonary Hypertension Predicts Post-transplantation Renal Allograft Failure. Transplant Proc 2017; 49:1256-1261. [PMID: 28735990 PMCID: PMC5567835 DOI: 10.1016/j.transproceed.2017.01.085] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 01/13/2017] [Accepted: 01/24/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Pulmonary hypertension in the setting of renal transplantation has been associated with early allograft dysfunction and increased mortality, but this relationship has not been extensively studied. METHODS We performed a retrospective cohort study of adult patients who underwent their first renal transplantation in the years 2003-2009 and had pre-transplantation echocardiograms. Pulmonary hypertension was defined as right ventricular systolic pressure ≥40 mm Hg in the absence of left-sided valvular disease and/or left ventricular ejection fraction ≤50%. Eighty-two of 205 patients (40%) met the inclusion criteria. The relationship between pulmonary hypertension and death-censored allograft failure (hemodialysis dependence or retransplantation) and serum creatinine was assessed with the use of Cox hazard regression and generalized mixed models. RESULTS The presence of pulmonary hypertension was associated with a 3-fold increase in the risk of death-censored allograft failure (95% confidence interval, 1.20-7.32; P = .02). Failure rates were 19% at 24 months and 51% at 96 months for those with pulmonary hypertension versus 7% at 24 months and 20% at 86 months for those without pulmonary hypertension (P = .01). Among those without graft failure, there was an increase in creatinine levels after transplantation (P = .01). Effect estimates were unchanged by adjustment for multiple covariates and when pulmonary hypertension was defined as right ventricular systolic pressure ≥36 mm Hg. CONCLUSIONS Pulmonary hypertension before renal transplantation carries a 3-fold increased risk of death-censored allograft failure. The relationship between the pulmonary circulation and renal allograft failure warrants further study.
Collapse
Affiliation(s)
- A E Foderaro
- Department of Medicine, Alpert Medical School of Brown University, Providence, Rhode Island
| | - G L Baird
- Department of Surgery, Brown University School of Public Health, Providence, Rhode Island
| | - A Bazargan-Lari
- Department of Health Services, Policy, and Practice, Alpert Medical School of Brown University, Providence, Rhode Island
| | - P E Morrissey
- Lifespan Biostatistics Core, Lifespan Hospital System, Providence, Rhode Island
| | - R Y Gohh
- Department of Medicine, Alpert Medical School of Brown University, Providence, Rhode Island
| | - A Poppas
- Department of Medicine, Alpert Medical School of Brown University, Providence, Rhode Island
| | - J R Klinger
- Department of Medicine, Alpert Medical School of Brown University, Providence, Rhode Island
| | - C E Ventetuolo
- Department of Medicine, Alpert Medical School of Brown University, Providence, Rhode Island; Department of Internal Medicine, Kaiser Permanente, West Los Angeles, California.
| |
Collapse
|
49
|
Frost AE. The Intersection of Pulmonary Hypertension and Solid Organ Transplantation. Methodist Debakey Cardiovasc J 2017; 12:10-13. [PMID: 28298957 DOI: 10.14797/mdcj-12-4s1-10] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Pulmonary hypertension (PH) is a complication and marker of disease severity in many parenchymal lung diseases. It also is a frequent complication of portal hypertension and negatively impacts survival with liver transplant. Pulmonary hypertension is frequently diagnosed in patients with end-stage renal disease who are undergoing dialysis, and it has recently been demonstrated to adversely affect posttransplant outcome in this patient population even though the mechanism of PH is substantially different from that associated with liver disease. The presence of PH in patients with heart failure is frequent, and the necessity for PH therapy prior to heart transplant has evolved in the last decade. We review the frequency of and risk factors for PH in recipients of and candidates for lung, liver, heart, and renal transplants as well as the impact of this diagnosis on posttransplant outcomes.
Collapse
Affiliation(s)
- Adaani E Frost
- Houston Methodist Hospital, Houston, Texas; Weill Cornell Medical College, New York, New York
| |
Collapse
|
50
|
Halawa A. Evaluation of the Cardiovascular Prior to Transplantation; An Endless Debate. ACTA ACUST UNITED AC 2017. [DOI: 10.15406/unoaj.2017.04.00126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|