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Zahid S, Sanchez-Nadales A, Hashem A, Sarkar A, Sleiman J, Lewis A, Uppal D, Nimmagadda M, Ullah W, Leiby B, Snipelisky D, Baez-Escudero J, Asher C. Trends and Outcomes of Left Atrial Appendage Occlusion in Renal and Liver Transplant Recipients: Insights From the United States National Inpatient and Readmission Database. Curr Probl Cardiol 2023; 48:101488. [PMID: 36351464 DOI: 10.1016/j.cpcardiol.2022.101488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 10/31/2022] [Indexed: 11/09/2022]
Abstract
Left atrial appendage occlusion using the Watchman device has emerged as an alternative treatment strategy for preventing strokes in patients with atrial fibrillation. However, there is no data on its safety and clinical outcomes in prior renal or liver transplant recipients. We included a total of 61,995 patients from the National Inpatient Sample (NIS, in-hospital outcomes) and 55,048 patients from the National Readmission Database (NRD, 30-day outcomes) who underwent percutaneous left atrial appendage occlusion (LAAO). From this group, 0.65% (n=405) and 0.62% (n=339) were renal and liver transplant recipients in NIS and NRD respectively. Transplant recipients were younger compared with non-transplant recipients (mean age 69 vs 77 years, P=<0.01). There was little difference in terms of in-hospital mortality (0% vs 0.2%, P=0.43), major complications (6.2% vs 5.6%, P=0.61), cardiovascular complications (2.5% vs 2.8%, P=0.73), neurological complications (1.2% vs 0.7%, P=0.21) or bleeding complications (1.2% vs 0.7%, P=0.99) between transplant vs. non-transplant patients. Based on the NRD database, 30-day readmission rate was not meaningfully different for transplant recipients undergoing LAAO (9.44%) when compared to non-transplant patients (8.12%, [log-rank, P=0.56]). There was no difference between 30-day major or cardiovascular complications, however vascular complication rates were significantly higher for transplant recipients (OR 2.56, 95% CI [(1.66-3.47]). Our study findings suggest that LAAO may be safe for patients with a prior renal or liver transplant in terms of major complications, cardiovascular complications, and all-cause readmission rates. However vascular complications may be higher in transplant recipients. Further large-scale studies are needed to confirm these findings.
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Affiliation(s)
- Salman Zahid
- Sands-Constellation Heart Institute, Rochester General Hospital, Rochester, NY.
| | | | - Anas Hashem
- Sands-Constellation Heart Institute, Rochester General Hospital, Rochester, NY
| | - Abdullah Sarkar
- Department of Cardiovascular Disease, Cleveland Clinic Florida, Weston, FL
| | - Jose Sleiman
- Department of Cardiovascular Disease, Cleveland Clinic Florida, Weston, FL
| | - Antonio Lewis
- Department of Cardiovascular Disease, Cleveland Clinic Florida, Weston, FL
| | - Dipan Uppal
- Department of Cardiovascular Disease, Cleveland Clinic Florida, Weston, FL
| | - Manojna Nimmagadda
- Department of Cardiovascular Disease, Cleveland Clinic Florida, Weston, FL
| | - Waqas Ullah
- Division of Biostatistics, Thomas Jefferson University, Philadelphia, PA
| | - Benjamin Leiby
- Department of Cardiovascular Disease, Thomas Jefferson University, Philadelphia, PA
| | - David Snipelisky
- Department of Cardiovascular Disease, Cleveland Clinic Florida, Weston, FL
| | - Jose Baez-Escudero
- Department of Cardiovascular Disease, Cleveland Clinic Florida, Weston, FL
| | - Craig Asher
- Department of Cardiovascular Disease, Cleveland Clinic Florida, Weston, FL
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2
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Faravelli I, Velardo D, Podestà MA, Ponticelli C. Immunosuppression-related neurological disorders in kidney transplantation. J Nephrol 2021; 34:539-555. [PMID: 33481222 PMCID: PMC8036223 DOI: 10.1007/s40620-020-00956-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 12/27/2020] [Indexed: 01/06/2023]
Abstract
A large number of neurological disorders can affect renal transplant recipients, potentially leading to disabling or life-threatening complications. Prevention, early diagnosis and appropriate management of these conditions are critical to avoid irreversible lesions. A pivotal role in the pathogenesis of common post-transplant neurological disorders is played by immunosuppressive therapy. The most frequently administered regimen consists of triple immunosuppression, which comprises a calcineurin inhibitor (CNI), a purine synthesis inhibitor and glucocorticoids. Some of these immunosuppressive drugs may lead to neurological signs and symptoms through direct neurotoxic effects, and all of them may be responsible for the development of tumors or opportunistic infections. In this review, after a brief summary of neurotoxic pathogenetic mechanisms encompassing recent advances in the field, we focus on the clinical presentation of more common and severe immunosuppression-related neurological complications, classifying them by characteristics of urgency and anatomic site. Our goal is to provide a general framework that addresses such clinical issues with a multidisciplinary approach, as these conditions require.
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Affiliation(s)
- Irene Faravelli
- Neuroscience Section, Department of Pathophysiology and Transplantation (DEPT), Dino Ferrari Centre, Università degli Studi di Milano, Milan, Italy.
| | - Daniele Velardo
- Neurology Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Manuel Alfredo Podestà
- Renal Division, ASST Santi Paolo e Carlo, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
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3
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Findlay M, MacIsaac R, MacLeod MJ, Metcalfe W, Traynor JP, Dawson J, Mark PB. Renal replacement modality and stroke risk in end-stage renal disease-a national registry study. Nephrol Dial Transplant 2019; 33:1564-1571. [PMID: 29069522 DOI: 10.1093/ndt/gfx291] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 09/06/2017] [Indexed: 11/12/2022] Open
Abstract
Background The risk of stroke in end-stage renal disease (ESRD) on renal replacement therapy (RRT) is up to 10-fold greater than the general population. However, whether this increased risk differs by RRT modality is unclear. Methods We used data contained in the Scottish Renal Registry and the Scottish Stroke Care Audit to identify stroke in all adult patients who commenced RRT for ESRD from 2005 to 2013. Incidence rate was calculated and regression analyses were performed to identify variables associated with stroke. We explored the effect of RRT modality at initiation and cumulative dialysis exposure by time-dependent regression analysis, using transplant recipients as the reference group. Results A total of 4957 patients commenced RRT for ESRD. Median age was 64.5 years, 41.5% were female and 277 patients suffered a stroke (incidence rate was 18.6/1000 patient-years). Patients who had stroke were older, had higher blood pressure and were more likely to be female and have diabetes. On multivariable regression older age, female sex, diabetes and higher serum phosphate were associated with risk of stroke. RRT modality at initiation was not. On time-dependent analysis, haemodialysis (HD) exposure was independently associated with increased risk of stroke. Conclusions In patients with ESRD who initiate RRT, HD use independently increases risk of stroke compared with transplantation. Use of peritoneal dialysis did not increase risk on adjusted analysis.
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Affiliation(s)
- Mark Findlay
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,The Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Rachael MacIsaac
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Mary Joan MacLeod
- Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK.,Scottish Stroke Care Audit, ISD, Edinburgh, UK
| | - Wendy Metcalfe
- Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK.,Scottish Renal Registry, ISD, Glasgow, UK
| | - Jamie P Traynor
- The Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK.,Scottish Renal Registry, ISD, Glasgow, UK
| | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,The Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Patrick B Mark
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,The Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
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4
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Dahdaleh S, Malhotra P. Treatment of Central Nervous System Complications of Renal Dialysis and Transplantation. Curr Treat Options Neurol 2019; 21:13. [DOI: 10.1007/s11940-019-0553-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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5
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Jagdale A, Cooper DKC, Iwase H, Gaston RS. Chronic dialysis in patients with end-stage renal disease: Relevance to kidney xenotransplantation. Xenotransplantation 2018; 26:e12471. [PMID: 30456901 DOI: 10.1111/xen.12471] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 10/09/2018] [Accepted: 10/19/2018] [Indexed: 01/08/2023]
Abstract
Renal allotransplantation clearly offers better survival and quality of life for end-stage renal disease (ESRD) patients than chronic dialysis. The median waiting time for a deceased donor kidney in a suitable ESRD patient is 3.9 years. The initial candidates for pig kidney xenotransplantation will be those with ESRD unlikely to receive an allograft within a reasonable period of time. It is thus reasonable to ascertain whether clinical trials of xenotransplantation might likewise offer superior outcomes. Chronic dialysis in patients with ESRD is associated with poor quality of life, significant morbidity, and relatively high mortality, with only 56% surviving 3 years and 42% at 5 years. However, a significant number of these patients, because of comorbidities, frailty, etc, would not be considered for renal allotransplantation and likely not for xenotransplantation. As genetically engineered pig kidneys have satisfactorily supported life in immunosuppressed nonhuman primates for many months or even more than a year, consideration in carefully selected patients could be given to pig kidney xenotransplantation. We suggest that, in order to give a patient the best possible outcome, the pig kidney could be transplanted pre-emptively (before dialysis is initiated). If it fails at any stage, the patient would then begin chronic dialysis and continue to await an allograft. The present (limited) evidence is that failure of a pig graft would not be detrimental to a subsequent allograft.
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Affiliation(s)
- Abhijit Jagdale
- Department of Surgery, Xenotransplantation Program, University of Alabama at Birmingham, Birmingham, Alabama
| | - David K C Cooper
- Department of Surgery, Xenotransplantation Program, University of Alabama at Birmingham, Birmingham, Alabama
| | - Hayato Iwase
- Department of Surgery, Xenotransplantation Program, University of Alabama at Birmingham, Birmingham, Alabama
| | - Robert S Gaston
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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Findlay MD, Dawson J, MacIsaac R, Jardine AG, MacLeod MJ, Metcalfe W, Traynor JP, Mark PB. Inequality in Care and Differences in Outcome Following Stroke in People With ESRD. Kidney Int Rep 2018; 3:1064-1076. [PMID: 30197973 PMCID: PMC6127409 DOI: 10.1016/j.ekir.2018.04.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 04/18/2018] [Accepted: 04/23/2018] [Indexed: 11/27/2022] Open
Abstract
Introduction Stroke rate and mortality are greater in individuals with end-stage renal disease (ESRD) than in those without ESRD. We examined discrepancies in stroke care in ESRD patients and their influence on mortality. Methods This is a national record linkage cohort study of hospitalized stroke individuals from 2005 to 2013. Presentation, measures of care quality (admission to stroke unit, swallow assessment, antithrombotics, or thrombolysis use), and outcomes were compared in those with and without ESRD after propensity score matching (PSM). We examined the effect of being admitted to a stroke unit on survival using Kaplan-Meier and Cox survival analyses. Results A total of 8757 individuals with ESRD and 61,367 individuals with stroke were identified. ESRD patients (n =486) experienced stroke over 34,551.9 patient-years of follow-up; incidence rates were 25.3 (dialysis) and 4.5 (kidney transplant)/1000 patient-years. After PSM, dialysis patients were less likely to be functionally independent (61.4% vs. 77.7%; P < 0.0001) before stroke, less frequently admitted to stroke units (64.6% vs. 79.6%; P < 0.001), or to receive aspirin (75.3% vs. 83.2%; P = 0.01) than non-ESRD stroke patients. There were no significant differences in management of kidney transplantation patients. Stroke with ESRD was associated with a higher death rate during admission (dialysis 22.9% vs.14.4%, P = 0.002; transplantation: 19.6% vs. 9.3%; P = 0.034). Managing ESRD patients in a stroke unit was associated with a lower risk of death at follow-up (hazard ratio: 0.68; 95% confidence interval: 0.55-0.84). Conclusion Stroke incidence is high in ESRD. Individuals on dialysis are functionally more dependent before stroke and less frequently receive optimal stroke care. After a stroke, death is more likely in ESRD patients. Acute stroke unit care may be associated with lower mortality.
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Affiliation(s)
- Mark D Findlay
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,The Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,The Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Rachael MacIsaac
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Alan G Jardine
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,The Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Mary Joan MacLeod
- Institute of Medical Sciences, University of Aberdeen, Foresterhill, Aberdeen, UK
| | - Wendy Metcalfe
- Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Jamie P Traynor
- The Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Patrick B Mark
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,The Glasgow Renal & Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
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7
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Is carotid revascularization worthwhile in patients waiting for kidney transplantation? Transplant Rev (Orlando) 2018; 32:79-84. [DOI: 10.1016/j.trre.2017.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 11/03/2017] [Accepted: 11/08/2017] [Indexed: 11/18/2022]
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Karunaratne K, Taube D, Khalil N, Perry R, Malhotra PA. Neurological complications of renal dialysis and transplantation. Pract Neurol 2017; 18:115-125. [PMID: 29288211 DOI: 10.1136/practneurol-2017-001657] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/17/2017] [Indexed: 11/04/2022]
Abstract
Neurological complications from renal replacement therapy contribute significantly to morbidity and mortality in patients with renal failure. Such complications can affect either the central or peripheral nervous systems. Most neurological disturbances associated with the uraemic state do not respond fully to renal replacement therapy. There are also complications specifically associated with dialysis and transplantation. A multidisciplinary approach, involving both nephrologists and neurologists, is critical for the diagnosis and effective management of these disorders.
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Affiliation(s)
- Kushan Karunaratne
- Department of Neurology, Imperial College Healthcare NHS Trust, London, UK
| | - David Taube
- Department of Renal and Transplantation Medicine, West London Renal and Transplant Centre, Imperial College Kidney and Transplant Institute, London, UK
| | - Nofal Khalil
- Department of Neurophysiology, Imperial College Healthcare NHS Trust, London, UK
| | - Richard Perry
- Department of Neurology, Imperial College Healthcare NHS Trust, London, UK.,Division of Brain Sciences, Imperial College London, London, UK
| | - Paresh A Malhotra
- Department of Neurology, Imperial College Healthcare NHS Trust, London, UK.,Division of Brain Sciences, Imperial College London, London, UK
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9
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Vascular Damage and Kidney Transplant Outcomes: An Unfriendly and Harmful Link. Am J Med Sci 2017; 354:7-16. [DOI: 10.1016/j.amjms.2017.01.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 12/20/2016] [Accepted: 01/09/2017] [Indexed: 12/31/2022]
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Findlay MD, Thomson PC, MacIsaac R, Jardine AG, Patel RK, Stevens KK, Rutherford E, Clancy M, Geddes CC, Dawson J, Mark PB. Risk factors and outcome of stroke in renal transplant recipients. Clin Transplant 2016; 30:918-24. [DOI: 10.1111/ctr.12765] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Mark D. Findlay
- Institute of Cardiovascular and Medical Sciences; University of Glasgow; Glasgow UK
- The Glasgow Renal & Transplant Unit; Queen Elizabeth University Hospital; Glasgow UK
| | - Peter C. Thomson
- The Glasgow Renal & Transplant Unit; Queen Elizabeth University Hospital; Glasgow UK
| | - Rachael MacIsaac
- Institute of Cardiovascular and Medical Sciences; University of Glasgow; Glasgow UK
| | - Alan G. Jardine
- Institute of Cardiovascular and Medical Sciences; University of Glasgow; Glasgow UK
- The Glasgow Renal & Transplant Unit; Queen Elizabeth University Hospital; Glasgow UK
| | - Rajan K. Patel
- Institute of Cardiovascular and Medical Sciences; University of Glasgow; Glasgow UK
- The Glasgow Renal & Transplant Unit; Queen Elizabeth University Hospital; Glasgow UK
| | - Kathryn K. Stevens
- Institute of Cardiovascular and Medical Sciences; University of Glasgow; Glasgow UK
- The Glasgow Renal & Transplant Unit; Queen Elizabeth University Hospital; Glasgow UK
| | - Elaine Rutherford
- Institute of Cardiovascular and Medical Sciences; University of Glasgow; Glasgow UK
- The Glasgow Renal & Transplant Unit; Queen Elizabeth University Hospital; Glasgow UK
| | - Marc Clancy
- The Glasgow Renal & Transplant Unit; Queen Elizabeth University Hospital; Glasgow UK
| | - Colin C. Geddes
- The Glasgow Renal & Transplant Unit; Queen Elizabeth University Hospital; Glasgow UK
| | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences; University of Glasgow; Glasgow UK
| | - Patrick B. Mark
- Institute of Cardiovascular and Medical Sciences; University of Glasgow; Glasgow UK
- The Glasgow Renal & Transplant Unit; Queen Elizabeth University Hospital; Glasgow UK
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Neale J, Smith AC. Cardiovascular risk factors following renal transplant. World J Transplant 2015; 5:183-95. [PMID: 26722646 PMCID: PMC4689929 DOI: 10.5500/wjt.v5.i4.183] [Citation(s) in RCA: 93] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 08/19/2015] [Accepted: 09/25/2015] [Indexed: 02/05/2023] Open
Abstract
Kidney transplantation is the gold-standard treatment for many patients with end-stage renal disease. Renal transplant recipients (RTRs) remain at an increased risk of fatal and non-fatal cardiovascular (CV) events compared to the general population, although rates are lower than those patients on maintenance haemodialysis. Death with a functioning graft is most commonly due to cardiovascular disease (CVD) and therefore this remains an important therapeutic target to prevent graft failure. Conventional CV risk factors such as diabetes, hypertension and renal dysfunction remain a major influence on CVD in RTRs. However it is now recognised that the morbidity and mortality from CVD are not entirely accounted for by these traditional risk-factors. Immunosuppression medications exert a deleterious effect on many of these well-recognised contributors to CVD and are known to exacerbate the probability of developing diabetes, graft dysfunction and hypertension which can all lead on to CVD. Non-traditional CV risk factors such as inflammation and anaemia have been strongly linked to increased CV events in RTRs and should be considered alongside those which are classified as conventional. This review summarises what is known about risk-factors for CVD in RTRs and how, through identification of those which are modifiable, outcomes can be improved. The overall CV risk in RTRs is likely to be multifactorial and a complex interaction between the multiple traditional and non-traditional factors; further studies are required to determine how these may be modified to enhance survival and quality of life in this unique population.
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