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Andrian T, Siriteanu L, Covic AS, Ipate CA, Miron A, Morosanu C, Caruntu ID, Covic A. Non-Traditional Non-Immunological Risk Factors for Kidney Allograft Loss-Opinion. J Clin Med 2023; 12:jcm12062364. [PMID: 36983364 PMCID: PMC10051358 DOI: 10.3390/jcm12062364] [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: 12/28/2022] [Revised: 02/16/2023] [Accepted: 03/16/2023] [Indexed: 03/30/2023] Open
Abstract
Rates of late allograft loss have improved slowly in the last decades. Well described traditional risk factors that influence allograft survival include cardiovascular events, rejection, infections and post-transplant neoplasia. Here, we critically evaluate the influence of several non-immunological, non-traditional risk factors and describe their impact on allograft survival and cardiovascular health of kidney transplant recipients. We assessed the following risk factors: arterial stiffness, persistent arteriovenous access, mineral bone disease, immunosuppressive drugs residual levels variability, hypomagnesemia, glomerular pathological alterations not included in Banff criteria, persistent inflammation and metabolic acidosis.
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Affiliation(s)
- Titus Andrian
- Nephrology Clinic, Dialysis and Renal Transplant Center, C. I. Parhon University Hospital, 700503 Iasi, Romania
- Department of Internal Medicine, 'Grigore T. Popa' University of Medicine, 700115 Iasi, Romania
| | - Lucian Siriteanu
- Nephrology Clinic, Dialysis and Renal Transplant Center, C. I. Parhon University Hospital, 700503 Iasi, Romania
- Department of Internal Medicine, 'Grigore T. Popa' University of Medicine, 700115 Iasi, Romania
| | - Andreea Simona Covic
- Nephrology Clinic, Dialysis and Renal Transplant Center, C. I. Parhon University Hospital, 700503 Iasi, Romania
- Department of Internal Medicine, 'Grigore T. Popa' University of Medicine, 700115 Iasi, Romania
| | - Cristina Alexandra Ipate
- Nephrology Clinic, Dialysis and Renal Transplant Center, C. I. Parhon University Hospital, 700503 Iasi, Romania
| | - Adelina Miron
- Nephrology Clinic, Dialysis and Renal Transplant Center, C. I. Parhon University Hospital, 700503 Iasi, Romania
- Department of Internal Medicine, 'Grigore T. Popa' University of Medicine, 700115 Iasi, Romania
| | - Corneliu Morosanu
- Nephrology Clinic, Dialysis and Renal Transplant Center, C. I. Parhon University Hospital, 700503 Iasi, Romania
| | - Irina-Draga Caruntu
- Department of Internal Medicine, 'Grigore T. Popa' University of Medicine, 700115 Iasi, Romania
| | - Adrian Covic
- Nephrology Clinic, Dialysis and Renal Transplant Center, C. I. Parhon University Hospital, 700503 Iasi, Romania
- Department of Internal Medicine, 'Grigore T. Popa' University of Medicine, 700115 Iasi, Romania
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2
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Ferro CJ, Townend JN. Risk for subsequent hypertension and cardiovascular disease after living kidney donation: is it clinically relevant? Clin Kidney J 2021; 15:644-656. [PMID: 35371443 PMCID: PMC8967677 DOI: 10.1093/ckj/sfab271] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Indexed: 11/17/2022] Open
Abstract
The first successful live donor kidney transplant was performed in 1954. Receiving a kidney transplant from a live kidney donor remains the best option for increasing both life expectancy and quality of life in patients with end-stage kidney disease. However, ever since 1954, there have been multiple questions raised on the ethics of live kidney donation in terms of negative impacts on donor life expectancy. Given the close relationship between reduced kidney function in patients with chronic kidney disease (CKD) and hypertension, cardiovascular disease and cardiovascular mortality, information on the impact of kidney donation on these is particularly relevant. In this article, we review the existing evidence, focusing on the more recent studies on the impact of kidney donation on all-cause mortality, cardiovascular mortality, cardiovascular disease and hypertension, as well as markers of cardiovascular damage including arterial stiffness and uraemic cardiomyopathy. We also discuss the similarities and differences between the pathological reduction in renal function that occurs in CKD, and the reduction in renal function that occurs because of a donor nephrectomy. Kidney donors perform an altruistic act that benefits individual patients as well as the wider society. They deserve to have high-quality evidence on which to make informed decisions.
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Affiliation(s)
- Charles J Ferro
- Institute of Cardiovascular Sciences, University of Birmingham, UK
- Department of Renal Medicine, Queen Elizabeth Hospital, Birmingham, UK
| | - Jonathan N Townend
- Institute of Cardiovascular Sciences, University of Birmingham, UK
- Department of Cardiology, Queen Elizabeth Hospital, Birmingham, UK
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3
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Rodriguez RA, Trentin Sonoda M, Agharazii M, Shorr R, Burns KD. Effects of living kidney donation on arterial stiffness: a systematic review protocol. BMJ Open 2021; 11:e045518. [PMID: 34006035 PMCID: PMC7942241 DOI: 10.1136/bmjopen-2020-045518] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 02/06/2021] [Accepted: 02/17/2021] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Kidney donors have been reported to have accelerated progression of aortic stiffness and decreased glomerular filtration compared with healthy non-donors. This is a concern because increased aortic stiffness is an independent predictor of overall cardiovascular disease and all-cause mortality in the general population. To confirm if arterial stiffness increases after donation, we will systematically review all studies that evaluated indices of arterial stiffness in healthy individuals who underwent unilateral nephrectomy for kidney donation compared with age-matched healthy non-nephrectomised controls. METHODS/ANALYSIS We will comprehensively search for studies published between 1 January 1960 and 15 March 2021 in MEDLINE, EMBASE, Cochrane Central, OVID and EBM reviews. All prospective (cohort, case-control, case series and before-and-after studies) and retrospective non-randomised studies reporting indices of arterial stiffness in nephrectomised and non-nephrectomised healthy participants will be included. Primary outcome will be the difference in the functional metrics of arterial stiffness between donors and non-donors. Secondary outcomes will be the differences in systolic/diastolic blood pressures, serum creatinine, glomerular filtration, carotid artery intima-media thickness and vascular calcification. Study screening, selection and data extraction will be performed by two independent reviewers. Risk of bias will be independently assessed with the ROBINS-I tool and confidence in evidence by the Grading of Recommendations Assessment, Development and Evaluation recommendations. Qualitative and quantitative data syntheses as well as clinical and statistical heterogeneity (Forest plots, I2 and Cochran's Q statistics) will be evaluated. If clinical and statistical heterogeneity are acceptable, inverse variance-weighted effects will be analysed by random effect models. ETHICS AND DISSEMINATION No ethical approval is necessary. Our results will be disseminated through peer-review publication and presentations to guide stakeholders on the evaluation and follow-up care of kidney donors. PROSPERO REGISTRATION NUMBER CRD42020185551.
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Affiliation(s)
- Rosendo A Rodriguez
- Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Mayra Trentin Sonoda
- Division of Nephrology, Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Mohsen Agharazii
- Division of Nephrology, CHU de Québec-Université Laval Research Centre, Quebec City, Québec, Canada
| | - Risa Shorr
- Learning Services, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Kevin D Burns
- Division of Nephrology, Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
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4
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Wilson S, Mone P, Jankauskas SS, Gambardella J, Santulli G. Chronic kidney disease: Definition, updated epidemiology, staging, and mechanisms of increased cardiovascular risk. J Clin Hypertens (Greenwich) 2021; 23:831-834. [PMID: 33455061 PMCID: PMC8035205 DOI: 10.1111/jch.14186] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 12/29/2020] [Accepted: 12/30/2020] [Indexed: 12/16/2022]
Affiliation(s)
- Scott Wilson
- Department of Medicine, Wilf Family Cardiovascular Research Institute, Einstein Institute for Aging Research, Albert Einstein College of Medicine, New York, NY, USA.,Department of Molecular Pharmacology, Einstein-Mount Sinai Diabetes Research Center (ES-DRC), Fleischer Institute for Diabetes and Metabolism (FIDAM), Albert Einstein College of Medicine, New York, NY, USA
| | - Pasquale Mone
- University of Campania "Luigi Vanvitelli", Naples, Italy.,ASL Avellino, Avellino, Italy
| | - Stanislovas S Jankauskas
- Department of Medicine, Wilf Family Cardiovascular Research Institute, Einstein Institute for Aging Research, Albert Einstein College of Medicine, New York, NY, USA.,Department of Molecular Pharmacology, Einstein-Mount Sinai Diabetes Research Center (ES-DRC), Fleischer Institute for Diabetes and Metabolism (FIDAM), Albert Einstein College of Medicine, New York, NY, USA
| | - Jessica Gambardella
- Department of Medicine, Wilf Family Cardiovascular Research Institute, Einstein Institute for Aging Research, Albert Einstein College of Medicine, New York, NY, USA.,Department of Molecular Pharmacology, Einstein-Mount Sinai Diabetes Research Center (ES-DRC), Fleischer Institute for Diabetes and Metabolism (FIDAM), Albert Einstein College of Medicine, New York, NY, USA.,Department of Advanced Biomedical Science, International Translational Research and Medical Education Consortium (ITME), "Federico II" University, Naples, Italy
| | - Gaetano Santulli
- Department of Medicine, Wilf Family Cardiovascular Research Institute, Einstein Institute for Aging Research, Albert Einstein College of Medicine, New York, NY, USA.,Department of Molecular Pharmacology, Einstein-Mount Sinai Diabetes Research Center (ES-DRC), Fleischer Institute for Diabetes and Metabolism (FIDAM), Albert Einstein College of Medicine, New York, NY, USA.,Department of Advanced Biomedical Science, International Translational Research and Medical Education Consortium (ITME), "Federico II" University, Naples, Italy
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5
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Price AM, Greenhall GHB, Moody WE, Steeds RP, Mark PB, Edwards NC, Hayer MK, Pickup LC, Radhakrishnan A, Law JP, Banerjee D, Campbell T, Tomson CRV, Cockcroft JR, Shrestha B, Wilkinson IB, Tomlinson LA, Ferro CJ, Townend JN. Changes in Blood Pressure and Arterial Hemodynamics following Living Kidney Donation. Clin J Am Soc Nephrol 2020; 15:1330-1339. [PMID: 32843374 PMCID: PMC7480552 DOI: 10.2215/cjn.15651219] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 06/19/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND OBJECTIVES The Effect of a Reduction in GFR after Nephrectomy on Arterial Stiffness and Central Hemodynamics (EARNEST) study was a multicenter, prospective, controlled study designed to investigate the associations of an isolated reduction in kidney function on BP and arterial hemodynamics. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Prospective living kidney donors and healthy controls who fulfilled criteria for donation were recruited from centers with expertise in vascular research. Participants underwent office and ambulatory BP measurement, assessment of arterial stiffness, and biochemical tests at baseline and 12 months. RESULTS A total of 469 participants were recruited, and 306 (168 donors and 138 controls) were followed up at 12 months. In the donor group, mean eGFR was 27 ml/min per 1.73 m2 lower than baseline at 12 months. Compared with baseline, at 12 months the mean within-group difference in ambulatory day systolic BP in donors was 0.1 mm Hg (95% confidence interval, -1.7 to 1.9) and 0.6 mm Hg (95% confidence interval, -0.7 to 2.0) in controls. The between-group difference was -0.5 mm Hg (95% confidence interval, -2.8 to 1.7; P=0.62). The mean within-group difference in pulse wave velocity in donors was 0.3 m/s (95% confidence interval, 0.1 to 0.4) and 0.2 m/s (95% confidence interval, -0.0 to 0.4) in controls. The between-group difference was 0.1 m/s (95% confidence interval, -0.2 to 0.3; P=0.49). CONCLUSIONS Changes in ambulatory peripheral BP and pulse wave velocity in kidney donors at 12 months after nephrectomy were small and not different from controls. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER NCT01769924 (https://clinicaltrials.gov/ct2/show/NCT01769924).
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Affiliation(s)
- Anna M Price
- Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom .,Department of Nephrology, University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, United Kingdom
| | | | - William E Moody
- Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom.,Department of Cardiology, University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, United Kingdom
| | - Richard P Steeds
- Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom.,Department of Cardiology, University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, United Kingdom
| | - Patrick B Mark
- British Heart Foundation Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Nicola C Edwards
- Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom.,Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
| | - Manvir K Hayer
- Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom.,Department of Nephrology, University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, United Kingdom
| | - Luke C Pickup
- Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom.,Department of Cardiology, University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, United Kingdom
| | - Ashwin Radhakrishnan
- Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom.,Department of Cardiology, University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, United Kingdom
| | - Jonathan P Law
- Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom.,Department of Nephrology, University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, United Kingdom
| | - Debasish Banerjee
- Renal and Transplantation Unit, St George's University Hospitals National Health Service Foundation Trust, London, United Kingdom
| | | | | | - John R Cockcroft
- Department of Cardiology, Wales Heart Research Institute, University Hospital, Cardiff, United Kingdom
| | - Badri Shrestha
- Sheffield Kidney Institute, Sheffield Teaching Hospitals National Health Service Foundation Trust, Sheffield, United Kingdom
| | - Ian B Wilkinson
- Cambridge Clinical Trials Unit, Clinical School, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | | | - Charles J Ferro
- Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom.,Department of Nephrology, University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, United Kingdom
| | - Jonathan N Townend
- Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom.,Department of Cardiology, University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, United Kingdom
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6
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Affiliation(s)
- Aldo J Peixoto
- Section of Nephrology, Yale School of Medicine, New Haven, Connecticut, and Hypertension Program, Yale New Haven Hospital Heart and Vascular Center, New Haven, Connecticut
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7
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Arterial Stiffness Assessed by Oscillometric Method in Kidney Transplant, Predialysis, and Dialysis Patients. Transplant Proc 2020; 52:2337-2340. [PMID: 32359829 DOI: 10.1016/j.transproceed.2020.01.132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 01/26/2020] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Chronic kidney disease (CKD) is strongly associated with a higher risk of cardiovascular disease (CV). An important nontraditional risk factor of cardiovascular disease in renal patients is vascular stiffness, which currently can be evaluated by oscillometric measuring of pulse wave velocity (PWV) and heart rate-corrected augmentation index (AIx@75). AIM The aim of our study was to compare vascular stiffness between kidney transplant (KTx) recipients, patients on dialysis maintenance, and those in the predialysis period. MATERIALS AND METHODS A cross-sectional study of 140 patients (52 in CKD stage 3-4; 37 in CKD stage 5 on hemodialysis maintenance [HD]; and 51 KTx recipients) had their PWV and AIx@75 measured with Mobil-O-Graph (IEM Gmbh, Stolberg, Germany) blood and pulse pressure monitor. RESULTS KTx, HD, and CKD G3-4 were comparable in term of age, sex, body mass index, and diagnoses of diabetes mellitus and hypertension. The PWV was higher in the HD group than in the KTx and CKD G3-4 (9.4 m/s vs 8.4 m/s vs 7.9 m/s respectively; P < .05 for HD vs other groups), while the difference between the KTx and CKD G3-4 was not significant. AIx@75 values were similar in the HD and KTx groups (27.1 and 25.6; P > .05) and significantly lower in CDK G3-4 (17.8; P < .05). CONCLUSIONS According to our results, the highest CV risk expressed by PWV (vascular stiffness) was found in hemodialysis patients. Although patients with CKD 3-4 and after KTx showed comparable large artery stiffness, transplant recipients additionally showed higher stiffness in smaller arteries as measured by heart rate-corrected AIx.
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8
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Dahle DO, Mjoen G. The Salutary Blood Pressure of a Solitary Kidney. Am J Hypertens 2020; 33:218-219. [PMID: 31907513 PMCID: PMC7285306 DOI: 10.1093/ajh/hpaa004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 01/06/2020] [Indexed: 11/22/2022] Open
Affiliation(s)
- Dag Olav Dahle
- Department of Transplant Medicine, Oslo University Hospital, Oslo, Norway
| | - Geir Mjoen
- Department of Transplant Medicine, Oslo University Hospital, Oslo, Norway
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9
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Mansour AG, Ahdab R, Daaboul Y, Korjian S, Morrison DA, Hariri E, Salem M, El Khoury C, Riachi N, Aoun Bahous S. Vitamin K2 Status and Arterial Stiffness Among Untreated Migraine Patients: A Case-Control Study. Headache 2020; 60:589-599. [PMID: 31769041 DOI: 10.1111/head.13715] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2019] [Indexed: 12/17/2022]
Abstract
OBJECTIVE We aimed to examine arterial stiffness and vitamin K2 status in migraine subjects by comparison to controls. BACKGROUND Migraine is a primary headache disorder that has been associated with an increased risk of cardiovascular events. Mechanisms underlying this increased risk, however, remain unclear. Vitamin K2 deficiency emerged as a cardiovascular risk factor, but vitamin K2 status has never been explored in migraine subjects. DESIGN AND METHODS This is a case-control, single-center, observational study that includes a cohort of subjects with migraine and their age- and sex-matched controls. Arterial stiffness was measured using carotid-femoral pulse wave velocity (cfPWV). Dephosphorylated-uncarboxylated matrix-Gla-protein (dp-ucMGP) was used as a marker for vitamin K2 status. A propensity-matched scoring method was used. RESULTS A total of 146 patients (73 matched pairs) were included in this study, of whom 89% were women with a mean age of 31.9 ± 8.4 years. Compared with controls, migraine patients had statistically significantly higher mean cfPWV (7.2 ± 1.1 vs 6.4 ± 0.8 m/s, 95% confidence interval (CI) of mean difference [0.45, 1.08], P < .001), as well as higher dp-ucMGP (454.3 ± 116.7 pmol/L vs 379.8 ± 126.6 pmol/L, 95% CI of mean difference [34.63, 114.31], P < .001). Higher cfPWV was associated with higher dp-ucMGP concentrations only in the migraine with aura (MWA) group. Moreover, migraine subjects had a higher frequency of vitamin K2 deficiency (dp-ucMGP ≥ 500 pmol/L) compared to controls, but this association was not statistically significant (23/73 [31.5%] vs 16/73 [21.9%], P = .193). CONCLUSIONS Individuals with migraine have worse indices of arterial stiffness as compared with their age- and sex-matched control subjects. This increase in arterial stiffness is associated with an increase in markers of vitamin K2 deficiency in the MWA group.
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Affiliation(s)
- Anthony G Mansour
- Division of Neurology, Department of Medicine, Lebanese American University School of Medicine, Byblos-Jbeil, Lebanon
- Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
| | - Rechdi Ahdab
- Division of Neurology, Department of Medicine, Lebanese American University School of Medicine, Byblos-Jbeil, Lebanon
- Division of Neurology, Hamidi Medical Center, Tripoli, Lebanon
| | | | - Serge Korjian
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Essa Hariri
- Department of Medicine, Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Maher Salem
- Gilbert and Rose-Marie Chagoury School of Medicine, Lebanese American University, Byblos-Jbeil, Lebanon
| | - Christelle El Khoury
- Gilbert and Rose-Marie Chagoury School of Medicine, Lebanese American University, Byblos-Jbeil, Lebanon
| | - Naji Riachi
- Division of Neurology, Department of Medicine, Lebanese American University School of Medicine, Byblos-Jbeil, Lebanon
- Division of Neurology, Hamidi Medical Center, Tripoli, Lebanon
| | - Sola Aoun Bahous
- Gilbert and Rose-Marie Chagoury School of Medicine, Lebanese American University, Byblos-Jbeil, Lebanon
- Division of Nephrology, Department of Medicine, Lebanese American University Medical Center - Rizk Hospital, Beirut, Lebanon
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10
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Korogiannou M, Xagas E, Marinaki S, Sarafidis P, Boletis JN. Arterial Stiffness in Patients With Renal Transplantation; Associations With Co-morbid Conditions, Evolution, and Prognostic Importance for Cardiovascular and Renal Outcomes. Front Cardiovasc Med 2019; 6:67. [PMID: 31179288 PMCID: PMC6543273 DOI: 10.3389/fcvm.2019.00067] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 05/07/2019] [Indexed: 12/12/2022] Open
Abstract
Patients with chronic kidney disease (CKD), particularly those with end-stage renal disease (ESRD), are at increased risk of cardiovascular events and mortality. The spectrum of arterial remodeling in CKD and ESRD includes atheromatosis of middle-sized conduit arteries and, most importantly, the process of arteriosclerosis, characterized by increased arterial stiffness of aorta and the large arteries. Longitudinal studies showed that arterial stiffness and abnormal wave reflections are independent cardiovascular risk factors in several populations, including patients with CKD and ESRD. Kidney transplantation is the treatment of choice for patients with ESRD, associated with improved survival and better quality of life in relation to hemodialysis or peritoneal dialysis. However, cardiovascular mortality in transplanted patients remains much higher than that in general population, a finding that is at least partly attributed to adverse lesions in the vascular tree of these patients, generated during the progression of CKD, which do not fully reverse after renal transplantation. This article attempts to provide an overview of the field of arterial stiffness in renal transplantation, discussing in detail available studies on the degree and the associations of arterial stiffness with other co-morbidities in renal transplant recipients, the prognostic significance of arterial stiffness for cardiovascular events, renal events and mortality in these individuals, as well as studies examining the changes in arterial stiffness following renal transplantation.
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Affiliation(s)
- Maria Korogiannou
- Department of Nephrology and Renal Transplantation Unit, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Efstathios Xagas
- Department of Nephrology and Renal Transplantation Unit, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Smaragdi Marinaki
- Department of Nephrology and Renal Transplantation Unit, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - John N Boletis
- Department of Nephrology and Renal Transplantation Unit, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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11
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Price AM, Edwards NC, Hayer MK, Moody WE, Steeds RP, Ferro CJ, Townend JN. Chronic kidney disease as a cardiovascular risk factor: lessons from kidney donors. ACTA ACUST UNITED AC 2018; 12:497-505.e4. [PMID: 29792262 PMCID: PMC6026388 DOI: 10.1016/j.jash.2018.04.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Revised: 03/28/2018] [Accepted: 04/25/2018] [Indexed: 12/22/2022]
Abstract
Chronic kidney disease (CKD) is a major risk factor for cardiovascular disease but is often associated with other risks such as diabetes and hypertension and can be both a cause and an effect of cardiovascular disease. Although epidemiologic data of an independent association of reduced glomerular filtration rate with cardiovascular risk are strong, causative mechanisms are unclear. Living kidney donors provide a useful model for assessing the “pure” effects of reduced kidney function on the cardiovascular system. After nephrectomy, the glomerular filtration rate ultimately falls by about one-third so many can be classified as having chronic kidney disease stages 2 or 3. This prompts concern based on the data showing an elevated cardiovascular risk with these stages of chronic kidney disease. However, initial data suggested no increase in adverse cardiovascular effects compared with control populations. Recent reports have shown a possible late increase in cardiovascular event rates and an early increase in left ventricular mass and markers of risk such as urate and albuminuria. The long-term significance of these small changes is unknown. More detailed and long-term research is needed to determine the natural history of these changes and their clinical significance. Subjects with chronic kidney disease (CKD) have an elevated risk of cardiovascular disease. Kidney donors have a reduced glomerular filtration rate and biochemical changes similar to CKD subjects. Most studies of donors have not shown an elevated risk of death or cardiac disease. Donors have structural and functional cardiovascular changes similar to early CKD. The clinical significance of these changes is currently unknown.
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Affiliation(s)
- Anna M Price
- Birmingham Cardio-Renal Group (University of Birmingham, Institute of Cardiovascular Sciences), Queen Elizabeth Hospital, Edgbaston, Birmingham, United Kingdom.
| | - Nicola C Edwards
- Birmingham Cardio-Renal Group (University of Birmingham, Institute of Cardiovascular Sciences), Queen Elizabeth Hospital, Edgbaston, Birmingham, United Kingdom
| | - Manvir K Hayer
- Birmingham Cardio-Renal Group (University of Birmingham, Institute of Cardiovascular Sciences), Queen Elizabeth Hospital, Edgbaston, Birmingham, United Kingdom
| | - William E Moody
- Birmingham Cardio-Renal Group (University of Birmingham, Institute of Cardiovascular Sciences), Queen Elizabeth Hospital, Edgbaston, Birmingham, United Kingdom
| | - Richard P Steeds
- Birmingham Cardio-Renal Group (University of Birmingham, Institute of Cardiovascular Sciences), Queen Elizabeth Hospital, Edgbaston, Birmingham, United Kingdom
| | - Charles J Ferro
- Birmingham Cardio-Renal Group (University of Birmingham, Institute of Cardiovascular Sciences), Queen Elizabeth Hospital, Edgbaston, Birmingham, United Kingdom
| | - Jonathan N Townend
- Birmingham Cardio-Renal Group (University of Birmingham, Institute of Cardiovascular Sciences), Queen Elizabeth Hospital, Edgbaston, Birmingham, United Kingdom
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12
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Henderson ML, Thomas AG, Shaffer A, Massie AB, Luo X, Holscher CM, Purnell TS, Lentine KL, Segev DL. The National Landscape of Living Kidney Donor Follow-Up in the United States. Am J Transplant 2017; 17:3131-3140. [PMID: 28510355 PMCID: PMC5690895 DOI: 10.1111/ajt.14356] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 04/28/2017] [Accepted: 05/04/2017] [Indexed: 01/25/2023]
Abstract
In 2013, the Organ Procurement and Transplantation Network (OPTN)/ United Network for Organ Sharing (UNOS) mandated that transplant centers collect data on living kidney donors (LKDs) at 6 months, 1 year, and 2 years postdonation, with policy-defined thresholds for the proportion of complete living donor follow-up (LDF) data submitted in a timely manner (60 days before or after the expected visit date). While mandated, it was unclear how centers across the country would perform in meeting thresholds, given potential donor and center-level challenges of LDF. To better understand the impact of this policy, we studied Scientific Registry of Transplant Recipients data for 31,615 LKDs between January 2010 and June 2015, comparing proportions of complete and timely LDF form submissions before and after policy implementation. We also used multilevel logistic regression to assess donor- and center-level characteristics associated with complete and timely LDF submissions. Complete and timely 2-year LDF increased from 33% prepolicy (January 2010 through January 2013) to 54% postpolicy (February 2013 through June 2015) (p < 0.001). In an adjusted model, the odds of 2-year LDF increased by 22% per year prepolicy (p < 0.001) and 23% per year postpolicy (p < 0.001). Despite these annual increases in LDF, only 43% (87/202) of centers met the OPTN/UNOS-required 6-month, 1-year, and 2-year LDF thresholds for LKDs who donated in 2013. These findings motivate further evaluation of LDF barriers and the optimal approaches to capturing outcomes after living donation.
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Affiliation(s)
- M L Henderson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - A G Thomas
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - A Shaffer
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - A B Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - X Luo
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - C M Holscher
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - T S Purnell
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - K L Lentine
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, MO
| | - D L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
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Mansour AG, Hariri E, Daaboul Y, Korjian S, El Alam A, Protogerou AD, Kilany H, Karam A, Stephan A, Bahous SA. Vitamin K2 supplementation and arterial stiffness among renal transplant recipients-a single-arm, single-center clinical trial. JOURNAL OF THE AMERICAN SOCIETY OF HYPERTENSION : JASH 2017; 11:589-597. [PMID: 28756183 DOI: 10.1016/j.jash.2017.07.001] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 06/26/2017] [Accepted: 07/08/2017] [Indexed: 01/07/2023]
Abstract
Subclinical vitamin K deficiency is prevalent among renal transplant recipients and is associated with an increased risk of cardiovascular disease. However, the association between vitamin K supplementation and improvement of arterial stiffness has not been explored in the renal transplant population. The KING trial (vitamin K2 In reNal Graft) is a single-arm study that evaluated the association between the change in vitamin K status and indices of arterial stiffness following 8 weeks of menaquinone-7 (vitamin K2) supplementation (360 μg once daily) among renal transplant recipients (n = 60). Arterial stiffness was measured using carotid-femoral pulse wave velocity (cfPWV). Subclinical vitamin K deficiency was defined as plasma concentration of dephosphorylated-uncarboxylated matrix Gla protein (dp-ucMGP) >500 pmol/L.At baseline, 53.3% of the study subjects had subclinical vitamin K deficiency. Supplementation was associated with a 14.2% reduction in mean cfPWV at 8 weeks (cfPWV pre-vitamin K2 = 9.8 ± 2.2 m/s vs. cfPWV post-vitamin K2 = 8.4 ± 1.5 m/s; P < .001). Mean dp-ucMGP concentrations were also significantly reduced by 55.1% following menaquinone-7 supplementation with a reduction in the prevalence of subclinical deficiency by 40% (P = .001). When controlled for age, durations of hemodialysis and transplantation, and the change in 24-hour mean arterial pressure, the improvement in arterial stiffness was independently associated with the reduction in dp-ucMGP concentration (P = .014).Among renal transplant recipients with stable graft function, vitamin K2 supplementation was associated with improvement in subclinical vitamin K deficiency and arterial stiffness. (Clinicaltrials.gov: NCT02517580).
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Affiliation(s)
| | - Essa Hariri
- Lebanese American University School of Medicine, Byblos, Lebanon
| | - Yazan Daaboul
- Department of Medicine, Tufts Medical Center, Tufts University School of Medicine, Boston, USA
| | - Serge Korjian
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Andrew El Alam
- Lebanese American University School of Medicine, Byblos, Lebanon
| | - Athanase D Protogerou
- Cardiovascular Prevention and Research Unit, Department of Pathophysiology, "Laiko" Hospital, Medical School, National & Kapodistrian University of Athens, Athens, Greece
| | - Hala Kilany
- Lebanese American University School of Medicine, Byblos, Lebanon; Division of Nephrology and Transplantation, Department of Medicine, Lebanese American University Medical Center-Rizk Hospital, Beirut, Lebanon
| | - Albert Karam
- Lebanese American University School of Medicine, Byblos, Lebanon; Division of Nephrology and Transplantation, Department of Medicine, Lebanese American University Medical Center-Rizk Hospital, Beirut, Lebanon
| | - Antoine Stephan
- Lebanese American University School of Medicine, Byblos, Lebanon; Division of Nephrology and Transplantation, Department of Medicine, Lebanese American University Medical Center-Rizk Hospital, Beirut, Lebanon
| | - Sola Aoun Bahous
- Lebanese American University School of Medicine, Byblos, Lebanon; Division of Nephrology and Transplantation, Department of Medicine, Lebanese American University Medical Center-Rizk Hospital, Beirut, Lebanon.
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Choi JW, Kim GS, Lee SW, Park JB, Lee JJ, Ko JS. Preoperative ultrasonographic findings of internal jugular veins and carotid arteries in kidney transplant recipients. Korean J Anesthesiol 2016; 69:375-81. [PMID: 27482315 PMCID: PMC4967633 DOI: 10.4097/kjae.2016.69.4.375] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 04/05/2016] [Accepted: 04/18/2016] [Indexed: 11/10/2022] Open
Abstract
Background Hemodialysis via the internal jugular vein (IJV) has been widely used for patients with end stage renal disease (ESRD) patients, as they have a higher risk of arterial diseases. We investigated the ultrasonographic findings of the IJV and carotid artery (CA) in recipients of kidney transplantation (KT) and identified factors influencing IJV/CA abnormalities. Methods We enrolled 120 adult KT recipients. Patients in group A (n = 57) had a history of IJV hemodialysis, while those in group B (n = 63) were not yet on dialysis or undergoing dialysis methods not involving the IJV. The day before surgery, we evaluated the state of the IJV and CA using ultrasonography. We followed patients with IJV stenosis for six months after KT. Results Ultrasonography revealed that four patients (7%) in group A had IJV abnormalities, while no patients in group B had abnormalities (P = 0.118). Of the four patients with abnormalities, one with 57.4% stenosis normalized during follow- up. However, another patient with 90.1% stenosis progressed to occlusion, while the two patients with total occlusion remained the same. Twenty patients in group A (n = 11) and B (n = 9) had several CA abnormalities (P = 0.462). Upon multivariate analysis with stepwise selection, height and age were significantly correlated with IJV stenosis (P = 0.043, odds ratio = 0.9) and CA abnormality (P = 0.012, odds ratio = 1.1), respectively. Conclusions IJV abnormalities (especially with a history of IJV hemodialysis) and CA abnormalities may be present in ESRD patients. Therefore, we recommend ultrasonographic evaluation before catheterization.
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Affiliation(s)
- Ji Won Choi
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Gaab Soo Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Won Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Bo Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Jin Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Justin Sangwook Ko
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Thomas B, Weir MR. The Evaluation and Therapeutic Management of Hypertension in the Transplant Patient. Curr Cardiol Rep 2015; 17:95. [DOI: 10.1007/s11886-015-0647-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Safar ME, Plante GE, Mimran A. Arterial stiffness, pulse pressure, and the kidney. Am J Hypertens 2015; 28:561-9. [PMID: 25480804 DOI: 10.1093/ajh/hpu206] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Accepted: 09/26/2014] [Indexed: 12/17/2022] Open
Abstract
Classical studies indicate that the contribution of kidneys to hypertension is almost exclusively related to the association between mean arterial pressure (MAP) and vascular resistance. Recent reports including estimates of glomerular filtration rate (GFR) have shown that pulse pressure (PP) and pulse wave velocity, 2 major indices of arterial stiffness, now emerge as significant predictors of cardiovascular risk and age-associated decline in GFR. Such findings are mainly observed in patients with hypertension and renal failure and in atherosclerotic subjects undergoing coronary angiography. In such patients, amplification of PP between ascending and terminal aorta at the renal site is constantly increased over 10mm Hg (P < 0.001), whereas MAP level remains continuously unmodified. This PP amplification is significantly associated with presence of proteinuria. Furthermore, increases in plasma creatinine and aortic stiffness are independently and positively correlated (P < 0.001) both in cross-sectional and longitudinal studies. All these relationships associating PP, arterial stiffness, and renal function are mainly observed in patients 60 years of age or older. Furthermore, in renal transplant patients and their donors, subjects have been recruited for evaluations of arterial stiffness and posttransplant decline in GFR. Determinants of GFR decline were evaluated 1 and 9 years after transplantation. The first year GFR decline was related to smoking and acute rejection, whereas the later was significantly and exclusively associated with donor age and aortic stiffness. Thus, in hypertensive humans, the observed association between PP and GFR suggests that the 2 parameters are substantially mediated by arterial stiffness, not exclusively by vascular resistance.
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Affiliation(s)
- Michel E Safar
- Faculty of Medicine, Paris Descartes University, Hôtel-Dieu Hospital, AP-HP, Diagnosis and Therapeutic Center, Paris, France;
| | | | - Albert Mimran
- Department of Internal Medicine, Lapeyronie Hospital, CHU Montpellier, Montpellier, France
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Bahous SA, Khairallah M, Al Danaf J, Halaby R, Korjian S, Daaboul Y, Salameh P, Stephan A, Blacher J, Safar ME. Renal function decline in recipients and donors of kidney grafts: role of aortic stiffness. Am J Nephrol 2015; 41:57-65. [PMID: 25662778 DOI: 10.1159/000371858] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2014] [Accepted: 12/28/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS Renal function decreases over time as a result of reduction in the number of functioning nephrons with age. In recipients and donors of kidney grafts, renal function decline may be linked differently to various parameters, namely arterial stiffness. METHODS We conducted a prospective cohort study including 101 recipients of kidney grafts and their donors aiming at determining the factors correlated to the renal function decline over time. Aortic stiffness was evaluated by the non-invasive measurement of aortic pulse wave velocity. The glomerular filtration rate was estimated using the Modification of Diet in Renal Disease (MDRD) equation and the annualized change was determined. RESULTS Decline in renal function was estimated at 1-year post-transplantation and annually thereafter (median follow-up 8 years, range 3.6-18.3), as the mean of the annualized decrease in the glomerular filtration rate. In recipients, filtration rate decreased by 4.8 ± 19.7 ml/min/1.73 m(2) the first post-transplant year and at a yearly rate of 2.2 ± 3.8 ml/min/1.73 m(2) thereafter. The first-year decline was related to smoking and acute rejection. Later decline was significantly associated with donor age and aortic stiffness. In living donors, renal function decline after the first year corresponded to 0.7 ml/min/1.73 m(2), was significantly lower than that of recipients (p < 0.001), and was determined by donor age at nephrectomy. CONCLUSION Recipients of kidney grafts show a glomerular filtration rate decline over time that is significantly associated with donor age and aortic stiffness after the first post-transplant year, while donors demonstrate a lower decline that is mostly determined by age at nephrectomy.
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Affiliation(s)
- Sola Aoun Bahous
- Division of Nephrology and Renal Transplantation, University Medical Center-Rizk Hospital, Ashrafieh, Beirut, Lebanon
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Lentine KL, Brennan DC. Transplantation: The relevance of the FAVORIT blood pressure associations. Nat Rev Nephrol 2014; 10:366-7. [PMID: 24802067 DOI: 10.1038/nrneph.2014.79] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Krista L Lentine
- Center for Outcomes Research and Department of Medicine, Saint Louis University School of Medicine, 3545 Lafayette Avenue, St Louis, MO 63104, USA
| | - Daniel C Brennan
- Transplant Nephrology, Department of Medicine, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8126, St Louis, MO 63110, USA
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Thomas B, Taber DJ, Srinivas TR. Hypertension after kidney transplantation: a pathophysiologic approach. Curr Hypertens Rep 2014; 15:458-69. [PMID: 23933793 DOI: 10.1007/s11906-013-0381-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Post-transplant hypertension is associated with decreased graft and patient survival and cardiovascular morbidity. Unfortunately, post-transplant hypertension is often poorly controlled. Important risk factors include immunosuppressive medications, complications of the transplant surgery, delayed graft function, rejection, and donor and recipient risk factors. The effects of immunosuppressive medications are multifactorial including increased vascular and sympathetic tone and salt and fluid retention. The immunosuppressive agents most commonly associated with hypertension are glucocorticoids and calcineurin inhibitors. Drug therapy for hypertension should be based on the comorbidities and pathophysiology. Evidence-based approaches to defining and treating hypertension in renal transplant recipients are predominantly extrapolated from large-scale studies performed in the general population. Thus, there continues to be a need for larger studies examining the pathophysiology, diagnosis and treatment of hypertension in renal transplant recipients.
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Affiliation(s)
- Beje Thomas
- Division of Nephrology, Medical University of South Carolina, 96 Jonathan Lucas Street CSB 829, Charleston, SC, 29425, USA,
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Moody WE, Tomlinson LA, Ferro CJ, Steeds RP, Mark PB, Zehnder D, Tomson CR, Cockcroft JR, Wilkinson IB, Townend JN. Effect of A Reduction in glomerular filtration rate after NEphrectomy on arterial STiffness and central hemodynamics: rationale and design of the EARNEST study. Am Heart J 2014; 167:141-149.e2. [PMID: 24439974 PMCID: PMC3904213 DOI: 10.1016/j.ahj.2013.10.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Accepted: 10/28/2013] [Indexed: 01/05/2023]
Abstract
Background There is strong evidence of an association between chronic kidney disease (CKD) and cardiovascular disease. To date, however, proof that a reduction in glomerular filtration rate (GFR) is a causative factor in cardiovascular disease is lacking. Kidney donors comprise a highly screened population without risk factors such as diabetes and inflammation, which invariably confound the association between CKD and cardiovascular disease. There is strong evidence that increased arterial stiffness and left ventricular hypertrophy and fibrosis, rather than atherosclerotic disease, mediate the adverse cardiovascular effects of CKD. The expanding practice of live kidney donation provides a unique opportunity to study the cardiovascular effects of an isolated reduction in GFR in a prospective fashion. At the same time, the proposed study will address ongoing safety concerns that persist because most longitudinal outcome studies have been undertaken at single centers and compared donor cohorts with an inappropriately selected control group. Hypotheses The reduction in GFR accompanying uninephrectomy causes (1) a pressure-independent increase in aortic stiffness (aortic pulse wave velocity) and (2) an increase in peripheral and central blood pressure. Methods This is a prospective, multicenter, longitudinal, parallel group study of 440 living kidney donors and 440 healthy controls. All controls will be eligible for living kidney donation using current UK transplant criteria. Investigations will be performed at baseline and repeated at 12 months in the first instance. These include measurement of arterial stiffness using applanation tonometry to determine pulse wave velocity and pulse wave analysis, office blood pressure, 24-hour ambulatory blood pressure monitoring, and a series of biomarkers for cardiovascular and bone mineral disease. Conclusions These data will prove valuable by characterizing the direction of causality between cardiovascular and renal disease. This should help inform whether targeting reduced GFR alongside more traditional cardiovascular risk factors is warranted. In addition, this study will contribute important safety data on living kidney donors by providing a longitudinal assessment of well-validated surrogate markers of cardiovascular disease, namely, blood pressure and arterial stiffness. If any adverse effects are detected, these may be potentially reversed with the early introduction of targeted therapy. This should ensure that kidney donors do not come to long-term harm and thereby preserve the ongoing expansion of the living donor transplant program (NCT01769924).
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Affiliation(s)
- William E Moody
- Birmingham Cardio-Renal Group, Centre for Clinical Cardiovascular Science, Nuffield House, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Laurie A Tomlinson
- Cambridge Clinical Trials Unit, Clinical School, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Charles J Ferro
- Birmingham Cardio-Renal Group, Centre for Clinical Cardiovascular Science, Nuffield House, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Richard P Steeds
- Birmingham Cardio-Renal Group, Centre for Clinical Cardiovascular Science, Nuffield House, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Patrick B Mark
- BHF Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Daniel Zehnder
- Clinical Science Research Laboratory, University of Warwick, Coventry, United Kingdom
| | - Charles R Tomson
- Academic Renal Unit, Learning and Research, Southmead Hospital, Westbury-on-Trym, Bristol, United Kingdom
| | - John R Cockcroft
- Department of Cardiology, Wales Heart Research Institute, University Hospital, Cardiff, United Kingdom
| | - Ian B Wilkinson
- Cambridge Clinical Trials Unit, Clinical School, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Jonathan N Townend
- Birmingham Cardio-Renal Group, Centre for Clinical Cardiovascular Science, Nuffield House, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom.
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Abstract
Arterial hypertension is prevalent among kidney transplant recipients. The multifactorial pathogenesis involves the interaction of the donor and the recipient's genetic backgrounds with several environmental parameters that may precede or follow the transplant procedure (eg, the nature of the renal disease, the duration of the chronic kidney disease phase and maintenance dialytic therapy, the commonly associated cardiovascular disease with atherosclerosis and arteriosclerosis, the renal mass at implantation, the immunosuppressive regimen used, life of the graft, and de novo medical and surgical complications that may occur after a transplant). Among calcineurin inhibitors, tacrolimus seems to have a better cardiovascular profile. Steroid-free protocols and calcineurin inhibitor-free regimens seem to be associated with better blood pressure control. Posttransplant hypertension is a major amplifier of the chronic kidney disease-cardiovascular disease continuum. Despite the adverse effects of hypertension on graft and patient survival, blood pressure control remains poor because of the high cardiovascular risk profile of the donor-recipient pair. Although the optimal blood pressure level remains unknown, it is recommended to maintain the blood pressure at < 130/80 mm Hg and < 125/75 mm Hg in the absence or presence of proteinuria.
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Affiliation(s)
- Antoine Barbari
- Renal Transplantation Unit, Rafik Hariri University Hospital, Bir Hassan, Beirut-Lebanon.
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Safar ME, Nawar T, Plante GE. Large arteries and the kidney. ACTA ACUST UNITED AC 2012; 1:169-77. [PMID: 20409849 DOI: 10.1016/j.jash.2007.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2006] [Revised: 02/16/2007] [Accepted: 02/28/2007] [Indexed: 01/09/2023]
Abstract
In subjects with chronic renal disease, high systolic blood pressure (SBP) is the most modifiable cardiovascular (CV) risk factor that enables prevention of the progression of chronic kidney disease renal failure and the occurrence of CV events. Although large-artery stiffness and wave reflections are the principal hemodynamic determinants of SBP, their precise role in the progression of chronic renal disease has been poorly investigated. However, in subjects with mild to severe renal insufficiency, increased arterial stiffness and reduced creatinine clearance are closely related, independently of age; mean arterial pressure level; and presence of other traditional risk factors, including atherosclerotic plaques. Through inflammatory mechanisms, as well as through the development of arterial calcifications (including microscopic) and sodium-related alterations in extracellular matrix composition, arterial stiffness is associated with significant SBP and increased pulse pressure (PP). In the presence of renal dysfunction, frequently observed in elderly hypertensive or diabetic subjects, or even in some living donors, the resulting increase in PP may be transmitted toward and across glomeruli, even when peripheral blood pressure values are maintained. This alteration alone may initiate glomerulosclerosis and/or tubulointerstitial damage, eventually leading to CV events. In subjects with end-stage renal disease and high CV risk, pharmacological modulation of the renin-angiotensin system has been shown to prevent independently such complications.
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Affiliation(s)
- Michel E Safar
- Faculty of Medicine, Paris Descartes University, Paris, France; Diagnosis Center, Hôtel-Dieu Hospital (AP-HP), Paris, France
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DeLoach SS, Meyers KEC, Townsend RR. Living donor kidney donation: another form of white coat effect. Am J Nephrol 2011; 35:75-9. [PMID: 22189100 DOI: 10.1159/000335070] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Accepted: 11/11/2011] [Indexed: 01/13/2023]
Abstract
BACKGROUND/AIMS Living donor nephrectomy can be associated with increases in blood pressure several years following the procedure, but the best method to assess blood pressure during the living donor evaluation process is unclear. METHODS Living kidney donors underwent casual clinic and ambulatory blood pressure monitoring (ABPM) and measurement of central aortic pressures at baseline and 6 months following donor nephrectomy. RESULTS There was a significant decline in clinic systolic blood pressure (SBP; p = 0.001) and central aortic systolic pressure (p = 0.011) during the study period. However, average ABPM was unchanged and other measures of central arterial pressures and Augmentation Index were unchanged at 6 months compared to baseline. CONCLUSIONS The remarkable differences between clinic SBP and ambulatory SBP prior to donation, and the disappearance of these differences 6 months later, suggest a substantial white coat effect on SBP associated with living kidney donor evaluation. Also, ABPM represents a better way to assess blood pressure prior to kidney donation.
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Bahous SA, Stephan A, Blacher J, Safar M. Cardiovascular and renal outcome in recipients of kidney grafts from living donors: role of aortic stiffness. Nephrol Dial Transplant 2011; 27:2095-100. [PMID: 21980156 DOI: 10.1093/ndt/gfr578] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Cardiovascular (CV) risk remains high in renal transplant patients despite a clear improvement conferred by transplantation. This risk is attributed mostly to recipient-related risk factors. Donor vascular characteristics, such as arterial stiffness, have been poorly investigated in this regard. METHODS Recipients of living-related (n = 75) and living-unrelated (n = 20) kidney grafts were recruited at a mean time of 107 ± 41 months after transplantation for baseline evaluation and follow-up for the occurrence of the following composite outcome: myocardial infarction, stroke, CV death, doubling of serum creatinine or development of end-stage renal disease (ESRD). At inclusion, recipients and their corresponding donors underwent complete history, physical examination, laboratory tests and non-invasive measurement of aortic pulse wave velocity (PWV). RESULTS During a mean follow-up of 56 ± 18 months, 20 recipients doubled their serum creatinine, of whom 16 reached ESRD, and 9 suffered of a new CV event (5 of which were fatal). Cox proportional hazards regression analysis showed that, in addition to recipient-related parameters, such as the presence of CV event and the estimated glomerular filtration rate at inclusion, donor aortic PWV was a strong and independent predictor of the composite recipient outcome. CONCLUSIONS Donor large artery stiffness may predict recipient CV and graft outcome. This finding demonstrates the tight link that exists between the vascular system and the kidneys and suggests that donor contribution to recipient outcome goes beyond simple parameters like age, gender and even familial or non-familial donor type.
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Affiliation(s)
- Sola Aoun Bahous
- Division of Nephrology and Hypertension, Centre Hospitalier du Nord, Zgharta, Lebanon
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Moody WE, Chue CD, Inston NG, Edwards NC, Steeds RP, Ferro CJ, Townend JN. Understanding the effects of chronic kidney disease on cardiovascular risk: are there lessons to be learnt from healthy kidney donors? J Hum Hypertens 2011; 26:141-8. [PMID: 21593781 DOI: 10.1038/jhh.2011.46] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Chronic kidney disease (CKD) is now a recognized global public health problem. It is highly prevalent and strongly associated with hypertension and cardiovascular disease (CVD); far more patients with a glomerular filtration rate below 60 ml min(-1) per 1.73 m(2) will die from cardiovascular causes than progress to end-stage renal disease. A better understanding of the complex mechanisms underlying the development of CVD among CKD patients is required if we are to begin devising therapy to prevent or reverse this process. Observational studies of CVD in CKD are difficult to interpret because renal impairment is almost always accompanied by confounding factors. These include the underlying disease process itself (for example, diabetes mellitus and systemic vasculitis) and the complications of CKD, such as hypertension, anaemia and inflammation. Kidney donors provide an ideal opportunity to study healthy subjects without manifest vascular disease who experience an acute change from having normal to modestly impaired renal function at the time of uninephrectomy. Prospectively examining the cardiovascular consequences of uninephrectomy using donors as a model of CKD may provide useful insight into the pathophysiology of CVD in CKD and, therefore, into how the CVD risk associated with renal impairment might eventually be reduced.
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Affiliation(s)
- W E Moody
- Department of Cardiovascular Medicine, Queen Elizabeth Hospital, University of Birmingham, Birmingham, UK.
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Hypertension in the kidney transplant recipient. Transplant Rev (Orlando) 2010; 24:105-20. [DOI: 10.1016/j.trre.2010.02.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2010] [Accepted: 02/02/2010] [Indexed: 12/31/2022]
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Kasiske B, Eckardt KU. Primum non Nocere. Am J Transplant 2009; 9:2204. [PMID: 19656131 DOI: 10.1111/j.1600-6143.2009.02780.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Bahous SA, Blacher J, Safar ME. Aortic stiffness, kidney disease, and renal transplantation. Curr Hypertens Rep 2009; 11:98-103. [DOI: 10.1007/s11906-009-0019-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Fassett RG, Healy H, Driver R, Robertson IK, Geraghty DP, Sharman JE, Coombes JS. Astaxanthin vs placebo on arterial stiffness, oxidative stress and inflammation in renal transplant patients (Xanthin): a randomised controlled trial. BMC Nephrol 2008; 9:17. [PMID: 19091127 PMCID: PMC2666668 DOI: 10.1186/1471-2369-9-17] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2008] [Accepted: 12/18/2008] [Indexed: 01/09/2023] Open
Abstract
Background There is evidence that renal transplant recipients have accelerated atherosclerosis manifest by increased cardiovascular morbidity and mortality. The high incidence of atherosclerosis is, in part, related to increased arterial stiffness, vascular dysfunction, elevated oxidative stress and inflammation associated with immunosuppressive therapy. The dietary supplement astaxanthin has shown promise as an antioxidant and anti-inflammatory therapeutic agent in cardiovascular disease. The aim of this trial is to investigate the effects of astaxanthin supplementation on arterial stiffness, oxidative stress and inflammation in renal transplant patients. Method and Design This is a randomised, placebo controlled clinical trial. A total of 66 renal transplant recipients will be enrolled and allocated to receive either 12 mg/day of astaxanthin or an identical placebo for one-year. Patients will be stratified into four groups according to the type of immunosuppressant therapy they receive: 1) cyclosporine, 2) sirolimus, 3) tacrolimus or 4) prednisolone+/-azathioprine, mycophenolate mofetil or mycophenolate sodium. Primary outcome measures will be changes in 1) arterial stiffness measured by aortic pulse wave velocity (PWV), 2) oxidative stress assessed by plasma isoprostanes and 3) inflammation by plasma pentraxin 3. Secondary outcomes will include changes in vascular function assessed using the brachial artery reactivity (BAR) technique, carotid artery intimal medial thickness (CIMT), augmentation index (AIx), left ventricular afterload and additional measures of oxidative stress and inflammation. Patients will undergo these measures at baseline, six and 12 months. Discussion The results of this study will help determine the efficacy of astaxanthin on vascular structure, oxidative stress and inflammation in renal transplant patients. This may lead to a larger intervention trial assessing cardiovascular morbidity and mortality. Trial Registration ACTRN12608000159358
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Affiliation(s)
- Robert G Fassett
- Renal Research, Royal Brisbane and Women's Hospital, Herston, Brisbane, Queensland, Australia.
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Schillaci G, Pirro M, Mannarino MR, Pucci G, Savarese G, Franklin SS, Mannarino E. Relation Between Renal Function Within the Normal Range and Central and Peripheral Arterial Stiffness in Hypertension. Hypertension 2006; 48:616-21. [PMID: 16952976 DOI: 10.1161/01.hyp.0000240346.42873.f6] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Chronic kidney disease is accompanied by increased large-artery stiffness, but the relation between glomerular filtration rate within the reference range and central or peripheral arterial stiffness has been understudied. The link between renal function and arterial stiffness was assessed in 305 patients with never-treated essential hypertension (men: 58%; age: 48±11 years, blood pressure: 151/95±20/11 mm Hg), free from overt cardiovascular disease and with serum creatinine values <1.4 mg/dL (men) and <1.2 mg/dL (women), who underwent noninvasive aortic and upper-limb pulse wave velocity (PWV) determination. Aortic PWV was strongly related to age (
r
=0.55;
P
<0.001), whereas upper-limb PWV had a weaker nonlinear relation with age (β=1.392;
P
<0.001 for age; β=−1.312;
P
<0.001 for age squared) and a weak relation with aortic PWV (
r
=0.22;
P
<0.001). Glomerular filtration rate (GFR), estimated according to the Mayo clinic equation for healthy subjects, was inversely correlated with large-artery stiffness, as assessed by aortic PWV (
r
=−0.34;
P
<0.001), and with peripheral artery stiffness, as assessed by upper-limb PWV (
r
=−0.25;
P
<0.001). In a multivariate linear regression, aortic PWV was independently predicted by age (β=0.48;
P
<0.001), mean arterial pressure (β=0.14;
P
=0.013), and GFR (β=−0.13,
P
=0.029). Upper-limb PWV was predicted by GFR (β=−0.24;
P
<0.001) and mean arterial pressure (β=0.20;
P
<0.001). We conclude that, in hypertensive patients with normal renal function, an inverse relationship exists between GFR and stiffness of both central elastic and peripheral muscular arteries. These relations are in part independent from the effect of several confounders, including age, sex, and blood pressure values.
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Affiliation(s)
- Giuseppe Schillaci
- Unit of Internal Medicine, Angiology and Arteriosclerosis, University of Perugia, Perugia, Italy.
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Kneifel M, Scholze A, Burkert A, Offermann G, Rothermund L, Zidek W, Tepel M. Impaired renal allograft function is associated with increased arterial stiffness in renal transplant recipients. Am J Transplant 2006; 6:1624-30. [PMID: 16827863 DOI: 10.1111/j.1600-6143.2006.01341.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
It is important whether impairment of renal allograft function may deteriorate arterial stiffness in renal transplant recipients. In a cross-sectional study, arterial vascular characteristics were non-invasively determined in 48 patients with renal allograft using applanation tonometry and digital photoplethysmography. Mean age was 51 +/- 2 years (mean +/- SEM), and studies were performed 17 +/- 1 months after transplantation. The stage of chronic kidney disease was based on the glomerular filtration rate. We observed a significant association between the stage of chronic kidney disease and arterial stiffness of large arteries S1 and small arteries S2 in renal transplant recipients (each p < 0.05 by non-parametric Kruskal-Wallis test between groups). Multivariate linear regression analysis showed that male gender of patients with renal allograft (p < 0.01) reduced glomerular filtration rate (p = 0.01), and older age of kidney donor (p = 0.04) were independently associated with an increase of large artery stiffness S1. Furthermore, a significant association between the stage of chronic kidney disease and arterial vascular reactivity during reactive hyperemia was observed (p < 0.05 by non-parametric Kruskal-Wallis test between groups). It is concluded that impairment of renal allograft function is associated with an increased arterial stiffness in renal transplant recipients.
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Affiliation(s)
- M Kneifel
- Charité Campus Benjamin Franklin, Berlin, Germany
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Ommen ES, Winston JA, Murphy B. Medical Risks in Living Kidney Donors: Absence of Proof Is Not Proof of Absence. Clin J Am Soc Nephrol 2006; 1:885-95. [PMID: 17699301 DOI: 10.2215/cjn.00840306] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Living-kidney donation has become increasingly widespread, yet there has been little critical analysis of existing studies of long-term medical outcomes in living donors. This review analyzes issues in study design that affect the quality of the evidence and summarizes possible risk factors in living donors. Virtually all studies of long-term outcomes in donors are retrospective, many with large losses to follow-up, and therefore are subject to selection bias. Most studies have small sample sizes and are underpowered to detect clinically meaningful differences between donors and comparison groups. Many studies compare donors with the general population, but donors are screened to be healthier than the general population and this may not be a valid comparison group. Difficulties in measurement of BP and renal function may underestimate the impact of donation on these outcomes. Several studies have identified possible risk factors for development of hypertension, proteinuria, and ESRD, but potential vulnerability factors in donors have not been well explored and there is a paucity of data on cardiovascular risk factors in donors. Prospective registration of living kidney donors and prospective studies of diverse populations of donors are essential to protect living donors and preserve living-kidney donation.
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Affiliation(s)
- Elizabeth S Ommen
- Mount Sinai Medical Center, Division of Nephrology, 1 Gustave Levy Place, Box 1243, New York, NY 10029, USA.
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Toto RD. Pressure, waves, and kidney outcomes in kidney transplant donors and recipients. Hypertension 2006; 47:141-2. [PMID: 16401760 DOI: 10.1161/01.hyp.0000201235.90035.6c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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