Echocardiographic changes after successful renal transplantation in young nondiabetic patients

Cardiac and vascular changes with kidney transplantation

Cardiovascular event rates are high in patients with chronic kidney disease (CKD), increasing with deteriorating kidney function, highest in CKD patients on dialysis, and improve with kidney transplantation (KTx). The cardiovascular events in CKD patients such as myocardial infarction and heart failure are related to abnormalities of vascular and cardiac structure and function. Many studies have investigated the structural and functional abnormalities of the heart and blood vessels in CKD, and the changes that occur with KTx, but the evidence is often sparse and occasionally contradictory. We have reviewed the available evidence and identified areas where more research is required to improve the understanding and mechanisms of these changes. There is enough evidence demonstrating improvement of left ventricular hypertrophy, except in children, and sufficient evidence of improvement of left ventricular function, with KTx. There is reasonable evidence of improvement in vascular function and stiffness. However, the evidence for improvement of vascular structure and atherosclerosis is insufficient. Further studies are necessary to establish the changes in vascular structure, and to understand the mechanisms of vascular and cardiac changes, following KTx.

End-stage renal disease and cardiomyopathy in children: cardiac effects of renal transplantation

BACKGROUND

The occurrence and progression of cardiomyopathy is well known in patients with end-stage renal disease (ESRD). However, the feasibility of renal transplantation in the setting of cardiac dysfunction and the effect of renal transplantation on this progression remain poorly studied in pediatric patients.

METHODS

A single-center, retrospective review of pediatric renal transplants between January 1, 2001, and December 31, 2010, was conducted. Six children with ESRD and severe systolic dysfunction underwent renal transplantation. Clinical data were collected and compared for the pretransplant, peritransplant, and posttransplant periods.

RESULTS

Nutritional support, dialysis, and chronic kidney disease and heart failure therapy led to improved cardiac function before transplantation (ejection fraction 28.8%±9.6% vs. 44.4%±11.5%; fractional shortening 12.7%±5.1% vs. 23.6%±6.2%); however, normal systolic function was not achieved before transplantation in any patient. After transplantation, two patients had normalization of systolic function by hospital discharge, while the systolic function of the remaining four patients normalized during the first posttransplant year. Mean ejection fraction 1 year posttransplant was 22 units greater than before transplant. All patients experienced excellent allograft function in the peritransplant period. Mean estimated creatinine clearance 1 year posttransplant was 93.2±33.3 mL/min/1.73 m(2).

CONCLUSIONS

Renal transplantation can be performed safely in children with ESRD and severe systolic dysfunction. After transplantation, systolic function continues to improve and may reach normal levels during the first posttransplant year. The presence of severe systolic dysfunction in pediatric dialysis patients should not deter referral for renal transplantation.

Changes in cardiac parameters of renal allograft recipients: a compilation of clinical, laboratory, and echocardiographic observations

INTRODUCTION

This study was undertaken to observe changes in cardiac parameters along with clinical and laboratory changes after renal transplantation.

PATIENTS AND METHODS

Cardiac parameters were evaluated by M-mode 2-dimensional echocardiography before transplantation and at monthly intervals. All subjects had functioning grafts at the time of the evaluations.

RESULTS

Fifty-two allograft recipients underwent pretransplant parameters for comparison to those at posttransplant months 1, 3, 6, and 12. When changes at month 1 and 3 were observed among 22 patients, improvements were evident at month 3. Comparisons of pretransplant versus month 3 showed systolic blood pressure (SBP), 161 +/- 16 to 133 +/- 26 mmHg (P < .002); diastolic BP (DBP), 101 +/- 9 to 86 +/- 11 mmHg, (P < .006); hemoglobin (Hgb), 7.3 +/- 1.6 to 11.2 +/- 3.9 g/dL (P < .006); left atrial diameter (LAD), 41 +/- 5 to 35 +/- 3 mm (P < .001); left ventricular muscle mass index (LVMI), 379 +/- 114 to 248 +/- 58 g/m2 (P < .001); and left ventricular end diastolic volume index (LVEDVI), 96 +/- 28 to 64 +/- 17 mL/m2 (P < .002). When changes at months 3, 6, and 12 were observed among 30 patients, improvements evident at month 3 were maintained. Comparisons of pretransplant and 3 and 12 months observations showed SBP, 157 +/- 17, 131 +/- 14, to 126 +/- 10 mm Hg (P < .001); DBP, 97 +/- 10, 83 +/- 16, to 85 +/- 6 mmHg (P < .001); Hgb, 7 +/- 1, 13 +/- 2, to 13 +/- 2 g/dL (P < .001); LAD, 39 +/- 7, 35 +/- 3, to 34 +/- 4 mm (P < .05); LVMI, 275 +/- 91, 191 +/- 38, to 159 +/- 26 g/m2 (P < .001); and LVEDVI, 87 +/- 29, 56 +/- 34, to 49 +/- 24 mL/m2 (P < .001).

CONCLUSION

Significant improvements in cardiac parameters were evident by the third month post-renal transplantation; the changes were maintained over a longer period among patients with functional grafts.

Reduction of left ventricular mass by lisinopril and nifedipine in hypertensive renal transplant recipients: a prospective randomized double-blind study

BACKGROUND

Cardiovascular disease is the dominant cause of death in renal transplant recipients. Left ventricular hypertrophy (LVH) is a known risk factor. After renal transplantation, persistent hypertension is an important determinant for the further evolution of LVH. The aim of the present study was to compare the effect of an angiotensin converting enzyme (ACE) inhibitor (lisinopril) with a calcium channel blocker (CCB) (controlled release nifedipine) in treatment of posttransplant hypertension focusing on changes in LVH.

METHODS

One hundred fifty-four renal transplant recipients presenting with hypertension (diastolic BP> or =95 mmHg) during the first 3 weeks after transplantation were randomized to receive double-blind 30 mg nifedipine or 10 mg lisinopril once daily.

RESULTS

One hundred twenty-three patients completed 1 year of treatment. Good quality echocardiographic data were available in 116 recipients (62 nifedipine/54 lisinopril) 2 and 12 months posttransplant. Blood pressure was equally well controlled in the two groups throughout the study (mean systolic/diastolic+/-SD after 1 year: 140+/-16/87+/-8 mmHg with nifedipine and 136+/-17/85+/-8 mmHg with lisinopril). Left ventricular mass index was reduced by 15% (P<0.001) in both groups (from 153+/-43 to 131+/-38 g/m2 with nifedipine and from 142+/-35 to 121+/-34 g/m2 with lisinopril). There were no statistically significant differences between the two treatment groups at baseline or at follow-up.

CONCLUSIONS

In hypertensive renal transplant recipients with well-controlled blood pressure, there is a regression of left ventricular mass after renal transplantation. The regression of left ventricular mass index is observed to a similar extent in patients treated with lisinopril or nifedipine.

Prediction of left ventricular mass changes after renal transplantation by polymorphism of the angiotensin-converting-enzyme gene

Cardiac complications are the main cause of death in renal transplant patients and left ventricular hypertrophy (LVH) may play a determinant role. An association between the insertion-deletion polymorphism of the angiotensin-converting enzyme (ACE) gene and LVH has been reported in adults. However, little is known about the genetic influence on left ventricular mass changes after renal transplantation, where unique environmental factors, such as cyclosporine A (CsA) and prednisone treatment concur. In fact, CsA treatment has recently been associated with the development of LVH. We prospectively determined the changes on cardiac structure and function, assessed by echocardiographic criteria, in 38 consecutive nondiabetic adults who received a cadaveric renal allograft. They were treated with cyclosporine and prednisone and maintained a good renal function during the follow-up. Echocardiographic studies (M-mode, 2-B and color flow Doppler) were performed without previous knowledge of the genetic typing, at the time of transplantation, and 6 and 12 months later. ACE alleles were typed using a PCR-based assay developed to ascertain the presence of an insertion (I)-deletion (D) polymorphism in intron 16 of the ACE gene. Patients with the so-called "unfavorable" DD genotype (N = 16) were compared with the ID or II genotypes (N = 22). The baseline left ventricular mass index was similar in patients with or without the unfavorable DD genotype (X +/- SE; 166.6 +/- 10.4 vs. 181.3 +/- 9 g/m2, respectively) and a similar proportion fulfilled the criteria of LVH (88% vs. 82%, respectively). The mean percent increase of the left ventricular mass index 12 months after renal transplantation was significantly higher in patients with the DD genotype compared to those with other genotypes (21.3 +/- 7.9 vs. -0.08 +/- 4.9%, respectively; P < 0.05). As a result, 94% of DD patients showed LVH at the end of the follow-up, while 68% of the ID or II patients had LVH (P < 0.05). In addition, the left ventricular ejection fraction significantly increased only in ID or II patients 12 months after transplantation with respect to baseline (ID/II patients, 70.4 +/- 1.5 vs. 63.7 +/- 1.8%; P < 0.05; DD patients, 68.3 +/- 2.1 vs. 63.3 +/- 2.9%). The deleterious effect of the DD genotype was independent of blood pressure, biochemical parameters, weight gain, and cumulative steroids dosages or cyclosporine levels. In conclusion, genetic factors determine the changes on cardiac structure and function after renal transplantation. The presence of the DD genotype of the ACE gene is a marker associated with an elevated risk of LVH in this population.

Comparison of echocardiographic changes associated with hemodialysis and renal transplantation

Long-term hemodialysis has been reported to cause progression of left ventricular (LV) hypertrophy with a tendency toward asymmetric septal hypertrophy. Renal transplantation is believed to reverse some of these changes. The aim of this prospective study was to compare the effects of long-term hemodialysis and of successful renal transplantation on cardiac structure and function assessed by echocardiography. Fifty-three patients were submitted to two echocardiographic evaluations separated by a 30 +/- 8 month interval. At the first control, all patients were on hemodialysis; at the second, 36 patients remained on dialysis while 17 had been submitted to renal transplantation. Age (44 +/- 13 vs. 40 +/- 10 years), gender (male, 50% vs 53%), and duration of dialysis at the initiation of the study (43 +/- 34 vs. 47 +/- 32 months) were comparable in the 2 groups. The prevalence of LV hypertrophy were 83% (first control) and 69% (second control) in the dialysis group and 82% and 71% in the transplant group. Comparisons between the two periods within each group showed that hemodialysis was associated with a significant reduction of the E/A ratio (1.25 +/- 0.4 vs. 1.02 +/- 0.4, p < 0.001) and systolic (155 +/- 28 vs. 137 +/- 26 mm Hg, p < 0.001) and diastolic (94 +/- 21 vs. 84 +/- 16 mm Hg, p < 0.05) blood pressure, and no change in LV mass index (171 +/- 51 vs. 156 +/- 43 g/m2, NS). In the transplanted group, there were reductions in the E/A ratio (1.42 +/- 0.6 vs 1.10 +/- 0.4, p < 0.05) and in LV diastolic dimension (50 +/- 7 vs. 46 +/- 5 mm, p < 0.05), but not in systolic (155 +/- 27 vs. 152 +/- 31 mm Hg, NS) or diastolic (97 +/- 11 vs. 97 +/- 20 mm Hg, NS) blood pressure. The LV mass index also did not change significantly (157 +/- 51 vs. 133 +/- 31 g/m2, NS).(ABSTRACT TRUNCATED AT 250 WORDS)

Course of left ventricular hypertrophy and function in end-stage renal disease after renal transplantation

Cardiovascular complications are frequent and related to left ventricular (LV) hypertrophy and dysfunction in end-stage renal disease. To examine cardiac changes after renal transplantation, 24 hemodialysis patients (18 men and 6 women, age 47 +/- 12 years) were analyzed in a prospective follow-up study with echocardiography immediately before and 41 +/- 30 months after renal transplantation. Mean systolic blood pressure (hemodialysis vs transplantation: 156 +/- 35 vs 144 +/- 15 mm Hg; p = not significant [NS]), as averages of 6 measurements from 2 weeks, remained constant and elevated. The most frequent echocardiographic findings at both assessments were left atrial dilatation (75 vs 79%; p = NS) and LV hypertrophy (71 vs 67%; p = NS). After transplantation, an increase was found in mean left atrial diameter (41 +/- 5 to 44 +/- 5 mm; p < 0.05) and end-diastolic LV diameter (50 +/- 5 to 53 +/- 5 mm; p < 0.05) at constant LV muscle mass (332 +/- 104 vs 329 +/- 94 g; p = NS). LV ejection fraction (58 +/- 10% to 63 +/- 12%; p < 0.02) and stroke volume (98 +/- 26 to 118 +/- 25 ml; p < 0.02) improved. No influence of blood pressure in sporadic morning determinations or of dialysis fistula patency on alterations of LV mass or function was found. Left atrial diameters increased in patients with patent dialysis fistulas (41 +/- 7 to 45 +/- 5 mm; p < 0.05), but not in those with occluded fistulas (41 +/- 7 vs 42 +/- 4 mm; p = NS).(ABSTRACT TRUNCATED AT 250 WORDS)

Diastolic left ventricular function after renal transplantation in patients with normal and hypertrophied myocardium

While diastolic left ventricular (LV) dysfunction is frequent and associated with cardiovascular complications in end-stage renal disease treated with dialysis, controversial information exists on diastolic LV function after renal transplantation. Therefore, Doppler echocardiographic parameters of LV diastolic filling were analyzed in 17 transplanted patients with normal LV mass (< 150 g/m2; mean: 128 +/- 17 g/m2) and 24 transplanted patients with LV hypertrophy (> 150 g/m2; mean: 197 +/- 36 g/m2) and compared with 28 normal controls without and 11 controls with LV hypertrophy. Mean age (normal vs. increased LV mass: 46 +/- 13 vs. 48 +/- 11 years; p = NS) and transplantation duration (60 +/- 35 vs. 50 +/- 37 months; p = NS) were comparable between renal patients, while systolic blood pressure (136 +/- 12 vs. 149 +/- 14 mmHg; p < 0.02) and serum creatinine (1.55 +/- 0.45 vs. 1.98 +/- 0.76 mg/dl; p < 0.05) were higher in patients with than without LV hypertrophy. In transplanted patients with LV hypertrophy, peak early/atrial filling velocity ratios were decreased (1.17 +/- 0.34 vs. 0.94 +/- 0.34; p < 0.05), mean atrial filling fractions were increased (37 +/- 7% vs. 42 +/- 7%; p < 0.05), and isovolumic relaxation periods were prolonged (86 +/- 23 vs. 106 +/- 26 ms; p < 0.02) compared with transplanted patients with normal LV mass. The frequency of pathologic peak early/atrial filling velocity ratios (12 vs. 42%; p < 0.05), atrial filling fractions (12 vs. 25%; p = NS) and isovolumic relaxation periods (6 vs. 29%; p = NS) was higher in transplanted patients with than without LV hypertrophy. Individual ratios of peak early/atrial filling velocity were inversely correlated with age in transplanted patients with normal LV mass (p < 0.002), and atrial filling fractions were correlated with LV mass index in transplanted patients with LV hypertrophy (p < 0.01). Diastolic LV function was comparable in both groups of transplanted patients with their corresponding non-renal controls. It is concluded that, in transplanted patients, diastolic LV filling is comparable to nonrenal controls; it is age-dependent in patients with normal LV mass and mass-dependent in those with LV hypertrophy.

Cardiac consequences of renal transplantation: changes in left ventricular morphology and function

To characterize changes in left ventricular morphology and function associated with renal transplantation, noninvasive cardiac evaluations were performed in 41 adults at the time of surgery and at follow-up. At the time of transplantation, 36 patients had undergone hemodialysis through a fistula for 2.3 +/- 2.5 years (mean +/- SD); their hematocrit level was 26 +/- 6% and systolic blood pressure was 151 +/- 19 mm Hg. Perioperatively, left ventricular hypertrophy was present in 93% of patients by echocardiography, but in only 37% by electrocardiography. Abnormal left ventricular diastolic function was present in 67% of patients and indicated a high risk for perioperative pulmonary edema. At follow-up (1.5 +/- 1.4 years), mean hematocrit level increased to 39 +/- 7%, systolic blood pressure decreased to 132 +/- 14 mm Hg and spontaneous closure of the fistula occurred in 13 patients. Left ventricular mass by echocardiography decreased from 237 +/- 66 to 182 +/- 47 g (p less than 0.001), a decrease of 23%. Left ventricular volumes and cardiac index also decreased significantly, reflecting the rapid resolution of a pretransplant high output state. Despite proportionate regression of left ventricular hypertrophy within months of transplantation, diastolic function did not improve. The significant regression of left ventricular hypertrophy that occurs after renal transplantation may help explain the improved cardiovascular survival of patients with a renal transplant over that of patients on long-term dialysis.

Exercise tolerance changes following renal transplantation

Maximal exercise capacity was measured in 20 nondiabetic patients with end-stage renal disease before and soon after successful renal transplantation. Maximal oxygen consumption increased significantly in all patients posttransplant. Increases in maximal heart rate and heart rates at 70% of maximal levels were also observed. The changes in maximal oxygen consumption were not significantly correlated with changes in hematocrit. The removal of uremia may result in improved functioning of one or more of the systems involved in oxygen transport and utilization that determine exercise capacity.

Serial echocardiographic observations in patients with primary systemic amyloidosis: an introduction to the concept of early (asymptomatic) amyloid infiltration of the heart

Echocardiography was used for the serial assessment of 27 patients with primary systemic amyloidosis. Thirteen patients had no clinical cardiac deterioration between the two echocardiographic studies (group 1), whereas in 14 patients (group 2), congestive heart failure or arrhythmias (or both) appeared or worsened during a mean observation period of 19 months. The only echocardiographic changes in group 1 were a mild increase in left ventricular mass and a mild decrease in left ventricular wall systolic thickening. Patients in group 2 had significant changes in left ventricular wall thickness (mean increase, 34%), in left ventricular mass (mean increase, 42%), in right ventricular wall thickness (mean increase, 78%), in left atrial size (mean increase, 19%), in left ventricular mass/voltage ratio (mean increase, 68%), in left ventricular radius/thickness ratio (mean decrease, 29%), and in left ventricular fractional shortening (mean decrease, 13%). Significant correlations were found in group 2 between changes in systolic and diastolic blood pressure and changes in ventricular wall thickness and mass. Changes in left ventricular systolic function did not correlate significantly with changes in other clinical, electrocardiographic, or echocardiographic measurements. In six cases (two in group 1), in which amyloid infiltration of the heart was proved by myocardial biopsy or autopsy, the only echocardiographic abnormality when the patients were asymptomatic was a moderate increase in left or right ventricular wall thickness. We found that M-mode and two-dimensional echocardiographic examinations can substantiate progressive amyloid infiltration of the heart and are useful tools for the noninvasive serial assessment of patients with primary systemic amyloidosis.