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Kim HJ, Kim KW, Joo YS, Ryu J, Jung HY, Jeong KH, Kim MG, Ju MK, Han S, Lee JS, Kang KP, Ro H, Lee KW, Huh KH, Kim MS, Kim BS, Yang J. Impact of Blood Pressure on Allograft Function and Survival in Kidney Transplant Recipients. Transpl Int 2024; 37:12574. [PMID: 39170864 PMCID: PMC11336573 DOI: 10.3389/ti.2024.12574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 07/22/2024] [Indexed: 08/23/2024]
Abstract
The optimal target blood pressure for kidney transplant (KT) patients remains unclear. We included 808 KT patients from the KNOW-KT as a discovery set, and 1,294 KT patients from the KOTRY as a validation set. The main exposures were baseline systolic blood pressure (SBP) at 1 year after KT and time-varying SBP. Patients were classified into five groups: SBP <110; 110-119; 120-129; 130-139; and ≥140 mmHg. SBP trajectories were classified into decreasing, stable, and increasing groups. Primary outcome was composite kidney outcome of ≥50% decrease in eGFR or death-censored graft loss. Compared with the 110-119 mmHg group, both the lowest (adjusted hazard ratio [aHR], 2.43) and the highest SBP (aHR, 2.25) were associated with a higher risk of composite kidney outcome. In time-varying model, also the lowest (aHR, 3.02) and the highest SBP (aHR, 3.60) were associated with a higher risk. In the trajectory model, an increasing SBP trajectory was associated with a higher risk than a stable SBP trajectory (aHR, 2.26). This associations were consistent in the validation set. In conclusion, SBP ≥140 mmHg and an increasing SBP trajectory were associated with a higher risk of allograft dysfunction and failure in KT patients.
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Affiliation(s)
- Hyo Jeong Kim
- Division of Nephrology, Department of Internal Medicine, Gangnam Severance Hospital, Seoul, Republic of Korea
| | - Kyung Won Kim
- Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Young Su Joo
- Department of Internal Medicine, College of Medicine, Yongin Severance Hospital, Yonsei University, Yongin, Republic of Korea
| | - Junghwa Ryu
- Department of Internal Medicine, Seoul Hospital, Ewha Womans University, Seoul, Republic of Korea
| | - Hee-Yeon Jung
- Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Kyung Hwan Jeong
- Department of Internal Medicine, Kyung Hee University College of Medicine, Seoul, Republic of Korea
| | - Myung-Gyu Kim
- Department of Internal Medicine, College of Medicine, Anam Hospital, Korea University, Seoul, Republic of Korea
| | - Man Ki Ju
- Department of Surgery, College of Medicine, Gangnam Severance Hospital, Yonsei University, Seoul, Republic of Korea
| | - Seungyeup Han
- Department of Internal Medicine, Dongsan Medical Center, Keimyung University, Daegu, Republic of Korea
| | - Jong Soo Lee
- Department of Internal Medicine, Ulsan University Hospital, Ulsan, Republic of Korea
| | - Kyung Pyo Kang
- Department of Internal Medicine, Research Institute of Clinical Medicine, Jeonbuk National University Medical School, Jeonju, Republic of Korea
| | - Han Ro
- Department of Internal Medicine, Gil Hospital, Gachon University, Incheon, Republic of Korea
| | - Kyo Won Lee
- Department of Surgery, Seoul Samsung Medical Center, Sungkyunkwan University, Seoul, Republic of Korea
| | - Kyu Ha Huh
- Department of Surgery, College of Medicine, Severance Hospital, Yonsei University, Seoul, Republic of Korea
| | - Myoung Soo Kim
- Department of Surgery, College of Medicine, Severance Hospital, Yonsei University, Seoul, Republic of Korea
| | - Beom Seok Kim
- Department of Internal Medicine, College of Medicine, Severance Hospital, Yonsei University, Seoul, Republic of Korea
| | - Jaeseok Yang
- Department of Internal Medicine, College of Medicine, Severance Hospital, Yonsei University, Seoul, Republic of Korea
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Natale P, Mooi PK, Palmer SC, Cross NB, Cooper TE, Webster AC, Masson P, Craig JC, Strippoli GF. Antihypertensive treatment for kidney transplant recipients. Cochrane Database Syst Rev 2024; 7:CD003598. [PMID: 39082471 PMCID: PMC11290053 DOI: 10.1002/14651858.cd003598.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/03/2024]
Abstract
BACKGROUND The comparative effects of specific blood pressure (BP) lowering treatments on patient-important outcomes following kidney transplantation are uncertain. Our 2009 Cochrane review found that calcium channel blockers (CCBs) improved graft function and prevented graft loss, while the evidence for other BP-lowering treatments was limited. This is an update of the 2009 Cochrane review. OBJECTIVES To compare the benefits and harms of different classes and combinations of antihypertensive drugs in kidney transplant recipients. SEARCH METHODS We contacted the Information Specialist and searched the Cochrane Kidney and Transplant Register of Studies up to 3 July 2024 using search terms relevant to this review. Studies in the Register were identified through searches of CENTRAL, MEDLINE, EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs evaluating any BP-lowering agent in recipients of a functioning kidney transplant for at least two weeks were eligible. DATA COLLECTION AND ANALYSIS Two authors independently assessed the risks of bias and extracted data. Treatment estimates were summarised using the random-effects model and expressed as relative risk (RR) or mean difference (MD) with 95% confidence intervals (CI). Evidence certainty was assessed using Grades of Recommendation, Assessment, Development and Evaluation (GRADE) processes. The primary outcomes included all-cause death, graft loss, and kidney function. MAIN RESULTS Ninety-seven studies (8706 participants) were included. One study evaluated treatment in children. The overall risk of bias was unclear to high across all domains. Compared to placebo or standard care alone, CCBs probably reduce all-cause death (23 studies, 3327 participants: RR 0.83, 95% CI 0.72 to 0.95; I2 = 0%; moderate certainty evidence) and graft loss (24 studies, 3577 participants: RR 0.84, 95% CI 0.75 to 0.95; I2 = 0%; moderate certainty evidence). CCBs may make little or no difference to estimated glomerular filtration rate (eGFR) (11 studies, 2250 participants: MD 1.89 mL/min/1.73 m2, 95% CI -0.70 to 4.48; I2 = 48%; low certainty evidence) and acute rejection (13 studies, 906 participants: RR 10.8, 95% CI 0.85 to 1.35; I2 = 0%; moderate certainty evidence). CCBs may reduce systolic BP (SBP) (3 studies, 329 participants: MD -5.83 mm Hg, 95% CI -10.24 to -1.42; I2 = 13%; low certainty evidence) and diastolic BP (DBP) (3 studies, 329 participants: MD -3.98 mm Hg, 95% CI -5.98 to -1.99; I2 = 0%; low certainty evidence). CCBs have uncertain effects on proteinuria. Compared to placebo or standard care alone, angiotensin-converting-enzyme inhibitors (ACEi) may make little or no difference to all-cause death (7 studies, 702 participants: RR 1.13, 95% CI 0.58 to 2.21; I2 = 0%; low certainty evidence), graft loss (6 studies, 718 participants: RR 0.75, 95% CI 0.49 to 1.13; I2 = 0%; low certainty evidence), eGFR (4 studies, 509 participants: MD -2.46 mL/min/1.73 m2, 95% CI -7.66 to 2.73; I2 = 64%; low certainty evidence) and acute rejection (4 studies, 388 participants: RR 1.75, 95% CI 0.76 to 4.04; I2 = 0%; low certainty evidence). ACEi may reduce proteinuria (5 studies, 441 participants: MD -0.33 g/24 hours, 95% CI -0.64 to -0.01; I2 = 67%; low certainty evidence) but had uncertain effects on SBP and DBP. Compared to placebo or standard care alone, angiotensin receptor blockers (ARB) may make little or no difference to all-cause death (6 studies, 1041 participants: RR 0.69, 95% CI 0.36 to 1.31; I2 = 0%; low certainty evidence), eGRF (5 studies, 300 participants: MD -1.91 mL/min/1.73 m2, 95% CI -6.20 to 2.38; I2 = 57%; low certainty evidence), and acute rejection (4 studies, 323 participants: RR 1.00, 95% CI 0.44 to 2.29; I2 = 0%; low certainty evidence). ARBs may reduce graft loss (6 studies, 892 participants: RR 0.35, 95% CI 0.15 to 0.84; I2 = 0%; low certainty evidence), SBP (10 studies, 1239 participants: MD -3.73 mm Hg, 95% CI -7.02 to -0.44; I2 = 63%; moderate certainty evidence) and DBP (9 studies, 1086 participants: MD -2.75 mm Hg, 95% CI -4.32 to -1.18; I2 = 47%; moderate certainty evidence), but has uncertain effects on proteinuria. The effects of CCBs, ACEi or ARB compared to placebo or standard care alone on cardiovascular outcomes (including fatal or nonfatal myocardial infarction, fatal or nonfatal stroke) or other adverse events were uncertain. The comparative effects of ACEi plus ARB dual therapy, alpha-blockers, and mineralocorticoid receptor antagonists compared to placebo or standard care alone were rarely evaluated. Head-to-head comparisons of ACEi, ARB or thiazide versus CCB, ACEi versus ARB, CCB or ACEi versus alpha- or beta-blockers, or ACEi plus CCB dual therapy versus ACEi or CCB monotherapy were scarce. No studies reported outcome data for cancer or life participation. AUTHORS' CONCLUSIONS For kidney transplant recipients, the use of CCB therapy to reduce BP probably reduces death and graft loss compared to placebo or standard care alone, while ARB may reduce graft loss. The effects of ACEi and ARB compared to placebo or standard care on other patient-centred outcomes were uncertain. The effects of dual therapy, alpha-blockers, and mineralocorticoid receptor antagonists compared to placebo or standard care alone and the comparative effects of different treatments were uncertain.
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Affiliation(s)
- Patrizia Natale
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
- Department of Precision and Regenerative Medicine and Ionian Area (DIMEPRE-J), University of Bari Aldo Moro, Bari, Italy
| | - Pamela Kl Mooi
- Department of Nephrology, Christchurch Hospital, Te Whatu Ora Waitaha Canterbury, Christchurch, New Zealand
| | - Suetonia C Palmer
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - Nicholas B Cross
- Department of Nephrology, Christchurch Hospital, Te Whatu Ora Waitaha Canterbury, Christchurch, New Zealand
- New Zealand Clinical Research, 3/264 Antigua St, Christchurch, New Zealand
| | - Tess E Cooper
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Angela C Webster
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Westmead Applied Research Centre, The University of Sydney at Westmead, Westmead, Australia
- Department of Transplant and Renal Medicine, Westmead Hospital, Westmead, Australia
| | - Philip Masson
- Department of Renal Medicine, Royal Free London NHS Foundation Trust, London, UK
| | - Jonathan C Craig
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Giovanni Fm Strippoli
- Department of Precision and Regenerative Medicine and Ionian Area (DIMEPRE-J), University of Bari Aldo Moro, Bari, Italy
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
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Kung CW, Lin YC, Tseng CS, Chou YH. Impact of Renin-Angiotensin System Blockade on Mortality and Allograft Loss among Renal Transplant Recipients: A Systematic Review and Meta-Analysis. Nephron Clin Pract 2024:1-11. [PMID: 39008959 DOI: 10.1159/000540305] [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: 03/10/2024] [Accepted: 07/08/2024] [Indexed: 07/17/2024] Open
Abstract
INTRODUCTION The blockade of the renin-angiotensin system (RAS) has a beneficial effect on reducing the levels of proteinuria and blood pressure in patients with chronic kidney disease (CKD) and reduces the risk of developing end-stage kidney disease in CKD patients. Nonetheless, a debate persists regarding the impact of RAS inhibitors on outcomes such as mortality and graft survival in renal transplant patients. To assess the effect of RAS inhibitors on graft recipients in the past decade, we conducted a systematic review and meta-analysis. METHODS We searched Embase, PubMed, and the Cochrane Central Register of Clinical Trials from January 1, 2012, to August 1, 2022. We included 14 articles, comprising 5 randomized controlled trials (RCTs) and 9 cohort studies, including 45,377 patients. These studies compared patient or graft survival between an RAS inhibitor treatment arm and a control arm. RESULTS The meta-analysis revealed that RAS blockade was significantly associated with lower mortality in cohort studies (risk ratio [RR] = 0.66, 95% confidence interval [CI]: 0.55-0.79), reduced allograft loss in cohort studies (RR = 0.62, 95% CI: 0.54-0.71), and significant changes in systolic blood pressure in RCTs. Subgroup analysis of the groups of interest (interventions involving RAS blockade, follow-up period of ≥5 years) showed consistently reduced mortality (RR = 0.67, 95% CI: 0.56-0.81) and reduced allograft loss (RR = 0.61, 95% CI: 0.54-0.70). CONCLUSIONS Our results demonstrated that the application of RAS blockade among renal transplant recipients was associated with lower mortality and allograft loss in cohort studies but not in RCTs. More powered clinical trials are needed to evaluate the effects of RAS blockade in renal transplant recipients.
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Affiliation(s)
| | - Yi-Chih Lin
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei City, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital Jin-Shan Branch, New Taipei City, Taiwan
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei City, Taiwan
| | - Chi-Shin Tseng
- Department of Urology, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei City, Taiwan
| | - Yu-Hsiang Chou
- Renal Division, Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei City, Taiwan
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Kukla A, Sahi SS, Navratil P, Benzo RP, Smith BH, Duffy D, Park WD, Shah M, Shah P, Clark MM, Fipps DC, Denic A, Schinstock CA, Dean PG, Stegall MD, Kudva YC, Diwan TS. Weight Loss Surgery Increases Kidney Transplant Rates in Patients With Renal Failure and Obesity. Mayo Clin Proc 2024; 99:705-715. [PMID: 38702124 DOI: 10.1016/j.mayocp.2024.01.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 12/23/2023] [Accepted: 01/25/2024] [Indexed: 05/06/2024]
Abstract
OBJECTIVE To describe the outcomes of kidney transplant (KT) candidates with obesity undergoing sleeve gastrectomy (SG) to meet the criteria for KT. METHODS Retrospective analysis was conducted of electronic medical records of KT candidates with obesity (body mass index >35 kg/m2) who underwent SG in our institution. Weight loss, adverse health events, and the listing and transplant rates were abstracted and compared with the nonsurgical cohort. RESULTS The SG was performed in 54 patients; 50 patients did not have surgery. Baseline demographic characteristics were comparable at the time of evaluation. Mean body mass index ± SD of the SG group was 41.7±3.6 kg/m2 at baseline (vs 41.5±4.3 kg/m2 for nonsurgical controls); at 2 and 12 months after SG, it was 36.4±4.1 kg/m2 and 32.6±4.0 kg/m2 (P<.01 for both). In the median follow-up time of 15.5 months (interquartile range, 6.4 to 23.9 months), SG was followed by active listing (37/54 people), and 20 of 54 received KT during a median follow-up time of 20.9 months (interquartile range, 14.7 to 28.3 months) after SG. In contrast, 14 of 50 patients in the nonsurgical cohort were listed, and 5 received a KT (P<.01). Three patients (5.6%) experienced surgical complications. There was no difference in overall hospitalization rates and adverse health outcomes, but the SG cohort experienced a higher risk of clinically significant functional decline. CONCLUSION In KT candidates with obesity, SG appears to be effective, with 37% of patients undergoing KT during the next 18 months (P<.01). Further research is needed to confirm and to improve the safety and efficacy of SG for patients with obesity seeking a KT.
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Affiliation(s)
- Aleksandra Kukla
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN; Von Liebig Transplant Center, Mayo Clinic, Rochester, MN.
| | - Sukhdeep S Sahi
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Pavel Navratil
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN; Department of Urology, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic; Faculty of Medicine in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
| | - Roberto P Benzo
- Department of Pulmonary Medicine, Mayo Clinic, Rochester, MN
| | - Byron H Smith
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Dustin Duffy
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Walter D Park
- Department of Cardiovascular Surgery Research, Mayo Clinic, Rochester, MN
| | - Meera Shah
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Pankaj Shah
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Matthew M Clark
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN; Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN
| | - David C Fipps
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN
| | - Aleksandar Denic
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Carrie A Schinstock
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN; Von Liebig Transplant Center, Mayo Clinic, Rochester, MN
| | - Patrick G Dean
- Von Liebig Transplant Center, Mayo Clinic, Rochester, MN; Department of Surgery and Immunology, Mayo Clinic, Rochester, MN
| | - Mark D Stegall
- Von Liebig Transplant Center, Mayo Clinic, Rochester, MN; Department of Surgery and Immunology, Mayo Clinic, Rochester, MN
| | - Yogish C Kudva
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Tayyab S Diwan
- Von Liebig Transplant Center, Mayo Clinic, Rochester, MN; Department of Surgery and Immunology, Mayo Clinic, Rochester, MN
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Okamoto T, Hatakeyama S, Hamaya T, Matsuura T, Saito M, Nishida H, Maita S, Murakami R, Tomita H, Saitoh H, Tsuchiya N, Habuchi T, Obara W, Ohyama C. Impact of timing of rejection episode on cardiovascular events in living donor kidney transplantation: a multicenter retrospective study. J Nephrol 2023; 36:2613-2620. [PMID: 37938544 DOI: 10.1007/s40620-023-01811-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 10/14/2023] [Indexed: 11/09/2023]
Abstract
BACKGROUND Cardiovascular diseases are still highly prevalent after kidney transplantation. However, little is known about the impact of the timing of rejection episodes on cardiovascular disease. The study aimed to analyze the influence of the timing of rejection episodes on cardiovascular events in recipients of living donor kidney transplantation. METHODS We studied 572 living donor kidney transplant recipients from the Michinoku Renal Transplant Network (MRTN), which includes 6 centers in the Tohoku region of Japan. Fine-Gray proportional hazards regression analysis with time-dependent variables was used to assess the effect of rejection episode on cardiovascular events. Recipients were divided into three groups: those without rejection (non-rejection, 370 patients), rejection within 6 months after transplantation (early rejection, 99 patients), and rejection after 6 months (late rejection, 103 patients). The effect of timing on cardiovascular events was evaluated using Fine-Gray proportional hazards regression analysis. RESULTS During a median follow-up of 77 months, 70 patients experienced cardiovascular events. Rejection episodes were significantly associated with cardiovascular events (hazard ratio [HR]: 2.08, 95% confidence interval [CI]: 1.26-3.43, P = 0.004), along with age and dialysis vintage. The 5-year cumulative incidence of cardiovascular events was significantly higher in the late rejection group than in the early rejection group (15% vs. 3.3%, P = 0.021). However, no significant difference in 5-year cumulative cardiovascular event incidence was observed between the early rejection and non-rejection groups. Late rejection was significantly associated with cardiovascular events (HR: 2.40, 95% CI: 1.38-4.18, P = 0.002), whereas early rejection was not significantly correlated with cardiovascular event risk (HR: 1.18, P = 0.670). CONCLUSIONS Rejections occurring more than 6 months after transplantation is significantly associated with risk of cardiovascular events. TRIAL REGISTRATION NUMBER 2019-099-1, date of registration; 3 Dec. 2019, retrospectively registered.
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Affiliation(s)
- Teppei Okamoto
- Department of Urology, Hirosaki University School of Medicine, 5 Zaifu-Cho, Hirosaki, Aomori, 036-8562, Japan
| | - Shingo Hatakeyama
- Department of Urology, Hirosaki University School of Medicine, 5 Zaifu-Cho, Hirosaki, Aomori, 036-8562, Japan.
| | - Tomoko Hamaya
- Department of Urology, Hirosaki University School of Medicine, 5 Zaifu-Cho, Hirosaki, Aomori, 036-8562, Japan
| | - Tomohiko Matsuura
- Department of Urology, Iwate Medical University, 1-1-1 Idaidori, Yahaba-Cho, Shiwa-Gun, Morioka, Iwate, 028-3694, Japan
| | - Mitsuru Saito
- Department of Urology, Akita University School of Medicine, 1-1-1, Hondo, Akita, 010-8543, Japan
| | - Hayato Nishida
- Department of Urology, Yamagata University School of Medicine, 2-2-2 Iidanishi, Yamagata, 990-9885, Japan
| | - Shinya Maita
- Department of Urology, Iwate Prefectural Isawa Hospital, 61 Mizusawaryuugababa, Oshu, Iwate, 023-0864, Japan
| | - Reiichi Murakami
- Department of Cardiology and Nephrology, Hirosaki University School of Medicine, 5 Zaifu-Cho, Hirosaki, Aomori, 036-8562, Japan
| | - Hirofumi Tomita
- Department of Cardiology and Nephrology, Hirosaki University School of Medicine, 5 Zaifu-Cho, Hirosaki, Aomori, 036-8562, Japan
| | - Hisao Saitoh
- Department of Urology, Oyokyo Kidney Research Institute, 90 Kozawa Yamazaki, Hirosaki, Aomori, 036-8243, Japan
| | - Norihiko Tsuchiya
- Department of Urology, Yamagata University School of Medicine, 2-2-2 Iidanishi, Yamagata, 990-9885, Japan
| | - Tomonori Habuchi
- Department of Urology, Akita University School of Medicine, 1-1-1, Hondo, Akita, 010-8543, Japan
| | - Wataru Obara
- Department of Urology, Iwate Medical University, 1-1-1 Idaidori, Yahaba-Cho, Shiwa-Gun, Morioka, Iwate, 028-3694, Japan
| | - Chikara Ohyama
- Department of Urology, Hirosaki University School of Medicine, 5 Zaifu-Cho, Hirosaki, Aomori, 036-8562, Japan
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Pilecki T, Czarkowska-Pączek B, Lisik W, Nazarewski S, Pączek L. Impact of Blood Pressure on Risk of Graft Failure or Death Among Patients After Kidney Transplantation in a 10-Year Observational Period: A Single-Center Retrospective Analysis. Ann Transplant 2023; 28:e939472. [PMID: 37786245 PMCID: PMC10559831 DOI: 10.12659/aot.939472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 07/26/2023] [Indexed: 10/04/2023] Open
Abstract
BACKGROUND Hypertension is a risk factor for graft failure and mortality among kidney transplant recipients (KTRs). The aim of the study was to examine blood pressure (BP) as a factor that contributes to graft failure or death during a 10-year observation period. MATERIAL AND METHODS The study group comprised 70 KTRs who were treated according to their clinical state. Data were collected at 1 month and 1 year after transplantation and included office and ambulatory BP monitoring (ABPM) BP values, eGFR, proteinuria, and BMI. During the observation period, 6 patients died, and 10 lost the graft, but not during the first year. RESULTS Office and ABPM BP values were within normal ranges and did not differ from each other. eGRF and BMI were higher at 1 year compared to 1 month after transplantation, and proteinuria decreased. Among those who died, DBP was lower compared to those of survivors with graft failure. Proteinuria and donor age were positively correlated with BP. CONCLUSIONS Monitoring of BP and adequate treatment of hypertension resulting in BP values within normal values among KTRs contribute to longer survival of the graft and recipient. Older donor age and proteinuria could predict post-transplant hypertension. Low diastolic BP of the recipient could increase the risk of death among KTRs. Despite the fact that ABPM is the blood pressure measurement method of choice, appropriate standard office measurement could also be used for BP monitoring.
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Affiliation(s)
- Tomasz Pilecki
- Department of Immunology, Transplantology, and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | | | - Wojciech Lisik
- Chair and Department of General and Transplantation Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Sławomir Nazarewski
- Chair and Department of General, Vascular and Transplant Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Leszek Pączek
- Department of Immunology, Transplantology, and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
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Bae SR, Bicki A, Coufal S, Jin E, Ku E. Cardiovascular disease risk factors and lifestyle modification strategies after pediatric kidney transplantation: what are we dealing with, and what can we target? Pediatr Nephrol 2023; 38:663-671. [PMID: 35552523 PMCID: PMC10799690 DOI: 10.1007/s00467-022-05589-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 04/14/2022] [Accepted: 04/15/2022] [Indexed: 01/19/2023]
Abstract
Kidney transplantation in pediatric patients can lead to partial improvement of some of the cardiometabolic parameters that increase the risk for cardiovascular disease (CVD) in patients with chronic kidney disease. However, even after restoration of kidney function, transplant recipients remain at risk for CVD due to the continual presence of traditional and non-traditional risk factors, including the side effects of immunosuppression and chronic inflammation. This educational review describes the prevalence of CVD risk factors in pediatric kidney transplant recipients and presents available evidence for therapeutic lifestyle changes and other non-pharmacologic strategies that can be used to improve traditional and modifiable CVD risk factors. Although trial-grade evidence for interventions that improve CVD in pediatric kidney transplant recipients is limited, potential strategies include lowering dietary sodium and saturated fat intake and increasing physical activity levels. Intensive follow-up may help patients achieve guideline-recommended goals for reducing their overall CVD risk.
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Affiliation(s)
- Se Ri Bae
- University of California, Davis, School of Medicine, Sacramento, CA, USA
| | - Alexandra Bicki
- Division of Pediatric Nephrology, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA.
| | - Sarah Coufal
- Division of Nephrology, Department of Medicine and Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Ethan Jin
- College of Osteopathic Medicine, Touro University, Vallejo, CA, USA
| | - Elaine Ku
- Division of Pediatric Nephrology, Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
- Division of Nephrology, Department of Medicine and Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
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Sugianto RI, Ostendorf K, Bauer E, von der Born J, Oh J, Kemper MJ, Buescher R, Schmidt BMW, Memaran N, Melk A. Arterial stiffness and blood pressure increase in pediatric kidney transplant recipients. Pediatr Nephrol 2023; 38:1319-1327. [PMID: 36094669 PMCID: PMC9925540 DOI: 10.1007/s00467-022-05611-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 05/02/2022] [Accepted: 05/03/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Pulse wave velocity (PWV) is a measure of arterial stiffness. We investigated PWV and blood pressure (BP) to determine to what extent BP changes contribute to arterial stiffness, and secondly, to identify influencing factors on BP in children after kidney transplantation. METHODS Seventy children ≥ 2.5 years post-transplantation with at least two PWV measurements were included. Changes of systolic (Δ SBP) and diastolic BP (Δ DBP) were classified into "stable/decreasing," "1-10 mmHg increase," and " > 10 mmHg increase." Linear mixed modeling for PWV z-score (PWVz) adjusted either for Δ SBP or Δ DBP was performed. An extended dataset with monthly entries of BP, immunosuppression, and creatinine was obtained in 35 participants over a median of 74 months to perform linear mixed modeling for SBP and DBP. RESULTS PWVz increased with a rate of 0.11/year (95% CI 0.054 to 0.16). Compared to participants with stable BP, those with 1-10-mmHg SBP and DBP increase showed a higher PWVz of 0.59 (95% CI 0.046 to 1.13) and 0.86 (95% CI 0.43 to 1.30), respectively. A > 10-mmHg BP increase was associated with an even higher PWVz (SBP β = 0.78, 95% CI 0.22 to 1.34; DBP β = 1.37, 95% CI 0.80 to 1.94). Female sex and participants with lower eGFR showed higher PWVz. In the extended analysis, DBP was positively associated with cyclosporin A and everolimus trough levels. CONCLUSIONS A higher increase of PWV is seen in patients with greater BP increase, with higher cyclosporin A and everolimus trough levels associated with higher BP. This emphasizes the role of BP as a modifiable risk factor for the improvement of cardiovascular outcome after transplantation. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Rizky Indrameikha Sugianto
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Children's Hospital, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Karen Ostendorf
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Children's Hospital, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Elena Bauer
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Children's Hospital, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Jeannine von der Born
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Children's Hospital, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Jun Oh
- University Children's Hospital, University Medical Center-Hamburg-Eppendorf, Hamburg, Germany
| | - Markus J Kemper
- Department of Pediatrics and Adolescent Medicine, Asklepios Hospital Nord-Heidberg, Hamburg, Germany
| | - Rainer Buescher
- University Children's Hospital, Essen University Hospital, Essen, Germany
| | - Bernhard M W Schmidt
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Nima Memaran
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Children's Hospital, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Anette Melk
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Children's Hospital, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
- Children's Hospital, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
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9
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Cardiovascular Risk after Kidney Transplantation: Causes and Current Approaches to a Relevant Burden. J Pers Med 2022; 12:jpm12081200. [PMID: 35893294 PMCID: PMC9329988 DOI: 10.3390/jpm12081200] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 07/11/2022] [Accepted: 07/20/2022] [Indexed: 11/17/2022] Open
Abstract
Background. Cardiovascular disease is a frequent complication after kidney transplantation and represents the leading cause of mortality in this population. Material and Methods. We searched for the relevant articles in the National Institutes of Health library of medicine, transplant, cardiologic and nephrological journals. Results. The pathogenesis of cardiovascular disease in kidney transplant is multifactorial. Apart from non-modifiable risk factors, such as age, gender, genetic predisposition and ethnicity, several traditional and non-traditional modifiable risk factors contribute to its development. Traditional factors, such as diabetes, hypertension and dyslipidemia, may be present before and may worsen after transplantation. Immunosuppressants and impaired graft function may strongly influence the exacerbation of these comorbidities. However, in the last years, several studies showed that many other cardiovascular risk factors may be involved in kidney transplantation, including hyperuricemia, inflammation, low klotho and elevated Fibroblast Growth Factor 23 levels, deficient levels of vitamin D, vascular calcifications, anemia and poor physical activity and quality of life. Conclusions. The timely and effective treatment of time-honored and recently discovered modifiable risk factors represent the basis of the prevention of cardiovascular complications in kidney transplantation. Reduction of cardiovascular risk can improve the life expectancy, the quality of life and the allograft function and survival.
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10
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Jan MY, Moe SM, Adebiyi O, Chen J, Powelson J, Burney HN, Yaqub MS, Mishler DP, Moorthi RN, Taber TE, Anderson MD, Li Y, Li X, Fridell JA, Goggins WC, Sharfuddin AA. Vasopressin for Post-kidney Transplant Hypotension. Kidney Int Rep 2022; 7:1364-1376. [PMID: 35694563 PMCID: PMC9174042 DOI: 10.1016/j.ekir.2022.03.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 03/24/2022] [Accepted: 03/29/2022] [Indexed: 12/02/2022] Open
Abstract
Introduction Hypotension after deceased donor kidney transplant (DDKT) is a risk factor for delayed graft function (DGF) and poor graft survival (GS). We hypothesize that vasopressin use in hypotensive DDKT recipients (DDKTRs) to increase blood pressure (BP) reduces DGF rates and is safe without increasing mortality. Methods Group with vasopressin "study group" (n = 45) was defined as DDKTRs between 2012 and 2017 who required vasopressin for hypotension systolic BP (SBP) <120 mm Hg or diastolic BP (DBP) <60 mm Hg. DDKTRs with no-vasopressin "comparison group" (n = 90) were propensity score-matched DDKTRs between 2012 and 2017 without vasopressin use. Primary outcomes were GS, creatinine and allograft biopsy rate at 1 year, DGF rate, and death during transplant hospitalization. Results Vasopressin group had lower mean maximum and minimum SBP and DBP in the operating room (OR). Median vasopressin start time post-DDKT was 2 hours (interquartile range [IQR] 1-6), and duration of use was 42 hours (IQR 24-63). DGF, creatinine at 1 year, and allograft biopsy rates were comparable. No deaths occurred during transplant hospitalization. Multivariable analysis did not find an effect of vasopressin use on GS. Conclusion Treatment of hypotensive DDKTRs with vasopressin is safe and facilitated similar graft function and survival with that of nonhypotensive patients. In the absence of a randomized control trial, our study supports the safety of vasopressin therapy to prevent the adverse effects of hypotension.
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Affiliation(s)
- Muhammad Y. Jan
- Division of Nephrology and Hypertension, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Sharon M. Moe
- Division of Nephrology and Hypertension, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Indiana Clinical and Translational Sciences Institute, Indianapolis, Indiana, USA
| | - Oluwafisayo Adebiyi
- Division of Nephrology and Hypertension, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jeannie Chen
- Department of Pharmacy, Indiana University Health, Indianapolis, Indiana, USA
| | - John Powelson
- Division Transplant Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Heather N. Burney
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Muhammad S. Yaqub
- Division of Nephrology and Hypertension, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Dennis P. Mishler
- Division of Nephrology and Hypertension, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Ranjani N. Moorthi
- Division of Nephrology and Hypertension, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Tim E. Taber
- Division of Nephrology and Hypertension, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Melissa D. Anderson
- Division of Nephrology and Hypertension, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Yang Li
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Xiaochun Li
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jonathan A. Fridell
- Division Transplant Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - William C. Goggins
- Division Transplant Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Asif A. Sharfuddin
- Division of Nephrology and Hypertension, Indiana University School of Medicine, Indianapolis, Indiana, USA
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11
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Drawz PE, Beddhu S, Bignall ONR, Cohen JB, Flynn JT, Ku E, Rahman M, Thomas G, Weir MR, Whelton PK. KDOQI US Commentary on the 2021 KDIGO Clinical Practice Guideline for the Management of Blood Pressure in CKD. Am J Kidney Dis 2022; 79:311-327. [PMID: 35063302 DOI: 10.1053/j.ajkd.2021.09.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 09/26/2021] [Indexed: 12/13/2022]
Abstract
The Kidney Disease Outcomes Quality Initiative (KDOQI) convened a work group to review the 2021 KDIGO (Kidney Disease: Improving Global Outcomes) guideline for the management of blood pressure in chronic kidney disease (CKD). This commentary is the product of that work group and presents the recommendations and practice points from the KDIGO guideline in the context of US clinical practice. A critical addition to the KDIGO guideline is the recommendation for accurate assessment of blood pressure using standardized office blood pressure measurement. In the general adult population with CKD, KDIGO recommends a goal systolic blood pressure less than 120 mm Hg on the basis of results from the Systolic Blood Pressure Intervention Trial (SPRINT) and secondary analyses of the Action to Control Cardiovascular Risk in Diabetes-Blood Pressure (ACCORD-BP) trial. The KDOQI work group agreed with most of the recommendations while highlighting the weak evidence base especially for patients with diabetes and advanced CKD.
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Affiliation(s)
- Paul E Drawz
- Division of Nephrology and Hypertension, University of Minnesota, Minneapolis, Minnesota.
| | | | - O N Ray Bignall
- Department of Pediatrics, The Ohio State University College of Medicine, Division of Nephrology and Hypertension, Nationwide Children's Hospital, Columbus, Ohio
| | - Jordana B Cohen
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Joseph T Flynn
- Department of Pediatrics, University of Washington School of Medicine, Division of Nephrology, Seattle Children's Hospital, Seattle, Washington
| | - Elaine Ku
- University of California-San Francisco, San Francisco, California
| | - Mahboob Rahman
- University Hospitals Cleveland Medical Center, Case Western Reserve University, Louis Stokes Cleveland VA Medical Center Cleveland, Ohio
| | - George Thomas
- Department of Kidney Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Matthew R Weir
- Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Paul K Whelton
- Department of Epidemiology, Tulane University School of Public Health & Tropical Medicine, New Orleans, Louisiana
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12
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Pisano A, Mallamaci F, D'Arrigo G, Bolignano D, Wuerzner G, Ortiz A, Burnier M, Kanaan N, Sarafidis P, Persu A, Ferro CJ, Loutradis C, Boletis IN, London G, Halimi JM, Sautenet B, Rossignol P, Vogt L, Zoccali C. Assessment of hypertension in kidney transplantation by ambulatory blood pressure monitoring: a systematic review and meta-analysis. Clin Kidney J 2022; 15:31-42. [PMID: 35035934 PMCID: PMC8757429 DOI: 10.1093/ckj/sfab135] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Indexed: 01/20/2023] Open
Abstract
Background Hypertension (HTN) is common following renal transplantation and it is associated with adverse effects on cardiovascular (CV) and graft health. Ambulatory blood pressure monitoring (ABPM) is the preferred method to characterize blood pressure (BP) status, since HTN misclassification by office BP (OBP) is quite common in this population. We performed a systematic review and meta-analysis aimed at determining the clinical utility of 24-h ABPM and its potential implications for the management of HTN in this population. Methods Ovid-MEDLINE and PubMed databases were searched for interventional or observational studies enrolling adult kidney transplant recipients (KTRs) undergoing 24-h ABP readings compared with OBP or home BP. The main outcome was the proportion of KTRs diagnosed with HTN by ABPM, home or OBP recordings. Additionally, day-night BP variability and dipper/non-dipper status were assessed. Results Forty-two eligible studies (4115 participants) were reviewed. A cumulative analysis including 27 studies (3481 participants) revealed a prevalence of uncontrolled HTN detected by ABPM of 56% [95% confidence interval (CI) 46-65%]. The pooled prevalence of uncontrolled HTN according to OBP was 47% (95% CI 36-58%) in 25 studies (3261 participants). Very few studies reported on home BP recordings. The average concordance rate between OBP and ABPM measurements in classifying patients as controlled or uncontrolled hypertensive was 66% (95% CI 59-73%). ABPM revealed HTN phenotypes among KTRs. Two pooled analyses of 11 and 10 studies, respectively, revealed an average prevalence of 26% (95% CI 19-33%) for masked HTN (MHT) and 10% (95% CI 6-17%) for white-coat HTN (WCH). The proportion of non-dippers was variable across the 28 studies that analysed dipping status, with an average prevalence of 54% (95% CI 45-63%). Conclusions In our systematic review, comparison of OBP versus ABP measurements disclosed a high proportion of MHT, uncontrolled HTN and, to a lesser extent, WCH in KTRs. These results suggest that HTN is not adequately diagnosed and controlled by OBP recordings in this population. Furthermore, the high prevalence of non-dippers confirmed that circadian rhythm is commonly disturbed in KTRs.
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Affiliation(s)
- Anna Pisano
- CNR-Institute of Clinical Physiology, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio Calabria, Italy
| | - Francesca Mallamaci
- CNR-Institute of Clinical Physiology, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio Calabria, Italy
| | - Graziella D'Arrigo
- CNR-Institute of Clinical Physiology, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio Calabria, Italy
| | - Davide Bolignano
- CNR-Institute of Clinical Physiology, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio Calabria, Italy
| | - Gregoire Wuerzner
- Service of Nephrology and Hypertension, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Alberto Ortiz
- Nephrology and Hypertension, IIS-Fundacion Jimenez Diaz UAM, Madrid, Spain
| | - Michel Burnier
- Service of Nephrology and Hypertension, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Nada Kanaan
- Division of Nephrology, Division of Cardiology, Cliniques Universitaires Saint-Luc and Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Greece
| | - Alexandre Persu
- Division of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Charles J Ferro
- Department of Renal Medicine, University Hospitals Birmingham and Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Charalampos Loutradis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Greece
| | - Ioannis N Boletis
- Department of Nephrology and Renal Transplantation, Athens Medical School, Laiko Hospital
| | - Gérard London
- FCRIN INI-CRCT Cardiovascular and Renal Clinical Trialists, Manhes Hospital and FCRIN INI-CRCT, Manhes, France
| | - Jean-Michel Halimi
- Service de Néphrologie-Hypertension, Dialyses, Transplantation rénale, CHRU Tours,Tours, France and INSERM SPHERE U1246, Université Tours, Université de Nantes, Tours, France
| | - Bénédicte Sautenet
- Service de Néphrologie-Hypertension, Dialyses, Transplantation rénale, CHRU Tours, Tours, France and INSERM SPHERE U1246, Université Tours, Université de Nantes, Tours, France, and FCRIN INI-CRCT, Nancy, France
| | - Patrick Rossignol
- Université de Lorraine, Inserm 1433 CIC-P CHRU de Nancy, Inserm U1116 and FCRIN INI-CRCT, Nancy, France
| | - Liffert Vogt
- Department of Internal Medicine, Section Nephrology, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Carmine Zoccali
- CNR-Institute of Clinical Physiology, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio Calabria, Italy
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13
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Nishimura N, Hori S, Tomizawa M, Yoneda T, Nakai Y, Miyake M, Torimoto K, Tanaka N, Fujimoto K. Relevance of the perioperative edema index measured by bioelectrical impedance analysis for prediction of cardiovascular disease in living-donor kidney transplantation. Int J Urol 2022; 29:309-316. [PMID: 34973157 DOI: 10.1111/iju.14772] [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: 08/23/2021] [Accepted: 12/01/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Perioperative management of fluid status during kidney transplantation is important, because volume overload can increase the risk of cardiovascular disease in recipients. The edema index calculated by bioelectrical impedance analysis is commonly used to correctly evaluate fluid status. We evaluated the relevance of the edema index for cardiovascular disease in kidney transplant recipients, and searched for predictors of high edema index in the perioperative period during kidney transplantation. METHODS A total of 88 recipients were included in this study. The group in which the edema index at discharge was >0.40 was termed as the "high edema index group", and that with ≤0.40 was termed as the "low edema index group". We assessed cardiovascular disease-free survival and cardiovascular disease-specific survival in the two groups by using Cox proportional regression analyses adjusted by inverse probability of treatment weighting analysis. The patients' background and conventional cardiovascular disease risk factors were assessed to estimate predictors for a high edema index. RESULTS A high edema index was significantly associated with short cardiovascular disease-free survival after kidney transplantation (hazard ratio 10.01; P < 0.05) in the inverse probability of treatment weighting model. There were no significant differences in the cardiovascular disease-specific survival. In multivariate logistic regression analyses, non-pre-emptive kidney transplantation and dyslipidemia were significant independent predictors of a high edema index (odds ratio 3.59, P < 0.05 and odds ratio 4.05, P < 0.01, respectively). CONCLUSIONS A high edema index is associated with the incidence of cardiovascular disease. Overhydration should be especially avoided in recipients with these factors, and their fluid volume should be carefully managed.
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Affiliation(s)
| | - Shunta Hori
- Department of Urology, Nara Medical University, Kashihara, Nara, Japan
| | - Mitsuru Tomizawa
- Department of Urology, Nara Medical University, Kashihara, Nara, Japan
| | - Tatsuo Yoneda
- Department of Urology, Nara Medical University, Kashihara, Nara, Japan
| | - Yasushi Nakai
- Department of Urology, Nara Medical University, Kashihara, Nara, Japan
| | - Makito Miyake
- Department of Urology, Nara Medical University, Kashihara, Nara, Japan
| | - Kazumasa Torimoto
- Department of Urology, Nara Medical University, Kashihara, Nara, Japan
| | - Nobumichi Tanaka
- Department of Urology, Nara Medical University, Kashihara, Nara, Japan
| | - Kiyohide Fujimoto
- Department of Urology, Nara Medical University, Kashihara, Nara, Japan
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14
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Rizk JG, Lazo JG, Quan D, Gabardi S, Rizk Y, Streja E, Kovesdy CP, Kalantar-Zadeh K. Mechanisms and management of drug-induced hyperkalemia in kidney transplant patients. Rev Endocr Metab Disord 2021; 22:1157-1170. [PMID: 34292479 DOI: 10.1007/s11154-021-09677-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/16/2021] [Indexed: 10/20/2022]
Abstract
Hyperkalemia is a common and potentially life-threatening complication following kidney transplantation that can be caused by a composite of factors such as medications, delayed graft function, and possibly potassium intake. Managing hyperkalemia after kidney transplantation is associated with increased morbidity and healthcare costs, and can be a cause of multiple hospital admissions and barriers to patient discharge. Medications used routinely after kidney transplantation are considered the most frequent culprit for post-transplant hyperkalemia in recipients with a well-functioning graft. These include calcineurin inhibitors (CNIs), pneumocystis pneumonia (PCP) prophylactic agents, and antihypertensives (angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta blockers). CNIs can cause hyperkalemic renal tubular acidosis. When hyperkalemia develops following transplantation, the potential offending medication may be discontinued, switched to another agent, or dose-reduced. Belatacept and mTOR inhibitors offer an alternative to calcineurin inhibitors in the event of hyperkalemia, however should be prescribed in the appropriate patient. While trimethoprim/sulfamethoxazole (TMP/SMX) remains the gold standard for prevention of PCP, alternative agents (e.g. dapsone, atovaquone) have been studied and can be recommend in place of TMP/SMX. Antihypertensives that act on the Renin-Angiotensin-Aldosterone System are generally avoided early after transplant but may be indicated later in the transplant course for patients with comorbidities. In cases of mild to moderate hyperkalemia, medical management can be used to normalize serum potassium levels and allow the transplant team additional time to evaluate the function of the graft. In the immediate post-operative setting following kidney transplantation, a rapidly rising potassium refractory to medical therapy can be an indication for dialysis. Patiromer and sodium zirconium cyclosilicate (ZS-9) may play an important role in the management of chronic hyperkalemia in kidney transplant patients, although additional long-term studies are necessary to confirm these effects.
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Affiliation(s)
- John G Rizk
- Arizona State University, Edson College, Phoenix, AZ, USA.
| | - Jose G Lazo
- UCSF Medical Center, University of California San Francisco, San Francisco, CA, USA
| | - David Quan
- UCSF Medical Center, University of California San Francisco, San Francisco, CA, USA
| | - Steven Gabardi
- Department of Transplant Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Youssef Rizk
- Department of Internal Medicine, Division of Family Medicine, Lebanese American University Medical Center - St. John's Hospital, Beirut, Lebanon
| | - Elani Streja
- Department of Medicine, Division of Nephrology, Hypertension and Kidney Transplantation, School of Medicine, University of California, CA, Irvine, Orange, USA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Kamyar Kalantar-Zadeh
- Department of Medicine, Division of Nephrology, Hypertension and Kidney Transplantation, School of Medicine, University of California, CA, Irvine, Orange, USA
- Department of Epidemiology, University of California, UCLA Fielding School of Public Health, Los Angeles, CA, USA
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15
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Abstract
Cardiovascular disease remains a leading cause of death and morbidity in kidney transplant recipients and a common reason for post-transplant hospitalization. Several traditional and nontraditional cardiovascular risk factors exist, and many of them present pretransplant and worsened, in part, due to the addition of immunosuppression post-transplant. We discuss optimal strategies for identification and treatment of these risk factors, including the emerging role of sodium-glucose cotransporter 2 inhibitors in post-transplant diabetes and cardiovascular disease. We present common types of cardiovascular disease observed after kidney transplant, including coronary artery disease, heart failure, pulmonary hypertension, arrhythmia, and valvular disease. We also discuss screening, treatment, and prevention of post-transplant cardiac disease. We highlight areas of future research, including the need for goals and best medications for risk factors, the role of biomarkers, and the role of screening and intervention.
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Affiliation(s)
- Kelly A. Birdwell
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Meyeon Park
- Division of Nephrology, Department of Medicine, University of California, San Francisco, California
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16
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Ibrahim HN, Murad DN, Knoll GA. Thinking Outside the Box: Novel Kidney Protective Strategies in Kidney Transplantation. Clin J Am Soc Nephrol 2021; 16:1890-1897. [PMID: 33757985 PMCID: PMC8729499 DOI: 10.2215/cjn.15070920] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Despite the reduction in the incidence of acute rejection, a major risk factor for graft loss, there has been only modest improvement in long-term graft survival. Most cases of kidney graft loss have an identifiable cause that is not idiopathic fibrosis/atrophy or calcineurin inhibitor nephrotoxicity. Distinct immunologic and nonimmunologic factors conspire to lead to a common pathway of allograft fibrosis. It remains plausible that mitigating nonimmunologic damage using strategies proven effective in native kidney disease may yield benefit in kidney transplantation. In this review, we will focus on nonimmunologic aspects of kidney transplant care that may prove to be valuable adjuncts to a well-managed immunosuppression regimen. Topics to be addressed include the roles of hypertension and agents used to treat it, lipid lowering, sodium and water intake, elevated uric acid, metabolic acidosis, and the use of sodium-glucose cotransporter 2 inhibitors on long-term kidney transplant health.
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Affiliation(s)
- Hassan N. Ibrahim
- Division of Renal Diseases and Hypertension, Department of Medicine, Houston Methodist Hospital, Houston, Texas
| | - Dina N. Murad
- Division of Renal Diseases and Hypertension, Department of Medicine, Houston Methodist Hospital, Houston, Texas
| | - Greg A. Knoll
- Division of Nephrology, Department of Medicine, Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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17
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Billany RE, Vadaszy N, Bishop NC, Wilkinson TJ, Adenwalla SF, Robinson KA, Croker K, Brady EM, Wormleighton JV, Parke KS, Cooper NJ, Webster AC, Barratt J, McCann GP, Burton JO, Smith AC, Graham-Brown MP. A pilot randomised controlled trial of a structured, home-based exercise programme on cardiovascular structure and function in kidney transplant recipients: the ECSERT study design and methods. BMJ Open 2021; 11:e046945. [PMID: 34610929 PMCID: PMC8493915 DOI: 10.1136/bmjopen-2020-046945] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Cardiovascular disease (CVD) is a major cause of morbidity and mortality in kidney transplant recipients (KTRs). CVD risk scores underestimate risk in this population as CVD is driven by clustering of traditional and non-traditional risk factors, which lead to prognostic pathological changes in cardiovascular structure and function. While exercise may mitigate CVD in this population, evidence is limited, and physical activity levels and patient activation towards exercise and self-management are low. This pilot study will assess the feasibility of delivering a structured, home-based exercise intervention in a population of KTRs at increased cardiometabolic risk and evaluate the putative effects on cardiovascular structural and functional changes, cardiorespiratory fitness, quality of life, patient activation, healthcare utilisation and engagement with the prescribed exercise programme. METHODS AND ANALYSIS Fifty KTRs will be randomised 1:1 to: (1) the intervention; a 12week, home-based combined resistance and aerobic exercise intervention; or (2) the control; usual care. Intervention participants will have one introductory session for instruction and practice of the recommended exercises prior to receiving an exercise diary, dumbbells, resistance bands and access to instructional videos. The study will evaluate the feasibility of recruitment, randomisation, retention, assessment procedures and the intervention implementation. Outcomes, to be assessed prior to randomisation and postintervention, include: cardiac structure and function with stress perfusion cardiac MRI, cardiorespiratory fitness, physical function, blood biomarkers of cardiometabolic health, quality of life and patient activation. These data will be used to inform the power calculations for future definitive trials. ETHICS AND DISSEMINATION The protocol was reviewed and given favourable opinion by the East Midlands-Nottingham 2 Research Ethics Committee (reference: 19/EM/0209; 14 October 2019). Results will be published in peer-reviewed academic journals and will be disseminated to the patient and public community via social media, newsletter articles and presentations at conferences. TRIAL REGISTRATION NUMBER NCT04123951.
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Affiliation(s)
- Roseanne E Billany
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Noemi Vadaszy
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Nicolette C Bishop
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | | | - Sherna F Adenwalla
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | - Kathryn Croker
- John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Emer M Brady
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | | | - Kelly S Parke
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- Department of Radiology, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Nicola J Cooper
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Angela C Webster
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Renal and Transplant Research, Westmead Hospital, Westmead, New South Wales, Australia
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - James O Burton
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Alice C Smith
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Matthew Pm Graham-Brown
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
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18
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Posttransplant Hypertension Matters! Transplantation 2021; 105:e150. [PMID: 34591816 DOI: 10.1097/tp.0000000000003831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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19
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Update on Treatment of Hypertension After Renal Transplantation. Curr Hypertens Rep 2021; 23:25. [PMID: 33961145 DOI: 10.1007/s11906-021-01151-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE OF REVIEW To incorporate novel findings on pathophysiology and treatment of posttransplant hypertension. RECENT FINDINGS (1) The sodium retaining effects of CNIs are mediated by stimulation of the thiazide-sensitive sodium chloride co-transporter in the distal convoluted tubule and in this regard chlorthalidone was proven to be an effective antihypertensive drug in renal transplantation. (2) Local and not systemic activation of the renin-angiotensin-aldosterone system plays a crucial role in the pathogenesis of posttransplant hypertension. (3) Recent randomized controlled trials failed to prove the presumed superiority of renin-angiotensin blockers in kidney transplantation. (4) Steroid-free and mammalian target of rapamycin-based immunosuppressive drug combinations did not show favorable effects on blood pressure control. (5) In a recent report the risk of non-melanoma skin cancer was higher with thiazide diuretics. But the increased cancer risk in transplant recipients is mainly attributed to comorbidities, such as diabetes and hypertension and of course to the transplantation condition itself or the obligatory application of immunosuppression, and has little to do with the antihypertensive medication Actual recommendations about BP targets in adult renal transplant recipients are coming from a post hoc analysis of a large randomized trial with another primary endpoint. Unless convincing studies on treatment of hypertension after renal transplantation are available, the ESC/ESH Guidelines 2018 should apply for these patients.
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20
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Kimura T, Ushigome E, Hashimoto Y, Nakanishi N, Hamaguchi M, Asano M, Yamazaki M, Fukui M. Home-Measured Blood Pressure Is Associated with Handgrip Strength in Patients with Type 2 Diabetes: The KAMOGAWA-HBP Study. J Clin Med 2021; 10:1913. [PMID: 33925028 PMCID: PMC8125019 DOI: 10.3390/jcm10091913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 04/17/2021] [Accepted: 04/26/2021] [Indexed: 12/02/2022] Open
Abstract
The association between blood pressure measured at home and handgrip strength in patients with diabetes has not been investigated. Therefore, in this study, we aimed to assess this association among patients with type 2 diabetes. In this cross-sectional study, 157 patients with type 2 diabetes underwent muscle tests and morning and evening blood-pressure measurements at home in triplicate for 14 consecutive days throughout the study period. Univariate and multivariate regression analyses were conducted to analyze the relationship between home blood-pressure parameters and handgrip strength. The average age and hemoglobin A1c of the patients were 70.5 years and 7.1%, respectively. Morning diastolic blood pressure of [β (95% confidence interval; CI): 0.20 (0.03, 0.37)] was associated with handgrip strength in men, while morning systolic blood pressure of [-0.09 (-0.15, -0.04)], morning pulse pressure of [-0.14 (-0.21, -0.08)], and evening pulse pressure of [-0.12 (-0.19, -0.04)] were associated with handgrip strength in women. Home-measured blood pressure was associated with handgrip strength. Sex differences were found in the relationship between home blood-pressure parameters and handgrip strength.
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Affiliation(s)
| | - Emi Ushigome
- Department of Endocrinology and Metabolism, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto 602-8566, Japan; (T.K.); (Y.H.); (N.N.); (M.H.); (M.A.); (M.Y.); (M.F.)
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21
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Blood Pressure Treatment in Kidney Transplant Recipients-Can We Improve? Transplant Direct 2021; 7:e688. [PMID: 33786373 PMCID: PMC7997102 DOI: 10.1097/txd.0000000000001142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 01/29/2021] [Accepted: 02/08/2021] [Indexed: 12/31/2022] Open
Abstract
Hypertension in kidney transplant (KTx) recipients is common, affecting both patient and graft survival. Annual data from the Norwegian Renal Registry reveal that <50% of adult (>18 y) KTx recipients reach target blood pressure (BP) ≤130/80 mm Hg. The aim of this study was to identify the determinants of failure to achieve BP control.
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22
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Cheung AK, Chang TI, Cushman WC, Furth SL, Hou FF, Ix JH, Knoll GA, Muntner P, Pecoits-Filho R, Sarnak MJ, Tobe SW, Tomson CR, Mann JF. KDIGO 2021 Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease. Kidney Int 2021; 99:S1-S87. [PMID: 33637192 DOI: 10.1016/j.kint.2020.11.003] [Citation(s) in RCA: 412] [Impact Index Per Article: 137.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 11/02/2020] [Indexed: 12/19/2022]
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23
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Frequency and Patterns of Prescribing Antihypertensive Agents in Outpatient Kidney Transplant Recipients Among Six Cities in China from 2011 to 2018. Clin Ther 2021; 43:602-612. [PMID: 33637331 DOI: 10.1016/j.clinthera.2021.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 12/27/2020] [Accepted: 01/11/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE Antihypertensive agents are frequently prescribed in kidney transplant recipients (KTRs). However, the frequency and patterns of prescribing antihypertensive agents remain uncharacterized in KTRs in China. Therefore, this investigation was carried out. METHODS Retrospective prescription data dated 2011 to 2018 from KTRs in China were accessed using the Hospital Prescription Analysis Program database. Information about sex, birth date, and identification number of the patient; city, date, and department of the medical visit; major diagnoses; and the generic names, specifications, quantities, and usage of prescribed drugs were collected. Antihypertensive agents were grouped into 5 classes: angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), β-blockers (BBs), calcium channel blockers (CCBs), and diuretics. The frequency and patterns of prescribing these antihypertensive agents were analyzed. FINDINGS Prescriptions from 174,749 KTRs (67.2% male; mean age, 42.5 [9.4] years) were obtained, and 58.2% of the patients were prescribed antihypertensive agents. The percentage of patients who received antihypertensive treatment increased from 52.9% in 2011 to 61.6% in 2018 and varied by city. Cyclosporine was associated with higher prescription frequency of antihypertensive agents than was tacrolimus (71.7% vs 63.4%; P < 0.0001). During the 8-year study period, CCBs were most frequently prescribed (39.0%), followed by ARBs (31.9%), BBs (14.3%), ACEIs (11.6%), and diuretics (3.2%). The mean (SD) number of antihypertensive drugs prescribed per KTR was 1.7 (0.8). Almost half of KTRs (51.2%) received just 1 antihypertensive drug. Co-administration of 2 or more antihypertensive drugs presented an obviously upward trend. The most commonly prescribed 2-drug combination was CCB + ARB (44.8%), followed by CCB + BB (20.1%) and CCB + ACEI (13.0%). In the patients who received 3 antihypertensive drugs, the 2 most frequently prescribed combinations were CCB + ARB + BB (37.5%) and CCB + ARB + ACEI (32.7%). Specific data varied by both year and city. IMPLICATIONS The prescribing patterns of antihypertensive agents in KTRs varied by city even within same country. Hence, more high-quality research studies on the use of antihypertensive agents in KTRs are needed.
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24
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Charnaya O, Seifert M. Promoting cardiovascular health post-transplant through early diagnosis and adequate management of hypertension and dyslipidemia. Pediatr Transplant 2021; 25:e13811. [PMID: 32871051 DOI: 10.1111/petr.13811] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/18/2020] [Accepted: 07/13/2020] [Indexed: 12/17/2022]
Abstract
Despite correction of underlying solid organ failure by transplantation, pediatric transplant recipients still have increased mortality rates compared to the general pediatric population, in part due to increased cardiovascular risk. In particular, pediatric kidney and non-kidney transplant recipients with chronic kidney disease have significant cardiovascular risk that worsens with declining kidney function. Biomarkers associated with future cardiovascular risk such as casual and ambulatory hypertension, dyslipidemia, vascular stiffness and calcification, and left ventricular hypertrophy can be detected throughout the post-transplant period and in patients with stable kidney function. Among these, hypertension and dyslipidemia are two potentially modifiable cardiovascular risk factors that are highly prevalent in kidney and non-kidney pediatric transplant recipients. Standardized approaches to appropriate BP measurement and lipid monitoring are needed to detect and address these risk factors in a timely fashion. To achieve sustained improvement in cardiovascular health, clinicians should partner with patients and their caregivers to address these and other risk factors with a combined approach that integrates pharmacologic with non-pharmacologic approaches. This review outlines the scope and impact of hypertension and dyslipidemia in pediatric transplant recipients, with a particular focus on pediatric kidney transplantation given the high burden of chronic kidney disease-associated cardiovascular risk. We also review the current published guidelines for monitoring and managing abnormalities in blood pressure and lipids, highlighting the important role of therapeutic lifestyle changes in concert with antihypertensive and lipid-lowering medications.
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Affiliation(s)
- Olga Charnaya
- Department of Pediatrics, Johns Hopkins University, Baltimore, MD, USA
| | - Michael Seifert
- Department of Pediatrics, University of Alabama School of Medicine, Birmingham, AL, USA
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25
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Yazdani B, Kleber ME, Yücel G, Delgado GE, Benck U, Krüger B, März W, Krämer BK. Association of double product and pulse pressure with cardiovascular and all-cause mortality in the LURIC study. J Clin Hypertens (Greenwich) 2020; 22:2332-2342. [PMID: 33035393 DOI: 10.1111/jch.14067] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 09/08/2020] [Accepted: 09/10/2020] [Indexed: 12/22/2022]
Abstract
Systolic (SBP) and diastolic blood pressure (DBP) and mean arterial pressure (MAP) are risk factors for cardiovascular mortality (CVM). Pulse pressure (PP) is considered as an easily available marker of vascular stiffness and the double product (DP) as a marker of cardiac workload. Therefore, we have examined the predictive value of PP and DP in the Ludwigshafen Risk and Cardiovascular Health study, a monocentric cohort study of 3316 patients referred to coronary angiography. An increase of SBP or PP by 1mmHg increased the risk of CVM with hazard ratios of 1.009 (95% CI, 1.005-1.012) and 1.016 (1.012-1.020), respectively. Increasing DP by 100 mm Hg/min was associated with a 1.010 (1.007-1.013) higher risk of CVM. In patient subgroups with coronary artery disease (CAD) and heart failure (HF), PP and DP predicted CVM better than SBP or MAP. In a multivariate analysis adjusted for sex, BMI, diabetes, eGFR, hazard ratios for CVM for z-standardized PP, DP, SBP, and HR were 1.20, 1.16, 1.12, and 1.14. After adding age to the multivariate analysis, only DP and HR remained significant. We provide evidence that PP and DP are powerful predictors of CVM and all-cause mortality in a CV medium- to high-risk population, especially in patients with CAD and HF. While DP proved to be an independent predictor of cardiovascular and all-cause mortality also in multivariate analysis, PP was no independent predictor in our cohort with widespread antihypertensive treatment (>85%). PP is associated with age, presence of diabetes, obesity, and impaired renal function.
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Affiliation(s)
- Babak Yazdani
- Fifth Department of Medicine, University Medical Center Mannheim UMM, Mannheim, Germany.,Faculty of Medicine of the University of Heidelberg, Mannheim, Germany
| | - Marcus E Kleber
- Fifth Department of Medicine, University Medical Center Mannheim UMM, Mannheim, Germany.,Faculty of Medicine of the University of Heidelberg, Mannheim, Germany
| | - Gökhan Yücel
- Fifth Department of Medicine, University Medical Center Mannheim UMM, Mannheim, Germany.,Faculty of Medicine of the University of Heidelberg, Mannheim, Germany
| | - Graciela E Delgado
- Fifth Department of Medicine, University Medical Center Mannheim UMM, Mannheim, Germany.,Faculty of Medicine of the University of Heidelberg, Mannheim, Germany.,Center for Preventive Medicine Baden-Württemberg (CPMBW), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Urs Benck
- Fifth Department of Medicine, University Medical Center Mannheim UMM, Mannheim, Germany
| | - Bernd Krüger
- Fifth Department of Medicine, University Medical Center Mannheim UMM, Mannheim, Germany.,Faculty of Medicine of the University of Heidelberg, Mannheim, Germany
| | - Winfried März
- Fifth Department of Medicine, University Medical Center Mannheim UMM, Mannheim, Germany.,Faculty of Medicine of the University of Heidelberg, Mannheim, Germany.,Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Austria.,Synlab Academy, SYNLAB Holding Deutschland GmbH, Mannheim, Germany
| | - Bernhard K Krämer
- Fifth Department of Medicine, University Medical Center Mannheim UMM, Mannheim, Germany.,Faculty of Medicine of the University of Heidelberg, Mannheim, Germany.,Center for Preventive Medicine Baden-Württemberg (CPMBW), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.,European Center for Angioscience ECAS, Faculty of Medicine of the University of Heidelberg, Mannheim, Germany
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26
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Sport and Exercise in Improving Outcomes After Solid Organ Transplantation: Overview From a UK Meeting. Transplantation 2020; 103:S1-S11. [PMID: 31259878 DOI: 10.1097/tp.0000000000002710] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Outcomes after solid organ transplantation continue to improve, but premature loss of life remains a major concern, with death from cerebrovascular disease and cardiovascular disease accounting for around 20% late deaths. There are multiple contributory factors including preexisting, and the posttransplant development of, cardiometabolic conditions (such as hypertension, diabetes mellitus, hyperlipidemia, and obesity). There is accumulating evidence that the regular engagement in exercise is an important factor affecting outcomes before, during, and after transplantation; yet most waitlist candidates and recipients have reduced levels of physical activity. The mechanisms whereby physical activity is associated with better outcomes and a reduction in risk factors for cardiovascular disease are incompletely understood. Attempts to increase physical activity in the transplant population, as in the general population, have had limited success. Use of concepts from Nudge theory provides an evidence-based approach that may help increase physical activity and so reduce premature mortality. Both National and International Transplant Games provide a vehicle for increasing physical activity in this population and may also help to reduce premature death by providing a forum for mutual support for recipients and their families as well as an excellent forum for highlighting the success and impact of organ donation.
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27
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Rangaswami J, Mathew RO, Parasuraman R, Tantisattamo E, Lubetzky M, Rao S, Yaqub MS, Birdwell KA, Bennett W, Dalal P, Kapoor R, Lerma EV, Lerman M, McCormick N, Bangalore S, McCullough PA, Dadhania DM. Cardiovascular disease in the kidney transplant recipient: epidemiology, diagnosis and management strategies. Nephrol Dial Transplant 2020; 34:760-773. [PMID: 30984976 DOI: 10.1093/ndt/gfz053] [Citation(s) in RCA: 105] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Indexed: 12/19/2022] Open
Abstract
Kidney transplantation (KT) is the optimal therapy for end-stage kidney disease (ESKD), resulting in significant improvement in survival as well as quality of life when compared with maintenance dialysis. The burden of cardiovascular disease (CVD) in ESKD is reduced after KT; however, it still remains the leading cause of premature patient and allograft loss, as well as a source of significant morbidity and healthcare costs. All major phenotypes of CVD including coronary artery disease, heart failure, valvular heart disease, arrhythmias and pulmonary hypertension are represented in the KT recipient population. Pre-existing risk factors for CVD in the KT recipient are amplified by superimposed cardio-metabolic derangements after transplantation such as the metabolic effects of immunosuppressive regimens, obesity, posttransplant diabetes, hypertension, dyslipidemia and allograft dysfunction. This review summarizes the major risk factors for CVD in KT recipients and describes the individual phenotypes of overt CVD in this population. It highlights gaps in the existing literature to emphasize the need for future studies in those areas and optimize cardiovascular outcomes after KT. Finally, it outlines the need for a joint 'cardio-nephrology' clinical care model to ensure continuity, multidisciplinary collaboration and implementation of best clinical practices toward reducing CVD after KT.
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Affiliation(s)
- Janani Rangaswami
- Einstein Medical Center, Philadelphia, PA, USA.,Sidney Kimmel College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Roy O Mathew
- Columbia Veterans Affairs Health Care System, Columbia, SC, USA
| | | | | | - Michelle Lubetzky
- Weill Cornell Medicine-New York Presbyterian Hospital, New York, NY, USA
| | - Swati Rao
- University of Virginia, Charlottesville, VA, USA
| | | | | | | | | | - Rajan Kapoor
- Augusta University Medical Center, Augusta, GA, USA
| | - Edgar V Lerma
- UIC/Advocate Christ Medical Center, Oak Lawn, IL, USA
| | - Mark Lerman
- Medical City Dallas Hospital, Dallas, TX, USA
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28
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Sex and age as determinants for high blood pressure in pediatric renal transplant recipients: a longitudinal analysis of the CERTAIN Registry. Pediatr Nephrol 2020; 35:415-426. [PMID: 31811541 DOI: 10.1007/s00467-019-04395-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 07/25/2019] [Accepted: 10/07/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND High prevalence of arterial hypertension is known in pediatric renal transplant patients, but how blood pressure (BP) distribution and control differ between age groups and whether sex and age interact and potentially impact BP after transplantation have not been investigated. METHODS This retrospective analysis included 336 pediatric renal transplant recipients (62% males) from the Cooperative European Pediatric Renal Transplant Initiative Registry (CERTAIN) with complete BP measurement at discharge and 1, 2 and 3 years post-transplant. RESULTS At discharge and 3 years post-transplant, arterial hypertension was highly prevalent (84% and 77%); antihypertensive drugs were used in 73% and 68% of the patients. 27% suffered from uncontrolled and 9% from untreated hypertension at 3 years post-transplant. Children transplanted at age < 5 years showed sustained high systolic BP z-score and received consistently less antihypertensive treatment over time. Younger age, shorter time since transplantation, male sex, higher body mass index (BMI), high cyclosporine A (CSA) trough levels, and a primary renal disease other than congenital anomalies of the kidney and urinary tract (CAKUT) were significantly associated with higher systolic BP z-score. Sex-stratified analysis revealed a significant association between high CSA and higher systolic BP in older girls that likely had started puberty already. An association between BP and estimated glomerular filtration rate was not detected. CONCLUSIONS BP control during the first 3 years was poor in this large European cohort. The description of age- and sex-specific risk profiles identified certain recipient groups that may benefit from more frequent BP monitoring (i.e. young children) or different choices of immunosuppression (i.e. older girls).
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29
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Kim DG, Lee J, Seo WJ, Lee JG, Kim BS, Kim MS, Kim SI, Kim YS, Huh KH. Rituximab protects against development of atherosclerotic cardiovascular disease after kidney transplantation: a propensity-matched study. Sci Rep 2019; 9:16475. [PMID: 31712593 PMCID: PMC6848081 DOI: 10.1038/s41598-019-52942-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 10/25/2019] [Indexed: 12/17/2022] Open
Abstract
Recent studies have implicated B cells in atherosclerosis and have verified the atheroprotective effect of rituximab. Rituximab is widely used for desensitization in ABO-incompatible or crossmatch-positive kidney transplantation (KT). Using a single-center KT database, we performed propensity-matched analysis to investigate the association between rituximab and posttransplant atherosclerotic cardiovascular disease (ASCVD). Among 1299 eligible patients, 239 given rituximab induction were matched with 401 controls in a 1:2 propensity score matching process. The cumulative rate of ASCVD during 8 years of follow-up was significantly lower in rituximab-treated patients, compared with matched controls (3.7% vs. 11.2%; P = 0.012). However, all-cause mortality did not differ by group (2.9% vs. 4%; P = 0.943). In multivariable Cox analysis, rituximab proved independently protective of ASCVD (hazard ratio = 0.34, 95% confidence interval: 0.14–0.83). The lower risk of ASCVD seen with rituximab induction reached significance only in patient subsets of diabetes mellitus, pretransplant dialysis, or older age (>50 years). Rituximab induction confers a lower risk of ASCVD during the posttransplant period. This atheroprotective effect appears particularly beneficial in patients whose risk of ASCVD is heightened.
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Affiliation(s)
- Deok Gie Kim
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Juhan Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Won Jun Seo
- Department of Surgery, Korea University College of Medicine, Seoul, Republic of Korea
| | - Jae Geun Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Beom Seok Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.,The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Myoung Soo Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea.,The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Soon Il Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea.,The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yu Seun Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea.,The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kyu Ha Huh
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea. .,The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Republic of Korea.
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30
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Whelan AM, Ku E. Use of ambulatory blood pressure monitoring in kidney transplant recipients. Nephrol Dial Transplant 2019; 34:1437-1439. [PMID: 30838404 PMCID: PMC6735770 DOI: 10.1093/ndt/gfz010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Indexed: 12/31/2022] Open
Affiliation(s)
- Adrian M Whelan
- Division of Nephrology, Department of Medicine, University of California, San Francisco, CA, USA
- Nephrology Section, San Francisco VA Medical Center, San Francisco, CA, USA
| | - Elaine Ku
- Division of Nephrology, Department of Medicine, University of California, San Francisco, CA, USA
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31
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Malhotra R, Katz R, Weiner DE, Levey AS, Cheung AK, Bostom AG, Ix JH. Blood Pressure, Chronic Kidney Disease Progression, and Kidney Allograft Failure in Kidney Transplant Recipients: A Secondary Analysis of the FAVORIT Trial. Am J Hypertens 2019; 32:816-823. [PMID: 31179500 DOI: 10.1093/ajh/hpz095] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 06/07/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND In chronic kidney disease, intensive systolic blood pressure (SBP) control reduces mortality at a cost of greater acute kidney injury risk. Kidney transplantation involves implantation of denervated kidneys and immunosuppressive medications that increase acute kidney injury risk. The optimal blood pressure (BP) target in kidney transplant recipients (KTRs) is uncertain. Prior observational studies from the Folic Acid for Vascular Outcome Reduction in Transplantation (FAVORIT) trial demonstrate associations of lower SBP levels and reduced mortality risk, but the relationship of BP with kidney allograft function remains unknown. Thus, in FAVORIT, we investigated the relationship of SBP and diastolic blood pressure (DBP) with risk of kidney allograft failure and estimated glomerular filtration rate (eGFR) slope among stable KTRs. METHODS Cox proportional hazards and multivariable linear regression models adjusted for demographics, transplant characteristics, comorbidities, baseline eGFR, and urine albumin-to-creatinine ratio were used to determine associations of SBP and DBP with time to a composite kidney outcome of ≥50% eGFR decline or dialysis dependence, and with annualized eGFR change, respectively. Multivariable restricted cubic spline plots were developed to evaluate the functional form of the relationships. RESULTS Among 3,598 KTRs, mean age was 52 ± 9 years, SBP was 136 ± 20 mm Hg, DBP was 79 ± 12 mm Hg, and eGFR was 49 ± 18 ml/minute/1.73 m2. There were 369 events of ≥50% eGFR decline or dialysis dependence during a mean follow-up of 4.0 ± 1.5 years. There was no association of either SBP (compared with SBP 120 to <130 mm Hg, hazard ratio (HR) for the SBP < 110 was 1.01 (95% confidence interval (CI) 0.60 to 1.70) and 130 to <140 was 0.89 (0.64 to 1.24)) or DBP (compared with DBP 70 to <80 mm Hg, HR for the DBP 60 to <70 was 1.00 (95% CI 0.74 to 1.34) and 80 to <90 was 0.90 (0.68 to 1.18)) with the kidney failure outcome or annualized eGFR slope, and, when examined using restricted cubic splines, there was no evidence of "J"- or "U"-shaped relationships. CONCLUSIONS In a large sample of stable KTRs, we found no evidence of thresholds at which lower BPs were related to higher risk of allograft failure or eGFR decline. In light of prior findings of mortality benefit at low SBP, these observational findings suggest lower BP may be beneficial in KTRs. This important question requires confirmation in future randomized trials in KTRs.
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Affiliation(s)
- Rakesh Malhotra
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, San Diego, California, USA
- Imperial Valley Family Care Medical Group, El Centro, California, USA
| | - Ronit Katz
- Kidney Research Institute, University of Washington, Seattle, Washington, USA
| | - Daniel E Weiner
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Andrew S Levey
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Alfred K Cheung
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
- Medical Service, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah, USA
| | - Andrew G Bostom
- Division of Hypertension and Kidney Diseases, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Joachim H Ix
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, San Diego, California, USA
- Division of Preventive Medicine, Department of Family Medicine and Public Health, University of California San Diego, San Diego, California, USA
- Nephrology Section, Veterans Affairs San Diego Healthcare System, La Jolla, California, USA
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Caring for the patient with a failing allograft: challenges and opportunities. Curr Opin Organ Transplant 2019; 24:416-423. [DOI: 10.1097/mot.0000000000000655] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Hypotensive Systolic Blood Pressure Predicts Severe Complications and In-Hospital Mortality in Acute Aortic Dissection. J Am Coll Cardiol 2019; 71:1441-1443. [PMID: 29598864 DOI: 10.1016/j.jacc.2018.02.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 02/15/2018] [Indexed: 01/16/2023]
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Pisano A, Bolignano D, Mallamaci F, D’Arrigo G, Halimi JM, Persu A, Wuerzner G, Sarafidis P, Watschinger B, Burnier M, Zoccali C. Comparative effectiveness of different antihypertensive agents in kidney transplantation: a systematic review and meta-analysis. Nephrol Dial Transplant 2019; 35:878-887. [DOI: 10.1093/ndt/gfz092] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 04/11/2019] [Indexed: 12/19/2022] Open
Abstract
Abstract
Background
We conducted a systematic review and meta-analysis to compare benefits and harms of different antihypertensive drug classes in kidney transplant recipients, as post-transplant hypertension (HTN) associates with increased cardiovascular (CV) morbidity and mortality.
Methods
The Ovid-MEDLINE, PubMed and CENTRAL databases were searched for randomized controlled trials (RCTs) comparing all main antihypertensive agents versus placebo/no treatment, routine treatment.
Results
The search identified 71 RCTs. Calcium channel blockers (CCBs) (26 trials) reduced the risk for graft loss {risk ratio [RR] 0.58 [95% confidence interval (CI) 0.38–0.89]}, increased glomerular filtration rate (GFR) [mean difference (MD) 3.08 mL/min (95% CI 0.38–5.78)] and reduced blood pressure (BP). Angiotensin-converting enzyme inhibitors (ACEIs) (13 trials) reduced the risk for graft loss [RR 0.62 (95% CI 0.40–0.96)] but decreased renal function and increased the risk for hyperkalaemia. Angiotensin receptor blockers (ARBs) (10 trials) did not modify the risk of death, graft loss and non-fatal CV events and increased the risk for hyperkalaemia. When pooling ACEI and ARB data, the risk for graft failure was lower in renin–angiotensin system (RAS) blockade as compared with control treatments. In direct comparison with ACEIs or ARBs (11 trials), CCBs increased GFR [MD 11.07 mL/min (95% CI 6.04–16.09)] and reduced potassium levels but were not more effective in reducing BP. There are few available data on mortality, graft loss and rejection. Very few studies performed comparisons with other active drugs.
Conclusions
CCBs could be the preferred first-step antihypertensive agents in kidney transplant patients, as they improve graft function and reduce graft loss. No definite patient or graft survival benefits were associated with RAS inhibitor use over conventional treatment.
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Affiliation(s)
- Anna Pisano
- CNR-Institute of Clinical Physiology, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio Calabria, Italy
| | - Davide Bolignano
- CNR-Institute of Clinical Physiology, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio Calabria, Italy
| | - Francesca Mallamaci
- CNR-Institute of Clinical Physiology, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio Calabria, Italy
| | - Graziella D’Arrigo
- CNR-Institute of Clinical Physiology, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio Calabria, Italy
| | - Jean-Michel Halimi
- Service de Néphrologie et Immunologie clinique, CHRU de Tours—Hôpital Bretonneau, Tours, France
| | - Alexandre Persu
- Division of Cardiology, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
- Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Brussels, Belgium
| | - Gregoire Wuerzner
- Service of Nephrology and Hypertension, University Hospital, Lausanne, Switzerland
| | | | - Bruno Watschinger
- Department of Internal Medicine III, Division of Nephrology, Medical University of Vienna, Vienna, Austria
| | - Michel Burnier
- Service of Nephrology and Hypertension, University Hospital, Lausanne, Switzerland
| | - Carmine Zoccali
- CNR-Institute of Clinical Physiology, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio Calabria, Italy
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Cheung AK, Chang TI, Cushman WC, Furth SL, Ix JH, Pecoits-Filho R, Perkovic V, Sarnak MJ, Tobe SW, Tomson CR, Cheung M, Wheeler DC, Winkelmayer WC, Mann JF, Bakris GL, Damasceno A, Dwyer JP, Fried LF, Haynes R, Hirawa N, Holdaas H, Ibrahim HN, Ingelfinger JR, Iseki K, Khwaja A, Kimmel PL, Kovesdy CP, Ku E, Lerma EV, Luft FC, Lv J, McFadden CB, Muntner P, Myers MG, Navaneethan SD, Parati G, Peixoto AJ, Prasad R, Rahman M, Rocco MV, Rodrigues CIS, Roger SD, Stergiou GS, Tomlinson LA, Tonelli M, Toto RD, Tsukamoto Y, Walker R, Wang AYM, Wang J, Warady BA, Whelton PK, Williamson JD. Blood pressure in chronic kidney disease: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2019; 95:1027-1036. [DOI: 10.1016/j.kint.2018.12.025] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 11/30/2018] [Accepted: 12/06/2018] [Indexed: 12/30/2022]
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Predictive value of achieved blood pressure for cardiac events in the long-term follow-up of heart transplant recipients. Blood Press Monit 2018; 24:7-11. [PMID: 30431482 DOI: 10.1097/mbp.0000000000000353] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND A low diastolic blood pressure (DBP) is associated with increased cardiovascular events in patients with coronary artery disease or chronic kidney disease. AIM The aim of this study was to assess the association of blood pressure with cardiac events during the long-term follow-up of heart transplant recipients. PATIENTS AND METHODS In this prospective cohort study, we performed ambulatory blood pressure monitoring and home blood pressure monitoring in 76 transplant heart recipients 13.5±6.6 years after transplantation. The patients were followed for 54±17 months after blood pressure monitoring. RESULTS Twenty-one patients had a cardiac event (cardiac death, acute coronary event, coronary revascularization procedure, and hospitalization for heart failure) during the follow-up. In the Kaplan-Meier survival analysis, we found that a DBP below the median value (<81 mmHg) was associated significantly with cardiac events (log-rank: P=0.01). In a multivariate model, plasma creatinine and left ventricular ejection fraction (LVEF), but not DBP, were associated significantly with cardiac events. Low DBP was associated significantly with LVEF less than 55% (P=0.004). CONCLUSION A DBP below the median value predicts cardiac events during the long-term follow-up of heart transplant recipients, but is not an independent predictor. The association between low DBP and low LVEF explains at least in part the predictive value of low DBP.
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Pulse Pressure and Outcome in Kidney Transplantation: Results From the Collaborative Transplant Study. Transplantation 2018; 103:772-780. [PMID: 30188413 DOI: 10.1097/tp.0000000000002440] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Systolic blood pressure (SBP) and diastolic blood pressure (DBP) are important predictors of graft and patient survival in renal transplantation. Pulse pressure (PP), the difference between systolic and diastolic pressure, has been associated with cardiovascular and renal morbidity in nontransplant epidemiological studies and clinical trials. METHODS In this large retrospective analysis of prospectively collected data, transplant recipients from 1995 to 2015 were examined for patient and death-censored graft survival. RESULTS In 43 006 recipients, a higher 1-year PP was significantly associated with inferior 10-year patient and death-censored graft survival. In patients 60 years or older, SBP but not DBP was associated with 10-year survival, an effect that was pronounced in patients with a normal SBP of <140 mm Hg and an increased PP of 60 mm Hg or greater, highlighting the superior impact of PP on survival in elderly recipients. In recipients 60 years or older, higher PP was associated with increased mortality due to circulatory system diseases but not to infection or cancer. The combination of PP 60 mm Hg or greater and high SBP of 140 mm Hg or greater showed the strongest association with death-censored graft survival across all age groups. CONCLUSIONS We found convincing evidence that PP 1-year posttransplant is predictive of patient survival, especially in elderly recipients with normal SBP. Combined analysis of SBP and PP showed that high PP confers additional predictive information for patient survival beyond that derived from analysis of SBP alone. With regard to prediction of death-censored graft survival, the combination of high SBP and high PP showed the best correlation across all age groups.
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Pulse Pressure: A Risk Factor for Renal Transplant Failure or a Useful Therapeutic Target? Transplantation 2018; 103:662-663. [PMID: 30188414 DOI: 10.1097/tp.0000000000002441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Weiner DE, Park M, Tighiouart H, Joseph AA, Carpenter MA, Goyal N, House AA, Hsu CY, Ix JH, Jacques PF, Kew CE, Kim SJ, Kusek JW, Pesavento TE, Pfeffer MA, Smith SR, Weir MR, Levey AS, Bostom AG. Albuminuria and Allograft Failure, Cardiovascular Disease Events, and All-Cause Death in Stable Kidney Transplant Recipients: A Cohort Analysis of the FAVORIT Trial. Am J Kidney Dis 2018; 73:51-61. [PMID: 30037726 DOI: 10.1053/j.ajkd.2018.05.015] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 05/23/2018] [Indexed: 12/30/2022]
Abstract
RATIONALE & OBJECTIVE Cardiovascular disease (CVD) is common and overall graft survival is suboptimal among kidney transplant recipients. Although albuminuria is a known risk factor for adverse outcomes among persons with native chronic kidney disease, the relationship of albuminuria with cardiovascular and kidney outcomes in transplant recipients is uncertain. STUDY DESIGN Post hoc longitudinal cohort analysis of the Folic Acid for Vascular Outcomes Reduction in Transplantation (FAVORIT) Trial. SETTING & PARTICIPANTS Stable kidney transplant recipients with elevated homocysteine levels from 30 sites in the United States, Canada, and Brazil. PREDICTOR Urine albumin-creatinine ratio (ACR) at randomization. OUTCOMES Allograft failure, CVD, and all-cause death. ANALYTICAL APPROACH Multivariable Cox models adjusted for age; sex; race; randomized treatment allocation; country; systolic and diastolic blood pressure; history of CVD, diabetes, and hypertension; smoking; cholesterol; body mass index; estimated glomerular filtration rate (eGFR); donor type; transplant vintage; medications; and immunosuppression. RESULTS Among 3,511 participants with complete data, median ACR was 24 (Q1-Q3, 9-98) mg/g, mean eGFR was 49±18 (standard deviation) mL/min/1.73m2, mean age was 52±9 years, and median graft vintage was 4.1 (Q1-Q3, 1.7-7.4) years. There were 1,017 (29%) with ACR < 10mg/g, 912 (26%) with ACR of 10 to 29mg/g, 1,134 (32%) with ACR of 30 to 299mg/g, and 448 (13%) with ACR ≥ 300mg/g. During approximately 4 years, 282 allograft failure events, 497 CVD events, and 407 deaths occurred. Event rates were higher at both lower eGFRs and higher ACR. ACR of 30 to 299 and ≥300mg/g relative to ACR < 10mg/g were independently associated with graft failure (HRs of 3.40 [95% CI, 2.19-5.30] and 9.96 [95% CI, 6.35-15.62], respectively), CVD events (HRs of 1.25 [95% CI, 0.96-1.61] and 1.55 [95% CI, 1.13-2.11], respectively), and all-cause death (HRs of 1.65 [95% CI, 1.23-2.21] and 2.07 [95% CI, 1.46-2.94], respectively). LIMITATIONS No data for rejection; single ACR assessment. CONCLUSIONS In a large population of stable kidney transplant recipients, elevated baseline ACR is independently associated with allograft failure, CVD, and death. Future studies are needed to evaluate whether reducing albuminuria improves these outcomes.
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Affiliation(s)
| | - Meyeon Park
- Division of Nephrology, University of California, San Francisco, San Francisco, CA
| | | | - Alin A Joseph
- Division of Nephrology, Tufts Medical Center, Boston, MA
| | - Myra A Carpenter
- Collaborative Studies Coordinating Center, University of North Carolina, Chapel Hill, NC
| | - Nitender Goyal
- Division of Nephrology, Tufts Medical Center, Boston, MA
| | - Andrew A House
- Division of Nephrology, London Health Sciences Centre, London, Ontario, Canada
| | - Chi-Yuan Hsu
- Division of Nephrology, University of California, San Francisco, San Francisco, CA
| | - Joachim H Ix
- Division of Nephrology-Hypertension, University of California, San Diego, San Diego, CA
| | - Paul F Jacques
- Human Nutrition Research Center on Aging, Tufts University, Boston, MA
| | - Clifton E Kew
- Division of Nephrology, University of Alabama, Birmingham, AL
| | - S Joseph Kim
- Division of Nephrology and the Kidney Transplant Program, Toronto General Hospital, Toronto, Ontario, Canada
| | - John W Kusek
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
| | | | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA
| | | | - Matthew R Weir
- Division of Nephrology, University of Maryland, Baltimore, MD
| | - Andrew S Levey
- Division of Nephrology, Tufts Medical Center, Boston, MA
| | - Andrew G Bostom
- Division of Hypertension and Kidney Diseases, Rhode Island Hospital, Providence, RI
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Bostom A, Steubl D, Garimella PS, Franceschini N, Roberts MB, Pasch A, Ix JH, Tuttle KR, Ivanova A, Shireman T, Kim SJ, Gohh R, Weiner DE, Levey AS, Hsu CY, Kusek JW, Eaton CB. Serum Uromodulin: A Biomarker of Long-Term Kidney Allograft Failure. Am J Nephrol 2018; 47:275-282. [PMID: 29698955 DOI: 10.1159/000489095] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 04/04/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Uromodulin is a kidney-derived glycoprotein and putative tubular function index. Lower serum uromodulin was recently associated with increased risk for kidney allograft failure in a preliminary, longitudinal single-center -European study involving 91 kidney transplant recipients (KTRs). METHODS The Folic Acid for Vascular Outcome Reduction in Transplantation (FAVORIT) trial is a completed, large, multiethnic controlled clinical trial cohort, which studied chronic, stable KTRs. We conducted a case cohort analysis using a randomly selected subset of patients (random subcohort, n = 433), and all individuals who developed kidney allograft failure (cases, n = 226) during follow-up. Serum uromodulin was determined in this total of n = 613 FAVORIT trial participants at randomization. Death-censored kidney allograft failure was the study outcome. RESULTS The 226 kidney allograft failures occurred during a median surveillance of 3.2 years. Unadjusted, weighted Cox proportional hazards modeling revealed that lower serum uromodulin, tertile 1 vs. tertile 3, was associated with a threefold greater risk for kidney allograft failure (hazards ratio [HR], 95% CI 3.20 [2.05-5.01]). This association was attenuated but persisted at twofold greater risk for allograft failure, after adjustment for age, sex, smoking, allograft type and vintage, prevalent diabetes mellitus and cardiovascular disease (CVD), total/high-density lipoprotein cholesterol ratio, systolic blood pressure, estimated glomerular filtration rate, and natural log urinary albumin/creatinine: HR 2.00, 95% CI (1.06-3.77). CONCLUSIONS Lower serum uromodulin, a possible indicator of less well-preserved renal tubular function, remained associated with greater risk for kidney allograft failure, after adjustment for major, established clinical kidney allograft failure and CVD risk factors, in a large, multiethnic cohort of long-term, stable KTRs.
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Affiliation(s)
- Andrew Bostom
- Center For Primary Care and Prevention, Memorial Hospital of Rhode Island, Pawtucket, Rhode Island, USA
| | - Dominik Steubl
- Klinikum rechts der Isar, Technische Universität, München, Germany
| | - Pranav S Garimella
- Division of Nephrology-Hypertension, Department of Medicine, University of California, San Diego, California, USA
| | - Nora Franceschini
- Department of Epidemiology, Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Mary B Roberts
- Center For Primary Care and Prevention, Memorial Hospital of Rhode Island, Pawtucket, Rhode Island, USA
| | | | - Joachim H Ix
- Division of Nephrology-Hypertension, Department of Medicine, University of California, San Diego, California, USA
| | - Katherine R Tuttle
- Providence Medical Research Center, University of Washington, Spokane, Washington, USA
| | - Anastasia Ivanova
- Department of Epidemiology, Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Theresa Shireman
- Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island, USA
| | - S Joseph Kim
- Division of Nephrology and the Kidney Transplant Program, Toronto General Hospital, Toronto, Ontario, Canada
| | - Reginald Gohh
- Division of Hypertension and Kidney Diseases, Department of Medicine, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Daniel E Weiner
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Andrew S Levey
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Chi-Yuan Hsu
- Division of Nephrology, University of California-San Francisco, San Francisco, California, USA
| | - John W Kusek
- National Institute of Diabetes, Digestive, and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Charles B Eaton
- Department of Family Medicine, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
- Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island, USA
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Takahashi A, Hu SL, Bostom A. Physical Activity in Kidney Transplant Recipients: A Review. Am J Kidney Dis 2018; 72:433-443. [PMID: 29482935 DOI: 10.1053/j.ajkd.2017.12.005] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 12/09/2017] [Indexed: 12/11/2022]
Abstract
Physical activity has known health benefits and is associated with reduced cardiovascular risk in the general population. Relatively few data are available for physical activity in kidney transplant recipients. Compared to the general population, physical activity levels are lower overall in kidney recipients, although somewhat higher compared to the dialysis population. Recipient comorbid condition, psychosocial and socioeconomic factors, and long-term immunosuppression use negatively affect physical activity. Physical inactivity in kidney recipients may be associated with reduced quality of life, as well as increased mortality. Interventions such as exercise training appear to be safe in kidney transplant recipients and are associated with improved quality of life and exercise capacity. Additional studies are required to evaluate long-term effects on cardiovascular risk factors and ultimately cardiovascular disease outcomes and patient survival. Currently available data are characterized by wide variability in the interventions and outcome measures investigated in studies, as well as use of small sample-sized cohorts. These limitations highlight the need for larger studies using objective and standardized measures of physical activity and physical fitness in kidney transplant recipients.
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Affiliation(s)
- Ashley Takahashi
- Warren Alpert Medical School of Brown University, Department of Medicine, Rhode Island Hospital, Providence, RI
| | - Susie L Hu
- Division of Kidney Disease and Hypertension, Department of Medicine, Rhode Island Hospital, Providence, RI.
| | - Andrew Bostom
- Division of Kidney Disease and Hypertension, Department of Medicine, Rhode Island Hospital, Providence, RI
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42
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Kalil RS, Carpenter MA, Ivanova A, Gravens-Mueller L, John AA, Weir MR, Pesavento T, Bostom AG, Pfeffer MA, Hunsicker LG. Impact of Hyperuricemia on Long-term Outcomes of Kidney Transplantation: Analysis of the FAVORIT Study. Am J Kidney Dis 2017; 70:762-769. [DOI: 10.1053/j.ajkd.2017.06.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 06/04/2017] [Indexed: 02/07/2023]
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44
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Halimi JM, Persu A, Sarafidis PA, Burnier M, Abramowicz D, Sautenet B, Oberbauer R, Mallamaci F, London G, Rossignol P, Wuerzner G, Watschinger B, Zoccali C. Optimizing hypertension management in renal transplantation: a call to action. Nephrol Dial Transplant 2017; 32:1959-1962. [PMID: 29099945 DOI: 10.1093/ndt/gfx283] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 08/14/2017] [Indexed: 12/19/2022] Open
Affiliation(s)
- Jean-Michel Halimi
- Service de Néphrologie-Immunologie Clinique, CHU Tours, Tours, France.,FCRIN INI-CRCT Cardiovascular and Renal Clinical Trialists, François-Rabelais University, Tours, France
| | - Alexandre Persu
- Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium.,Division of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Pantelis A Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Greece
| | - Michel Burnier
- Service of Nephrology and Hypertension, University Hospital (CHUV), Lausanne, Switzerland
| | - Daniel Abramowicz
- Antwerp University Hospital, Department of Nephrology, and Antwerp University, Belgium
| | - Bénédicte Sautenet
- Service de Néphrologie-Immunologie Clinique, CHU Tours, Tours, France.,FCRIN INI-CRCT Cardiovascular and Renal Clinical Trialists, François-Rabelais University, Tours, France
| | - Rainer Oberbauer
- Departement of Nephrology, Medical University of Vienna, Austria
| | - Francesca Mallamaci
- CNR-IFC, Clinical Epidemiology and Pathophysiology of Hypertension and Renal Diseases Unit, Ospedali Riuniti, Reggio Calabria, Italy
| | - Gérard London
- FCRIN INI-CRCT Cardiovascular and Renal Clinical Trialists, Manhes Hospital and FCRIN INI-CRCTC, Manhes, France
| | - Patrick Rossignol
- INSERM, Centre, d'Investigations Cliniques Plurithématique 1433, Université de Lorraine, CHU de Nancy, and FCRIN INI-CRCT Cardiovascular and Renal Clinical Trialists, Vandoeuvre-lès-Nancy, France
| | - Grégoire Wuerzner
- Service of Nephrology and Hypertension, University Hospital (CHUV), Lausanne, Switzerland
| | | | - Carmine Zoccali
- CNR-IFC, Clinical Epidemiology and Pathophysiology of Hypertension and Renal Diseases Unit, Ospedali Riuniti, Reggio Calabria, Italy
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Hypertension in the Kidney Transplant Recipient: Overview of Pathogenesis, Clinical Assessment, and Treatment. Cardiol Rev 2017; 25:102-109. [PMID: 27548684 DOI: 10.1097/crd.0000000000000126] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Cardiovascular disease is the leading cause of death in patients with chronic renal disease and the most common cause of death and allograft loss among kidney transplant recipients. Transplant patients often have multiple cardiovascular risk factors antedating transplantation. Among the most prominent is hypertension (HTN), which affects at least 90% of transplant patients. Uncontrolled HTN is an independent risk factor for allograft loss. The etiology of HTN in transplant recipients is complex and multifactorial, including the use of essential immunosuppressive medications. Post-transplant HTN management requires a systematic and individualized approach with nonpharmacologic and pharmacologic therapies. There is no single ideal agent or treatment algorithm. Patients should regularly monitor and record their blood pressure at home. Often, multiple antihypertensive drugs are needed to achieve a goal blood pressure of 120-140/70-90 mm Hg. As transplant recipients commonly must take 8 to 12 different medications daily, adherence must be continually encouraged and monitored. Special attention must be paid to potential drug side effects and drug interactions with immunosuppressive medications.
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Pretransplant Midodrine Use: A Newly Identified Risk Marker for Complications After Kidney Transplantation. Transplantation 2017; 100:1086-93. [PMID: 26950718 DOI: 10.1097/tp.0000000000001113] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Midodrine is prescribed to prevent symptomatic hypotension and decrease complications associated with hypotension during dialysis. We hypothesized that midodrine use before kidney transplantation may be a novel marker for posttransplant risk. METHODS We analyzed integrated national US transplant registry, pharmacy records, and Medicare claims data for 16 308 kidney transplant recipients transplanted 2006 to 2008, of whom 308 (1.9%) had filled midodrine prescriptions in the year before transplantation. Delayed graft function (DGF), graft failure, and patient death were ascertained from the registry. Posttransplant cardiovascular complications were identified using diagnosis codes on Medicare billing claims. Adjusted associations of pretransplant midodrine use with complications at 3 and 12 months posttransplant were quantified by multivariate Cox or logistic regression, including propensity for midodrine exposure. RESULTS At 3 months, patients who used midodrine pretransplant had significantly (P < 0.05) higher rates of DGF, 32% versus 19%; hypotension, 14% versus 4%; acute myocardial infarction, 4% versus 2%; cardiac arrest, 2% versus 0.9%, graft failure, 5% versus 2%; and death, 4% versus 1% than nonusers. After multivariate adjustment including recipient and donor factors, as well as for the propensity of midodrine exposure, pretransplant midodrine use was independently associated with risks of DGF (adjusted odds ratio, 1.78; 95% confidence interval [CI], 1.36-2.32), and 3 month death-censored graft failure (adjusted hazard ratio, 2.0; 95% CI, 1.18-3.39), and death (adjusted hazard ratio, 3.49; 95% CI, 1.95-6.24). Patterns were similar at 12 months. CONCLUSIONS Although associations may in part reflect underlying conditions, the need for midodrine before kidney transplantation is a risk marker for complications including DGF, graft failure, and death.
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Riella LV, Djamali A, Pascual J. Chronic allograft injury: Mechanisms and potential treatment targets. Transplant Rev (Orlando) 2017; 31:1-9. [DOI: 10.1016/j.trre.2016.10.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Accepted: 10/05/2016] [Indexed: 01/05/2023]
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Medical management of chronic kidney disease in the renal transplant recipient. Curr Opin Nephrol Hypertens 2016; 24:587-93. [PMID: 26371526 DOI: 10.1097/mnh.0000000000000166] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW An updated overview of the state-of-the-art approaches to the care of chronic kidney disease-related issues in renal transplant recipients. RECENT FINDINGS These include the impact of immunosuppression therapy on kidney function, the management of cardiovascular risk, metabolic bone disease, and hematologic complications, with a focus on the care of the patient with a failing allograft. SUMMARY A kidney transplant improves patient morbidity and mortality, but almost all transplant patients continue to have morbidity related to chronic kidney disease. It is increasingly clear that the provision of adequate immunosuppression is important to preserve allograft function. Recent studies have lent support to current guidelines for the management of cardiovascular risk factors in transplant patients. New data regarding the management of metabolic bone disease are sparse. Erythropoietin replacement may improve outcomes in transplant recipients, but the optimal target hemoglobin level is not known. Cessation of immunosuppression in the failed allograft carries the risk of rejection and allosensitization. New evidence suggests that nephrectomy may reduce mortality in patients with a failed allograft, but likely enhances sensitization in the patient awaiting retransplantation.
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Stabouli S, Printza N, Dotis J, Gkogka C, Kollios K, Kotsis V, Papachristou F. Long-Term Changes in Blood Pressure After Pediatric Kidney Transplantation. Am J Hypertens 2016; 29:860-5. [PMID: 26657420 DOI: 10.1093/ajh/hpv192] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 11/13/2015] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Hypertension presents high prevalence rates following kidney transplantation (Tx). The aims of the present study were to investigate the prevalence and possible risk factors for hypertension and blood pressure (BP) control over time after pediatric kidney Tx, as well as to assess possible effects of hypertension on graft survival. METHODS We reviewed the medical records of all pediatric kidney recipients followed up in our pediatric nephrology department. Hypertension was defined as systolic and/or diastolic BP greater than the 95th percentile for age and sex, or as being on antihypertensive medication. BP control was defined as normotension while on antihypertensive medication. RESULTS The study population included 74 pediatric kidney recipients (median age 11 years). The prevalence of hypertension was found 77% before Tx, 82.4%, 71.7%, and 61% at 1, 5, and 10 years after Tx, respectively. Deceased donor Tx and pre-transplant hypertension on antihypertensive medication were significant risk factors for hypertension after kidney Tx over the follow-up period. BP control among patients on antihypertensive treatment was 16.7% before Tx, 43.8%, 66.7%, and 42.9% at 1, 5, and 10 years post-Tx, respectively. Hypertensive patients at 10 years post-Tx had 8.079 times higher hazard of graft loss compared to normotensives (95% CI 1.561-41.807, P < 0.05). CONCLUSIONS Hypertension remains a frequent complication in pediatric kidney recipients even years after kidney Tx. BP control by antihypertensive treatment is unsatisfactory in about half of the patients. The adverse effects of hypertension on graft survival may appear in the long-term.
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Affiliation(s)
- Stella Stabouli
- Pediatric Nephrology Unit, 1st Department of Pediatrics, Aristotle University of Thessaloniki, Thessaloniki, Greece;
| | - Nikoleta Printza
- Pediatric Nephrology Unit, 1st Department of Pediatrics, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - John Dotis
- Pediatric Nephrology Unit, 1st Department of Pediatrics, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Chrysa Gkogka
- Pediatric Nephrology Unit, 1st Department of Pediatrics, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Konstantinos Kollios
- 3rd Department of Pediatrics, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vasilios Kotsis
- 3rd Department of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Fotios Papachristou
- Pediatric Nephrology Unit, 1st Department of Pediatrics, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Brennan DC, Kopetskie HA, Sayre PH, Alejandro R, Cagliero E, Shapiro AMJ, Goldstein JS, DesMarais MR, Booher S, Bianchine PJ. Long-Term Follow-Up of the Edmonton Protocol of Islet Transplantation in the United States. Am J Transplant 2016; 16:509-17. [PMID: 26433206 DOI: 10.1111/ajt.13458] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Revised: 06/15/2015] [Accepted: 07/03/2015] [Indexed: 01/25/2023]
Abstract
We report the long-term follow-up of the efficacy and safety of islet transplantation in seven type 1 diabetic subjects from the United States enrolled in the multicenter international Edmonton Protocol who had persistent islet function after completion of the Edmonton Protocol. Subjects were followed up to 12 years with serial testing for sustained islet allograft function as measured by C-peptide. All seven subjects demonstrated continued islet function longer than a decade from the time of first islet transplantation. One subject remained insulin independent without the need for diabetic medications or supplemental transplants. One subject who was insulin-independent for over 8 years experienced graft failure 10.9 years after the first islet transplant. The remaining six subjects demonstrated continued islet function upon trial completion, although three had received a supplemental islet transplant each. At trial completion, five subjects were receiving insulin and two remained insulin independent, although one was treated with liraglutide. The median hemoglobin A1c was 6.3% (45 mmol/mol). All subjects experienced progressive decline in the C-peptide/glucose ratio. No patients experienced severe hypoglycemia, opportunistic infection, or lymphoma. Thus, although the rate and duration of insulin independence was low, the Edmonton Protocol was safe in the long term. Alternative approaches to islet transplantation are under investigation.
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Affiliation(s)
- D C Brennan
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | | | - P H Sayre
- Immune Tolerance Network, San Francisco, CA
| | - R Alejandro
- University of Miami Leonard M. Miller School of Medicine, Miami, FL
| | - E Cagliero
- Massachusetts General Hospital/Harvard Medical School, Boston, MA
| | | | - J S Goldstein
- National Institute of Allergy and Infectious Diseases, Bethesda, MD
| | | | - S Booher
- National Institute of Allergy and Infectious Diseases, Bethesda, MD
| | - P J Bianchine
- National Institute of Allergy and Infectious Diseases, Bethesda, MD
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