Left atrial diameter and survival among renal allograft recipients

Long-term changes in cardiac remodelling in prevalent kidney graft recipients

BACKGROUND

Approximately 15% of kidney transplant (KT) recipients develop de novo heart failure after KT. There are scarce data reporting the long-term changes in cardiac structure and function among KT recipients. Despite the improvement in renal function, transplant-related complications as well as immunosuppressive therapy could have an impact on cardiac remodelling during follow-up. We aimed to describe the long-term changes in echocardiographic parameters in prevalent KT recipients and identify the clinical and laboratory factors associated with these changes.

METHODS

A centralised blinded review of two echocardiographic examinations after KT (on average after 17 and 39 months post-KT respectively) was performed among 80 patients (age 50.4 ± 16.2, diabetes 13.8% pre-KT), followed by linear regression to identify clinico-biological factors related to echocardiographic changes.

RESULTS

Left atrial volume index (LAVI) increased significantly (34.2 ± 10.8 mL/m2vs. 37.6 ± 15.0 mL/m2, annualised delta 3.1 ± 11.4 mL/m2/year; p = 0.034) while left ventricular ejection fraction (LVEF) decreased (62.1 ± 9.0% vs. 59.7 ± 9.9%, annualised delta -2.7 ± 13.6%/year; p = 0.04). Male sex (β = 8.112 ± 2.747; p < 0.01), pre-KT hypertension (β = 9.725 ± 4.156; p < 0.05), graft from expanded criteria donor (β = 3.791 ± 3.587; p < 0.05), and induction by anti-thymocyte globulin (β = 7.920 ± 2.974; p = 0.01) were associated with an increase in LAVI during follow-up. Higher haemoglobin (>12.9 g/dL) at the time of the first echocardiography (β = 6.029 ± 2.967; p < 0.05) and ACEi/ARB therapy (β = 8.306 ± 3.161; p < 0.05) were associated with an increase in LVEF during follow-up.

CONCLUSION

This study confirms the existence of long-term cardiac remodelling after KT despite dialysis cessation, characterised by an increase in LAVI and a decrease in LVEF. A better management of anaemia and using ACEi/ARB therapy may prevent such remodelling.

Factors associated with changes in echocardiographic parameters following kidney transplantation

BACKGROUND

Chronic kidney disease leads to cardiac remodelling of multifactorial origin known as "uraemic cardiomyopathy", the reversibility of which after kidney transplantation (KT) remains controversial. Our objectives were to assess, in the modern era, changes in echocardiographic parameters following KT and identify predictive clinical and biological factors associated with echocardiographic changes.

METHODS

One hundred six patients (mean age 48 ± 16, 73% male) who underwent KT at the University Hospital of Nancy between 2007 and 2018 were retrospectively investigated. Pre- and post-KT echocardiography findings (8.6 months before and 22 months after KT on average, respectively) were centralised, blind-reviewed and compared.

RESULTS

A majority of patients (60%) had either a left ventricular (LV) ejection fraction < 50%, at least moderately abnormal LV mass index or left atrial (LA) dilatation at pretransplanted echocardiography. After KT, LV remodelling and diastolic doppler indices did not significantly change whereas LA volume index (LAVI) increased (35.9 mL/m2 post-KT vs. 30.9 mL/m2 pre-KT, p = 0.006). Advancing age, cardiac valvular disease, delayed graft function, lower post-KT haemoglobin, and more severe post-KT hypertension were associated with higher LAVI after KT. Higher post-KT serum creatinine, more severe post-KT hypertension and lower pre-KT blood calcium levels were associated with a deterioration in LAVI after KT.

DISCUSSION/CONCLUSION

Adverse remodelling of the left atrial volume occurred after KT, predominantly in patients with lower pre-KT blood calcium, poorer graft function and post-KT hypertension. These results suggest that a better management of modifiable factors such as pre-KT hyperparathyroidism or post-KT hypertension could limit post-KT cardiac remodelling.

Etelcalcetide Inhibits the Progression of Left Atrial Volume Index Compared to Alfacalcidol in Hemodialysis Patients

INTRODUCTION

Increased left atrial (LA) size is a risk factor for cardiovascular events and all-cause mortality. It is closely related to left ventricular hypertrophy and chronic volume overload, both of which are common in hemodialysis. Calcimimetic treatment with etelcalcetide (ETL) previously showed an inhibitory effect on left ventricular mass index (LVMI) progression in this population.

METHODS

This is a post hoc analysis of the EtECAR-HD trial, where 62 patients were randomized to ETL or alfacalcidol (ALFA) for 1 year. LA volume index (LAVI) was measured using cardiac magnetic resonance imaging. The aim of the study was to investigate whether ETL was associated with a change of LAVI.

RESULTS

Median baseline levels of LAVI were 40 mL/m2 (31, 54 IQR) in the ETL group and 36 mL/m2 (26, 46 IQR) in the ALFA group. In the ITT population, the change of LAVI was 5.0 mL/m2 [95% CI: -0.04, 10] lower under ETL, compared to ALFA (p = 0.052, R2adj = 0.259). In the PP population, the difference in LAVI changes widened to 5.8 [95% CI: 0.36, 11], p = 0.037, R2adj = 0.302). Secondary analysis showed that the study delta of LVMI was correlated with the LAVI delta (r = 0.387) and that an inclusion of LVMI delta in the ANCOVA model mediated the effect on LAVI delta to β = 3.3 [95% CI: -0.04, 10] (p = 0.2, R2adj = 0.323). The same could not be observed for parameters assessing the volume status.

CONCLUSIONS

The analysis indicates that ETL could inhibit LAVI progression compared with ALFA. This effect was mediated by the change of LVMI.

Associated factors of cardiac valve calcification and its prognostic effects among patients with chronic kidney disease: a systematic review and meta-analysis

Background

Cardiac valve calcification (CVC) is highly prevalent and a risk factor for adverse outcomes in patients with chronic kidney disease (CKD). This meta-analysis aimed to investigate the risk factors for CVC and association between CVC and mortality in CKD patients.

Method

Three electronic databases including PubMed, Embase, and Web of Science were searched for relevant studies up to November 2022. Hazard ratios (HR), odds ratios (OR), and 95% confidence intervals (CI) were pooled using random-effect meta-analyses.

Results

22 studies were included in the meta-analysis. Pooled analyses showed that CKD patients with CVC were relatively older, had a higher body mass index, left atrial dimension, C-reaction protein level, and a declined ejection fraction. Calcium and phosphate metabolism dysfunction, diabetes, coronary heart disease, and duration of dialysis were all predictors for CVC in CKD patients. The presence of CVC (both aortic valve and mitral valve) increased the risk of all-cause and cardiovascular mortality in CKD patients. However, the prognostic value of CVC for mortality was not significant anymore in patients with peritoneal dialysis.

Conclusion

CKD patients with CVC had a greater risk of all-cause and cardiovascular mortality. Multiple associated factors for development of CVC in CKD patients should be taken into consideration by healthcare professionals to improve prognosis.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/, identifier [CRD42022364970].

Cardiac valve calcification is associated with mortality in hemodialysis patients: a retrospective cohort study

Background

Cardiac valve calcification (CVC) is common in end-stage renal disease (ESRD). We investigated the effect of CVC on all-cause and cardiovascular (CV) mortality in maintenance hemodialysis (MHD) patients.

Methods

A retrospective cohort study was conducted on 434 hemodialysis patients who underwent echocardiography for qualitative assessment of valve calcification with complete follow-up data from January 1, 2014, to April 30, 2021. The baseline data between the CVC and non-CVC groups were compared. The Kaplan–Meier method was used to analyse all-cause and cardiovascular mortality. The association of CVC with all-cause and cardiovascular mortality was evaluated using multivariate Cox regression analysis.

Results

Overall, 27.2% of patients had mitral valve calcification (MVC), and 31.8% had aortic valve calcification (AVC) on echocardiography. Patients with CVC showed significantly higher all-cause (log-rank P < 0.001) and cardiovascular (log-rank P < 0.001) mortality rates than patients without CVC. In multivariate regression analyses, MVC (HR: 1.517, P = 0.010) and AVC (HR: 1.433, P = 0.028) were significant factors associated with all-cause mortality. MVC (HR: 2.340, P < 0.001) and AVC (HR: 2.410, P < 0.001) were also significant factors associated with cardiovascular mortality.

Conclusions

MVC and AVC increased the risk of all-cause and cardiovascular mortality in MHD patients. Regular follow-up with echocardiography could be a useful method for risk stratification in MHD patients.

The echocardiographic course of pretransplant pulmonary hypertension following kidney transplantation and associated outcomes

The post 3 kidney transplant course of pretransplant echocardiographically‐defined pulmonary hypertension (PH) was reviewed in 115 patients. Of these 61 patients (the largest cohort reported to date), underwent 160 “for indication” echocardiograms posttransplant (mean echocardiograms per patient: 2.6 ± 2.3). Patients undergoing posttransplant echocardiograms demonstrated greater risks for worse outcomes than those without posttransplant echocardiograms; however, there was no difference in mortality, death‐censored graft failure or the composite of death or graft failure between these two groups. Of patients tested, 36 (59%) showed resolution of PH at a median of 37.5 months. Six patients (16.7%) in whom PH resolved (at a median of 29 months), experienced recurrence of PH after an interval of 48 months. No pretransplant demographic or echocardiographic characteristics distinguished those in whom PH persisted versus resolved. Though there was no difference in the risk for mortality or death‐censored graft loss between the two groups at 3 and 5 years, there was a higher risk for the composite of mortality or graft loss at three but not at five years in the group with persistent PH. In conclusion, echocardiographically defined PH resolved in 59% of patients following kidney transplantation; but irrespective of resolution there was no clear association with worse outcome.

Impact of Different Approaches to Kidney Transplant with and without Chronic Hemodialysis on Cardiac Function and Morphology: A Case-Control Study

Patients with end-stage renal disease have higher cardiovascular morbidity and mortality compared with the general population. Preemptive kidney transplant (KTx) has been shown to be associated with improved survival, better quality of life, lower healthcare burden, and reduced cardiovascular risk. In this case–control study, we investigated the cardiovascular benefits of two approaches to KTx: with and without previous chronic hemodialysis. We enrolled 21 patients who underwent preemptive KTx and 21 matched controls who received chronic hemodialysis before KTx. Cardiac morphological and functional parameters were assessed by echocardiography. Overall, patients undergoing preemptive KTx showed less extensive cardiac damage compared with controls, as evidenced by higher global longitudinal strain, peak atrial and contractile strain, and early diastolic mitral annular velocity as well as a lower left ventricular mass, left atrial volume index, and the ratio of mitral inflow early diastolic velocity to the mitral annular early diastolic velocity. In the multivariable analysis, the presence of chronic hemodialysis prior to KTx was an independent determinant of post-transplant cardiac functional and structural remodeling. These findings may have important clinical implications, supporting the use of preemptive KTx as a preferred treatment strategy in patients with end-stage renal disease.

Impact of Pre-existing Comorbidities on Long-term Outcomes in Kidney Transplant Recipients

BACKGROUND

Outcomes of patients with end-stage renal disease are mainly affected by their comorbidities. Detailed data evaluating the impact of pre-transplant comorbidities on long-term outcome after kidney transplantation are largely missing.

METHODS

In a long-term retrospective analysis, we investigated 839 deceased donor kidney transplant recipients (KTRs) who received transplants between 1999 and 2014. The prevalence and impact of the most relevant comorbidities were studied in detail.

RESULTS

At the time of transplantation, 25% of KTRs had coronary artery disease (CAD), 16% had diabetes mellitus (DM), 11% had peripheral arterial disease (PAD), 8% had chronic heart failure (CHF), and 7% had cerebrovascular disease (CVD). KTRs with pre-existing CAD, DM, PAD, and CHF showed a significantly inferior patient survival. Multivariate analysis adjusting for all relevant factors and comorbidities confirmed CAD as most hazardous independent risk factor for premature death (hazard ratio [HR] 1.70; P = .002). A multivariate analysis revealed CHF and PAD as independent risk factors for death censored graft loss (HR 2.20; P = .003 and HR 1.80; P = .013). Diabetes was independently and significantly associated with T-cell- (HR 1.46; P = .020) and antibody-mediated rejections (HR 2.27; P = .030).

CONCLUSIONS

Detailed quantification of the impact of pre-transplant comorbidities may facilitate the evaluation of transplant candidates, guide post-transplant follow-up, and may help to further refine prediction algorithms and allocation systems.

Atrial changes after kidney transplant: what diagnostic and therapeutic perspectives?

Kidney transplant is known to be the first choice therapy for end stage chronic kidney disease, also for its positive effects on kidney transplant recipients cardiovascular morbidity and mortality. Several evidences evaluated the morphological changes of the left ventricle before and after transplantation, demonstrating a positive effect of at least partial regression of left ventricular hypertrophy (LVH) in kidney transplant recipients. This article is protected by copyright. All rights reserved.

Regression of left atrial diameter after kidney transplantation is associated with prolonged survival: an observational study

Renal transplantation reduces the dramatically elevated risk of cardiovascular death in dialysis patients. We previously showed that left atrial diameter before transplantation predicts cardiovascular and overall mortality. Now, we investigated the association of changes in cardiac morphology after transplantation and mortality. We retrospectively analyzed data from the Austrian transplant repository using multivariable Cox and competing risk models and multivariable logistic regression for the prediction of changes in cardiac morphology. We identified 414 patients with a median follow-up of 8 years and observed a significant progression of mean diameter of left atrium (LA), right atrium and right ventricle and a significant regression of left ventricle. Complete case analysis of 243 patients with a regression of initially enlarged LA diameter had a significantly lower risk of adjusted overall and cardiovascular mortality; hazard ratio (HR 0.45, 95% CI 0.30-0.69, P < 0.001, 124 deaths), and HR of 0.43 [95% CI 0.21-0.92, P = 0.029, 48 cardiovascular (CV) deaths], respectively. Only age at transplantation was significantly associated with regression of LA (OR 0.75, 95% CI 0.60-0.93, P = 0.007). Patients with regression of LA after kidney transplantation exhibited a lower overall and CV mortality risk. Besides age, peritoneal dialysis and antihypertensive therapy were mediators of LA regression.

The prognostic significance of preoperative left ventricular diastolic dysfunction and left atrial enlargement on acute coronary syndrome in kidney transplantation

Echocardiography is commonly performed as a screening test to evaluate perioperative risks before kidney transplantation. However, only limited data are available on echocardiographic parameters of left ventricular diastolic dysfunction (LVDD) and left atrial enlargement (LAE) on acute coronary syndrome and mortality in kidney transplant recipients. We reviewed 2779 adult recipients who underwent pretransplant echocardiography from 1997 to 2012. We divided the patients into two and four groups by two categories: LVDD grades 0-1 vs. 2-3, and left atrial size quartile groups. During a mean follow-up of 4.5 years, acute coronary syndrome occurred in 89 (3.2%) patients. The recipients with LVDD grades 2-3 (P = 0.005 for non-fatal, P = 0.02 for fatal/non-fatal) and LAE (P = 0.001 for non-fatal, P = 0.03 for fatal/non-fatal) had a higher incidence of acute coronary syndrome after kidney transplantation. All-cause mortality did not differ significantly between the groups. In a multivariate analysis, LVDD of grades 2-3 (hazard ratio 2.98, 95% confidence interval 1.535-5.787; P = 0.001), and LAE (hazard ratio 1.052, 95% confidence interval 1.006-1.101; P = 0.03) were independently associated with non-fatal acute coronary syndrome. In patients who are kidney transplant candidates, pretransplant LVDD and LAE were independently associated with a higher incidence of acute coronary syndrome after kidney transplantation.

Longitudinal assessment of cardiac morphology and function following kidney transplantation

BACKGROUND

Abnormal cardiac morphology is a risk factor for cardiovascular complications in kidney transplant patients. A supraphysiologic level of fibroblast growth factor 23 (FGF-23) has been associated with myocardial hypertrophy in this patient population. Our aim was to evaluate the change in cardiac morphology and function following kidney transplantation and to evaluate the association between the change in FGF-23 concentrations and cardiac morphology.

METHODS

We performed a longitudinal, prospective cohort study of 143 kidney transplant recipients (73% male, 75% white) measuring left ventricular (LV) mass index, left atrial (LA) volume index, and ejection fraction (EF) by echocardiography at months 1, 12, and 24 post-transplant. FGF-23 levels were measured at months 1 and 24 post-transplant.

RESULTS

Unadjusted and adjusted linear mixed-effects models were used to examine changes in outcomes over time. In the adjusted model, LV mass index (P<.001) and LA volume index (P<.001) decreased and EF (P=.009) increased significantly over time. There was a significant association between decreasing FGF-23 levels and improving LV mass index following transplant (P=.036) in the unadjusted model; however, there was no significant relationship in the adjusted model (0.195).

CONCLUSION

Understanding the progression of unique cardiovascular risk factors associated with kidney transplantation may provide potential opportunities to improve survival.

Predictive value of echocardiography and its relation to Kt/V and anthropometric parameters in hemodialysis patients

BACKGROUND

In order to evaluate the predictive value of echocardiograph parameters for mortality of hemodialysis patients and their relation to Kt/V and anthropometry, a prospective, single center study was analyzed post-hoc.

METHODS

This analysis encompassed 106 patients on maintenance hemodialysis monitored for 108 months from 1996 to 2004. spKt/V was calculated using the Daugirdas formula. Anthropometric measurements included mid-arm muscle measurements (MAMC) and percentage of body fat (%fat). Echocardiography included the estimations of left ventricular wall thickness, dimensions and volumes (EDV, ESV), systolic LV function (ejection fraction - EFLV, fractional shortening - VCF, stroke volume - SV) and diastolic LV function (E/A, VTI-A wave of transmitral flow velocity), left atrial diameter, as well as assessment of clinical and biochemical parameters. The Cox proportional hazard model was used to estimate predictive values of echocardiograph parameters.

RESULTS

Kt/V correlated significantly with left ventricular systolic and diastolic volumes and function, septal and posterior wall thickness and left atrium dimension. MAMC and %fat also correlated with many echocardiograph parameters. Multivariate Cox regression selected age [HR 1.07; CI (1.03-1.12); p < 0.01], albumin [HR 0.88; CI (0.79-0.97); p < 0.05] and left atrium dimension - binary [values > 4 cm were marked as "1" and others "0" - HR 3.76; CI (1.56-9.03); p < 0.01] as independent predictors of death.

CONCLUSION

Left atrium dimension was the most important predictor of mortality among the echocardiograph parameters. Many of these parameters were related to Kt/V and anthropometric measurements and could be the combined consequence of hypervolemia and hypertension.

Effect of left atrial and ventricular abnormalities on renal transplant recipient outcome-a single-center study

Background

Premature cardiovascular (CV) death is the commonest cause of death in renal transplant recipients. Abnormalities of left ventricular (LV) structure (collectively termed uremic cardiomyopathy) and left atrial (LA) dilation, a marker of fluid status and diastolic function, are risk factors for reduced survival in patients with end stage renal disease (ESRD). In the present analysis, we studied the impact of pre-transplant LA and LV abnormalities on survival after successful renal transplantation (RT).

Methods

One hundred nineteen renal transplant recipients (first transplant, deceased donors) underwent cardiovascular MRI (CMR) as part of CV screening prior to inclusion on the waiting list. Data regarding transplant function and patient survival after transplantation were collected.

Results

Median post-transplant follow-up was 4.3 years (interquartile range (IQR) 1.9, 6.2). During the post-transplant period, 13 patients returned to dialysis after graft failure and 23 patients died with a functioning graft. Survival analyses, censoring for patients returning to dialysis, showed that pre-transplant LV hypertrophy and elevated LA volume were significantly associated with reduced survival after transplantation. Multivariate Cox regression analyses demonstrated that longer waiting time, poorer transplant function, presence of LV hypertrophy and higher LA volume on screening CMR and female sex were independent predictors of death in patients with a functioning transplant.

Conclusions

Presence of LVH and higher LA volume are significant, independent predictors of death in patients who are wait-listed and proceed with renal transplantation.