Risk factors for cardiovascular disease in the renal transplant recipient
|Authors||Section Editor||Deputy Editor|
|John Vella, MD, FACP, FRCP, FASN||Daniel C Brennan, MD, FACP||Alice M Sheridan, MD|
|Krista L Lentine, MD, PhD|
Cardiovascular disease is a leading cause of morbidity and mortality after kidney transplantation. Death from cardiovascular disease is also the most common cause of graft loss.
This topic reviews the risk factors of cardiovascular disease among renal transplant recipients. The epidemiology of cardiovascular disease following transplantation, cardiovascular outcomes compared with dialysis patients and the evaluation of renal transplant candidates are discussed elsewhere. (See "Patient survival after renal transplantation" and "Evaluation of the potential renal transplant recipient".)
OVERVIEW OF CARDIOVASCULAR RISK
Transplant recipients have a lower risk of fatal and non-fatal cardiovascular events compared with wait-listed patients on dialysis [1-4], but a much higher risk compared with the general population . Fifty to 60 percent of post-transplant deaths are directly attributable to cardiovascular disease, with an incidence of ischemic heart disease of approximately one per 100 person years at risk [6,7]. Cardiovascular disease is the most common cause of death with graft function after transplant, and accounts for 30 percent of graft loss from death overall, with the greatest rates early after transplant .
The high rate of cardiovascular deaths in the transplant population is due in part to the large number of diabetic patients in the end-stage renal disease (ESRD) population, who are at markedly increased cardiovascular risk compared with non-diabetic transplant recipients. As an example, in one study of 933 transplant recipients, cardiovascular disease was the most common cause of death among diabetic recipients; in contrast, most deaths among nondiabetic recipients were due to infection, malignancy or other causes .
However the cardiovascular risk among transplant recipients who do not have ESRD related to diabetes is still higher than in the general population . The increased cardiovascular risk is due to the following:
Subscribers log in here
To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Jan 2014. | This topic last updated: Jan 10, 2013.
1. Lentine KL, Brennan DC, Schnitzler MA. Incidence and predictors of myocardial infarction after kidney transplantation. J Am Soc Nephrol 2005; 16:496.
2. Meier-Kriesche HU, Schold JD, Srinivas TR, et al. Kidney transplantation halts cardiovascular disease progression in patients with endstage renal disease. Am J Transplant 2004; 4:1662.
3. Lentine KL, Rocca Rey LA, Kolli S, et al. Variations in the risk for cerebrovascular events after kidney transplant compared with experience on the waiting list and after graft failure. Clin J Am Soc Nephrol 2008; 3:1090.
4. Lentine KL, Schnitzler MA, Abbott KC, et al. De novo congestive heart failure after kidney transplantation: a common condition with poor prognostic implications. Am J Kidney Dis 2005; 46:720.
5. Jardine AG, Gaston RS, Fellstrom BC, Holdaas H. Prevention of cardiovascular disease in adult recipients of kidney transplants. Lancet 2011; 378:1419.
6. Yeo FE, Villines TC, Bucci JR, et al. Cardiovascular risk in stage 4 and 5 nephropathy. Adv Chronic Kidney Dis 2004; 11:116.
7. Ojo AO. Cardiovascular complications after renal transplantation and their prevention. Transplantation 2006; 82:603.
8. US Renal Data System. USRDS 2008 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Bethesda, MD 2008.
9. Cosio FG, Hickson LJ, Griffin MD, et al. Patient survival and cardiovascular risk after kidney transplantation: the challenge of diabetes. Am J Transplant 2008; 8:593.
10. Kasiske BL. Risk factors for accelerated atherosclerosis in renal transplant recipients. Am J Med 1988; 84:985.
11. de Mattos AM, Prather J, Olyaei AJ, et al. Cardiovascular events following renal transplantation: role of traditional and transplant-specific risk factors. Kidney Int 2006; 70:757.
12. Jardine AG, Fellström B, Logan JO, et al. Cardiovascular risk and renal transplantation: post hoc analyses of the Assessment of Lescol in Renal Transplantation (ALERT) Study. Am J Kidney Dis 2005; 46:529.
13. Vanrenterghem YF, Claes K, Montagnino G, et al. Risk factors for cardiovascular events after successful renal transplantation. Transplantation 2008; 85:209.
14. Ducloux D, Kazory A, Chalopin JM. Predicting coronary heart disease in renal transplant recipients: a prospective study. Kidney Int 2004; 66:441.
15. Rigatto C, Parfrey P, Foley R, et al. Congestive heart failure in renal transplant recipients: risk factors, outcomes, and relationship with ischemic heart disease. J Am Soc Nephrol 2002; 13:1084.
16. Abbott KC, Bucci JR, Cruess D, et al. Graft loss and acute coronary syndromes after renal transplantation in the United States. J Am Soc Nephrol 2002; 13:2560.
17. Jindal RM, Zawada ET Jr. Obesity and kidney transplantation. Am J Kidney Dis 2004; 43:943.
18. Dussol B, Bonnet JL, Sampol J, et al. Prognostic value of inducible myocardial ischemia in predicting cardiovascular events after renal transplantation. Kidney Int 2004; 66:1633.
19. Abedini S, Holme I, März W, et al. Inflammation in renal transplantation. Clin J Am Soc Nephrol 2009; 4:1246.
20. Meier-Kriesche HU, Baliga R, Kaplan B. Decreased renal function is a strong risk factor for cardiovascular death after renal transplantation. Transplantation 2003; 75:1291.
21. Zelle DM, Corpeleijn E, Stolk RP, et al. Low physical activity and risk of cardiovascular and all-cause mortality in renal transplant recipients. Clin J Am Soc Nephrol 2011; 6:898.
22. Rosas SE, Mensah K, Weinstein RB, et al. Coronary artery calification in renal transplant recipients. Am J Transplant 2005; 5:1942.
23. Hernández D, Rufino M, Bartolomei S, et al. Clinical impact of preexisting vascular calcifications on mortality after renal transplantation. Kidney Int 2005; 67:2015.
24. Kasiske BL, Maclean JR, Snyder JJ. Acute myocardial infarction and kidney transplantation. J Am Soc Nephrol 2006; 17:900.
25. Kasiske BL, Chakkera HA, Roel J. Explained and unexplained ischemic heart disease risk after renal transplantation. J Am Soc Nephrol 2000; 11:1735.
26. Kiberd B, Panek R. Cardiovascular outcomes in the outpatient kidney transplant clinic: the Framingham risk score revisited. Clin J Am Soc Nephrol 2008; 3:822.
27. Jaffe AS, Babuin L, Apple FS. Biomarkers in acute cardiac disease: the present and the future. J Am Coll Cardiol 2006; 48:1.
28. Hickson LT, El-Zoghby ZM, Lorenz EC, et al. Patient survival after kidney transplantation: relationship to pretransplant cardiac troponin T levels. Am J Transplant 2009; 9:1354.
29. Claes K, Bammens B, Evenepoel P, et al. Troponin I is a predictor of acute cardiac events in the immediate postoperative renal transplant period. Transplantation 2010; 89:341.
30. U.S. Renal Data System, USRDS 2007 Annual Data Report: Atlas f Chronic Kidney Disease and End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2007.
31. Abbott KC, Hypolite IO, Hshieh P, et al. Hospitalized congestive heart failure after renal transplantation in the United States. Ann Epidemiol 2002; 12:115.
32. Lentine KL, Rocca-Rey LA, Bacchi G, et al. Obesity and cardiac risk after kidney transplantation: experience at one center and comprehensive literature review. Transplantation 2008; 86:303.
33. Abbott KC, Yuan CM, Taylor AJ, et al. Early renal insufficiency and hospitalized heart disease after renal transplantation in the era of modern immunosuppression. J Am Soc Nephrol 2003; 14:2358.
34. Abbott KC, Reynolds JC, Taylor AJ, Agodoa LY. Hospitalized atrial fibrillation after renal transplantation in the United States. Am J Transplant 2003; 3:471.
35. Siedlecki A, Foushee M, Curtis JJ, et al. The impact of left ventricular systolic dysfunction on survival after renal transplantation. Transplantation 2007; 84:1610.
36. Gill JS, Ma I, Landsberg D, et al. Cardiovascular events and investigation in patients who are awaiting cadaveric kidney transplantation. J Am Soc Nephrol 2005; 16:808.
37. Fellström B, Jardine AG, Soveri I, et al. Renal dysfunction as a risk factor for mortality and cardiovascular disease in renal transplantation: experience from the Assessment of Lescol in Renal Transplantation trial. Transplantation 2005; 79:1160.
38. Fellström B, Jardine AG, Soveri I, et al. Renal dysfunction is a strong and independent risk factor for mortality and cardiovascular complications in renal transplantation. Am J Transplant 2005; 5:1986.
39. Bostom AG, Shemin D, Lapane KL, et al. Hyperhomocysteinemia, hyperfibrinogenemia, and lipoprotein (a) excess in maintenance dialysis patients: a matched case-control study. Atherosclerosis 1996; 125:91.
40. Guijarro C, Keane WF. Lipid abnormalities and changes in plasma proteins in glomerular diseases and chronic renal failure. Curr Opin Nephrol Hypertens 1993; 2:372.
41. Makita Z, Yanagisawa K, Kuwajima S, et al. The role of advanced glycosylation end-products in the pathogenesis of atherosclerosis. Nephrol Dial Transplant 1996; 11 Suppl 5:31.
42. Vanrenterghem Y, Ponticelli C, Morales JM, et al. Prevalence and management of anemia in renal transplant recipients: a European survey. Am J Transplant 2003; 3:835.
43. Shah N, Al-Khoury S, Afzali B, et al. Posttransplantation anemia in adult renal allograft recipients: prevalence and predictors. Transplantation 2006; 81:1112.
44. Lentine KL, Schnitzler MA, Abbott KC, et al. Incidence, predictors, and associated outcomes of atrial fibrillation after kidney transplantation. Clin J Am Soc Nephrol 2006; 1:288.
45. Molnar MZ, Czira M, Ambrus C, et al. Anemia is associated with mortality in kidney-transplanted patients--a prospective cohort study. Am J Transplant 2007; 7:818.
46. Kamar N, Rostaing L. Negative impact of one-year anemia on long-term patient and graft survival in kidney transplant patients receiving calcineurin inhibitors and mycophenolate mofetil. Transplantation 2008; 85:1120.
47. Gore JL, Pham PT, Danovitch GM, et al. Obesity and outcome following renal transplantation. Am J Transplant 2006; 6:357.
48. van den Ham EC, Kooman JP, Christiaans MH, van Hooff JP. Relation between steroid dose, body composition and physical activity in renal transplant patients. Transplantation 2000; 69:1591.
49. de Vries AP, Bakker SJ, van Son WJ, et al. Metabolic syndrome is associated with impaired long-term renal allograft function; not all component criteria contribute equally. Am J Transplant 2004; 4:1675.
50. Courivaud C, Kazory A, Simula-Faivre D, et al. Metabolic syndrome and atherosclerotic events in renal transplant recipients. Transplantation 2007; 83:1577.
51. Meier-Kriesche HU, Arndorfer JA, Kaplan B. The impact of body mass index on renal transplant outcomes: a significant independent risk factor for graft failure and patient death. Transplantation 2002; 73:70.
52. van den Ham EC, Kooman JP, van Hooff JP. Nutritional considerations in renal transplant patients. Blood Purif 2002; 20:139.
53. Modanlou KA, Muthyala U, Xiao H, et al. Bariatric surgery among kidney transplant candidates and recipients: analysis of the United States renal data system and literature review. Transplantation 2009; 87:1167.
54. Kasiske BL, Klinger D. Cigarette smoking in renal transplant recipients. J Am Soc Nephrol 2000; 11:753.
55. Cosio FG, Falkenhain ME, Pesavento TE, et al. Patient survival after renal transplantation: II. The impact of smoking. Clin Transplant 1999; 13:336.
56. Dennis VW, Robinson K. Homocysteinemia and vascular disease in end-stage renal disease. Kidney Int Suppl 1996; 57:S11.
57. Robinson K, Gupta A, Dennis V, et al. Hyperhomocysteinemia confers an independent increased risk of atherosclerosis in end-stage renal disease and is closely linked to plasma folate and pyridoxine concentrations. Circulation 1996; 94:2743.
58. Selhub J, Jacques PF, Bostom AG, et al. Association between plasma homocysteine concentrations and extracranial carotid-artery stenosis. N Engl J Med 1995; 332:286.
59. Nygård O, Nordrehaug JE, Refsum H, et al. Plasma homocysteine levels and mortality in patients with coronary artery disease. N Engl J Med 1997; 337:230.
60. Ducloux D, Motte G, Challier B, et al. Serum total homocysteine and cardiovascular disease occurrence in chronic, stable renal transplant recipients: a prospective study. J Am Soc Nephrol 2000; 11:134.
61. Winkelmayer WC, Kramar R, Curhan GC, et al. Fasting plasma total homocysteine levels and mortality and allograft loss in kidney transplant recipients: a prospective study. J Am Soc Nephrol 2005; 16:255.
62. Berger PB, Jones JD, Olson LJ, et al. Increase in total plasma homocysteine concentration after cardiac transplantation. Mayo Clin Proc 1995; 70:125
63. Ambrosi P, Barlatier A, Habib G, et al. Hyperhomocysteinaemia in heart transplant recipients. Eur Heart J 1994; 15:1191.
64. Arnadottir M, Hultberg B, Vladov V, et al. Hyperhomocysteinemia in cyclosporine-treated renal transplant recipients. Transplantation 1996; 61:509.
65. Arnadottir M, Hultberg B, Wahlberg J, et al. Serum total homocysteine concentration before and after renal transplantation. Kidney Int 1998; 54:1380.
66. Ducloux D, Fournier V, Rebibou JM, et al. Hyperhomocyst(e)inemia in renal transplant recipients with and without cyclosporine. Clin Nephrol 1998; 49:232.
67. Bostom AG, Gohh RY, Beaulieu AJ, et al. Treatment of hyperhomocysteinemia in renal transplant recipients. A randomized, placebocontrolled trial. Ann Intern Med 1997; 127:1089.
68. Bostom AG, Carpenter MA, Kusek JW, et al. Homocysteine-lowering and cardiovascular disease outcomes in kidney transplant recipients: primary results from the Folic Acid for Vascular Outcome Reduction in Transplantation trial. Circulation 2011; 123:1763.
69. Zlotnick DM, Axelrod DA, Chobanian MC, et al. Non-invasive detection of pulmonary hypertension prior to renal transplantation is a predictor of increased risk for early graft dysfunction. Nephrol Dial Transplant 2010; 25:3090.
70. Issa N, Krowka MJ, Griffin MD, et al. Pulmonary hypertension is associated with reduced patient survival after kidney transplantation. Transplantation 2008; 86:1384.
71. Gaston RS, Kasiske BL, Fieberg AM, et al. Use of cardioprotective medications in kidney transplant recipients. Am J Transplant 2009; 9:1811.
72. Pilmore HL, Skeans MA, Snyder JJ, et al. Cardiovascular disease medications after renal transplantation: results from the Patient Outcomes in Renal Transplantation study. Transplantation 2011; 91:542.
73. Lentine KL, Villines TC, Xiao H, et al. Cardioprotective medication use after acute myocardial infarction in kidney transplant recipients. Transplantation 2011.
For a printable copy of this, click here.