APPROACH AND MANAGEMENT OF CARDIOVASCULAR DISEASE AFTER KIDNEY TRANSPLANTATION
Keywords:
kidney transplantation, cardiovascular disease, risk factors, immunosuppressive drugs, post-transplant prognosisAbstract
Kidney transplantation is the gold standard of care for patients with end-stage renal disease, providing marked improvements in quality of life and long-term survival. Nevertheless, cardiovascular disease has emerged as a prevalent and life-threatening post-transplant complication, covertly undermining clinical outcomes and patient longevity. This condition arises from the synergy between traditional risk factors and transplant-specific contributors, such as the adverse effects of immunosuppressive agents, chronic inflammatory states, and metabolic dysregulation. This review offers a comprehensive overview of diagnostic and therapeutic strategies for cardiovascular management following kidney transplantation, aiming to optimize patient prognosis.
References
1. Brosius FC, Hostetter TH, Kelepouris E, Mitsnefes MM, Moe SM, et al. Detection of chronic kidney disease in patients with or at increased risk of cardiovascular disease. A science advisory from the American Heart Association Kidney and Cardiovascular Disease Council; the councils on high blood pressure research, cardiovascular disease in the young, and epidemiology and prevention; and the quality of care and outcomes research interdisciplinary working group. Developed in collaboration with the National Kidney Foundation. Circulation. 2006;114(10):1083-1087. DOI:10.1161/CIRCULATIONAHA.106.177321
2. Wang LW, Fahim MA, Hayen A, Mitchell RL, Lord SW, et al. Cardiac testing for coronary artery disease in potential kidney transplant recipients: a systematic review of test accuracy studies. Am J Kidney Dis. 2011;57:476-487. DOI:10.1053/j.ajkd.2010.11.018
3. Palepu S, Prasad R. Screening for cardiovascular disease before kidney transplantation. World J Transplant. 2015;24:276-286. DOI:10.5500/wjt.v5.i4.276
4. Levin A. Clinical epidemiology of cardiovascular disease in chronic kidney disease prior to dialysis. Semin Dial. 2003;16:101-105. DOI:10.1046/j.1525-139X.2003.16025.x
5. Rigatto C. Clinical epidemiology of cardiac disease in renal transplant recipients. Semin Dial. 2003;16:106-110. DOI:10.1046/j.1525-139X.2003.16026.x
6. Gowdak LHW, Paula FJ, Cesar LAM, Filho EEM, Lanhez LE, et al. Screening for significant coronary artery disease in high-risk renal transplant candidates. Coron Artery Dis. 2007;18:553-558. DOI:10.1097/MCA.0b013e3282f08e99
7. Jeloka TK, Ross H, Smith R, Huang M, Fenton S, et al. Renal transplant outcome in high-cardiovascular risk recipients. Clin Transplant. 2007;21:609-614. DOI:10.1111/j.1399-0012.2007.00695.x
8. Briggs JD. Causes of death after renal transplantation. Nephrol Dial Transplant. 2001;16:1545-1549. DOI:10.1093/ndt/16.8.1545
9. Carpenter MA, Weir MR, Adey DB, House AA, Bostom AG, Kusek JW. Inadequacy of cardiovascular risk factor management in chronic kidney transplantation evidence from the FAVORIT study. Clin Transplant. 2012;26:E438-E446. DOI:10.1111/j.1399-0012.2012.01676.x
10. Chukwu CA, Rao A, Middleton R, Kalra PA. Post-transplant cardiovascular disease in kidney transplant recipients: incidence, risk factors, and outcomes in the era of modern immunosuppression. J Clin Med. 2024;13:2734. DOI:10.3390/jcm13102734
11. Andersson C, Hansen D, Sørensen SS, McGrath M, McCausland FR, Torp-Pedersen C, et al. Long-term cardiovascular events, graft failure, and mortality in kidney transplant recipients. Eur J Intern Med. 2024;121:109-113. DOI:10.1016/j.ejim.2023.10.026
12. Aakhus S, Dahl K, Widerøe TE. Cardiovascular disease in stable renal transplant patients in Norway: morbidity and mortality during a 5-year follow-up. Clin Transplant. 2004;18:596-604. DOI:10.1111/j.1399-0012.2004.00235.x
13. Kasiske BL, Maclean JR, Snyder JJ. Acute myocardial infarction and kidney transplantation. J Am Soc Nephrol. 2006;17:900. DOI:10.1681/ASN.2005090984
14. Pilmore H. Cardiac assessment for renal transplantation. Am J Transplant. 2006;6:659-665. DOI:10.1111/j.1600-6143.2006.01253.x
15. Sharma R, Pellerin D, Gaze DC, Gregson H, Streather CP, et al. Dobutamine stress echocardiography and the resting but not exercise electrocardiography predict severe coronary artery disease in renal transplant candidates. Nephrol Dial Transplant. 2005;20:2207-2214. DOI:10.1093/ndt/gfi005
16. Rautavaara J, et all. Asystole episodes bradycardia in patients with end-stage renal disease. Nephrol Dial Transplants. 2022;25;37(3):575-583. DOI:10.1093/ndt/gfab023
17. de Mattos AM, Siedlecki A, Gaston RS, Perry GJ, Julian BA, et al. Systolic dysfunction portends increased mortality among those waiting for renal transplant. J Am Soc Nephrol. 2008;19:1191-1196. DOI:10.1681/ASN.2007040503
18. Yamada S, Ishii H, Takahashi H, Aoyama T, Morita Y, et al. Prognostic value of reduced left ventricular ejection fraction at start of hemodialysis therapy on cardiovascular and all-cause mortality in end-stage renal disease patients. Clin J Am Son Nephrol. 2010;5:1793-1798. DOI:10.2215/CJN.00050110
19. Cheng XS, Mohanty S, Turner V, Mastrodicasa D, Winther S, Fleischmann D, et al. Coronary computed tomography angiography in diagnosing obstructive coronary artery disease in patients with advanced chronic kidney disease: a systematic review and meta-analysis. Cardiorenal Med. 2021;11:44-51. DOI:10.1159/000510402
20. Winther S, Svensson M, Jørgensen HS, Bouchelouche K, Gormsen LC, Pedersen BB, et al. Diagnostic performance of coronary CT angiography and myocardial perfusion imaging in kidney transplantation candidates. JACC Cardiovasc Imaging. 2015;8:553-562. DOI:10.1016/j.jcmg.2014.12.028
21. Vrints C, Andreotti F, Koskinas KC, Rossello X, Adamo M, Ainslie J, et al. 2024 ESC guidelines for the management of chronic coronary syndromes. Eur Heart J. 2024;45:3415-3537. DOI:10.1093/eurheartj/ehae177
22. Bangalore S, Guo Y, Samadashvili Z, Blecker S, Xu J, Hannan EL. Revascularization in patients with multivessel coronary artery disease and chronic kidney disease: everolimus-eluting stents versus coronary artery bypass graft surgery. J Am Coll Cardiol. 2015;66:1209-1220. DOI:10.1016/j.jacc.2015.06.1334
23. Li X, Xiao F, Zhang S. Coronary revascularisation in patients with chronic kidney disease and end-stage renal disease: a meta-analysis. Int J Clin Pract. 2021;75:e14506. DOI:10.1111/ijcp.14506
24. Bangalore S, Maron DJ, O’Brien SM, Fleg JL, Kretov EI, Briguori C, et al. Management of coronary disease in patients with advanced kidney disease. N Engl J Med. 2020;382:1608-1618. DOI:10.1056/NEJMoa1915925
25. Lee MS, Batiste C, Onwuzurike J, Elkoustaf R, Wu YL, Chen W, et al. Pretransplant cardiac stress testing and transplant wait time in kidney transplantation candidates. Open Heart. 2024;11:e002738. DOI:10.1136/openhrt-2024-002738
26. Pullen LC. Rethinking coronary heart disease tests in pretransplant evaluation: cardiologists no longer screen asymptomatic patients for coronary artery disease—so why are transplant centers still doing it? Am J Transplant. 2023;23:1087-1089. DOI:10.1016/j.ajt.2023.07.001
27. Ying T, Gill J, Webster A, Kim SJ, Morton R, Klarenbach SW, et al. Canadian-Australasian randomised trial of screening kidney transplant candidates for coronary artery disease: a trial protocol for the CARSK study. Am Heart J. 2019;214:175-183. DOI:10.1016/j.ahj.2019.05.008
28. Kelly DM, Ademi Z, Doehner W, Lip GYH, Mark P, Toyoda K, et al. Chronic kidney disease and cerebrovascular disease: consensus and guidance from a KDIGO controversies conference. Stroke. 2021;52:e328-e346. DOI:10.1161/STROKEAHA.120.029680
29. Bobot M, Suissa L, Hak JF, Burtey S, Guillet B, Hache G. Kidney disease and stroke: epidemiology and potential mechanisms of susceptibility. Nephrol Dial Transplant. 2023;38:1940-1951. DOI:10.1093/ndt/gfad029
30. Bobot M, Guedj E, Resseguier N, Faraut J, Garrigue P, Nail V, et al. Increased blood-brain barrier permeability and cognitive impairment in patients with ESKD. Kidney Int Rep. 2024;9:2988-2995. DOI:10.1016/j.ekir.2024.07.021
31. Zhang L, Wang Z, Lv J, Zheng M, Zhu Y. Outcomes of acute ischemic stroke in kidney transplant recipients: an analysis of US Nationwide inpatient sample. Transl Neurosci. 2022;13:327-334. DOI:10.1515/tnsci-2022-0247
32. Kelly DM, Ademi Z, Doehner W, Lip GYH, Mark P, Toyoda K, et al. Chronic kidney disease and cerebrovascular disease: consensus and guidance from a KDIGO controversies conference. Stroke. 2021;52:e328-e346. DOI:10.1161/STROKEAHA.120.029680
33. Reiff T, Eckstein HH, Mansmann U, Jansen O, Fraedrich G, Mudra H, et al. Carotid endarterectomy or stenting or best medical treatment alone for moderate-to-severe asymptomatic carotid artery stenosis: 5-year results of a multicentre randomised controlled trial. Lancet Neurol. 2022;21:877-888. DOI:10.1016/S1474-4422(22)00290-3
34. Kwon H, Shin S, Baek CH, Chang JY, Kang DW, Kwon SU, et al. Characteristics of stroke after liver and kidney transplantation. Front Neurol. 2023;14:1123518. DOI:10.3389/fneur.2023.1123518
35. Pokorney SD, Chertow GM, Al-Khalidi HR, Gallup D, Dignacco P, Mussina K, et al. Apixaban for patients with atrial fibrillation on hemodialysis: a multicenter randomized controlled trial. Circulation. 2022;146:1735-1745. DOI:10.1161/CIRCULATIONAHA.121.054990
36. Fu EL, Desai RJ, Paik JM, Kim DH, Zhang Y, Mastrorilli JM, et al. Comparative safety and effectiveness of warfarin or rivaroxaban versus apixaban in patients with advanced CKD and atrial fibrillation: nationwide US cohort study. Am J Kidney Dis. 2024;83:293-305.e1. DOI:10.1053/j.ajkd.2023.08.017
37. Elenjickal EJ, Travlos CK, Marques P, Mavrakanas TA. Anticoagulation in patients with chronic kidney disease. Am J Nephrol. 2024;55:146-164. DOI:10.1159/000535546
38. Wazni OM, Saliba WI, Nair DG, et al. Left atrial appendage closure after ablation for atrial fibrillation. N Engl J Med. 2025;392:1277-1287. DOI:10.1056/NEJMoa2408308.
39. Mora MMR, Reis AM, Tavares FP, Oliveira LS, Godoi A, Viana P, et al. Safety and efficacy of direct oral anticoagulants in kidney transplant recipients: a systematic review and meta-analysis. Transplant Rev. 2024;39:100899. DOI:10.1016/j.trre.2024.100899
40. Thongprayoon C, Chokesuwattanaskul R, Bathini T, et al. Epidemiology and prognostic importance of atrial fibrillation in kidney transplant recipients: a meta-analysis. J Clin Med. 2018;7:370. DOI:10.3390/jcm7100370
41. Abu Dabrh AM, Steffen MW, Undavalli C, Asi N, Wang Z, Elamin MB, et al. The natural history of untreated severe or critical limb ischemia. J Vasc Surg. 2015;62:1642-1651.e3. DOI:10.1016/j.jvs.2015.07.065
42. Tsuyuki K, Kohno K, Ebine K, et al. Exercise-ankle brachial pressure index with one-minute treadmill walking in patients on maintenance hemodialysis. Ann Vasc Dis. 2013;6:52-56. DOI:10.3400/avd.oa.12.00070
43. Arinze NV, Gregory A, Francis JM, Farber A, Chitalia VC. Unique aspects of peripheral artery disease in patients with chronic kidney disease. Vasc Med Lond Engl. 2019;24:251-260. DOI:10.1177/1358863X18824654
44. Hernández D, Vázquez T, Armas-Padrón AM, et al. Peripheral vascular disease and kidney transplant outcomes: rethinking an important ongoing complication. Transplantation. 2021;105:1188-1202. DOI:10.1097/TP.0000000000003518
45. Snyder JJ, Kasiske BL, Maclean R. Peripheral arterial disease and renal transplantation. J Am Soc Nephrol. 2006;17:2056-2068. DOI:10.1681/ASN.2006030201
46. Patel SI, Chakkera HA, Wennberg PW, et al. Peripheral arterial disease preoperatively may predict graft failure and mortality in kidney transplant recipients. Vasc Med Lond Engl. 2017;22:225-230. DOI:10.1177/1358863X16689830
47. Franquet Q, Terrier N, Pirvu A, et al. Aortic bypass surgery for asymptomatic patients awaiting a kidney transplant: a word of caution. Clin Transplant. 2018;32:e13218. DOI:10.1111/ctr.13218
48. Kasiske BL, Cangro CB, Hariharan S, et al. American Society of Transplantation the evaluation of renal transplantation candidates: clinical practice guidelines. Am J Transplant. 2001;1(suppl S2):3-95. DOI:10.1034/j.1600-6143.2001.000100.x
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