Cardiovascular Risk in Renal Transplantation

Bengt C. Fellström; Halvard Holdaas; Alan G. Jardine

Disclosures

Trends Transplant. 2008;2(2):62-68. 

In This Article

Abstract and Introduction

Renal transplant patients suffer from a higher risk of cardiovascular morbidity and mortality. The risk-factor spectrum is different from the general population; several risk factors are transplantation specific, and to a large extent dependent on the immunosuppressive drugs used to prevent rejection. Due to the complexity of the risk factors, the variable impact of each factor on different cardiovascular outcomes and the inter-relationships between risk factors, it is difficult to judge the overall cardiovascular risk in a single renal transplant patient. In this paper we review risk-factor data from the literature, limited to single risk factors and their impact on single cardiovascular outcomes. We believe that a cardiovascular risk calculator specific to the renal transplant population, which takes into account all the important risk factors for a cardiovascular event, based upon a high quality database such as the ALERT data set, may provide a solid guidance to means to assess the overall cardiovascular risk in renal transplant recipients.

Patient and graft survival following renal transplantation have improved progressively over the last few decades, largely as a consequence of improved immunosuppressive agents. One result of the effective prevention of acute rejection episodes, however, is the emergence of longterm problems in renal transplantation, including graft failure due to chronic allograph nephropathy (CAN) and premature patient death.[1,2,3]

Mortality after renal transplantation is mainly due to cardiovascular disease (CVD), infections, and malignancies. In most countries that have active renal transplant programs, CVD are the predominant cause of premature death.[4] An exception may be Australia, where malignancy (skin malignancies in particular) has been reported to be the dominating cause of patient death in some years. However, CVD recently surpassed it as the leading cause of death. Although cardiovascular (CV) mortality is increased in renal transplant recipients (RTR) (3-5-times that of the general population), it is still significantly lower than in dialysis patients,[4,5] where mortality rates are 10-100-fold higher than the general population. The CV complications that affect RTR include myocardial infarction, left ventricular hypertrophy, heart failure, sudden (presumed arrhythmic) cardiac death, stroke, and peripheral vascular disease. These different manifestations of CVD in RTR differ from the general population, both in their prevalence and the relationship between CV risk factors and individual events.

The spectrum of risk factors in RTR includes traditional risk factors (found in the general population) such as age, smoking, male gender, hyperlipidemia, hypertension, diabetes, and preexisting CVD.[3] However, there are also risk factors that are transplantation-specific, such as the impact of immunosuppressive treatment on the CV risk, and the differing impact of individual agents on conventional CV risk factors.[6,7] Previously treated acute rejection episodes, graft loss, return to dialysis treatment, and the overall duration of renal replacement therapy (RRT) have also been identified as CV risk factors in RTR.

A useful way of classifying risk factors is to divide them into modifiable and non-modifiable risk factors, which gives direction to treatment or prevention of CV events in this population. A further important aspect in the assessment of CV risk is the interaction or co- variation between risk factors, as well as difficulties in comparing the relative influence of one risk factor versus another for future CV events. These problems encouraged us to develop a cardiovascular risk calculator based on the placebo group in the ALERT trial and comparable to the Framingham model used in the general population.[8] In the present review we will discuss some of the reported risk factors, how they are interrelated, and what may be done to reduce the influence of respective risk factors.

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