Cardiovascular Disease in Kidney Transplant Recipients

Leave No Stone Unturned

Steven Van Laecke; Daniel Abramowicz

Disclosures

Nephrol Dial Transplant. 2019;34(5):727-730. 

In This Article

Abstract and Introduction

Introduction

In the current edition of Nephrology Dialysis and Transplantation, Rangaswami et al.[1] on behalf of the American Society of Transplantation's Kidney-Pancreas Community of Practice Cardiovascular Disease Workgroup comprehensively summarized the current evidence on the diagnostic and therapeutic approach to cardiovascular disease (CVD) in kidney transplant recipients (KTRs). The authors provided an extensive outline, including both observational and interventional data, with a prime focus on classical Framingham-based risk factors, which still dominate contemporary cardiovascular risk stratification and treatment approach.[2] In addition to these classical risk factors, it is now clear that chronic kidney disease (CKD; estimated glomerular filtration rate <60 mL/min/1.73 m[2]) negatively impacts cardiovascular mortality, both in the general population as well in the specific group of KTRs.[3,4] Some gaps in the existing literature were reviewed, such as the relevance of arterial pulmonary hypertension and the current status of transcatheter aortic valve replacement in KTRs. Yet, as highlighted in the article, the ongoing scarcity of randomized controlled trials (RCTs) complicates the decision process and renders some recommendations less persuasive. As the mainstay of studies evaluating CVD in KTR is observational, inherent methodological concerns should be taken into account. Established risk factors such as smoking, hyperlipidaemia and diabetes are mostly being narrowed to hic et nunc effects, neglecting the biological reality of cumulative, proportional and dynamic exposure. Also, prediction models still fail to properly account for competing risks.[5] Finally, bias by indication is a potential catalyst of variable outcome between KTR allocated to more aggressive or restricted cardiovascular screening and to different immunosuppressive regimens.

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