A population cohort analysis of English transplant centers indicates major adverse cardiovascular events after kidney transplantation

Risk and management of cardiac disease in kidney and liver transplant recipients

Organ transplantation is the treatment of choice for individuals with kidney failure requiring kidney replacement therapy, as well as for those with end-stage liver disease. Despite the significant reduction in long-term morbidity and mortality with transplantation, kidney and liver allograft recipients remain at high risk for cardiovascular disease (CVD) and premature death from cardiovascular causes. This heightened risk is represented across all phenotypes of CVD, including coronary heart disease, heart failure, arrhythmias, valvulopathies and pulmonary hypertension. Pre-existing vascular risk factors for CVD, coupled with superimposed cardiovascular-kidney-metabolic derangements after transplantation, driven at least in part by post-transplant weight gain, immunosuppressive therapies and de novo risk factors such as dyslipidaemia and diabetes, coalesce to increase total CVD risk. In this review, we summarise pathophysiological considerations for both the short- and long-term increase in CVD risk following kidney/liver transplantation. We review the different phenotypes of CVD, with unique considerations for post-transplant care in this patient population. Finally, we highlight the need for awareness about long-term CVD risk and a multidisciplinary approach to managing organ-specific CVD risk in kidney and liver transplant patients.

Impact of sirolimus on long-term adverse cardiovascular outcomes in kidney transplant recipients: A nationwide cohort study

BACKGROUND

Kidney transplant recipients (KTRs) are at high risk for cardiovascular disease due to the long-term use of immunosuppressive therapy. This study aims to evaluate the long-term impact of sirolimus on cardiovascular outcomes in Korean KTRs.

METHODS

From a cohort of 7180 eligible KTRs identified from 2010 to 2021, 387 KTRs who received sirolimus were included. To control for confounding variables, propensity score matching was applied, and the landmark method was used to address immortal time bias. The primary outcome was major adverse cardiovascular events (MACE), defined as a composite of myocardial infarction, coronary revascularization, ischaemic stroke and all-cause mortality.

RESULTS

The analysis showed no significant difference in MACE between the sirolimus-treated and untreated groups (hazard ratio, 1.40; 95% confidence interval, .77-2.55), despite a higher incidence of dyslipidaemia in the sirolimus-treated group. However, subgroup analysis revealed an increased MACE risk in KTRs with pre-transplant congestive heart failure (CHF) who were treated with sirolimus (hazard ratio, 6.22; 95% confidence interval, 1.78-21.74), while no significant differences were found in other subgroups.

CONCLUSIONS

These findings suggest that while sirolimus can be a viable option for immunosuppression, it should be used cautiously in those with pre-existing CHF.

Novel Predictors of Major Adverse Cardiovascular Events in Renal Transplant Patients: A Systematic Review and Meta-Analysis

Adult patients with a prior renal transplantation are at increased risk of accelerated cardiovascular disease. This study aims to identify key clinical and biochemical predictors of major adverse cardiovascular events (MACEs) in this population. Understanding these predictors may improve risk stratification and enhance long-term outcomes for kidney transplant recipients. A systematic literature search of medical databases was performed using PRISMA principles to identify all relevant studies assessing clinical and biochemical parameters in adult patients with a prior renal transplantation (2000-2024; English only; PROSPERO registration CRD42024596207). Data for a range of clinical and biochemical parameters were individually extracted, and those with low heterogeneity were then meta-analysed using a random-effects model for overall effect size and assessed through standardised mean difference (SMD) and odds ratios (ORs). The primary outcomes assessed were fatal or non-fatal cardiovascular events occurring after renal transplantation during hospitalisation and up to 10 years post discharge. Of 506 screened studies, 17 peer-reviewed articles met inclusion criteria and included a total of 181,938 renal transplant patients. The key novel predictors of MACE included pre-transplant haemodialysis (OR 2.562, 95% CI = 1.585-4.139, p < 0.001) and delayed graft function (OR 2.113, 95% CI = 1.397-3.198, p < 0.001). Importantly, transplant from a living donor (OR 0.463, 95% CI = 0.393-0.546, p < 0.001) was a protective factor. Traditional cardiovascular risk factor profiles were all predictors of MACE events (p < 0.05). This study identified several traditional and novel predictors of cardiovascular events in patients with pre-existing renal transplantation. Early recognition of these high-risk clinical predictors should prompt more aggressive monitoring and treatment.

Sex disparities in mortality and cardiovascular outcomes in chronic kidney disease

Sex (biologically determined) and gender (socially constructed) modulate manifestations and prognosis of a vast number of diseases, including cardiovascular disease (CVD) and chronic kidney disease (CKD). CVD remains the leading cause of death in CKD patients. Population-based studies indicate that women present a higher prevalence of CKD and experience less CVD than men in all CKD stages, although this is not as clear in patients on dialysis or transplantation. When compared to the general population of the same sex, CKD has a more negative impact on women on kidney replacement therapy. European women on dialysis or recipients of kidney transplants have life expectancy up to 44.8 and 19.8 years lower, respectively, than their counterparts of similar age in the general population. For men, these figures stand at 37.1 and 16.5 years, representing a 21% to 20% difference, respectively. Hormonal, genetic, societal, and cultural influences may contribute to these sex-based disparities. To gain a more comprehensive understanding of these differences and their implications for patient care, well-designed clinical trials that involve a larger representation of women and focus on sex-related variables are urgently needed. This narrative review emphasizes the importance of acknowledging the epidemiology and prognosis of sex disparities in CVD among CKD patients. Such insights can guide research into the underlying pathophysiological mechanisms, leading to optimized treatment strategies and ultimately, improved clinical outcomes.

Association between sleep quality and cardiovascular disease in maintenance hemodialysis patients: a prospective cohort study

OBJECTIVE

This study aimed to analyze the association between sleep quality and cardiovascular disease in patients on maintenance hemodialysis (MHD).

METHODS

A total of 601 patients with MHD in the second affiliated hospital of Nanjing Medical University, were prospectively enrolled in this cohort study from January 2019 to December2019. The global Pittsburgh sleep quality index (PSQI) score > 7 indicates that a person with poor sleep quality. Patients were divided into two groups according to the PSQI score. Follow-up was conducted about 3 years with all-cause death and major adverse cardiovascular events (MACEs) as the endpoint events.

RESULTS

Of the 601 patients, 595 patients completed the PSQI assessment, with 278 patients having poor sleep quality. Patients in the PSQI > 7 group were older and had a higher proportion of cardiovascular disease or diabetes. Years of education, diastolic blood pressure, and heart rate were lower in the PSQI > 7 group. At a mean follow-up period of 3 years, 116 patients died, 64 patients were lost to follow-up, and 115 patients experienced MACEs. After adjusting for confounding factors such as age, gender, dialysis age, and previous cardiovascular disease, the risk of MACE in patients with poor sleep quality was twice that of patients with good sleep quality (HR = 2.037 (1.339, 3.097), p = 0.001). There was no significant difference in the risk of all-cause death between the two groups.

CONCLUSION

The prevalence of poor sleep quality was 46.7% in patients with MHD. Poor sleep quality was an independent risk factor for MACEs in patients with MHD.

Stroke and kidney transplantation

PURPOSE OF REVIEW

This review will focus on the epidemiological data, risk factors, and management of stroke before and after kidney transplant. Stroke is highly prevalent in waitlisted patients as well as kidney transplant recipients and is associated with impaired transplant outcomes. Multiple traditional, nontraditional, and transplanted risk factors increase the risk of stroke.

RECENT FINDINGS

Although the risk of stroke is reduced after kidney transplantation compared with remaining on dialysis, the morbidity and mortality from stroke after transplantation remain significant.

SUMMARY

Early screening for risk factors before and after a kidney transplant and following the Kidney Disease Improving Global Outcomes (KDIGO) management guidelines could minimize the incidence of stroke and transplant outcomes.