Patient survival after renal transplantation: II. The impact of smoking

How to manage cigarette smoking in kidney transplant candidates and recipients?

Tobacco smoking is a frequent problem affecting many kidney transplant (KT) candidates and recipients. The negative impact of active smoking on KT outcomes has been demonstrated. Consequently, most guidelines strongly recommend quitting smoking before considering kidney transplantation. However, nicotine addiction is a complex multifactorial disease and only 3–5% of the patients who try to quit by themselves achieve prolonged abstinence. Smoking cessation programmes (SCPs) have proven their efficacy in the general population to increase the rate of quitting and should therefore be proposed to all smoking KT candidates and recipients. Nevertheless, SCPs have not been evaluated in the KT field and not all KT centres have easy access to these programmes. In this work, we aim to review the current knowledge on the subject and provide an overview of the available interventions to help smoking patients quit. We detail non-pharmaceutical and pharmaceutical approaches and discuss their use in KT candidates and recipients.

Peripheral Vascular Disease and Kidney Transplant Outcomes: Rethinking an Important Ongoing Complication

Peripheral vascular disease (PVD) is highly prevalent in patients on the waiting list for kidney transplantation (KT) and after transplantation and is associated with impaired transplant outcomes. Multiple traditional and nontraditional risk factors, as well as uremia- and transplant-related factors, affect 2 processes that can coexist, atherosclerosis and arteriosclerosis, leading to PVD. Some pathogenic mechanisms, such as inflammation-related endothelial dysfunction, mineral metabolism disorders, lipid alterations, or diabetic status, may contribute to the development and progression of PVD. Early detection of PVD before and after KT, better understanding of the mechanisms of vascular damage, and application of suitable therapeutic approaches could all minimize the impact of PVD on transplant outcomes. This review focuses on the following issues: (1) definition, epidemiological data, diagnosis, risk factors, and pathogenic mechanisms in KT candidates and recipients; (2) adverse clinical consequences and outcomes; and (3) classical and new therapeutic approaches.

Cardiovascular disease in the kidney transplant recipient: epidemiology, diagnosis and management strategies

Kidney transplantation (KT) is the optimal therapy for end-stage kidney disease (ESKD), resulting in significant improvement in survival as well as quality of life when compared with maintenance dialysis. The burden of cardiovascular disease (CVD) in ESKD is reduced after KT; however, it still remains the leading cause of premature patient and allograft loss, as well as a source of significant morbidity and healthcare costs. All major phenotypes of CVD including coronary artery disease, heart failure, valvular heart disease, arrhythmias and pulmonary hypertension are represented in the KT recipient population. Pre-existing risk factors for CVD in the KT recipient are amplified by superimposed cardio-metabolic derangements after transplantation such as the metabolic effects of immunosuppressive regimens, obesity, posttransplant diabetes, hypertension, dyslipidemia and allograft dysfunction. This review summarizes the major risk factors for CVD in KT recipients and describes the individual phenotypes of overt CVD in this population. It highlights gaps in the existing literature to emphasize the need for future studies in those areas and optimize cardiovascular outcomes after KT. Finally, it outlines the need for a joint 'cardio-nephrology' clinical care model to ensure continuity, multidisciplinary collaboration and implementation of best clinical practices toward reducing CVD after KT.

The impact of blood pressure variability and pulse pressure on graft survival and mortality after kidney transplantation

BACKGROUND

Blood pressure variability and pulse pressure are strong and independent predictors of cardiovascular morbidity and mortality in the general population. So far, there are no data on the impact of blood pressure variability on mortality and graft survival after renal transplantation.

METHODS

We performed a retrospective analysis of 877 patients who underwent kidney transplantation between 1997 and 2011 in two transplant centers in Germany (Berlin and Bochum) with a follow-up of 12-266 months. Visit-to-visit blood pressure variability over the first 12 months after transplantation (3 visits) and during the first 120 months after transplantation (7 visits) was calculated as the coefficient of variation (CV = standard deviation (SD)/mean blood pressure). Patient and graft survival was defined as composite endpoint.

RESULTS

Cumulative survival was significantly higher for those patients with lower systolic blood pressure and pulse pressure within both the first 12 months and the 120 months posttransplant. After adjustment of data for gender, age, body mass index, and coronary artery disease, the cumulative incidence of the combined endpoint did not significantly differ between patients with lower vs higher CV (12 months CV hazard ratio (HR) (95% CI) = 0.90 (0.66-1.23), P = 0.51; 120 months CV HR (95% CI) = 0.92 (0.67-1.26), P = 0.60). A lower systolic blood pressure remained highly predictive for better survival in adjusted analyses.

CONCLUSION

Visit-to-visit blood pressure variability is not associated with mortality or graft loss after kidney transplantation in this retrospective analysis. In analogy to the general population, however, there is an inverse relationship of survival and pulse pressure as a marker of arterial stiffness.

Should donors who have used marijuana be considered candidates for living kidney donation?

Background

The use of marijuana in the USA has been steadily increasing over the last 10 years. This study is the first to investigate the effect of marijuana use by live kidney donors upon outcomes in both donors and recipients.

Methods

Living kidney donor transplants performed between January 2000 and May 2016 in a single academic institution were retrospectively reviewed. Donor and recipient groups were each divided into two groups by donor marijuana usage. Outcomes in donor and recipient groups were compared using t-test, Chi-square and mixed linear analysis (P < 0.05 considered significant).

Results

This was 294 living renal donor medical records were reviewed including 31 marijuana-using donors (MUD) and 263 non-MUDs (NMUD). It was 230 living kidney recipient records were reviewed including 27 marijuana kidney recipients (MKRs) and 203 non-MKRs (NMKR). There was no difference in donor or recipient perioperative characteristics or postoperative outcomes based upon donor marijuana use (P > 0.05 for all comparisons). There was no difference in renal function between NMUD and MUD groups and no long-term difference in kidney allograft function between NMKR and MKR groups.

Conclusions

Considering individuals with a history of marijuana use for living kidney donation could increase the donor pool and yield acceptable outcomes.

Deceased-Donor Smoking History Is Associated With Increased Recipient Mortality After Kidney Transplant: A Population-Cohort Study

OBJECTIVES

Historical data have suggested that donor smoking is associated with detrimental clinical outcomes for recipients of kidneys from deceased donors. However, the effects of smoking status of a kidney donor on the outcomes of the recipient in a contemporary setting of immunosuppression and transplant practice have not yet been ascertained.

MATERIALS AND METHODS

This retrospective, population-cohort study analyzed data of all deceased-donor kidney-alone transplant procedures performed in the United Kingdom between April 2001 and April 2013. Our study included 11?199 deceased-donor kidney allograft recipients, with median follow-up of 46 months posttransplant.

RESULTS

In our cohort, 5280 deceased donors (47.1%) had a documented history of smoking. Deceased donors with versus those without smoking history were more likely to be younger (mean age of 48 vs 50 years; P < .001), be of white ethnicity (96.6% vs 95.3%; P < .001), and have brain death before donation (77.1% vs 74.9%; P = .006). On unadjusted survival analyses, overall patient survival was significantly shorter in patients who received kidney allografts from deceased donors with smoking history (hazard ratio of 1.12, 95% confidence interval, 1.00-1.25; P = .044). No significant association was seen for death-censored or overall graft survival. Our multivariate survival analyses showed that, after accounting for confounding factors, the effects of donor smoking status remained significant for patient survival (hazard ratio of 1.16, 95% CI, 1.03-1.29; P =.011) but not graft survival.

CONCLUSIONS

This population-cohort study suggests that deceased-donor kidneys from smokers contribute to an increased risk of death for kidney allograft recipients. These study findings imply donor smoking history should be factored into the risk stratification decision for recipient selection to optimize decision making; however, further clarification and validation of these data are warranted.

Smoking and outcomes in kidney transplant recipients: a post hoc survival analysis of the FAVORIT trial

Background

Tobacco use remains an international health problem with between 10% and 40% of adults currently using tobacco. Given the rising number of patients either awaiting or having received a kidney transplant and the absence of smoking cessation as the criterion for transplantation in guidelines, we explored the association between smoking status and clinical outcomes in kidney transplant recipients.

Patients and methods

In this post hoc analysis of the Folic Acid for Vascular Outcome Reduction in Transplant trial, the associations between smoking status, defined as never having smoked, formerly or currently smoking, and both all-cause mortality and graft survival were assessed using Cox proportional hazards models. Fatal events were centrally adjudicated into prespecified categories: all-cause, cardiovascular and non-cardiovascular causes. Graft loss was defined as return to dialysis or retransplantation. Clinical Trials URL: http://www.clinicaltrials.gov/show/NCT00064753.

Results

Among 4110 transplant recipients, there were 451 current smokers and 1611 former smokers. The mortality rate per 100 patient-years was 4.0 (71 deaths) for smokers, 3.5 (226 deaths) for former smokers and 2.4 (116 deaths) for never smokers. Hazard ratio for mortality for current smokers was 1.70 (CI=1.26–2.29, p=0.001) and for former smokers was 1.21 (0.98–1.50, p=0.08) with 1.0 representing never smokers. As the number of cardiovascular deaths was similar in each group (all p>0.3), the differences between groups was driven by non-cardiovascular death rates. Current smokers (2.39; 1.62–3.61, p<0.001) and former smokers (1.50; 1.12–2.01, p=0.007) had increased hazard of non-cardiovascular death. Kidney allograft failure was more likely in current smokers than in either former or never smokers (3.5, 2.1 and 2.0 per 100 patient-years, p<0.001, adjusted hazard ratio 1.49 and 1.05, respectively).

Conclusion

Continued smoking was associated with >100% increased risk of non-cardiovascular death, 70% greater risk of all-cause mortality and a 50% greater risk of graft loss, a risk not seen in former smokers. These findings confirm previous non-adjudicated observations that smoking is associated with adverse clinical outcomes and suggest that more emphasis should be placed on smoking cessation prior to kidney transplantation.

Impact of environmental factors on alloimmunity and transplant fate

Although gene-environment interactions have been investigated for many years to understand people's susceptibility to autoimmune diseases or cancer, a role for environmental factors in modulating alloimmune responses and transplant outcomes is only now beginning to emerge. New data suggest that diet, hyperlipidemia, pollutants, commensal microbes, and pathogenic infections can all affect T cell activation, differentiation, and the kinetics of graft rejection. These observations reveal opportunities for novel therapeutic interventions to improve graft outcomes as well as for noninvasive biomarker discovery to predict or diagnose graft deterioration before it becomes irreversible. In this Review, we will focus on the impact of these environmental factors on immune function and, when known, on alloimmune function, as well as on transplant fate.

Smoking in Renal Transplantation; Facts Beyond Myth

Smoking is one of the preventable leading causes of death worldwide. Most of the studies focused on the association between smoking and cardiovascular disease, pulmonary diseases, malignancy and death. However, the direct effect of smoking on the renal system was undermind. There are emerging evidence correlating tobacco use with pathological changes in the normal kidneys. The effect is more obvious on the renal allograft most probably due to the chronic immune suppression status and the metabolic effect of the drugs. Several studies have documented a deleterious effect of smoking on the renal transplant recipients. Smoking was associated with lowering patient and graft survival. Smoking cessation proved to improve graft survival and to a lesser extent recipient survival. Even receiving a renal transplant from a smoker donor increases the risk of death for the recipient and carries a poorer graft survival compared to non-smoking donors. Most of the studies investigating the effect of smoking were based on self-reporting questioners, which may be misleading due to poor recall or the desire to give socially acceptable answers. This made the need of a reliable biomarker of ultimate importance. Cotinine was proposed as a promising biomarker that may help to provide objective evidence regarding the status of smoking and the dose of nicotine exposure, yet there are still some limitations of its use. The aim of this work is to review the current evidence to improve our understanding of this critical topic. Indeed, this will help to guide better-designed studies in the future.

Cigarette Smoking and Its Hazards in Kidney Transplantation

Cigarette smoking affects many organs. It causes vasoconstriction through activation of sympathetic nervous system which leads to elevation of blood pressure and reduction in glomerular filtration rate and filtration pressure. It also causes thickening of renal arterioles. Cigarette smoking increases the risk of microalbuminuria and accelerates progression of microalbuminuria to macroalbuminuria. Furthermore, it causes rapid loss of glomerular filtration rate in chronic kidney disease patients. After kidney donation, these factors may be injurious to the solitary kidney. Kidney donors with history of cigarette smoking are prone to develop perioperative complications, pneumonia, and wound infection. Postkidney transplantation various stressors including warm and cold ischemia time, delayed graft function, and exposure to calcineurin inhibitors may result in poor graft function. Continuation of cigarette smoking in kidney transplant recipients will add further risk. In this review, we will specifically discuss the effects of cigarette smoking on normal kidneys, live kidney donors, and kidney transplant recipients. This will include adverse effects of cigarette smoking on graft and patient survival, cardiovascular events, rejection, infections, and cancers in kidney transplant recipients. Lastly, the impact of kidney transplantation on behavior and smoking cessation will also be discussed.

Use of the 'Accountability for Reasonableness' Approach to Improve Fairness in Accessing Dialysis in a Middle-Income Country

Universal access to renal replacement therapy is beyond the economic capability of most low and middle-income countries due to large patient numbers and the high recurrent cost of treating end stage kidney disease. In countries where limited access is available, no systems exist that allow for optimal use of the scarce dialysis facilities. We previously reported that using national guidelines to select patients for renal replacement therapy resulted in biased allocation. We reengineered selection guidelines using the ‘Accountability for Reasonableness’ (procedural fairness) framework in collaboration with relevant stakeholders, applying these in a novel way to categorize and prioritize patients in a unique hierarchical fashion. The guidelines were primarily premised on patients being transplantable. We examined whether the revised guidelines enhanced fairness of dialysis resource allocation. This is a descriptive study of 1101 end stage kidney failure patients presenting to a tertiary renal unit in a middle-income country, evaluated for dialysis treatment over a seven-year period. The Assessment Committee used the accountability for reasonableness-based guidelines to allocate patients to one of three assessment groups. Category 1 patients were guaranteed renal replacement therapy, Category 3 patients were palliated, and Category 2 were offered treatment if resources allowed. Only 25.2% of all end stage kidney disease patients assessed were accepted for renal replacement treatment. The majority of patients (48%) were allocated to Category 2. Of 134 Category 1 patients, 98% were accepted for treatment while 438 (99.5%) Category 3 patients were excluded. Compared with those palliated, patients accepted for dialysis treatment were almost 10 years younger, employed, married with children and not diabetic. Compared with our previous selection process our current method of priority setting based on procedural fairness arguably resulted in more equitable allocation of treatment but, more importantly, it is a model that is morally, legally and ethically more defensible.

Differential impact of smoking on mortality and kidney transplantation among adult Men and Women undergoing dialysis

BACKGROUND

The extent to which smoking contributes to adverse outcomes among men and women of all ages undergoing dialysis is uncertain. The objective of this study was to determine the differential impact of smoking on risks of mortality and kidney transplantation by age and by sex at dialysis initiation.

METHODS

We conducted a population-based cohort of incident U.S dialysis patients (n = 1, 220, 000) from 1995-2010. Age- and sex-specific mortality and kidney transplantation rates were determined for patients with and without a history of cardiovascular disease. Multivariable Cox regression evaluated relative hazard ratios (HR) for death and kidney transplantation at 2 years stratified by atherosclerotic condition, smoking status and age. Analyses were adjusted for demographic characteristics, non-cardiovascular conditions, laboratory variables, socioeconomic and lifestyle factors.

RESULTS

The average age was 62.8 (±15) years old, 54 % were male, and the majority was white. During 2-year follow-up, 40.5 % died and 5.7 % were transplanted. Age- and sex-specific mortality rates were significantly higher while transplantation rates were significantly lower for smokers with atherosclerotic conditions than non-smokers (P < 0.01). The adjusted mortality hazards were significantly higher for smokers with pre-existing coronary disease (HR 1.15, 95 % CI (1.11-1.18), stroke (HR 1.21, 1.16-1.27) and peripheral vascular disease (HR = 1.21, 1.17-1.25) compared to non-smokers without these conditions (HR 1.00, referent group). The magnitude of effect was greatest for younger patients than older patients. Contrastingly, the adjusted risks of kidney transplantation were significantly lower for smokers with coronary disease: (HR 0.60, 0.52-0.69), stroke; (HR 0.47, 0.37-0.60), and peripheral arterial disease (HR 0.55, 0.46-0.66) respectively compared to non-smokers without these conditions.

CONCLUSIONS

We provide compelling evidence that smoking is associated with adverse clinical outcomes and reduced lifespans among dialysis patients of all ages and sexes. The adverse impact is greatest for younger men and women.

Treating Tobacco Use and Dependence in Kidney Transplant Recipients: Development and Implementation of a Program

Tobacco use adversely affects transplant outcomes such as graft survival, patient survival, and other conditions that alter transplant patient longevity. Especially concerning is tobacco's relationship to cardiovascular disease, the number 1 cause of death in kidney transplant recipients. Many authors conclude that tobacco interventions ought to be provided to patients and sometimes lament that there are no tobacco dependence interventions designed for kidney transplant recipients. European Best Practice Guidelines for Renal Transplantation also support tobacco dependence interventions. The purpose of this article is to describe one institution's experience in implementing the clinical practice guideline for treating tobacco use and dependence within a kidney and pancreas transplant program.

Mortality Prediction after the First Year of Kidney Transplantation: An Observational Study on Two European Cohorts

After the first year post transplantation, prognostic mortality scores in kidney transplant recipients can be useful for personalizing medical management. We developed a new prognostic score based on 5 parameters and computable at 1-year post transplantation. The outcome was the time between the first anniversary of the transplantation and the patient’s death with a functioning graft. Afterwards, we appraised the prognostic capacities of this score by estimating time-dependent Receiver Operating Characteristic (ROC) curves from two prospective and multicentric European cohorts: the DIVAT (Données Informatisées et VAlidées en Transplantation) cohort composed of patients transplanted between 2000 and 2012 in 6 French centers; and the STCS (Swiss Transplant Cohort Study) cohort composed of patients transplanted between 2008 and 2012 in 6 Swiss centers. We also compared the results with those of two existing scoring systems: one from Spain (Hernandez et al.) and one from the United States (the Recipient Risk Score, RRS, Baskin-Bey et al.). From the DIVAT validation cohort and for a prognostic time at 10 years, the new prognostic score (AUC = 0.78, 95%CI = [0.69, 0.85]) seemed to present significantly higher prognostic capacities than the scoring system proposed by Hernandez et al. (p = 0.04) and tended to perform better than the initial RRS (p = 0.10). By using the Swiss cohort, the RRS and the the new prognostic score had comparable prognostic capacities at 4 years (AUC = 0.77 and 0.76 respectively, p = 0.31). In addition to the current available scores related to the risk to return in dialysis, we recommend to further study the use of the score we propose or the RRS for a more efficient personalized follow-up of kidney transplant recipients.

Influence of Current and Previous Smoking on Cancer and Mortality After Kidney Transplantation

BACKGROUND

Evidence is limited regarding the effect of stopping smoking before kidney transplantation.

METHODS

Collaborative Transplant Study data from 46 548 recipients of first kidney transplants (1995-2012) were analyzed to 10 years after transplantation.

RESULTS

Compared with patients who had never smoked (n = 31,462), patients who stopped smoking before transplantation (n = 10,291) only had a modestly increased risk of all-cause graft failure (hazard ratio [HR], 1.1; 95% confidence interval [95% CI], 1.0-1.1; P < 0.001) or death (HR,1.1; 95% CI, 1.0-1.2; P < 0.001) and a similar risk of death-censored graft failure (HR,1.0, 95% CI, 1.0-1.1; P = 0.19), but a 40% increase in death from malignancy (HR, 1.4; 95% CI, 1.2-1.7; P < 0.001). The risk of events was generally markedly higher in patients who continued to smoke (n = 4795) versus those who had stopped. For tumors of the lip, oral cavity and pharynx, digestive organs, respiratory tract, female genitalia and urinary tract, HR values increased significantly from never-smoked to former smokers to current smokers. The risk of respiratory tumors or cervical cancer was approximately halved when smoking was stopped versus continued.

CONCLUSIONS

This large series provides clear evidence that patients who stop smoking before transplantation experience substantial benefits, including a substantial reduction in certain types of malignancy.

A randomized clinical trial to determine the effectiveness of CO-oximetry and anti-smoking brief advice in a cohort of kidney transplant patients who smoke: study protocol for a randomized controlled trial

Background

The cardiovascular risk in renal transplant patients is increased in patients who continue to smoke after transplantation.

The aim of the study is to measure the effectiveness of exhaled carbon monoxide (CO) measurement plus brief advisory sessions, in comparison to brief advice, to reduce smoking exposure and smoking behavior in kidney transplant recipients who smoke. The effectiveness will be measured by: (1) abandonment of smoking, (2) increase in motivation to stop smoking, and (3) reduction in the number of cigarettes smoked per day.

Methods/design

Design: a randomized, controlled, open clinical trial with blinded evaluation.

Scope: A Coruña Hospital (Spain), reference to renal transplantation in the period 2012–2015.

Inclusion criteria: renal transplant patients who smoke in the precontemplation, contemplation or preparation stages according to the Prochaska and DiClemente’s Stages of Change model, and who give their consent to participate.

Exclusion criteria: smokers attempting to stop smoking, patients with terminal illness or mental disability that prevents them from participating.

Randomization: patients will be randomized to the control group (brief advisory session) or the intervention group (brief advisory session plus measuring exhaled CO). The sample target size is n = 112, with 56 patients in each group. Allowing for up to 10 % loss to follow-up, this would provide 80 % power to detect a 13 % difference in attempting to give up smoking outcomes at a two-tailed significance level of 5 %. Measurements: sociodemographic characteristics, cardiovascular risk factors, treatment, rejection episodes, infections, self-reported smoking habit, drug use, level of dependence (the Fagerström test), stage of change (Prochaska and DiClemente’s Stages of Change model), and motivation to giving up smoking (the Richmond test).

Response: the effectiveness will be evaluated every 3, 6, 9 and 12 months as: pattern of tobacco use (self-reported tobacco use), smoking cessation rates, carbon monoxide (CO) levels in exhaled air measured by CO-oximetry, urinary cotinine tests, nicotine dependence (Fagerström test), motivational stages of change (Prochaska and DiClemente’s stages) and motivation to stop smoking (the Richmond test).

Analysis: descriptive statistics and linear/logistic multiple regression models will be performed. Clinical relevance will be measured as relative risk reduction, absolute risk reduction and the number needed to treat.

Ethics: informed consent of the patients and Ethical Review Board was obtained (code 2011/061).

Discussion

Tobacco is a modifiable risk factor that increase the risk of morbidity and mortality in kidney transplant recipients. If effectiveness of CO-oximetry is confirmed to reduce tobacco exposure, we would have an intervention that is easy to use, low cost and with great implications about cardiovascular risk prevention in these patients.

Trial registration

Current Controlled Trials ISRCTN16615772.

EudraCT number: 2015-002009-12.

Vascular calcification, bone and mineral metabolism after kidney transplantation

The development of end stage renal failure can be seen as a catastrophic health event and patients with this condition are considered at the highest risk of cardiovascular disease among any other patient groups and risk categories. Although kidney transplantation was hailed as an optimal solution to such devastating disease, many issues related to immune-suppressive drugs soon emerged and it became evident that cardiovascular disease would remain a vexing problem. Progression of chronic kidney disease is accompanied by profound alterations of mineral and bone metabolism that are believed to have an impact on the cardiovascular health of patients with advanced degrees of renal failure. Cardiovascular risk factors remain highly prevalent after kidney transplantation, some immune-suppression drugs worsen the risk profile of graft recipients and the alterations of mineral and bone metabolism seen in end stage renal failure are not completely resolved. Whether this complex situation promotes progression of vascular calcification, a hall-mark of advanced chronic kidney disease, and whether vascular calcifications contribute to the poor cardiovascular outcome of post-transplant patients is reviewed in this article.

Cardiovascular morbidity and mortality after kidney transplantation

Kidney transplantation is the optimal treatment for patients with end stage renal disease (ESRD) who would otherwise require dialysis. Patients with ESRD are at dramatically increased cardiovascular (CV) risk compared with the general population. As well as improving quality of life, successful transplantation accords major benefits by reducing CV risk in these patients. Worldwide, cardiovascular disease remains the leading cause of death with a functioning graft and therefore is a leading cause of graft failure. This review focuses on the mechanisms underpinning excess CV morbidity and mortality and current evidence for improving CV risk in kidney transplant recipients. Conventional CV risk factors such as hypertension, diabetes mellitus, dyslipidaemia and pre-existing ischaemic heart disease are all highly prevalent in this group. In addition, kidney transplant recipients exhibit a number of risk factors associated with pre-existing renal disease. Furthermore, complications specific to transplantation may ensue including reduced graft function, side effects of immunosuppression and post-transplantation diabetes mellitus. Strategies to improve CV outcomes post-transplantation may include pharmacological intervention including lipid-lowering or antihypertensive therapy, optimization of graft function, lifestyle intervention and personalizing immunosuppression to the individual patients risk profile.

Cigarette smoking in living kidney donors: donor and recipient outcomes

BACKGROUND

Living kidney donor pools are expanding with the use of "medically complex" donors. Whether or not to include cigarette smokers as living kidney donors remains unclear. The aim of this study was to determine the relationship between donor smoking and recipient outcomes. We hypothesized that donor smoking would increase donor complications and decrease allograft and recipient survival over time.

METHODS

The charts of 602 living kidney donors and their recipients were retrospectively reviewed. Kaplan-Meier survival analysis and Cox modeling were used to assess the relationships between smoking and recipient and allograft survival.

RESULTS

No difference in postoperative complications was seen in smoking versus non-smoking donors. Donor smoking at time of evaluation did not significantly decrease allograft survival (HR = 1.19, p = 0.52), but recipient smoking at evaluation did reduce allograft survival (HR = 1.74, p = 0.05). Both donor and recipient smoking decreased recipient survival (HR = 1.93, p < 0.01 vs HR = 1.74, p = 0.048).

DISCUSSION

When controlled for donor and recipient factors, cigarette smoking by living kidney donors significantly reduced recipient survival. This datum suggests that careful attention to smoking history is an important clinical measure in which to counsel potential donors and recipients. Policy efforts to limit donors with a recent smoking history should be balanced with the overall shortage of appropriate kidney donors.

[Smoking cessation in case of chronic kidney disease]

Smoking is one of the main causes of morbidity and mortality around the world. In France, despite increase of cost of cigarettes and exclusion of smoking in public places, daily smoking consummation remains high, particularly in women and young. Now, smoking is considered as a compartmental and/or psychologic and/or physic addiction. There are many categories of smokers and smoking cessation strategies must be tailored to individual level. Whatever the etiology of chronic kidney disease, in dialysis patient as transplanted, hypertension and vascular diseases are strong determinants of prognosis. In this way, there is a need for stronger involvement of nephrologists in the process of smoking cessation of their patients. Therapeutics and strategies are reviewed.

Effect of smoking on kidney transplant outcomes: analysis of the United States Renal Data System

BACKGROUND

We investigated the effect of smoking on postkidney transplant outcomes in the United States Renal Data System.

METHODS

In a retrospective cohort of 41,705 adult Medicare primary renal transplant recipients in the United States Renal Data System database transplanted from January 1, 2000, to June 30, 2006, and followed through October 31, 2006, we assessed Medicare claims for smoking. The association between renal allograft loss and death and smoking as a time-dependent variable was assessed with Cox nonproportional hazards regression.

RESULTS

Of 41,705 Medicare primary adult renal transplant patients, there were 9.9% patients who had evidence of prior smoking and 4.6% patients with new claims for smoking after transplant. Incident smoking (new onset smokers) occurred at a mean of 1.29±0.88 years after transplant. In the adjusted analysis, factors associated with new smoking included male gender, history of drug or alcohol use, history of chronic obstructive pulmonary disease, and later year of transplant. Compared with never smokers, incident smoking after transplant was associated with increased risk of death-censored allograft loss (adjusted hazard ratio [AHR] 1.46 [95% confidence interval {CI}: 1.19-1.79]; P<0.001) and death (AHR 2.32 [95% CI: 1.98-2.72]; P<0.001). In a sensitivity analysis excluding patients with history of chronic obstructive pulmonary disease, similar results were obtained with increased risk of death-censored allograft loss (AHR 1.43 [95% CI: 1.16-1.76]; P=0.001) and death (AHR 2.26 [95% CI: 1.91-2.66]; P<0.001).

DISCUSSION

Incident smoking was detrimental to graft and patient survival. Transplant programs should screen those at risk during transplant follow-up and have smoking cessation programs.

Donor Smoking Negatively Affects Donor and Recipient Renal Function following Living Donor Nephrectomy

Background. While tobacco use by a renal transplant recipient has been shown to negatively affect graft and patient survival, the effect of smoking on the part of the kidney donor remains unknown. Methods. 29 smoking donors (SD) and their recipients (SD-R) as well as 71 non-smoking donors (ND) and their recipients (ND-R) were retrospectively reviewed. Preoperative demographics and perioperative variables including serum creatinine (Cr) and glomerular filtration rate (GFR) were calculated and stratified by amount of tobacco exposure in pack-years. Clinical outcomes were analyzed with a Student's t-test, chi-square, and multiple linear regression analysis (α = 0.05). Results. At most recent followup, SD-R's had a significantly smaller percent decrease in postoperative Cr than ND-R's (-57% versus -81%; P = 0.015) and lower calculated GFR's (37.0 versus 53.0 mL/min per 1.73 m(2); P < 0.001). SD's had a larger percent increase in Cr than ND's at most recent followup (57% versus 40%; P < 0.001), with active smokers having a larger increase than those who quit, although this difference was not statistically significant (68% versus 52%; P = 0.055). Conclusions. Use of tobacco by kidney donors is associated with decreased posttransplant renal function, although smoking cessation can improve outcomes. Kidneys from donors who smoke should be used with caution.

Chronic kidney disease, pediatric nephrologists, and tobacco counseling: perceptions and practice patterns. A study from the Midwest Pediatric Nephrology Consortium

We sought to identify practice patterns of pediatric nephrologists for tobacco counseling, because of a high incidence of secondhand smoke exposure and tobacco use in adolescents with chronic kidney disease. Counseling was minimal for several reasons, thus increasing the risk for heart disease inherent in children with chronic kidney disease.

Social Adaptability Index: application and outcomes in a dialysis population

BACKGROUND

Patient groups associated with disparities in health care are usually defined on the basis of race, gender or geographic location. Social Adaptability Index (SAI), calculated based on education, marital status, income, employment and substance abuse, has been strongly associated with clinical outcome in other patient populations and may be used to identify individuals at risk. We used data from the United States Renal Data System to evaluate the role of SAI in survival of patients on dialysis.

METHODS

We used Cox model analyses to study the association between SAI and patient survival in patients with ESRD on dialysis, as well as in the subgroups based on age, race, sex, comorbidites and diabetic status.

RESULTS

We analyzed 3396 patients (age of ESRD onset 56.9 ± 16.1 years, 54.2% males, 64.2% white, 30.3% African-American). Mean SAI of the entire population was 7.1 ± 2.5 (range 0-12 points). SAI was higher in whites (7.4 ± 2.4) than in African-Americans (6.5 ± 2.5) (analysis of variance, P <0.001) and greater in men (7.4 ± 2.4) than in women (6.7 ± 2.5) (t-test, P <0.001). In a Cox model adjusted for potential confounders, SAI was associated with decreased mortality [hazards ratio of 0.97 (95% confidence interval 0.95-0.99), P = 0.006]. Subgroup analysis demonstrated an association of SAI with survival in most of the subgroups. Potential limitations of the study include reverse causality, possible misclassification and retrospective design.

CONCLUSION

We demonstrated that SAI is significantly associated with mortality in dialysis patients. SAI could be used to identify individuals at risk for inferior clinical outcomes.

Cigarette smoking and second-hand smoking exposure in adolescents with chronic kidney disease: a study from the Midwest Pediatric Nephrology Consortium

BACKGROUND

Smoking and second-hand smoking [SHS] cause significant cardiovascular mortality and morbidity. In healthy individuals and adults with chronic kidney disease [CKD], cigarette smoking is associated with albuminuria, increased risk for CKD, increased graft loss and progression of renal insufficiency. In children, SHS has been associated with higher blood pressure variability, blood pressure load, elevated C-reactive protein and decreased cognitive function. Using a survey document and urine cotinine, we sought to investigate prevalence of cigarette use and SHS in adolescents with CKD.

METHODS

A cross-sectional study was conducted in which adolescents aged 13 to 18 years with CKD were asked to complete a single anonymous self-administered survey. In addition, a single freshly voided urine sample for cotinine measurement was obtained from eligible subjects.

RESULTS

Of 182 subjects, 60 (34%), 25 (14%) and 93 (52%) were transplant recipients, were dialysis dependent and had a glomerulopathy, respectively. Renal status was lacking in four. Twenty-four per cent (24%) had smoked at some point in their lives, and 13% had smoked within the last 30 days of taking the survey. Fifty-two per cent (52%) of all respondents reported living with an adult who smoked, and 54% reported having friends that smoked. Forty-seven per cent (47%) and 44% of those who had never smoked lived with an adult and had friends that smoked, respectively. There was a discrepancy rate of 7% between self-reported non-smokers and urine cotinine, suggesting smoking rates were higher. The highest cotinine/creatinine levels among the non-smokers were observed in those who lived with a smoker and had friends that smoked.

CONCLUSION

Among adolescents with CKD, cigarette smoking and SHS exposure are prevalent and may be important variables to consider when evaluating renal and cardiovascular risk factors and outcomes in children with CKD.

Cigarette smoking, kidney function, and mortality after live donor kidney transplant

BACKGROUND

The role of smoking as a risk factor for adverse renal outcomes after kidney transplant has not been well studied. We therefore undertook this investigation to assess the association of smoking with transplant outcomes.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

997 consecutive laparoscopic live donor kidney transplant recipients at a tertiary-care transplant center.

PREDICTOR

Smoking at the time of the transplant evaluation.

OUTCOMES & MEASUREMENTS

Primary outcome is transplant survival.

RESULTS

At the time of pretransplant evaluation, 329 participants had ever smoked and 668 participants had never smoked. Transplant survival was worse in ever smokers compared with never smokers (adjusted HR, 1.47; 95% CI, 1.08-1.99; P = 0.01), as was patient survival (adjusted HR, 1.60; 95% CI, 1.06-2.41; P = 0.02). First-year rejection-free survival was substantially worse (adjusted HR, 1.46; 95% CI, 1.05-2.03; P = 0.03) and risk of rejection on or before posttransplant day 10 was much higher (adjusted HR, 1.8; 95% CI, 1.10-2.94; P = 0.02) in ever smokers compared with never smokers. Glomerular filtration rate (estimated using the Modification of Diet in Renal Disease Study equation) at 1 year posttransplant was lower and poor early transplant function was more common in ever smokers on univariate, but not multivariate, analysis.

LIMITATIONS

Lack of quantitation of smoking exposure and uncertainty about whether patients were still smoking at the time of transplant.

CONCLUSIONS

Our results suggest that any history of smoking before transplant is associated with impaired transplant and patient survival and increases the risk of early rejection after live donor kidney transplant. Further study is needed to determine whether smoking may impart immunomodulatory and perhaps nephrotoxic effects.

KDIGO clinical practice guideline for the care of kidney transplant recipients

The 2009 Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guideline on the monitoring, management, and treatment of kidney transplant recipients is intended to assist the practitioner caring for adults and children after kidney transplantation. The guideline development process followed an evidence-based approach, and management recommendations are based on systematic reviews of relevant treatment trials. Critical appraisal of the quality of the evidence and the strength of recommendations followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach. The guideline makes recommendations for immunosuppression, graft monitoring, as well as prevention and treatment of infection, cardiovascular disease, malignancy, and other complications that are common in kidney transplant recipients, including hematological and bone disorders. Limitations of the evidence, especially on the lack of definitive clinical outcome trials, are discussed and suggestions are provided for future research.

Long-term graft and patient survival following renal transplantation in diabetic patients

OBJECTIVE

To study long-term graft and patient survival following renal transplantation in diabetic and non-diabetic patients.

MATERIAL AND METHODS

Over the time period 1985-99, 498 transplantations in 399 non-diabetic patients and 68 transplantations in 62 diabetic patients were performed. The groups were similar with respect to age and sex.

RESULTS

The patient survival rates (diabetic versus non-diabetic patients) were 88% vs 91% (p=NS) at 1 year, 68% vs 73% (p=NS) at 5 years and 31% vs 52% (p<0.05) at 10 years. The graft survival rates (diabetic versus non-diabetic patients) were 72% vs 72% at 1 year, 52% vs 52% at 5 years and 27% vs 33% (p=NS) at 10 years. In the diabetic patients, mean haemoglobin (Hb)A1c 2 years before and 2 years after the transplantation was 7.5+/-1.4 vs 8.2+/-1.6 mmol/l (p<0.05) and the mean blood pressure was 112+/-12 vs 107+/-9 mmHg (p<0.05). Of the diabetic patients, 55% were smokers. Among the diabetic patients, graft and patient survival were independent of smoking habits, blood pressure, HbA1c and total cholesterol.

CONCLUSIONS

Graft survival was similar in diabetic and non-diabetic patients. For the first 5 years following renal transplantation, the patient survival rates in the two groups were similar. Thereafter, survival among diabetic patients was poor. Mean HbA1c was relatively high, especially after the transplantation, and this may have contributed to the more rapid progression of cardiovascular disease seen in diabetic patients with nephropathy.

Ethical analysis and consideration of health behaviors in organ allocation: focus on tobacco use

Health behaviors are significantly understudied in transplant patients, contributing to significant ethical debate among transplant professionals. Some of these health behaviors (tobacco use and overweight/obesity) are the leading preventable causes of mortality in the US general population and likely have a higher prevalence and impact among transplant populations. For example, tobacco use has been linked to worse graft survival, patient survival, complications, and comorbidities, whereas tobacco cessation has been associated with improved patient and graft survival. Over time, transplant professionals increasingly believe that tobacco use should be a relative contraindication to organ allocation. That belief seems to be strengthened after provider education on pertinent evidence linking tobacco use to medical consequences in both the general and the transplant populations. A core framework for ethical analysis of health behaviors in the context of organ allocation is described, using concepts of utility, justice, and respect for all persons. This framework is designed to help transplant professionals discuss and formulate policy on consideration of health behaviors in the context of organ allocation. More research is needed to advance our knowledge of the impact of health behaviors on transplant patient outcomes.

Risk factors for cardiovascular events after successful renal transplantation

BACKGROUND

Cardiovascular disease is a frequent cause of morbidity after renal transplantation. The aims of this study were to evaluate the incidence of cardiovascular events and to identify the main risk factors for cardiovascular complications and mortality in 2071 white adults with a renal transplant functioning for at least 1 year.

METHODS

Clinical events, routine biochemistry, and prescribed drugs at month 1, month 6, and yearly after transplantation were analyzed.

RESULTS

The incidence of cardiovascular events increased over time. At 15 years after transplantation, only 47% of surviving patients had not experienced any cardiovascular event. Risk factors associated with cardiovascular complications were male gender (P=0.04), age (P<0.0001), arterial hypertension before transplantation (P<0.0001), longer pretransplant dialysis (P<0.0001), cardiovascular event before transplantation (P<0.0001), older era of transplantation (P=0.0009), center-specific effect (P=0.003), posttransplant diabetes mellitus (P=0.01), increased pulse pressure after transplantation (P=0.02), intake of corticosteroids (P=0.016), intake of azathioprine (P=0.016), lower serum albumin after transplantation (P=0.004), and higher serum triglyceride levels after transplantation (P=0.007). The risk of death was increased in patients with low or elevated hematocrit, while it was minimal with values around 38%.

CONCLUSIONS

The occurrence of fatal and nonfatal cardiovascular events after successful renal transplantation not only relates to baseline cardiovascular risk factors present at transplantation, but also to immunosuppressive drugs and posttransplantation traditional and nontraditional risk factors.

Management of cardiovascular disease in renal transplant recipients

Cardiovascular disease is a major cause of graft loss and the leading cause of death in renal transplant recipients. Although there are robust data on the frequency of risk factors and their contributions to cardiovascular disease in this population, few trials have demonstrated the benefit of modifying these risk factors to reduce cardiovascular events. Nevertheless, it is widely accepted that the clinical acumen filtered through the best available studies in the general population be used to treat individual renal transplant recipients given their high cardiovascular mortality. Transplant task forces and the Kidney Disease Outcomes Quality Initiative have created guidelines for this purpose. This review examines the data available for prevention and treatment of major risk factors contributing to cardiovascular disease in renal transplant recipients. The contribution of immunosuppressive agents to each risk factor and the evidence to support lifestyle modification as well as drug therapy are examined. Reducing cardiovascular risk factors requires an integrative approach that is best accomplished by a team of health care professionals. It creates a significant challenge but one that must be met if allograft survival is to improve.

Ischemic heart disease after renal transplantation in patients on cyclosporine in Spain

Ischemic heart disease (IHD), more common among transplant recipients than in the general population, accounts for approximately 50% of cardiovascular deaths. Despite its importance, only a few publications have addressed the prevalence of and risk factors for this complication. This was a retrospective cohort study in 2382 cadaver renal transplant recipients who were treated with cyclosporine as initial immunosuppression. Two groups were formed. The first group consisted of 163 patients with IHD, and the second group consisted of 326 patients without IHD. The prevalence of IHD was 6.8%, and the incidence was 15.7/1000 patient-years. Cardiac events presented during the first year in 62 (38%) patients. Multivariate analysis showed that the risk factors for IHD were age at transplant in years (relative risk [RR] 1.054; 95% confidence interval [CI] 1.033 to 1.075; P = 0.000), male gender (RR 1.940; 95% CI 1.221 to 3.081; P = 0.005), body weight at transplant in kg (RR 1.020; 95% CI 1.007 to 1.033; P = 0.002), pretransplantation cardiovascular disease (RR 2.150; 95% CI 1.733 to 3.359; P = 0.001), and a history of pretransplantation hypercholesterolemia (RR 2.032; 95% CI 1.378 to 2.998; P = 0.000). When only ischemic events that occurred 12 mo after transplantation were taken into consideration, the risk factors were age, male gender, body weight, smoking, and pretransplantation and posttransplantation hypercholesterolemia, whereas pretransplantation cardiovascular disease disappeared from the model. IHD affected nearly 7% of transplant recipients. Smoking, hypertension, and hypercholesterolemia constituted the treatable risk factors for IHD in this population. Emphasis should be placed on the need to stop smoking and to control hypertension and pre- and posttransplantation levels of serum cholesterol.

Smoking: a risk factor for progression of chronic kidney disease and for cardiovascular morbidity and mortality in renal patients--absence of evidence or evidence of absence?

Although it is beyond any doubt that smoking is the number one preventable cause of death in most countries, smoking as an independent progression factor in renal disease has been questioned against the background of evidence-based criteria. This is because information from large, randomized, prospective studies that investigate the effects of smoking on renal function in healthy individuals as well as in patients with primary or secondary renal disease are lacking. Since 2003, a substantial number of clinical and experimental data concerning the adverse renal effects of smoking have been published, including large, prospective, population-based, observational studies. These more recent data together with evidence from experimental studies clearly indicate that smoking is a relevant risk factor, conferring a substantial increase in risk for renal function deterioration. This review summarizes the present knowledge about the renal risks of smoking as well as the increased cardiovascular risk caused by smoking in patients with chronic kidney disease. The conclusion is that smoking is an important renal risk factor, and nephrologists have to invest more efforts to motivate patients to stop smoking.

The Impact of Recipient History of Cardiovascular Disease on Kidney Transplant Outcome

Cardiovascular disease (CVD) leads to increased mortality rates among renal transplant recipients; however, its effect on allograft survival has not been well studied. The records from the United States Renal Data System and the United Network for Organ Sharing from January 1, 1995, through December 31, 2002, were examined in this retrospective study. The outcome variables were allograft survival time and recipient survival time. The primary variable of interest was CVD, defined as the presence of at least one of the following: cardiac arrest, myocardial infarction, dysrhythmia, congestive heart failure, ischemic heart disease, peripheral vascular disease, and unstable angina. The Cox models were adjusted for potential confounding factors. Of the 105,181 patients in the data set, 20,371 had a diagnosis of CVD. The presence of CVD had an adverse effect on allograft survival time (HR 1.12, p < 0.001) and recipient survival time (HR 1.41, p < 0.001). Among the subcategories, congestive heart failure (HR 1.14, p < 0.005) and dysrhythmia (HR 1.26, p < 0.05) had adverse effects on allograft survival time. In addition to increasing mortality rates, CVD at the time of end-stage renal disease onset is also a significant risk factor for renal allograft failure. Further research is needed to evaluate the role of specific forms of CVD in allograft and recipient outcome.

Cigarette smoking as a risk factor for atherosclerosis and renal disease: novel pathogenic insights

Cigarette smoking is the major cause of preventable morbidity and mortality in the United States. It is a major risk factor for atherosclerotic vascular disease and recently was identified as an important risk factor in the progression of chronic kidney disease. Several compounds in cigarette smoke, including nicotine and reactive aldehydes (eg, acrolein), have been implicated as mediators of endothelial dysfunction and atherosclerosis in smokers. In addition, studies have demonstrated that nicotine induces endothelial dysfunction in humans and accelerates atherosclerosis in animals. Large clinical trials have suggested that cigarette smoking is a risk factor for progression of chronic kidney disease in diabetics and nondiabetics, and in polycystic kidney disease, lupus nephritis, and IgA nephropathy. Recent studies suggest that nicotine has powerful mitogenic effects and induces extracellular matrix production in human mesangial cells via reactive oxygen species generation. These effects of nicotine may play a major role in the pathogenic mechanisms that mediate the deleterious effects of smoking in renal disease.

Decision-making about suitability for kidney transplantation: Results of a national survey of Australian nephrologists

AIM

This study aimed to elucidate the factors affecting nephrologists' decision-making on patients' suitability for kidney transplantation. Given the reduced access to transplantation for Indigenous Australians, the role of patient's ethnicity was of particular interest.

METHODS

A postal survey of practising nephrologists and trainees was undertaken in Australia. Each participant was provided with a unique set of 15 hypothetical patient descriptions, with demographic, clinical and behavioural factors randomly generated to ensure an overall balance of factors across the cases. The main outcome measure was whether kidney transplantation was recommended.

RESULTS

Responding nephrologists and trainees were more likely to recommend transplantation for hypothetical patients who were young, of normal weight and described as compliant. They were less likely to recommend transplantation for smokers, or for people with diabetes or heart disease. No significant differences related to the patients' sex or ethnicity. The geographical location of the respondent was a significant determinant, with differences according to their State/Territory and their metropolitan/non-metropolitan location.

CONCLUSION

When all other factors were held constant, nephrologists and trainees appear to base their decision-making regarding suitability for transplant on clinical and behavioural factors, rather than on the basis of ethnicity or sex. In practice, however, clinical and behavioural factors cluster with ethnicity, and this is likely to contribute to the current poor access to transplantation for Indigenous end-stage kidney disease patients. Apparent differences in decision-making according to the respondent's location may reflect variations in practice across the country.

The use of psychosocial criteria in Australian patient selection guidelines for kidney transplantation

Psychosocial criteria are increasingly being included in practice guidelines for determining patient suitability for kidney transplantation. Although intended to promote evidence-based decision-making, if poorly defined, the inclusion of psychosocial criteria has the potential to reduce transparency in patient selection and equity of access. We reviewed all Australian practice guidelines concerning patient suitability for kidney transplantation and qualitatively analysed their inclusion of, and approach towards, psychosocial criteria. Transplant Directors from all Australian adult transplant units were invited to submit their unit's guidelines for this national research audit. All 16 units (100%) submitted some form of documentation. We analysed only those documents that were purposely structured tools for directing patient selection (eight guidelines used in 10 transplant units). Content analysis was performed on the abstracted psychosocial criteria. Psychosocial criteria--particularly non-compliance and smoking--were commonly included. In general, the psychosocial criteria were ill-defined and lacking in substantiating evidence and recommendations for assessment or action. Our results reveal that current Australian patient selection guidelines for kidney transplantation incorporate poorly defined psychosocial criteria that vary greatly. Furthermore, there appears to be a weak evidence base underpinning their inclusion. The use of psychosocial criteria in this manner decreases the transparency of patient selection and increases the potential for subjective estimates of social worth to influence patient selection. The priority given to such criteria in transplant guidelines requires attention and debate.

Cardiovascular complications after renal transplantation and their prevention

By the time of renal transplantation, end-stage renal disease patients have a huge burden of cardiovascular disease (CVD) and are heavily saturated with atherosclerotic risk factors. Worsening of preexisting risk factors or new CVD risk factors may develop in the posttransplant period consequent in part to the diabetogenic and atherogenic potential of immunosuppressive drugs. The annual risk of a fatal or non-fatal CVD event of 3.5 to 5% in kidney transplant recipients is 50-fold higher than the general population. Renal allograft dysfunction, proteinuria, anemia, moderate hyperhomocysteinemia and elevated serum C-reactive protein concentrations, each dependently confer greater risk of CVD morbidity and mortality in the posttransplant period. Long-term care of renal transplant recipients should programmatically incorporate the recommendations of the National Kidney Foundation Working Groups and European Best Practice Guidelines Expert Group on Renal Transplantations into the management of hypertension, dyslipidemia, smoking, and posttransplant diabetes mellitus. Timely utilization of coronary revascularization procedures should be undertaken as these treatments are equally effective in the kidney transplant population.