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Hagmayer L, Mayer C, Ebert N, Amann K, Daniel C. Experimental renal transplantation in rats improves cardiac dysfunction caused by chronic kidney disease while LVH persists. Front Cardiovasc Med 2023; 10:1200323. [PMID: 37456824 PMCID: PMC10340545 DOI: 10.3389/fcvm.2023.1200323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 06/19/2023] [Indexed: 07/18/2023] Open
Abstract
Background Chronic kidney disease (CKD) causes congestive heart failure (CHF) with systolic dysfunction and left ventricular hypertrophy (LVH), which is a major contributor to increased mortality in CKD patients. It remains unclear whether cardiovascular changes that occur during the course of CKD can be reversed when renal function is restored by transplantation. Methods To investigate this, chronic kidney disease was established in F344 rats by subtotal nephrectomy (SNx) for 8 weeks, followed by transplantation of a functional kidney from an isogenic F344 donor. SNx rats without transplantation and sham-operated animals served as controls. Renal function was assessed before and throughout the experiment. In addition, cardiac ultrasound was performed at weeks 0, 8, 12 and 16. At the end of the experiment, intra-arterial blood pressure was measured and kidneys and hearts were histologically and molecularly examined. Results Eight weeks after SNx, rats developed marked renal dysfunction associated with significant glomerulosclerosis and tubulointerstitial fibrosis, but also an increase in left ventricular mass. After transplantation, renal function normalized but relative heart weight and ventricular mass as assessed by ultrasound scans showed no reduction compared with SNx controls. However, left ventricular wall thickness, fractional shortening and ejection fraction was normalized by renal transplantation. At 8 weeks after kidney transplantation, cardiac expression of BNP and FGF23 was also at levels comparable to healthy controls, whereas these factors were significantly increased in SNx rats. Cardiac fibrosis, as measured by fibronectin mRNA expression, was completely normalized, whereas cardiac fibronectin protein was still slightly but not significantly increased in transplanted animals compared to controls. In addition, the myofibroblast marker collagen 1, as assessed by immunohistochemistry, was significantly increased in SNx rats and also normalized by renal transplantation. Interestingly, CD68+ macrophages were significantly reduced in the hearts of SNx rats and in transplanted animals at slightly higher levels compared to controls. Conclusion Restoration of renal function by kidney transplantation normalized early cardiac changes at most functional and molecular levels, but did not completely reverse LVH. However, further studies are needed to determine whether restoration of renal function can also reverse LVH at a later time point.
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2
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Echocardiogram screening in pediatric dialysis and transplantation. Pediatr Nephrol 2023; 38:957-974. [PMID: 36114889 PMCID: PMC9925481 DOI: 10.1007/s00467-022-05721-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 08/04/2022] [Accepted: 08/05/2022] [Indexed: 10/14/2022]
Abstract
Transthoracic echocardiography is commonly used to identify structural and functional cardiac abnormalities that can be prevalent in childhood chronic kidney failure (KF). Left ventricular mass (LVM) increase is most frequently reported and may persist post-kidney transplant especially with hypertension and obesity. While systolic dysfunction is infrequently seen in childhood chronic KF, systolic strain identified by speckle tracking echocardiography has been frequently identified in dialysis and it can also persist post-transplant. Echocardiogram association with long-term outcomes has not been studied in childhood KF but there are many adult studies demonstrating associations between increased LVM, systolic dysfunction, strain, diastolic dysfunction, and cardiovascular events and mortality. There has been limited study of interventions to improve echocardiogram status. In childhood, improved blood pressure has been associated with better LVM, and conversion from hemodialysis to hemodiafiltration has been associated with better diastolic and systolic function. Whether long-term cardiac outcomes are also improved with these interventions is unclear. Echocardiography is a well-established technique, and regular use in childhood chronic KF seems justified. A case can be made to extend screening to include speckle tracking echocardiography and intradialytic studies in high-risk populations. Further longitudinal studies including these newer echocardiogram modalities, interventions, and long-term outcomes would help clarify recommendations for optimal use as a screening tool.
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Kasap Demir B, Soyaltin E, Alparslan C, Arslansoyu Çamlar S, Demircan T, Yavaşcan Ö, Mutlubaş F, Alaygut D, Karadeniz C. Risk Assessment for Arrhythmia in Pediatric Renal Transplant Recipients. EXP CLIN TRANSPLANT 2023; 21:28-35. [PMID: 33535941 DOI: 10.6002/ect.2020.0162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Renal transplant recipients are at risk for ventricular arrhythmia and sudden death. To assess that risk, we compared the ventricular repolarization markers of pediatric renal transplant recipients with those of healthy children. MATERIALS AND METHODS We included 30 children and adolescents who were followed for at least 6 months after renal transplant; 30 age- and sex-matched children were included for the control group. Demographic features, medications, and laboratory findings were recorded. Blood pressure measurements, ventricular repolarization indexes including QT dispersion, corrected QT dispersion, T-wave peak-to-end interval dispersion, the T-wave peak-to-end interval∕QT ratio, the T-wave peak-to-end interval∕corrected QT ratio, left ventricular mass index, and relative wall thickness were compared between groups. In addition, the correlations of ventricular repolarization indexes with other variables were evaluated. RESULTS Blood pressure standard deviation scores, the mean heart rate, QT dispersion, corrected QT dispersion, the T-wave peak-to-end interval∕QT ratio, the T-wave peak-to-end interval/corrected QT ratio, left ventricular mass index, and relative wall thickness values were significantly higher in renal transplant patients, whereas T-wave peak-to-end interval dispersion, ejection fraction, and fractional shortening were similar between groups. Although ventricular repolarization indexes were similar in patients with and without left ventricular hypertrophy, only corrected QT dispersion was significantly higher in patients with hypertension (P = .006). The only variable that significantly predicted prolonged corrected QT dispersion was the systolic blood pressure standard deviation score (P = .005, β = .403). CONCLUSIONS Ventricular repolarization anomalies, hypertension, left ventricular hypertrophy, and cardiac geometry irregularity may be observed after renal transplant in pediatric recipients despite acceptable allograft functions and normal serum electrolyte levels. Control of systolic blood pressure would decrease the risk of ventricular repolarization abnormalities, namely, the corrected QT dispersion. Follow-up of cardiovascular risks with noninvasive methods is recommended in all pediatric renal transplant recipients.
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Affiliation(s)
- Belde Kasap Demir
- From the Izmir Katip Celebi University, Faculty of Medicine, Department of Pediatrics, Division of Nephrology and Rheumatology, Izmir, Turkey.,the Izmir University of Health Sciences, Tepecik Training and Research Hospital, Department of Pediatrics, Division of Nephrology, Izmir, Turkey
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Sobhy R, Moustafa B, Zekry H, Hashim R, Salah D, Abdelfattah A. Echocardiographic findings in children with chronic kidney disease. SAUDI JOURNAL OF KIDNEY DISEASES AND TRANSPLANTATION 2020; 31:1234-1244. [DOI: 10.4103/1319-2442.308332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Masuda T, Hamasaki Y, Kubota M, Hashimoto J, Takahashi Y, Muramatsu M, Takatsuki S, Matsuura H, Sakai K, Shishido S. Changes in cardiac function after renal transplantation in children: Significance of pre-transplantation left ventricular hypertrophy. Pediatr Transplant 2019; 23:e13558. [PMID: 31407865 DOI: 10.1111/petr.13558] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 07/03/2019] [Accepted: 07/05/2019] [Indexed: 01/26/2023]
Abstract
LVH is a significant risk factor for the development of cardiovascular morbidity. However, few studies have evaluated the changes in cardiac function that occur in pediatric patients with ESRD undergoing RTx. Therefore, we assessed the changes in parameters associated with LVH in children within the first year after RTx. We retrospectively evaluated patients aged < 18 years who underwent initial RTx from April 2014 to December 2016. The patients were divided into 2 groups according to the presence of LVH before RTx. Clinical, biochemical, and echocardiographic parameters including the LVMI before and 1 year after RTx were evaluated in both groups. Twenty-six patients were included in this study. Seven of the 26 patients had LVH before RTx. Among the echocardiographic parameters, the LVMI was significantly improved 1 year after RTx in the initial LVH group (57.79 ± 11.86 vs 42.20 ± 6.03 g/cm2.7 , P = .018), while no change was observed in the initial non-LVH group (32.66 ± 7.52 vs 35.17 ± 12.86 g/cm2.7 , P = .376). Improvement of the ejection fraction was also observed only in the initial LVH group (66.5% ± 5.3% vs 72.2% ± 5.2%, P = .042). Children who had LVH before RTx showed significant improvements in the LVMI and ejection fraction even within 1 year after RTx. To minimize aggravation of cardiac function, early RTx should be considered for patients with LVH.
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Affiliation(s)
- Toshiki Masuda
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Yuko Hamasaki
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Mai Kubota
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Junya Hashimoto
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Yusuke Takahashi
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Masaki Muramatsu
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Shinichi Takatsuki
- Department of Pediatrics, Toho University Faculty of Medicine, Tokyo, Japan
| | - Hiroyuki Matsuura
- Department of Pediatrics, Toho University Faculty of Medicine, Tokyo, Japan
| | - Ken Sakai
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Seiichiro Shishido
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
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Tangnararatchakit K, Kongkhanin U, Katanyuwong P, Saisawat P, Chantarogh S, Pirojsakul K. Inadequate blood pressure control demonstrated by ambulatory blood pressure monitoring in pediatric renal transplant recipients. Pediatr Transplant 2019; 23:e13499. [PMID: 31157501 DOI: 10.1111/petr.13499] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 04/01/2019] [Accepted: 05/02/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Adequate BP control in RT recipients should not rely only by normal office BP but also on normal 24-hour BP. This study aims to assess adequacy of BP control by ABPM and to assess ABPM parameters associated with LVMI in pediatric RT recipients. MATERIALS AND METHODS Patients aged 5-20 years who have been followed after RT were enrolled. Demographic data and BP assessed by office and ABPM were collected. Echocardiography was performed to detect LVMI. RESULTS Thirty RT recipients (18 males) with median age of 15 years (IQR 13-18.5) were included. Among 23 patients who were taking antihypertensive drugs, uncontrolled hypertension was detected in 34.8% and 78.3% by office BP measurement and ABPM, respectively. Thus, the difference in prevalence of uncontrolled hypertension observed by ABPM versus office BP was 43.5%. Those seven patients who were not taking antihypertensive drugs because of normal office BP, four patients (57.1%) had masked hypertension and one patient had elevated BP. Fifteen patients have progression of LVH after RT. Multivariate analysis revealed that age (OR 1.369, 95%CI 0.985-1.904, P-value = 0.062) had a trend to be associated with progression of LVH. Moreover, nighttime systolic BP z-score was significantly correlated with LVMI (r = 0.551, P-value = 0.002). CONCLUSION The difference in prevalence of uncontrolled hypertension uncovered by ABPM was 43.5%. Nighttime SBP z-score was significantly correlated with LVMI.
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Affiliation(s)
| | - Uthaiwan Kongkhanin
- Department of Pediatrics, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Poomiporn Katanyuwong
- Department of Pediatrics, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pawaree Saisawat
- Department of Pediatrics, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Songkiat Chantarogh
- Department of Pediatrics, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Kwanchai Pirojsakul
- Department of Pediatrics, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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8
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Ramoğlu MG, Uçar T, Yılmaz S, Özçakar ZB, Kurt-Şükür ED, Tutar E, Yalçınkaya F, Atalay S. Hypertension and improved left ventricular mass index in children after renal transplantation. Pediatr Transplant 2017; 21. [PMID: 28984026 DOI: 10.1111/petr.13066] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/30/2017] [Indexed: 12/01/2022]
Abstract
This study was conducted to evaluate the changes in BP and LVH after the transplantation and to evaluate the effect of BP changes in LVH. Forty-three pediatric renal transplant patients, with a mean age of 16.99 ± 3.88 years, were enrolled in this study. Twenty-three (53.5%) of the patients were male. Medical records for pretransplantation period (closest to the time of transplantation) and for post-transplantation period (9-12 months after transplantation) were reviewed. All the patients had BP measurements and echocardiographic evaluation in pre- and post-transplantation period. Hypertension was defined as an average systolic and/or diastolic BP that is ≥95th percentile for sex, age, and height. Although the number of patients with hypertension increased from 30 (69.76%) to 35 (81.4%), the number of patients with LVH decreased from 19 (44.1%) to 9 (20.9%) after the transplantation. Although the only significant difference in BP measurements was between the mean Z scores of 24 hour and nighttime mean DBP before and after the transplantation; the mean LVMI, and the prevalence of LVH was significantly lower after the transplantation. There was no significant correlation between the LVMI and the BP measurements. Even though hypertension may persist, there is significant improvement in LVH after renal transplantation.
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Affiliation(s)
- Mehmet G Ramoğlu
- Department of Pediatric Cardiology, Medical School, Ankara University, Ankara, Turkey
| | - Tayfun Uçar
- Department of Pediatric Cardiology, Medical School, Ankara University, Ankara, Turkey
| | - Songül Yılmaz
- Department of Pediatric Nephrology, Medical School, Ankara University, Ankara, Turkey
| | - Z Birsin Özçakar
- Department of Pediatric Nephrology, Medical School, Ankara University, Ankara, Turkey
| | - Eda Didem Kurt-Şükür
- Department of Pediatric Nephrology, Medical School, Ankara University, Ankara, Turkey
| | - Ercan Tutar
- Department of Pediatric Cardiology, Medical School, Ankara University, Ankara, Turkey
| | - Fatoş Yalçınkaya
- Department of Pediatric Nephrology, Medical School, Ankara University, Ankara, Turkey
| | - Semra Atalay
- Department of Pediatric Cardiology, Medical School, Ankara University, Ankara, Turkey
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9
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Charnaya O, Moudgil A. Hypertension in the Pediatric Kidney Transplant Recipient. Front Pediatr 2017; 5:86. [PMID: 28507980 PMCID: PMC5410589 DOI: 10.3389/fped.2017.00086] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2017] [Accepted: 04/07/2017] [Indexed: 12/14/2022] Open
Abstract
Hypertension after kidney transplant is a frequent occurrence in pediatric patients. It is a risk factor for graft loss and contributes to the significant burden of cardiovascular disease (CVD) in this population. The etiology of posttransplant hypertension is multifactorial including donor factors, recipient factors, medications, and lifestyle factors similar to those prevalent in the general population. Ambulatory blood pressure monitoring has emerged as the most reliable method for measuring hypertension in pediatric transplant recipients, and many consider it to be essential in the care of these patients. Recent technological advances including measurement of carotid intima-media thickness, pulse wave velocity, and myocardial strain using specked echocardiography and cardiac magnetic resonance imaging have improved our ability to assess CVD burden. Since hypertension remains underrecognized and inadequately treated, an early diagnosis and an appropriate control should be the focus of therapy to help improve patient and graft survival.
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Affiliation(s)
- Olga Charnaya
- Division of Pediatric Nephrology, Children's National Health System, Washington, DC, USA
| | - Asha Moudgil
- Division of Pediatric Nephrology, Children's National Health System, Washington, DC, USA
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10
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El-Khashab SO, Mohamed EES, Soliman MA, Kassem HH, Soliman AR. Impact of renal transplantation on cardiac morphological and functional characteristics in children and adults. World J Nephrol 2016; 5:517-523. [PMID: 27872833 PMCID: PMC5099597 DOI: 10.5527/wjn.v5.i6.517] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Revised: 07/18/2016] [Accepted: 09/18/2016] [Indexed: 02/05/2023] Open
Abstract
AIM To compare the effects of renal transplantation on cardiac functions in children and adults.
METHODS One hundred and ten patients attending the nephrology outpatient clinic were enrolled in this study and were divided into six groups. The first two groups consisted each of 30 renal transplant patients who had a successful renal transplantation more than six months, but less than one year. Group I were less than 18 years and group II were more than 18 years. The third and fourth groups, each were 20 chronic renal failure patients on regular hemodialysis. Again, group III were less than 18 years and group IV were more than 18 years. Group V and VI (The control Groups) consisted each of 5 subjects below and above 18 years of age, respectively with normal kidney functions. All patients were subjected to history and examination. The kidney functions and the hemoglobin were analyzed. After obtaining informed consent, echocardiography was done to all patients.
RESULTS There was a statistically significant improvement (P < 0.0001) in all cardiac parameters. A regression in left ventricular end diastolic volume (LVED) both in children (4.7 ± 0.8 to 4.2 ± 0.5) and in adults (5.9 ± 0.7 to 4.9 ± 0.6) were found. There was a regression in left ventricular end systolic volume (LVES) both in children (3.1 ± 0.6 to 2.4 ± 0.4) and in adults (4.1 ± 0.9 to 3.1 ± 0.5). Fractional shortening improves both in children (32.6 ± 5.3 to 41.7 ± 7.6) and in adults (29.0 ± 6.6 to 36.5 ± 4.1). The improvement in ejection fraction (EF) was higher in children (59.7 ± 7.0 to 71.9 ± 6.1) than in adults (52.0 ± 12.5 to 64.8 ± 5.9). However, this degree of improvement (in children: 12.2 ± 5.1) did not show statistical difference (P-value 0.8), when compared to adults (12.7 ± 9.8).
CONCLUSION After renal transplantation cardiac functions and morphology (EF/LVED/LVES) do improve markedly and rapidly in both children and adults.
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11
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Taylor K, Lorenzo A, Mertens L, Dragulescu A. Pilot study on the feasibility of limited focused real-time echocardiography during pediatric renal transplantation. Pediatr Transplant 2016; 20:778-82. [PMID: 27235185 DOI: 10.1111/petr.12726] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/26/2016] [Indexed: 11/30/2022]
Abstract
Pediatric renal transplantation protocols describe supraphysiological blood pressure and CVP to optimize graft perfusion. Ideal CVP and blood pressure targets in children are uncertain and difficult to achieve and/or sustain without incurring morbidity. We correlated intra-operative ECHO with standard monitoring to assess intravascular volume at critical intra-operative stages. A feasibility pilot study of real-time limited ECHO images during four critical stages of pediatric renal transplantation (baseline; venous and arterial clamps on; clamps off; 5-10 min post-clamp release) was conducted. Simultaneous CVP, SBP and DBP measurements were obtained with ECHO images. A surgeon blinded to the ECHO study assessed the quality of graft perfusion. Thirteen patients (nine TTE and four TEE) were enrolled. The CI increased in all patients at vascular clamp removal and the post-resuscitation period (average increase in CI 20%, range 8-49%). SBP, DBP and CVP were inconsistent. ECHO data confirmed an appropriate CI increase even when the targeted CVP and BP values described in protocols were not achieved. The surgeons were satisfied with graft perfusion in 12 of 13 cases, with one locally obstructed vessel. We suggested that aiming for fixed targets in CVP and BP is not necessary to augment CI and encourage good renal perfusion.
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Affiliation(s)
- Katherine Taylor
- Department of Anesthesia, Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Armando Lorenzo
- Department of Urology, Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Luc Mertens
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Department of Cardiology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Andreea Dragulescu
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Department of Cardiology, Hospital for Sick Children, Toronto, Ontario, Canada
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12
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Ali A, Macphee I, Kaski JC, Banerjee D. Cardiac and vascular changes with kidney transplantation. Indian J Nephrol 2016; 26:1-9. [PMID: 26937071 PMCID: PMC4753734 DOI: 10.4103/0971-4065.165003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Cardiovascular event rates are high in patients with chronic kidney disease (CKD), increasing with deteriorating kidney function, highest in CKD patients on dialysis, and improve with kidney transplantation (KTx). The cardiovascular events in CKD patients such as myocardial infarction and heart failure are related to abnormalities of vascular and cardiac structure and function. Many studies have investigated the structural and functional abnormalities of the heart and blood vessels in CKD, and the changes that occur with KTx, but the evidence is often sparse and occasionally contradictory. We have reviewed the available evidence and identified areas where more research is required to improve the understanding and mechanisms of these changes. There is enough evidence demonstrating improvement of left ventricular hypertrophy, except in children, and sufficient evidence of improvement of left ventricular function, with KTx. There is reasonable evidence of improvement in vascular function and stiffness. However, the evidence for improvement of vascular structure and atherosclerosis is insufficient. Further studies are necessary to establish the changes in vascular structure, and to understand the mechanisms of vascular and cardiac changes, following KTx.
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Affiliation(s)
- A Ali
- Renal and Transplantation Unit, St. George's University Hospitals NHS Foundation Trust, Tooting, London SW17 0QT, UK
| | - I Macphee
- Renal and Transplantation Unit, St. George's University Hospitals NHS Foundation Trust, Tooting, London SW17 0QT, UK
| | - J C Kaski
- Division of Clinical Sciences, Cardiovascular and Cell Sciences Research Institute, St George's University of London, Tooting, London SW17 0RE, UK
| | - D Banerjee
- Renal and Transplantation Unit, St. George's University Hospitals NHS Foundation Trust, Tooting, London SW17 0QT, UK; Division of Clinical Sciences, Cardiovascular and Cell Sciences Research Institute, St George's University of London, Tooting, London SW17 0RE, UK
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13
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Alparslan C, Yavascan O, Doğan MS, Saritas S, Mutlubas Ozsan F, Kasap Demir B, Bakiler AR, Aksu N. Pretransplant Stable Systolic Cardiac Functions Play an Important Role in Short-term Systolic Cardiac Functions After Kidney Transplant in Children. EXP CLIN TRANSPLANT 2016; 15:34-39. [PMID: 26867571 DOI: 10.6002/ect.2015.0208] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES In this study, our aim was to evaluate the systolic cardiac parameters and related risk factors in children within 6 months after kidney transplant. MATERIALS AND METHODS We retrospectively evaluated 24 children who received kidney transplants. Clinical and laboratory parameters before and after transplant were recorded. Results were evaluated statistically, with a P value less than .05 considered significant. RESULTS Before transplant, systolic cardiac functions were within normal limits. After transplant, ejection fraction (63.35% ± 5.38% vs 66.95% ± 4.62%; P = .01) was significantly increased and left ventricular mass index (32.63 ± 17.21 g/m2.7 vs 31.29 ± 15.65 g/m2.7; P = .78) was not significantly decreased, whereas fractional shortening (52.16% ± 15.32% vs 59.8% ± 12.94%; P = .54) did not change. Systolic blood pressure, systolic blood pressure index, diastolic blood pressure, and diastolic blood pressure index values were not statistically different before and after transplant (P > .05). The number of antihypertensive agents was significantly decreased (P = .001). Before and after transplant, cardiac geometry was normal in 15 patients (62.5%) and 17 patients (70.8%). CONCLUSIONS Our patients, who had stable systolic cardiac function before transplant, showed further improvements in systolic cardiac function even within 6 months after transplant. Therefore, strictly monitored and controlled blood pressure, volume, anemia, and nutrition in children before transplant may play important roles in achieving better cardiac systolic function after kidney transplant.
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Affiliation(s)
- Caner Alparslan
- From the Department of Pediatrics and Pediatric Nephrology, Izmir Tepecik Training and Research Hospital, Izmir, Turkey
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14
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Weaver DJ, Selewski D, Janjua H, Iorember F. Improved cardiovascular risk factors in pediatric renal transplant recipients on steroid avoidance immunosuppression: A study of the Midwest Pediatric Nephrology Consortium. Pediatr Transplant 2016; 20:59-67. [PMID: 26585354 DOI: 10.1111/petr.12633] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/12/2015] [Indexed: 12/01/2022]
Abstract
Several centers have examined the implementation of immunosuppression protocols that minimize steroid exposure. This study retrospectively examined cardiovascular risk factors in 70 pediatric renal transplant recipients on steroid avoidance-based immunosuppression over three yr compared to matched pediatric patients maintained on chronic corticosteroids. Although higher rates of acute rejection were noted in the steroid-avoidant group (22% vs. 16%, p = 0.034), graft function was similar (67 + 10 mL/min/1.73 m(2) vs. 72 + 12 mL/min/1.73 m(2)) (p = 0.053). The steroid-avoidant group demonstrated improved growth (height z-score -0.41 + 5.9 vs. -1.1 + 0.041) with a decrease in the prevalence of obesity (24% vs. 34%, p = 0.021). Indexed systolic blood pressures were lower beginning at six months post-transplant in the steroid-avoidant group (1.21 + 0.15 vs. 1.51 + 0.22, p = 0.020). Indexed diastolic blood pressures were lower beginning at 12 months post-transplant (0.91 + 0.11 vs. 1.12 + 0.18, p = 0.037). Differences in total serum cholesterol values and serum glucose values were not statistically significant. Beginning at 12 months, a statistically significant decrease in left ventricular mass index (39.2 + 11.3 vs. 49.4 + 14.5, p = 0.014) was noted in patients on steroid-avoidant immunosuppression, which corresponded to a significant decrease in the prevalence of left ventricular hypertrophy in these patients by two yr post-transplant (35% vs. 48%, p = 0.012). Systolic blood pressure and BMI were independent predictors of left ventricular hypertrophy.
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Affiliation(s)
- Donald J Weaver
- Division of Nephrology and Hypertension, Department of Pediatrics, Levine Children's Hospital at Carolinas Medical Center, Charlotte, NC, USA
| | - David Selewski
- Division of Nephrology, Department of Pediatrics, C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Halima Janjua
- Division of Nephrology, Cleveland Clinic Children's Hospital, Cleveland, OH, USA
| | - Franca Iorember
- Division of Nephrology, Louisiana State University Health Sciences Center, New Orleans, LA, USA
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15
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Bulum B, Özçakar ZB, Kavaz A, Tutar E, Ekim M, Yalçınkaya F. Hypertension in children after renal transplantation. Pediatr Int 2015; 57:1138-42. [PMID: 26009796 DOI: 10.1111/ped.12703] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Revised: 04/13/2015] [Accepted: 04/23/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Hypertension (HT) is a common and serious complication following renal transplantation in children, and an important risk factor for cardiovascular morbidity and mortality. This study evaluated the clinical characteristics of HT in children after renal transplantation. METHODS Twenty-four children who were followed up at least 6 months after renal transplantation were enrolled in the study. From the clinical records, demographic and laboratory data, casual blood pressure (BP) measurement, ambulatory BP monitoring (ABPM), medication, and left ventricular mass index (LVMI) at echocardiogram were documented. RESULTS Mean age at time of transplantation was 12.6 ± 3.0 years and mean follow-up period was 19.6 ± 15.8 months. HT was detected in 21 children (87.5%) after renal transplantation. Twelve patients (50%) had HT both before and after transplantation and nine (38%) had HT only after transplantation. HT developed in 67% within the first week and in 95% within the first month. All hypertensive children had night-time HT and no child had isolated daytime HT. The efficacy of HT control was 42%. Median LVMI in patients with HT after renal transplantation was 42.3 g/m(2.7). CONCLUSIONS Severe HT, an important complication, was frequently seen in the early period after renal transplantation. Predominance of nocturnal HT and the lack of isolated daytime HT after transplantation underline the importance of ABPM. ABPM should be performed regularly in the first year after transplantation, not only for diagnosis but also for evaluation of HT control.
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Affiliation(s)
- Burcu Bulum
- Department of Pediatric Nephrology, Ankara University School of Medicine, Ankara, Turkey
| | - Z Birsin Özçakar
- Department of Pediatric Nephrology, Ankara University School of Medicine, Ankara, Turkey
| | - Aslı Kavaz
- Department of Pediatric Nephrology, Ankara University School of Medicine, Ankara, Turkey
| | - Ercan Tutar
- Department of Pediatric Cardiology, Ankara University School of Medicine, Ankara, Turkey
| | - Mesiha Ekim
- Department of Pediatric Nephrology, Ankara University School of Medicine, Ankara, Turkey
| | - Fatoş Yalçınkaya
- Department of Pediatric Nephrology, Ankara University School of Medicine, Ankara, Turkey
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Weir MR, Burgess ED, Cooper JE, Fenves AZ, Goldsmith D, McKay D, Mehrotra A, Mitsnefes MM, Sica DA, Taler SJ. Assessment and management of hypertension in transplant patients. J Am Soc Nephrol 2015; 26:1248-60. [PMID: 25653099 DOI: 10.1681/asn.2014080834] [Citation(s) in RCA: 109] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Hypertension in renal transplant recipients is common and ranges from 50% to 80% in adult recipients and from 47% to 82% in pediatric recipients. Cardiovascular morbidity and mortality and shortened allograft survival are important consequences of inadequate control of hypertension. In this review, we examine the epidemiology, pathophysiology, and management considerations of post-transplant hypertension. Donor and recipient factors, acute and chronic allograft injury, and immunosuppressive medications may each explain some of the pathophysiology of post-transplant hypertension. As observed in other patient cohorts, renal artery stenosis and adrenal causes of hypertension may be important contributing factors. Notably, BP treatment goals for renal transplant recipients remain an enigma because there are no adequate randomized controlled trials to support a benefit from targeting lower BP levels on graft and patient survival. The potential for drug-drug interactions and altered pharmacokinetics and pharmacodynamics of the different antihypertensive medications need to be carefully considered. To date, no specific antihypertensive medications have been shown to be more effective than others at improving either patient or graft survival. Identifying the underlying pathophysiology and subsequent individualization of treatment goals are important for improving long-term patient and graft outcomes in these patients.
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Affiliation(s)
- Matthew R Weir
- Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland;
| | - Ellen D Burgess
- Division of Renal Medicine, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - James E Cooper
- Division of Renal Disease and Hypertension, Department of Medicine, University of Colorado, Denver, Colorado
| | - Andrew Z Fenves
- Division of Nephrology, Department of Medicine, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts
| | - David Goldsmith
- Division of Cardio-Renal Medicine, St. Thomas and Guy's Hospital, London, United Kingdom
| | - Dianne McKay
- Division of Nephrology, Department of Medicine, University of California, San Diego, San Diego, California
| | - Anita Mehrotra
- Division of Nephrology, Department of Medicine, Mount Sinai School of Medicine, New York, New York
| | - Mark M Mitsnefes
- Division of Nephrology, Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Domenic A Sica
- Division of Nephrology, Department of Medicine, Virginia Commonwealth University, Richmond, Virginia; and
| | - Sandra J Taler
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota
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McLaughlin R, Hamiwka L, Samuel S, Fruitman D, Grisaru S. A longitudinal retrospective analysis of left ventricular mass in a cohort of pediatric kidney transplant recipients. Pediatr Transplant 2014; 18:810-5. [PMID: 25283997 DOI: 10.1111/petr.12365] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/30/2014] [Indexed: 12/23/2022]
Abstract
Childhood end-stage kidney disease is associated with increased risk for early adulthood cardiovascular (CV) morbidity and mortality. Increased LVM is an early indicator of CV disease. Previous studies have suggested that LVM decreases after kidney transplantation; however, trends have been inconsistent. A single center retrospective longitudinal cohort analysis of LVM, documented annually, starting before kidney transplantation for up to 10 yr after transplantation was performed. BP documented by annual 24-h ambulatory monitoring studies, and BMI values were also reviewed. Twenty-seven children followed for a mean period of 5.3 yr were included. Depending on definition of LVH, its prevalence pretransplant and in the first years post-transplant was up to 33% dropping to 0-25% thereafter. Individual longitudinal LVM z-score trends were highly variable but generally trended toward the mean immediately after transplant and toward negative values in the following years. BP was stable during the follow-up period while mean annual BMI increased in the first-year post-transplant but declined thereafter. In a cohort of pediatric renal transplant recipients, prevalence of LVH decreased after transplant; however, individual longitudinal LVM trends were highly variable among patients. Prospective studies are needed to correlate individual LVM trends with outcomes.
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Affiliation(s)
- Robyn McLaughlin
- Division of Pediatric Nephrology, Alberta Children's Hospital, University of Calgary, Calgary, AB, Canada
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18
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Kolonko A, Kujawa-Szewieczek A, Szotowska M, Kuczera P, Chudek J, Więcek A. The association of long-functioning hemodialysis vascular access with prevalence of left ventricular hypertrophy in kidney transplant recipients. BIOMED RESEARCH INTERNATIONAL 2014; 2014:603459. [PMID: 24616896 PMCID: PMC3925527 DOI: 10.1155/2014/603459] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Revised: 11/23/2013] [Accepted: 11/26/2013] [Indexed: 11/17/2022]
Abstract
Left ventricular hypertrophy (LVH) is frequently observed in chronic dialysis patients and is also highly prevalent in kidney transplant recipients. This study evaluates the impact of long-functioning hemodialysis vascular access on LVH in single center cohort of kidney transplant recipients. 162 patients at 8.7 ± 1.8 years after kidney transplantation were enrolled. Echocardiography, carotid ultrasound, and assessment of pulse wave velocity were performed. LVH was defined based on left ventricular mass (LVM) indexed for body surface area (BSA) and height(2.7). There were 67 patients with and 95 without patent vascular access. Both study groups were comparable with respect to gender, age, duration of dialysis therapy, and time after transplantation, kidney graft function, and cardiovascular comorbidities. Patients with patent vascular access were characterized by significantly elevated LVM and significantly greater percentage of LVH, based on LVMI/BSA (66.7 versus 48.4%, P = 0.02). OR for LVH in patients with patent vascular access was 2.39 (1.19-4.76), P = 0.01. Regression analyses confirmed an independent contribution of patent vascular access to higher LVM and increased prevalence of LVH. We concluded that long-lasting patent hemodialysis vascular access after kidney transplantation is associated with the increased prevalence of LVH in kidney transplant recipients.
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Affiliation(s)
- Aureliusz Kolonko
- Department of Nephrology, Endocrinology and Metabolic Diseases, Medical University of Silesia, Francuska Street 20/24, 40-027 Katowice, Poland
| | - Agata Kujawa-Szewieczek
- Department of Nephrology, Endocrinology and Metabolic Diseases, Medical University of Silesia, Francuska Street 20/24, 40-027 Katowice, Poland
| | - Magdalena Szotowska
- Department of Nephrology, Endocrinology and Metabolic Diseases, Medical University of Silesia, Francuska Street 20/24, 40-027 Katowice, Poland
| | - Piotr Kuczera
- Department of Nephrology, Endocrinology and Metabolic Diseases, Medical University of Silesia, Francuska Street 20/24, 40-027 Katowice, Poland
| | - Jerzy Chudek
- Department of Nephrology, Endocrinology and Metabolic Diseases, Medical University of Silesia, Francuska Street 20/24, 40-027 Katowice, Poland
- Department of Pathophysiology, Medical University of Silesia, 40-752 Katowice, Poland
| | - Andrzej Więcek
- Department of Nephrology, Endocrinology and Metabolic Diseases, Medical University of Silesia, Francuska Street 20/24, 40-027 Katowice, Poland
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Abstract
Solid organ transplantation has transformed the lives of many children and adults by providing treatment for patients with organ failure who would have otherwise succumbed to their disease. The first successful transplant in 1954 was a kidney transplant between identical twins, which circumvented the problem of rejection from MHC incompatibility. Further progress in solid organ transplantation was enabled by the discovery of immunosuppressive agents such as corticosteroids and azathioprine in the 1950s and ciclosporin in 1970. Today, solid organ transplantation is a conventional treatment with improved patient and allograft survival rates. However, the challenge that lies ahead is to extend allograft survival time while simultaneously reducing the side effects of immunosuppression. This is particularly important for children who have irreversible organ failure and may require multiple transplants. Pediatric transplant teams also need to improve patient quality of life at a time of physical, emotional and psychosocial development. This review will elaborate on the long-term outcomes of children after kidney, liver, heart, lung and intestinal transplantation. As mortality rates after transplantation have declined, there has emerged an increased focus on reducing longer-term morbidity with improved outcomes in optimizing cardiovascular risk, renal impairment, growth and quality of life. Data were obtained from a review of the literature and particularly from national registries and databases such as the North American Pediatric Renal Trials and Collaborative Studies for the kidney, SPLIT for liver, International Society for Heart and Lung Transplantation and UNOS for intestinal transplantation.
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Affiliation(s)
- Jon Jin Kim
- Department of Pediatric Nephrology, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, England, United Kingdom
| | - Stephen D Marks
- Department of Pediatric Nephrology, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, England, United Kingdom
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20
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Left Ventricular Hypertrophy in Hypertensive Children and Adolescents: Predictors and Prevalence. Curr Hypertens Rep 2013; 15:453-7. [DOI: 10.1007/s11906-013-0370-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Paglialonga F, Ardissino G, Galli MA, Scarfia RV, Testa S, Edefonti A. Bioimpedance analysis and cardiovascular status in pediatric patients on chronic hemodialysis. Hemodial Int 2013; 16 Suppl 1:S20-5. [PMID: 23036032 DOI: 10.1111/j.1542-4758.2012.00743.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Bioimpedance analysis (BIA) is reported to be useful in assessing dry weight (DW) in patients on hemodialysis (HD), but its exact role has never been clearly defined. We reviewed our experience of using the BIA measure of reactance (Xc) in pediatric patients on chronic HD. Our approach is currently based on identifying a range of patient-specific Xc values at which a child can be considered at DW according to a multidisciplinary assessment. Values lower than the patient-specific limit suggests the need for a reduction in DW, whereas values higher than the limit suggest that DW should be increased. The accuracy of our approach was retrospectively assessed by analyzing the left ventricular mass index (LVMI) and the incidence of pulmonary edema (PE) in two groups: The first consisted of 13 patients (median age 15.6 years) on dialysis in 2007, before the introduction of the BIA-based approach; the second included 18 patients (median 14.8 years) on dialysis in 2011. In 2007, three children experienced four episodes of PE, whereas no PE occurred in 2011. The median LVMI was 56.8 g/m(2.7) in 2007, and 44.5 g/m(2.7) in 2011 (P < 0.05). The percentage of patients with LV hypertrophy (LVMI>38.5 g/m(2.7)) was 92.3% in 2007 and 61.1% in 2011 (P < 0.05). There were no between-group differences in terms of blood pressure, antihypertensive medications, percentage of symptomatic sessions, or biochemistry. In conclusion, a simple approach based on BIA may be useful in assessing DW in pediatric patients on HD, and thus improve their cardiovascular status.
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Affiliation(s)
- Fabio Paglialonga
- Pediatric Nephrology and Dialysis Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
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Abstract
More than a decade ago, cardiovascular disease (CVD) was recognized as a major cause of death in children with advanced CKD. This observation has sparked the publication of multiple studies assessing cardiovascular risk, mechanisms of disease, and early markers of CVD in this population. Similar to adults, children with CKD have an extremely high prevalence of traditional and uremia-related CVD risk factors. Early markers of cardiomyopathy, such as left ventricular hypertrophy and dysfunction, and early markers of atherosclerosis, such as increased carotid artery intima-media thickness, carotid arterial wall stiffness, and coronary artery calcification, are frequently present in these children, especially those on maintenance dialysis. As a population without preexisting symptomatic cardiac disease, children with CKD potentially receive significant benefit from aggressive attempts to prevent and treat CVD. Early CKD, before needing dialysis, is the optimal time to both identify modifiable risk factors and intervene in an effort to avert future CVD. Slowing the progression of CKD, avoiding long-term dialysis and, if possible, conducting preemptive transplantation may represent the best strategies to decrease the risk of premature cardiac disease and death in children with CKD.
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Affiliation(s)
- Mark M Mitsnefes
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229-3039, USA.
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23
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Flynn JT. Hypertension and future cardiovascular health in pediatric end-stage renal disease patients. Blood Purif 2012; 33:138-43. [PMID: 22269342 DOI: 10.1159/000334140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND There are now numerous studies that have documented an increased risk of cardiovascular morbidity and mortality in young adults who had childhood-onset end-stage renal disease (ESRD). Since the number of such patients surviving to adulthood is increasing, strategies to reduce this risk are urgently needed. METHODS The various risk factors contributing to adult cardiovascular disease in this population will be reviewed, with an emphasis on hypertension and its control. Data demonstrating the prevalence of hypertension in childhood chronic kidney disease as well as the results of improved blood pressure control in ESRD will also be presented. CONCLUSIONS Hypertension is exceedingly common in pediatric ESRD patients and frequently poorly controlled. Efforts to improve blood pressure control in this patient population could potentially reduce future cardiovascular morbidity and mortality.
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Affiliation(s)
- Joseph T Flynn
- University of Washington School of Medicine, and Pediatric Hypertension Program, Seattle Children's Hospital, Seattle, WA 98105, USA.
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24
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Cavallini M, Di Zazzo G, Giordano U, Pongiglione G, Dello Strologo L, Capozza N, Emma F, Matteucci MC. Long-term cardiovascular effects of pre-transplant native kidney nephrectomy in children. Pediatr Nephrol 2010; 25:2523-9. [PMID: 20865433 DOI: 10.1007/s00467-010-1638-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2010] [Revised: 07/09/2010] [Accepted: 08/03/2010] [Indexed: 01/20/2023]
Abstract
Left ventricular (LV) hypertrophy (H) and hypertension are prevalent in children with end-stage renal disease (ESRD) and after renal transplantation. Severe hypertension prior to renal transplantation has traditionally been an indication for native kidney nephrectomy. The impact of nephrectomy on cardiovascular disease has not been well documented. We retrospectively evaluated echocardiographic and ambulatory blood pressure monitoring (ABPM) data in 67 young adults who had undergone transplantation in the pediatric age with a mean follow-up of 10.4 years. Unilateral or bilateral nephrectomies had been performed in 32 patients. The number of antihypertensive drugs used prior to transplantation was significantly higher in the nephrectomized groups. At follow-up the amount of antihypertensive medications was similar between groups and no significant differences were observed in mean arterial blood pressure (MAP) or LV mass index (LVMi). LVH was observed in 50% of non-nephrectomized patients, 45.4% of patients with unilateral nephrectomy, and 44.4% of patients without native kidneys (p = n.s.). In conclusion, unilateral or bilateral nephrectomies prior to transplantation do not appear to influence blood pressure control or the prevalence of LVH after renal transplantation. Longitudinal studies with repeated assessment of LVMi, before and after renal transplantation, are needed to assess the impact of residual activity of native kidneys on arterial blood pressure and cardiac structural changes, even in normotensive patients, to evaluate cardiovascular morbidity.
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Affiliation(s)
- Marco Cavallini
- Division of Pediatric Nephrology, Bambino Gesú Hospital, Rome, Italy
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25
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Querfeld U, Anarat A, Bayazit AK, Bakkaloglu AS, Bilginer Y, Caliskan S, Civilibal M, Doyon A, Duzova A, Kracht D, Litwin M, Melk A, Mir S, Sözeri B, Shroff R, Zeller R, Wühl E, Schaefer F. The Cardiovascular Comorbidity in Children with Chronic Kidney Disease (4C) study: objectives, design, and methodology. Clin J Am Soc Nephrol 2010; 5:1642-8. [PMID: 20576824 DOI: 10.2215/cjn.08791209] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Children and adolescents with chronic kidney disease (CKD) are at high risk for cardiovascular morbidity and mortality. A systemic arteriopathy and cardiomyopathy has been characterized in pediatric dialysis patients by the presence of morphologic and functional abnormalities. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The Cardiovascular Comorbidity in Children with CKD (4C) Study is a multicenter, prospective, observational study aiming to recruit more than 600 children, aged 6 to 17 years, with initial GFR of 10 to 45 ml/min per 1.73 m(2). The prevalence, degree, and progression of cardiovascular comorbidity as well as its association with CKD progression will be explored through longitudinal follow-up. The morphology and function of the heart and large arteries will be monitored by sensitive noninvasive methods and compared with aged-matched healthy controls. Multiple clinical, anthropometric, biochemical, and pharmacologic risk factors will be monitored prospectively and related to the cardiovascular status. A whole-genome association study will be performed to identify common genetic variants associated with progression of cardiovascular alterations and/or renal failure. Monitoring will be continued as patients reach end-stage renal disease and undergo different renal replacement therapies. RESULTS While cardiovascular morbidity in adults is related to older age and additional risk factor load (e.g., diabetes), the role of CKD-specific factors in the initiation and progression of cardiac and vascular disease are likely to be characterized with greater sensitivity in the pediatric age group. CONCLUSIONS The 4C study is expected to provide innovative insight into cardiovascular and renal disease progression in CKD.
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Affiliation(s)
- Uwe Querfeld
- Department of Pediatric Nephrology, Charité Universitätsmedizin Berlin CVK, Augustenburger Platz 1, 13353 Berlin, Germany.
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Association and prognostic impact of persistent left ventricular hypertrophy after live-donor kidney transplantation: a prospective study. Clin Exp Nephrol 2009; 14:68-74. [PMID: 19876703 DOI: 10.1007/s10157-009-0231-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2009] [Accepted: 09/14/2009] [Indexed: 12/31/2022]
Abstract
AIM Persistent or de novo left ventricular hypertrophy (LVH) is a risk factor for cardiovascular diseases and congestive heart failure following renal transplantation (RT). Our aim was to determine the associations and impact of persistent LVH on RT outcome. MATERIALS AND METHODS We included 72 live-donor renal allograft recipients with mean age of 28.5 years who had evidence of LVH at time of transplantation and had stable functioning grafts 1 year after transplantation. Cardiac status of all recipients was assessed before transplantation and at 1 year after transplantation by echocardiography. Recipients were subdivided into two groups according to persistence or regression of LVH 1 year after transplantation. The first group included 33 patients who had persistent LVH. The second group included 39 patients in whom LVH had regressed (control group). Both groups were closely followed for 10 years. RESULTS Univariate analysis showed that persistent LVH 1 year after RT was significantly associated with high serum creatinine, higher incidence of medical infection, and acute and chronic rejection. Chronic rejection and infection were the only valid associations on multivariate logistic regression analysis. Patient and graft survival were significantly lower in the persistent LVH group (P = 0.012). CONCLUSION Persistent LVH may be associated with higher incidence of medical infection and chronic rejection that worsen the prognosis for renal transplant recipients.
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Wilson AC, Mitsnefes MM. Cardiovascular disease in CKD in children: update on risk factors, risk assessment, and management. Am J Kidney Dis 2009; 54:345-60. [PMID: 19619845 PMCID: PMC2714283 DOI: 10.1053/j.ajkd.2009.04.027] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2009] [Accepted: 04/17/2009] [Indexed: 12/20/2022]
Abstract
In young adults with onset of chronic kidney disease in childhood, cardiovascular disease is the most common cause of death. The likely reason for increased cardiovascular disease in these patients is a high prevalence of traditional and uremia-related cardiovascular disease risk factors during childhood chronic kidney disease. Early markers of cardiomyopathy, such as left ventricular hypertrophy and left ventricular dysfunction, and early markers of atherosclerosis, such as increased carotid artery intima-media thickness, carotid arterial wall stiffness, and coronary artery calcification, frequently are found in this patient population. The purpose of this review is to provide an update of recent advances in the understanding and management of cardiovascular disease risks in this population.
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Affiliation(s)
- Amy C Wilson
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
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Abstract
Cardiovascular disease accounts for 40% of all deaths among pediatric patients with end-stage renal disease (ESRD). ESRD has a particularly large influence on the cardiovascular system in children, as indicated by the more than 700-fold increased risk of cardiac death in affected individuals compared with healthy children of the same age. The prevalence of ESRD is low in children, however, and, consequently, few cardiac deaths occur. As a result, prospective follow-up studies of cardiac risk factors in the pediatric setting are lacking. Nevertheless, cross-sectional data on cardiac disease in children with ESRD have started to emerge. Arterial medial calcification is more prominent in children than classic atherosclerotic intimal calcification. Current data suggest that endothelial dysfunction appears early in renal failure in children, and is followed by arterial medial calcification. This calcification causes arterial wall stiffening and subsequently left ventricular hypertrophy. High systolic blood pressure and serum concentrations of intact parathyroid hormone, calcium and phosphate, as well as long-term dialysis, seem to be important risk factors for cardiovascular disease in pediatric patients with ESRD. These features are important targets for preventive intervention. This Review summarizes the currently available data on cardiovascular disease in children with renal failure.
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Affiliation(s)
- Marc R Lilien
- Department of Pediatric Nephrology, Wilhelmina Children's Hospital, University Medical Center, Utrecht, The Netherlands.
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Ten Harkel ADJ, Cransberg K, Van Osch-Gevers M, Nauta J. Diastolic dysfunction in paediatric patients on peritoneal dialysis and after renal transplantation. Nephrol Dial Transplant 2009; 24:1987-91. [PMID: 19225014 DOI: 10.1093/ndt/gfp049] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Cardiovascular disease is the leading cause of death in children with end-stage renal disease. We investigated the presence of cardiac systolic and diastolic dysfunction in patients on peritoneal dialysis or after renal transplantation. Methods and results. Fourteen patients on peritoneal dialysis for a mean of 1.4 years (range 0.1-5.3) and 39 patients with a functioning kidney transplant for a median time of 3.3 years (range 1.2-14.5) were studied. These patients were compared to 153 age-matched healthy controls. As assessed by echocardiography, both dialysis and transplant patients showed left ventricular dysfunction. Systolic tissue Doppler values were lower as compared to controls. Mitral E/A ratios were significantly lower as well, indicating diastolic dysfunction (transplant 1.82 +/- 0.58 versus 2.15 +/- 0.63, P < 0.01; dialysis patients 1.57 +/- 0.73 versus 2.31 +/- 0.52, P < 0.01). Also, tissue Doppler values were different, showing an increased E/E' ratio in the patients, indicating diastolic dysfunction (transplant 9.49 +/- 1.71 versus 7.50 +/- 1.60, P < 0.01; dialysis patients 11.90 +/- 2.11 versus 8.10 +/- 1.24, P < 0.01). The left ventricular mass index was increased in the transplant patients (controls 25 +/- 7 g/m(2.7); transplant 59 +/- 64 g/m(2.7); P < 0.01), as well as in the dialysis patients (controls 28 +/- 7 g/m(2.7); dialysis 43 +/- 11 g/m(2.7); P < 0.01) and was associated with systolic hypertension (R = 0.46, P < 0.05). High parathyroid hormone (PTH) levels, more prevalent in dialysis patients, were associated with abnormal E/A and E/E' ratios. CONCLUSIONS Abnormalities in diastolic function are present in both peritoneal dialysis and renal transplanted patients. In the dialysis group, abnormalities in calcium-phosphate metabolism are associated with diastolic dysfunction. Cardiac hypertrophy was noted in both patient groups and was associated with systolic hypertension.
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Improved left ventricular mass index in children after renal transplantation. Pediatr Nephrol 2008; 23:1545-50. [PMID: 18548286 DOI: 10.1007/s00467-008-0855-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2008] [Revised: 03/24/2008] [Accepted: 04/02/2008] [Indexed: 11/27/2022]
Abstract
Left ventricular hypertrophy (LVH) is a risk factor for cardiovascular disease, and it is prevalent in children with end-stage renal disease (ESRD) and after renal transplantation (RTx) on cross-sectional studies. Our aim was to compare prospectively left ventricular mass index (LVMI) in children with ESRD, before and after RTx. Thirteen patients aged 1.5-15 years underwent echocardiogram prior to and at least 3 months after RTx, and again in the second year after transplantation. A control group consisted of children with ESRD who remained on dialysis. Systolic and diastolic blood pressure index decreased significantly over the study period only in the children who had undergone RTx. Mean LVMI in children with ESRD decreased from 45.4 +/- 12.6 g/m(2.7) to 34.9 +/- 10.4 g/m(2.7) after RTx (P = 0.001), but it remained unchanged in patients who remained on dialysis. The prevalence of LVH decreased from 54% to 8% (P = 0.03) after RTx. Systolic and diastolic blood pressure index were correlated with LVMI. Mean body mass index increased during the study period from 17.3 +/- 2.5 to 20 +/- 4.6 (P = 0.05); however, no correlation was found with LVMI. LVH in children with ESRD is potentially reversible after RTx, especially with good control of hypertension.
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Left ventricular systolic and diastolic function and carotid intima-media thickness in pediatric dialysis patients. Int Urol Nephrol 2008; 41:401-8. [PMID: 18690547 DOI: 10.1007/s11255-008-9438-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2008] [Accepted: 07/01/2008] [Indexed: 10/21/2022]
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Mitsnefes MM. Cardiovascular complications of pediatric chronic kidney disease. Pediatr Nephrol 2008; 23:27-39. [PMID: 17120060 PMCID: PMC2100430 DOI: 10.1007/s00467-006-0359-0] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2006] [Revised: 09/08/2006] [Accepted: 09/11/2006] [Indexed: 02/07/2023]
Abstract
Cardiovascular disease (CVD) mortality is a leading cause of death in adult chronic kidney disease (CKD), with exceptionally high rates in young adults, according to the Task Force on Cardiovascular Disease. Recent data indicate that cardiovascular complications are already present in children with CKD. This review summarizes the current literature on cardiac risk factors, mortality and morbidity in children with CKD.
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Affiliation(s)
- Mark M Mitsnefes
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229-3039, USA.
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Civilibal M, Caliskan S, Oflaz H, Sever L, Candan C, Canpolat N, Kasapcopur O, Bugra Z, Arisoy N. Traditional and "new" cardiovascular risk markers and factors in pediatric dialysis patients. Pediatr Nephrol 2007; 22:1021-9. [PMID: 17340147 DOI: 10.1007/s00467-007-0451-0] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2006] [Revised: 01/03/2007] [Accepted: 01/24/2007] [Indexed: 02/07/2023]
Abstract
Cardiovascular disease (CVD) is the principal cause of mortality in patients with end-stage renal disease (ESRD). The aim of this study was to analyze carotid intima-media thickness (cIMT), endothelium-dependent dilatation (EDD), and left ventricular mass index (LVMI) as the cardiovascular risk markers and to investigate the independent risk factors of these markers in pediatric dialysis patients. This study included 39 children and adolescents undergoing dialysis (15 hemodialysis and 24 peritoneal dialysis) and 15 age- and gender-matched healthy subjects. The cIMT and EDD were assessed by high-resolution ultrasound, and LVMI was calculated from standard echocardiographic measurements. Compared with control subjects, cIMT standard deviation scores (SDS), LVMI, total homocysteine (tHcy), and high-sensitivity C-reactive protein (hs-CRP) values were significantly higher in patients, but EDD values did not differ. The mean hs-CRP level was significantly higher in hemodialysis (HD) patients than in peritoneal dialysis (PD) patients. The cIMT-SDS and LVMI were associated with several variables in univariate analysis. Stepwise linear regression analysis, indexed SBP (p = 0.017), and hemoglobin (p = 0.001) turned out to be independent variables for predicting LVMI, and a significant predictor of cIMT was indexed diastolic blood pressure (DBP) (p = 0.035). The causes of atherosclerosis and left ventricular hypertrophy are multifactorial in children and adolescents with ESRD. Better management of hypertension and anemia may be priorities for preventing or improving CVD in these patients.
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Affiliation(s)
- Mahmut Civilibal
- Department of Pediatric Nephrology, Istanbul University Cerrahpasa Medical Faculty, 34303 Cerrahpasa, Istanbul, Turkey.
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Bullington N, Kartel J, Khoury P, Mitsnefes M. Left ventricular hypertrophy in pediatric kidney transplant recipients: long-term follow-up study. Pediatr Transplant 2006; 10:811-5. [PMID: 17032427 DOI: 10.1111/j.1399-3046.2006.00565.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Cross-sectional studies indicate that LVH, known cardiovascular risk factor, is frequent in pediatric patients post-kidney transplant. We performed a retrospective longitudinal analysis of echocardiographic data collected in children and adolescents who received kidney transplant from 1998 to 2003. The first echo was performed at a median time post-transplant of 14 months in 47 children; a second echo (echo 2) was carried out at a median time of 33 months in 31 and a third echo (echo 3) was performed at a median time of 49 months in 14 children. LVH was defined as LV mass index >/=95th percentile for children. LVH was present in echo 1 in 25 (54%) subjects. Systolic blood pressure (p = 0.02) and BMI (p = 0.02) independently predicted the LVH seen in echo1 in multivariate logistic regression. In 14 subjects with three consecutive echocardiograms LVM index significantly decreased from echo 1 to echo 2 and from echo 1 to echo3 (p < 0.05), but no significant changes were observed between echo 2 and echo 3. The overall prevalence of LVH remained unchanged but its severity significantly decreased during the follow-up. The results of the study suggest that despite regression of LVM index overtime-pediatric patients post-kidney transplant are at continuous risk for developing cardiovascular disease.
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Affiliation(s)
- Nathan Bullington
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Guízar-Mendoza JM, Amador-Licona N, Lozada EE, Rodriguez L, Gutiérrez-Navarro M, Dubey-Ortega LA, Trejo-Bellido J, Encarnación JDJ, Ruiz-Jaramillo MDLC. Left ventricular mass and heart sympathetic activity after renal transplantation in children and young adults. Pediatr Nephrol 2006; 21:1413-8. [PMID: 16909241 DOI: 10.1007/s00467-006-0238-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2006] [Revised: 06/02/2006] [Accepted: 06/02/2006] [Indexed: 10/24/2022]
Abstract
Recent studies considered that an increase in sympathetic activity (SA) may be responsible for left ventricular hypertrophy (LVH). Before and after renal transplantation (RT), we evaluated changes on left ventricular mass (LVM) and SA in 40 end-stage renal disease patients between 8 and 35 years old. Hypertension (95.0% vs. 71.0%; p=0.005), use of combined antihypertensive drugs (57.5% vs. 30.0%; p=0.01), and LVH (77.5% vs. 52.5%; p=0.01) significantly decreased after RT whereas low-to-high frequency ratio (LF/HF), which represents SA, increased (3.1 vs. 5.3; p=0.0001). However, LVM regressors (with decrease on LVM index more than 20%) showed a trend of lower change on LF/HF ratio (1.6 vs. 2.4; p= 0.09) than nonregressors. Living-donor graft, baseline LVM, use of antihypertensive drugs, lower change on LF/HF ratio, and lower systolic blood pressure levels were associated with LVM regression in the simple correlation analysis. However, in the logistic regression analysis, only baseline LVM and donor type remained in the model (R(2)=0.35; p=0.0003). Thus, LVH decreased after RT and was related to baseline LVM and living-donor type. However, it is possible that the higher persistence of LVH after RT could be explained at least in part by increase in heart sympathetic activity and use of immunosuppressors.
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Affiliation(s)
- Juan Manuel Guízar-Mendoza
- Unidad de Investigación Epidemiológica UMAE 48 del Instituto Mexicano del Seguro Social, Lopez Mateos e Insurgentes s/n Colonia Paraísos, Z.C. 37320, León, Mexico
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Ulinski T, Genty J, Viau C, Tillous-Borde I, Deschênes G. Reduction of left ventricular hypertrophy in children undergoing hemodialysis. Pediatr Nephrol 2006; 21:1171-8. [PMID: 16850307 DOI: 10.1007/s00467-006-0122-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2005] [Revised: 02/12/2006] [Accepted: 02/13/2006] [Indexed: 10/24/2022]
Abstract
Left ventricular hypertrophy (LVH) is related to a 1,000-fold increased risk of cardiovascular morbidity and mortality in young adults with end-stage renal disease (ESRD) treated with hemodialysis (HD) or peritoneal dialysis. We report a series of 17 children (5 girls, 12 boys), with a median (range) age of 11 (2-18) years, all treated by HD, who presented with an increased left ventricular mass (LVM) index of 54.8+/-4.5 g/m2.7 at onset of HD and reached 36.2+/-2.6 g/m2.7 (mean+/-SEM, P<0.0001) at last follow up. Over the observation period, systolic (P<0.0001) and diastolic (P<0.0001) blood pressure (indexed for height, gender, and age) decreased and hemoglobin (+2.8 g/dL; P<0.0001) increased compared to initial values. Only BP as well as plasma protein level at onset of HD session correlated with LVM in multiple correlation analysis. In conclusion, increased LVM is a common feature in pediatric patients with ESRD. Normalization of BP and reduction of the extracellular volume (represented by plasma protein at onset of HD session) are key points in reducing LVH during HD in children.
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Affiliation(s)
- Tim Ulinski
- Department of Pediatric Nephrology, Hôpital Armand Trousseau, 26 Av. du Docteur Netter, 75571 Paris, France.
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Abstract
Cardiovascular disease (CVD), including atherosclerosis, hypertension, myocardial infarction, and cerebrovascular accidents, constitutes an important cause of morbidity and mortality in adults with chronic kidney disease (CKD). However, evidence has been accumulating over the past several years that children and young adults with CKD also experience significant cardiovascular complications. Studies in the United States and Europe have shown that CVD is a leading cause of death in young adults diagnosed with CKD in childhood. Risk factors include hypertension, dyslipidemia, anemia, and abnormal calcium-phosphorus metabolism, all of which are present in many children with CKD. Although improved control of uremia and treatment of traditional and nontraditional cardiovascular risk factors have proved to be beneficial in adults with CKD, no such data exist for children. The NIH is currently conducting a large-scale, prospective observational study of children with CKD that should help to elucidate the role of CVD in the progression of CKD in children and what interventions might reduce the risk of cardiovascular complications in these young patients.
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Affiliation(s)
- Joseph T Flynn
- Department of Pediatrics, Division of Pediatric Nephrology, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467, USA.
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Lurbe E, Torró I. Beneficios de la medida de la masa ventricular en adolescentes con hipertensión arterial. HIPERTENSION Y RIESGO VASCULAR 2006. [DOI: 10.1016/s1889-1837(06)71656-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Abstract
In children with end-stage renal disease (ESRD), cardiovascular disease (CVD) mortality has not changed for the past 3 decades. Cardiac disease remains the second most common cause of death. Recent data demonstrate a high incidence and prevalence of traditional and chronic kidney disease (CKD)-related CVD risk factors in children. Early markers of cardiomyopathy, such as left ventricular hypertrophy (LVH) and left ventricular dysfunction (LV dysfunction), and early markers of atherosclerosis, such as increased carotid artery intima-media thickness (IMT) and carotid arterial wall stiffness, are frequently found in this patient population. Early identification of modifiable risk factors and treatment of asymptomatic CVD might lead to decrease of cardiovascular morbidity and mortality in young adults who developed CKD during childhood.
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Affiliation(s)
- Mark M Mitsnefes
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229-3039, USA.
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Groothoff JW, Lilien MR, van de Kar NCAJ, Wolff ED, Davin JC. Cardiovascular disease as a late complication of end-stage renal disease in children. Pediatr Nephrol 2005; 20:374-9. [PMID: 15549413 DOI: 10.1007/s00467-004-1624-8] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2004] [Revised: 06/14/2004] [Accepted: 06/15/2004] [Indexed: 11/30/2022]
Abstract
As in older adults, cardiovascular disease is the most important cause of death in adolescents and young adult patients with end-stage renal disease (ESRD) since childhood. This concerns patients on dialysis as well as transplant patients, despite the fact that a long duration of dialysis during childhood is an extra mortality risk factor. Left ventricular hypertrophy (LVH), aortic valve calcification, and increased arterial stiffness, but not increased arterial intima media thickening, are the most frequently observed alterations in young adult survivors with childhood ESRD. In transplanted patients a concentric LVH as a result of chronic hypertension is mostly observed; in dialysis patients a more asymmetric septal LVH is found as a result of chronic volume overload. These results suggest that in children and young adults with ESRD chronic pressure and volume overload, a high calcium-phosphate product, and chronic inflammation, but not dyslipidemia, play a role in the development of cardiovascular disease.
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Hanevold CD, Ho PL, Talley L, Mitsnefes MM. Obesity and renal transplant outcome: a report of the North American Pediatric Renal Transplant Cooperative Study. Pediatrics 2005; 115:352-6. [PMID: 15687444 DOI: 10.1542/peds.2004-0289] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE Obesity is increasing in the end-stage renal disease population. Studies that have evaluated the effect of obesity on transplant outcomes in adults have yielded varying results. This issue has received little attention in the pediatric population. METHODS We performed a retrospective study of the effect of obesity on pediatric renal transplant outcomes using the North American Pediatric Renal Transplant Cooperative Study database. Registry data from 1987 through 2002 on 6658 children aged 2 to 17 years were analyzed. Obesity was defined by a BMI >95th percentile for age. RESULTS Overall, 9.7% were obese with an increase noted in recent years (12.4% after 1995 vs 8% before 1995). Obese children were significantly younger and shorter and had been on dialysis for a longer time than nonobese children. There was no significant difference in the overall patient and allograft survival between the 2 groups. However, obese children aged 6 to 12 years had higher risk for death than nonobese patients (adjusted relative risk: 3.65 for living donor; adjusted relative risk: 2.94 for cadaver), and death was more likely as a result of cardiopulmonary disease (27% in obese vs 17% in nonobese). Overall, graft loss as a result of thrombosis was more common in obese as compared with nonobese (19% vs 10%). CONCLUSIONS Obesity is an increasing problem in children who present for transplantation and may have an adverse effect on allograft and patient survival.
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Kitzmueller E, Vécsei A, Pichler J, Böhm M, Müller T, Vargha R, Csaicsich D, Aufricht C. Changes of blood pressure and left ventricular mass in pediatric renal transplantation. Pediatr Nephrol 2004; 19:1385-9. [PMID: 15517413 DOI: 10.1007/s00467-004-1672-0] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Cardiovascular events are among the most frequent causes for long-term morbidity and mortality in children after renal transplantation. The aim of this study was to analyze the effects of post-transplant changes in arterial hypertension, as assessed by 24-h ambulatory blood pressure measurement (ABPM), on myocardial architecture, as assessed by echocardiography. In a retrospective chart review analysis, 39 children were identified in whom 24-h ABPM and echocardiography had been assessed within a 3-month interval after a mean of 4 years post transplantation; 20 repeated pairs of measurements after a mean of 2 years of follow-up were available to analyze the longitudinal effects of post-transplant changes of blood pressure control on left ventricular mass index (LVMI). Arterial hypertension (59%) and left ventricular hypertrophy (50%) were highly prevalent in children after renal transplantation. Renal allograft function and number of antihypertensive medications, but not ABPM variables, were correlated with LVMI at the initial observation. However, at repeat assessment, a significant correlation between ABPM and LVMI was found. In the longitudinal assessment, left ventricular remodeling was dependent on change of dosage of cyclosporine and interval changes of blood pressure levels. Hence, control of blood pressure correlates with changes of LVMI in children with renal allografts. These results clearly underline the importance of blood pressure control for the maintenance of the myocardial architecture.
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Büscher R, Vester U, Wingen AM, Hoyer PF. Pathomechanisms and the diagnosis of arterial hypertension in pediatric renal allograft recipients. Pediatr Nephrol 2004; 19:1202-11. [PMID: 15365804 DOI: 10.1007/s00467-004-1601-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Arterial hypertension is common in pediatric renal allograft recipients. While the causes are multifactorial, including chronic graft rejection, immunosuppressive therapy, and renal vascular disorders, the effect of hypertension on renal allograft function is detrimental. As in adults, if not treated early and aggressively, hypertension may lead to cardiovascular damage and graft failure. Pathophysiological changes in the arteries and kidney af-ter renal transplantation and the impact of receptor regulation have not been studied extensively in children. For identifying children with hypertension following renal transplantation casual blood pressure measurements do not accurately reflect average arterial blood pressure and circadian blood pressure rhythm. Ambulatory 24-h blood pressure monitoring should regularly be applied in trans-plant patients. The purpose of this review is to analyze pathophysiological aspects of risk factors for arterial hypertension and underline the importance of regular blood pressure monitoring and early therapeutic intervention.
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Affiliation(s)
- R Büscher
- Department of Pediatric Nephrology, University Hospital, Essen, Germany.
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Abstract
The prevalence of hypertension in pediatric patients with renal transplant (Tx) has not changed for the last three decades, remaining at 50-80%. Long-standing and uncontrolled hypertension is associated with the development of end-organ damage including allograft dysfunction, early cardiomyopathy and premature atherosclerosis. Aggressive treatment of elevated BP is an essential part of Tx care with the goal to delay graft failure and prevent the development of symptomatic cardiovascular disease in young recipients of renal Tx.
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Affiliation(s)
- Mark M Mitsnefes
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229-9039, USA.
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Mitsnefes MM, Kimball TR, Border WL, Witt SA, Glascock BJ, Khoury PR, Daniels SR. Abnormal cardiac function in children after renal transplantation. Am J Kidney Dis 2004; 43:721-6. [PMID: 15042550 DOI: 10.1053/j.ajkd.2003.12.033] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Cardiac hypertrophy frequently is found in children with a renal transplant. In adults with a transplant, left ventricular (LV) mass (LVM) is associated with cardiac dysfunction. However, in children with a transplant, the relationship between LVM and LV function has not been evaluated. METHODS Twenty-nine children who underwent transplantation and 33 controls had echocardiographic evaluations during rest and peak exercise. LV contractility was determined based on the relation between heart rate-corrected velocity of circumferential fiber shortening and end-systolic wall stress. Contractile reserve was assessed by the difference between contractility at rest and peak exercise. Early diastole was assessed using indices of LV relaxation derived from transmitral and tissue Doppler and reported as maximal early (E wave) and late (A wave) wave ratio (E-A ratio) and septal mitral annular velocities (Em). Late diastole was determined using an index of LV compliance (E-Em ratio). RESULTS Compared with controls, children with a transplant had a significantly greater LVM index (P < 0.001) and high prevalence of LV hypertrophy (LVH; 55%). Transplant recipients had increased LV contractility (P < 0.001). Contractile reserve was similar to that of controls. Patients with a transplant had a lower E-A ratio and Em (P < 0.01 for both variables) and higher E-Em ratio (P < 0.001) than controls. In children with a transplant, LVM index was a significant independent predictor for both abnormal LV relaxation (Em; P = 0.03) and abnormal LV compliance (E-Em ratio; P = 0.02). CONCLUSION Results show impaired cardiac structure and diastolic function in pediatric renal allograft recipients. This suggests that LVH may be a risk factor for diastolic dysfunction in these children.
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Affiliation(s)
- Mark M Mitsnefes
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
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El-Husseini AA, Sheashaa HA, Hassan NA, El-Demerdash FM, Sobh MA, Ghoneim MA. Echocardiographic changes and risk factors for left ventricular hypertrophy in children and adolescents after renal transplantation. Pediatr Transplant 2004; 8:249-54. [PMID: 15176962 DOI: 10.1111/j.1399-3046.2004.00159.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Long-term consequences of cardiac alteration in children with chronic renal failure and after renal transplantation are largely unknown. In chronic uremia, cardiomyopathy manifests itself as systolic dysfunction, concentric left ventricular hypertrophy (LVH) or left ventricular dilatation. The correction of uremic state by renal transplantation leads to normalization of left ventricular contractility, regression of LVH and improvement of cavity volume and so dialysis patients with uremic cardiomyopathy would benefit from renal transplantation. We studied 73 patients, aged 17 yr or less, who underwent renal transplantation in our center. This cross-sectional study was performed 4.6 yr (median) after transplantation. Of the total, 48 were males and 25 were females. Transthoracic echocardiographic examination was performed for all cases. The effects of clinical, demographic, biochemical and therapeutic data on echocardiographic parameters were assessed. Multivariate analysis was used to assess the relation between the risk factors and the left ventricular muscle mass index. The most common echocardiographic abnormalities were the LVH (47.9%), left atrial enlargement (31.5%) and left ventricular dilatation and systolic dysfunction (13.7% for each). The pretransplant dialysis, arteriovenous fistula, acute rejection, cumulative steroid dose per square meter surface area, post-transplant hypertension, anemia and graft dysfunction were significant risk factors for LVH by univariate analysis. The significant factors by multivariate analysis were pretransplant dialysis, post-transplant hypertension and anemia. From this study we may conclude that LVH is a common problem among renal transplant children and adolescents. Early transplantation, control of hypertension and correction of anemia may be beneficial regarding left ventricular function and structure.
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Affiliation(s)
- Amr A El-Husseini
- Mansoura Urology and Nephrology Center, Mansoura University, Mansoura, Egypt.
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References. Am J Kidney Dis 2004. [DOI: 10.1053/j.ajkd.2004.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Swinford RD, Portman RJ. Measurement and treatment of elevated blood pressure in the pediatric patient with chronic kidney disease. Adv Chronic Kidney Dis 2004; 11:143-61. [PMID: 15216486 DOI: 10.1053/j.arrt.2004.02.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Hypertension, as in adults, is a frequent complication found in children with chronic kidney disease (CKD). Indeed, hypertension has now become one of the most prevalent chronic diseases of childhood. The most recent data available (2003) indicate that at least 38% of children with CKD in the United States are receiving antihypertensive therapy. Only recently has it been shown in children that hypertension, traditionally considered a marker for disease severity in children, is additionally a significant and independent risk factor for accelerated deterioration of kidney function and progression of CKD and a significant risk factor for cardiovascular disease. The following review outlines the differences and similarities of childhood versus adult hypertension with respect to measurement, diagnosis, treatment, and consequence in CKD. The definition of hypertension changes continually as a child grows with or without CKD. Despite numerous guidelines, the diagnosis of childhood hypertension continues to be based on epidemiologic data rather than evidence. For children, the current definition includes 2 categories: high normal, which is blood pressure (BP) between the 90th and 95th percentile, and hypertensive, which is BP above the 95th percentile. The evaluation of all hypertensive children should include a complete assessment of end-organ damage, including eyes, cardiovascular system (including blood vessels), kidneys, and nervous system. For children with CKD and end-stage renal disease (ESRD), a high percentage have left ventricular hypertrophy (LVH). The finding of end-organ damage or comorbidity (CKD, diabetes) in any child is an absolute indication for immediate pharmacologic therapy, whereas the presence of hypertension above the 95th percentile in children without CKD warrants initial intervention such as life style modification. The guidelines for measurement of BP in children with CKD are similar to those in children without CKD and include casual BP measurement, self-measured BP, and ambulatory BP monitoring. The recommendation for BP measurement in children is, when permitted, by auscultative method with a well-calibrated mercury manometer. Most casual BP measurements are performed with an automated oscillometric device whose validation has not been confirmed in children with CKD. The ambulatory BP monitor (ABPM) has 2 advantages: it significantly correlates with the presence of end-organ damage, and it identifies abnormal BP patterns that are frequently present in CKD patients, such as hypertension during the sleep period. An abnormal ABPM pattern can also be predictive of the development of end-organ damage. Treatment of hypertension in children, with and without CKD, is based on 3 factors: degree of BP elevation, the presence of cardiovascular risk factors, and the presence of end-organ damage. Additionally, the initial antihypertensive agent may be selected on available and age-appropriate formulations (eg, suspension and dosage selection). A physician treating a hypertensive child with CKD faces multiple challenges. They include selecting the convenience of available automated devices and the ABPM versus traditional auscultatory techniques upon which all normative standards have been based. Current research initiatives propose to develop pharmacokinetic and pharmacodynamics properties of antihypertensive medications and to study the effect of early intervention on end-organ damage.
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Affiliation(s)
- Rita D Swinford
- Division of Pediatric Nephrology, University of Texas, Houston, TX, USA
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Affiliation(s)
- Empar Lurbe
- Pediatric Nephrology Unit, Hospital General of Valencia, University of Valencia, Spain
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50
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Covic A, Goldsmith DJA, Gusbeth-Tatomir P, Buhaescu I, Covic M. Successful renal transplantation decreases aortic stiffness and increases vascular reactivity in dialysis patients. Transplantation 2003; 76:1573-7. [PMID: 14702526 DOI: 10.1097/01.tp.0000086343.32903.a8] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients with end-stage renal disease on dialysis have among the highest cardiovascular event rates documented. Abnormal nitric oxide (NO)-dependent endothelial reactivity and increased arterial stiffness are commonly described in hemodialysis (HD) patients. Measures of aortic stiffness--aortic pulse wave velocity (PWV) and augmentation index (AGI)--have been shown to be powerful predictors of survival on hemodialysis. It is not known how these parameters interfere with successful renal transplantation. METHODS PWV and aortic AGI (difference between the first and second systolic peak on the aortic pressure waveform divided by the pulse wave height) were determined from contour analysis of arterial waveforms recorded by applanation tonometry using a SphygmoCor device in 41 HD patients (20 men; age, 41.8 years) and in a control group of 20 patients with essential hypertension (HTA) (10 men; age, 43.6 years). Twenty of the HD patients (10 men; age, 39.7 years) received live-related renal transplants (RTx) and were restudied (3 months after RTx, normal serum creatinine). NO-dependent and NO-independent vascular reactivity were assessed by changes in AGI after challenges with inhaled salbutamol (SAL) and sublingual nitroglycerin (NTG), respectively. RESULTS AGI values were significantly lower in RTx patients compared with subjects on hemodialysis (15.9 +/- 13.9% vs. 27.9 +/- 11.9%, P<0.05), but similar to essential HTA controls (16.5 +/- 17%). Serial AGI measurements showed that successful renal transplantation is associated with a decrease in AGI in all cases, from a mean of 25.1 +/- 7.8% while on dialysis to 15.9 +/- 7.0% 3 months after transplantation (P<0.0001). The responsiveness to both endothelium-dependent stimuli (inhaled SAL) and endothelium-independent stimuli (sublingual NTG) was greater in transplant patients than in hemodialysis patients (SAL-induced decrease in AGI -82.3 +/- 65.7% vs. 45 +/- 72.3%, P<0.01; and NTG-induced decrease in AGI 197 +/- 108 vs. -129.0 +/- 215.5%, P<0.01). PWV values in dialysis patients (7.19 +/- 1.88 m/sec) were significantly higher than those measured in essential HTA patients (6.34 +/- 1.32 m/sec, P<0.05) with normal renal function (despite similar blood pressure levels). PWV after RTx was 6.59 +/- 1.62 m/sec, significantly different from pretransplantation (dialysis) values (P<0.05 for comparison) but similar to the control group of essential HTA patients. CONCLUSIONS Renal transplantation is associated with marked improvements in vascular structure and function to a profile comparable to essential HTA patients.
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Affiliation(s)
- A Covic
- C I Parhon University Hospital, Dialysis and Transplantation Center, Iasi, Romania.
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