Peripheral Artery Disease in CKD: Anatomically Peripheral But Clinically Central

Left Ventricular Reverse Remodeling after Successful Living Donor Kidney Transplantation: The Visualizing the Pathophysiology of Kidney Transplantation in Modern Age Study

Key Points

Kidney transplantation (KT) can improve even advanced left ventricular (LV) geometric patterns, but this effect may be attenuated by pre-KT decreased diastolic function and acute antibody-mediated rejection. Regardless of the pre-KT LV geometric pattern, the postoperative LV geometric pattern tended to shift toward concentric remodeling. Geometric patterns may be an easy-to-understand and useful cardiac function assessment tool for nephrologists.

Background

The effect of kidney transplantation (KT) on left ventricular (LV) remodeling remains poorly understood. The aim of this study was to evaluate the effect of KT on LV reverse remodeling, using echocardiographic LV geometric patterns as a key assessment tool.

Methods

In 100 recipients who underwent living KT between 2012 and 2022, we evaluated changes in the distribution of LV geometric patterns (normal geometry, concentric remodeling [CR], eccentric hypertrophy [EH], and concentric hypertrophy [CH]) between baseline and 1 year after transplantation. These patterns were categorized on the basis of LV mass index and relative wall thickness assessed by echocardiography.

Results

Overall, LV geometric patterns improved or remained stable in 81% of recipients, with worsening in 19%. The proportion of normal geometry increased from 15% to 19% and CR from 30% to 45%, whereas EH decreased markedly from 20% to 3%. CH remained relatively stable at 33% (P = 0.036). Subgroup analysis revealed that 47% of those with pre-KT normal geometry progressed to LV remodeling, whereas 77% with CR remained stable. By contrast, 55% with EH experienced reverse remodeling and 49% with CH also showed reverse remodeling. These subgroup results suggest an interaction between the effect of KT on LV reverse remodeling and pre-KT LV geometric patterns. Multivariable analysis identified E/e′ > 9.5 (odds ratio, 2.01; 95% confidence interval, 1.10 to 3.67; P = 0.024) and acute antibody-mediated rejection (odds ratio, 2.44; 95% confidence interval, 1.01 to 5.87; P = 0.047) as independent predictors of LV remodeling progression.

Conclusions

KT can lead to improvements in even advanced LV geometric patterns, although this effect may be diminished in the presence of pre-KT diastolic dysfunction or the occurrence of acute rejection. Because recipients rarely achieve complete renal recovery, echocardiographic monitoring remains crucial after KT. Future studies are needed to establish whether these observed improvements in LV reverse remodeling directly translate into long-term reductions in cardiovascular events.

Cardiovascular changes in young renal failure patients

Progresses in medical care of severe kidney disease and congenital anomalies of kidney and urinary tract make it possible for a higher percentage of young renal failure patients to survive and enter adulthood. There is thus an increasing need to focus on the long-term effects of severely reduced kidney function early in life. Cardiovascular changes are known to contribute considerably in adulthood to the severe complications of renal failure. In young chronic kidney disease patients, there is limited knowledge of subclinical cardiovascular disease. In this issue of Clinical Kidney Journal, Lalayiannis et al. describe significant structural and functional cardiovascular changes in a young cohort of kidney failure patients with glomerular filtration rate <30 mL/min/1.73 m². Among the 100 patients between 5 and 30 years of age included in the study, 84 presented with signs of cardiovascular disease. There is a need for long-term follow-up data on cardiovascular consequences of renal failure early in life and evaluation of prophylactic and therapeutic measures that can ameliorate the overall prognosis for these patients. We look forward to planned future long-term data from this cohort as well as increased focus in general on cardiovascular changes in young renal failure patients.

Lower Extremity Peripheral Artery Disease: Contemporary Epidemiology, Management Gaps, and Future Directions: A Scientific Statement From the American Heart Association

Lower extremity peripheral artery disease (PAD) affects >230 million adults worldwide and is associated with increased risk of various adverse clinical outcomes (other cardiovascular diseases such as coronary heart disease and stroke and leg outcomes such as amputation). Despite its prevalence and clinical importance, PAD has been historically underappreciated by health care professionals and patients. This underappreciation seems multifactorial (eg, limited availability of the first-line diagnostic test, the ankle-brachial index, in clinics; incorrect perceptions that a leg vascular disease is not fatal and that the diagnosis of PAD would not necessarily change clinical practice). In the past several years, a body of evidence has indicated that these perceptions are incorrect. Several studies have consistently demonstrated that many patients with PAD are not receiving evidence-based therapies. Thus, this scientific statement provides an update for health care professionals regarding contemporary epidemiology (eg, prevalence, temporal trends, risk factors, and complications) of PAD, the present status of diagnosis (physiological tests and imaging modalities), and the major gaps in the management of PAD (eg, medications, exercise therapy, and revascularization). The statement also lists key gaps in research, clinical practice, and implementation related to PAD. Orchestrated efforts among different parties (eg, health care providers, researchers, expert organizations, and health care organizations) will be needed to increase the awareness and understanding of PAD and improve the diagnostic approaches, management, and prognosis of PAD.

The Impact of Chronic Kidney Disease on Peripheral Artery Disease and Peripheral Revascularization

Chronic kidney disease (CKD) is a clinical condition characterized by high morbidity and mortality. Globally, CKD is also increasing in prevalence and incidence. The two principal kidney measures namely estimated glomerular filtration rate (eGFR) and albuminuria have been found to be predictors of renal and cardiovascular (CV) endpoints including peripheral artery disease (PAD). The prevalence of PAD was increased in CKD patients and, particularly, in patients with more severe CKD stages. Despite the fact that revascularization strategies are suitable in CKD patients in similar fashion to non-CKD patients, few CKD patients underwent these procedures. In fact, if it is true that revascularization improves prognosis in PAD patients irrespective of baseline eGFR, it was also demonstrated that CKD patients, who underwent revascularization, were at higher risk for amputations, mortality, re-intervention and perioperative complications. With the present review article, we have examined the association between CKD, PAD and peripheral revascularization highlighting data about epidemiology, pathophysiologic mechanisms, and results from previous observational and intervention studies. We have also examined the future perspectives and challenges of research around the association between CKD and PAD.