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

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

Recent Insights in Noninvasive Diagnostic for the Assessment of Kidney and Cardiovascular Outcome in Kidney Transplant Recipients

Kidney transplantation improves quality of life and prolongs survival of patients with end-stage kidney disease. However, kidney transplant recipients present a higher risk for cardiovascular events compared to the general population. Risk assessment for graft failure as well as cardiovascular events is still based on invasive procedures. Biomarkers in blood and urine, but also new diagnostic approaches like genetic or molecular testing, can be useful tools to monitor graft function and to identify patients of high cardiovascular risk. Many biomarkers have been introduced, whereas most of these biomarkers have not been implemented in clinical routine. Here, we discuss recent developments in biomarkers and diagnostic models in kidney transplant recipients. Because many factors impact graft function and cardiovascular risk, it is most likely that no biomarker will meet the highest demands and standards. We advocate to shift focus to the identification of patients benefitting from molecular and genetic testing as well as from analysis of more specific biomarkers instead of finding one biomarker fitting to all patients.

The role of transcription factor 7-like 2 in metabolic disorders

Transcription factor 7-like 2 (TCF7L2), a member of the T cell factor/lymphoid enhancer factor family, generally forms a complex with β-catenin to regulate the downstream target genes as an effector of the canonical Wnt signalling pathway. TCF7L2 plays a vital role in various biological processes and functions in many organs and tissues, including the liver, islet and adipose tissues. Further, TCF7L2 down-regulates hepatic gluconeogenesis and promotes lipid accumulation. In islets, TCF7L2 not only affects the insulin secretion of the β-cells but also has an impact on other cells. In addition, TCF7L2 influences adipogenesis in adipose tissues. Thus, an out-of-control TCF7L2 expression can result in metabolic disorders. The TCF7L2 gene is composed of 17 exons, generating 13 different transcripts, and has many single-nucleotide polymorphisms (SNPs). The discovery that these SNPs have an impact on the risk of type 2 diabetes (T2D) has attracted thorough investigations in the study of TCF7L2. Apart from T2D, TCF7L2 SNPs are also associated with type 1, posttransplant and other types of diabetes. Furthermore, TCF7L2 variants affect the progression of other disorders, such as obesity, cancers, metabolic syndrome and heart diseases. Finally, the interaction between TCF7L2 variants and diet also needs to be investigated.

Genetic markers associated with long-term cardiovascular outcome in kidney transplant recipients

There is a clear genetic contribution to the risk of cardiovascular diseases, and a composite genetic risk score (GRS) based on 27 single nucleotide polymorphisms (SNPs) was reported to predict risk of cardiovascular events in the general population. We aimed to evaluate this risk score in renal transplant recipients, a population with heightened cardiovascular risk, with a yet unknown genetic contribution. A total of 1640 participants from the ALERT trial (Assessment of Lescol in Renal Transplantation), a study comparing fluvastatin with placebo in stable renal transplant recipients, were genotyped for all SNPs making up the GRS. Risk alleles were weighted by the log of odds ratios reported in genome wide association studies and summed. Associations between GRS and time from study inclusion to first major cardiovascular event (MACE) were analyzed by Cox regression. In analyses adjusted for cardiovascular risk factors, GRS was significantly associated with MACE (hazard ratio [HR] 1.81, P = .006) when comparing genetic high-risk patients (quartile 4) with genetic low-risk participants (quartile 1). A 27-SNP GRS, which predicted cardiovascular events in the nontransplant population, appears to have predictive value also in kidney allograft recipients. Refining the score to better fit the transplant population seems feasible.