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Shroff GR, Benjamin MM, Rangaswami J, Lentine KL. Risk and management of cardiac disease in kidney and liver transplant recipients. Heart 2025:heartjnl-2024-324796. [PMID: 40306758 DOI: 10.1136/heartjnl-2024-324796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2025] [Accepted: 03/31/2025] [Indexed: 05/02/2025] Open
Abstract
Organ transplantation is the treatment of choice for individuals with kidney failure requiring kidney replacement therapy, as well as for those with end-stage liver disease. Despite the significant reduction in long-term morbidity and mortality with transplantation, kidney and liver allograft recipients remain at high risk for cardiovascular disease (CVD) and premature death from cardiovascular causes. This heightened risk is represented across all phenotypes of CVD, including coronary heart disease, heart failure, arrhythmias, valvulopathies and pulmonary hypertension. Pre-existing vascular risk factors for CVD, coupled with superimposed cardiovascular-kidney-metabolic derangements after transplantation, driven at least in part by post-transplant weight gain, immunosuppressive therapies and de novo risk factors such as dyslipidaemia and diabetes, coalesce to increase total CVD risk. In this review, we summarise pathophysiological considerations for both the short- and long-term increase in CVD risk following kidney/liver transplantation. We review the different phenotypes of CVD, with unique considerations for post-transplant care in this patient population. Finally, we highlight the need for awareness about long-term CVD risk and a multidisciplinary approach to managing organ-specific CVD risk in kidney and liver transplant patients.
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Affiliation(s)
- Gautam R Shroff
- Division of Cardiology, Department of Medicine, Hennepin Healthcare and University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Mina M Benjamin
- Division of Cardiology, Department of Internal Medicine, SSM Health Saint Louis University Hospital, St Louis, Missouri, USA
| | - Janani Rangaswami
- Internal Medicine, The George Washington University Hospital, Washington, DC, USA
| | - Krista L Lentine
- Saint Louis University Transplant Center, SSM Health Saint Louis University Hospital, St Louis, Missouri, USA
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Hill MC, Legg K, Ardati A, Groo V. Heart failure medication use and follow-up patterns in renal transplant recipients with reduced ejection fraction: A single-center experience. IJC HEART & VASCULATURE 2024; 55:101535. [PMID: 39483150 PMCID: PMC11525616 DOI: 10.1016/j.ijcha.2024.101535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2024] [Revised: 09/30/2024] [Accepted: 10/10/2024] [Indexed: 11/03/2024]
Abstract
Background The role of medical therapy for heart failure with reduced ejection fraction (HFrEF) in subjects with end-stage renal disease receiving renal transplantation (RT) is understudied. Here, we describe post-RT HFrEF medical management practices at a single urban, academic tertiary care center. Methods RT recipients between January 1, 2015 and November 30, 2020 with history of ejection fraction (EF) <40 % prior to RT were included. Medications, renal function, blood pressure, cardiology follow-up, and echocardiograms ≥90d post-RT were retrospectively collected for 2 years post-RT. Results and conclusions 47/750 (6.3 %) of RT recipients had prior HFrEF diagnosis, of whom 26 experienced improvement in EF prior to RT. Pre-RT medical therapy included beta blocker (BB) in 43 (92 %) of subjects and renin-angiotensin-aldosterone inhibitors (RAASi) in 23 (49 %). By 24 months post-RT, BB were used in 34 (76 %) and RAASi were used in 12 (27 %) of subjects. Rates of post-RT cardiology follow-up (51 %) and echocardiogram (38 %) were lower than expected in this cohort. Of 29 subjects potentially eligible for RAASi based on preserved renal function and no hyperkalemia or hypotension episodes during follow-up, only 6 (21 %) received RAASi. Of 6 subjects with post-RT EF <50 %, 4 were eligible but did not receive RAASi. Multidisciplinary collaboration between cardiology and transplant teams may help improve care for this high-risk patient population.
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Affiliation(s)
- Michael C. Hill
- Division of Cardiology, Department of Medicine, University of Illinois Chicago College of Medicine, Chicago, IL, USA
| | - Kaitlyn Legg
- Department of Pharmacy, University of Maryland Medical Center, USA
| | - Amer Ardati
- Division of Cardiology, Department of Medicine, University of Illinois Chicago College of Medicine, Chicago, IL, USA
| | - Vicki Groo
- Department of Pharmacy Practice, University of Illinois Chicago Retzky College of Pharmacy, Chicago, IL, USA
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Lentine KL, Miyata KN, Lam NN, Joseph C, McAdams-DeMarco M, Bae S, Chen Y, Caliskan Y, Sarabu N, Dhindsa S, Xiao H, Segev DL, Axelrod DA, Schnitzler MA. Sociodemographic disparities in sodium-glucose cotransporter-2 inhibitor use among US kidney transplant recipients: An observational study of real-world pharmacy records. Clin Transplant 2024; 38:e15257. [PMID: 38563475 DOI: 10.1111/ctr.15257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 01/19/2024] [Accepted: 01/23/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Recent clinical trials demonstrate benefits of sodium-glucose cotransporter-2 inhibitors (SGLT2i) in patients with chronic kidney disease, but data on use in kidney transplant (KTx) recipients are limited. METHODS We examined a novel database linking SRTR registry data for KTx recipients (2000-2021) with outpatient fill records from a large pharmaceutical claims warehouse (2015-2021). Adult (≥18 years) KTx recipients treated with SGLT2i were compared to those who received other noninsulin diabetes medications without SGLT2i. Characteristics associated with SGLT2i use were quantified by multivariable logistic regression (adjusted odds ratio, 95%LCLaOR95%UCL). RESULTS Among 18 988 KTx recipients treated with noninsulin diabetes agents in the study period, 2224 filled an SGLT2i. Mean time from KTx to prescription was 6.7 years for SGLT2i versus 4.7 years for non-SGLT2i medications. SGLT2i use was more common in Asian adults (aOR, 1.091.311.58) and those aged > 30-59 years (compared with 18-30 years) or with BMI > 35 kg/m2 (aOR, 1.191.411.67), and trended higher with self-pay status. SGLT2i use was lower among KTx recipients who were women (aOR, .79.87.96), Black (aOR, .77.881.00) and other (aOR, .52.751.07) race, publicly insured (aOR, .82.921.03), or with less than college education (aOR, .78.87.96), and trended lower in those age 75 years and older. SGLT2i use in KTx patients increased dramatically in 2019-2021 (aOR, 5.015.636.33 vs. prior years). CONCLUSION SGLT2i use is increasing in KTx recipients but varies with factors including race, education, and insurance. While ongoing study is needed to define risks and benefits of SGLT2i use in KTx patients, attention should also focus on reducing treatment disparities related to sociodemographic traits.
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Affiliation(s)
- Krista L Lentine
- Saint Louis University Transplant Center, SSM Health Saint Louis University Hospital, Saint Louis, Missouri, USA
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | - Kana N Miyata
- Saint Louis University Transplant Center, SSM Health Saint Louis University Hospital, Saint Louis, Missouri, USA
| | - Ngan N Lam
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Corey Joseph
- Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Sunjae Bae
- New York University, New York, New York, USA
| | - Yusi Chen
- New York University, New York, New York, USA
| | - Yasar Caliskan
- Saint Louis University Transplant Center, SSM Health Saint Louis University Hospital, Saint Louis, Missouri, USA
| | | | - Sandeep Dhindsa
- Saint Louis University Transplant Center, SSM Health Saint Louis University Hospital, Saint Louis, Missouri, USA
| | - Huiling Xiao
- Saint Louis University Transplant Center, SSM Health Saint Louis University Hospital, Saint Louis, Missouri, USA
| | - Dorry L Segev
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
- New York University, New York, New York, USA
| | - David A Axelrod
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
- University of Iowa, Iowa City, Iowa, USA
| | - Mark A Schnitzler
- Saint Louis University Transplant Center, SSM Health Saint Louis University Hospital, Saint Louis, Missouri, USA
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
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Update on Treatment of Hypertension After Renal Transplantation. Curr Hypertens Rep 2021; 23:25. [PMID: 33961145 DOI: 10.1007/s11906-021-01151-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE OF REVIEW To incorporate novel findings on pathophysiology and treatment of posttransplant hypertension. RECENT FINDINGS (1) The sodium retaining effects of CNIs are mediated by stimulation of the thiazide-sensitive sodium chloride co-transporter in the distal convoluted tubule and in this regard chlorthalidone was proven to be an effective antihypertensive drug in renal transplantation. (2) Local and not systemic activation of the renin-angiotensin-aldosterone system plays a crucial role in the pathogenesis of posttransplant hypertension. (3) Recent randomized controlled trials failed to prove the presumed superiority of renin-angiotensin blockers in kidney transplantation. (4) Steroid-free and mammalian target of rapamycin-based immunosuppressive drug combinations did not show favorable effects on blood pressure control. (5) In a recent report the risk of non-melanoma skin cancer was higher with thiazide diuretics. But the increased cancer risk in transplant recipients is mainly attributed to comorbidities, such as diabetes and hypertension and of course to the transplantation condition itself or the obligatory application of immunosuppression, and has little to do with the antihypertensive medication Actual recommendations about BP targets in adult renal transplant recipients are coming from a post hoc analysis of a large randomized trial with another primary endpoint. Unless convincing studies on treatment of hypertension after renal transplantation are available, the ESC/ESH Guidelines 2018 should apply for these patients.
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