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Balafa O, Fernandez-Fernandez B, Ortiz A, Dounousi E, Ekart R, Ferro CJ, Mark PB, Valdivielso JM, Del Vecchio L, Mallamaci F. Sex disparities in mortality and cardiovascular outcomes in chronic kidney disease. Clin Kidney J 2024; 17:sfae044. [PMID: 38638550 PMCID: PMC11024840 DOI: 10.1093/ckj/sfae044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Indexed: 04/20/2024] Open
Abstract
Sex (biologically determined) and gender (socially constructed) modulate manifestations and prognosis of a vast number of diseases, including cardiovascular disease (CVD) and chronic kidney disease (CKD). CVD remains the leading cause of death in CKD patients. Population-based studies indicate that women present a higher prevalence of CKD and experience less CVD than men in all CKD stages, although this is not as clear in patients on dialysis or transplantation. When compared to the general population of the same sex, CKD has a more negative impact on women on kidney replacement therapy. European women on dialysis or recipients of kidney transplants have life expectancy up to 44.8 and 19.8 years lower, respectively, than their counterparts of similar age in the general population. For men, these figures stand at 37.1 and 16.5 years, representing a 21% to 20% difference, respectively. Hormonal, genetic, societal, and cultural influences may contribute to these sex-based disparities. To gain a more comprehensive understanding of these differences and their implications for patient care, well-designed clinical trials that involve a larger representation of women and focus on sex-related variables are urgently needed. This narrative review emphasizes the importance of acknowledging the epidemiology and prognosis of sex disparities in CVD among CKD patients. Such insights can guide research into the underlying pathophysiological mechanisms, leading to optimized treatment strategies and ultimately, improved clinical outcomes.
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Affiliation(s)
- Olga Balafa
- Department of Nephrology, University Hospital of Ioannina, Ioannina, Greece
| | | | - Alberto Ortiz
- Department of Nephrology and Hypertension, IIS-Fundacion Jimenez Diaz UAM, Madrid, Spain
| | - Evangelia Dounousi
- Nephrology Dept, Faculty of Medicine, University of Ioannina and University Hospital of Ioannina. Ioannina, Greece
| | - Robert Ekart
- Department of Dialysis, Clinic for Internal Medicine, Faculty of Medicine, University Medical Centre Maribor, Maribor, Slovenia
| | - Charles J Ferro
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Patrick B Mark
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Jose M Valdivielso
- Vascular and Renal Traslational Research Group, UDETMA, Biomedical Research Institute of Lleida, IRBLleida, Lleida, Spain
| | - Lucia Del Vecchio
- Department of Nephrology and Dialysis, Sant'Anna Hospital, ASST Lariana, Como, Italy
| | - Francesca Mallamaci
- Department of Nephrology, Dialysis, and Transplantation Azienda Ospedaliera ‘Bianchi-Melacrino-Morelli’ & CNR-IFC, Reggio Calabria, Italy
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2
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Otunla AA, Shanmugarajah K, Davies AH, Lucia Madariaga M, Shalhoub J. The Biological Parallels Between Atherosclerosis and Cardiac Allograft Vasculopathy: Implications for Solid Organ Chronic Rejection. Cardiol Rev 2024; 32:2-11. [PMID: 38051983 DOI: 10.1097/crd.0000000000000437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Atherosclerosis and solid organ chronic rejection are pervasive chronic disease states that account for significant morbidity and mortality in developed countries. Recently, a series of shared molecular pathways have emerged, revealing biological parallels from early stages of development up to the advanced forms of pathology. These shared mechanistic processes are inflammatory in nature, reflecting the importance of inflammation in both disorders. Vascular inflammation triggers endothelial dysfunction and disease initiation through aberrant vasomotor control and shared patterns of endothelial activation. Endothelial dysfunction leads to the recruitment of immune cells and the perpetuation of the inflammatory response. This drives lesion formation through the release of key cytokines such as IFN-y, TNF-alpha, and IL-2. Continued interplay between the adaptive and innate immune response (represented by T lymphocytes and macrophages, respectively) promotes lesion instability and thrombotic complications; hallmarks of advanced disease in both atherosclerosis and solid organ chronic rejection. The aim of this study is to identify areas of overlap between atherosclerosis and chronic rejection. We then discuss new approaches to improve current understanding of the pathophysiology of both disorders, and eventually design novel therapeutics.
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Affiliation(s)
- Afolarin A Otunla
- From the Medical Sciences Division, University of Oxford, Oxford, United Kingdom
| | | | - Alun H Davies
- Section of Vascular Surgery, Department of Surgery & Cancer, Imperial College London, London, United Kingdom
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, United Kingdom
| | | | - Joseph Shalhoub
- Section of Vascular Surgery, Department of Surgery & Cancer, Imperial College London, London, United Kingdom
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, United Kingdom
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3
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Nguyen BN, Mital S, Bugden S, Nguyen HV. Cost-effectiveness of canagliflozin and dapagliflozin for treatment of patients with chronic kidney disease and type 2 diabetes. Diabetes Obes Metab 2023; 25:3030-3039. [PMID: 37409571 DOI: 10.1111/dom.15201] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 06/14/2023] [Accepted: 06/16/2023] [Indexed: 07/07/2023]
Abstract
AIM To examine the cost-effectiveness of adding canagliflozin or dapagliflozin to standard of care (SoC) versus SoC alone in patients with chronic kidney disease (CKD) and type 2 diabetes (T2D). MATERIALS AND METHODS We used a Markov microsimulation model to assess the cost-effectiveness of canagliflozin plus SoC (canagliflozin + SoC), dapagliflozin plus SoC (dapagliflozin + SoC) and SoC alone. Analyses were conducted from a healthcare system perspective. Costs were measured in 2021 Canadian dollars (C$), and effectiveness was measured in quality-adjusted life-years (QALYs). RESULTS Over a patient's lifetime, canagliflozin + SoC and dapagliflozin + SoC yielded cost savings of C$33 460 and C$26 764 and generated 1.38 and 1.44 additional QALYs compared with SoC alone, respectively. While QALY gains with dapagliflozin + SoC were higher than those with canagliflozin + SoC, this strategy was also more costly with the incremental cost-effectiveness ratio exceeding the willingness to pay threshold of C$50 000 per QALY. Dapagliflozin + SoC, however, generated cost savings and QALY gains compared with canagliflozin + SoC over shorter time horizons of 5 or 10 years. CONCLUSIONS Dapagliflozin + SoC was not cost-effective versus canagliflozin + SoC in patients with CKD and T2D over the lifetime horizon. However, adding canagliflozin or dapagliflozin to SoC was less costly and more effective relative to SoC alone for treatment of CKD and T2D.
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Affiliation(s)
- Bao-Ngoc Nguyen
- School of Pharmacy, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Shweta Mital
- College of Pharmacy, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Shawn Bugden
- School of Pharmacy, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Hai V Nguyen
- School of Pharmacy, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
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Kim JE, Park J, Park S, Yu MY, Baek SH, Park SH, Han K, Kim YC, Kim DK, Oh KH, Joo KW, Kim YS, Lee H. De novo major cardiovascular events in kidney transplant recipients: a comparative matched cohort study. Nephrol Dial Transplant 2023; 38:499-506. [PMID: 35396847 DOI: 10.1093/ndt/gfac144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Although cardiovascular disease is known to be one of the leading causes of death after kidney transplantation (KT), evidence on the risk difference of de novo major adverse cardiovascular events (MACEs) in kidney transplant recipients (KTRs) compared with that in dialysis patients or the general population (GP) remains rare. METHODS We identified KTRs using the nationwide health insurance database in South Korea and then 1:1 matched them with the dialysis and GP controls without a pre-existing MACE. The primary endpoint was defined as de novo MACEs consisting of myocardial infarction, coronary revascularization and ischemic stroke. The secondary endpoints were all-cause mortality and death-censored graft failure (DCGF) in KTRs. RESULTS We included 4156 individuals in each of the three groups and followed them up for 4.7 years. De novo MACEs occurred in 3.7, 21.7 and 2.5 individuals per 1000 person-years in the KTRs, dialysis controls and GP controls, respectively. KTRs showed a lower MACE risk {adjusted hazard ratio (aHR) 0.16 [95% confidence interval (CI) 0.12-0.20], P < .001} than dialysis controls, whereas a similar MACE risk to GP controls [aHR 0.81 (95% CI 0.52-1.27), P = .365]. In addition, KTRs showed a similar MACE risk compared with the GP group, regardless of age, sex and the presence of comorbidities, including hypertension, diabetes and dyslipidemia. Among KTRs, de novo MACEs were associated with an increased risk of all-cause mortality, but not with DCGF. CONCLUSIONS De novo MACEs in KTRs were much lower than that in dialysis patients and had a similar risk to the GP, but once it occurred it caused elevated mortality risk in KTRs.
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Affiliation(s)
- Ji Eun Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Internal Medicine, Korea University Guro Hospital, Seoul, Republic of Korea
| | - Jina Park
- Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sehoon Park
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Mi-Yeon Yu
- Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Republic of Korea
| | - Seon Ha Baek
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Republic of Korea
| | - Sang Hyun Park
- Department of Biostatistics, College of Medicine, Catholic University of Korea, Seoul, Republic of Korea
| | - Kyungdo Han
- Department of Statistics and Actuarial Science, Soongsil University, Seoul, Republic of Korea
| | - Yong Chul Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Dong Ki Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.,Kidney Research Institute, Seoul National University, Seoul, Republic of Korea
| | - Kook-Hwan Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kwon Wook Joo
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.,Kidney Research Institute, Seoul National University, Seoul, Republic of Korea
| | - Yon Su Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.,Kidney Research Institute, Seoul National University, Seoul, Republic of Korea
| | - Hajeong Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
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Anderson B, Qasim M, Evison F, Gallier S, Townend JN, Ferro CJ, Sharif A. A population cohort analysis of English transplant centers indicates major adverse cardiovascular events after kidney transplantation. Kidney Int 2022; 102:876-884. [PMID: 35716956 DOI: 10.1016/j.kint.2022.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 04/27/2022] [Accepted: 05/09/2022] [Indexed: 11/16/2022]
Abstract
Major adverse cardiovascular event (MACE) rates immediately after kidney transplantation remain uncertain due to heterogeneous reporting in the literature. To clarify this, we retrospectively studied every eligible kidney transplant procedure performed in England between April 1, 2002 and March 31. 2018 with follow-up through August 31, 2019. The primary outcome of interest was MACE broadly defined as any hospital admission with myocardial infarction, stroke, unstable angina, heart failure, any coronary revascularisation procedure and/or any cardiovascular death. Among 30,325 kidney transplant recipients, MACE occurred in 781 within the first year after transplantation (2.6% of all kidney transplant procedures). Of these 781 events, 201 occurred during the index admission for kidney transplantation surgery representing 25.7% of all first-year MACE and 0.7% of all kidney transplant procedures. Kidney transplant recipients who suffered a non-fatal MACE within the first year had significantly decreased 1-, 3-, 5- and 10-year patient survival of 80.5%, 70.2%, 59.5% and 38.6% respectively, compared to 97.4%, 94.4%, 90.7% and 78.4% for kidney transplant recipients not developing MACE.. In an adjusted Cox proportional hazard model, non-fatal MACE within the first-year post-transplant was associated with significant long-term mortality risk (hazard ratio 2.59; 95% confidence interval 2.34-2.88). Kidney transplant recipients experiencing MACE during the index admission compared to subsequent admissions were differentiated by age, sex and previous cardiac history but had similar patient survival. These rates are significantly lower than those reported in North America. Thus, our data confirms MACE is not a benign post-transplant event and has a strong association with long-term mortality risk.
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Affiliation(s)
- Benjamin Anderson
- Department of Nephrology and Transplantation, Queen Elizabeth Hospital, Birmingham, UK
| | - Muhammad Qasim
- Department of Nephrology and Transplantation, Queen Elizabeth Hospital, Birmingham, UK
| | - Felicity Evison
- Department of Health Informatics, Queen Elizabeth Hospital, Birmingham, UK
| | - Suzy Gallier
- Department of Health Informatics, Queen Elizabeth Hospital, Birmingham, UK
| | - Jonathan N Townend
- Department of Cardiology, University Hospitals Birmingham, UK; Institute of Cardiovascular Sciences, University of Birmingham, UK
| | - Charles J Ferro
- Department of Nephrology and Transplantation, Queen Elizabeth Hospital, Birmingham, UK; Institute of Cardiovascular Sciences, University of Birmingham, UK
| | - Adnan Sharif
- Department of Nephrology and Transplantation, Queen Elizabeth Hospital, Birmingham, UK; Institute of Immunology and Immunotherapy, University of Birmingham, UK.
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Chen HH, Chern YB, Hsu CY, Tang PL, Lai CC. Kidney transplantation waiting times and risk of cardiovascular events and mortality: a retrospective observational cohort study in Taiwan. BMJ Open 2022; 12:e058033. [PMID: 35613763 PMCID: PMC9131177 DOI: 10.1136/bmjopen-2021-058033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Patients with end-stage renal disease (ESRD) are at a high risk of cardiovascular events (CVEs), and kidney transplantation (KT) has been reported to improve risk of CVEs and survival. As the association of KT timing on long-term survival and clinical outcomes remains unclear, we investigated the association of different KT waiting times with clinical outcomes. DESIGN Retrospective observational cohort study. SETTING We conducted an observational cohort study using data from the National Health Insurance Research Database in Taiwan. Adult patients who initiated KT therapy from 1997 to 2013 were included. PARTICIPANTS A total of 3562 adult patients who initiated uncomplicated KT therapy were included and categorised into four groups according to KT waiting times after ESRD: group 1 (<1 year), group 2 (1-3 years), group 3 (3-6 years) and group 4 (>6 years). PRIMARY OUTCOME MEASURES The main outcomes were composite of all-cause death, non-fatal myocardial infarction or non-fatal stroke, based on the primary diagnosis in medical records during hospitalisation. RESULTS Compared with group 1, the adjusted risk of primary outcome events (all-cause death, non-fatal myocardial infarction or non-fatal stroke) increased by 1.67 times in group 2 (95% CI: 1.40 to 2.00; p<0.001), 2.17 times in group 3 (95% CI: 1.73 to 2.71; p<0.001) and 3.10 times in group 4 (95% CI: 2.21 to 4.35; p<0.001). The rates of primary outcome events were 6.7%, 13.4% and 14.0% within 5 years, increasing to 19.5%, 26.3% and 30.8% within 10 years in groups 1, 2 and 3, respectively. CONCLUSIONS Our results demonstrate that early KT is associated with superior long-term cardiovascular outcomes compared with late KT in selected patients with ESRD receiving uncomplicated KT, suggesting that an early KT could be a better treatment option for patients with ESRD who are eligible for transplantation.
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Affiliation(s)
- Hsin-Hung Chen
- Department of Medical Education and Research, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Yahn-Bor Chern
- Division of Nephrology, Department of Medicine, E-DA Hospital, Kaohsiung, Taiwan
- School of medicine, College of medicine, I-Shou University, Kaohsiung, Taiwan
| | - Chih-Yang Hsu
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Pei-Ling Tang
- Research Center of Medical Informatics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- College of Nursing, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chi-Cheng Lai
- Department of Cardiology, Kaohsiung Municipal United Hospital, Kaohsiung, Taiwan
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Mir T, Uddin M, Shah A, Khan MZ, Sheikh M, Rab T. ST elevation myocardial infarction and kidney transplant: A large cohort study: STEMI and renal transplant. J Cardiol 2021; 79:270-276. [PMID: 34565688 DOI: 10.1016/j.jjcc.2021.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 08/30/2021] [Accepted: 08/31/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND The literature on outcomes of ST-elevation myocardial infarction (STEMI) amongst kidney transplant recipients (KTR) is limited. OBJECTIVE To study the outcomes of STEMI among KTR. METHODS Data from the national readmissions database (NRD) sample that constitutes 49.1% of the stratified sample of all hospitals in the USA were analyzed for hospitalizations with STEMI among KTR for the years 2012-2018. Complications associated with STEMI were extracted using International Classification of Diseases codes. RESULTS A total of 588,668 index KTR hospitalizations (mean age 57.67±14.22 years; female 44.5%) of which 3,496 (0.59%) had STEMI were recorded in the NRD for the years 2012-2018. A total of 11,676 (1.98%) patients died during the hospitalization. In-hospital mortality among STEMI was higher, 465 (13.3%), than without-STEMI 11,211 (1.92%). Among the complications, mechanical complications occurred among 1.0% vs 0.02%, cardiogenic shock 10.6 vs 0.3%, ventricular arrythmias 8.3% vs 0.8%, conduction block 6.9% vs 2%, stroke 4.1% vs 1.9%, and acute kidney injury 31.6% vs 28.3% among STEMI and without-STEMI respectively. Among coronary procedures, coronary angiography was performed among 1,999 (57.2%) of which 1,777 (50.8%) had percutaneous coronary intervention (PCI). On coarsened exact matching of baseline characteristics, PCI was less likely associated with mortality, odds ratio 0.39 (95% confidence interval 0.24-0.64; p=0.0002). The trends of mortality among STEMI were steady (p-trend 0.11). PCI trend increased (p-trend 0.008) and incidence of STEMI decreased over the study years 2012 (0.66%)-2018(0.474%). A total of 84,810 (14.4%) patients were readmitted in 30 days of which 696 (20%) patients were among the STEMI subgroup. CONCLUSION STEMI is not an uncommon complication among KTR and is associated with significant mechanical complications. Improvement in cardiovascular risk factors might improve the STEMI rates among KTR.
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Affiliation(s)
- Tanveer Mir
- Internal Medicine, Detroit Medical Center Wayne State University, Detroit, MI, United States.
| | - Mohammed Uddin
- Internal Medicine, Detroit Medical Center Wayne State University, Detroit, MI, United States
| | - Asif Shah
- Internal Medicine, Redmond Regional Medical Center, Rome, GA, United States
| | - Mohammad Zia Khan
- Division of Cardiology, University of Virginia, Morgantown, WV, United States
| | - Mujeeb Sheikh
- Division of Cardiology, Promedica Toledo, Toledo, OH, United States
| | - Tanveer Rab
- Division of Cardiology, Emory University, Atlanta, GA, United States
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8
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Dehom S, Knutsen S, Bahjri K, Shavlik D, Oda K, Ali H, Pompe L, Spencer-Hwang R. Racial Difference in the Association of Long-Term Exposure to Fine Particulate Matter (PM 2.5) and Cardiovascular Disease Mortality among Renal Transplant Recipients. Int J Environ Res Public Health 2021; 18:4297. [PMID: 33919563 PMCID: PMC8073484 DOI: 10.3390/ijerph18084297] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 04/11/2021] [Accepted: 04/13/2021] [Indexed: 11/16/2022]
Abstract
Ambient air pollutants are known risk factors for cardiovascular disease (CVD) morbidity and mortality with significant racial disparities. However, few studies have explored racial differences among highly susceptible subpopulations, such as renal transplant recipients (RTRs). Despite improvements in quality of life after transplantation, CVD remains the major cause of mortality, especially among Black recipients. This study aimed to evaluate potential racial differences in the association between long-term levels of PM2.5 and the risk of all-cause, total CVD, and coronary heart disease (CHD) mortality among RTRs. This retrospective study consists of 93,857 non-smoking adults who received a renal transplant between 2001 and 2015. Time-dependent Cox regression was used to assess the association between annual concentrations of PM2.5 and mortality risk. In the multivariable-adjusted models, a 10 μg/m3 increase in ambient PM2.5 levels found increased risk of all-cause (HR = 3.45, 95% CI: 3.08-3.78), CVD (HR = 2.38, 95% CI: 1.94-2.92), and CHD mortality (HR = 3.10, 95% CI: 1.96-4.90). Black recipients had higher risks of all-cause (HR = 4.09, 95% CI: 3.43-4.88) and CHD mortality (HR = 6.73, 95% CI: 2.96-15.32). High levels of ambient PM2.5 were associated with all-cause, CVD, and CHD mortality. The association tended to be higher among Black recipients than non-Blacks.
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Affiliation(s)
- Salem Dehom
- School of Public Health, Loma Linda University, 24951 Circle Drive, Loma Linda, CA 92354, USA; (S.K.); (K.B.); (D.S.); (K.O.); (L.P.); (R.S.-H.)
- School of Nursing, Loma Linda University, 11262 Campus Street, Loma Linda, CA 92350, USA
| | - Synnove Knutsen
- School of Public Health, Loma Linda University, 24951 Circle Drive, Loma Linda, CA 92354, USA; (S.K.); (K.B.); (D.S.); (K.O.); (L.P.); (R.S.-H.)
| | - Khaled Bahjri
- School of Public Health, Loma Linda University, 24951 Circle Drive, Loma Linda, CA 92354, USA; (S.K.); (K.B.); (D.S.); (K.O.); (L.P.); (R.S.-H.)
- School of Pharmacy, Loma Linda University, 24745 Stewart Street, Loma Linda, CA 92350, USA
| | - David Shavlik
- School of Public Health, Loma Linda University, 24951 Circle Drive, Loma Linda, CA 92354, USA; (S.K.); (K.B.); (D.S.); (K.O.); (L.P.); (R.S.-H.)
| | - Keiji Oda
- School of Public Health, Loma Linda University, 24951 Circle Drive, Loma Linda, CA 92354, USA; (S.K.); (K.B.); (D.S.); (K.O.); (L.P.); (R.S.-H.)
| | - Hatem Ali
- Redlands Community Hospital, 305 Terracina Blvd, Redlands, CA 92350, USA;
| | - Lance Pompe
- School of Public Health, Loma Linda University, 24951 Circle Drive, Loma Linda, CA 92354, USA; (S.K.); (K.B.); (D.S.); (K.O.); (L.P.); (R.S.-H.)
| | - Rhonda Spencer-Hwang
- School of Public Health, Loma Linda University, 24951 Circle Drive, Loma Linda, CA 92354, USA; (S.K.); (K.B.); (D.S.); (K.O.); (L.P.); (R.S.-H.)
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9
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Nimmo A, Forsyth JL, Oniscu GC, Robb M, Watson C, Fotheringham J, Roderick PJ, Ravanan R, Taylor DM. A propensity score-matched analysis indicates screening for asymptomatic coronary artery disease does not predict cardiac events in kidney transplant recipients. Kidney Int 2021; 99:431-42. [PMID: 33171171 DOI: 10.1016/j.kint.2020.10.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 09/09/2020] [Accepted: 10/02/2020] [Indexed: 12/14/2022]
Abstract
Screening for asymptomatic coronary artery disease prior to kidney transplantation aims to reduce peri- and post-operative cardiac events. It is uncertain if this is achieved. Here, we investigated whether pre-transplant screening with a stress test or coronary angiogram associated with any difference in major adverse cardiac events (MACE) up to five years post-transplantation. We examined a national prospective cohort recruited to the Access to Transplant and Transplant Outcome Measures study who received a kidney transplant between 2011-2017, and linked patient demographics and details of cardiac screening investigations to outcome data extracted from the Hospital Episode Statistics dataset and United Kingdom Renal Registry. Propensity score matched groups were analyzed using Kaplan-Meier and Cox survival analyses. Overall, 2572 individuals were transplanted in 18 centers; 51% underwent screening and the proportion undergoing screening by center ranged from 5-100%. The incidence of MACE at 90 days, one and five years was 0.9%, 2.1% and 9.4% respectively. After propensity score matching based on the presence or absence of screening, 1760 individuals were examined (880 each in screened and unscreened groups). There was no statistically significant association between screening and MACE at 90 days (hazard ratio 0.80, 95% Confidence Interval 0.31-2.05), one year (1.12, 0.51-2.47) or five years (1.31, 0.86-1.99). Age, male sex and history of ischemic heart disease were associated with MACE. Thus, there is no association between screening for asymptomatic coronary artery disease and MACE up to five years post-transplant. Practices involving unselected screening of transplant recipients should be reviewed.
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10
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Didier R, Yao H, Legendre M, Halimi JM, Rebibou JM, Herbert J, Zeller M, Fauchier L, Cottin Y. Myocardial Infarction after Kidney Transplantation: A Risk and Specific Profile Analysis from a Nationwide French Medical Information Database. J Clin Med 2020; 9:jcm9103356. [PMID: 33086719 PMCID: PMC7589663 DOI: 10.3390/jcm9103356] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 10/12/2020] [Accepted: 10/16/2020] [Indexed: 12/19/2022] Open
Abstract
Introduction: Renal transplant recipients have a high peri-operative risk for cardiovascular events. The post-transplantation period also carries a risk of myocardial infarction (MI). Coronary artery disease (CAD) is a leading cause of death in these patients. We aimed to assess the risk of MI, the specific morbidity profile of MI after transplantation as well as the long-term prognosis after MI in renal transplantation (RT) patients regarding cardiovascular (CV) death and all-cause death. Methods: From a French national medical information database, all of the patients seen in French hospitals in 2013 with at least 5-years follow-up were retrospectively identified and patients without transplantation but with previous dialysis at baseline were excluded. There were 17,526 patients with RT and 3,288,857 with no RT. Results: Among these patients, 1020 in the RT group (5.8%), and 93,320 in the non-RT group (2.8%) suffered acute MI during a median follow-up of 5.4 years. After multivariable adjustment, risk of MI was higher in RT patients than in non-RT patients (HR 1.45, IC 95% 1.35–1.55). The mean age was 59.5 years for transplant patients with MI, and 70.6 years for the reference population with MI (p < 0.0001). MI patients with RT (vs. non RT patients) were more likely to have hypertension, diabetes dyslipidemia, and peripheral artery disease (76.0% vs. 48.1%, 38.7% vs. 25.2%, 33.2% vs. 23.2%, and 31.2% vs. 17.3%, respectively, p < 0.0001). Incidence of non ST-elevation MI (NSTEMI) was higher in RT patients while incidence of ST-elevation MI (STEMI) was higher in patients without RT. In unadjusted analysis, risk of all-cause death and CV death within the first month after MI were higher in patients without RT (18% vs. 11.1% p < 0.0001 and 12.3% vs. 7.8%, p < 0.0001, respectively). However, multivariable analysis indicated that risk of all-cause death was higher in patients with RT than in those with no RT (adjusted HR 1.15 IC 95% 1.03–1.28). Conclusions: MI is not an uncommon complication after RT (incidence of around 5.8% after 5 years). RT is independently associated with a 45% higher risk of MI than in patients without RT, with a predominance of NSTEMI. MI in patients with RT is independently associated with a 15% higher risk of all-cause death than that in patients with MI and no RT.
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Affiliation(s)
- Romain Didier
- Department of Cardiology, University Teaching Hospital Burgundy, 21000 Dijon, France; (R.D.); (H.Y.)
| | - Hermann Yao
- Department of Cardiology, University Teaching Hospital Burgundy, 21000 Dijon, France; (R.D.); (H.Y.)
| | - Mathieu Legendre
- Department of Nephrology, University Teaching Hospital Burgundy, 21000 Dijon, France; (M.L.); (J.M.R.)
| | - Jean Michel Halimi
- Department of Nephrology, University Teaching Hospital of Trousseau and University François Rabelais University, 37000 Tours, France;
| | - Jean Michel Rebibou
- Department of Nephrology, University Teaching Hospital Burgundy, 21000 Dijon, France; (M.L.); (J.M.R.)
| | - Julien Herbert
- Department of Cardiology, University Teaching Hospital of Trousseau and EA7505, University François Rabelais University, 37000 Tours, France; (J.H.); (L.F.)
- Department of Informatics and Epidemiology, University Teaching Hospital of Trousseau and EA7505, University François Rabelais University, 37000 Tours, France
| | - Marianne Zeller
- PEC2 Research Team, EA 7460, Department of Health Sciences, University of Burgundy Franche Comté, 25000 Besançon, France;
| | - Laurent Fauchier
- Department of Cardiology, University Teaching Hospital of Trousseau and EA7505, University François Rabelais University, 37000 Tours, France; (J.H.); (L.F.)
| | - Yves Cottin
- Department of Cardiology, University Teaching Hospital Burgundy, 21000 Dijon, France; (R.D.); (H.Y.)
- Correspondence: ; Tel.: +33-380-293-536; Fax: +33-329-3879
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11
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Goyal A, Lo KB, Chatterjee K, Mathew RO, McCullough PA, Bangalore S, Rangaswami J. Acute coronary syndromes in the peri‐operative period after kidney transplantation in United States. Clin Transplant 2020; 34:e14083. [DOI: 10.1111/ctr.14083] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 08/07/2020] [Accepted: 09/03/2020] [Indexed: 12/21/2022]
Affiliation(s)
- Abhinav Goyal
- Department of Digestive Diseases and Transplantation Einstein Medical Center Philadelphia PA USA
| | - Kevin Bryan Lo
- Department of Internal Medicine Einstein Medical Center Philadelphia PA USA
| | | | - Roy O. Mathew
- Division of Nephrology Columbia VA Health Care System Columbia SC USA
| | - Peter A. McCullough
- Baylor University Medical Center Dallas TX USA
- Baylor Jack and Jane Hamilton Heart and Vascular Hospital Baylor Heart and Vascular Institute Dallas TX USA
| | | | - Janani Rangaswami
- Division of Nephrology Department of Medicine Einstein Medical Center Philadelphia PA USA
- Sidney Kimmel College of Thomas Jefferson University Philadelphia PA USA
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12
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Soliman K, Fülöp T, Rohan V, Argula R. More on the debate of ligating arteriovenous fistula in kidney transplant recipients. J Vasc Surg 2020; 70:1727-1728. [PMID: 31653390 DOI: 10.1016/j.jvs.2019.06.209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Accepted: 06/30/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Karim Soliman
- Division of Nephrology, Department of Medicine, Medical University of South Carolina, Charleston, SC; Division of Nephrology, Department of Medicine, Cairo University, Cairo, Egypt
| | - Tibor Fülöp
- Division of Nephrology, Department of Medicine, Medical University of South Carolina, Charleston, SC; Medicine Service, Ralph H. Johnson VA Medical Center, Charleston, SC
| | - Vinayak Rohan
- Division of Transplant Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Rahul Argula
- Division of Pulmonology and Critical Care, Department of Medicine, Medical University of South Carolina, Charleston, SC
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13
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Gawor M, Puntmann VO. Aortic Stiffness and Heart Failure in Chronic Kidney Disease. Curr Cardiovasc Imaging Rep 2020; 13. [DOI: 10.1007/s12410-020-9534-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Abstract
Purpose of Review
To provide an update on the recent findings in the field of aortic stiffness and heart failure in patients with chronic kidney disease (CKD).
Recent Findings
Stratification of cardiovascular risk in CKD remains an open question. Recent reports suggest that aortic stiffness, an independent predictor of cardiovascular events in many patient populations, is also an important prognostic factor in CKD. Also, novel measures of myocardial tissue characterization, native T1 and T2 mapping techniques, have potential as diagnostic and prognostic factors in CKD.
Summary
Cardiovascular magnetic resonance has the ability to thoroughly evaluate novel imaging markers: aortic stiffness, native T1, and native T2. Novel imaging markers can be used for diagnostic and prognostic purposes as well as potential therapeutic targets in CKD population.
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14
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Molcho M, Rozen-Zvi B, Shteinmats T, Ben Dor N, Vahav I, Nesher E, Rahamimov R. Temporal changes of proteinuria after kidney transplantation: association with cardiovascular morbidity and mortality. J Nephrol 2020; 33:1059-1066. [PMID: 31953621 DOI: 10.1007/s40620-020-00703-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 01/06/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Proteinuria is common in kidney transplant recipients and has been established as a risk factor for graft-loss and mortality. In the general population, proteinuria has also been tied to a higher risk of cardiovascular disease. There is limited data exploring the association between changes in proteinuria over time and cardiovascular disease in kidney transplant recipients. METHODS In this retrospective cohort study we evaluated proteinuria as a time-varying covariate using urine dipstick protein values at 6 month intervals post-transplant. The primary outcome was the occurrence a major cardiovascular event (MACE). Univariate and multivariate time varying Cox model was used. RESULTS 579 patients were included in the final cohort. 120 episodes of MACE were documented in 98 patients. Time varying proteinuria was associated with MACE by univariate and multivariate analysis (HR 2.63, 95% CI 1.76-3.93, p < 0.001) and (HR 2.33, 95% CI 1.53-3.54, p < 0.001). Reduction of proteinuria to normal was associated with reduced risk of MACE compared with active proteinuria (HR 0.44, 95% CI 0.28-0.69, p < 0.001) and (HR 0.47, 95% CI 0.3-0.76, p = 0.002) for univariate and multivariate analyses. Exposure to proteinuria for more than 1 year was significantly associated with an increased risk of MACE for univariate and multivariate analysis (HR 2.33, 95% CI 1.48-3.68, p < 0.001) and (HR 2.18, 95% CI 1.37-3.45, p = 0.002) respectively, in comparison to exposure of less than 1 year. CONCLUSION These findings may suggest that we should consider applying clinical interventions that are known to reduce cardiovascular morbidity in these patients.
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Affiliation(s)
- Maya Molcho
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Benaya Rozen-Zvi
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Department of Nephrology and Hypertension, Rabin Medical Center, Beilinson campus. 39, Jabutinsky St., Petah-Tikva, Israel
| | - Tali Shteinmats
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Department of Nephrology and Hypertension, Rabin Medical Center, Beilinson campus. 39, Jabutinsky St., Petah-Tikva, Israel
| | - Naomi Ben Dor
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Department of Nephrology and Hypertension, Rabin Medical Center, Beilinson campus. 39, Jabutinsky St., Petah-Tikva, Israel
| | - Itay Vahav
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Eviatar Nesher
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Department of Transplantation, Rabin Medical Center, Beilinson campus, Petah-Tikva, Israel
| | - Ruth Rahamimov
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel. .,Department of Nephrology and Hypertension, Rabin Medical Center, Beilinson campus. 39, Jabutinsky St., Petah-Tikva, Israel. .,Department of Transplantation, Rabin Medical Center, Beilinson campus, Petah-Tikva, Israel.
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15
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Dogan U, Yaprak M, Dogan EA, Onac M, Yılmaz VT, Aydinli B. Cardiovascular and Neurologic Complications in Kidney Transplant Recipients: A Focused Appraisal of Symptoms. Transplant Proc 2019; 51:1101-1107. [PMID: 31101180 DOI: 10.1016/j.transproceed.2019.02.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 01/27/2019] [Accepted: 02/03/2019] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND OBJECTIVE After a kidney transplantation, all efforts are focused on graft function. However, cardiovascular and neurologic complications might lead to decreased quality of life and shortened life expectancy. Early recognition of related symptoms might be critical to successfully manage these complications. METHODS AND PATIENTS We retrospectively reviewed the medical records of patients who had undergone kidney transplantation in a tertiary center between January 2014 and December 2017. Demographic data and past medical history were systematically gathered. Symptoms related to cardiac or neurologic disorders and final diagnoses were recorded. RESULTS One hundred eighty-six patients were evaluated by a cardiologist or a neurologist in the early post-operative period or long-term follow-up. Chest pain (n = 17; 9.1%) and palpitations (n = 13; 7.0%) were the most prevalent symptoms. Coronary artery disease was diagnosed in 70.6% (n = 12) of the patients presenting with chest pain. All of the patients were treated successfully, with either antianginal drugs or percutaneous angioplasty. Atrial fibrillation was diagnosed in 53.9% (n = 7) of the patients presenting with palpitations. Headache was the most prevalent chronic neurologic symptom (n = 16; 8.6%). Transient ischemic attack occured in 7 patients (3.8%) and 5 (2.7%) patients experienced ischemic stroke. CONCLUSION Kidney transplantation is associated with short- and long-term cardiac and neurologic complications. Our findings underscore the crucial role of questioning symptoms that might be related to severe disorders. Asymptomatic patients with high risk factors must also be under scope. Attending physicians should have a low threshold for referring these patients to cardiologists and neurologists.
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Affiliation(s)
- U Dogan
- Department of Cardiology, Faculty of Medicine, Akdeniz University, Antalya, Turkey.
| | - M Yaprak
- Department of General Surgery, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - E A Dogan
- Department of Neurology, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - M Onac
- Department of Cardiology, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - V T Yılmaz
- Department of Internal Medicine, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - B Aydinli
- Department of General Surgery, Faculty of Medicine, Akdeniz University, Antalya, Turkey
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16
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Abstract
Renal transplantation is the preferred treatment for patients with end-stage kidney disease. However, despite successful kidney transplantation, cardiovascular disease (CVD) remains one of the major causes of patient death and hence graft loss. The antecedents of this increased risk reside within the development of end-stage kidney disease and dialysis. Risk factors for the development of CVD include diabetes, hypertension, and dyslipidemia. Other transplant-specific factors include the presence of a patent arteriovenous fistula and immunosuppressive therapy. Efforts to modify these factors should be strongly encouraged to improve long-term outcomes of transplant patients and reduce death from CVD in this at-risk patient population.
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Affiliation(s)
- Nitesh N Rao
- Renal Unit, Lyell McEwin Hospital, Elizabeth Vale, South Australia
| | - P Toby Coates
- Renal Unit, Lyell McEwin Hospital, Elizabeth Vale, South Australia; Central Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, South Australia.
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17
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Oguntola SO, Hassan MO, Duarte R, Dix-Peek T, Dickens C, Olorunfemi G, Vachiat A, Paget G, Manga P, Naicker S. Atherosclerotic vascular disease and its correlates in stable black South African kidney transplant recipients. Int J Nephrol Renovasc Dis 2018; 11:187-193. [PMID: 30038514 PMCID: PMC6053296 DOI: 10.2147/ijnrd.s160553] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background Despite remarkable improvement in renal function attributable to kidney transplantation, the burden of cardiovascular disease (CVD) among kidney transplant recipients (KTRs) remains high in the post-transplant period. Aggressive use of statins in KTRs may make lipoprotein ratios correlate better with atherosclerotic vascular disease (AsVD) when compared with traditional lipid profile parameters. We therefore evaluated the clinical and echocardiographic correlates of AsVD among non-diabetic, stable, black KTRs in South Africa. Methods This was a cross-sectional study of 41 adult (18–65 years), non-diabetic, stable KTRs and 41 age- and sex-matched healthy controls. An interviewer-administered questionnaire was used to obtain information on participants’ sociodemographic and cardiovascular risk factors. Anthropometric parameters were measured. Urine and blood samples were obtained and analyzed. Echocardiography was performed and carotid intima media thickness (CIMT) was assessed in both right and left carotid arteries. Spearman’s rank correlation and binary logistic regression were performed to determine the relationship between CVD risk factors and AsVD. Results AsVD was present in 46.3% of KTRs compared to 17.1% of healthy controls (p = 0.004). Left ventricular hypertrophy was present in 92.7% of the KTRs. There were statistically significant differences in waist–hip ratio, systolic blood pressure, mean arterial pressure, urine albumin–creatinine ratio, serum fibrinogen, serum creatinine, estimated glomerular filtration rate, left atrial diameter, left ventricular mass (LVM), and left ventricular mass index (LVMI) between KTRs and controls. A positive relationship was seen between CIMT and certain risk factors for CVD including LVM, LVMI, and mitral valve deceleration time, (p < 0.001). Castelli index 2 and lipoprotein combine index (LCI) showed positive correlation with CIMT. On multivariate analysis, increasing age and kidney transplant status were independent predictors of AsVD after controlling for other risk factors. Conclusion AsVD was common among KTRs. Older age and kidney transplant status independently predicted AsVD. Castelli index 2 and LCI correlated with AsVD better than serum lipid parameters.
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Affiliation(s)
- Stephen Olawale Oguntola
- Department of Internal Medicine, Division of Nephrology, University of Witwatersrand, Johannesburg, South Africa,
| | - Muzamil Olamide Hassan
- Department of Internal Medicine, Dialysis Unit, Ladoke Akintola University of Technology Teaching Hospital, Osogbo, Nigeria
| | - Raquel Duarte
- Department of Internal Medicine Laboratory, University of Witwatersrand, Johannesburg, South Africa
| | - Therese Dix-Peek
- Department of Internal Medicine Laboratory, University of Witwatersrand, Johannesburg, South Africa
| | - Caroline Dickens
- Department of Internal Medicine Laboratory, University of Witwatersrand, Johannesburg, South Africa
| | - Gbenga Olorunfemi
- Department of Epidemiology and Biostatistics, School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Ahmed Vachiat
- Department of Internal Medicine, Division of Cardiology, University of Witwatersrand, Johannesburg, South Africa
| | - Graham Paget
- Department of Internal Medicine, Division of Nephrology, University of Witwatersrand, Johannesburg, South Africa,
| | - Pravin Manga
- Department of Internal Medicine, Division of Cardiology, University of Witwatersrand, Johannesburg, South Africa
| | - Saraladevi Naicker
- Department of Internal Medicine, Division of Nephrology, University of Witwatersrand, Johannesburg, South Africa,
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