RISK FACTORS FOR CARDIOVASCULAR DISEASE DEVELOPMENT IN THE RENAL TRANSPLANT RECIPIENTS

Cardiovascular (CVS) disease is commonly reported as the leading cause of mortality among kidney transplant recipients (KTRs).

Risk factors for cardiovascular disease in the renal transplant recipient

Cardiovascular (CVS) disease is commonly reported as the leading cause of mortality among kidney transplant recipients (KTRs). Moreover, CVS disease-related mortalities is the commonest cause of allograft loss. Transplant recipients may show a lowered risk of CVS events as compared to dialysis patients enrolled in waiting-list, however, they are at a much higher risk in comparison with those in general population. The Framingham risk score may underestimate the risk of CVS events among KTRs. Despite that individual Framingham risk factors are clearly associated with CVS risks among KTRs, the effect size is increased among these patients, particularly those at highest risk. 

Framingham risk scores (FRS)

The first FRS (1998) including age, gender, lipid profile, blood pressure (BP) (managed or not), DM, and smoking habits to provide an estimated risks of coronary heart disease (CHD) evolution (myocardial infarction (MI), coronary death, and angina pectoris) through 10 years. A validation report has shown that FRS CHD predictor performed well for predictive values of CHD events in either black or white, either male or females. The FRS risk score has been modified (2002) by ATP III for application in the recommendations of screening/therapy of dyslipidemia.

That modification involved exclusion of DM from the algorithm, as it was dealt as a CHD equivalent, expansion of aging, and included hypertensive therapy and age-related issues for smoking habits and total cholesterol. The FRS/ATP III criteria were applied for estimating the CHD risk prevalence in the US in analyzed data from NHANES III with no self-reported CHD, stroke, peripheral vascular disease, or DM. The 10-y. CHD risks and percentage of patients in each category were given:

• Low risk (<10 % CHD risk at 10 y.): 82 % of the studied patients
• Intermediate risk (10-20 %): 16 %
• High risk (>20 %): 3 %

The frequency of high-risk subjects is currently increasing by aging and was higher in male than female.

The common risk factors that observed in the general population can be also seen in KTRs. Unfortunately, these factors may be intensified by the exposure to the immunosuppressive medications. Dyslipidemia appears to be a significant issue in the transplant cohort. Glucocorticoids, CyA, rapamycin, and tacrolimus increase the triglyceride and cholesterol levels. Hypertension can be induced or even worsened by CNI (calcineurin inhibitors) and, to a less extent - due to rapid withdrawal - corticosteroids. 

Both pre-transplant DM and NODAT (new-onset diabetes after transplantation) are commonly complicated with an increased risk of post-transplant CVS Sequelae e.g., MI (myocardial infarction) and HF (heart failure). Immunosuppressive medications that may induce NODAT include steroids, CNI, and MTOR inhibitors. 

Post-transplant allograft dysfunction and prolonged dialysis vintage before transplantation are significantly considered CVS risk factors post-transplant. In the general and transplant cohorts, smoking habits can augment the risk of CVS disease. However, smoking abstinence may alleviate these risks by time. In transplant cohort, complete cessation of smoking is highly recommended

CMP (Cardiomyopathy), with or without clinically evident HF (heart failure), is commonly observed among KTRs, and ca be accompanied with increased mortalities. Congestive heart failure (CHF) is reported to be only second to infectious causes as an etiology of patients’ hospitalization after kidney transplant.

Post-transplant risk factors for CHF development may include aging, DM, anemia and HT (hypertension) and allograft dysfunction.  Finally, it is worthy to mention that the primary and secondary precautions to guard against CVS disease evolution are underestimated in KTRs.

 https://www.wjgnet.com/2220-3230/full/v8/i5/122.htm

N.B. This Blogger is created to declare cardiovascular risks after renal transplantation

 

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