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Incidence of Cardiovascular Risk Factors and Complications Before and After Kidney Transplantation A. Fazelzadeh, A. Mehdizadeh,

Incidence of Cardiovascular Risk Factors and Complications Before and After Kidney Transplantation

A. Fazelzadeh, A. Mehdizadeh, M.A. Ostovan, and G.A. Raiss-Jalali

ABSTRACT

Background. Cardiovascular disease is a leading cause of death after renal transplan- tation with an incidence considerably higher than that in the general population. The aim of this study was to evaluate the association of atherosclerotic cardiovascular complications and the prevalence of cardiovascular risk factors prior to and following transplantation.

Patients and methods. Atherosclerotic cardiovascular diseases including coronary artery disease, as well as cerebral and peripheral vascular disease, and cardiovascular risk factors pre- and posttransplantation were analyzed in 500 renal transplant recipients between 1988 and 1992. The mean recipient age at transplantation was 45 12 years, with 58% men and 7% diabetics.

Results. Following transplantation 11.7% developed atherosclerotic cardiovascular dis- eases, the majority being coronary artery disease (9.8%). Comparison of the risk factors before and after transplantation showed the increased prevalence of systemic hypertension to be 67% to 86%, of diabetes mellitus, 7% to 16%, and obesity, with a body mass index 25 kg/m 2 from 26% to 48%, whereas the number of smokers was halved to 20%. The triglycerides decreased significantly (from 235 144 mg/dL to 217 122 mg/dL) but the total and high-density lipoprotein (HDL) cholesterol rose significantly (from 232 65 mg/dL to 273 62 mg/dL and from 47 29 mg/dL to 56 21 mg/dL, respectively). The low-density lipoprotein (LDL) cholesterol increase was insignificant (from 180 62 mg/dL to 189 53 mg/dL). Upon univariate analysis, cardiovascular diseases were significantly associated with male gender; age over 50 years; diabetes mellitus (DM); smoking; total cholesterol 200 mg/dL; LDL cholesterol 180 mg/dL; HDL cholesterol 55 mg/dL; fibrinogen 350 mg/dL; body mass index 25 kg/m 2 ; and more than two antihypertensive agents per day. The Cox proportional hazards model revealed DM with a relative risk (RR) of 4.3; age 50 years (RR 2.7); body mass index 25 kg/m 2 (RR 2.6); smoking (RR 2.5); and LDL cholesterol 180 mg/dL (RR 2.3) as independent risk factors.

Conclusions. The high incidence of cardiovascular disease following renal transplanta- tion is mainly due to a high prevalence and accumulation of classical risk factors before and following transplantation. The treatment of risk factors must be introduced early in the course of renal failure and continued following transplantation. Future prospective studies should evaluate the success of treatment regarding reduction of cardiovascular morbidity and mortality in this high-risk population.

From the Shiraz Transplant Research Center (A.F.), Shiraz Transplant Center (A.M., G.A.R.-J.), Nemazee Hospital, and the Cardiology Department (M.A.O.), Shiraz University of Medical Sciences, Shiraz, Iran.

This study was supported by a grant from the Shiraz Medical University and Namazi Hospital Transplantation Center. Address reprint requests to Afsoon Fazelzadeh, PO Box 71455- 166, Shiraz, Iran. E-mail: fazelzadeh23@yahoo.com

0041-1345/06/$–see front matter

doi:10.1016/j.transproceed.2006.01.001

506

© 2006 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710

Transplantation Proceedings, 38, 506 –508 (2006)

CARDIOVASCULAR RISK FACTORS AND COMPLICATIONS

C ARDIOVASCULAR DISEASE is a leading cause of death after renal transplantation, with an inci-

dence considerably higher than in the general popula- tion. 1 The grossly increased cardiovascular risk in renal transplant patients is related to a combination of partly related risk factors. Most of the causative factors may be influenced, but to be fully effective, the necessary mea- sures must be started early in the natural history of this process, which means not only before transplant but indeed in most cases well before the start of dialysis. 2 The

aim of this study was to evaluate the association of atherosclerotic cardiovascular complications after trans- plant and the prevalence of cardiovascular risk factors prior to versus following the procedure.

MATERIALS AND METHODS

We retrospectively analyzed the outcomes of 500 recipients of renal transplant from 1988 to 1992. We reviewed all inpatient and outpatient records, abstracting data on pretransplant eval- uations and posttransplant outcomes of recipients. The variables included: age, gender, presence/absence of diabetes, hyperten- sion, body mass index (BMI) at the time of transplant, lipid profile (total cholesterol, triglycerides, high-density lipoprotein [HDL], low-density lipoprotein [LDL]), fibrinogen level, and smoking status transplant records. We recorded atherosclerotic cardiovascular diseases involving coronary arteries or cerebral and peripheral vessels during this period. Outcomes are de- scribed using event-free Kaplan-Meier survival curves. Cox proportional hazards regression was used for both univariate and multivariate analyses.

RESULTS

Of the 500 patients who received transplants between 1988 and 1992, 11.7% developed atherosclerotic cardio- vascular disease, the majority being coronary artery disease (9.8%). The mean age at transplantation was 45 12 years, and 58% of patients were men. Comparison of risk factors before and after transplantation showed an increased prevalence of systemic hypertension to be from 67% to 86%; diabetes mellitus, from 7% to 16%, and obesity with a BMI 25 kg/m 2 , from 26% to 48%, whereas the number of smokers halved to 20% ( Table 1 ). The triglycerides decreased significantly (from 235 144 mg/dL to 217 122 mg/dL). The total and HDL cholesterol

Table 1. Humoral Parameters (Mean SD) and Percentage of Clinical Findings in Patients Before and After Renal Transplantation

 

Before

After

Cardiovascular Risk Factors

Transplant

Transplant

P Value

Hypertension (%)

67

86

.01

Diabetes mellitus (%)

7

16

.001

Obesity (BMI 25 kg/m 2 ) (%)

26

48

.005

Triglycerides (mg/dL)

235 44

217 122

.04

Total cholesterol (mg/dL)

232 65

273 62

.03

HDL cholesterol (mg/dL)

47 29

56 21

.04

LDL cholesterol (mg/dL)

180 62

189 53

.04

507

rose significantly (from 232 65 mg/dL to 273 62 mg/dL and from 47 29 mg/dL to 56 21 mg/dL, respectively). The LDL cholesterol increase was insignificant (from 180 62 mg/dL to 189 53 mg/dL). In the univariate analysis, cardio- vascular diseases were significantly associated with male gen- der, age over 50 years, diabetes mellitus, smoking, total cholesterol 200 mg/dL, LDL cholesterol 180 mg/dL, HDL cholesterol 55 mg/dL, fibrinogen 350 mg/dL, BMI 25 kg/m 2 , and more than two antihypertensive agents per day. The Cox proportional hazards model revealed diabet- ics to show a relative risk (RR) of 4.3; age 50 years (RR 2.7); BMI 25 kg/m 2 (RR 2.6); smoking (RR 2.5); and LDL cholesterol 180 mg/dL (RR 2.3) as indepen- dent risk factors.

DISCUSSION

Although cardiovascular disease is a major cause for death after renal transplantation, risk factors for cardio- vascular events other than dialysis have not been well defined. 3 Pre- and posttransplant screening of cardiovas- cular risk factors and also detection of occult cardiovas- cular diseases can improve the outcome of renal trans- plant patients. Smoking is the most important adverse factor. An analysis of 434 transplant patients in one center showed that smokers had a greater than twofold increased risk of cardiovascular death when compared with nonsmokers, namely, a hazard ratio of 2.2 ( P .001). 4 Our data also showed that smoking was associated with development of cardiovascular disease. Short-term studies have demonstrated that hypercholesterolemia with raised LDL cholesterol represented the most fre- quent abnormality, which was associated with corticoste- roid and cyclosporine treatment in a dose-dependent manner. 5 Our results supported these findings. As we know statins have been found to improve the lipid profile in transplant recipients without undue side effects and with a decreased risk of cardiovascular mortality. 5 So, we have used lipid-lowering diets and drugs to lower the risk of cardiovascular diseases. For many years new-onset diabetes after transplantation has been recognized as a complication of solid-organ trans- plantation, although its importance has been greatly under- estimated. 6 Our results showed that an increased incidence of diabetes predisposed patients to the development of cardiovascular disease. It is clear that efforts should be made to reduce the risk of diabetes and treat this condition appropriately. Management of transplant recipients with new-onset diabetes after transplantation has been assisted by the recent publication of International Consensus Guidelines. The guidelines were developed to establish a standard definition and describe risk factors for new- onset diabetes after transplantation. Use of these guide- lines will help to prospectively identify patients at risk of developing new-onset diabetes after transplantation so that therapeutic strategies can be individualized early in the treatment regimen. 6

508

Future prospective studies must evaluate the success of treatment of these risk factors regarding reduction of cardio- vascular morbidity and mortality in this high-risk population.

REFERENCES

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FAZELZADEH, MEHDIZADEH, OSTOVAN ET AL

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