Commentary on cardiovascular risk

Abstract

T he questionnaire-based study from the Transplant Therapy Outcomes Study Group documents the influence of cardiovascular morbidity and mortality on outcomes in patients who underwent transplantation after 1997. In the study by First and coworkers, it was found that attention devoted to reducing cardiovascular risk factors, as recommended by the Third Report of the National Cholesterol Education Program,1 remains quite variable. If we are to demand more attention to pretransplantation risk reduction, we must be equally vigilant afterward. Another study presented at the American Transplant Congress 2003 found a tacrolimus (TAC) and mycophenolate mofetil combination, even with corticosteroids, to be associated with the lowest risk of hypercholesterolemia, confirming results of other trials.2-4 The multicenter conversion trial performed by Waid and associates is of particular significance. Patients with biopsy-documented chronic allograft nephropathy were randomized to remain on a regimen of cyclosporine or undergo conversion to TAC. After 2 years, patients who underwent conversion had significantly better glomerular filtration rate, lower low-density lipoprotein cholesterol levels, and almost 80% fewer new cardiovascular events than those remaining on a regimen of cyclosporine (with no adverse impact on glucose metabolism). These compelling results indicate that greater attention to surveillance of cardiovascular risk, with intervention strategies when appropriate, can improve long-term outcomes for our patients. Achieving target blood pressure readings (130/80 mm Hg) and low-density lipoprotein cholesterol levels ( 100 mg/dL) is critical for maximal risk reduction. It is now apparent that sirolimus exerts the greatest adverse impact on plasma lipid profiles; unless its antiproliferative effect can be convincingly shown to otherwise diminish vascular lesions, its use will remain problematic in the kidney transplant population. Although intervention with statins is increasingly recognized as an important tool in most patients, the broad cardiovascular risk profile seen in the Waid et al study indicates that this is a larger issue. For many patients, TAC and mycophenolate mofetil (with or without steroids) may offer the least atherogenic immunosuppressant combination.5