Post-transplant Cardiac Events Research Articles

S1968 Pre-Transplant Cardiovascular Risk Stratification and Early Post-transplant Cardiac Events in Liver Transplant Recipients

S1968 Pre-Transplant Cardiovascular Risk Stratification and Early Post-transplant Cardiac Events in Liver Transplant Recipients

Propensity Score and Instrumental Variable Techniques in Observational Transplantation Studies: An Overview and Worked Example Relating to Pre-Transplant Cardiac Screening.

Inferring causality from observational studies is difficult due to inherent differences in patient characteristics between treated and untreated groups. The randomised controlled trial is the gold standard study design as the random allocation of individuals to treatment and control arms should result in an equal distribution of known and unknown prognostic factors at baseline. However, it is not always ethically or practically possible to perform such a study in the field of transplantation. Propensity score and instrumental variable techniques have theoretical advantages over conventional multivariable regression methods and are increasingly being used within observational studies to reduce the risk of confounding bias. An understanding of these techniques is required to critically appraise the literature. We provide an overview of propensity score and instrumental variable techniques for transplant clinicians, describing their principles, assumptions, strengths, and weaknesses. We discuss the different patient populations included in analyses and how to interpret results. We illustrate these points using data from the Access to Transplant and Transplant Outcome Measures study examining the association between pre-transplant cardiac screening in kidney transplant recipients and post-transplant cardiac events.

Non-obstructive coronary angiogram findings prior to kidney transplantation do not predict post-transplant cardiac events.

This study aimed to determine the risk factors associated with cardiac events 1 year after transplant in kidney transplant recipients (KTRs). We analyzed the incidence of cardiac events in all KTRs transplanted at our center between 01/2000 and 12/2016, who had non-obstructive cardiac catheterization findings at their pre-transplant evaluation. We identified 141 patients with non-obstructive pre-transplant cardiac catheterization. 83 patients (59%) had cardiac events 1 year after the kidney transplant during a mean follow-up of 7.3 ± 5.3 years. Multivariate Cox regression analysis determined dialysis ≥ 1 year (HR = 2.27, 95% Cl 1.41 - 3.67, p = 0.001), body mass index (BMI) ≥ 35 kg/m2 at time of transplant (HR = 2.24, 95% Cl 1.43 - 3.52, p = 0.0004), tacrolimus trough ≥ 7 ng/mL at 1 year post-transplant (HR = 4.24, 95% Cl 1.95 - 9.22, p = 0.0003), and HBA1-c ≥ 7% at 1 year post-transplant (HR = 1.71, 95% Cl 1.09 - 2.70, p = 0.02) as significant predictors of cardiac events 1 year post-transplant. In unadjusted Kaplan-Meier analysis, any cardiac event post-transplant was associated with a significant risk of death or graft loss (p = 0.02). Dialysis duration, morbid obesity, diabetes control, and tacrolimus levels may represent modifiable risk factors to reduce cardiac events in kidney transplant recipients with non-obstructive cardiac catheterization findings at the time of transplant.

P1628ASSESSING CORONARY HEART DISEASE IN SIMULTANEOUS PANCREAS-KIDNEY TRANSPLANTATION - IS THERE SPACE FOR A RISK SCORE MODEL?

Abstract Background and Aims Type 1 diabetes mellitus (DM1) is associated with an increased risk of coronary heart disease (CHD), which is generally more aggressive and frequently asymptomatic. This risk substantially increases for those with nephropathy. In selected patients, simultaneous pancreas-kidney transplantation (SPKT) is the renal and pancreatic replacement therapy of choice, as it increases longevity and stabilizes diabetic complications. Despite essential, universal screening protocols for silent CHD in this population are still debatable. As so, Gowdak recently developed a simple clinical risk score to determine the pre-test probability of significant CHD in single kidney transplant candidates. Our aim was to identify potential risk factors associated with the presence of significant lesions on pre-SPKT coronary angiography (CA) and test the utility of Gowdak score in SPKT candidates. Method 77 patients submitted to SPKT between 2011 and 2018 were retrospectively included in this study. All subjects underwent CA as screening method for CHD during the eligibility evaluation. Demographic, clinical, laboratory, therapeutic and imaging characteristics were studied. Continuous variables are presented as means or medians; categorical variables as frequencies. Univariate analysis (Qui2 or Fisher test) and multivariate analysis (logistic regression) were performed. Comparison between groups of patients with and without CA injury was performed using SPSS statistics version 23 and a p <0.05 was considered significant. Results In the past 8 years, 99 SPKT were performed; 78% of these patients (N=77) were submitted to preoperative CA; mean age was 36±5.9 years and 64% were male. The mean duration of DM1 was 25 years and 97% had retinopathy, 43% neuropathy, 31% dysautonomia, 19% peripheral arterial disease and 7% cerebrovascular disease. We excluded 1 due to missing data. A minority of SPKT (3%, N=2) was preemptive. The mean time on dialysis was 37 months. Only one patient had angor, wh0 was excluded of Gowdak risk score assessment. Most patients (87%, N=67) were hypertensive; 56% (N=43) were on statin; 48% (N=37) had smoking habits, and 5% (N=4) had a BMI>30 kg/m2. CA identified at least one lesion in 48% (N = 37) of the patients, of which 30% (N=11; 14% of all CA) underwent intervention; none had complaints of angor. Based on Gowdak risk score, mean probability for CHD was 30.8% and 19 patients had a risk >40% - the recommended cut off to pursuit CA as screening method - but only 2 required intervention. In a univariate analysis, we found that the only distinguishing feature between the group of patients with and without CA lesions was smoking (p=0.005). DM1 with 20 or more years of evolution was found to have a significant association with coronary artery disease development (identifiable by any diagnostic test) (p=0.048). In our population of SPKT recipients Gowdak risk score did not predicted those with significant CHD. Conclusion In our study, CA was positive for lesion in almost half of the patients, all of them asymptomatic. Despite the fact that Gowdak probability score failed to identify those with significant CHD before CA (probably because all of our patients were diabetic), in our population for every seven patients submitted to CA, one needed coronary intervention. We highlight that asymptomatic patients with long-term DM and smokers should be carefully evaluated. The task of correctly ascertaining the presence of CAD can be more overwhelming when we take into account that there is a high prevalence of asymptomatic patients with extensive CAD. Facing the importance of an unmissed diagnosis we encourage the use of CA as an initial screening method, even if it is invasive. Further studies should be encouraged to create screening algorithm for SPKT candidates. Finally, medium- and long-term follow-up studies are needed to evaluate the effects of preoperative selection on posttransplant cardiac events and survival rates.

Pre-liver transplant cardiovascular risk profile and correlation with early post-transplant cardiac events

Background/aims: There are limited data about optimal strategy of cardiovascular (CV) risk assessment during liver transplant (LT) workup. We evaluated CV risk profile and its correlation with early post-LT cardiac events.

Advanced Cirrhosis, Statins, and Future Implications of Rising Nonalcoholic Fatty Liver Disease (NAFLD)

Introduction: Nonalcoholic fatty liver disease (NAFLD) is among the most common causes of cirrhosis in the United States and clinicians may see an increasing proportion of patients with cirrhosis and hyperlipidemia. We sought to describe the lipid profiles in patients with cirrhosis and to determine if these patients were appropriately prescribed statins. Methods: We retrospectively reviewed 100 consecutive patients listed for liver transplant from 2012-2014 and collected data on demographics, MELD, Childs-Pugh score (CP), etiology of cirrhosis, statin use and cardiac risk factors. Cardiac risk factors included history of hypertension, history of tobacco use, low HDL ( < 40mg/dL), diabetes mellitus, or family history of premature coronary artery disease (CAD). Results: Among 100 cirrhotic patients, 35 had hepatitis C, 19 had NAFLD, 13 had alcoholic cirrhosis, 9 had primary sclerosing cholangitis/primary biliary cholangitis (PSC/PBC), and 24 had other diagnoses. The mean age was 56 ± 9 and 67 were male. The mean MELD score was 18 ± 7. Sixty-seven patients were Child's Class C. Mean lipid profiles were as follows: LDL 82, triglycerides 95, cholesterol 144, and HDL 43. The mean LDL in Child's C cirrhotics compared to Child's A/B cirrhotics was 79 and 88, respectively. Within the Child's Class C NAFLD patient population, the mean LDL was 70 compared to mean LDL of 100 in Child's Class A/B, p = 0.41. Nine patients met Adult Treatment Panel (ATP) guidelines for statin therapy of which only one was on treatment. Of the 8 patients who were not on therapy, 6 were Child's Class C with an average MELD of 23. Four patients had post-transplant cardiac events and 2 should have been on statins based on risk factors for cardiovascular disease. No toxicity related to statins was reported. Conclusion: 88% of cirrhotics who had indications for statin therapy may have not been on treatment due to advanced cirrhosis and perceived toxicity. Two potentially avoidable post-transplant cardiovascular events occurred and thus further strategies are needed to identify patients with cirrhosis that need statin therapy. Given the increasing number of patients with NAFLD and hyperlipidemia, gastroenterologists will need to be aware of current guidelines for statin therapy in patients with early and advanced cirrhosis.

Post-transplant Cardiac Events Among Patients Receiving Orthotopic Liver Transplant (OLT)

Post-transplant Cardiac Events Among Patients Receiving Orthotopic Liver Transplant (OLT)

Pre-Transplant Renal Impairment Predicts Posttransplant Cardiac Events in Patients With Liver Cirrhosis

Cardiovascular disease and renal impairment are common in cirrhotic transplant candidates. We aimed to investigate potential association between pretransplant renal function impairment and cardiac events after liver transplantation. Adult cirrhotic patients undergoing first-time liver transplantation between 1999 and 2007 in a single institution with available glomerular filtration rate (GFR), assessed by Cr-EDTA clearance at pre-transplant evaluation, were retrospectively enrolled (n=202). Impaired renal function was defined as GFR less than 60 mL/min/1.73 sqm. Pretransplant QT-time corrected by heart rate (QTc) and left-ventricular dysfunction was also registered. Mortality and cardiac events were analyzed, until death or last follow-up (end 2009). Renal impairment was present in 24% (48/202). Cardiac events occurred in 28% (56/202) after transplantation, mean follow-up time of 3.8 years (2.2). Events were more common in patients with renal impairment compared with those without (48% versus 21%, P<0.001). In Cox regression analysis, pretransplant renal impairment was found to be an independent predictor of posttransplant cardiac events (HR 2.19, 95% CI 1.25-3.85) and reduced cardiac event-free survival (HR 2.27, 95% CI 1.31-3.94). Prolonged QTc interval was an independent predictor of posttransplant cardiac events in the subgroup with pretransplant electrocardiogram and echocardiogram (n=166 and n=112, HR 4.75, 95% CI 2.07-10.9); however, left-ventricular diastolic dysfunction was not (P>0.05). A pretransplant score comprising renal impairment, prolonged QTc interval, and age older than 52 was developed for prediction of 3- and 12-month cardiac events (c-statistic 0.73 and 0.75, respectively). Pretransplant renal impairment is a predictor of cardiac event after liver transplantation together with prolonged QTc interval.

Abstract 599: Cardiovascular Risk Factors and Cardiovascular Events in Patients Undergoing Liver Transplantation

Introduction: Patients undergoing liver transplantation often have cardiovascular risk factors and may experience cardiovascular morbidity and mortality. Understanding the role of risk factors and the benefit of treatment is important for the careful selection of liver transplantation candidates to minimize post-transplant cardiac morbidity. We investigated the prevalence of cardiovascular risk factors and their association with cardiovascular events in liver transplantation patients. Methods: We studied 182 consecutive patients undergoing liver transplantation in our center between 1997 and 2011 to evaluate factors associated with new cardiovascular events after liver transplantation. Results: The cohort consisted of 179 men and 3 women with a mean age of 58.8 ± 6.2 years, model for end-stage liver disease (MELD) score of 17.4 ±7 at initial evaluation, and Framingham risk score of 9.0 ±5.1. In this cohort 15 ( 8.2%) patients were smokers, 48 (26.4%) had hypertension, 47 (25.8%) had diabetes mellitus, 35 (19.2%) had coronary artery disease, and 27 (14.8%) had dyslipidemia prior to their transplant surgery. After a median follow-up of 5.6 years, a total of 52 (28.6%) patients died and 6 (3.3%) died of cardiac causes. New coronary events and/or revascularization procedures post-transplant occurred in 22 (12%) patients. The pre-transplant variable associated with post-transplant cardiac events and/or revascularization was smoking status at the time of evaluation (P=0.01). Post-transplant factors associated with cardiac events included use of beta-blockers (P=0.01) or statins (P=0.01). Conclusion: Although cardiovascular risk factors and coronary disease are very common, cardiovascular events are relatively infrequent in patients undergoing liver transplantation. Smoking at time of transplant evaluation and post-transplant medical therapy with beta-blockers and statins are significantly associated with the occurrence of post-transplant cardiac events including revascularization.

Prevalence of pre-transplant electrocardiographic abnormalities and post-transplant cardiac events in patients with liver cirrhosis

BackgroundAlthough cardiovascular disease is thouht to be common in cirrhosis, there are no systematic investigations on the prevalence of electrocardiographic (ECG) abnormalities in these patients and data on the occurrence of post-transplant cardiac events in comparison with the general population are lacking. We aimed to study the prevalence and predictors of ECG abnormalities in patients with cirrhosis undergoing liver transplantation and to define the risk of cardiac events post-transplant compared to the general population.MethodsCirrhotic patients undergoing first-time liver transplantation between 1999–2007 were retrospectively enrolled. ECGs at pre-transplant evaluation were reviewed using the Minnesota classification and compared to healthy controls. Standardized incidence ratios for post-transplant cardiac events were calculated.Results234 patients with cirrhosis were included, 186 with an available ECG (36% with alcoholic and 24% with viral cirrhosis; mean follow-up 4 years). Cirrhotics had a prolonged QTc interval, a Q wave, abnormal QRS axis deviation, ST segment depression and a pathologic T wave more frequently compared to controls (p < 0.05 for all). Arterial hypertension, older age, cirrhosis severity and etiology were related to ECG abnormalities. Compared to the general Swedish population, patients were 14 times more likely to suffer a cardiac event post-transplant (p < 0.001). A prolonged QTc interval and Q wave were related to post-transplant cardiac events (p < 0.05 for all).ConclusionsPre-transplant ECG abnormalities are common in cirrhosis and are associated with cardiovascular risk factors and cirrhosis severity and etiology. Post-transplant cardiac events are more common than in the general population.

Chronotropic Incompetence on Dobutamine Stress Echocardiography in Candidates for a Liver Transplant

We evaluated dobutamine stress echocardiography as an initial screening test for a cardiac evaluation before a liver transplant. We retrospectively examined 111 liver transplant candidates who had undergone previous cardiac evaluation; 30 of whom had undergone a liver transplant. Eighty patients (72.1%) completed a dobutamine stress echocardiography (41 chronotropically competent, 39 incompetent), while 31 patients (27.9%) required us to terminate early. Overall, 68 patients (61%) were on β-blockers (21 required early dobutamine stress echocardiography termination, 30 chronotropically incompetent, and 17 competent). Patient results were normal. Thirty patients underwent a liver transplant. Among candidates requiring termination of early dobutamine stress echocardiography, posttransplant cardiac events included 1 fatal acute myocardial infarction, 1 nonfatal acute myocardial infarction, and 1 idiopathic cardiomyopathy. Among chronotropically incompetent patients, 2 patients had transient bradycardia, and among those who were chronotropically competent, 1 had refractory atrial fibrillation, and 1 had transient bradycardia. Nearly 50% of patients with end-stage liver disease may not reach the target heart rate. Early termination of dobutamine stress echocardiography because of cardiac symptoms or significant echocardiographic changes have more effect in predicting postoperative cardiac events, but further evaluation is required even if their target heart rate is close to that desired. Lower target heart rate may be acceptable in chronotropically incompetent individuals provided they are asymptomatic, have no echocardiographic changes, or cardiovascular risk factors, especially if they are on β-blockers.

869 Patients With Coronary Artery Disease (CAD) May Be At Higher Risk of Post-Transplant Mortality, Graft Rejection and Cardiac Events

869 Patients With Coronary Artery Disease (CAD) May Be At Higher Risk of Post-Transplant Mortality, Graft Rejection and Cardiac Events

Cardiac Complications Following Allogeneic Bone Marrow Transplantation: Evaluation of Risk Factors, Outcomes and Enhanced Screening for At Risk Populations.

AbstractAbstract 3070Life-threatening cardiac events following allogeneic bone marrow transplants (BMT) are not uncommon at 5–12.5% of patients. While BMT programs perform screening EKGs and ejection fraction measurements, solid organ transplant centers follow a risk stratification screening algorithm to assess for coronary artery disease (CAD) which includes stress tests and as indicated, angiography in those with 2 or more risk factors. It is currently unknown whether this algorithm should be applied in the BMT setting. Methods:We performed a retrospective review of 296 patients who underwent allogeneic BMT at Loyola University Medical Center 2007–2011, to assess cardiac events using the solid organ transplant advanced screening criteria: age over 60 or over 40 with peripheral vascular disease or diabetes and then divided patients into low risk (one CV risk factor) and high risk groups (greater than one CV risk factor). Risk factors included age, hypertension, diabetes, smoking, family history of CAD, and obesity according to the Framingham risk assessment score for CAD. Cardiac events during the first year post-transplant were recorded including CHF, myocardial infarction (MI), and symptomatic arrhythmias. One hundred day and 1-year Kaplan-Meier survival for high and low risk patients were determined and curves compared by log-rank tests. A multivariate analysis of the various prognostic factors was performed using the Cox regression model. Results:Of the 296 total allografts, 116 patients (39%) fit the solid organ transplant criteria for advanced screening; 62% were male (n = 72) and the mean age was 60.6 (range 40–72). Graft source was evenly distributed between siblings (42%), unrelated (39%) and cord blood (28%). Acute myeloid leukemia was the most common indication for BMT at 40%, followed by MDS (21%), non-Hodgkin lymphoma (16%), and CLL (10%). Of the 116, 21 were considered low risk (1 risk factor), while 95 were high risk (2+ risk factors). Low risk and high risk groups did not differ in disease type (p = 0.43), graft source (p = 0.81), or graft type (p = 0.54). Surprisingly, both high and low risk patients had a similar incidence of cardiac events of 36% and 48%, respectively. This correlated to comparable 100-day and 1 year survival rates. To determine the importance of cardiac complications on outcome and whether there were other risk factors for complications we analyzed those with a complication. Forty-four cardiac events occurred in the first year after transplant in 38 (33%) patients. Cardiac events included arrhythmias (n = 33), new onset CHF (n = 6), and MI (n = 5). Median time to event was 16 days post-transplant. Symptomatic arrhythmias included atrial fibrillation (n = 27, 82%), supraventricular tachycardia (n = 5, 15%) and sustained ventricular tachycardia (n =1, 3%). Median age for patients with cardiac events was 62.7 years, compared to 59.6 for patients who experienced no cardiac events (hazard ratio estimate: 1.076; p = 0.02). As compared to patients with no post-transplant cardiac events, both the 100 day and 1 year survival rates of patients with cardiac events were lower with one year survival of 21% vs. 63% (p < 0.0001). Evaluating risk factors, 3 were significant: donor source with MUD donors the highest hazard (p = 0.04); age, with cardiac events occurring at a rate twice as high in patients greater than age 60 (n = 27, 36.5% vs. n = 6, 19.4%), and with all five cases of myocardial infarction and 5/6 new CHF diagnoses occurring in patients aged 60 or greater; and patients with a history of atrial fibrillation demonstrated a higher probability of developing a cardiac event post-transplant (p = 0.02). Conclusions:In this analysis, we saw a much higher incidence of post-BMT cardiac events (33%) than previously reported, although we focused only on at risk patients using the solid organ screening algorithm (pts > 40 with significant risk factors or all pts > 60). As mortality rates at 100 day and 1 year are higher for patients who suffer a post-BMT cardiac event, and only graft source, age and prior atrial fibrillation marked patients at a very high risk, this data indicates that it is appropriate to investigate prospectively the solid organ transplant algorithm in all allogeneic BMT patients > age 40, with low cardiac risk or any patient > 60 with stress tests and as indicated, cardiac catheterization. Whether this will decrease events and thereby improve survival remains to be determined by prospective studies. [Display omitted] Disclosures:No relevant conflicts of interest to declare.

Predictors of cardiovascular events after liver transplantation: A role for pretransplant serum troponin levels

Cardiovascular complications are major causes of morbidity and mortality after liver transplantation. Identifying candidates at highest risk of postoperative complications is a cornerstone of optimizing outcomes and utility. Using traditional cardiac risk factors in addition to C-reactive protein (CRP) levels, troponin levels, and echocardiographic parameters before transplantation, we sought to define cardiac risk so that we could predict cardiovascular events after transplantation. From December 1998 to December 2001, 230 adult patients who underwent liver transplantation with a median follow-up of 8.2 years were studied. The risk factors for cardiac disease were as follows: male gender with a mean age of approximately 50 years (57%), smoking history (60%), diabetes (23%), hypertension (19%), elevated troponin (25%), elevated CRP (25%), and preexisting cardiac disease (16%). Fifty-nine cardiac events occurred over 8.2 years. Risk factors (univariate analysis) for first cardiac events included age in decades [hazard ratio (HR) = 1.31, P = 0.047], diabetes (HR = 2.20, P = 0.004), prior cardiovascular disease (HR = 4.77, P < 0.0001), a troponin I level > 0.07 ng/mL (HR = 2.00, P = 0.023), left ventricular hypertrophy (HR = 2.06, P = 0.047), stress wall abnormalities (HR = 2.25, P = 0.018), and ischemia on stress imaging (HR = 2.89, P = 0.015). Multivariate analysis confirmed age, diabetes, a troponin I level > 0.07, and prior cardiac disease as independent risk factors for posttransplant cardiac events. In conclusion, pretransplant elevated troponin levels, diabetes, and a history of cardiovascular disease, alone or in combination, are strongly associated with the occurrence of posttransplant cardiovascular events.

South Asian ethnicity as a risk factor for major adverse cardiovascular events after renal transplantation.

South Asians (SAs) comprise 25% of all Canadian visible minorities. SAs constitute a group at high risk for cardiovascular disease in the general population, but the risk in SA kidney transplant recipients has never been studied. In a cohort study of 864 kidney recipients transplanted from 1998 to 2007 and followed to June 2009, we identified risk factors including ethnicity associated with major cardiac events (MACEs, a composite of nonfatal myocardial infarction, coronary intervention, and cardiac death) within and beyond 3 months after transplant. Kaplan-Meier methodology and multivariate Cox regression analysis were used to determine risk factors for MACEs. There was no difference among SAs (n = 139), whites (n = 550), blacks (n = 65), or East Asians (n = 110) in baseline risk, including pre-existing cardiac disease. Post-transplant MACE rate in SAs was 4.4/100 patient-years compared with 1.31, 1.16, and 1.61/100 patient-years in whites, blacks, and East Asians, respectively (P < 0.0001 versus each). SA ethnicity independently predicted MACEs along with age, male gender, diabetes, systolic BP, and prior cardiac disease. SAs also experienced more MACEs within 3 months after transplant compared with whites (P < 0.0001), blacks (P = 0.04), and East Asians (P = 0.006). However, graft and patient survival was similar to other groups. SA ethnicity is an independent risk factor for post-transplant cardiac events. Further study of this high-risk group is warranted.

Renal transplant outcome in high‐cardiovascular risk recipients

Cardiovascular (CV) disease is the foremost cause of mortality and an important cause of morbidity in renal transplant recipients. The disease burden is likely to increase as older patients are accepted for transplantation. The outcome of these high-CV risk patients after renal transplantation, especially with known pre-transplant coronary artery disease (CAD), has not been studied. Hence, we looked at the CV outcome in patients with known pre-transplant CAD. All renal transplants performed between 1998 and 2002 at our center, followed up to 2005, were divided into high- and low-risk groups, based on the presence of one or more of the following: pre-transplant angina, myocardial infarction, and positive coronary angiogram. The two groups were compared for post-transplant cardiac events and patient and graft survival. The factors predictive of post-transplant cardiac events were also determined by Cox-regression multivariate analysis. Forty-five patients (10.5%), out of 429, had post-transplant cardiac events; 31.3% in the high risk, and 6.5% in the low-risk group (p = 0.001). Five-yr patient survival was lower in the high-risk group (82.8% vs. 93.1%, p = 0.004), while five-yr overall graft survival and death censored graft survival were statistically not different (74.8% vs. 84.1%, p = 0.08 and 87.3% vs. 90%, p = 0.25). Forty-one percent of patients who were treated with angioplasty plus stenting or bypass graft prior to transplantation had post-transplant cardiac events, as compared with 28% of those without intervention in the high-risk group and 6.5% of patients in the low-risk group (p = 0.001). Age, pre-transplant cardiac disease, arrhythmias, and low-ejection fraction (< or = 40%) were significant independent predictors of post-transplant cardiac events. Post-transplant survival of high-CV risk patients (with known CAD) is lower than that of low-risk recipients but remains acceptable. Cardiac interventions may reduce perioperative risk but do not reduce the probability of post-transplant cardiac events to that of low-risk group.

New onset hyperglycemia and diabetes are associated with increased cardiovascular risk after kidney transplantation

Post-transplant diabetes (PTDM) is a common and serious complication of kidney transplantation. The implications of developing hyperglycemia of lesser severity are not well understood. In this study we used American Diabetes Association (ADA) criteria to assess the incidence of abnormal glycemia post-transplant, the variables that relate to this complication, and the relationship between hyperglycemia and cardiovascular (CV) disease. Included in the study were 490 kidney recipients, transplanted from 1998 to 2003, without a history of diabetes, and with a pretransplant fasting glucose <126 mg/dL. Within one week post-transplant, 45% of recipients had impaired fasting glycemia (IFG, glucose 100-125 mg/dL), and 21% PTDM (glucose > or =126). One year post-transplant, 33% of patients had IFG, and 13% PTDM. Risk factors for hyperglycemia at one year included: older recipient, male gender, higher BMI, higher pretransplant glucose, and higher glucose one week post-transplant (all P < 0.002 by multivariable analyses). During a follow-up period of 40 +/- 14 months, 12% of recipients had CV events (cardiac, CVA, and/or peripheral). Increasing fasting glucose levels at one, four, and/or 12 months post-transplant were significantly related to CV events. Furthermore, these relationships were independent of other CV risk factors, including: older age, CV events pretransplant, male gender, dyslipidemia, and transplant year. Fasting glucose levels >100 mg/dL were associated with higher incidence of post-transplant cardiac (P= 0.001) and peripheral vascular disease events (P= 0.003). The incidence of post-transplant hyperglycemia and its CV impact have been underestimated. Pretransplant characteristics and, particularly, the glycemia during the first month post-transplant identified patients at risk of PTDM. Increasing glucose levels greater than 100 mg/dL, any time after the first month post-transplant, are associated with increasing CV risk. We postulate that aggressive detection and treatment of post-transplant hyperglycemia may significantly reduce CV morbidity and mortality after kidney transplantation.

Incidence of Coronary Heart Disease and Cardiac Events in Patients Undergoing Kidney and Pancreatic Transplantation

One major cause of graft loss after kidney transplantation or simultaneous kidney and pancreas transplantation is death of the recipient due to cardiac events. Records of 261 patients who underwent sole kidney (group A) or combined kidney-pancreas transplantation (group B) were retrospectively analyzed. Patients were divided into groups with basic cardiac evaluation (chest X-ray, electrocardiogram) and patients with additional diagnostics [echocardiography, exercise stress test, myocardial perfusion test, and coronary angiography (CAG)]. The results of the performed CAGs were as follows: proven coronary artery disease (CAD) in 22 patients (12.43%) in group A and 37 patients (44.05%) in group B; stensosis of one main coronary artery of 70% or greater in 8.47% (group A) and 16.67% (group B) of the patients. Subsequent revascularization procedures were performed in 15 candidates (8.47%) of group A and 11 (13.10%) of group B. The incidence of posttransplant cardiac events (PCE) was lower in recipients in both groups who underwent additional cardiac evaluation. Late postoperative deaths were reported in 3.45% of kidney recipients with no additional evaluation (group A), in 2.06% of patients with further diagnostics (group A), and in only 1.19% of patients with invasive pretransplant evaluation (group B). Patients with known CAD and no further invasive diagnostics or subsequent revascularization are at great risk. PCE were observed in three of seven patients in this subgroup. Careful cardiac evaluation including echocardiography, exercise stress test, myocardial perfusion test, and CAG is associated with a low incidence of PCE.