Incidence, risk factors, and outcomes of stroke post‐transplantation in patients receiving a steroid sparing immunosuppression protocol

Abstract

Corticosteroid use after transplantation is associated with an increased incidence of cardiovascular events and death. Cerebrovascular disease is a common cause of morbidity and mortality post-renal transplantation; however, a dedicated analysis of cerebrovascular disease in recipients of a steroid sparing protocol has not been reported. The aim of this study was to examine the incidence, risk factors, and outcomes of CVA in transplant recipients receiving a steroid sparing protocol. We retrospectively analyzed 1237 patients who received a kidney alone or a simultaneous pancreas and kidney (SPK) transplant. Fifty-six of 1237 (4.53%) patients had a CVA post-transplant. All-cause mortality was significantly higher in the CVA group compared with the non-CVA group, OR: 3.4 (1.7-7.0), p < 0.001. Factors found to be associated with increased risk of CVA by multivariate analysis were older age, HR: 1.07 (1.04-1.09), p < 0.001; diabetes at the time of transplantation, HR: 2.83 (1.42-5.64), p = 0.003; corticosteroid use pre-transplant, HR: 3.27 (1.29-8.27), p = 0.013 and recipients of a SPK, HR: 4.03 (1.85-8.79), p < 0.001. This study has identified subgroups of patients who are at increased risk of CVA post-transplant in patients otherwise receiving a steroid sparing immunosuppression protocol.

Cardiovascular risk factors following renal transplant

“…Patients with chronic kidney disease (CKD), and those on dialysis in particular, have an elevated cardiovas cular (CV) risk compared to the general population [13] , with haemodialysis (HD) patients having a 1020 times increased risk of cardiovascular disease (CVD) mor tality [4] . The preferred method of renal replacement therapy is currently renal transplantation as this confers improved survival rates compared to those patients on HD or peritoneal dialysis [5] .…”

“…Cerebrovascular events are comprised of ischaemic and haemorrhagic strokes and are less common than cardiac events but still have an increased incidence compared to the general population. They represent a significant cause of morbidity, with a prevalence of around 4.5%, and ischaemic strokes account for 89%, with the remainder being classed as haemorrhagic or due to a subarachnoid haemorrhage [13] . The tenyear cumulative incidence of lowerlimb peripheral vascular occlusive disease (PVOD) in RTRs is 5.9% and the overall survival and graft-survival rates are significantly lower than that of RTRs who do not have PVOD [14] .…”

Neurological complications of renal dialysis and transplantation

“…Cardiovascular and cerebrovascular disorders remain the leading causes of mortality resulting in ‘death with a functioning allograft’ 41. Most studies report an increased risk of ischaemic (rather than haemorrhagic) strokes but mortality is higher with haemorrhagic events 42 43.…”

“…A retrospective analysis of more than 1000 patients from our unit found that 4.5% of people who received a kidney alone or a simultaneous pancreas and kidney transplant had a stroke post-transplant 41. Predictors of stroke were age, diabetes mellitus, corticosteroid use and simultaneous pancreas and kidney transplantation.…”

“…Transplant-specific risk factors for stroke included graft failure, immunosuppression, long duration on dialysis pretransplant and deceased donor transplantation 41. However, transplant appears to lead to an overall improvement in cerebrovascular risk compared with dialysis patients 43…”