Cardiovascular disease after liver transplantation: When, What, and Who Is at Risk

Abstract

The evolution of metabolic and cardiovascular disease (CVD) complications after liver transplantation (LT) is poorly characterized. We aim to illustrate the prevalence of obesity and metabolic syndrome (MS), define the cumulative incidence of CVD, and characterize risk factors associated with these comorbidities after LT. A retrospective review of 455 consecutive LT recipients from 1999 to 2004 with an 8-to 12-year follow-up was performed. Obesity increased from 23.8% (4 months) to 40.8% (3 years) after LT. Increase in body mass index predicted MS at 1 year after LT (odds ratio, 1.1; P < 0.001, per point). CVD developed in 10.6%, 20.7%, and 30.3% of recipients within 1, 5, and 8 years, respectively. Age, diabetes, hypertension, glomerular filtration rate < 60 mL/minute, prior CVD, ejection fraction < 60%, left ventricular hypertrophy, and serum troponin (TN) > 0.07 ng/mL were associated with CVD on univariate analysis. Age (hazard ratio [HR], 1.03; 95% confidence interval [CI], 1.01-1.06; P 5 0.019), diabetes (HR, 1.78; 95% CI, 1.09-2.92; P 5 0.022), prior history of CVD (HR, 2.46; 95% CI, 1.45-4.16; P < 0.001), and serum TN > 0.07 ng/mL (HR, 1.98; 95% CI, 1.23-3.18; P 5 0.005) were independently associated with CVD in the long term. Smoking history (ever), sex, hyperlipidemia, and serum ferritin levels were not predictive of CVD. Tacrolimus use versus noncalcineurin-based immunosuppression (HR, 0.26; 95% CI, 0.14-0.49; P < 0.001) was associated with reduced risk of CVD but not versus cyclosporine (HR, 0.67; 95% CI, 0.30-1.49; P 5 0.322). CVD is common after LT. Independent of MS, more data are needed to identify nonconventional risk factors and biomarkers like serum TN. Curbing weight gain in the early months after transplant may impact MS and subsequent CVD in the long term. Liver Transpl 21:889-896, 2015. V C 2015 AASLD.Received December 31, 2014; accepted March 22, 2015. See Editorial on Page 870Patient selection for liver transplantation (LT) is a multifaceted process aimed at identifying those at highest risk of poor outcomes. Many patients are excluded as candidates because of severe metabolic syndrome (MS) or cardiovascular disease (CVD). Despite exclusion of these individuals, LT recipients remain at high risk for development of CVD, but the risk is poorly characterized. Obesity and MS are more common in LT recipients than in the general

Cardiovascular diseases after liver transplantation—a still emerging and unsolved problem!

“…In summary, this study by Fussner et al 10 from the Mayo Clinic provides new, clinically relevant information regarding the prevalence of CVD, its impact on the short-and long-term outcome as well as potential risk factors. However, more data from larger, prospective studies are needed both to identify patients with high risk of CVD and to optimize the post-LT management in order to minimize MS and CVD and to further improve the long-term outcome of LT recipients.…”

“…In the current issue of Liver Transplantation, Fussner et al 10 provide interesting data regarding the cumulative incidence of obesity, MS, and CVD and potential risk factors associated with these morbidities following LT. In this single-center, retrospective study, 455 patients were included.…”

Practical Recommendations for Long-term Management of Modifiable Risks in Kidney and Liver Transplant Recipients

“…305,306 A retrospective review of 455 consecutive liver transplant patients has shown that despite the exclusion of high CV risk candidates for liver transplantation, CVD occurs in 10.6% of liver transplant recipients at 1 year, 20.7% at 5 years, and 30.3% at 8 years posttransplant. 307 Fatal and nonfatal CVEs can also persist into the second decade postliver transplant. 308 …”

“…295 For liver transplant recipients, diabetes and hypertension are each associated with an approximate twofold higher risk of experiencing a CVE posttransplant (multivariate analysis). 288 In liver transplantation, diabetes has also been linked with long-term CVD, 307 with duration of diabetes, but not hypertension or hyperlipidemia, shown to be an independent predictor of long-term mortality due to the combination of CVE, recurrent HCV, and infection. 330 The evaluation of inflammatory markers also suggests that patients are at high cardiovascular risk after liver transplantation.…”

Risk factors and outcomes of carbapenem‐resistant Klebsiella pneumoniae infections in liver transplant recipients

“…2 Whether the patients were excluded from the candidate list before LT or not, some cardiovascular risk factors could be overlooked due to end-stage liver disease. 2 Fussner et al 3 pointed out that more than 30% of their transplant recipients had a risk of cardiovascular disease, including coronary artery disease, congestive heart failure, stroke or transient ischemic attack, arrhythmias, cardiac arrest, and symptomatic peripheral vascular disease, despite the exclusion of high cardiovascular risk candidates.…”