Cardiovascular Disease Reduction in the Outpatient Kidney Transplant Clinic

Abstract

Cardiovascular disease (CVD) is an important cause of death in kidney transplant recipients. Future CVD mortality was estimated by a risk calculator in all patients (n = = 439) with a functioning transplant (>6 months), followed at our center. In addition to CURRENT mortality rates, an OPTIMAL rate (adding anti-hypertensive and lipid-lowering therapy in uncontrolled patients) and an HISTORIC rate (higher systolic blood pressures and the absence of statin use in our population 5 years ago) were also calculated. Overall, the predicted CUR-RENT CVD mortality rates are 0.82 (95% CI 0.81-0.83) of HISTORIC rates. Predicted OPTIMAL CVD mortality rates are 0.90 (95% CI 0.87-0.92) of CURRENT rates. To achieve OPTIMAL rates, a 27% increase in blood pressure and lipid-lowering drug use is required. There were few contraindications to these medications, implying that physician prescribing was the major barrier to minimizing risk. Despite OPTIMAL rates, the transplant population's relative risk is 2.3 (median, 95% CI 2.1-2.5) times higher than that in the general population. Therefore, targeted therapy to reduce CVD risk can have substantial benefit, but CVD mortality may continue to exceed that in the general population.

Cardiovascular Outcomes in the Outpatient Kidney Transplant Clinic

“…Those without information on smoking or EKG were assumed to be nonsmokers in calculating cardiovascular disease risk (13). b An individual may have more than one cardiovascular disease.…”

“…Although patient reluctance, medication cost, and side effects are important barriers, there still is a significant gap in physician prescribing in our transplant population (13). Clinical inertia is the failure to intensify or add medications when indicated and this has been demonstrated to be quite high for hypertension in our kidney transplant population.…”

“…Many of these patients (n ϭ 439) were described in an earlier report and consisted of prevalent patients followed in the transplant clinic in July 2002 (13). These patients were followed prospectively from this time point onward.…”

“…Unfortunately the clinical utility of these markers and the evidence that specific directed therapy is of benefit are limited if not controversial even in the general population where there has been more intense study (9 -12). Nonetheless a large effort is expended in the clinic to achieve recommended BP and cholesterol targets and use cardioprotective medications [angiotensin converting enzyme inhibitors (ACEi) and/or angiotensin receptor blockers (ARB), ␤-blockers, statins, and acetylsalicylic acid (ASA)] (13,14). Identifying patients in whom more intense therapy is required would be useful, as combined use of these four classes of cardioprotective agents has the potential to reduce cardiac events rates by approximately 75% (15).…”

Ezetimibe for the Treatment of Uncontrolled Hypercholesterolemia in Patients with High-Dose Statin Therapy After Renal Transplantation

“…Hypercholesterolemia as a major contributor of cardiovascular disease is very common in patients after renal transplantation. Although a large clinical trial (ALERT study) and epidemiological data have supported that cholesterol lowering reduces cardiovascular events in this population (6)(7)(8), there are significant difficulties in reaching the cholesterol target levels as recommended by the American Heart Association (AHA) (9)(10)(11) by therapy with statins alone (12). Therapy with statins is often limited due to pharmacologic interactions (e.g.…”