Cardiovascular Outcomes in the Outpatient Kidney Transplant Clinic

Abstract

Background and objectives: Cardiovascular disease is an important cause of morbidity and death in kidney transplant recipients. This study examines the Framingham risk score's ability to predict cardiac and stroke events. Because cyclosporine and tacrolimus have different cardiovascular risk profiles, these agents were also examined.Design, setting, participants, & measurements: A prospective cohort evaluation of 540 patients were followed for a median of 4.7 yr in an outpatient kidney transplant clinic. Baseline Framingham risk scores were calculated and all cardiovascular outcomes were collected.Results: Rates per 100 patient-years were 1.79 for cardiac and 0.78 for stroke events. The ratio of observed-to-predicted cardiac events was 1.64-fold higher [95% confidence interval (CI) 1.19 to 2.94] for the cohort, 2.74-fold higher (95% CI 1.70 to 4.24) in patients age 45 to 60 with prior cardiac disease or diabetes mellitus, but not higher in other age subgroups. Stroke was not increased above predicted. Risk scores for cardiac (c ‫؍‬ 0.65, P ‫؍‬ 0.003) and stroke (c ‫؍‬ 0.71, P ‫؍‬ 0.004) events were modest predictors. 10-yr event scores for cardiac (9.3 versus 13.5%, P < 0.001) and stroke (7.1 versus 10.0%, P ‫؍‬ 0.002) were lower for tacrolimus compared with cyclosporine-treated patients. However observed cardiac events were higher in tacrolimus recipients (2.50, 95% CI 1.09 to 5.90) in an adjusted Cox model. Conclusions: Although risk scores are only modest predictors, patients with the highest event rates are easily identified. Treating high-risk patients with cardioprotective medications should remain a priority.

Cardiac Disease Evaluation and Management Among Kidney and Liver Transplantation Candidates

“…86 A prospective cohort evaluation of 540 prevalent transplant recipients enrolled at average of 6.6 years after transplantation and followed up for an average of 4.7 years found that the ratio of observed to predicted cardiac events based on the FHS was 1.64 for the cohort overall. 87 Observed cardiac events rates exceeded FHS predictions in patients with pretransplantation diabetes mellitus and those with prior cardiac disease, being 2.74 times the predicted risk in patients 45 to 60 years of age with prior cardiac disease or diabetes mellitus. 87 However, observed risk did not exceed predictions in older patients considered without regard to comorbidity or in younger patients free of prior diabetes mellitus or cardiac history.…”

“…87 Observed cardiac events rates exceeded FHS predictions in patients with pretransplantation diabetes mellitus and those with prior cardiac disease, being 2.74 times the predicted risk in patients 45 to 60 years of age with prior cardiac disease or diabetes mellitus. 87 However, observed risk did not exceed predictions in older patients considered without regard to comorbidity or in younger patients free of prior diabetes mellitus or cardiac history.…”

Clinical Outcomes of ABO-Incompatible Kidney Transplantation in Patients with End-Stage Kidney Disease due to Diabetes Nephropathy

“…However, kidney transplant recipients with diabetes have a higher mortality than those without diabetes because of their elevated risk of cardiovascular complications and infectious complications [2, 3]. Several reports demonstrated that recipients with diabetes had a higher frequency of cardiovascular events and deteriorated patient survival rates [3, 23]. Four patients enrolled in this study had cardiovascular disease before transplantation.…”

Cardiovascular Risk 10 Years After Liver Transplant

“…In kidney transplants, 2 different studies have demonstrated that the Framingham model, which estimates the 10-year risk of fatal and nonfatal coronary event, did not predict absolute ischemic heart disease in the transplant population, particularly in high riskpatients. 25,26 In liver transplant, only 1 study from Germany has performed an external validation of 3 different scores and has demonstrated that SCORE and PROCAM can discriminate liver transplant recipients for their individual risk of cardiovascular events, whereas the Framingham score did not. 27 Neal and associates reported that the predicted 10-year risk of coronary heart disease according to Framingham equation increased from 6.9% before transplant to 11.5% at 1 year after transplant, whereas that of a matched local population was 7%.…”

“…Given they have been developed in the general population, they underestimate the real risk in high-risk groups such as diabetic patients, patients with advanced chronic renal failure, and patients with prior history of cardiovascular events. 26,32,33 Besides, they are not validated in young and/or older populations. For instance, the SCORE system is only recommended for use in a 40-to 65-year age range, 6 so 29% patients of our cohort were not eligible.…”