Cumulative risk of cardiovascular events after orthotopic liver transplantation

Abstract

As survival after orthotopic liver transplantation (OLT) improves, cardiovascular (CV) disease has emerged as the leading cause of non-graft-related deaths. The aims of our study were to determine the cumulative risk of CV events after OLT and to analyze predictive risk factors for those experiencing a CV event after OLT. We identified all adult patients who underwent OLT at our institution for end-stage liver disease between October 1996 and July 2008. The cumulative risk of CV events after OLT was analyzed with the Kaplan-Meier method. Multivariate logistic regression analysis was used to identify factors independently associated with CV events after OLT. In all, 775 patients were included in our study cohort (mean age of 53.3 years, female proportion ¼ 44%, Caucasian proportion ¼ 84%, median follow-up ¼ 40 months). The most common indications for OLT were hepatitis C virus (33.2%), alcohol (14.5%), and cryptogenic cirrhosis (12.7%). Eighty-three patients suffered 1 or more CV events after OLT. Posttransplant metabolic syndrome was more prevalent in patients with CV events versus patients with no CV events (61.4% versus 34.1%, P < 0.001). According to a multivariate analysis, independent predictors of CV events were an older age at transplantation [odds ratio (OR) ¼ 1. Posttransplant cardiovascular (CV) complications are the leading cause of non-graft-related death for orthotopic liver transplantation (OLT) patients.1 Although the high incidence of posttransplant CV events is regarded as multifactorial, the increased prevalence of metabolic syndrome, which is attributed to immunosuppressant therapy and end-stage liver disease, likely plays a role. End-stage liver disease leads to metabolic disturbances that alter lipid, glucose, and blood pressure levels considerably; for instance, hepatitis C virus (HCV) has been associated with an elevated risk of diabetes.2 With a national shortage of donors, the selection of candidates who are likely to benefit the most and live the longest after receiving a

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“…9,10 Albeldawi and coworkers showed that components of metabolic syndrome before transplant predicted an increased risk of major cardiovascular events. 11 Payne and associates have shown that regular physical activity improves general health of patients after liver transplant. 12 The relation between physical activity and graft outcomes is understandable in consideration of other related research on the effects of physical activity on health.…”

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

“…CVD is a leading cause of morbidity and nongraft-related mortality in liver and kidney transplant recipients, 287,288 with heart failure (HF), coronary artery disease (CAD), and sudden cardiac death being the most common CVEs impacting on transplant recipients. 289,290 Prevalence of CVEs is likely to increase in liver transplantation with the increasing number of older and higher-risk patients undergoing transplantation.…”

“…Pretransplant risk factors for CVEs include conventional demographic (and nonmodifiable) factors, such as age (young age in kidney transplantation and older age in liver transplantation), sex, race, preexisting conditions, such as diabetes, ischemic heart disease, duration of dialysis for kidney transplant recipients, smoking and general patient health (Figure 12). 289,292,313,314 Posttransplant risk factors for CVEs include NODAT, hypertension, impaired glucose tolerance, 288,289,292,315 impaired kidney function 295,316 and posttransplant hyperglycemia (Table 11 and Figure 12). 317,318 In clinical trials and registry studies in kidney transplantation, hypertension shows a strong association with major adverse cardiovascular event (MACE), as well as graft failure and mortality 289 ; increased systolic and pulse pressuremarkers of vascular stiffness-are specifically associated with cardiac death and stroke.…”

“…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.…”

“…299 Educating patients in lifestyle changes, including the addition of exercise into their daily/weekly routine, reduction of high salt intake and cessation of smoking and alcohol consumption, is important to minimize the risk of cardiovascular complications after transplantation. Risk factors for CVE after liver transplantation 288,304,305,307,316,[322][323][324][325][326][327][328][329][330][331][332][333] Pretransplantation factors…”