Long-term evolution, secular trends, and risk factors of renal dysfunction following cardiac transplantation

Abstract

SummaryRecent reports suggest that individuals who underwent heart transplantation in the last decade have improved post-transplant kidney function. The objectives of this retrospective study were to describe the incidence and to identify fixed and time-dependent predictors of renal dysfunction in cardiac recipients transplanted over a 25-year period (1983-2008). To illustrate temporal trends, patients (n = 306) were divided into five groups based on year of transplantation. The primary endpoint was the estimated glomerular filtration rate (eGFR) at year 1. Secondary endpoints were time to moderate (eGFR <60 ml/min/1.73 m 2 ) and severe renal dysfunction (eGFR <30 ml/min/1.73 m 2 ). Risk factor analyses relied on multivariable regression models. Kidney function was mildly impaired before transplant (median eGFR=61.0 ml/min/1.73 m 2 ), improved at discharge (eGFR=72.3 ml/min/1.73 m 2 ; P < 0.001), decreased considerably in the first year (eGFR = 54.7 ml/min/1.73 m 2 ; P < 0.001), and deteriorated less rapidly thereafter. At year 1, 2004-2008 recipients exhibited a higher eGFR compared with all other patients (P < 0.001). Factors independently associated with eGFR at year 1 and with moderate and severe renal dysfunction included age, gender, pretransplant eGFR, blood pressure, glycemia, and use of prednisone (P < 0.05). In summary, kidney function worsens constantly up to two decades after cardiac transplantation, with the greatest decline occurring in the first year. Corticosteroid minimization and treatment of modifiable risk factors (hypertension, diabetes) may minimize renal deterioration.

Everolimus Initiation With Early Calcineurin Inhibitor Withdrawal in De Novo Heart Transplant Recipients: Three-Year Results From the Randomized SCHEDULE Study

“…Improved hemodynamic performance after heart transplantation often results in a short-term increase in renal function, but this is typically followed by a progressive decline over time (2). One in 10 heart transplant patients ultimately develop chronic renal failure (3).…”

“…One in 10 heart transplant patients ultimately develop chronic renal failure (3). Posttransplant renal deterioration is multifactorial in etiology, with pretransplant renal dysfunction (2,4), older age (2) and comorbidities such as diabetes (2,4) known to contribute, but long-term calcineurin inhibitor (CNI) therapy also plays an important role (3,5). A recent meta-analysis of randomized controlled trials in de novo and maintenance heart transplant patients found that reducing CNI exposure significantly improved posttransplant renal function (6).…”

Thymoglobulin induction in heart transplantation: patient selection and implications for maintenance immunosuppression

“…As would be expected, patients with poor kidney function pretransplant are significantly more likely to show deteriorating renal function after heart transplantation . Other risk factors include older age and possibly the presence of diabetes or hyperglycemia .…”

“…By 10 years, chronic kidney disease stage 3A or worse is almost universal [19] and approximately 10% of heart transplant patients eventually progress to chronic renal failure [23]. As would be expected, patients with poor kidney function pretransplant are significantly more likely to show deteriorating renal function after heart transplantation [20,21,24]. Other risk factors include older age [21,25] and possibly the presence of diabetes or hyperglycemia [20,21].…”

Does Renal Dysfunction and Method of Bridging Support Influence Heart Transplant Graft Survival?

“…If the GFR remains less than 45 despite attempts at improving renal dysfunction, proceeding with isolated HT may carry increased risk of worse survival and should be balanced by consideration of HKT in collaboration with transplant nephrologists versus continuation of LVAD support as destination therapy. If isolated HT in the setting of significant renal dysfunction is chosen, aggressive comorbidity management (diabetes and hypertension) delaying or minimizing calcineurin inhibitor use through induction therapy and innovative combinations of immunosuppressive therapy (and steroid minimization) should be considered [30].…”