Patients with chronic kidney disease, and dialysis patients especially; have a significantly higher cardiovascular morbidity and mortality than healthy people. Kidney transplantation is the best renal replacement therapy available. Compared to dialysis patients, transplant recipients have significantly better long-term survival and quality of life.
Although their cardiovascular risk decreases, cardiovascular complications are still the main cause of shortened patient and organ survival. One recently published review shows current data and derives important conclusions for further long-term improvements in outcomes; after kidney transplantation -a highly topical issue, especially for cost reasons and organ or donor scarcity.
The cardiovascular risk factors
Most of the ‘traditional’ cardiovascular risk factors; are reinforced by chronic kidney disease. Severe disorders of mineral and bone metabolism may also include in the multiple consequences and forms of damage resulting from poor clearance of toxins in the body; the imbalance in the calcium and phosphate metabolism leads to bone decalcification and, parallel to that, to an increase in calcium/phosphate deposits in the cardiovascular system.
This is due not only to existing damage but also to cardiovascular risk factors specific to transplantation. The immunosuppressive drugs that transplant patients; need on a daily basis for the rest of their life may cause metabolic disorders such as post-transplantation diabetes (up to 42% of patients), dyslipidemia (50%); hypertension (up to 90%) (‘de novo traditional CVD risk factors’). Unfortunately, almost one transplant patient out of four continues to smoke.
Non-traditional risk factors include metabolic effects of immunosuppressive therapies, chronic inflammatory responses, infectious complications, chronic anemia, proteinuria, and compromised function of the transplanted kidney resulting in CKD stage 3 or greater).
The side-effects of immunosuppressive
Transplantation aftercare is now focused primarily on preventing organ rejection and the side-effects of immunosuppressive therapies. ‘Early diagnosis and management of the cardiovascular disease is a secondary focus at best and due to complex interactions between traditional risk factors, immunosuppressive medications, and chronic kidney disease, a traditional approach to cardiovascular disease management is inadequate. ´
‘The multi-disciplinary team of physicians needs to work collaboratively to manage cardiovascular disease pre and post-transplant to ensure long-term event-free survival of the patient. In addition, the knowledge gap between the optimal management of cardiovascular disease in a patient with and without CKD must closed with reliable data and evidence on modification of cardiovascular risk factors; a critical issue that is a consequence of kidney patients generally being under-represented in cardiovascular outcome studies.
Medical consensus on optimal procedures
Ultimately, this is the only way to reach a medical consensus on optimal procedures. A new analysis of data in the ERA-EDTA Registry shows that men are by kidney failure much more often than women. In 2016, 26,446 men and 14,820 women started renal replacement therapy. Amongst older patients (>75 years of age); the difference was even more striking; the incidence in men was 2.7 times higher than that in women.
‘One can only speculate about the reasons; explains Professor Ziad Massy. The protective effects of estrogens in women and/or the damaging effects of testosterone; might cause kidney function to decline faster in men than in women. Moreover, elderly women seem to more inclined to choose conservative care instead of RRT.