Metabolic Syndrome Is Related to Long-Term Graft Function in Renal Transplant Recipients

The metabolic syndrome (MS) is a known cardiovascular risk factor in the general population and a common problem among renal transplant recipients. This study investigated whether MS after renal transplantation affected long-term graft function.We included 112 transplants at our center between 2000 and 2002. We excluded patients with the presence of pretransplant diabetes or nonstable renal function at 1 year after transplantation. We evaluated parameters such as demographic features, medications, smoking history, body mass index, daily proteinuria, blood pressure, number of HLA mismatches, number of acute rejection episodes, delayed graft function, and laboratory parameters. Patients were followed for a mean of 69.86 ± 21.94 months. The prevalence of MS was determined using the National Cholesterol Education Program—Adult Treatment Panel III criteria.At 1 year after transplant, 28.6% of subjects had MS, whereas only 10.7% had MS before transplantation. Among 27.7% of patients graft failure had occurred during the follow-up; MS was more frequent among these individuals compared with those displaying stable renal function (51.6% vs 19.8%; P = .002). Older donor age, delayed graft function, acute rejection episodes, smoking history, MS, proteinuria, serum creatinine level, and C-reactive protein were associated with graft failure. Upon multivariate Cox regression analysis, patients with MS at 1 year after transplantation showed an increased risk for graft failure (relative risk, 0.22; 95% confidence interval, 0.06-0.75; P = .016). Older donor age and proteinuria level were other independent risk factors for graft failure.The MS was a prominent risk factor for graft failure. Because MS is a cluster of modifiable risk factors, early identification of patients at risk and intervention in due time may improve graft survival.     

Anaemia is common after kidney transplantation, especially among African Americans.

BACKGROUND: Anaemia is a major cardiovascular risk factor in renal disease. It might be appropriate to extrapolate this association of anaemia with cardiovascular disease to renal transplant recipients who continue to have a significant cardiovascular risk. There are very few studies addressing the issue of anaemia after renal transplantation. METHODS: We studied 192 consecutive kidney transplant recipients over a 5-year period in a tertiary referral centre in Michigan, USA. Patients who were followed up at the ambulatory transplant clinic for at least 1 year after transplantation were studied. Haemoglobin (Hb) level at 6 months and 1 year after renal transplantation was recorded. Risk factors for anaemia were evaluated using multivariate regression analysis. RESULTS: Significant anaemia (Hb <11 g/dl in females and <12 g/dl in males) was common (19.3% at 6 months, 19.8% at 1 year). Anaemia was more common in African American (AA) than in non-AA patients both at 6 months and 1 year after transplantation. Multivariate analysis showed that serum creatinine was an independent risk factor for anaemia. Female gender was associated with significant anaemia at 1 year. Intriguingly, AA race was also an independent risk factor at 6 months and strong trend for risk at 1 year. CONCLUSIONS: Anaemia is common during the first year after kidney transplantation. AA race as well as high serum creatinine and female gender are independent risk factors for post-transplant anaemia. The importance of anaemia as a risk factor in AA patients after renal transplantation should be more recognised.     

The association between cytomegalovirus infection and atherosclerotic events in renal transplant recipients

Cytomegalovirus (CMV) infection is a risk factor for arteriosclerosis in renal transplant recipients. We sought to investigate the effects of CMV infection on atherosclerotic events (AE) in renal transplant recipients. This retrospective analysis included 200 patients: 52 women and 148 men of overall mean age of 36.18 +/- 10.23 years who were transplanted at our center between 1998 and 2001. We analyzed demographic features, dialysis duration, diabetes, blood pressure level, body mass index (BMI), medications, and lipid parameters. CMV infection was diagnosed in 23.5% of patients in the first 2 years after transplantation; these patients were followed for 4 years. All patients had been assessed for AE, including previous myocardial infarction, angina, revascularization procedures, intermittent claudication, stroke, or transient ischemic attack. AE occurred in 13% during the follow-up period. CMV infection was more frequent among these patients compared to those without AE, namely 42.3% versus 20.6%, respectively. Although the gender, dialysis duration, serum cholesterol level, presence of acute rejection, and BMI were not associated with AE, age, hypertension, and CMV infection did show a relation. A multivariate analysis by logistic regression revealed mean age and CMV infection to be independent risk factors for AE: odds ratio (OR)=5.6, 95% confidence interval (CI)=1.3 to 24.6 (P=0.02) and OR=4, 95% CI = 1.3 to 12.3 (P=.01). This study suggested that the presence of CMV infection may be a triggering factor for AE in renal transplant recipients.     

Gastric bypass in morbidly obese patients with chronic renal failure and kidney transplant

BACKGROUND: Morbid obesity occurs frequently in patients with renal failure and is associated with an increased mortality, particularly from cardiovascular disease, as well as a marked increase in comorbid conditions affecting quality of life. Morbid obesity is also associated with an increased risk of complications and death in transplant patients and is often a cause for denial for access to transplantation. METHODS: Thirty morbidly obese patients with chronic renal failure or transplantation underwent gastric bypass (GBP). Nineteen patients had chronic renal failure at the time of GBP, eight had transplantation followed by GBP, and three had GBP and then transplantation. RESULTS: The reduction in excess body mass index (above 25) after GBP at 1, 2, and 3 years was similar to patients without transplantation or chronic renal failure, approximately 70% at 1 year. Comorbid conditions were diminished in each subset of patients, decreasing their risk for potential cardiovascular complications. One patient died 7.9 years after a GBP and 6.1 years after transplantation from cardiovascular disease related to longstanding diabetes that was present before her renal failure. CONCLUSIONS: GBP is a safe and effective means for achieving significant long-term weight loss and relief of comorbid conditions in patients with renal failure on dialysis, in preparation for transplantation, or after transplantation.     

Impact of the metabolic syndrome on long-term outcomes in simultaneous kidney-pancreas transplantation

The metabolic syndrome (MS) has been implicated as an important nonimmunologic risk factor for chronic renal transplant dysfunction. The aim of this study was to determine the impact of the MS on outcomes in simultaneous kidney-pancreas transplantation (SKPT). Data were available on 241 patients enrolled in a prospective, multicenter randomized study of daclizumab compared with no antibody induction in SKPT. Presence of MS before and after SKPT was defined using NCEP-ATP III (National Cholesterol Education Program Adult Treatment Panel III) criteria. Body mass index (BMI) was used as a surrogate for waist circumference. MS was present in 59% of patients pretransplantation but only in 19% of patients 1 year after SKPT (P < .0001). Demographic and transplant characteristics were well matched for those with MS (MS+) and without MS (MS-) at 1 year. Presence of MS at 1 year was associated with the following changes at 3 years: increased serum creatinine level (1.65 mg/dL MS- vs 2.05 mg/dL MS+; P = .13); decreased modification of diet in renal disease calculated glomerular filtration rate (GFR; 58 mL/min MS- vs 48 mL/min MS+; P = .02); increased HgbA1C level (5.6% MS- vs 6.6% MS+; P < .001); and lower pancreas graft (PG) survival rate (88% MS- vs 71% MS+; P = .01). Linear regression analysis identified MS+ and the subgroup of MS+ without functioning PG at 1 year as independent risk factors for renal dysfunction, whereas MS+ with functioning PG at 1 year was not a risk factor for renal dysfunction. Presence of MS at 1 year is associated with long-term renal dysfunction after SKPT. Efforts to decrease early PG failure may help mitigate against MS-associated renal dysfunction.     

Associations between pre‐kidney‐transplant risk factors and post‐transplant cardiovascular events and death

The prevalence of cardiovascular risk factors in renal transplant candidates is high. A better understanding of the relation between these risk factors and cardiovascular morbidity and mortality is mandatory to improve transplantation outcome. In this retrospective cohort study 2187 adult patients who received a first kidney transplant between 1984 and 1997 were included. We analyzed the incidence of post‐transplant cardiovascular events and tried to identify independent pretransplant risk factors for post‐transplant cardiovascular events and all‐cause mortality. The cumulative incidence of post‐transplant cardiovascular events was 40%. The incidence was highest in the first 3 months after transplantation. Independent pretransplant risk factors for a post‐transplant cardiovascular event were diabetic nephropathy [Hazard ratio (HR) 3.02; 95% CI 2.85–3.98], claudication [HR 2.17 (1.42–3.31)], cardiac event [HR 1.76 (1.32–2.33)], cerebrovascular accident HR 1.53 (1.03–2.28), time‐on‐dialysis [HR 1.06 (1.02–1.11)], recipient age [HR 1.04 (1.04–1.05)], and body mass index [HR 1.03 (1.00–1.05)]. Diabetic nephropathy and cardiovascular disease were also important predictors for all‐cause mortality. Diabetic nephropathy and cardiovascular disease were the most important predictors for cardiovascular events and all‐cause mortality after renal transplantation. Early treatment of cardiovascular risk factors and pretransplant cardiovascular evaluation might improve transplantation outcome.     

Cardiovascular risk factors in diabetic patients with renal transplants

There is a progressive increase in cardiovascular events post-renal transplantation and diabetes mellitus (DM) is one of the major cardiovascular risk factors. The objective of this study was to analyze the prevalence of cardiovascular risk factors and nonfatal cardiovascular events among renal transplant recipients, according to the status of their carbohydrate metabolism. We studied 214 renal transplant recipients, among whom 18% diabetic and 82% were nondiabetic. The 16% prevalence of cardiovascular events were higher among the posttransplantation DM (PTDM) group (33%) compared with the other groups, 19% in pre-renal transplantation DM, 17% in altered baseline glycemia, and 13% in normal patients. Diabetic renal transplant recipients showed a greater prevalence of pretransplantation ischemic cardiopathy when they were older and had a higher pretransplantation body mass index (BMI) a heavier smoking habit, significantly increased microinflammation markers, and a greater need for antihypertensive and hypolipidemic treatment. Renal transplant recipients with altered baseline glycemia show greater BMI after transplantation, as well as higher Hb1Ac than patients with normoglycemia.     

Metabolic syndrome, insulin resistance, and chronic allograft dysfunction

Metabolic syndrome (MS) is a cluster of cardiovascular (CV) risk factors (hypertension, dyslipidemia, obesity, and glucose homeostasis alterations), and insulin resistance (IR) is suggested to be a common pathogenic background. In the general population, MS and IR have been proven to be risk factors for diabetes, CV disease, and chronic kidney disease. In the renal transplant setting, few studies have analyzed the relevance of MS and IR. According to the few data available, the prevalence of MS in renal transplant patients has been described as 22.6% at 12 months, 37.7% at 36 months, and 64% at 6 years after transplantation. Importantly, MS has been shown to be an independent risk factor for chronic allograft dysfunction (CAD), graft failure, new-onset diabetes, and CV disease. Also, persistent hyperinsulinemia during the first posttransplant year has been related to an increase in glomerular filtration rate, probably reflecting glomerular hyperfiltration as observed in prediabetes and early type 2 diabetes. Importantly, prediabetes (impaired fasting glucose and impaired glucose tolerance), a state hallmarked by IR, proved to be highly frequent among stable renal transplant recipients (30%), which is nearly three times its incidence in the general population. Posttransplant IR has been associated with subclinical atheromatosis as assessed by carotid intima-media thickness, and with chronic subclinical inflammation. In conclusion, MS and IR are important modifiable risk factors in renal transplant recipients, and prompt interventions to avoid its deleterious effects at the metabolic, CV, and graft function levels are needed.     

Metabolic syndrome and new onset diabetes after transplantation in kidney transplant recipients

Luan FL, Langewisch E, Ojo A. Metabolic syndrome and new onset diabetes after transplantation in kidney transplant recipients.
Clin Transplant 2010: 24: 778–783. © 2009 John Wiley & Sons A/S. Abstract: Background: Metabolic syndrome (MS) and new onset diabetes after transplant (NODAT) are common in kidney transplant patients. We studied the relationship between the two conditions and their impact on metabolic and cardiovascular risk profiles. Methods: All non‐diabetic patients transplanted between 1999 and 2005 who were followed up to 2006 were included. MS and NODAT were determined. Kaplan–Meier survival and various regression analyses were performed to determine the clinical correlates for both conditions and their association with various cardiovascular risk factors. Results: Among 591 patients, 314 (53.1%) had MS and 90 (15.2%) developed NODAT. The two conditions were highly associated with each other as 84 patients with NODAT also had MS (14.2%). Elevated body mass index and fasting glucose levels at transplant were risk factors for both conditions, whereas weight gain after transplant was associated only with MS. African American, old age, and hypertension‐related ESRD were risk factors for NODAT. Finally, the presence of MS was associated with reduced kidney function and elevated uric acid levels, whereas the presence of NODAT with elevated pulse pressure. Conclusions: MS and NODAT are highly prevalent and significantly associated with impaired metabolic and cardiovascular risk profiles. Early identification of such conditions may facilitate targeted therapeutic intervention.     

Sleep Disordered Breathing in Renal Transplant Patients

Sleep disordered breathing (SDB) is a prevalent, important nontraditional cardiovascular (CV) risk factor in end-stage renal disease patients. The prevalence of SDB in renal transplant patients is unknown. We compared polysomnographic studies in 163 transplant patients with matched samples in the general population and explored longitudinally the effect of return to dialysis after graft failure on SDB in three consecutive cases. Episodes of nocturnal hypoxemia, average and minimal O₂ saturation overnight in transplant patients did not differ from those in individuals in the general population matched for age, gender and body mass index (BMI). The prevalence of moderate-to-severe SBD in these patients did not exceed the estimated prevalence of the same disturbance in the general population. The respiratory disturbance index in transplant patients was directly associated with BMI (p < 0.001). In the longitudinal study all indicators of SDB coherently increased after transplant failure. The prevalence of SDB in transplant patients does not differ from that in well-matched individuals in the general population. The favorable effect of renal transplantation on CV risk may be at least partially explained by the lack of risk excess for SDB in this population. Longitudinal observations after transplant failure are compatible with the hypothesis that renal transplantation reverses SDB.     

Cardiovascular morbidity and mortality in patients with diabetes mellitus type I after kidney transplantation: a case-control study

BACKGROUND: The proportion of diabetics among patients requiring renal replacement therapy continues to increase in most western countries. The acceptance rate for renal transplantation varies among transplant centers and is influenced by the current opinion on the outcome of transplantation in diabetics. Controlled data on patient and graft survival in type I diabetics, however, are scarce. METHODS: We performed a retrospective case-control analysis on patient and graft survival and the cardiovascular morbidity of patients with type I diabetes after renal transplantation versus carefully matched non-diabetic transplant recipients. Match criteria were duration of previous hemodialysis, age and date of renal transplantation. Moreover, risk factors for cardiovascular disease in uremic patients were evaluated at the time of registration for renal transplantation and at the end of the observation period. RESULTS: Seventy-seven matched pairs were enclosed. Patient survival was significantly worse in the diabetic patients, graft survival was comparable in both groups, when graft loss because of patient's death was censored. In the diabetic patients, risk of death (odds ratio: 4.38) as well as the prevalence of cardiovascular morbidity (odds ratio: 4.47) were significantly higher than in the matched nondiabetic controls. Cox regression analysis showed that diabetes mellitus was an independent risk factor for patient survival; no association was found with hypertension, hyperlipidemia, hyperparathyroidism, calcium x phosphate product, body mass index and HbA1c. Cardiovascular morbidity, however, was already significantly higher in the diabetic group at the time of registration. CONCLUSIONS: Diabetes mellitus type I has a dominant impact on morbidity and mortality after renal transplantation and is associated with an approximately 4-fold higher risk of death. Cardiovascular disease accounts for the significantly worse long-term outcome of diabetic patients after renal transplantation.     

The risk of cardiovascular disease associated with proteinuria in renal transplant patients

Proteinuria in the general population has been shown to be associated with cardiovascular disease, which is the main cause of death in renal transplantation. We investigated the effect of proteinuria on cardiovascular disease after renal transplantation in 532 renal transplant patients with functioning grafts for more than 1 year. Patients were classified into two groups depending on the presence of persistent proteinuria. We analyzed graft and patient survival, posttransplantation cardiovascular disease, and main causes of graft loss and death. Five- and 10-year graft and patient survival rates were lower in the group with proteinuria. The main cause of death was vascular disease in both groups. The presence of posttransplantation cardiovascular disease was higher in the group with proteinuria. Persistent proteinuria was associated with graft loss (RR=4.18), patient death (RR=1.92), and cardiovascular disease (RR=2.45). In conclusion, persistent proteinuria was an independent risk factor for increased cardiovascular morbidity and mortality in renal transplant patients.     

Effects of successful renal transplantation on left ventricular mass

Left ventricular hypertrophy is an independent cardiovascular risk factor in the general population and in patients with chronic renal failure. Relatively little is known about the effects of renal transplantation on left ventricular hypertrophy. The aim of this study was to determine the changes in left ventricular mass after successful renal transplantation and to evaluate the importance of some clinical, laboratory, and echocardiographic variables on the trend to left ventricular hypertrophy. Twenty-three patients with end-stage renal disease were studied by ambulatory blood pressure monitoring and echocardiography before and 2 years following renal transplantation. After 24 months of follow-up, all transplant recipients had adequate renal function (serum creatinine <2 mg/dL). At the end of the study, we observed a significant decrease in left ventricular mass and left ventricular mass index compared to the pretransplantation period. In renal transplant recipients, the prevalence of left ventricular hypertrophy significantly decreased (78% versus 44%, P < .03) after 2 years of follow-up. Systolic 24-hour blood pressure was the only predictor of left ventricular mass and of left ventricular mass index at 2 years after transplantation. In conclusion, successful renal transplantation produces a regression of left ventricular hypertrophy. This beneficial effect depends on a decrease in systolic pressure levels.     

New-onset gout after kidney transplantation: incidence, risk factors and implications

BACKGROUND: Although cyclosporine use has been associated with an increased risk of new-onset gout after renal transplantation, the incidence and risk factors for new-onset gout have not been reported in the era of modern immunosuppression. METHODS: We conducted a retrospective cohort study of Medicare primary renal transplant patients reported in the United States Renal Data System (USRDS), using Medicare claims data to determine the incidence of new-onset gout. Cox regression analysis was used to calculate adjusted hazard ratios (AHR) for cyclosporine (including separate analysis of Neoral) compared directly with tacrolimus, for the risk of new-onset gout, adjusted for baseline demographic factors and posttransplant renal function. RESULTS: The cumulative incidence of new-onset gout was 7.6% at 3 years posttransplant. The following factors were independently associated with an increased risk of new-onset gout: use of Neoral (vs. tacrolimus, AHR 1.25, 95% CI 1.07-1.47) at discharge, recipient male sex (AHR 1.44, 95% CI 1.25-1.67), older age, higher body mass index, and more recent year of transplant. No other immunosuppressive medications were associated with new-onset gout. Diabetes was associated with a significantly lower risk of new-onset gout. The development of new-onset gout was independently associated with decreased patient survival (AHR 1.26, 95% CI 1.08-1.47) as well as death-censored graft survival. CONCLUSIONS: Cyclosporine is an independent risk factor for new-onset gout after transplantation. The incidence of new-onset gout appears to be increasing even while the use of cyclosporine is decreasing, and the development of new-onset gout was an independent predictor for death and graft loss in this population.     

Incidence of cardiovascular risk factors and complications before and after kidney transplantation

BACKGROUND: Cardiovascular disease is a leading cause of death after renal transplantation with an incidence considerably higher than that in the general population. The aim of this study was to evaluate the association of atherosclerotic cardiovascular complications and the prevalence of cardiovascular risk factors prior to and following transplantation. PATIENTS AND METHODS: Atherosclerotic cardiovascular diseases including coronary artery disease, as well as cerebral and peripheral vascular disease, and cardiovascular risk factors pre- and posttransplantation were analyzed in 500 renal transplant recipients between 1988 and 1992. The mean recipient age at transplantation was 45 +/- 12 years, with 58% men and 7% diabetics. RESULTS: Following transplantation 11.7% developed atherosclerotic cardiovascular diseases, the majority being coronary artery disease (9.8%). Comparison of the risk factors before and after transplantation showed the increased prevalence of systemic hypertension to be 67% to 86%, of diabetes mellitus, 7% to 16%, and obesity, with a body mass index > 25 kg/m2 from 26% to 48%, whereas the number of smokers was halved to 20%. The triglycerides decreased significantly (from 235 +/- 144 mg/dL to 217 +/- 122 mg/dL) but the total and high-density lipoprotein (HDL) cholesterol rose significantly (from 232 +/- 65 mg/dL to 273 +/- 62 mg/dL and from 47 +/- 29 mg/dL to 56 +/- 21 mg/dL, respectively). The low-density lipoprotein (LDL) cholesterol increase was insignificant (from 180 +/- 62 mg/dL to 189 +/- 53 mg/dL). Upon univariate analysis, cardiovascular diseases were significantly associated with male gender; age over 50 years; diabetes mellitus (DM); smoking; total cholesterol > 200 mg/dL; LDL cholesterol > 180 mg/dL; HDL cholesterol < 55 mg/dL; fibrinogen > 350 mg/dL; body mass index > 25 kg/m2; and more than two antihypertensive agents per day. The Cox proportional hazards model revealed DM with a relative risk (RR) of 4.3; age > 50 years (RR = 2.7); body mass index > 25 kg/m2 (RR = 2.6); smoking (RR = 2.5); and LDL cholesterol > 180 mg/dL (RR = 2.3) as independent risk factors. CONCLUSIONS: The high incidence of cardiovascular disease following renal transplantation is mainly due to a high prevalence and accumulation of classical risk factors before and following transplantation. The treatment of risk factors must be introduced early in the course of renal failure and continued following transplantation. Future prospective studies should evaluate the success of treatment regarding reduction of cardiovascular morbidity and mortality in this high-risk population.     

Metabolic syndrome after kidney transplantation

BACKGROUND: Metabolic syndrome (MS) includes some risk factors for development of diabetes and cardiovascular disease, obesity (BMI > 30), high triglycerides, low HDL cholesterol, hypertension and impaired glucose tolerance. Following the definition of the Adult Treatment Panel III criteria, a diagnosis of MS was established when 3 or more factors were present. In renal transplant patients MS has been reported to negatively influence both patient and graft survivals. The present study sought to verify the effect of MS among our cases. METHODS: 298 cadaveric renal transplant recipients operated between January 1, 1996 and December 31, 2001 with absence of diabetes before transplantation, stable renal function 1 year posttransplantation and at least 4 years follow up were retrospectively evaluated from the end of the first post-operative year. RESULTS: 50 patients out of 298 (16,7%) had MS at the beginning of the study, including 37 of them with 3 and 13 with 4 risk factors. Only one patient with MS died of cardiovascular disease. Graft failure was observed in 23.5% MS patients versus 9,7% patients without the Syndrome (p:n.s.) Only Creatinine and the incidence of Cardiovascular Diseases at 4 years were statistically higher in MS patients (P < .001). CONCLUSIONS: These results suggested that MS is a risk factor for increasing CVD morbidity and decreased graft function, but early treatment of risk factors as soon as they become apparent can limit the adverse effects on patient and graft survival.     

Metabolic syndrome and cardiovascular disease in kidney transplantation

Introduction

Metabolic syndrome (MS) is an important cardiovascular risk factor. The aim of this study was to evaluate the incidence of MS in an Italian kidney transplant recipient population and its relationship to the incidence of major adverse cardiovascular events (MACE) after renal transplantation.

Methods

The prevalence of MS was evaluated according to the National Cholesterol Education Program Adult Treatment Panel III criteria among adult recipients who underwent a renal transplant between January 1997 and December 2007. In this period, we prospectively recorded the incidence of MACE to be related to the presence of MS.

Results

We included 425 kidney transplant recipients in the study including 62% males and an overall median age 46 years (interquartile range = 36-54). The prevalence of MS was 41.2% at 6 months after transplantation and 46.6% at 5 years. During the follow-up (median = 5.1 years), 32 patients (7.5%) experienced at least one MACE. The detection of MS at 6 months after transplantation was significantly associated with an increased risk of MACE occurrence (MS IRR = 2.2 P = .05).

Conclusions

Our findings indicated that MS was largely present in the transplant population confirming that as in the general population, it was a significant risk factor for the occurrence of severe cardiovascular disease. Early identification and treatment of patients with MS may improve long-term patient survival.     

Metabolic Syndrome Is Associated with Impaired Long-term Renal Allograft Function; Not All Component criteria Contribute Equally

Chronic renal transplant dysfunction (CRTD) remains a leading cause of renal allograft loss. Evidence suggests that immunological and ischemic insults are mainly associated with CRTD occurring within the first year after transplantation, whereas nonimmunological insults are predominantly associated with CRTD beyond the first year. Several cardiovascular risk factors, such as obesity, dyslipidemia, hypertension, and diabetes mellitus have been identified as important nonimmunological risk factors for CRTD. These risk factors constitute the metabolic syndrome (MS). As renal allograft function is a surrogate marker of renal allograft loss, we investigated the association of MS with impairment of renal allograft function beyond the first year after transplantation in a cross-sectional study of 606 renal transplant outpatients. Metabolic syndrome was defined using the definition of the National Cholesterol Education Program. Renal allograft function was assessed as the 24-h urinary creatinine clearance. A total of 383 out of 606 patients (63%) suffered from MS at a median time of 6 years (2.6-11.4) post-transplant. Presence of MS was associated with impaired renal allograft function beyond 1 year post-transplant [-4.1 mL/min, 95%CI (-7.1, -1.1)]. The impact of MS did not change appreciably after adjustment for established risk factors for CRTD [-3.1 mL/min, 95%CI (-6.0, -0.2)]. However, not all component criteria of MS contributed equally. Only systolic blood pressure and hypertriglyceridemia were independently associated with impaired renal allograft function beyond 1 year post-transplant in multivariate analyses.     

Antiphospholipid antibodies after renal transplantation and cardiovascular disease

Abstract: Background: The aim was to assess the presence of pre‐ or post‐transplant serum antiphospholipid antibodies (APA) and its association with the development of cardiovascular disease (CVD) in renal transplantation. Methods: We studied 138 patients transplanted with a cadaver kidney graft between 1990 and 1998 and with a graft functioning for longer than one yr. One pre‐transplant sample and another obtained after transplantation from our serum bank were analyzed. The ELISA used were set up in our laboratory, following established international guidelines, and results were confirmed in three different runs. Results: 23.9% and 31.2% of patients had pre‐ and post‐transplant positive titers of APA, respectively. 16% developed those antibodies de novo after transplantation. Post‐transplant CVD was observed in 20.3% of patients but they were not associated with the production of APA in the whole population studied. However, multivariate analysis demonstrated an increased risk (RR 2.27; p = 0.02) for CVD when APA were produced after acute rejection. Conclusions: The presence of serum APA alone was not an independent risk factor for CVD after kidney transplantation. Nonetheless, in kidney recipients who produced APA de novo after acute rejection, the control of cardiovascular risk factors must be intensified.     

Incidence and risk factors for the metabolic syndrome and posttransplant diabetes in renal transplant recipients taking tacrolimus

Objectives

We investigated the incidence and risk factors for the metabolic syndrome (MS) and posttransplant diabetes mellitus (PTDM) among renal transplant recipients on tacrolimus-based immunosuppressive regimens during the first year posttransplant. In addition, we studied the relationship between MS and PTDM with transplant renal function at 1 year.

Methods

We included the 100 patients who received a renal transplant in our unit between January 2007 and June 2008, collecting demographic, clinical and biochemical characteristics at 1, 6, and 12 months posttransplantation. We excluded 15% of patients with pretransplantation diabetes. MS was defined according to the National Cholesterol Education Program criteria and PTDM according to World Health Organization criteria. Insulin resistance at one year posttransplant was measured using the homeostasis model assessment (HOMA) index.

Results

Insulin therapy was required in 46% of patients during the first hospitalization and hyperglycemia was present in 65% of the cases. The incidence of PTDM decreased throughout the first year posttransplant, namely, 44%, 24%, and 13% at 1, 6, and 12 months, respectively. The incidence of MS increased to 33%, 48% and 50% at 1, 6, and 12 months, respectively. Age, body mass index, plasma fasting glucose levels at 1 month posttransplant, and pretransplant fasting triglyceridemia predicted PTDM. Rejection and in-patient hyperglycemia predicted MS. PTDM and MS were closely correlated (P = .004). The HOMA index was higher among patients with MS than other subjects at 1 year posttransplant: 3.2 (1.2) versus 2.3 (0.9; P = .035). Neither PTDM nor MS was associated with impaired plasma creatinine levels at 1 year after kidney transplantation.

Conclusion

There was an high incidence of PTDM and MS among kidney transplant recipients treated with tacrolimus as the main immunosuppressive agent. The HOMA index was a good test of insulin resistance in this population. Screening and treatment of risk factors may avoid the development of these entities, which are related to poor cardiovascular outcomes.