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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE  
Year : 2020  |  Volume : 31  |  Issue : 5  |  Page : 1051-1056
The Effect of Renal Transplantation on Cardiac Functions


1 Department of Cardiology, Baskent University Faculty of Medicine, Ankara, Turkey
2 Department of General Surgery, Division of Transplantation, Baskent University Faculty of Medicine, Ankara, Turkey

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Date of Web Publication21-Nov-2020
 

   Abstract 


Chronic renal failure is a well-known risk factor for cardiovascular poor outcome. Despite advances in dialysis and renal transplantation, these patients still have high cardiovascular morbidity and mortality. The aim of our study was to evaluate the changes in blood parameters and echocardiographic parameters of patients undergoing renal transplantation in our center. One hundred and eighty-three patients who underwent renal transplantation between September 2012 and January 2016 were included in the study. Pre- and postoperative hemoglobin values, lipid profiles, ejection fractions, presence of left ventricular hypertrophy, presence of diastolic dysfunction, and valve pathologies were retrospectively scanned. Data were obtained from all patients in terms of blood parameters, but we compared 92 patients’ echocardiographic data because of lack of both pre- and postoperative echocardiography records. In our study, 124 patients (67.8%) were male, and the mean age was 42.6 ± 14.4 years. Hemoglobin levels (11.2 ± 1.98, 12.7 ± 2.2 mg/dL, P <0.001) and high-density lipoprotein (HDL) values (37.6 ± 10.5, 46.6 ± 13.6 mg/dL, P <0.001) were found to be different significantly. In echocardiographic evaluation, there was no difference between pre- and postoperative ejection fractions in 92 patients. However, patients with preoperative ejection fraction <50% had a significant increase in postoperative ejection fraction (40.1 ± 6.2, 48.4% ± 9.4%, P = 0.012). Renal transplantation can improve left ventricle ejection fraction in patients with basal ejection fraction less than 50% and also provide a significant increase in hemoglobin and HDL levels in all patients. This suggests that renal transplantation may reverse the process for dilated cardiomyopathy and may improve cardiac function in patients with low ejection fraction. However, transplantation should be performed as early as possible in these patients.

How to cite this article:
Yilmaz KC, Akgun AN, Keskin S, Ciftci O, Moray G, Muderrisoglu H, Haberal M. The Effect of Renal Transplantation on Cardiac Functions. Saudi J Kidney Dis Transpl 2020;31:1051-6

How to cite this URL:
Yilmaz KC, Akgun AN, Keskin S, Ciftci O, Moray G, Muderrisoglu H, Haberal M. The Effect of Renal Transplantation on Cardiac Functions. Saudi J Kidney Dis Transpl [serial online] 2020 [cited 2020 Dec 1];31:1051-6. Available from: https://www.sjkdt.org/text.asp?2020/31/5/1051/301170



   Introduction Top


Chronic renal failure is a well-known risk factor for cardiovascular poor outcome.[1] Despite advances in dialysis and renal transplantation, these patients still have high cardiovascular morbidity and mortality.[2],[3],[4] Renal transplantation provides longer survival and better quality of life in long-term dialysis patients.[2] Despite significant progress in the care of patients with heart failure (HF), individuals with ESRD and concomitant cardiac dysfunction are generally considered less suitable candidates for kidney transplantation due to increased risk of operative morbidity and mortality. Therefore, the coexistence of HF and renal failure becomes important. In fact, some previous studies have shown that kidney transplantation improves cardiac function.[5],[6],[7] The aim of our study was to evaluate the changes in blood parameters and echocardiographic parameters of patients undergoing renal transplantation in our center.


   Materials and Methods Top


Two hundred and thirteen patients were included in the study who underwent renal transplantation between September 2012 and January 2016 in our center. Pre- and postoperative hemoglobin values, lipid profiles, ejection fractions, presence of left ventricular hypertrophy, presence of diastolic dysfunction, and mitral and tricuspid valve insufficiencies were retrospectively scanned. Thirty patients who could not reach any of the pre- or postoperative blood or echo parameters were excluded from the study. Thirty patients were excluded from the study who we could not reach one of the pre- and postoperative blood parameters; as a result, we examined 183 patients’ laboratory parameters. Likewise, since the pre- and postoperative echocardiography results of 92 of these 183 patients were obtained, the data of these 92 patients were examined. The reference values for echo parameters were defined based on the American Society of Echocardiography guidelines.[8] Laboratory parameters were obtained from the most recent pretransplant and 12-month post-transplant office visits. One exception was echocardiographic data, the timing of which could not be controlled for in this retrospective study. Echocardiograms were obtained during the pretransplant evaluation, with the most recent one taken into account and the time closest to 12–24 months posttransplantation.

Continuous data were compared preoperatively and postoperatively with K-related samples. Data are expressed as the mean ± standard deviation unless otherwise stated. Categorical data were analyzed with Fisher's exact test and the Chi-squared test. A P <0.05 was considered statistically significant. All analyses were undertaken using the IBM SPSS Statistics version 25.0 (IBM Corp., Armonk, NY, USA).

Protocols approved by the local ethics committee were utilized throughout the study. A standardized questionnaire was used to collect clinical and demographic information, including medication history.


   Results Top


In our study, 124 patients (67.8%) were male, and the mean age was 42.6 ± 14.4 years. The demographic data of the patients in the study are given in [Table 1]. In terms of blood parameters, preoperative hemoglobin levels were 11.2 ± 1.98 mg/dL, postoperative hemoglobin values were 12.7 ± 2.2 mg/dL, and this difference was statistically significant (P = 0.001). High-density lipoprotein (HDL) values, one of the lipid parameters, were significantly increased postoperatively (37.6 ± 10.5, 46.6 ± 13.6 mg/dL, respectively, P = 0.001). There was no significant change in low-density lipoprotein (LDL) and triglyceride levels.
Table 1: Demographic and laboratory parameters of all patients.

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For echo parameters, there was no significant difference between the values of 92 patients whose ejection fractions were screened pre-operatively and postoperatively, whereas 21 patients with a preoperative ejection fraction below 50% had a significant increase after transplantation (40.1% ± 6.2%, 48.4% ± 9.4%, P = 0.012) [Table 2].
Table 2: Comparison of laboratory parameters and ejection fraction in pre- and postoperative patients.

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Patients’ immunosuppressive treatment and other medical treatments are given in [Table 3]. All of the patients were given deltacortril. The most preferred immunosuppressive agents were mycophenolate mofetil (MMF) and tacrolimus.
Table 3: Drug usage of all patients.

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Therefore, to investigate the effect of other drugs that affect HDL increase, we compared the drugs for two groups of patients whose HDL levels raised and decreased after transplantation, as shown in [Table 4]. There was no difference between the groups in terms of the drugs.
Table 4: Comparison of drug usage between high-density lipoprotein increased and decreased patients.

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According to the other echocardiographic parameters such as left ventricular hypertrophy, valve insufficiencies, and diastolic dysfunction, there were no significant differences between the two groups [Table 5].
Table 5: Comparison of pre- and postoperative echocardiography parameters.

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   Discussion Top


Renal transplantation decreases mortality in end-stage renal disease patients. Previously, there are several studies investigating the effects of renal transplantation on cardiac functions. In a study performed with SPECT imaging,[9] renal transplant patients were compared with nontransplant patients, and a significant change was observed in the ejection fractions of transplanted patients (72 ± 10% vs. 67% ± 10%, P =0.001). Although the improvement in ejection fraction was thought to be due to volume management, no significant changes were found in the left ventricular end-diastolic volumes between the two groups. This was thought to be due to the effective removal of toxins and the prevention of uremic cardiomyopathy rather than the effect of transplantation on volume. In the same study, electrocardiographic parameters were also screened, but no significant difference was found. In our study, there were no significant differences in ejection fractions when 92 patients were considered. However, in patients with ejection fraction of 50% and less, ejection fraction was significantly improved after transplantation (40.1 ± 6.2 vs. 48.4 ± 9.4, P = 0.012). One reason of this situation may be due to the high mean ejection fraction in pretransplant echocardiographies. In our study, the number of patients who compared their echoes was 92 and higher like the previous study. On the other hand, it can be predicted that patients with low ejection fraction may benefit more than patients with normal ejection fraction.

In another study,[10] patients with ejection fraction below 50% before renal transplantation were examined, and it was found that EF was significantly improved in patients with both mild and moderate HFs after transplantation. In 66 patients with mild left ventricular systolic dysfunction, EF before transplantation was 41% ± 10% and 50% ± 12% after transplantation (P <0.0001). In patients with moderate dysfunction (n = 28), EF was 32% ± 7% before transplantation and 47% ± 14% after transplantation (P <0.001). This suggests that the ejection fraction is not the most important value for determining the preoperative cardiac risk. In the same study, they found that the best survival was determined in patients with normal ejection fraction. Survival of patients with more than 10% improvement in ejection fraction after transplantation was significantly better than patients with <10% improvement in ejection fraction. In our study, mortality was observed in only six patients during follow-up, so no data were compared for survival.

Omrani et al[11] studied 181 patients with ejection fraction below 50% and performed echocardiography at six and 12 months. Echocardiography showed a significant improvement in ejection fractions compared to basal echoes both six and 12 months. In the same study, they found that left ventricular hypertrophy also regressed and mitral and tricuspid valve insufficiencies decreased after transplantation. In another study examining left ventricular hypertrophy (LVH)[12] post transplantation, 63% of renal transplant recipients showed normal echocardiographic finding of LV, while 37% of patients remained with LVH after first post-transplant year. These findings were similar to our study. In our study, left ventricular hypertrophy regressed after transplantation (P = 0.05). Unlike, there was no significant difference in valve insufficiencies before and after transplantation [Table 5]. This may be due to the small number of patients with severe valve insufficiency in our study cohort. There was no significant difference between the two groups in terms of diastolic functions although they were reduced numerically.

Dyslipidemia is often seen with renal disease and is associated with increased cardiovascular mortality and morbidity.[13] Immunosuppressants and steroids used after transplantation have important effects on lipid metabolism. In a comprehensive study in which these effects were investigated by drug classes,[14] the highest change in total cholesterol and triglyceride was shown to be associated with cyclosporine/sirolimus or cyclosporine/everolimus use. Moreover, it was shown that average HDL cholesterol decreased by 14% in men and 22% in women. However, in subgroup analyses, in patients who were receiving tacrolimus and mycophenolate mofetil, HDL cholesterol increased in men from 41 ± 10 mg/dL to 47 ± 12 mg/dL, in women HDL cholesterol increased from 47 ± 12 mg/dL to 56 ± 11 mg/dL. In our patient population, MMF (94.5%) and tacrolimus (72.1%) were the most commonly used drugs, and it may be the reason of increased HDL cholesterol. While LDL and triglyceride increased slightly, HDL cholesterol increased significantly after trans-plantation (37.6 ± 10.5 vs. 46.6 ± 13.6, P = 0.001). This emphasizes the importance of drug selection after transplantation. No significant difference was seen with the use of other drugs on HDL levels. In another study, serum total cholesterol and triglyceride levels tended to increase during CyA and steroid therapy among patients undergoing renal transplantation Independent of hyperlipidemia risk factors.[15] Following the transplantation, the lipid profiles of the patients should be followed up during the controls and medical treatment should be kept in mind if LDL cholesterol is persistently higher which is a cardiovascular risk factor.

As a result, renal transplantation can improve left ventricle ejection fraction in patients with basal ejection fraction <50%. This suggests that the risk assessment of patients with low ejection fraction should be made carefully before transplantation because there will be improvement after transplantation in cardiac functions. At the same time, lipid side effects of some immunosuppressive agents were observed less than others, so it could be a guide for treatment selection.

Conflict of interest: None declared.



 
   References Top

1.
Foley RN, Parfrey PS, Sarnak MJ. Clinical epidemiology of cardiovascular disease in chronic renal disease. Am J Kidney Dis 1998; 32:S112-9.  Back to cited text no. 1
    
2.
Wolfe RA, Ashby VB, Milford EL, et al. Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. N Engl J Med 1999;341:1725-30.  Back to cited text no. 2
    
3.
Tonelli M, Wiebe N, Knoll G, et al. Systematic review: Kidney transplantation compared with dialysis in clinically relevant outcomes. Am J Transplant 2011;11:2093-109.  Back to cited text no. 3
    
4.
Jardine AG, Gaston RS, Fellstrom BC, Holdaas H. Prevention of cardiovascular disease in adult recipients of kidney transplants. Lancet 2011;378:1419-27.  Back to cited text no. 4
    
5.
Wali RK, Wang GS, Gottlieb SS, et al. Effect of kidney transplantation on left ventricular systolic dysfunction and congestive heart failure in patients with end-stage renal disease. J Am Coll Cardiol 2005;45:1051-60.  Back to cited text no. 5
    
6.
Deng Y, Pandit A, Heilman RL, Chakkera HA, Mazur MJ, Mookadam F. Left ventricular torsion changes post kidney transplantation. J Cardiovasc Ultrasound 2013;21:171-6.  Back to cited text no. 6
    
7.
Namazi MH, Parsa SA, Hosseini B, et al. Changes of left ventricular mass index among end-stage renal disease patients after renal transplantation. Urol J 2010;7:105-9.  Back to cited text no. 7
    
8.
Lang RM, Badano LP, Mor-Avi V, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: An update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 2015;28:1-39.e14.  Back to cited text no. 8
    
9.
Crosland W, Aggarwal H, Farag A, et al. The effect of renal transplantation on left ventricular function, electrocardiography, and mechanical synchrony by gated myocardial perfusion imaging. J Nucl Cardiol 2019;26: 1962-70.  Back to cited text no. 9
    
10.
Hawwa N, Shrestha K, Hammadah M, et al. Reverse remodelling and prognosis following kidney transplantation in contemporary patients with cardiac dysfunction. J Am Coll Cardiol 2015;66:1779-87.  Back to cited text no. 10
    
11.
Omrani H, Rai A, Daraei Z, Sadeghi M. Study of echocardiographic changes after kidney transplantation in end-stage renal disease patients. Med Arch 2017;71:408-11.  Back to cited text no. 11
    
12.
Dzemidzic J, Rasic S, Saracevic A, et al. Predictors of left ventricular remodelling in kidney transplant recipents in the first posttransplant year. Bosn J Basic Med Sci 2010;10 Suppl 1:S51-5.  Back to cited text no. 12
    
13.
US Renal Data System: 1999 USRDS Annual Data Report. Bethesda, Md: The National Institutes of Health. National Institute of Diabetes and Digestive and Kidney Diseases; 1999.  Back to cited text no. 13
    
14.
Spinelli GA, Felipe CR, Park SI, Mandia-Sampaio EL, Tedesco-Silva H Jr., Medina-Pestana JO. Lipid profile changes during the first year after kidney transplantation: Risk factors and influence of the immuno-suppressive drug regimen. Transplant Proc 2011;43:3730-7.  Back to cited text no. 14
    
15.
Akman B, Uyar M, Afsar B, Sezer S, Ozdemir FN, Haberal M. Lipid profile during azathioprine or mycophenolate mofetil combinations with cyclosporine and steroids. Transplant Proc 2007;39:135-7.  Back to cited text no. 15
    

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Correspondence Address:
Kerem Can Yilmaz
Department of Cardiology, Baskent University Faculty of Medicine, Ankara
Turkey
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DOI: 10.4103/1319-2442.301170

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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