ERA-EDTA 2019 | Addressing cardiovascular risk factors can help to improve access to, and outcomes of, kidney transplantation

A review [1] published in Nephrology Dialysis Transplantation (NDT) during the ERA-EDTA Congress in Copenhagen highlights the importance of controlling all metabolic risk factors for cardiovascular disease in every potential kidney transplant candidate, both before and after transplantation. Review author Dr Umberto Maggiore, Parma University Hospital, commented: “By the time the patient is offered a kidney transplant, it may be too late to address their risk of cardiovascular disease. Interventions aimed at controlling metabolic abnormalities therefore need to be initiated early in the course of chronic kidney disease. In our review we provide many practical advices concerning interventions before and after transplantation.”

Metabolic risk factors for cardiovascular disease are common in kidney transplant candidates and recipients, and include abnormal glucose regulation, obesity and metabolic syndrome, dyslipidemia, metabolic bone disease, hyperuricemia and several ‘non-traditional’ factors. Prolonged exposure to these risk factors may reduce access to transplantation by increasing the risk of developing comorbidities while on the waiting list, prolong time to waitlisting, and in some patients, eventually jeopardize their suitability for transplantation or increase their risk of post-operative complications. After kidney transplantation, metabolic risk factors may be associated with a greater risk of death and shorter renal graft survival. The adverse effects of drugs given to prevent rejection may exacerbate these negative outcomes which, however, may be prevented by undertaking appropriate therapeutic measures.

The review sets out the evidence for interventions to address metabolic risk factors before and after kidney transplantation and provides many practical advices for the clinicians. Dr Maggiore explained: “Each patient’s metabolic and cardiovascular risk profile should be assessed, followed by interventions designed to ameliorate these risks.” In kidney transplant candidates, interventions include support for lifestyle measures, such as physical exercise and maintenance of a healthy weight, and interventions aimed at preventing the development of vascular calcifications such as correction of hyperphosphatemia. Following kidney transplantation, metabolic abnormalities resulting from the adverse effects of  antirejection therapy can be controlled by lifestyle measures and judicious use of drug therapy to regulate glucose metabolism and dyslipidemia, which should be prescribed after taking into account of factors such as potential drug-to-drug interactions and degree of renal graft function.

References: 
[1] Piotti G, Gandolfini I, Palmisano A, Maggiore U. Metabolic risk profile in kidney transplant candidates and kidney transplant recipients. Nephrol Dial Transplant 2018