The impact of kidney transplantation on heart failure risk varies with candidate body mass index

doi:10.1016/j.ahj.2009.10.009

American Heart Journal

Volume 158, Issue 6, December 2009, Pages 972-982

https://doi.org/10.1016/j.ahj.2009.10.009 Get rights and content

Background

The relationship of body mass index (BMI) with heart failure (HF) risk before and after kidney transplant is not well described.

Methods

We examined United States Renal Data System records for 67,591 kidney transplant candidates (1995-2004) with Medicare insurance and BMI data at listing. Heart failure diagnoses were ascertained from Medicare billing claims. Body mass index was categorized per World Health Organization criteria. We modeled time-dependent associations (adjusted hazard ratio, aHR) of transplant with HF risk after listing compared with waiting in each BMI group by multivariable, stratified Cox regression. The time-dependent exposure variables partitioned relative risk of HF after transplant versus waiting into early (≤90 days) and late (>90 days) posttransplant periods.

Results

The BMI distribution of listed candidates was as follows: 3.7% under, 40.4% normal, 32.0% over, 16.2% obese, and 7.7% morbidly obese weight. The prevalence of HF among patients awaiting transplant reached 57.4% by 3 years. Deceased-donor transplant was associated with increased early HF risk compared with continued waiting—aHRs ranged from 2.23 for normal-BMI to 2.82 for morbidly obese patients. However, transplant reduced the risk of HF in the late posttransplant period from 54% (aHR 0.46) in normal-BMI to 32% (aHR 0.68) for morbidly obese patients. Relative benefits were largest for normal-weight candidates who received live-donor transplants (aHR 0.31).

Conclusions

Heart failure risk improves in obese patients in the long term after kidney transplant, but not as much as for nonobese patients. There is need for close monitoring and for new strategies to reduce HF risk in obese patients before and after transplant.

Section snippets

Data sources

We performed sample selection, outcomes ascertainment, and covariate determinations using registry data collected by the USRDS that incorporate information from the Organ Procurement and Transplantation Network and Medicare billing claims records. Details of the source USRDS data, as well as limitations of Medicare claims data, have been described previously.¹⁵

Participant selection

The primary sample included adult (≥18 years old) ESRD patients listed for kidney transplantation from January 1995 to December 2004

BMI distribution and baseline characteristics according to BMI

There were 180,233 unique adults listed for kidney transplantation per USRDS records in the study period, of whom 89,297 had Medicare primary insurance at the time of listing. Of these Medicare-insured transplant candidates, 67,591 (75.7%) also had BMI data at listing and were selected for analysis. The BMI distribution of this sample of waitlisted subjects was as follows: 3.7% underweight, 40.4% normal, 32.0% overweight, 16.2% obese, and 7.7% morbidly obese weight. Forty-one percent of the

Discussion

Heart failure is a common but serious complication in patients with renal failure. We examined the joint effects of kidney transplantation and patient BMI on acquisition of HF diagnoses among a large national sample of transplant candidates and observed several main findings: (1) Heart failure is common among ESRD patients awaiting transplantation, with incidence and prevalence rising progressively with waiting time. (2) Kidney transplantation is associated with a brief early rise in HF risk

Disclosures

The data reported here have been supplied by the USRDS. Dr Lentine received a “Top Ten Abstract Award” for presentation of portions of this work at the Ninth Annual State of the Art Winter Symposium of the American Society of Transplant Surgeons; January 17, 2009, Marco Island, FL. The interpretation and reporting of these data are the responsibility of the authors and in no way should be seen as an official policy or interpretation of the US government, the NIDDK, or the National Institutes of

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Following kidney transplant, an increase in LVEF is may be noted in those with pretransplant HF, highlighting the interconnected relationship between HF and renal dysfunction.10 Kidney transplantation also appears to reduce the risk of clinical HF diagnosis beyond the perioperative period, although the magnitude of risk reduction is modified by patient factors such as obesity.11 Type V CRS or secondary CRS is characterized by simultaneous development of cardiac and kidney injury which is caused by a systemic disease process such as sepsis, autoimmune or hematologic conditions.
Cardiorenal syndrome (CRS) is an increasingly recognized diagnostic entity associated with high morbidity and mortality among acutely ill heart failure (HF) patients with acute and/ or chronic kidney diseases (CKD). While traditionally viewed as a state of decline in glomerular filtration rate (GFR) due to decreased renal perfusion, mainly due to therapeutic interventions to relieve congestive in HF, recent insights into the underlying pathophysiologic mechanisms of CRS led to a broader definition and further classification of CRS into 5 distinct types. In this comprehensive review, we discuss the classification of CRS, highlighting the underlying common pathogenetic pathways of heart failure and kidney injury, including increased congestion, neurohormonal dysregulation, oxidative stress as well as inflammation, and cytokine storm that are particularly evident in COVID-19 patients with multiorgan failure and also in those with other disorders including sepsis, systemic lupus erythematosus and amyloidosis. In this review we also present the recent advances in the diagnostic strategies of CRS including cardiac and renal biomarkers as well as advanced cardiac and renal imaging techniques that are available to aid in the diagnosis as well as in the prognostication of this disorder. Finally, we discuss the various therapeutic options available to-date, including fluid optimization, hemofiltration, renal replacement therapy as well as the role of SGLT2 inhibitors in light of recent data from RCTs. It is important to note that, CRS population are either excluded or underrepresented, at best, in major RCTs and therefore, therapeutic recommendations are largely extrapolated from HF and CKD clinical trials.
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: Institution at which work was performed: Saint Louis University Center for Outcomes Research, St Louis, MO.

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Clinical InvestigationCongestive Heart FailureThe impact of kidney transplantation on heart failure risk varies with candidate body mass index

Background

Methods

Results

Conclusions

Section snippets

Data sources

Participant selection

BMI distribution and baseline characteristics according to BMI

Discussion

Disclosures

J Am Coll Cardiol

Kidney Int

J Am Coll Cardiol

Transplant Proc

Am J Transplant

Ann Epidemiol

Am J Kidney Dis

Kidney Int

Am J Kidney Dis

J Am Soc Echocardiogr

Am J Cardiol

Kidney Int

Ann Epidemiol

Am J Clin Nutr

Am J Transplant

Am J Transplant

Systolic dysfunction portends increased mortality among those waiting for renal transplant

J Am Soc Nephrol

Cardiovascular effects of successful renal transplantation: a 1-year sequential study of left ventricular morphology and function, and 24-hour blood pressure profile

Transplantation

Obesity and the risk of heart failure

N Engl J Med

Clinical Investigation
Congestive Heart Failure
The impact of kidney transplantation on heart failure risk varies with candidate body mass index