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ORIGINAL PAPER
Year : 2004  |  Volume : 5  |  Issue : 1  |  Page : 8-12 Table of Contents     

Cardiovascular Disease and Diabetes : Effect on Recipient Outcome after Renal Transplantation


Department Of Internal Medicine, Hamad Medical Corporation, Doha, Qatar

Date of Web Publication22-Jun-2010

Correspondence Address:
Omar Aboud
Consultant Nephrologist, Hamad Medical Corporation, P.O. Box 3050, Doha
Qatar
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Source of Support: None, Conflict of Interest: None


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   Abstract 

A total of 432 patients in Qatar received renal transplant (RT) from1986 through 2002 at Hamad Medical Corporation (HMC) as well as abroad. The recipients were of mixed nationalities, 238 Qatari national (Q) and 194 expatriates (NQ). Since 1986 when we started our local transplant program, 70 cases were performed at our center and 362 performed abroad. Diabetic nephropathy was the most common cause of end stage renal disease (ESRD) in Q transplants patients (23.9%), while chronic glomerulonephritis was the most common cause of ESRD in NQ (28.7%). New onset diabetes was reported after the transplant operation in 7.3% of the total cases.

Recipient age ranged from 14 to 75 years with the mean age 48.5 years in diabetics and 34.5 years in non-diabetics. Immunosuppressive therapy included cyclosporine azathioprine, mycophenolate mofetil and steroids. Post-transplant acute rejection was reported in 9.7% of all cases and chronic rejection developed over the years in 14.3%. Two years survival at our center compared to other centers abroad was 98%, 97% for patients and 85.7%, 82.5% for grafts respectively.
Mortality in the 432 patients was mainly related to cardiovascular disease accounting for the death of 24 cases (5.5%). In the 88 diabetic patients 11 cases suffered a fatal myocardial infarction (12.5%) compared to 13 cases of myocardial infarction in the 344 non-diabetic patients (5.3%). Other causes of mortality such as sepsis, hepatic failure, and cytomegalovirus infection did not differ significantly in diabetic patients compared to non-diabetics.


How to cite this article:
Aboud O, Rashed A. Cardiovascular Disease and Diabetes : Effect on Recipient Outcome after Renal Transplantation. Heart Views 2004;5:8-12

How to cite this URL:
Aboud O, Rashed A. Cardiovascular Disease and Diabetes : Effect on Recipient Outcome after Renal Transplantation. Heart Views [serial online] 2004 [cited 2020 Nov 23];5:8-12. Available from: https://www.heartviews.org/text.asp?2004/5/1/8/64543


   Introduction Top


Studies on the occurrence of End-Stage Renal Disease (ESRD) in Qatar in 1998 showed an incidence of 122 patients per million population per year [1] . Progressive increase in the incidence has been observed since then both locally and worldwide [2] .

Diabetic nephropathy has become a major cause of ESRD in Qatar increasing from 26.1% in the year 1998 [1] to 30.6 % in 2001 [3] . With the shortage in donors, the number of patients with end stage renal disease has been progressively increasing, reaching 480 cases at the end of 2001 [2] . Patients are treated with different dialysis modalities while waiting for renal transplantation.

Cardiovascular disease is a major risk factor for morbidity and mortality in dialysis patients and renal transplant recipients [4] .

We report our experience with a total of 432 renal transplantation that have had transplantation locally and abroad, during the period between 1986 and 2002, with especial emphasis on diabetes and cardiovascular diseases.


   Methods Top


The hospital medical records from 1986 through 2002 were identified and reviewed. The study includes ESRD patients of different nationalities who live in Qatar and were on regular dialysis at our dialysis unit. Renal transplantations were performed at HMC and at other transplant centers abroad over the last 17 years. Full information about patients was kept in special transplant files separately from the hospital medical records filing system.

The pre-transplant recipient work up for a total of 432 patients, that includes cardiac and other systemic evaluations were performed at our center and post-transplant follow up of all cases was our responsibility. Operative and immediate post-transplant management information for patients who had their transplants performed abroad was obtained from the reports supplied to our patients by the concerned transplant centers.


   Results Top


Renal transplant at our center started in the year 1986 and accounts for 70 cases of the total compared to 352 transplants performed abroad at different centers mostly in India, UK, USA, Pakistan and Philippines. Out of the total recipients, 238 were of Qatari nationality (Q) and 194 expatriates living in Qatar (NQ) [Table 1]. The recipients' age ranged from 14 to 74 years, median age 36.5 in the total group, 48.5 years in recipients with diabetic nephropathy and 34.5 years in non-diabetic patients. The patient age at the time of transplant was less than 60 years in 402 cases and 60 years or above in 30 cases; 284 males (65.7%) and 148 females (34.3%). Chronic glomerulonephritis was the most common cause in expatriate patients and diabetic nephropathy was the most common in Qatari patients [Table 2].

Post-transplant complications were: acute rejection 9.7%; acute tubular necrosis 3.9%; and lymphocele 2.1%. Chronic rejection developed over the years in 14.3%.

Graft and patient survival at our center was identical to other centers outside Qatar [Figure 1], [Figure 2]. As expected, the death rate was higher in diabetics compared to non-diabetic patients [Figure 3]. Myocardial infarction and sepsis were the most common causes of death [Figure 4].


   Discussion Top


Renal transplantation is the definitive treatment of ESRD, treating all manifestations of chronic kidney disease. A successful kidney transplant improves the quality of life and reduces the mortality risk for most patients when compared with maintenance dialysis. Survival with renal transplantation is superior to dialysis. According to the USRDS data, the annual death rate was significantly lower among transplant recipients compared to waiting list patients (3.8 versus 6.3 per 100-patients-years) [5] .

In our patients, cardiovascular mortality was the commonest cause of death accounting for 16.9% of the causes of death in general. Among the risk factors associated with increased incidence of cardiovascular disease in patients with ESRD are hypertension and left ventricular hypertrophy leading to systolic dysfunction. The anemia of chronic renal failure and fluid overload predispose to diastolic dysfunction. Hyperparathyroidism secondary to ESRD induces soft tissue and vascular calcifications. Homocysteine blood level is inversely related to the renal function. Dyslipidemia and increased level of C-reactive protein is a common finding in ESRD [6] . The enhanced risk of death from cardiovascular disease is related in part to a history of cigarette smoking. At one transplant center, patients with a 25 pack-year smoking history at transplant had an adjusted relative risk of 2.05 of experiencing a major cardiovascular disease event, thereby resulting in an increased risk of death (relative risk of 1.42) [7] .

Although transplantation confers the highest survival benefit among all the different renal replacement therapies, renal allograft recipients still have a high mortality rate compared with population controls. A European study report the mortality of recipients of first renal transplants to 14 times higher than the age-matched population without renal failure during the first year after transplantation, and was four times higher after this period [8] .

The overall most common original disease in our present study was glomerulonephritis (33.3%) followed by diabetes mellitus (19.2%) [Table 1]. More recently, diabetic nephropathy has become the overall most common cause of ESRD in our patients accounting for 33.9% of the cases [3] . The median age in all our patients was 36.5 years but the patients with diabetic nephropathy as their original disease have significantly higher age (48.5 years) than with other diseases causing ESRD (34.5 years). In a study by Arend et al [8] increased risk of death was observed among patients over the age of 40 years, men, cadaver transplant recipients, and those with diabetes or hypertension. Grenfell et al reported that survival of diabetic patients after renal transplantation is markedly lower than non-diabetic patients: 45% compared to 75% these suboptimal results are due largely to extra-renal vascular disease but they are significantly better than those seen with patients on hemo- or peritoneal dialysis where the five-year patient survival is 0-35% [9] .

According to Briggs et al, all cardiac causes of death in all renal transplant recipients account for 18-37% and the higher the patient's age, the higher the mortality [10] . Asymptomatic coronary artery disease is also reported in diabetic renal transplant recipients by Koch et al [11] . They found that approximately 20 to 30% of diabetic transplant candidates have significant coronary artery disease, which may be asymptomatic or not associated with conventional cardiovascular risk factors.

Zeier et al reported that patients with other diseases like glomerulonephritis and autosomal dominant polycystic kidney disease survive longer than diabetic patients [12] . In our patients infectious causes accounted for the second cause of death (5.5%). Other causes of death were hepatic failure, and cerebrovascular accident [Table 3]. Similar to worldwide status, existing kidney organ supply is clearly inadequate to meet the current and future needs in Qatar. In our center most of the donors were live related (LRD) 78.6%, while donors for transplants performed abroad were mostly live unrelated (LURD) 59.4%. Shortage of medically suitable donors and avoiding exposure of family members to donation were the primary causes of our patients going abroad for LURD transplants. The tendency to go abroad to India started in 1980 and continued until it was abandoned due to the Indian legislation prohibiting live unrelated donor transplants for foreigners in 1998, leading to shift of patients to Pakistan and Philippines. There were reports suggesting that wealthy recipients from the Middle East who had gone to India or other countries in the third world for LURD transplants had received inferior medical care, had sustained higher than normal complication rates, and had been financially exploited along with their donors [13],[14] . More recently, though, there is a shift to LURD in countries with more stringent ethical laws. The United States Renal Data records show that transplant centers in the country reported a ten-fold increase in LURD compared to only 16% and 68% increase in cadaver and LR donors respectively [2] .

The low number of cadaver donors in our center (18.6%) is due to absence of family members authorized to give consent in the case of expatriates and reluctance of the relatives among national citizens. The latter is partly due to social and religious beliefs and poor faith in the brain death concept. It is speculative to presume that increased educational programs, new legal approaches or financial or other incentives can increase the supply of cadaver organs. At present, organ donor cards are not yet implemented in Qatar. It is worth noting that renal transplantation was officially legalized in 1997 in Qatar.

We recommend evaluation of the extent and severity of coronary disease prior to transplantation. Since cardiovascular disease is the leading cause of death for adult renal allograft recipients, nearly one-third of all such deaths are due to acute myocardial infarction, with diabetic patients having the worst survival post-MI [4] . Among those who require intervention for coronary artery disease after transplantation, myocardial revascularization is associated with acceptable survival. In one study of nearly 3000 renal transplant recipients at one institution, survival of the 83 who required either bypass surgery or angioplasty was 89, 77, and 65 percent at one, three, and five years post procedure, respectively. [15]

 
   References Top

1.Rashed A, Abboud O, et al. Renal replacement therapy in Qatar. Saudi J Kidney Dis Transplant 1998; 9(1): 36-39.  Back to cited text no. 1      
2.USRDS 2003 Annual Data Report.  Back to cited text no. 2      
3.Rashed A, Abboud O, et al. Management of End Stage Renal Failure in Qatar: Kidney Forum 1999; 1,29-32.  Back to cited text no. 3      
4.Herzog CA, Ma JZ, Collins AJ. Long-term survival of renal transplant recipients in the United States after acute myocardial infarction. Am J Kidney Dis 2000; 36: 145-152.  Back to cited text no. 4      
5.United States Renal Data System. 1998 Annual Data Report. Am J Kidney Dis 1998; 32 (Suppl 1): S91-5.  Back to cited text no. 5      
6.Parfrey PS, Foley RN. The clinical epidemiology of cardiac disease in chronic renal failure. J Am Soc Nephrol 1999; 10:1606-1615.   Back to cited text no. 6      
7.Kasiske BL, Klinger D. Cigarette smoking in renal transplants recipients [In Process Citation]. J Am Soc Nephrol 2000; 11:753-759.   Back to cited text no. 7      
8.Arend SM, Mallat MJ, Westendorp RJ, et al. Patient survival after renal transplantation; more than 25 years follow-up. Nephrol Dial Transplant 1997; 12: 1672-1679.  Back to cited text no. 8      
9.Grenfell A, Bewick M, Snowden S, et al. Renal replacement for diabetic patients. Experience at King's College Hospital 1980-1989. QJ Med 1992; 85:861-874.  Back to cited text no. 9      
10.Briggs JD. Causes of death after renal transplantation. Nephrol Dial Transplant 2001; 16:1545-1549.   Back to cited text no. 10      
11.Koch M, Gradaus F, Schoebel FC, et al. Relevance of conventional cardiovascular risk factors for the prediction of coronary artery disease in diabetic patients on renal replacement therapy. Nephrol Dial Transplant 1997; 12: 1187-1191.   Back to cited text no. 11      
12.Zeier M, Jones E, Ritz E. Autosomal dominant polycystic kidney disease-the patient on renal replacement therapy. Nephrol Dial Transplant 1996;11 Suppl 6: 18-20.   Back to cited text no. 12      
13.Qunibi W, Abulrub, Shaheen F, et al. Attitudes of commercial renal transplant recipients toward renal transplantation in India. Clin Transplantation 1995; 934:317-321.  Back to cited text no. 13      
14.Aburomeh S, et al. Living non-related kidney transplantation in Bombay. Lancet 1990; 336: 725-728.  Back to cited text no. 14      
15.Ferguson ER, Hudson SL, Diethelm AG, et al. Outcome after myocardial revascularization and renal transplantation: A 25-year single-institution experience. Ann Surg 1999 Aug; 230 (2): 232- 241.  Back to cited text no. 15      


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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