Adverse cardiovascular events after liver and kidney transplantation

Transplantacija jetre i transplantacija bubrega terapija su zlatnog standarda u završnim stadijima jetrenih i bubrežnih bolesti. Zbog sve starijih kandidata sa sve više kardiovaskularnih rizičnih čimbenika i dugoročne imunosupresivne terapije, bolesnici s transplantiranom jetrom i bolesnici s transplantiranim bubregom pod povećanim su rizikom od neželjenih kardiovaskularnih događaja. Svrha istraživanja bila je utvrditi i usporediti rizik smrti od kardiovaskularnih događaja nakon transplantacije jetre i nakon transplantacije bubrega. Provedena je retrospektivna deskriptivna analiza na 577 bolesnika, 370 kojima je učinjena ortotopna transplantacija jetre u razdoblju od listopada 2014. do ožujka 2018. i 207 kojima je učinjena transplantacija bubrega sa živog ili preminulog davatelja u razdoblju od prosinca 2013. do prosinca 2017. u Kliničkoj bolnici Merkur. Kardiovaskularni uzroci smrti bili su srčani arest, zatajenje srca, plućna embolija ili infarkt miokarda. Vrijeme praćenja bilo je od transplantacije do smrti ili zadnje kontrole odnosno lipnja 2019. godine. Medijan praćenja bio je 36,5 mjeseci. Kaplan-Meier procjene preživljenja nakon transplantacije jetre iznosile su 93,2% (95% CI 90,7 – 95,8%) u prvom mjesecu i 87% (95% CI 83,6 – 90,6%) u prvoj godini, a nakon transplantacije bubrega 99% (95% CI 97,7 – 100%) u prvom mjesecu i 95,6% (95% CI 92,8 – 98,5%) u prvoj godini (p = 0,008). Najčešći uzrok smrti bila je sepsa u obje skupine. Rizik smrti od kardiovaskularnih uzroka uz smrt od ostalih uzroka kao kompetitivni rizik bio je sličan nakon transplantacije jetre i transplantacije bubrega i u prvih 30 dana i u prvoj godini nakon transplantacije (1,4% vs 1%; 1,6% vs 1,5%), globalna razlika nije bila značajna (p = 0,364). Međutim, u daljnjem praćenju nije zabilježena niti jedna kardiovaskularna smrt nakon transplantacije jetre, dok su kod bolesnika s transplantiranim bubregom zabilježene tri. Neprilagođena stopa kardiovaskularne smrtnosti nakon transplantacije bubrega bila je 0,94 na 100 osoba-godina. Pri univarijatnoj analizi Coxovom regresijom proporcionalnih rizika za ukupnu smrtnost nakon transplantacije jetre statistički značajni bili su dob > 60 godina i >/= umjerena trikuspidalna regurgitacija; u multivarijatnom modelu obje varijable bile su tek granično statistički značajne. U multivarijatnom modelu za ukupnu smrtnost nakon transplantacije bubrega neovisni prediktori bili su dob, ejekcijska frakcija lijeve klijetke /= 2. stupnja. Zaključno, karakteristike kardiovaskularne smrtnosti razlikuju se nakon transplantacije jetre i nakon transplantacije bubrega. Individualiziran pristup potreban je za optimizaciju ishoda.Liver transplantation and kidney transplantation are treatments of choice for end-stage liver disease and end-stage renal disease. Transplant candidates are becoming increasingly older and have a higher burden of cardiovascular risk factors than ever before. This combined with long-term immunosuppression puts both liver and kidney transplant recipients at a higher risk for adverse cardiovascular outcomes. This retrospective descriptive study aimed to establish and compare cardiovascular mortality in liver and kidney transplant recipients. A total of 577 patients were included; 370 patients underwent orthotopic liver transplantation between October 2014 and March 2018 and 207 patients underwent live or deceased donor kidney transplantation between December 2013 and December 2017 at University Hospital “Merkur”. Cardiovascular causes of death were defined as cardiac arrest, heart failure, pulmonary embolism or myocardial infarction. Follow-up time was from the date of transplantation until date of death, last follow-up or June 2019. Median follow-up time was 36.5 months. Kaplan-Meier survival estimates following liver transplantation were 93.2% (95% CI 90.7 – 95.8%) at one month and 87% (95% CI 83.6 - 90.6%) at one year and following kidney transplantation 99% (95% CI 97.7 – 100%) at one month and 95.6% (95% CI, 92.8 – 98.5%) at one year (p = 0.008). The most common cause of death was sepsis in both groups. Cumulative cardiovascular mortality with all-cause mortality as the competing risk was similar in liver and kidney transplant recipients both at 30 days and at one year of follow-up (1.4% vs 1%; 1.6% vs 1.5%), the overall difference was not significant (p = 0.364). However, after one year of follow-up there were no new events in liver transplant recipients as opposed to three additional events in kidney transplant recipients. In kidney transplant recipients the unadjusted cardiovascular mortality rate was 0.94 per 100 person-years. In univariate Cox proportional hazards analyses age > 60 years and >/= tricuspid regurgitation were significant predictors of all-cause mortality after liver transplantation; at an attempt at multivariate modelling both were merely marginally significant. A multivariate model was constructed for all-cause mortality following kidney transplantation with age, left ventricular ejection fraction < 50% and stage 2 or greater left ventricular diastolic dysfunction as independent risk factors. In conclusion, liver and kidney transplant recipients differ in characteristics of posttransplant cardiovascular mortality. To achieve optimal outcomes, both require an individualized approach