Chronic rejection and atherosclerosis in post-transplant cardiovascular mortality: two sides of the same coin

Post-transplant cardiovascular disease (CVD) is the single most common cause of death in solid organ transplant recipients. The prevailing school of thought is that post-transplant CVD is driven by the same underlying atherosclerotic processes as the CVD of aging seen in the general population. This is reflected in current management strategies, which focus on the minimisation of traditional cardiovascular risk factors. In this article, we argue that atherosclerosis is not the sole aetiology of post-transplant CVD. Instead, chronic rejection drives post-transplant CVD through an antibody-mediated systemic vasculopathy termed systemic accelerated arteriosclerosis (SAA). SAA is fundamentally distinct from atherosclerosis, associated with unique histology, pathophysiology and risk factors. In order to effectively manage post-transplant CVD, SAA needs to be addressed in current management strategies through revised risk factor minimisation and use of immunomodulatory pharmaceuticals