Pretransplant management of end-stage renal disease patients to minimize posttransplant risk.

Renal transplant recipients die of CVD at an accelerated rate compared with the general population. Successful management of CVD risk would prolong patient and renal allograft life, but management must begin early in the pretransplant period. By the time a renal transplant becomes available, patients often have advanced CVD because of prolonged and progressive renal disease. The most effective way to reduce premature CVD in renal transplant recipients is to address the problem of cardiac disease and vascular disease at the earliest stages in the natural history of progressive renal disease. Based largely on the success of such treatments in the general population, pretransplant modification may include the use of statins to control hyperlipidemia and ACE inhibitors to control elevated blood pressure. Elevated blood pressure has been related to the development of cardiomyopathy prior to transplantation; thus, therapeutic goals should be revised to include reversal of LVH. Longitudinal studies are needed to evaluate the effects of blood pressure lowering on LVH (and other echocardiographic abnormalities) in patients with progressive renal disease, patients on dialysis, and even following transplantation. Echocardiographic parameters have been shown to be stronger determinants of CVD mortality than conventional risk factors in the transplant population, and studies are needed to look at regression of these echocardiographic abnormalities with blood pressure control.