Madden Michelle, Gallen Rory, Newman Hana R, Zhang Nan, Lim Elisabeth, LeMond Lisa M, Steidley D Eric, Keddis Mira T
Division of Nephrology, Mayo Clinic, Scottsdale, AZ.
Department of Cardiology, Mayo Clinic Hospital, Phoenix, AZ.
Transplant Direct. 2023 Jan 6;9(2):e1421. doi: 10.1097/TXD.0000000000001421. eCollection 2023 Feb.
End-stage kidney disease patients with concomitant heart failure (HF) with reduced ejection fraction are often denied kidney transplantation. The aims of this study were to explore factors predictive of suitability for kidney transplant and to assess cardiovascular outcomes in patients with impaired left ventricular ejection fraction (LVEF) after transplant.
We evaluated 109 consecutive adults with LVEF ≤40% at the time of initial kidney transplant evaluation between 2013 and 2018. Posttransplant cardiovascular outcomes were defined as nonfatal myocardial infarction (MI), admission for HF, cardiovascular death, and all-cause mortality.
A cardiologist participated in kidney transplant evaluation for 87% of patients and was present at 49% of transplant selection conferences. Twenty-four patients (22%) were denied by a cardiologist for kidney transplant' and 59 (54%) were denied by the selection committee, of whom 43 were because of cardiovascular risk. Forty-two (38%) patients were approved for kidney transplant. On univariate analysis, the variables associated with denial for kidney transplant included cardiologist denial, higher cardiac troponin T, prior coronary intervention, cardiovascular event, positive stress study, lower ejection fraction, and lower VO max (all < 0.05). Cardiologist denial was the most significant predictor of denial for kidney transplant in different multivariate models. At a median follow-up of 15 mo, 5 (5%) suffered nonfatal MI, 13 (12%) were hospitalized for HF exacerbation, and 17 (16%) died. Only 22 patients, 52% of those approved, underwent kidney transplant. After kidney transplant, there was 1 death, 1 nonfatal MI, and 3 hospitalizations for HF. Median LVEF improved from 38% before listing to 55% posttransplant.
Cardiologist denial was the primary predictor of rejection for kidney transplant. Despite careful selection, prevalence of cardiovascular events and mortality after kidney transplant was 23%. There is need for a structured multidisciplinary approach for patients with impaired LVEF.
射血分数降低的终末期肾病合并心力衰竭患者通常被拒绝进行肾移植。本研究的目的是探讨预测肾移植适用性的因素，并评估移植后左心室射血分数（LVEF）受损患者的心血管结局。
我们评估了2013年至2018年期间在初次肾移植评估时连续的109例LVEF≤40%的成年人。移植后的心血管结局定义为非致命性心肌梗死（MI）、因心力衰竭入院、心血管死亡和全因死亡。
一名心脏病专家参与了87%患者的肾移植评估，并出席了49%的移植选择会议。24例（22%）患者被心脏病专家拒绝肾移植，59例（54%）被选择委员会拒绝，其中43例是因为心血管风险。42例（38%）患者被批准进行肾移植。单因素分析显示，与拒绝肾移植相关的变量包括心脏病专家的拒绝、较高的心肌肌钙蛋白T、既往冠状动脉介入治疗、心血管事件、阳性负荷试验、较低的射血分数和较低的最大摄氧量（均P<0.05）。在不同的多变量模型中，心脏病专家的拒绝是拒绝肾移植的最显著预测因素。中位随访15个月时，5例（5%）发生非致命性MI，13例（12%）因心力衰竭加重住院，17例（16%）死亡。只有22例患者（占获批患者的52%）接受了肾移植。肾移植后，有1例死亡、1例非致命性MI和3例因心力衰竭住院。中位LVEF从列入名单前的38%提高到移植后的55%。
心脏病专家的拒绝是肾移植被拒的主要预测因素。尽管进行了仔细筛选，但肾移植后心血管事件和死亡率的发生率仍为23%。对于LVEF受损的患者，需要一种结构化的多学科方法。
