Kumar Dhiren, Raju Nihar, Prajapati Bhupinder, Moinuddin Irfan, Tripathi Shreyank, Grinnan Daniel, Thomas Deepak, Gupta Gaurav
Virginia Commonwealth University, Internal Medicine, Richmond, VA.
Richmond Nephrology Associates, Nephrology, Richmond, VA.
Transplant Direct. 2024 May 16;10(6):e1640. doi: 10.1097/TXD.0000000000001640. eCollection 2024 Jun.
Severe pulmonary hypertension (PH) is associated with high mortality posttransplant and thus is considered a contraindication to kidney transplantation. In this study, we describe the pretransplant management and posttransplant outcomes in patients with severe PH using a multidisciplinary approach.
Between 11 of 2013 and 8 of 2022, we identified all patients with severe PH on initial pretransplant workup who underwent ultrafiltration (UF) or medical therapy for PH before transplant. Posttransplant we evaluated the perioperative course, renal function, graft, and patient survival. We compared survival to those who remained waitlisted or were delisted.
Three-two patients (mean age = 55.03 ± 10.22 y) diagnosed with severe PH on pretransplant screening echocardiogram. Thirty patients (94%) were subjected to a median of 4 (range, 3-8) UF sessions with an average weight loss of 4.33 ± 2.6 kg. Repeat assessment of PH revealed a decline in mean pulmonary artery systolic pressure from 67 ± 12 mm Hg to 43 ± 13 mm Hg ( < 0.0001). Seventeen patients (53%) received a kidney transplant. The mean estimated Glomerular Filtration Rate at 3, 6, 9, and 12 mo was 72 ± 27, 72 ± 28, 75 ± 29, and 75 ± 29 mL/min/1.73 m. Among, those who underwent transplantation both graft and patient survival was 100% at 1-y posttransplant. Overall, since the UF intervention, at a median follow-up of 88 ± 12 mo those transplanted had a patient survival of 88% while those who remained on dialysis had a survival of 53% ( = 0.0003).
In this single-center study, we report postcapillary PH can be a significant contributor to elevations in pulmonary artery systolic pressure. Using a multidisciplinary approach, PH can improve with volume removal and phosphodiesterase 5 inhibitors therapy leading to a successful posttransplant outcome.
重度肺动脉高压（PH）与移植后高死亡率相关，因此被视为肾移植的禁忌证。在本研究中，我们描述了采用多学科方法对重度PH患者进行移植前管理及移植后结局。
在2013年11月至2022年8月期间，我们确定了所有在移植前初始检查时被诊断为重度PH且在移植前接受过超滤（UF）或PH药物治疗的患者。移植后，我们评估了围手术期过程、肾功能、移植物和患者生存率。我们将生存率与那些仍在等待名单上或被除名的患者进行了比较。
32例患者（平均年龄=55.03±10.22岁）在移植前筛查超声心动图时被诊断为重度PH。30例患者（94%）接受了中位数为4次（范围3 - 8次）的UF治疗，平均体重减轻4.33±2.6 kg。对PH的重复评估显示，平均肺动脉收缩压从67±12 mmHg降至43±13 mmHg（P<0.0001）。17例患者（53%）接受了肾移植。移植后3、6、9和12个月时的平均估计肾小球滤过率分别为72±27、72±28、75±29和75±29 mL/min/1.73 m²。其中，接受移植的患者在移植后1年时移植物和患者生存率均为100%。总体而言，自UF干预以来，在中位随访88±12个月时，移植患者的生存率为88%，而仍接受透析的患者生存率为53%（P=0.0003）。
在这项单中心研究中，我们报告毛细血管后PH可能是肺动脉收缩压升高的重要原因。采用多学科方法，通过容量清除和磷酸二酯酶5抑制剂治疗，PH可得到改善，从而实现成功的移植后结局。
