Prevalence and management of cardiovascular risks in renal transplant recipients Dr VS Aithal...

Prevalence and management of cardiovascular risks in renal transplant recipients

Dr VS AithalConsultant Nephrologist Swansea

• Transplantation improves survival when compared with dialysis

• Survival remains well below general population

• 50% die with a functioning transplant and 50% of these from cardiovascular causes

• Annual rate of fatal/nonfatal CVD events 3.5-5% in transplant recipients

Cardiovascular risk factors

• Smoking• HTN • Hyperlipidaemia (low HDL included)• Family history of CV disease• Age (men >45,women >55y)• Diabetes

Cardiovascular risk factors

• BMI>30• Physical inactivity• Ethnicity• Immunosuppressives• Graft dysfunction/failure• Anaemia• Rejection episodes• Proteinuria

• Renal transplants older than 1yr as of July 2015 were included in the audit

• Patients less than 18yrs of age were excluded from the analysis

Cardiff Swansea Wrexham Bangor GC

Patients 933 308 137 74 74

Age

<40 40-60 60-70 70-80 >80 MEDIAN0

10

20

30

40

50

60

70

cardiffswanseawrexhambangorGC

20-30% of patients 60-70yrs. 10-15% of patients >70yrs

Cardiff Swansea Wrexham Bangor GC0

1

2

3

4

5

6

7

8

9

10

Transplant age

Transplant age

Audit standards for cholesterol

• Annual check (2C)• Treatment targets should be the same as in

general population (2C)• ALERT study: after a 5yr FU, LDL reduced by

32% in fluvastatin arm. Risk of cardiac death of non-fatal MI was reduced by 35%

Cholesterol <5

Cardiff swansea wrexham Bangor GC0

10

20

30

40

50

60

70

80

90

70.99

75.64

89.78

68.91

54.05

<5

Statin and Aspirin

CARDIFF SWANSEA WREXHAM BANGOR GC0

10

20

30

40

50

60

70

80

STATINASPIRIN

Cholesterol >5

Cardiff swansea wrexham Bangor GC0

5

10

15

20

25

30

35

40

20.3417.53

5.83

18.91

37.83

7.155.84

2.91

12.16

8.1

5 to 66 to 8>8no data

Creatinine

<100 100-200 200-300 300-400 >400 median0

20

40

60

80

100

120

140

CardiffSwanseaWrexhamBangorGC

6-20% had Cr 200-300. 2-4 % had Cr 300-400

Haemoglobin


1

2

3

4

5

6

7

8

9

<100<90160-170>170

<10g 3-8% <9G 1-5%

BMI

Cardiff Swansea Wrexham GC0

10

20

30

40

50

60

70

80

90

33.11

26.05 25.7719.67

<30>30no data

• 5mmHg reduction in BP reduces risk of MI by 10-15%

• Modest reduction of BP with treatment of hyperlipidaemia in high risk patients with transplants improved patient survival by 2yrs

Hypertension

• RA/KDIGO guidline: <130/80 and <127/75 in pts with PCR >50 (2C)

• BP should be recorded at every visit (1C)

Systolic BP


10

20

30

40

50

60

7062.73

69.3665.41

56.7

67.14

24.7727.27 28.57 29.85

27.14

10.77

3.36 4.51

10.445.71

1.71 0 1.5 2.980

<140140-160160-180>180no data

3-13.5% have systolic HTN1-3% have severe systolic HTN

Diastolic BP


10

20

30

40

50

60

17.01

10.43

15.78

5.97 7.14

<8080-9090-100no data

Aspirin

• Metanalysis of 287 studies (135000pts) absolute reductions in serious vascular event in patients with previous MI was 36/1000 treated pts and 22/1000 treated high risk patients (stable angina,PVD)

Statin and Aspirin


10

20

30

40

50

60

70

80

53.0556.16

61.02

29.72

46.5

69.5673.05

34.3

44.59

53.9

STATINASPIRIN

ACE-I/ARB


5

10

15

20

25

30

35

40

32.0333.76

39.4

16.21

31.57

ARBACEIACE/ARB

Antihypertensives


10

20

30

40

50

60

CCBBblockerDIURETIC

Not on antihypertensives


2

4

6

8

10

12

14

16

18

5.3

2.27

5.1

17.5

5.4

No antihypertensives

No antihypertensives

Diabetes

• Check blood glucose every visit (2C)• Annual HbA1c• HbA1c 7-7.5(53-58)

Swansea Wrexham Bangor GC0

10

20

30

40

50

60

70

80

90

100

19.4 2113.5 10.8

DiabeticsHbA1c in 1yr

HbA1c in target range

swansea Wrexham Bangor GC0

10

20

30

40

50

60

7056.6

51.71

70

50

HbA1c

HbA1c

HbA1c >60

Swansea Wrexham Bangor GC0

5

10

15

20

25

30

35

40

45

5043.2

48.25

30

50

HbA1c>60

HbA1c>60

HbA1c >60

60-70 70-80 80-90 90-100 >1000

5

10

15

20

25

SwanseaWrexhamBangorGC

HbA1c Swansea

60-70 70-80 80-90 90-100 >1000

5

10

15

20

25

3/60

1/60

6/60

1/60

15/60

43.2% had HbA1c >60

Wrexham HbA1c

60-70 70-80 80-90 90-100 >1000

2

4

6

8

10

12

14

16

18

2/29

5/29

2/29

3/29

2/29

48.25% had HbA1c >60

60-70 70-80 80-90 90-100 >1000

2

4

6

8

10

12

14

16

18

20

Bangor

Bangor

2/10

1/10

30% had HbA1c >60

GC HbA1c

60-70 70-80 80-90 90-100 >1000

5

10

15

20

25 2/8

50% had HbA1c >60

HbA1c Cardiff

<50 50-60 60-70 70-80 80-90 90-100 >1000

10

20

30

40

50

60

70

Cardiff

Cardiff

209/326

37/326 27/326

29/326 9/326 7/326 8/326

326 patients had HbA1c in the last 12months

Conclusions

• 30-45% had cholesterol >5 , 6-12% had 6-8 (except Wrexham)

• 30 to 50% had HbA1c >60• 20-30% of our patients are obese• 3-8% of our transplant patients had Hb<10,

1-5% had Hb<9

Conclusions

• 30-45% did not meet BP standards for systolic and 4-14% had systolic BP>160

• 35-59% did not meet standards for diastolic BP and 5-17% had diastolic >90

Data for next audit

• Smoking history• Family history of CV events• Proteinuria• Patients on prednisolone

Data for next audit

• Need to audit data on random glucose from every visit and see if there are undiagnosed diabetics

• Need data on proteinuria. ? Document proteinuria from every visit and check if PCR requested in all pts with proteinuria. Alternatively check urine PCR/ACR at regular intervals

• Data on use of ACE-I in those with proteinuria

Acknowledgements

• Dr Donovan, Dr Griffin, Gary Hunter Cardiff• Dr Judith Welham Wrexham• Dr Abdul Alejmi Bangor• Dr Aled Lewis GC• Mike Wakelyn and Cathy Blakemore Swansea

• 50 patients from swansea had urine PCR,26 pts had PCR >50. 12/26 were on ACE-I

• 27 patients from Wrexham had urine PCR checked. 12 had PCR>50. 9/12 were on ACE-I

4 to 6 >6 >8 median no data0

10

20

30

40

50

60

70

cardiffswanseawrexhamBangorGC

Cholesterol


10

20

30

40

50

60

70

58.87

7.76

0.7000000000000014.5

0.3

55.5

6.16

0.6400000000000024.3

0.600000000000001

39.41

2.910

3.90

48.64

12.16

0

4.5

0

63.51

8.1

0

4.95

0


cardiff swansea wrexham Bangor GC0

10

20

30

40

50

60

70

58.8755.5

39.41

48.64

63.51

7.76 6.162.91

12.168.1

0.7000000000000010.640000000000002 0 0 0

4 to 6>6>8medianno data

Cholesterol


10

20

30

40

50

60

32.67

37.7

57.68

39.2

28.69

cholesterol <4

cholesterol <4


10

20

30

40

50

60

70


cardiff swansea wrexham Bangor GC0

10

20

30

40

50

60

70

58.8755.5

39.41

48.64

63.51

7.76 6.162.91

12.168.1

0.7000000000000010.640000000000002 0 0 0

4 to 6>6>8medianno data

N0t required

<50 50-60 60-70 70-80 80-90 90-100 >1000

10

20

30

40

50

60

SwanseaWrexhamBangorGC

• 5mmHg reduction in BP reduces risk of MI by 10-15%

• Modest reduction of BP with treatment of hyperlipidaemia in high risk patients with transplants improved patient survival by 2yrs (55)

Prevalence and management of cardiovascular risks in renal transplant recipients Dr VS Aithal...

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