Chronic kidney disease after heart transplantation

Abstract

Background: Chronic kidney disease (CKD) is a complication of heart transplantation related to calcineurin inhibitor nephrotoxicity. However, it is unclear whether early ciclosporin (CsA) exposure influences CKD in the long term.

Methods: We analysed risk factors for CKD in 352 patients who underwent orthotopic heart transplantation (1995-2005). In 2000, we reduced our target CsA levels in the first year after transplantation.

Results: Actuarial patient survival was 79% at 1 year and 62% at 10 years. Estimated median glomerular filtration rate (eGFR) by the four-variable Modification of Diet in Renal Disease formula was 64 ml/min/1.73 m2 before transplantation, inter-quartile range (IQR) 54-78. After transplantation, the eGFR was 48 (IQR 37-61) at Year 1, and 41(35-57) at Year 10. The cumulative probability of eGFR <45 ml/min/1.73 m2 was 45% at Year 1, 71% at Year 5 and 83% at Year 10. A multivariable logistic regression model was constructed for the development of eGFR <45 ml/min/1.73 m2 by 3 years. The risk factors were post-operative renal replacement therapy for acute renal failure (ARF), P < 0.001; pretransplant diabetes, P = 0.005; increasing recipient age, P < 0.001; female recipient, P = 0.029; female donor, P = 0.04, but not CsA regimen. The cumulative probability of developing stage 5 CKD (eGFR <15) was 3% at Year 5 and 12% at Year 10. Although lower ciclosporin initial levels were associated with less renal dysfunction at Year 1 (P = 0.008), there was no significant effect by Year 3 (P = 0.7).

Conclusion: The incidence of CKD increased with time and was not influenced by the CsA regimen. Some risk factors are not modifiable but measures to reduce the incidence of post-operative ARF may help to reduce CKD.