Complexities and outcomes of pulmonary hypertension in kidney transplant patients: a comprehensive review

Abstract

Pulmonary hypertension (PH) is often present in patients presenting for kidney transplant listing. While PH can complicate kidney transplant (KTx), with multidisciplinary management that includes both the transplant center and pulmonary hypertension center or experts both pre- and post-transplant. This review summaries the approach and management of PH in KTx candidates and recipients, along with expected outcomes and controversies surrounding arteriovenous fistula and graft management.

Keywords: Dialysis access; Echocardiogram; Kidney transplant; Pulmonary arterial pressure; Pulmonary hypertension; Right heart catheterization; Vascular access.

Figure 1.

Conceptual framework for the physiology of pulmonary hypertension based on underlying disease states intrinsic to or affecting the pulmonary vasculature, as currently categorized by the World Health Organization (WHO). Reproduced from Lentine et al.^, COPD, chronic obstructive pulmonary disease; LAP, left atrial pressure; LV, left ventricle; NO, nitric oxide; OSA, obstructive sleep apnea; PAH, pulmonary arterial hypertension; PCWP, pulmonary capillary wedge pressure; PH, pulmonary hypertension

Figure 2.

Suggested algorithm for the evaluation of kidney transplant recipients with echocardiographic evidence of pulmonary hypertension. Reproduced from Lentine et al. ACC, American College of Cardiology; AHA, American Heart Association; AVF, arteriovenous fistula; CO, cardiac output; HTN, hypertension; PAP, pulmonary artery pressure; PASP, pulmonary artery systolic pressure; PCWP, pulmonary capillary wedge pressure; PH, pulmonary hypertension; PVR, pulmonary vascular resistance; RHC, right heart catheterization; RV, right ventricle; WT, weight

FIGURE 3.

Center-level variation in post-transplant AV access ligation. On average, 4.2% of patients KTx underwent AV access ligation. From , used with permission.

Figure 4.

Adjusted association of kidney transplant (within 6 months post-KTx (A) and >6 months post-KTx (B) with risk of PH after listing vs. continued waiting, by age at listing. Reproduced from Lentine et al

Figure 5.

Current management strategies for kidney transplant recipients with pulmonary hypertension, including recommendations for general care for all affected patients and treatments specific to World Health Organization (WHO) diagnosis group. Reproduced from Lentine et al. AVF, arteriovenous fistula; CO, cardiac output; CPAP, continuous positive airway pressure; ERAs, endothelin receptor antagonists; NO, nitric oxide; OSA, obstructive sleep apnea; PAH, pulmonary arterial hypertension; PAP, pulmonary artery pressure; PCWP, pulmonary capillary wedge pressure; PDE-5, phosphodiesterase type 5; PH, pulmonary hypertension; RHC, right heart catheterization