Left Ventricular Reverse Remodeling after Successful Living Donor Kidney Transplantation: The Visualizing the Pathophysiology of Kidney Transplantation in Modern Age Study

Abstract

Key Points:

1. Kidney transplantation (KT) can improve even advanced left ventricular (LV) geometric patterns, but this effect may be attenuated by pre-KT decreased diastolic function and acute antibody-mediated rejection.

2. Regardless of the pre-KT LV geometric pattern, the postoperative LV geometric pattern tended to shift toward concentric remodeling.

3. Geometric patterns may be an easy-to-understand and useful cardiac function assessment tool for nephrologists.

Background: The effect of kidney transplantation (KT) on left ventricular (LV) remodeling remains poorly understood. The aim of this study was to evaluate the effect of KT on LV reverse remodeling, using echocardiographic LV geometric patterns as a key assessment tool.

Methods: In 100 recipients who underwent living KT between 2012 and 2022, we evaluated changes in the distribution of LV geometric patterns (normal geometry, concentric remodeling [CR], eccentric hypertrophy [EH], and concentric hypertrophy [CH]) between baseline and 1 year after transplantation. These patterns were categorized on the basis of LV mass index and relative wall thickness assessed by echocardiography.

Results: Overall, LV geometric patterns improved or remained stable in 81% of recipients, with worsening in 19%. The proportion of normal geometry increased from 15% to 19% and CR from 30% to 45%, whereas EH decreased markedly from 20% to 3%. CH remained relatively stable at 33% (P = 0.036). Subgroup analysis revealed that 47% of those with pre-KT normal geometry progressed to LV remodeling, whereas 77% with CR remained stable. By contrast, 55% with EH experienced reverse remodeling and 49% with CH also showed reverse remodeling. These subgroup results suggest an interaction between the effect of KT on LV reverse remodeling and pre-KT LV geometric patterns. Multivariable analysis identified E/e′ > 9.5 (odds ratio, 2.01; 95% confidence interval, 1.10 to 3.67; P = 0.024) and acute antibody-mediated rejection (odds ratio, 2.44; 95% confidence interval, 1.01 to 5.87; P = 0.047) as independent predictors of LV remodeling progression.

Conclusions: KT can lead to improvements in even advanced LV geometric patterns, although this effect may be diminished in the presence of pre-KT diastolic dysfunction or the occurrence of acute rejection. Because recipients rarely achieve complete renal recovery, echocardiographic monitoring remains crucial after KT. Future studies are needed to establish whether these observed improvements in LV reverse remodeling directly translate into long-term reductions in cardiovascular events.

Graphical abstract

Figure 1

LV geometric patterns. For the definitions of LVMI and RWT, see the explanation in the Echocardiographic Parameters subsection under Methods. The VALsartan In Acute myocardial iNfarcTion study showed that CH was associated with the highest CVD risk, followed by EH, CR, and normal geometry. CH, concentric hypertrophy; CR, concentric remodeling; CVD, cardiovascular disease; EH, eccentric hypertrophy; LV, left ventricular; LVMI, left ventricular mass index; RWT, relative wall thickness.

Figure 2

Echocardiographic findings before and after KT (1 year). The percentage changes in LVMI, RWT, E/e′, and LVEF were calculated as ([value 1 year after KT−value before KT]/value before KT)×100 and were −9.4%, +10.9%, −3.3%, and +3.0%, respectively. E/e′, ratio between early mitral inflow velocity and mitral annular early diastolic velocity; KT, kidney transplantation; LVEF, left ventricular ejection fraction; LVMI, left ventricular mass index; RWT, relative wall thickness.

Figure 3

Overall LV geometric patterns before and after KT (1 year). P value was calculated using the Wilcoxon signed rank test.

Figure 4

Post-KT (1 year) LV geometric patterns by pre-KT LV geometric patterns. The numbers above each graph represent the number of KTRs, and the numbers below represent the percentage. The underlines indicate that the LV geometric patterns were unchanged before and after KT. Progression of LV remodeling was observed in 19 of 100 KTRs. KTR, kidney transplant recipient.

Figure 5

Unfavorable factors for LV reverse remodeling. The continuous data were dichotomized using the median. ABMR, antibody-mediated rejection; PKT, preemptive kidney transplantation; RAS, renin-angiotensin system.