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Pulse pressure is an independent risk factor of cardiovascular disease in renal transplant patients
Pulse Pressure Is an Independent Risk Factor of Cardiovascular Disease in Renal Transplant Patients G. Ferna´ndez-Fresnedo, R. Escallada, E. Rodrigo, A.L.M. de Francisco, S. Sanz de Castro, J.C. Ruiz, C. Pin˜era, J.G. Cotorruelo, and M. Arias ABSTRACT Elevated pulse pressure in the general population has been shown to be associated with cardiovascular disease, which is the main cause of death in renal transplant patients. We investigated the effects that a wide pulse pressure has on cardiovascular disease after renal transplantation in a cohort of 532 transplant patients with functioning grafts for more than one year. Patients were classified into two groups depending on whether the one-year pulse pressure was less than or greater than 65 mm Hg. We analyzed patient survival, posttransplant cardiovascular disease and principle causes of death. Five- and ten-year patient survival were lower among the group with higher pulse pressures. The main cause of death was vascular disease in both groups. The presence of posttransplant cardiovascular disease was higher among the group with higher pulse pressures (RR ⫽ 1.73). In addition, the incidence of an elevated pulse pressure was directly associated with recipient age and posttransplant diabetes mellitus. In conclusion, pulse pressure represents an independent risk factor for increased cardiovascular morbidity and mortality in renal transplant patients.
H
YPERTENSION is a Potent Contributor to a poor prognosis and a significant predictor of cardiovascular mortality.1 The pulsatile component of blood pressure is pulse pressure (PP), which depends on ventricular ejection, arterial stiffness and timing of wave reflections. PP has been shown to be an independent risk factor for mortality or cardiovascular events in several studies in the general population, in hypertensive subjects and in the elderly cohort.2 However, the impact of PP in renal transplant patients has not been sufficiently studied. The aim of the present study was to determine the effect of high PP after renal transplantation on total mortality and cardiovascular events, which are the main cause of death in recipients.3
MATERIALS AND METHODS 532 caucasian patients transplanted between 1985 and 1998 with functioning grafts for more than one year were included in the study. Immunosuppressive regimen consisted of triple therapy with cyclosporine. The patients were divided into two groups depending on their pulse pressure at one year after transplantation: group A [⬍65 mm Hg (n ⫽ 392)] and group B [⬎65 mm Hg (n ⫽ 140)].
RESULTS
There were no statistical differences in sex distribution, etiology of chronic renal failure, number of retransplants,
ischemia time or immunological characteristics. Recipient and donor ages were higher among group B (40.8 ⫾ 12.6 vs 50 ⫾ 11.3 years, P ⬍ .01; 36.2 ⫾ 16 vs 40.7 ⫾ 17 years, P ⫽ 0.01). The prevalence of pretransplant hypertension and cardiovascular disease were similar in both groups. At one-year posttransplant systolic blood pressure was higher among group B without differences in diastolic blood pressure (132/84 vs 164/84 mm Hg). Five- and ten-year patient survivals were lower among group B (80% and 69%) than group A (93% and 80%), [P ⬍ .05]. The main cause of death was vascular disease in both groups. Posttransplant cardiovascular disease was higher among patients of group B (33.6%) than group A (23.4%) [P ⬍ .05], including peripheral vascular disease (7.5% vs 10.7%), cerebral vascular disease (3.9% vs 4.2%) and chronic heart failure (4.6% vs 10%) (P ⬍ .05). Incidence of posttransplant diabetes mellitus was higher in the group B cohort (14% vs 23%, P ⬍ .05). According to a Cox From the Nephrology Service, Universitary Hospital Marque´s de Valdecilla, 39008, Santander, Spain. Address reprint requests to Gema Ferna´ndez Fresnedo, Servicio de Nefrologia, Hospital Marque´s de Valdecilla, Avda de Valdecilla, 39008, Santander, Spain. E-mail: [email protected]
0041-1345/03/$–see front matter doi:10.1016/S0041-1345(03)00605-5
© 2003 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
1730
Transplantation Proceedings, 35, 1730 –1731 (2003)
PULSE PRESSURE ON CARDIOVASCULAR DISEASE
regression model, the higher PP was associated with cardiovascular disease (RR⫽1.73, 95% CI 1.2–2.5, P ⬍ .01). DISCUSSION
Pulse pressure was an independent risk factor for increased mortality, especially cardiovascular morbidity/mortality in our renal transplant patients, like in the general population with hypertension.2 Higher systolic blood pressure and lower diastolic blood pressure, that is, a wider PP range, correlated with a significant risk of cardiovascular disease in
1731
renal transplant patients. In summary, our data show the importance of focusing on PP in renal transplant recipients to select a high-risk population, for whom more intensive strategies should be implemented. REFERENCES 1. MacMahon S, Peto R, Cutler J, et al: Lancet 335:765, 1990 2. Benetos A, Rudnichi A, Safar M: Hypertension 32:560, 1998 3. Kasiske BL, Guijarro C, Massy ZA, et al: J Am Soc Nephrol 7:158, 1996
H
YPERTENSION is a Potent Contributor to a poor prognosis and a significant predictor of cardiovascular mortality.1 The pulsatile component of blood pressure is pulse pressure (PP), which depends on ventricular ejection, arterial stiffness and timing of wave reflections. PP has been shown to be an independent risk factor for mortality or cardiovascular events in several studies in the general population, in hypertensive subjects and in the elderly cohort.2 However, the impact of PP in renal transplant patients has not been sufficiently studied. The aim of the present study was to determine the effect of high PP after renal transplantation on total mortality and cardiovascular events, which are the main cause of death in recipients.3
MATERIALS AND METHODS 532 caucasian patients transplanted between 1985 and 1998 with functioning grafts for more than one year were included in the study. Immunosuppressive regimen consisted of triple therapy with cyclosporine. The patients were divided into two groups depending on their pulse pressure at one year after transplantation: group A [⬍65 mm Hg (n ⫽ 392)] and group B [⬎65 mm Hg (n ⫽ 140)].
RESULTS
There were no statistical differences in sex distribution, etiology of chronic renal failure, number of retransplants,
ischemia time or immunological characteristics. Recipient and donor ages were higher among group B (40.8 ⫾ 12.6 vs 50 ⫾ 11.3 years, P ⬍ .01; 36.2 ⫾ 16 vs 40.7 ⫾ 17 years, P ⫽ 0.01). The prevalence of pretransplant hypertension and cardiovascular disease were similar in both groups. At one-year posttransplant systolic blood pressure was higher among group B without differences in diastolic blood pressure (132/84 vs 164/84 mm Hg). Five- and ten-year patient survivals were lower among group B (80% and 69%) than group A (93% and 80%), [P ⬍ .05]. The main cause of death was vascular disease in both groups. Posttransplant cardiovascular disease was higher among patients of group B (33.6%) than group A (23.4%) [P ⬍ .05], including peripheral vascular disease (7.5% vs 10.7%), cerebral vascular disease (3.9% vs 4.2%) and chronic heart failure (4.6% vs 10%) (P ⬍ .05). Incidence of posttransplant diabetes mellitus was higher in the group B cohort (14% vs 23%, P ⬍ .05). According to a Cox From the Nephrology Service, Universitary Hospital Marque´s de Valdecilla, 39008, Santander, Spain. Address reprint requests to Gema Ferna´ndez Fresnedo, Servicio de Nefrologia, Hospital Marque´s de Valdecilla, Avda de Valdecilla, 39008, Santander, Spain. E-mail: [email protected]
0041-1345/03/$–see front matter doi:10.1016/S0041-1345(03)00605-5
© 2003 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
1730
Transplantation Proceedings, 35, 1730 –1731 (2003)
PULSE PRESSURE ON CARDIOVASCULAR DISEASE
regression model, the higher PP was associated with cardiovascular disease (RR⫽1.73, 95% CI 1.2–2.5, P ⬍ .01). DISCUSSION
Pulse pressure was an independent risk factor for increased mortality, especially cardiovascular morbidity/mortality in our renal transplant patients, like in the general population with hypertension.2 Higher systolic blood pressure and lower diastolic blood pressure, that is, a wider PP range, correlated with a significant risk of cardiovascular disease in
1731
renal transplant patients. In summary, our data show the importance of focusing on PP in renal transplant recipients to select a high-risk population, for whom more intensive strategies should be implemented. REFERENCES 1. MacMahon S, Peto R, Cutler J, et al: Lancet 335:765, 1990 2. Benetos A, Rudnichi A, Safar M: Hypertension 32:560, 1998 3. Kasiske BL, Guijarro C, Massy ZA, et al: J Am Soc Nephrol 7:158, 1996