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
Cardiff Swansea Wrexham Bangor GC0
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
Cardiff Swansea Wrexham Bangor GC0
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
Cardiff Swansea Wrexham Bangor GC0
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
CARDIFF SWANSEA WREXHAM BANGOR GC0
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
CARDIFF SWANSEA WREXHAM BANGOR GC0
5
10
15
20
25
30
35
40
32.0333.76
39.4
16.21
31.57
ARBACEIACE/ARB
Antihypertensives
CARDIFF SWANSEA WREXHAM BANGOR GC0
10
20
30
40
50
60
CCBBblockerDIURETIC
Not on antihypertensives
Cardiff Swansea Wrexham Bangor GC0
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
4 to 6 >6 >8 median no data0
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
cardiffswanseawrexhamBangorGC
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
Cardiff Swansea Wrexham Bangor GC0
10
20
30
40
50
60
32.67
37.7
57.68
39.2
28.69
cholesterol <4
cholesterol <4
4 to 6 >6 >8 median no data0
10
20
30
40
50
60
70
cardiffswanseawrexhamBangorGC
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)