Enfermedad coronaria en el trasplante renalincidencia, tipología, factores de riesgo y pronóstico

Resum

BACKGROUND: The most important cause of dead in renal transplant recipients is the cardiovascular mortality. The coronary disese is the main cause of cardiac pathology after kidney transplantation, being responsible for angor, infarct, heart failure or arrythmias. OBJECTIVE:The aim of this Thesis is to know the coronary disease incidence, the risk factors, the tipology of coronary afecttion and the relationship with clinical parameters, treatment received and outcome so patient survival as allograft survival. MATERIAL AND METHODS: The kidney transplant recipients in Hospital Universitario A Coruña were studied from 1981 to 2016. The coronary event was defined as angor or infarct according to clinic characteristics and complementary data. Parameters analyzed: incidence of coronary events according with the period after kidney transplantation, age (donors and recipients),sex, primary disease, kind of transplant,combined transplant, history of previous cardiovascular disease before transplantation, hypertension, tobacco habit, diabetes, left ventricular hypertrophy, cholesterol, triglycerides, glycemia, hemoglobin, delayed graft function, creatinine, proteinuria, number of affected vessels, multivessel disease, type of coronary artery affected, valvular calcification, ejection fraction, percentage of coronary stenosis, treatment (medical, percutaneous intervention or By‐pass surgery), and the outcome according the coronary event and the treatment administered. RESULTS: 2889 kidney transplant recipients were studied from 1981 to 2016. In this period ( 36 years), 245 coronary events had been registered, 1,23/100 patientsyear. The cumuled incidence was 3,4% at 3rdmonth, 4,1% at 1st year, 5,3% at 3rd year, 6,6% at 5th year, 10,5% at 10th year and 14,5% at 15th year.The cumuled incidence was less in the period 2002‐2016 than the period 1981‐2001: 6,8% vs 12,1% at 10th year (p=0,002).This incidence of coronary events was highest at three months 37,9% and it increased with respect to total events by 21,8% in the second period. (p=0,002). The risk factors found in Cox model were age, time on waiting list, cardiovascular disease before transplantation, cholesterol levels, creatinine, smoking, diabetes after transplantation and Systolic Arterial Tension. The most important risk factors during the first three months after transplantation were age, presence of cardiovascular disease before transplantation and delayed graft function. The change of long‐term risk factors is very important because it makes the regression models change according to the period of study. The most affected coronary artery was the anterior descending artery. Non‐occlusive coronary disease was found in 24, 2 % while there is three vessels coronary disease in 27,5%. The ejection fraction has a negative relationship with the number of affected vessels and with the degree of coronary stenosis.In ROC curves, a ejection fraction less than 57% is associated with three vessels disease with a sensitivity of 81% and specificity of 53,2%. The coronary disease treatment consisted in medical therapy only in 56, 6 %, PCI in 31% and 19, 5% of patients received By‐PASS surgery.This last therapy was indicated more frequently in young people and in patients with three vessels disease.In Cox regression, the use of surgery is associated with less mortality but when we use the competitive risk model it is not significative. The patient survival after presenting a coronary event was 67, 2% at 5th year. The allograft survival was 78, 1% at 5th year. Coronary mortality using a competitive risks model was lower in the period 2002‐2016 vs 1981‐2001: 2, 25% at 6th vs 0, 84% at 6th respectively. CONCLUSIONS: The incidence of coronary disease after kidney transplantation has decreased the last 15 years and mortality too. There is an increment in the percentage of coronary events in the first three months with respect to total events in the second period. The three vessels coronary disease was 27,5%.Threre is a negative relationship between the ejection fraction and severity of coronary disease. Patients with infarct have more severe disease than patients with angor. The treatment with by‐pass is associated to young patients and three vessels disease and it’s a variable associated with lower mortality.The survival patient after coronary event is 85,2% at 1 st year and 67,2% al 5th year.