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CLINICAL RESEARCH: HEART FAILURE

Effect of kidney transplantation on left ventricular systolic dysfunction and congestive heart failure in patients with end-stage renal disease

Ravinder K. Wali, MD^_*,_*, Gregory S. Wang, MD^,¶, Stephen S. Gottlieb, MD, Lavanya Bellumkonda, MD^_*,¶, Riple Hansalia, MD^,¶, Emilio Ramos, MD^_*, Cinthia Drachenberg, MD^||, John Papadimitriou, MD^||, Meredith A. Brisco, MD^,¶, Steve Blahut, PhD^_*, Jeffrey C. Fink, MD^_*, Michael L. Fisher, MD^,¶, Stephen T. Bartlett, MD and Matthew R. Weir, MD^_*

^_* Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
Department of Internal Medicine, University of Maryland School of Medicine, Baltimore, Maryland
Division of Cardiology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
Division of Transplant Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
^|| Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland
^¶ Current author affiliations: Dr. Wang, Department of Internal Medicine, Emory University School of Medicine, Atlanta, Georgia; Dr. Bellumkonda, Department of Medicine, University of Connecticut Health Center, Farmington, Connecticut; Dr. Hansalia, Zena and Michael A. Weiner Cardiovascular Institute, New York, New York; Dr. Fisher, Department of Cardiology, Kaiser Permanente, Denver, Colorado; and Dr. Brisco, Department of Internal Medicine, Barnes-Jewish Hospital, St. Louis, Missouri

Manuscript received August 25, 2004; revised manuscript received November 23, 2004, accepted November 29, 2004.

^_* Reprint requests and correspondence: Dr. Ravinder K. Wali, University of Maryland School of Medicine, Department of Medicine, Division of Nephrology, N3W143, 22 South Greene Street, Baltimore, Maryland 21201 (Email: rwali{at}medicine.umaryland.edu).

OBJECTIVES: We examined the impact of kidney transplantation on left ventricular ejection fraction (LVEF) in end-stage renal disease (ESRD) patients with congestive heart failure (CHF).

BACKGROUND: The ESRD patients with decreased LVEF and a poor New York Heart Association (NYHA) functional class are not usually referred for transplant evaluations, as they are considered to be at increased risk of cardiac and surgical complications.

METHODS: Between June 1998 and November 2002, 103 recipients with LVEF 40% and CHF underwent kidney transplantation. The LVEF was re-assessed by radionuclide ventriculography gated-blood pool (MUGA) scan at six and 12 months and at the last follow-up during the post-transplant period.

RESULTS: Mean pre-transplant LVEF% increased from 31.6 ± 6.7 (95% confidence interval [CI] 30.3 to 32.9) to 52.2 ± 12.0 (95% CI 49.9 to 54.6, p = 0.002) at 12 months after transplantation. There was no perioperative death. After transplantation, 69.9% of patients achieved LVEF 50% (normal LVEF). A longer duration of dialysis (in months) before transplantation decreased the likelihood of normalization of LVEF in the post-transplant period (odds ratio 0.82, 95% CI 0.74 to 0.91; p < 0.001). The NYHA functional class improved significantly in those with normalization of LVEF (p = 0.003). After transplantation, LVEF >50% was the only significant factor associated with a lower hazard for death or hospitalizations for CHF (relative risk 0.90, 95% CI 0.86 to 0.95; p < 0.0001).

CONCLUSIONS: Kidney transplantation in ESRD patients with advanced systolic heart failure results in an increase in LVEF, improves functional status of CHF, and increases survival. To abrogate the adverse effects of prolonged dialysis on myocardial function, ESRD patients should be counseled for kidney transplantation as soon as the diagnosis of systolic heart failure is established.

Abbreviations and Acronyms   ACE = angiotensin-converting enzyme   CABG = coronary artery bypass graft   CHF = congestive heart failure   ESRD = end-stage renal disease   LVEF = left ventricular ejection fraction   MUGA = radionuclide ventriculography gated-blood pool scan   NYHA = New York Heart Association   PTCA = percutaneous transluminal coronary angioplasty   PTH-I = intact parathyroid hormone   URR = urea reduction ratio

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