Recently reported study findings provide a detailed look at how a major adverse cardiovascular event (MACE) after kidney transplantation adversely affects survival and identify which patients are at elevated risk for MACE. Data also demonstrate that patients who receive a kidney transplant are at lower MACE risk compared with those who remain on dialysis.  

In a study of 30,325 KTRs in England published in Kidney International, a MACE occurred in 781 within the first year of transplantation surgery. KTRs who had a non-fatal MACE within that timeframe had significantly decreased patient survival compared with KTRs who did not experience a MACE at 1 year (80.5% vs 97.4%), 3 years (70.2% vs 94.4%), 5 years (59.5% vs 90.7%), and 10 years (38.6% vs 78.4%). A non-fatal MACE within the first-year of transplant surgery was significantly associated with 2.6-fold increased risk for long-term mortality, Adnan Sharif, MBChB, MD, of Queen Elizabeth Hospital, Edgbaston, Birmingham, United Kingdom and colleagues reported.

“Non-fatal MACE within the first year, regardless of the precise timing, was a powerful predictor of increased future mortality,” the investigators wrote. “Understanding MACE rates is important for service providers, healthcare professionals and kidney transplant recipients themselves.”

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The investigators defined post-kidney transplant MACE broadly as any hospitalization for unstable angina, myocardial infarction, stroke, heart failure, any coronary revascularization procedure and/or any cardiovascular death. A MACE occurred in 781 patients (2.6%) within the first 12 months of transplant surgery. Unstable angina occurred in 0.2%, heart failure in 0.3%, myocardial infarction in 1.1%, coronary revascularization in 0.4%, stroke in 0.8%, and immediate cardiac death in 0.1% within the first 12 months of transplant surgery. The investigators noted that these rates are lower than rates reported in North America.

Results also showed that men had a 20% higher risk for a post-kidney transplant MACE within 12 months than women. Compared with KTRs younger than 40 years, those aged 40-49, 50-59, and 60 years or older had a 2.4-, 4.3-, and 7.1-fold greater risk for an early MACE after kidney transplantation. Recipients of deceased donor living donor kidneys had a 37% higher 1-year MACE risk. Previous myocardial infarction, stroke, or angina was significantly associated with a 6.9-, 4.1-, and 2.6-fold increased risk of an early MACE, respectively. Diabetes at transplantation was significantly associated with a 2.2-fold increased risk for a 1-year MACE after kidney transplantation.

ADPKD Tied to Lower MACE Risk

In a study published in Kidney International Reports, investigatorsfound that KTRs with autosomal dominant polycystic kidney disease (ADPKD) have a more favorable MACE-free survival rate than patients with diabetes and other forms of kidney disease. In an age- and sex-matched analysis, KTRs with ADPKD had a significant 29% reduced risk for post-kidney transplant MACE after kidney transplantation compared with those with diabetic nephropathy and those without diabetes or ADPKD, Fouad T. Chebib, MD, of Mayo Clinic in Jacksonville, Florida, and colleagues reported. MACE included myocardial infarction, stroke, revascularization, and heart failure hospitalization. Echocardiography at time of transplant showed that the ADPKD group had lower rates of left ventricular hypertrophy, mitral (2.7% vs 6.3% vs 7.5%) and tricuspid regurgitations (1.8% vs 6.6% vs 7.2%). They also had less diastolic and systolic dysfunction at time of transplantation. However, ADPKD patients had worsening of valvular function and an increase in the sinus of Valsalva diameter after transplantation.

Benefit of Transplantation vs Dialysis

In a Korean study published in Nephrology Dialysis Transplantation, investigators examined de novo MACE in KTRs compared with patients receiving dialysis. Using the South Korean nationwide health insurance database, they matched 4156 patients without a pre-existing MACE in each of 3 groups: KTRs, dialysis recipients, and the general population.

Over 4.7 years of follow-up, de novo MACE occurred in 3.7, 21.7, and 2.5 individuals per 1000 person-years in the KTR, dialysis, and general population groups, respectively. De novo MACE included myocardial infarction, revascularization, and ischemic stroke. The investigators noted that these rates are lower than those reported in Western populations. KTRs had a significant 84% lower risk for de novo MACE compared with patients on dialysis, but a similar risk compared with the general population after adjusting for underlying co-morbidities such as diabetes and hypertension, Hajeong Lee, MD, of Seoul National University Hospital and colleagues reported. This finding suggests that kidney transplantation effectively reduces the risk of MACE compared with remaining on dialysis, according to Dr Lee’s team. Nonetheless, KTRs with and without de novo MACE had a significant 7.5-fold increased risk of all-cause mortality.

“Successful kidney transplantation reduces cardiovascular burden compared to remaining on dialysis, but risk remains elevated compared to the age-matched general population,” Dr Sharif’s team commented in their paper. “Adequate counselling aside, strategies to predict and/or mitigate cardiovascular risk in the setting of kidney transplantation are urgently required.”

Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original references for a full list of authors’ disclosures.


Anderson B, Qasim M, Evison F, et al. A population cohort analysis of English transplant centers indicates major adverse cardiovascular events after kidney transplantation. Kidney Int. Published online June 15, 2022. doi:10.1016/j.kint.2022.05.017

Chedid M, Kaidbay HD, Wigerinck S, et al. Cardiovascular outcomes in kidney transplant recipients with autosomal dominant polycystic kidney disease. Kidney Int Rep. Published online June 10, 2022. doi:10.1016/j.ekir.2022.06.006

Kim JE, Park J, Park S, et al. De novo major cardiovascular events in kidney transplant recipients: a comparative matched cohort study. Nephrol Dial Transplant. Published online April 9, 2022. doi:10.1093/ndt/gfac144