Longitudinal Changes in Left Ventricular Geometry After Kidney Transplantation and Their Implications on Cardiovascular Risk

Rationale & Objective: Kidney transplantation (KT) alleviates the hemodynamic burden in chronic kidney disease on dialysis. However, cardiovascular disease remains the leading cause of death after KT. This study evaluated the metabolic and hemodynamic burden and its impact on myocardial remodeling and clinical outcomes after KT. Study Design: Multicenter observational prospective cohort study. Setting & Participants: 600 patients who underwent echocardiography before and 3 years after KT from 8 university hospitals in Korea. Predictors: Changes in metabolic parameters (glycosylated hemoglobin [HbA_1C] and triglyceride [TG] levels) and hemodynamic parameters (hemoglobin [Hb] and systolic blood pressure [SBP]) from baseline to 3 years after KT. Outcomes: Primary outcome was major adverse cardiovascular events (MACE). Secondary outcomes included left ventricular geometry changes. Analytical Approach: Cox proportional hazards models were used to assess the association between echocardiographic changes and MACE. Results: TG and HbA_1c levels increased 3 years after KT; however, Hb levels and SBP improved (P < 0.05). Left ventricular end-diastolic dimension also improved for 3 years (P < 0.05). Nevertheless, the relative wall thickness (RWT) increased from 0.39 ± 0.07-0.41 ± 0.07. Changes in hemodynamic parameters (Hb level and SBP) were associated with a change in the left ventricular end-diastolic dimension, whereas changes in metabolic parameters (HbA_1c and TG levels) were associated with a change in RWT (P < 0.05). During the 5-year follow-up, 30 MACE occurred, and an increase in RWT independently predicted MACE occurrence (hazard ratio, 2.20; 95% confidence interval, 1.21-3.99; P < 0.01). Limitations: Only patients with baseline and follow-up echocardiography were included, potentially introducing selection bias. Conclusions: Hemodynamic improvements are associated with decreased left ventricular size; better metabolic control is associated with greater wall thickness improvement. RWT increases predicted MACE. Optimizing metabolic control to promote balanced left ventricular improvement could enhance cardiovascular outcomes in patients receiving KTs. Plain-Language Summary: Patients receiving a kidney transplant often develop cardiovascular complications despite successful transplantation. To examine how cardiac structure changes posttransplant and their impact on future cardiovascular risk, we analyzed 600 patients in the prospective multicenter cohort, performing echocardiography before and 3 years after transplant. Overall, cardiac structure improved following transplantation, but some developed increased relative wall thickness. Better blood pressure and anemia control showed greater improvement in cardiac chamber size, whereas better glycemic and lipid control achieved superior wall thickness improvement. Importantly, patients with increased relative wall thickness faced twice the risk of major adverse cardiovascular events, including myocardial infarction and stroke. These findings highlight the importance of optimizing metabolic control to promote balanced cardiac remodeling and reduce cardiovascular risk after transplantation.