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Disclaimer: CME certification for these activities has expired. All information is pertinent to the timeframe in which it was released.


The Cardio-Renal Link: Preventing Cardiovascular Disease and Diabetes in Renal Transplant Recipients


GOAL
To provide nephrologists, nephrology nurses, and renal transplant coordinators with up-to-date information on the management of renal transplant recipients at risk for cardiovascular disease and diabetes.

TARGET AUDIENCE
This activity is designed for nephrologists and nephrology nurses working in renal transplant centers, in addition to renal transplant coordinators. No prerequisites required.

LEARNING OBJECTIVES
The Johns Hopkins University School of Medicine, The Institute for Johns Hopkins Nursing, and the American Board for Transplant Certification take responsibility for the content, quality, and scientific integrity of this CE activity. At the conclusion of this activity, the participant should be able to:
  • Recognize cardiovascular risk factors in renal transplant patients to improve patient quality of life.
  •  Apply practical therapeutic strategies to minimize cardiovascular risk in transplant recipients.
  • Summarize the burden of diabetes in the renal transplant population.
  • Propose aggressive strategies to prevent, detect, and manage diabetes to augment outcomes in renal transplant patients.
ACCREDITATION STATEMENT
The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Institute for Johns Hopkins Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

The American Board for Transplant Certification (ABTC) has established a continuing certification program whereby certified coordinators meeting the eligibility requirements may seek to maintain certification through the Continuing Education Points for Transplant Certification (CEPTC) program. The ABTC has approved this educational offering.

CREDIT DESIGNATION STATEMENT
The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 2 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

This 2 contact hour Educational Activity (Provider Directed/Learner Paced) is provided by The Institute for Johns Hopkins Nursing. Claim only those contact hours actually spent in the activity.

The American Board for Transplant Certification (ABTC) has approved this educational offering for up to 2.0 Category I Continuing Education Points for Transplant Certification (CEPTCs).

The estimated time to complete this educational activity: 2 hours.

Release date: June 15, 2007. Expiration date: June 15, 2009.

DISCLAIMER STATEMENT
The opinions and recommendations expressed by faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of The Johns Hopkins University School of Medicine name implies review of educational format, design, and approach. Please review the complete prescribing information of specific drugs or combinations of drugs, including indications, contraindications, warnings, and adverse effects, before administering pharmacologic therapy to patients.

This program is supported by an educational grant from Wyeth Pharmaceuticals.
Full Disclosure Policy Affecting CME Activities
As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of the Johns Hopkins University School of Medicine to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or a provider has with the manufacturer(s) of any commercial product(s) discussed in an educational presentation.  The presenting faculty reported the following:

PROGRAM DIRECTORS
Hamid Rabb, MD
Physician Director, Kidney and Pancreas Transplantation
Associate Professor of Medicine
Division of Nephrology
Johns Hopkins School of Medicine
Baltimore, Maryland
Dr Rabb reports having no significant financial or advisory relationships with corporate organizations related to this activity.

Flavio G. Vincenti, MD
President, American Society of Transplantation
Professor of Clinical Medicine
University of California, San Francisco
San Francisco, California
Dr Vincenti reports receiving grants/research support from Bristol-Myers Squibb Company, Genentech, Inc, Novartis, and Roche Pharmaceuticals.
PARTICIPATING FACULTY
Bryce A. Kiberd, MD
Professor of Medicine
Dalhousie University
Halifax, Nova Scotia, Canada
Dr Kiberd reports having no significant financial or advisory relationships with corporate organizations related to this activity.

Alan Wilkinson, MD
Professor of Medicine
Director, UCLA Kidney and Kidney/Pancreas Transplantation
University of California, Los Angeles
Los Angeles, California
Dr Wilkinson reports receiving grants/research support from Astellas Pharma Inc, Novartis, Roche Pharmaceuticals, and Wyeth.
Notice: The audience is advised that the articles in this CE activity contain no reference(s) to unlabeled or unapproved uses of drugs or devices.

Johns Hopkins Advanced Studies in Medicine provides disclosure information from contributing authors, lead presenters, and participating faculty. Johns Hopkins Advanced Studies in Medicine does not provide disclosure information from authors of abstracts and poster presentations. The reader shall be advised that these contributors may or may not maintain financial relationships with pharmaceutical companies.The Cardio-Renal Link: Preventing Cardiovascular Disease and Diabetes in Renal Transplant Recipients
Hamid Rabb, MD,* and Flavio G. Vincenti, MD

With advances in immunosuppressive therapy, the survival of patients who undergo renal transplantation has increased substantially in the past 25 years. One-year survival rates are 95%, and 9 of 10 renal transplant recipients survive at least 3 to 5 years after transplantation.1 Despite improvements in survival during the first few years after the transplant period, the 10-year survival rate of renal transplant recipients remains below that of the general population.2 Cardiovascular disease accounts for the majority of deaths of renal transplant recipients, and cardiovascular mortality in renal transplant recipients exceeds that in the general population (Figure).3 Type 2 diabetes, which is highly prevalent in renal transplant recipients, contributes to excess cardiovascular morbidity and mortality. Effective management of cardiovascular and metabolic risk is among the important challenges in improving long-term outcomes after renal transplantation, and transplant clinicians play an integral role in meeting this challenge. This monograph discusses the recognition and management of cardiovascular disease and type 2 diabetes in renal transplant recipients.

Bryce A. Kiberd, MD, professor of medicine at Dalhousie University in Halifax, Nova Scotia, Canada, emphasizes the importance of identifying and managing cardiovascular risk factors in his article. In kidney transplant recipients, cardiovascular risk factors are often present before transplantation. Renal transplantation is associated with development of new risk factors and exacerbation of pre-existing risk factors that contribute to excess cardiovascular morbidity and mortality. Besides traditional cardiovascular risk factors, such as hypertension and dyslipidemia, atypical risk factors, such as graft dysfunction, graft failure, and use of specific immunosuppressive medications, increase cardiovascular risk in renal transplant recipients. Dr Kiberd advocates initiating risk-factorÐmanagement strategies early–before transplantation–and implementing them continuously throughout the post-transplant course. Therapeutic lifestyle practices, including a healthy diet, exercise, and avoidance of smoking, in addition to evidence-based use of pharmacotherapy, are key components of managing cardiovascular risk in the renal transplant recipient.

Type 2 diabetes is one of the major contributors to excess cardiovascular risk in renal transplant recipients and the general population. Although renal transplant recipients frequently have diabetes or its precursor, prediabetes, before transplantation, new-onset diabetes caused by factors such as use of immunosuppressive therapy often occurs after transplantation. In his article, Alan Wilkinson, MD, director of kidney and kidney/pancreas transplantation at University of California at Los Angeles, discusses the epidemiology, consequences, diagnosis, and management of post-transplant diabetes in the renal transplant recipient. Post-transplant diabetes is linked to elevated risks of cardiovascular disease and cardiovascular death, microvascular complications, and reduced graft survival.
Many of the risk factors for post-transplant diabetes are the same as those for type 2 diabetes in the general population, whereas others, such as use of immunosuppressive therapy, are uncommon in the general population. Like cardiovascular disease, post-transplant diabetes can be managed through judicious selection of immunosuppressive therapy, maintenance of a healthy body weight, regular physical activity, and pharmacologic and nonpharmacologic control of hypertension and dyslipidemia. Dr Wilkinson advises that judicious selection of immunosuppressive therapy is among the most important means of modifying risk of post-transplant diabetes given the contribution of specific immunotherapies to metabolic dysfunction. Selection of immunosuppressive therapy for the recipient of a kidney transplant involves consideration of the benefits of effective immunosuppression and the diabetogenic risks of therapy in the context of patient-specific factors, including immunological, cardiovascular, and metabolic risk profiles.

Significant advances in transplant outcomes notwithstanding, the care of renal transplant recipients continues to pose challenges to nephrology clinicians. Among several determinants of the success of the renal transplant, prevention and management of complications are crucial to maintaining graft health and prolonging patient survival. Cardiovascular disease and type 2 diabetes, 2 of the most significant threats to the transplant recipient's health, are healthcare priorities. It is hoped that transplant clinicians find the information in this monograph useful in improving the ability to provide quality care for their patients at cardiovascular and metabolic risk.

Figure-1

REFERENCES
1.    Fazelzadeh A, Mehdizadeh AR, Ostovan MA, et al. Predictors of cardiovascular events and associated mortality of kidney transplant recipients. Transplant Proc. 2006;38:509-511.
2.    Ojo AO, Hanson JA, Wolfe RA, et al. Long-term survival in renal transplant recipients with graft function. Kidney Int. 2000;57:307-313.
3.    Foley RN, Parfrey PS, Sarnak MJ. Clinical epidemiology of cardiovascular disease in chronic renal disease. Am J Kidney Dis. 1998;32:S112-S119.

*Physician Director, Kidney and Pancreas Transplantation, Associate Professor of Medicine, Division of Nephrology, Johns Hopkins School of Medicine, Baltimore, Maryland.  President, American Society of Transplantation, Professor of Clinical Medicine, University of California, San Francisco.
Address correspondence to: Hamid Rabb, MD, Physician Director, Kidney and Pancreas Transplantation, Associate Professor of Medicine, Division of Nephrology, Johns Hopkins School of Medicine, East Baltimore Campus, Ross 970 Nephrology, 600 North Wolfe Street, Baltimore, MD 21287. E-mail: Hrabb1@jhmi.edu.

The content in this monograph was developed with the assistance of a medical writer. Each author had final approval of his article and all its contents.



Johns Hopkins Advanced Studies in Medicine (ISSN-1558-0334), is published by Galen Publishing, LLC, d/b/a ASiM, PO Box 340, Somerville, NJ 08876. (908) 253-9001. Copyright ©2012 by Galen Publishing. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, without first obtaining permission from the publisher. ASiM is a registered trademark of The Healthcare Media Group, LLC.