Larry A Weinrauch1, John A D'Elia2, Matthew R Weir3, Suphamai Bunnapradist4, Peter V Finn5, Jiankang Liu5, Brian Claggett5, Anthony P Monaco6. 1. Cardiovascular Division, Brigham and Women's Hospital, Boston, Mass; Kidney and Hypertension Section, Joslin Diabetes Center, Boston, Mass; Departments of Medicine and Surgery, Beth Israel Deaconess Medical Center, Boston, Mass; Harvard Medical School, Boston, Mass. Electronic address: lweinrauch@hms.harvard.edu. 2. Kidney and Hypertension Section, Joslin Diabetes Center, Boston, Mass; Departments of Medicine and Surgery, Beth Israel Deaconess Medical Center, Boston, Mass; Harvard Medical School, Boston, Mass. 3. Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Md. 4. Division of Nephrology, Department of Medicine, University of California at Los Angeles, Los Angeles, Calif. 5. Cardiovascular Division, Brigham and Women's Hospital, Boston, Mass. 6. Departments of Medicine and Surgery, Beth Israel Deaconess Medical Center, Boston, Mass; Harvard Medical School, Boston, Mass; Division of Nephrology, New England Medical Center, Tufts University School of Medicine, Boston, Mass.
Abstract
OBJECTIVE: Now that long-term survival after successful renal transplantation is no longer limited by excessive cardiovascular risk, the primary care physician should consider that infection and malignancy are leading noncardiovascular causes of death even in the recipient with diabetes. METHODS: We accessed the National Institutes of Health-sponsored Folic Acid for Vascular Outcome Reduction in Transplantation (FAVORIT) study population (4010 renal transplant recipients with elevated homocysteine levels) studied to determine whether folate and B12 supplementation would reduce cardiovascular end points. This trial had a null result. Patients were classified as being nondiabetic or having type 1 or type 2 diabetes. RESULTS: We report an excess (cardiovascular and noncardiovascular) 6-year mortality risk associated with the presence of diabetes mellitus. Two thirds of fatal events in our renal transplant recipients were centrally adjudicated as noncardiovascular. The incidence of noncardiovascular death was 70% higher in the diabetic patient cohort than in the nondiabetic cohort. CONCLUSIONS: These results demonstrate that infection (but not malignancy) risks are far higher in diabetic than nondiabetic immunosuppressed individuals (although noncardiovascular death rate in nondiabetic individuals also exceeded cardiovascular deaths) and may play a larger role in the excess mortality populations than previously thought. Given that follow-up in this study was 4 to 10 years after allograft surgery, there was a lesser degree of acute rejection requiring high-dose immunosuppression than in the initial postallograft years. This unique perspective allows transplant recipients to return to primary physicians when taking low doses of immunosuppressive agents and provides focus for follow-up care.
RCT Entities:
OBJECTIVE: Now that long-term survival after successful renal transplantation is no longer limited by excessive cardiovascular risk, the primary care physician should consider that infection and malignancy are leading noncardiovascular causes of death even in the recipient with diabetes. METHODS: We accessed the National Institutes of Health-sponsored Folic Acid for Vascular Outcome Reduction in Transplantation (FAVORIT) study population (4010 renal transplant recipients with elevated homocysteine levels) studied to determine whether folate and B12 supplementation would reduce cardiovascular end points. This trial had a null result. Patients were classified as being nondiabetic or having type 1 or type 2 diabetes. RESULTS: We report an excess (cardiovascular and noncardiovascular) 6-year mortality risk associated with the presence of diabetes mellitus. Two thirds of fatal events in our renal transplant recipients were centrally adjudicated as noncardiovascular. The incidence of noncardiovascular death was 70% higher in the diabeticpatient cohort than in the nondiabetic cohort. CONCLUSIONS: These results demonstrate that infection (but not malignancy) risks are far higher in diabetic than nondiabetic immunosuppressed individuals (although noncardiovascular death rate in nondiabetic individuals also exceeded cardiovascular deaths) and may play a larger role in the excess mortality populations than previously thought. Given that follow-up in this study was 4 to 10 years after allograft surgery, there was a lesser degree of acute rejection requiring high-dose immunosuppression than in the initial postallograft years. This unique perspective allows transplant recipients to return to primary physicians when taking low doses of immunosuppressive agents and provides focus for follow-up care.
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