Aorto-Iliac Artery Calcification and Graft Outcomes in Kidney Transplant Recipients

Stan Benjamens, Saleh Z Alghamdi, Elsaline Rijkse, Charlotte A Te Velde-Keyzer, Stefan P Berger, Cyril Moers, Martin H de Borst, Riemer H J A Slart, Frank J M F Dor, Robert C Minnee, Robert A Pol, Stan Benjamens, Saleh Z Alghamdi, Elsaline Rijkse, Charlotte A Te Velde-Keyzer, Stefan P Berger, Cyril Moers, Martin H de Borst, Riemer H J A Slart, Frank J M F Dor, Robert C Minnee, Robert A Pol

Abstract

While the association of vascular calcification with inferior patient outcomes in kidney transplant recipients is well-established, the association with graft outcomes has received less attention. With this dual-centre cohort study, we aimed to determine the clinical impact of recipient pre-transplant aorto-iliac calcification, measured on non-contrast enhanced computed tomography (CT)-imaging within three years prior to transplantation (2005-2018). We included 547 patients (61.4% male, age 60 (interquartile range 51-68) years), with a median follow-up of 3.1 (1.4-5.2) years after transplantation. The aorto-iliac calcification score (CaScore) was inversely associated with one-year estimated-glomerular filtration rate (eGFR) in univariate linear regression analysis (standard β -3.3 (95% CI -5.1 to -1.5, p < 0.0001), but not after adjustment for potential confounders, including donor and recipient age (p = 0.077). In multivariable Cox regression analyses, a high CaScore was associated with overall graft failure (p = 0.004) and death with a functioning graft (p = 0.002), but not with death-censored graft failure and graft function decline. This study demonstrated that pre-transplant aorto-iliac calcification is associated with one-year eGFR in univariate, but not in multivariable linear regression analyses. Moreover, this study underlines that transplantation in patients with a high CaScore does not result in earlier transplant function decline or worse death censored graft survival, although ongoing efforts for the prevention of death with a functioning graft remain essential.

Keywords: aorta; graft failure; graft function; graft function decline; iliac artery; kidney transplantation; vascular calcification.

Conflict of interest statement

The authors declare no conflict of interest. The funder had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.

Figures

Figure 1
Figure 1
Graphical illustration of the magnitude of confounding for one-year estimated glomerular filtration rate (eGFR), showing the regression coefficients for the associations (*** indicating a p-value < 0.0001). The direct effect of the aorto-iliac CaScore on one-year eGFR was −3.3 (95%CI −5.1 to −1.5) and the effect on the confounder (donor age) was 5.0 (95%CI 3.8 to 6.2). The direct effect of the confounder on one-year eGFR was −0.6 (95%CI −0.7 to −0.5), with a bootstrapped indirect effect of −2.9 (95% CI −4.0 to −1.9).
Figure 2
Figure 2
Kaplan–Meier survival curve for (A) death-censored and (B) overall graft failure free-survival for the low and high aorto-iliac CaScore group, stratified by living and deceased donor kidney transplantation and including a life table applicable for both graphs. Number at risk (No. at risk) provided for all four groups.
Figure 3
Figure 3
Kaplan–Meier survival curve for death with a functioning graft free-survival for the low and high aorto-iliac CaScore group, stratified by living and deceased donor kidney transplantation. Number at risk (No. at risk) provided for all four groups.
Figure 4
Figure 4
Kaplan–Meier survival curve for graft function decline free-survival for the low and high aorto-iliac CaScore group, stratified by living and deceased donor kidney transplantation. Number at risk (No. at risk) provided for all four groups.

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