Ischemic heart disease after renal transplantation

until 18 years posttransplant, when he again developed chest pain. At that time percutaneous angioplasty of a single coronary artery relieved his symptoms. Throughout his post-transplant course, he had elevated low-density lipoprotein (LDL) cholesterol ( 130 mg/dL). He was prescribed 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors, but he took these irregularly, complaining that they caused bloating and nausea. Fasting triglycerides were generally 200 mg/dL, and the highdensity lipoprotein (HDL) cholesterol was low ( 35 mg/dL) on several occasions. Lipoprotein(a) also was elevated ( 30 mg/dL). He began taking an aspirin, 325 mg daily, after his first myocardial infarction, and he continued taking aspirin throughout his posttransplant course. He continued to smoke 1⁄2 packs of cigarettes per day; his fasting blood glucose was always normal. His blood pressure was well controlled with CASE PRESENTATION antihypertensive medications that included beta-blockers and A 33-year-old man received a haplo-identical kidney transconverting enzyme inhibitors. plant from his brother in 1979. He had had proteinuria for Twenty years after transplantation he had an acute rise in 16 years prior to transplantation, and his renal disease was serum creatinine, but an allograft biopsy showed only mild attributed to chronic glomerulonephritis. He had developed chronic allograft nephropathy, and his immunosuppressive reghypertension 10 years before transplantation. He started mainimen (azathioprine and prednisone) was not changed. He detenance hemodialysis 6 months before transplantation, and veloped intermittent atrial fibrillation, which was treated with after initiating hemodialysis he underwent bilateral nephrecrepeated cardioversion and warfarin. Ultimately, he developed tomy and splenectomy. In that same month he was hospitalized severe congestive cardiomyopathy, and his name was placed with chest pain, and a myocardial infarction was ruled out. He on the waiting list for a heart transplant shortly before he died, had no clinical signs and symptoms of ischemic heart disease 21 years after renal transplantation. Just before he died, his (IHD); however, he had smoked 1⁄2 packs of cigarettes daily serum creatinine was 1.8 mg/dL, his creatinine clearance was for approximately 7 years. He was not obese and his physical 53 mL/min, and he had 506 mg/day of protein in his urine. examination was unremarkable. An electrocardiogram and chest radiograph were normal. After transplantation he was treated with azathioprine and DISCUSSION corticosteroids. He had no acute rejection. Approximately 3 Dr. Bertram L. Kasiske (Director of Nephrology, Henmonths after transplantation he sustained an anteroseptal myonepin County Medical Center, Minneapolis, Minnesota, cardial infarction, documented by cardiac enzyme elevation and electrocardiographic changes. He continued to have chest USA): This patient illustrates a typical clinical course of pain, underwent coronary angiography, and had a 3-vessel corpost-transplant ischemic heart disease (IHD). The only onary bypass operation 7 months posttransplant. He did well screening for IHD in the pre-transplant evaluation was until he developed angina pectoris 8 years after transplantation. a history, physical examination, chest radiograph, and Angiography disclosed occlusions of all 3 bypass grafts and electrocardiogram, all of which were unremarkable. Nevdiffuse underlying coronary artery disease. He had a 2-vessel ertheless, it is likely that the myocardial infarction three coronary artery bypass operation and remained symptom free months after transplantation resulted from coronary artery disease already present at the time of transplantaThe Nephrology Forum is funded in part by grants from Amgen, tion. Throughout the post-transplant course, the patient Incorporated; Merck & Co., Incorporated; Dialysis Clinic, Incorpohad recurrent coronary artery disease. Despite the prorated; and Bristol-Myers Squibb Company. gressive nature of this patient’s coronary artery disease