POST TRANSPLANT CARDIOVASCULAR RISK

Post Transplant Cardiovascular Risk

Dr David Wheeler

Consultant Nephrologist, Royal Free Hospital, London

A 55-year-old female weighing 48kg attends a busy renal transplant clinic 6 years after receiving her kidney. Serum creatinine at her last clinic visit was 180 mol/l and her blood pressure is recorded at 155/90 mmHg. During a 3-minute consultation, the patient receives reassurance from her doctor and a follow-up visit is arranged in 4 months' time. The obvious advantage of this superficial approach is that it allows a large number of patients to be reviewed in a short time, but it results in many missed opportunities for delivery of optimal care. The patient in question has a calculated GFR of 23 ml/min/1.73m2. On closer review of her results, she is anaemic and has elevated serum levels of phosphate, parathyroid hormone and cholesterol. A holistic approach to her management might include correction of anaemia and hypercholesterolaemia, improved control of blood pressure and prescription of a phosphate binder and vitamin D analogue to control her hyperparathyroidism, strategies which may help to reduce her future risk of cardiovascular disease and bone fracture. Plans should be made to prepare her for dialysis (including vascular access surgery) and to minimise her time on dialysis; she could be considered for transplant re-listing at this stage. Finally, the psychological impact of the failing graft needs to be considered and appropriate counselling provided in the run up to dialysis.

Holistic patient care might be largely achievable through simple changes in practice and may not require many additional resources. For example, use of standardised care protocols can help to ensure that all relevant medical problems are addressed at each clinic visit. The availability of such a resource could facilitate greater use of nurses in the routine follow-up of transplant recipients. The development of integrated hospital clinics, which bring together several specialists, can also help to ensure completeness of medical follow-up. Such a team approach to patient care should involve primary care staff, who might take over many aspects of monitoring which are traditionally assigned to the hospital. All team members will require access to an efficient communication system, the development of which will be greatly facilitated by abandoning paper-based records and increasing use of the Internet.

Whilst many health care professionals will resist such an approach on the basis that it breaks down well-established boundaries of responsibility, benefits for patients may include fewer hospital visits, less duplication of clinical tests, and better communication amongst those responsible for providing medical care.

The success of the holistic approach to the care of transplant recipients will be difficult to judge in terms of patient outcomes, although it may be possible to audit specific aspects such as impact on cardiovascular risk factors. Transplant recipients may well be the best judge of the advantages and disadvantages of efforts to integrate the multifaceted aspects of the healthcare they receive.