Association of Pre-Transplant Pulmonary Hypertension and Post-Transplant Major Adverse Cardiovascular Events in Kidney Transplant Recipients

Background: Pulmonary hypertension (PH) frequently complicates chronic kidney disease and end-stage kidney disease, contributing significantly to cardiovascular morbidity and mortality. We investigated the association between pre-transplant PH and major adverse cardiovascular events (MACE) after kidney transplantation (KT). Methods: This retrospective cohort study included 468 adult KT recipients from an academic medical center between January 2015 and December 2024. We excluded patients who did not follow up at our institution. Patients were stratified based on the presence of pre-transplant PH (defined as pulmonary artery systolic pressure >35 mmHg on echocardiography or mean pulmonary artery pressure >20 mmHg via right heart catheterization. The primary outcome was the occurrence of MACE, defined as cardiovascular death, myocardial infarction, stroke, or hospitalization for heart failure. Multivariable Cox proportional hazards models were used to evaluate the independent association between pre-transplant PH and post-KT MACE. Results: Of the 468 recipients who qualified for the study, 86 (18.4%) had pre-transplant PH. Over a mean follow-up of 54.7 ± 28.4 months, 89 patients (19.0%) experienced MACE. The incidence of MACE was significantly higher in recipients with pre-KT PH compared with those without at one-year (8.1% vs 2.9%, p=0.031) and five-year (22.0% vs 11.0%, p=0.008). After adjusting for age, sex, and confounding variables, PH remained independently associated with MACE (adjusted HR 2.16; 95% CI 1.31–3.55; p=0.003). Conclusions: In this retrospective single-center study, pre-transplant PH was independently associated with an increased risk for MACE following KT. These findings highlight the importance of identifying PH in KT candidates. More intensified risk mitigation measures might be needed in this population.