1. Prevalence and management of cardiovascular risks in renal transplant recipients Dr VS Aithal Consultant Nephrologist Swansea

2. Transplantation improves survival when compared with dialysis Survival remains well below general population 50% die with a functioning transplant and 50% of these from cardiovascular causes Annual rate of fatal/nonfatal CVD events 3.5- 5% in transplant recipients

3. Cardiovascular risk factors Smoking HTN Hyperlipidaemia (low HDL included) Family history of CV disease Age (men >45,women >55y) Diabetes

4. Cardiovascular risk factors BMI>30 Physical inactivity Ethnicity Immunosuppressives Graft dysfunction/failure Anaemia Rejection episodes Proteinuria

5. Renal transplants older than 1yr as of July 2015 were included in the audit Patients less than 18yrs of age were excluded from the analysis CardiffSwanseaWrexhamBangorGC Patients93330813774

6. Age 20-30% of patients 60-70yrs. 10-15% of patients >70yrs

8. Audit standards for cholesterol Annual check (2C) Treatment targets should be the same as in general population (2C) ALERT study: after a 5yr FU, LDL reduced by 32% in fluvastatin arm. Risk of cardiac death of non-fatal MI was reduced by 35%

9. Cholesterol <5

10. Statin and Aspirin

11. Cholesterol >5

12. Creatinine 6-20% had Cr 200-300. 2-4 % had Cr 300-400

13. Haemoglobin <10g 3-8% <9G 1-5%

14. BMI

15. 5mmHg reduction in BP reduces risk of MI by 10-15% Modest reduction of BP with treatment of hyperlipidaemia in high risk patients with transplants improved patient survival by 2yrs

16. Hypertension RA/KDIGO guidline: 50 (2C) BP should be recorded at every visit (1C)

17. Systolic BP 3-13.5% have systolic HTN 1-3% have severe systolic HTN

18. Diastolic BP

19. Aspirin Metanalysis of 287 studies (135000pts) absolute reductions in serious vascular event in patients with previous MI was 36/1000 treated pts and 22/1000 treated high risk patients (stable angina,PVD)

20. Statin and Aspirin

21. ACE-I/ARB

22. Antihypertensives

23. Not on antihypertensives

24. Diabetes Check blood glucose every visit (2C) Annual HbA1c HbA1c 7-7.5(53-58)

26. HbA1c in target range

27. HbA1c >60

29. HbA1c Swansea 15/60 43.2% had HbA1c >60

30. Wrexham HbA1c 48.25% had HbA1c >60

31. 30% had HbA1c >60

32. GC HbA1c 50% had HbA1c >60

33. HbA1c Cardiff 326 patients had HbA1c in the last 12months

34. Conclusions 30-45% had cholesterol >5, 6-12% had 6-8 (except Wrexham) 30 to 50% had HbA1c >60 20-30% of our patients are obese 3-8% of our transplant patients had Hb<10, 1-5% had Hb<9

35. Conclusions 30-45% did not meet BP standards for systolic and 4-14% had systolic BP>160 35-59% did not meet standards for diastolic BP and 5-17% had diastolic >90

36. Data for next audit Smoking history Family history of CV events Proteinuria Patients on prednisolone

37. Data for next audit Need to audit data on random glucose from every visit and see if there are undiagnosed diabetics Need data on proteinuria. ? Document proteinuria from every visit and check if PCR requested in all pts with proteinuria. Alternatively check urine PCR/ACR at regular intervals Data on use of ACE-I in those with proteinuria

38. Acknowledgements Dr Donovan, Dr Griffin, Gary Hunter Cardiff Dr Judith Welham Wrexham Dr Abdul Alejmi Bangor Dr Aled Lewis GC Mike Wakelyn and Cathy Blakemore Swansea

39. 50 patients from swansea had urine PCR,26 pts had PCR >50. 12/26 were on ACE-I 27 patients from Wrexham had urine PCR checked. 12 had PCR>50. 9/12 were on ACE-I

42. Cholesterol

47. N0t required

49. 5mmHg reduction in BP reduces risk of MI by 10-15% Modest reduction of BP with treatment of hyperlipidaemia in high risk patients with transplants improved patient survival by 2yrs (55)