POST KIDNEY TRANSPLANT STRESS TO NEPHROLOGIST AND PATIENTS HEART TOO !! POST RENAL TRANSPLANT CARDIOMYOPATHY –A LIFE THREATENING BUT ESSENTIALLY REVERSIBLE CONDITION

post kidney transplant can be sometimes be mired by unusual clinal consequences,  due to multiple metabolic and systemic effects of anesthesia and medications used to prevent rejection. We report here two cases of – post kidney transplant heart failure – with previous history of coronary artery disease and normal ejection fraction pre operatively 

There were two cases of immediate post kidney transplant patients- who developed unexplained cardiomyopathy  All the demographic details and cardiac enzymes were tested as per protocol .

Case 1 – 35yrs old lady with non diabetic kidney disease – presumed chronic interstitial disease. Had a successful renal transplant – donor being her mother who was 56yrs old. Pre transplant she was only on 1 month of dialysis as renal transplant was planned early.  Pre transplant cardiac evaluation was normal with normal ejection fraction. She received Thymoglobulin or ATG-Fresenius (Grafallon ®) as induction agent along with steroids and was started on triple immunosuppression which included tacrolimus, mycophenolate mofetil and steroids. Immediate post transplant had good diuresis, but developed sudden onset breathlessness, tachycardia and 2 D Echo showed reduction in ejection fraction to 32% with global hypokinesia. All other tests were normal with Trop I being 956.60 pg/ml and NT pro bnp was  68450 pg/ml (elevated). Was evaluated by cardiology team and opined as stress cardiomyopathy. She was managed conservatively with diuretics and supportive medication. Renal functions stabilized and tacrolimus level was increased gradually. Cardiology team deferred coronary angiogram as her clinical status stabilized gradually and there was no regional wall motion abnormality. She recovered well and repeat echo after 1 year showed normal ejection fraction (55%)  with normal renal function. Its been 3 years post transplant currently with no evidence of any heart failure and volume retention with normal renal functions.

Case 2 – 58 years old lady with non diabetic kidney disease underwent live renal transplant – donor being her twin sister with 5/6 HLA match. She did not have any preceding cardiac issues and her pre transplant cardiac work up was normal with normal ejection fraction. She was on dialysis for 8 months before transplant. She received low dose ATG along with steroids as induction. Post transplant after 24 hrs though she had good diuresis and serum creatinine was 1.6, she developed sudden onset breathlessness. On evaluation her ejection fraction had declined to 25% and NT pro bn was high 55651 pg/ml  with elevated Hs Trop I – 4456.50 pg/ml. Cardiology team reviewed and opined as stress cardiomyopathy, she underwent coronary angiogram in view of persistently elevated trop I which was normal. She was managed conservatively with inotropic support in the initial days and diuretics. She responded well was discharged on day 10 with normal renal functions. Its now 4 weeks post transplant, she is stable with no complaints of breathlessness. And due for her repeat echocardiogram

Both the cases described, are rare cases of post kidney transplant stress cardiomyopathy, without any preceding cardiac involvement and recovered post transplant period with conservative management with normalization of ejection fraction in the first case and second case is symptomatically recovered. This is to emphasis the recognition of this entity also called as Takotsubo syndrome (TTS) is a stress-induced cardiomyopathy well recognised in post liver transplant cases ( 0.3 -1.7%) but not well described in  post  kidney transplant scenario, and most often there is full recovery with good supportive management