Pulmonary hypertension in renal transplant candidates: A systematic review and meta-analysis of the available evidence and a proposed algorithm for pre-transplant management

Background: Pulmonary hypertension (PHT) is common in patients with end stage renal disease (ESRD). Moderate to severe PHT is a strong independent predictor of mortality in hemodialysis (HD) patients, and in those undergoing noncardiac surgery. The studies which have evaluated the association of PHT with renal transplant outcomes have shown conflicting results. We performed a systematic review and meta-analysis of the current available evidence examining the effect of existing PHT on relevant clinical outcomes following renal transplantation. Materials and methods: Major databases (Pubmed, Embase, Cochrane, Web of Science, and Scopus) were searched for studies of patients undergoing renal transplantation that reported pulmonary pressures and transplantation outcomes. Data were extracted from the original publications. Results: Out of 259 publications, only 3 (with a total of 502 patients) were eligible for inclusion in the current analysis. Our meta-analysis of these three studies suggests a three-fold increase in mortality after renal transplantation in patients with PHT compared to those without PHT (OR 3.15, 95% confidence interval 1.42-6.97; p = 0.005). A qualitative review indicates that PHT is associated with both early graft dysfunction and worse renal function at 12 months post-transplant. Conclusions: There is paucity of clinical trial data examining the effect of pulmonary hypertension and its management on renal transplant outcomes. In this meta- analysis we found that there is an increased risk of mortality in patients with pulmonary hypertension who undergo renal transplantation.