Is there a reversal of reverse epidemiology in renal transplant recipients?

Similar to the general population, cardiovascular disease is the leading cause of death in patients with a functioning renal graft. Recent studies have shown an inverse relationship between cardiovascular risk factors and outcomes in dialysis patients. Low blood pressure, low body mass index (BMI) and low serum cholesterol levels are correlated with a higher risk of adverse cardiovascular outcomes in dialysis patients. The explanation for these observations is unclear. In renal transplant recipients (RTR), these parameters are correlated with a lower risk of cardiovascular adverse outcomes, a phenomenon labeled as "reversal of reverse epidemiology." The aims of this review are: (1) to explore the association between cardiovascular risk factors and outcomes in RTR; (2) to assess whether these effects are reversal of the reverse epidemiology in dialysis predecessors; and (3) to determine the strategies for minimizing cardiovascular risk in RTR. This article also compares the determinants of cardiovascular risk factors among the general population, maintenance dialysis patients and RTR. Because definitive evidence on optimal intervention is lacking, population-specific clinical trials are needed to define optimum targets for treatment of these risk factors in maintenance dialysis patients and RTR separately.