Association between immunologic risk factors and cardiovascular complications following pediatric kidney transplantation

Abstract Background Children with chronic kidney disease (CKD) are at markedly increased risk for cardiovascular morbidity beginning early in life. While cardiovascular risk factors have been extensively studied in adult kidney transplant recipients, contemporary data in pediatric kidney transplant recipients (PKTR) remain limited, particularly regarding post-transplant cardiovascular complications. Methods We retrospectively analyzed cardiovascular complications in 72 PKTR between 2014 and 2024 at a tertiary center in northern Israel, with follow-up ranging from 1 to 12 years (median 7.3 years). Cardiovascular complications were defined as a composite of post-transplant hypertension requiring pharmacologic treatment, left ventricular hypertrophy (LVH), reduced left ventricular ejection fraction, or aortic root enlargement. Associations between cardiovascular outcomes and demographic, dialysis-related, and transplant-related factors were examined using multivariable logistic regression, including assessment of interaction effects. Results Post-transplant hypertension was the most common cardiovascular complication (41.6%), whereas structural or functional cardiac abnormalities were infrequent. A significant interaction was observed between donor type and the need for intensified immunosuppression due to rejection and cardiovascular outcomes (adjusted OR 9.9, 95% CI 1.03–95.6; p = 0.047). Intensified immunosuppression was associated with a markedly higher probability of cardiovascular complications among recipients of living donor grafts, whereas donor type had minimal impact in patients who did not require intensified therapy. No other clinical or dialysis-related variables demonstrated statistically significant associations. Conclusions In this contemporary cohort of PKTR, immune-related transplant factors—in particular intensified immunosuppression following living donor transplantation—were associated with post-transplant cardiovascular complications. These findings may incline the importance of vigilant cardiovascular surveillance in PKTR with high immunologic risk profiles. Larger, longitudinal studies are required to clarify the long-term cardiovascular implications of post-transplant risk markers.