Ridler FE; University of Leicester, United Kingdom.
Graham-Brown MPM; Billany RE
Renal Failure. 48(1):2626621, 2026 Dec.
BACKGROUND: Despite improved survival following kidney transplantation,
cardiovascular disease (CVD) remains a leading cause of mortality in
kidney transplant recipients (KTRs). This risk is driven by complex
traditional and nontraditional mechanisms contributing to uremic
cardiomyopathy. Cardiorespiratory fitness (CRF) is consistently reduced in
KTRs and strongly associated with cardiovascular outcomes. However, while
cardiac structure and function may partially improve post-transplant,
recovery of CRF often remains incomplete compared to healthy individuals,
suggesting that structural reverse remodeling does not necessarily equate
to restored cardiovascular reserve.
METHODS: This review synthesises current evidence on post-transplant
changes in left ventricular structure and function and trajectories of CRF
recovery. We highlight persistent discrepancies between
echocardiography-based and cardiac magnetic resonance (CMR)-based
findings, together with the limited use of cardiopulmonary exercise
testing (CPET) in longitudinal studies.
KEY FINDINGS: We discuss the concept of a ‘transplant cardio-recovery
gap’, reflecting the dissociation between structural normalisation and
functional capacity restoration.
FUTURE DIRECTIONS: We outline future directions for research including
phenotype-specific monitoring using CMR-derived strain, native T1 mapping,
and CPET parameters, integrated through AI-enabled predictive analytics,
to enable digital twin models capable of forecasting individualised
recovery trajectories. We discuss CMR-CRF coupling models, and adaptive
rehabilitation trials stratified by functional cardiovascular reserve
rather than structural metrics alone.
CONCLUSION: While kidney transplantation offers partial cardiovascular
recovery, restoration of cardiopulmonary resilience remains an unmet
therapeutic target. Precision, AI-guided CRF evaluation and rehabilitation
may redefine cardiovascular risk management in KTRs and inform the next
generation of transplant optimisation strategies.