Distinct prognostic trajectories of heart failure phenotypes following kidney transplantation

Heart failure (HF) drives post-kidney transplant (KT) morbidity. While KT reverses components of uraemic cardiomyopathy, the persistence of post-transplant risk in HF with preserved (HFpEF) versus HF with reduced ejection fraction (HFrEF) remains unclear. We evaluated phenotype-specific remodelling and clinical outcomes.

Retrospective cohort of adult KT recipients stratified by pre-transplant echocardiography: HFpEF (left ventricular ejection fraction [LVEF] ≥50% with elevated filling pressures), HFrEF (LVEF <50%), or controls. Longitudinal echocardiographic remodelling and post-transplant outcomes were analysed using multivariable Cox regression.

Of 442 recipients, 64 (14.5%) had HFpEF, 44 (10.0%) HFrEF, and 334 (75.5%) controls. Over a 49-month median follow-up, HFpEF was independently associated with HF hospitalization (adjusted hazard ratio [aHR] 9.57; 95% confidence interval [CI] 3.37–27.2, P < .001) and composite death/HF hospitalization (aHR 4.46; 95% CI 2.36–8.42, P < .001). Paired longitudinal echocardiography demonstrated persistent diastolic stiffness within the HFpEF group (E/e': 12.7 ± 4.6 to 11.8 ± 5.3, P = .117). Conversely, HFrEF patients exhibited systolic recovery (ΔLVEF +8.7 ± 10.2%, P = .003), remaining independently associated with all-cause mortality (aHR 2.9; 95% CI 1.16–7.25, P = .023) but not HF hospitalization (aHR 3.11; 95% CI 0.71–13.6, P = .13). Mechanistically, ΔLVEF predicted lower HF hospitalization risk (aHR 0.94; 95% CI 0.90–0.99, P = .02), whereas mortality tracked with continuous changes in haemoglobin (aHR 0.71; 95% CI 0.60–0.83, P < .001) and calcium (aHR 0.69; 95% CI 0.50–0.96, P = .027).

Post-KT trajectories differ by pre-transplant HF phenotype. Uraemic HFpEF is a persistent, non-reversible phenotype driving severe post-KT morbidity. HFrEF demonstrates systolic reversibility. Pre-transplant evaluation should incorporate targeted diastolic profiling beyond standard LVEF-centred assessment to identify KT candidates at high risk for recurrent post-transplant HF morbidity.