Late Allograft Loss and Contemporary Cardio-Renal Metabolic Therapies

Abstract Late kidney allograft loss occurs through one of two mechanisms: a) deterioration of kidney function leading to re-transplantation or dialysis (death-censored graft loss) and b) premature death with a normally functioning transplant (death with graft function) –each accounting for approximately 50% of late kidney graft losses. Late death-censored graft loss typically results from a combination of immune and nonimmune events leading to common nonspecific endpoints (e.g., tubular atrophy, interstitial fibrosis and glomerulosclerosis). Conversely, leading causes of death with graft function typically include cardiovascular events, malignancy, and infection. With an improved understanding of the multiple mechanism by which late graft dysfunction develops, there is an opportunity to identify patients at greatest risk and institute novel strategies to quell the process. Newer cardiometabolic agents with proven benefit in the general population have not been well-studied in kidney transplant recipients. However, in addition to their potential benefits in terms of reducing cardiovascular, infectious and malignancy endpoints (thus minimizing death with graft function risk), many novel agents may have additional anti-inflammatory and/or anti-fibrotic benefit (minimizing death-censored graft loss risk) in the kidney transplant population. In this review, we summarize existing literature regarding major causes of death-censored graft loss and death with graft function, and discuss the potential roles of new cardio-renal metabolic agents including sodium-glucose cotransport 2 inhibitors (SGLT2i), non-steroidal mineralocorticoid receptor antagonists (MRA), glucagon-like peptide 1 receptor agonists (GLP1-RA), and dual endothelin and angiotensin receptor antagonists in the kidney transplant population, including potential mechanisms to improve death with graft function and death-censored graft loss outcomes.