Post-kidney transplant trajectories differ by pre-transplant HF phenotype: uraemic HFpEF is a persistent, non-reversible phenotype driving severe post-transplant morbidity, while HFrEF demonstrates systolic reversibility.
HFpEF was independently associated with a markedly elevated risk of HF hospitalization after kidney transplantation.
HFpEF patients demonstrated persistent diastolic stiffness following kidney transplantation, with no significant improvement in diastolic filling pressures.
HFrEF patients showed significant systolic recovery following kidney transplantation.
Despite systolic recovery, HFrEF remained independently associated with all-cause mortality but not HF hospitalization after kidney transplantation.
Post-transplant all-cause mortality in HFrEF patients tracked with changes in haemoglobin and calcium levels rather than cardiac functional recovery alone.
The study cohort consisted of 442 adult kidney transplant recipients stratified by pre-transplant echocardiography into three groups: HFpEF, HFrEF, and controls.
Pre-transplant evaluation incorporating targeted diastolic profiling beyond standard LVEF-centred assessment is recommended to identify high-risk kidney transplant candidates.
This research studied 442 adults who received kidney transplants and looked at how different types of pre-existing heart failure affected their outcomes after transplantation. The patients were divided into three groups based on heart ultrasound (echocardiography) done before transplant: those with heart failure with preserved ejection fraction (HFpEF, where the heart pumps normally but is stiff), heart failure with reduced ejection fraction (HFrEF, where the heart's pumping is weakened), and a control group without heart failure. Over a median follow-up of about four years, the researchers tracked hospitalizations for heart failure, deaths, and changes in heart function. The study found that the two types of heart failure followed very different paths after kidney transplantation. Patients with HFrEF (the type where the heart pumps weakly) showed meaningful recovery in pumping function after transplant — on average, their ejection fraction improved by nearly 9 percentage points — and this recovery was linked to fewer heart failure hospitalizations. However, despite this cardiac improvement, HFrEF patients still faced roughly three times the risk of dying from any cause compared to controls, with survival appearing tied more to improvements in blood count (haemoglobin) and calcium levels than to heart recovery alone. In contrast, patients with HFpEF (stiff heart) showed no meaningful improvement in their heart's stiffness after transplant, and they faced a nearly 10-fold higher risk of being hospitalized for heart failure compared to controls. This research suggests that the type of heart failure a kidney transplant candidate has before surgery matters enormously for predicting what will happen after transplantation. A stiff-heart type of heart failure (HFpEF) appears to be a persistent condition that does not resolve even after kidney function is restored, making it a major driver of complications post-transplant. Because standard pre-transplant cardiac assessments typically focus on how well the heart pumps (ejection fraction), they may miss the stiffness problem entirely. The findings suggest that more thorough heart assessments — specifically looking at signs of heart stiffness — should become part of routine evaluation before kidney transplantation to better identify patients who may need extra monitoring and support after surgery.
Bril M, Imam A, Parnasa E, Rivin M, Shabaneh S, Tzukert K, et al.. (2026). Distinct prognostic trajectories of heart failure phenotypes following kidney transplantation.. ESC heart failure. https://doi.org/10.1093/eschf/xvag221