Metabolic Acidosis 1 Year Following Kidney Transplantation and Subsequent Cardiovascular Events and Mortality: An Observational Cohort Study

Arjang Djamali, Tripti Singh, Michal L. Melamed, James H. Stein, Fahad Aziz, Sandesh Parajuli, Maha Mohamed, Neetika Garg, Didier Mandelbrot, Donald E. Wesson, Brad C. Astor

Research output: Contribution to journalArticlepeer-review

11 Scopus citations


Rationale & Objective: Recent studies suggest that metabolic acidosis is associated with mortality and graft failure in kidney transplant recipients. However, it is unknown whether serum bicarbonate (measured as total carbon dioxide [tCO2] in serum) levels predict cardiovascular events (CVEs) following kidney transplantation. Study Design: Observational cohort study. Settings & Participants: Single-center study of 2,128 kidney transplant recipients free of CVEs during the first 13.5 months following transplantation. Predictor: tCO2 level at 1 year posttransplantation. Outcomes: Ischemic, arrhythmic, and heart failure CVEs and death from any cause. Analytical Approach: Independent associations were assessed using multivariable proportional hazards regression models. Restricted cubic spline Poisson models were used to explore nonlinear associations. Linear spline proportional hazards models were used to assess associations at different tCO2 levels. Results: The prevalence of metabolic acidosis defined as tCO2 level < 24 mEq/L was 38.8% (n = 826). There were 384 recipients with a CVE and 610 deaths during a median follow-up of 4.0 years. CVEs included 241 ischemic, 137 arrhythmic, and 150 heart failure events. tCO2 level < 20 mEq/L was associated with increased risk for CVEs (adjusted HR [aHR], 2.00; 95% CI, 1.29-3.10) compared to the reference category of tCO2 level of 24.0 to 25.9 mEq/L. This association was primarily due to ischemic CVEs (aHR, 2.28; 95% CI, 1.34-3.90). For every 1 mEq/L lower tCO2 level for those with tCO2 < 24 mEq/L, risks for all CVEs and ischemic events were 17% and 15% higher, respectively (aHR for all CVEs of 0.83 [95% CI, 0.74-0.94] and aHR for ischemic CVEs of 0.85 [95% CI, 0.74-0.99]). Notably, tCO2 level < 20 mEq/L, compared to tCO2 level of 24.0 to 25.9 mEq/L, was independently associated with all-cause mortality (aHR, 1.43; 95% CI, 1.02-2.02). For every 1-mEq/L lower tCO2 level for those with tCO2 < 24 mEq/L, there was 17% higher risk for death (aHR, 0.83; 95% CI, 0.75-0.92). Limitations: Single-center observational study. Conclusions: Metabolic acidosis is an independent risk factor for ischemic CVEs after kidney transplantation. It is unknown whether correction of acidosis improves outcomes in these patients.

Original languageEnglish (US)
JournalAmerican Journal of Kidney Diseases
StateAccepted/In press - Jan 1 2019


  • arrhythmia
  • cardiovascular events (CVE)
  • coronary artery disease
  • heart failure
  • hypobicarbonatemia
  • kidney transplantation
  • Metabolic acidosis
  • mortality
  • myocardial infarction
  • serum bicarbonate
  • total CO

ASJC Scopus subject areas

  • Nephrology

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