Research Article: Cigarette Smoking and Its Hazards in Kidney Transplantation

Date Published: July 27, 2017

Publisher: Hindawi

Author(s): Muhammad Abdul Mabood Khalil, Jackson Tan, Said Khamis, Muhammad AshhadUllah Khalil, Rabeea Azmat, Arslan Rahat Ullah.


Cigarette smoking affects many organs. It causes vasoconstriction through activation of sympathetic nervous system which leads to elevation of blood pressure and reduction in glomerular filtration rate and filtration pressure. It also causes thickening of renal arterioles. Cigarette smoking increases the risk of microalbuminuria and accelerates progression of microalbuminuria to macroalbuminuria. Furthermore, it causes rapid loss of glomerular filtration rate in chronic kidney disease patients. After kidney donation, these factors may be injurious to the solitary kidney. Kidney donors with history of cigarette smoking are prone to develop perioperative complications, pneumonia, and wound infection. Postkidney transplantation various stressors including warm and cold ischemia time, delayed graft function, and exposure to calcineurin inhibitors may result in poor graft function. Continuation of cigarette smoking in kidney transplant recipients will add further risk. In this review, we will specifically discuss the effects of cigarette smoking on normal kidneys, live kidney donors, and kidney transplant recipients. This will include adverse effects of cigarette smoking on graft and patient survival, cardiovascular events, rejection, infections, and cancers in kidney transplant recipients. Lastly, the impact of kidney transplantation on behavior and smoking cessation will also be discussed.

Partial Text

Cigarette smoking is common worldwide, despite the numerous deterrent measures that have been put in place over the decades. The number of smokers reported in 2015 was 1.1 billion [1]. Worldwide, tobacco use causes nearly 6 million deaths per year, and current trends show that tobacco use will cause more than 8 million deaths annually by 2030 [2]. On average, smokers die 10 years earlier than nonsmokers [3]. The association of cigarette smoking with cardiovascular diseases, chronic obstructive pulmonary disease, and cancers is well known. Cigarette smoking increases the risk of coronary heart disease and stroke by 2–4 times and that of lung cancer by 25 times [4]. Cigarette smoking also causes chronic obstructive pulmonary disease (COPD) and smokers are 12 to 13 times more likely to die from COPD than nonsmokers [4]. The present review focuses on adverse effects of smoking in normal kidneys, kidney donors, and kidney transplant recipient and effect of kidney transplantation on smoking cessation.

Cigarette smoking can cause acute and chronic effects [5, 6]. Acutely, cigarette smoking increases sympathetic nervous system activity resulting in tachycardia and high blood pressure. Increased sympathetic nervous system activity causes increased catecholamine activity in the circulation. This causes vasoconstriction in the vascular system [7]. Vascular resistance in renovascular bed increases by 11% [7]. This reduces glomerular filtration rate by 15% and filtration fraction by 18%. The chronic effects of cigarette smoking on kidney are less clear. There is evidence that renal plasma flow decreases in chronic smokers and this is accompanied by modest elevation of endothelin. Endothelin through vasoconstriction will induce functional abnormalities. Cigarette smoking has been associated with thickening of renal and myocardial arterioles [8, 9] and has been shown to be an independent predictor of proteinuria [10, 11]. The effect of cigarette smoking in diabetic kidneys has been documented in various studies. Cigarette smoking increases the risk of microalbuminuria in smokers [12]. It also causes rapid progression of microalbuminuria to macroalbuminuria [13] and causes rapid loss of glomerular filtration rate (GFR) leading to rapid progression of diabetic nephropathy [14]. Beside diabetic kidney disease, cigarette smoking has been implicated in nondiabetic kidney diseases. Various studies have shown progression of nondiabetic chronic kidney diseases due to cigarette smoking [15, 16]. Cigarette smoking is deleterious after kidney transplantation. Figure 1 shows cigarette smoking and its effects in both kidney donors and recipient.

Kidney donors undergo general anesthesia for donor nephrectomy and are prone to develop complications in the perioperative period. Cigarette smoking causes increased bronchial secretion and impaired mucociliary clearance. It also results in increased carboxyhemoglobin and secondary polycythemia. Stopping cigarette smoking for only 12 hours can greatly reduce carboxyhemoglobin concentrations, improve oxygen content and availability, and reverse negative inotropic and arrhythmic effects [17, 18]. Smokers’ polycythemia and blood viscosity reverses within few days while sputum production declines over a period of 6 weeks after smoking cessation [19]. Pneumonia is the third most common infection after urinary tract and wound infection in kidney donors [20]. Smokers have a higher risk of pulmonary and wound infections after surgery than nonsmokers [21]. Based on this data, the Amsterdam Forum Guidelines recommends cessation of cigarette smoking 6 weeks before kidney donation [22].

It is well established that cigarette smoking causes chronic obstructive airway disease, coronary artery disease, and cancer [4]. Cigarette smoking is also associated with increased mortality and graft loss in kidney transplant recipients [31]. In this section, we will review the implications of cigarette smoking on cardiovascular disease, mortality, graft survival, rejection, infections, and cancer in kidney transplant recipients.

Kidney transplantation provides an opportunity to both donors and recipients to quit cigarette smoking. Continuation of cigarette smoking causes fatal medical events in both donor and recipient. Kidney donors who are smokers are less likely to provide follow-up information requested by transplant centers [26]. Kidney transplantation is in fact an incentive for patients to stop cigarette smoking. Keles and his colleagues [30] reported that preoperative cigarette smoking status in live donors was 47%. Postoperatively, it reduced significantly to 29%. This could be because of predonation counselling. Other reasons for this could be frequent contacts of the donor in the donor clinic and resulting fear that continuation of cigarette smoking may affect the solitary kidney. Banas et al. [109] reported that 27.6% of smokers stopped cigarette smoking after kidney transplantation. The cessation of cigarette smoking was more prevalent in patients < 55 years of age and females. The cessation of cigarette smoking after transplantation in kidney transplant recipients was greater in magnitude when compared to nicotine patch which was successful only 16.4% of the times at 12 months [109]. This was almost comparable with bupropion plus nicotine patch combination which results in cigarette smoking cessation in 35.5% at 12 months of therapy. Major medical events like myocardial infarction and stroke also increase health consciousness to quit cigarette smoking [52]. Getting a new kidney also transforms patient's life and may increase health consciousness of the recipient to quit cigarette smoking. Therefore, extensive counselling should be done with donors and recipients to encourage smoking cessation and this should be continued throughout subsequent clinic consultations. Keeping in view the evidence available for hazards due to cigarette smoking, we highly recommend the following:A detailed history of smoking should be taken from both donor and recipient.Detailed explanation of possible hazards of cigarette smoking for the donor (perioperative complications, postoperative wound infection, and kidney dysfunction in future) should be done.Detailed explanation of possible hazards of cigarette smoking in recipient (increased cardiovascular mortality, decreased graft survival, decreased patient survival, possible rejection, infections, and malignancies) should be explained to the recipient.Those with history of cigarette smoking should be referred to dedicated smoking cessation clinic.Kidney donor should stop smoking at least 6 weeks before the surgery.Smoking cessation advice should be part of chronic kidney disease management before transplantation.All efforts should be put in to ensure smoking cessation in kidney transplant recipients at least 6 weeks before surgery.Transplantation results in cigarette smoking cessation in both recipients and donors. However, to achieve 100% cessation, continuous education and counseling should be provided to both donor and recipient by transplant coordinator and transplant physiciansThose who continue to smoke should have regular follow-up in smoking cessation clinic. Use of nicotine, bupropion, or varenicline can be used to quit cigarette smoking. Those using bupropion will need to monitor cyclosporine blood level. Cigarette smoking has significant implications for both kidney donors and recipients. Cigarette smoking has been associated with perioperative complications, wound infections, and mortality in transplant recipients. Kidney donation increases health consciousness and decreases cigarette smoking in significant number of donors. However, more work is needed to assess the impact of cigarette smoking on renal function and mortality in kidney donors. Cigarette smoking causes increased cardiovascular events and leads to decreased patient and graft survival. Cigarette smoking may also be associated with rejections but this needs further studies for verifications. Additionally, cigarette smoking is associated with opportunistic infections and malignancies in kidney transplant recipients.   Source: