*Purpose: Transplant recipients experience excess cardiovascular morbidity and mortality. We compared cardiovascular death rates in kidney transplant recipients to the general population and identified risk factors for cardiovascular death in kidney transplant recipients.

*Methods: Primary cause of death for kidney transplant recipients was established through ICD-10 codes and data linkage between the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) and the national death registers of Australia and New Zealand. Cardiovascular deaths included death from ischaemic heart disease, valve disease, cardiomyopathy, arrhythmias, and cardiac failure. We used indirect standardisation to estimate standardised mortality ratios (SMR) and, Fine and Gray competing risks regression model to determine risk factors for cardiovascular mortality (subhazard ratios, SHR).

*Results: During 1988-2013, there were 5286 deaths in 17,628 kidney transplant recipients in 175,084 person-years of follow up. Of these deaths 936 (17.8%) were cardiovascular, of which 788 (84%) were caused by ischaemic heart disease. The crude rate of cardiovascular death in transplant patients fell over time from >800/100,000 person-years in the early 1990s to <400/100,000 person-years in the 2010s (p<0.001). Cardiovascular death rates increase with age for both men and women (p<0.001).Cardiovascular SMR in transplant patients was 5.46 (95%CI: 5.12, 5.82). SMRs fell over time from a high of 16.92 (95%CI: 9.61, 29.80) in 1984 to 4.03 (95%CI: 4.03, 7.05) in 2013 (p<0.001). Females had significantly higher relative cardiovascular mortality than men at all age groups until age 75 when the differences were no longer statistically significant (Figure 1).Risk factors for cardiovascular death included male sex (SHR 1.61, 95%CI:1.39,1.85), age >55 (SHR 2.97, 95%CI:2.48,3.55), >36 months on dialysis (SHR 1.63, 95%CI:1.30,2.05), pre-existing coronary artery disease (SHR 1.49, 95%CI: 1.20,1.85), and either diabetes (SHR 1.6, 95%CI:1.28, 2.0) or hypertension (SHR 1.53, 95%CI: 1.16,2.02) as the cause of kidney failure.

*Conclusions: Transplant recipients have greatly increased risk of cardiovascular mortality compared to the general population. Excess risk is much higher for female than male transplant recipients suggesting cardiovascular risks may be under-recognized, and/or prevention and treatment interventions less effective in females with ESKD.

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