[Coronary ischemia after kidney transplantation in patients over 60 years of age]
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J P Cristol1, G Mourad, X Rebillard
1Service de Néphrologie, Hôpital Lapeyronie, Montpellier.
Insights
Elderly kidney transplant candidates with no signs of heart disease are good candidates. Pre-transplant screening with stress thallium testing (STT) can identify and prevent cardiovascular risks in this population.
Area of Science:
- Nephrology
- Cardiology
- Transplantation Medicine
Background:
- Elderly patients awaiting kidney transplants are at high risk for myocardial infarction and sudden cardiac death.
- Cardiovascular assessment is crucial for this patient group before renal allograft transplantation.
Purpose of the Study:
- To evaluate the cardiovascular risk and outcomes of kidney transplantation in elderly patients.
- To determine the efficacy of pre-transplant cardiovascular screening in identifying at-risk individuals.
Main Methods:
- 22 elderly patients (60-69 years) underwent cadaveric kidney transplantation between 1987 and 1990.
- Cardiovascular risk factors were assessed using medical history, cervical arterial Doppler, echocardiography, and stress thallium testing (STT).
- Coronary angiography was performed for suspected myocardial ischemia.
Main Results:
- Two patients died of myocardial infarction; one had silent ischemia detected by STT.
- 19 patients had functioning allografts after 9-32 months with an 85% actuarial graft survival rate at 18 months.
- 36% of patients experienced acute rejection, all responsive to corticosteroids.
Conclusions:
- Elderly patients without clinical or silent myocardial ischemia are suitable for kidney transplantation.
- Stress thallium testing (STT) is effective in pre-transplant screening for cardiovascular risk.
- Coronary angiography is mandatory if STT is non-maximal or indicates ischemia.
Abstract:
Many elderly patients (aged over 60) are waiting for renal allograft but are considered a risk population for myocardial infarction or sudden cardiac death. Between 1987 and January 1st, 1990, 22 elderly patients (16 men and 6 women; mean age 63.4 +/- 0.7 years; range 60-69 years) underwent cadaveric kidney transplantation. Twenty patients had been on haemodialysis for 4.8 +/- 1 years (range: 1-16.3), one had been on peritoneal dialysis for 5 years and one had developed chronic rejection of a previous cadaveric allograft. Among these 22 patients, 6 (27 percent) developed antibodies directed against the random lymphocyte panel and one had a second transplant. Cardiovascular risk factors were systematically estimated, including medical history, cervical arterial Doppler, echocardiography and stress thallium testing (STT). Coronary angiography was performed if there was evidence of myocardial ischaemia. STT did not show any coronary disease in 16 patients and was not maximal (less than 60 percent of maximal theoretical stress) in 4 patients. In 2 patients, STT showed myocardial ischaemia: one, with a history of angina, underwent coronary angiography and angioplasty; the other had silent ischaemia and refused coronary angiography. Two patients died of myocardial infarction. One of them was the patient with silent ischaemia and positive STT test. The patient with angioplasty had a successful transplantation 20 months later, without any cardiovascular complication. After 9 to 32 months of follow-up, 19 patients have functioning allografts (mean serum creatinine level 151 +/- 6 mumol/l). One patient lost his kidney from urinary fistula. Eight patients (36 percent) developed acute rejection and all responded to intravenous corticosteroids. No immunological transplant loss was observed. After 18 months, the graft actuarial survival rate was 85 percent. We conclude that elderly patients free of clinical or silent myocardial ischaemia are good transplant recipients. The cardiovascular risk could be prevented by using STT during the pretransplant screening. If the STT is not maximal or shows coronary ischaemia, coronary angiography is mandatory.