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Cardiovascular risk assessment among potential kidney transplant candidates: approaches and controversies
Krista L Lentine1, Frank P Hurst, Rahul M Jindal
1Center for Outcomes Research, Saint Louis University School of Medicine, St Louis, MO 63104, USA. lentine.krista@stanfordalumni.org
Insights
Pre-transplant cardiac evaluation for kidney transplant candidates is crucial due to high cardiovascular disease rates. Current noninvasive tests offer prognostic value but require further refinement for optimal risk assessment in end-stage renal disease patients.
Area of Science:
- Nephrology
- Cardiology
- Transplantation Medicine
Background:
- Cardiovascular disease (CVD) is the leading cause of mortality post-kidney transplantation.
- Inconsistent pretransplant cardiac evaluation practices exist for potential kidney transplant recipients.
- Coronary artery disease (CAD) is highly prevalent and poses significant risks in this population.
Purpose of the Study:
- To review the evidence supporting cardiac evaluation in kidney transplant candidates.
- To assess the role of coronary artery disease screening based on World Health Organization principles.
- To evaluate current noninvasive testing modalities and biomarkers for cardiovascular risk stratification.
Main Methods:
- Review of existing literature on pretransplant cardiac evaluation for kidney transplant candidates.
- Analysis of data regarding the prevalence and impact of coronary artery disease in end-stage renal disease (ESRD) patients.
- Evaluation of noninvasive diagnostic tests like nuclear myocardial perfusion studies and dobutamine stress echocardiography.
- Consideration of prognostic biomarkers such as cardiac troponin.
Main Results:
- Noninvasive tests provide prognostic information for mortality but have limitations in sensitivity and specificity for detecting angiographically defined CAD in ESRD.
- The link between angiographic CAD and survival is inconsistent, suggesting plaque instability is a key factor.
- Biomarkers like cardiac troponin show prognostic value but need further research for clinical application in guiding evaluations.
- Large clinical trials on myocardial revascularization efficacy in ESRD are lacking.
Conclusions:
- Pretransplant cardiac evaluation is essential for kidney transplant candidates due to high cardiovascular risks.
- Current noninvasive testing methods offer prognostic insights but require optimization for ESRD patients.
- Further research is needed to refine risk assessment strategies and guide interventions, including the role of biomarkers.
Abstract:
Cardiovascular disease is the most common cause of death after kidney transplantation. However, uncertainties regarding the optimal assessment of cardiovascular risk in potential transplant candidates have produced controversy and inconsistency in pretransplantation cardiac evaluation practices. In this review, we consider the evidence supporting cardiac evaluation in kidney transplant candidates, generally focused on coronary artery disease, according to the World Health Organization principles for screening. The importance of pretransplant cardiac evaluation is supported by the high prevalence of coronary artery disease and the incidence and adverse consequences of acute coronary syndromes in this population. Testing for coronary artery disease may be performed noninvasively by using modalities that include nuclear myocardial perfusion studies and dobutamine stress echocardiography. These tests have prognostic value for mortality, but imperfect sensitivity and specificity for detecting angiographically defined coronary artery disease in patients with end-stage renal disease. Associations of angiographically-defined coronary artery disease with subsequent survival also are inconsistent, likely because plaque instability is more critical for infarction risk than angiographic stenosis. The efficacy and best methods of myocardial revascularization have not been examined in large contemporary clinical trials in patients with end-stage renal disease. Biomarkers, such as cardiac troponin, have prognostic value in end-stage renal disease, but require further study to determine clinical applications in directing more expensive and invasive cardiac evaluation.
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