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Published on: April 12, 2021
Cardiovascular Risk Assessment and Management in Prerenal Transplantation Candidates
Eric M Lindley1, Amanda K Hall2, Jordan Hess3
1Division of Cardiovascular Medicine, University of Utah Hospitals and Clinics, Salt Lake City, Utah.
Insights
Stress testing poorly predicts obstructive coronary artery disease (CAD) in kidney transplant candidates. Coronary angiography and revascularization may improve outcomes for these high-risk patients.
Area of Science:
- Nephrology
- Cardiology
- Transplant Surgery
Background:
- Cardiovascular (CV) assessment protocols for kidney transplant candidates lack standardization.
- Current guidelines suggest stress testing for patients with ≥ 3 CV risk factors.
Purpose of the Study:
- To evaluate CV assessment and management strategies in patients referred for kidney transplantation.
- To determine the effectiveness of stress testing in identifying obstructive coronary artery disease (CAD).
Main Methods:
- Retrospective analysis of 685 kidney transplant referrals over 7 years.
- Comparison of outcomes between patients who underwent coronary angiography versus those who did not.
- Assessment of stress testing sensitivity for obstructive CAD.
Main Results:
- Stress testing demonstrated poor sensitivity (0.26) for detecting obstructive CAD.
- Patients with no CAD, nonobstructive CAD, or CAD with intervention had better event-free survival.
- No adverse events occurred within 30 days post-transplant in 77 patients with preoperative angiography.
Conclusions:
- Standard risk factors and stress testing are inadequate predictors of obstructive CAD in this population.
- Coronary angiography and potential revascularization may be beneficial for kidney transplant candidates.
- Preoperative angiography was associated with improved short-term post-transplant outcomes.
Abstract:
Cardiovascular (CV) assessment in prerenal transplant patients varies by center. Current guidelines recommend stress testing for candidates if ≥ 3 CV risk factors exist. We evaluated the CV assessment and management in 685 patients referred for kidney transplant over a 7-year period. All patients had CV risk factors, and the most common cause of end-stage renal disease was diabetes. Thirty-three percent (n = 229) underwent coronary angiography. The sensitivity of stress testing to detect obstructive coronary artery disease (CAD) was poor (0.26). Patients who had no CAD, nonobstructive CAD, or CAD with intervention had significantly higher event-free survival compared with patients with obstructive CAD without intervention. There were no adverse clinical events (death, myocardial infarction, stroke, revascularization, and graft failure) within 30 days post-transplant in patients who had preoperative angiography (n = 77). Of the transplanted patients who did not have an angiogram (n = 289), there were 8 clinical events (6 myocardial infarctions) in the first 30 days. In conclusion, our results indicate that stress testing and usual risk factors were poor predictors of obstructive CAD and that revascularization may prove beneficial in these patients.
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