The Challenges With the Cardiac Evaluation of Liver and Kidney Transplant Candidates

Cardiovascular events are among the leading cause of mortality in kidney and liver transplant recipients. Thus, screening for cardiovascular disease and risk stratification for cardiovascular events constitute an important part of the pretransplant evaluation. In this review, we first summarize current guidelines in the cardiac risk assessment of kidney and liver transplant candidates. We then elaborate on the limitations of these guidelines, summarize the current knowledge gaps, and narrow down a spectrum of 6 themes that serve as challenges to research and practice development. This spectrum pertains to understanding the disease itself, which is challenging due to the altered cardiac physiology in these patients and current guidelines that do not adequately account for nonischemic diseases and events. We then describe the challenges in assessing these patients, their symptoms, and individualizing their risk of cardiovascular events with a special consideration for nontraditional risk factors. We also explore the limitations of the current and novel diagnostic tests and the lack of evidence of therapeutic efficacy in intervening in patients with asymptomatic disease. The transplant procedure itself can be a potential modifiable risk factor for cardiovascular events, that is, surgical technique, type of donor, and induction immunosuppression. Lastly, we describe the potential issues with the current literature when defining cardiac diseases and events across different studies and shortcomings of extrapolating data from the nontransplant literature. We conclude by proposing research and practice implications of our discussion and that there is a need for evidence to guide the revision of current guidelines.