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Updated: Nov 5, 2025
Robot-Assisted Kidney Transplantation
Published on: July 19, 2021
Kidney Transplant List Status and Outcomes in the ISCHEMIA-CKD Trial
Charles A Herzog1, Mengistu A Simegn1, Yifan Xu2
1Department of Medicine, Hennepin Healthcare, Minneapolis, Minnesota, USA; University of Minnesota, Minneapolis, Minnesota, USA.
Insights
For patients with advanced chronic kidney disease and coronary artery disease, an invasive strategy like revascularization did not improve outcomes compared to conservative management. These findings suggest against routine invasive procedures for transplant candidates.
Area of Science:
- Cardiology
- Nephrology
- Transplantation
Background:
- Patients with chronic kidney disease (CKD) and coronary artery disease (CAD) often receive preemptive revascularization before kidney transplantation.
- The ISCHEMIA-CKD trial investigated the effectiveness of medical versus invasive approaches in patients with CKD and coronary syndromes.
Purpose of the Study:
- To compare outcomes of patients listed for kidney transplant versus those not listed.
- To analyze the effectiveness of invasive versus conservative management strategies in kidney transplant candidates with CKD and CAD.
Main Methods:
- A post hoc analysis of the ISCHEMIA-CKD trial involving 777 patients.
- 194 patients (25%) were listed for transplant and outcomes were analyzed using Cox multivariable modeling.
- Assessed heterogeneity of treatment effects between listed and not listed groups.
Main Results:
- Listed patients were younger, more likely to be on dialysis, and had fewer anginal symptoms than unlisted patients.
- An invasive strategy did not significantly improve the primary outcome (all-cause mortality or nonfatal myocardial infarction) in listed (aHR 0.91) or unlisted (aHR 1.03) patients.
- No significant difference in secondary outcomes was observed between listed and unlisted patients, with adjusted hazard ratios of 0.89 and 1.17, respectively.
Conclusions:
- An invasive strategy did not improve outcomes in kidney transplant candidates with advanced CKD and chronic coronary syndromes compared to conservative management.
- These findings do not support routine coronary angiography or revascularization in this patient population.
- The ISCHEMIA-CKD trial results emphasize a conservative approach for selected patients awaiting kidney transplantation.
Background:
Patients with chronic kidney disease (CKD) and coronary artery disease frequently undergo preemptive revascularization before kidney transplant listing.
Objectives:
In this post hoc analysis from ISCHEMIA-CKD (International Study of Comparative Health Effectiveness of Medical and Invasive Approaches-Chronic Kidney Disease), we compared outcomes of patients not listed versus those listed according to management strategy.
Methods:
In the ISCHEMIA-CKD trial (n = 777), 194 patients (25%) with chronic coronary syndromes and at least moderate ischemia were listed for transplant. The primary (all-cause mortality or nonfatal myocardial infarction) and secondary (death, nonfatal myocardial infarction, hospitalization for unstable angina, heart failure, resuscitated cardiac arrest, or stroke) outcomes were analyzed using Cox multivariable modeling. Heterogeneity of randomized treatment effect between listed versus not listed groups was assessed.
Results:
Compared with those not listed, listed patients were younger (60 years vs 65 years), were less likely to be of Asian race (15% vs 29%), were more likely to be on dialysis (83% vs 44%), had fewer anginal symptoms, and were more likely to have coronary angiography and coronary revascularization irrespective of treatment assignment. Among patients assigned to an invasive strategy versus conservative strategy, the adjusted hazard ratios for the primary outcome were 0.91 (95% confidence interval [CI]: 0.54-1.54) and 1.03 (95% CI: 0.78-1.37) for those listed and not listed, respectively (pinteraction= 0.68). Adjusted hazard ratios for secondary outcomes were 0.89 (95% CI: 0.55-1.46) in listed and 1.17 (95% CI: 0.89-1.53) in those not listed (pinteraction = 0.35).
Conclusions:
In ISCHEMIA-CKD, an invasive strategy in kidney transplant candidates did not improve outcomes compared with conservative management. These data do not support routine coronary angiography or revascularization in patients with advanced CKD and chronic coronary syndromes listed for transplant. (ISCHEMIA-Chronic Kidney Disease Trial [ISCHEMIA-CKD]; NCT01985360).
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