Cardiac risk assessment for end-stage renal disease patients on the renal transplant waiting list (original) (raw)
Related papers
Korean Journal of Transplantation
Background: Cardiac evaluation before deceased donor kidney transplant (DDKT) remains a matter of debate. Data on Asian countries and countries with prolonged waiting times are lacking. This study aimed to assess the outcomes of patients referred for DDKT after a cardiac evaluation at an Asian tertiary transplant center. Methods: This single-center retrospective review analyzed patients who were referred for waitlist placement and underwent cardiac stress testing between January 2009 and December 2015. Patients with cardiac symptoms were excluded. The primary outcome was three-point major adverse cardiovascular events (MACE), a composite of non-fatal myocardial infarction, non-fatal stroke, and cardiovascular death. Results: Of 468 patients referred for DDKT, 198 who underwent cardiac stress testing (myocardial perfusion studies in 159 patients and stress echocardiography in 39 patients) were analyzed. MACE occurred in 20.7% of the patients over a median follow-up of 4.6 years. Cardiac stress tests were positive for ischemia in 19.7% of the patients. Coronary angiography was performed in 63 patients, including 29 patients with diabetic kidney disease and negative cardiac stress tests. Significant coronary artery disease (CAD) was detected in 27 patients (42.8%), of whom 18 underwent revascularization. MACE was associated with significant CAD on coronary angiography in the multivariable analysis. Cardiac stress test results were not associated with MACE. Amongst diabetic patients who had negative cardiac stress tests, 37.9% had significant CAD on coronary angiography. Conclusions: The cardiovascular disease burden is significant amongst DDKT waitlist candidates. Pretransplant cardiac screening may identify patients with significant CAD at higher risk of MACE.
American Journal of Kidney Diseases, 2010
Cardiovascular disease is the most common cause of death after kidney transplant. However, uncertainties regarding the optimal assessment of cardiovascular risk in potential transplant candidates have produced controversy and inconsistency in pretransplant 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 by the incidence and adverse consequences of acute coronary syndromes in this population. Testing for coronary artery disease may be performed noninvasively by modalities including 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 end-stage renal disease patients. Associations of angiographically-defined coronary artery disease with subsequent survival are also 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 among end-stage renal disease patients. 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.
American Journal of Transplantation, 2009
The purpose of this study is to explore the relationship between coronary artery disease (CAD), transplantation status and subsequent mortality in end-stage renal disease (ESRD) patients undergoing evaluation for renal transplantation. Two hundred fifty-three ESRD patients at high risk for CAD underwent coronary angiography as part of a renal transplant evaluation. The cohort was divided into three groups: Group 1 (n = 127) had no vessels with ≥50% stenosis, Group 2 (n = 56) had one vessel with ≥50% stenosis and Group 3 (n = 70) had two or more vessels with ≥50% stenosis. Long-term survival was determined; median follow-up was 3.3 years. The baseline characteristics were similar except for older age and higher proportion of diabetes mellitus, dyslipidemia and peripheral vascular disease in Groups 2 and 3 patients as compared to Group 1. Survival was worse in Group 3 compared to Group 1 (p < 0.0001). Each of the three subgroups had better survival with renal transplantation than those who did not undergo transplantation (p < 0.0001). Although the degree of CAD is related to subsequent mortality, transplantation is associated with better survival regardless of the extent and severity of CAD. Thus, the presence of CAD should not exclude ESRD patients from consideration for this therapy.
Clinical and Experimental Nephrology, 2021
Background: The purpose of this study was to verify the risk factors present in patients on the kidney transplant waiting list that may interfere with the incidence of CV events and death during the first 12 months after transplantation. Methods: Based on data collected prospectively during pre-transplant workup, a retrospective study was conducted including 665 patients followed up until death or completing 12 months post-transplantation. Endpoints were the composite incidence of CV events and death. Results: The prevalence of diabetes, LV hypertrophy and CV disease at baseline was high; 14% of patients had angina, 26% an abnormal myocardial scan, and 47% coronary artery disease (CAD). CV events occurred in 53 patients (8.4%) and in 29 (55%) caused death. The independent predictors of events were age ≥ 50 years (HR: 2.292; CI%: 1.093-4.806), angina (HR: 1.969; CI%: 1.039-3.732), and altered myocardial scan (HR: 1.905, CI% 1.059-3.428). Altered myocardial scan (HR: 2.601; CI%: 1.129-5.988) was the sole predictor of CV death. Conclusion: The incidence of CV events and death were predicted by variables associated with myocardial ischemia. Patients with pre-transplantation myocardial ischemia should be considered at a higher risk of developing early CV complications and managed accordingly before, during, and after the operation.
Transplantation Proceedings, 2004
Background. Cardiovascular disease is the most common cause of death after renal transplantation. Furthermore, acute coronary syndrome (ACS) attributable to coronary artery disease (CAD) accounts for the majority of deaths due to cardiovascular disease posttransplant. While renal transplantation is the treatment of choice for end-stage renal disease, understanding the causes of graft and patient loss is exceedingly important to improve outcomes.
BMC nephrology, 2018
Despite pre-kidney-transplant cardiovascular (CV) assessment being routine care to minimise perioperative risk, the utility of such assessment is not well established. The study reviewed the evaluation and outcome of a standardised CV assessment protocol. Data were analysed for 231 patients (age 53.4 ± 12.9 years, diabetes 34.6%) referred for kidney transplantation between 1/2/2012-31/12/2014. One hundred forty-three patients were high-risk (age > 60 years, diabetes, CV disease, heart failure, peripheral vascular disease) and offered dobutamine stress echocardiography (DSE); 88 patients were low-risk and offered ECG and echocardiography with/without exercise treadmill test. At the end of follow-up (579 ± 289 days), 35 patients underwent kidney transplantation and 50 were active on the waitlist. There were 24 events (CV or death), none were perioperative. One hundred fifteen patients had DSE with proportionally more events in DSE-positive compared to DSE-negative patients (6/34 vs...
Predicting coronary heart disease in renal transplant recipients: A prospective study
Kidney International, 2004
Predicting coronary heart disease in renal transplant recipients: A prospective study.BackgroundCurrent cardiovascular risk calculators, widely used in the general population, have not yet been validated in renal transplant recipients. We conducted a prospective study to determine the incidence and risk factors for ischemic heart disease in renal transplant recipients and to assess the relevance of the Framingham Heart Study risk
ASEAN Heart Journal, 2015
For suitable end-stage renal failure (ESRF) patients, renal transplantation gives better long term survival and quality of life as compared to dialysis. (1-6) However the wait for a suitable renal transplant is usually long, with a median waiting time of 9.44 years for a cadaveric renal transplant in Singapore. (7) During this period, this group of patients can develop signifi cant cardiovascular diseases. In Singapore General Hospital (SGH), patients have to undergo a thorough evaluation and a battery of screening tests prior to entry into the cadaveric renal transplant list. Patients will be excluded if they have any of the following: cardiovascular disease with ABSTRACT Introduction: For suitable end-stage renal failure (ESRF) patients, renal transplantation gives better long term survival and quality of life as compared to dialysis. Prior to entry into the renal transplant wait list, potential candidates are screened for the presence of cardiovascular disease. However, the waiting time on the transplant list is long, and interval screening for cardiac fi tness for surgery is not well defi ned. We aim to study the risk factors for the development of a cardiovascular event (CVE) and the time interval from recruitment to onset of a CVE that resulted in their removal from the transplant wait list. Methods: A retrospective study of all patients registered under the cadaveric renal transplant waiting list in Singapore General Hospital (SGH) from 16 th April 1987 to 31 st October 2010. We identifi ed patients who developed a CVE among this cohort. We compared the demographics and clinical characteristics of patients who experienced a CVE versus those who did not. Univariable and multivariable cox regression were performed to investigate the signifi cant variables for the development of a CVE. The time to development of CVE was estimated using Kaplan Meier estimation and log-rank test was used to compare the time to CVE between those with diabetes mellitus and those without. Results: 1265 patients were enrolled in this study. 273 patients dropped out of the wait list due to medical reasons or death, of which 38.8% were due to CVE. The mean and median time duration from recruitment into the waiting list to development of a CVE was 14.42 (95% CI 13.72 to 15.11) and 15.69 (95% CI 13.86 to 17.51) years respectively. For patients with diabetes mellitus, this was 8.22 (95% CI 6.30 to 10.14) and 8.16 (95% CI 4.95 to 11.36) years respectively. Factors associated with an increased risk of developing a CVE included male gender (adjusted HR 2.21, 95% CI 1.43 to 3.41, p<0.001), presence of diabetes mellitus (adjusted HR 5.13, 95% CI 2.85 to 9.24, p<0.001) and patients who were either not working or working part-time as compared to their full-time counterparts (adjusted HR 1.76, 95% CI 1.14 to 2.72, p=0.010). In addition, hazard ratio for CVE signifi cantly increased with advancing age quartile (p<0.001 by log rank test for trend). Conclusion: A signifi cant proportion of patients exited from the renal transplant wait list due to a CVE. Being male, age 37 years old or more, presence of diabetes mellitus and non-working or part-time workers as compared to full-time workers were found to increase the risk of developing a CVE during the wait period for transplantation. The presence of diabetes mellitus signifi cantly shortened the time to development of a CVE.
Cardiovascular morbidity and risk factors in renal transplant patients
Nephrology Dialysis Transplantation, 1999
for 55% of their total mortality [1]. The cardiovascular Background. Cardiovascular disease is now the major mortality is, however, significantly higher in the cause of death in renal transplant patients. This study Northern than in the Southern parts of Europe [2]. aimed to assess the prevalence of cardiovascular disease Thus, cardiovascular mortality rates in renal transplant in stable renal transplant patients as compared with patients in Norway are particularly high, and up to 10 the general background population, and to assess risk times higher than found in Southern Europe [3]. factors for cardiovascular disease in this patient group. Whereas in European renal transplant patients at large, Methods. A cross-sectional multicentre study compriscardiovascular disease accounts for 36% of the total ing 406 stable renal transplant patients (age 47±16 late mortality [3], ischaemic heart disease alone causes years, 60% males, 71% taking cyclosporin A) were as much as 53% of deaths in these patients in assessed clinically and biochemically 48 months Scandinavia [4]. (median) after transplantation and compared with the Only a few studies have compared mortality in general population. Multivariate analysis was used to patients on renal replacement therapy in general with assess the relation between cardiovascular disease and that of the background population [3-5], and to our risk factors. knowledge none has assessed the cardiovascular mor-Results. Hypertension was present in 55% of males bidity specifically in renal transplant patients in the and 34% of females (P<0.001), in 51% with cyclospocyclosporin era. rin A and in 33% without (P<0.001). Ischaemic heart Thus, the aims of this study were first to assess the disease (i.e. angina pectoris and/or previous myocardial prevalence of cardiovascular disease in renal transplant infarction) was present in 14% (males: 18%, females: patients using a predominantly cyclosporin A based 10%, P<0.05) and in 24% of diabetics vs 12% of nonimmunosuppressive regimen as compared with the diabetics (P<0.01). Cerebro-and peripheral vascular general background population, and second to evaluate disease was found in 3% and 4%, respectively. Odds the relation between cardiovascular disease and risk ratio for angina pectoris (patients vs general populafactors in the patients. tion) was: in age group 40-49 years (males/females), 12/16; 50-59 years, 6/4; 60-69 years, 3/4. Ischaemic heart disease was, besides age and gender, independ-Subjects and methods ently associated with total cholesterol (P<0.01), and peripheral vascular disease to systolic blood pressure The present study extends a recent analysis on hyperlipidae-(P<0.01). mia in renal transplant patients in Norway [6 ]. In all, 406 Conclusions. Cardiovascular disease is highly prevalent stable renal transplant patients completed registration in in renal transplant patients, and is independently asso-1991 at 18 centres of nephrology covering all regions of ciated with age, gender, total cholesterol and systolic Norway. The study patients represented 43% of the total blood pressure. national renal transplant population at the time, and had a similar age and gender distribution. Each patient was assessed Key words: cardiovascular disease; cross-sectional by a nephrologist who recorded patient history, clinical study; cyclosporin A; ischaemic heart disease; renal findings and laboratory investigations. Cause of pretransplant patients; risk factors transplant renal failure was chronic glomerulonephritis in 42.5%, chronic pyelonephritis in 12.8%, diabetic nephropathy in 11.5%, cystic renal disease in 7.6%, other primary renal Cardiovascular disease is now the major cause of death (P<0.05, males vs females). Brachial artery blood pressure in patients on renal replacement therapy and accounts was measured in the sitting position with a manometer and an appropriately sized cuff. A 12-lead electrocardiogram was