1
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Butler CR, Reese PP, Cheng XS. Referral and Beyond: Restructuring the Kidney Transplant Process to Support Greater Access in the United States. Am J Kidney Dis 2024:S0272-6386(24)00743-1. [PMID: 38670253 DOI: 10.1053/j.ajkd.2024.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 03/01/2024] [Accepted: 03/04/2024] [Indexed: 04/28/2024]
Abstract
Advocates for improved equity in kidney transplants in the United States have recently focused their efforts on initiatives to increase referral for transplant evaluation. However, because donor kidneys remain scarce, increased referrals are likely to result in an increasing number of patients proceeding through the evaluation process without ultimately receiving a kidney. Unfortunately, the process of referral and evaluation can be highly resource-intensive for patients, families, transplant programs, and payers. Patients and families may incur out-of-pocket expenses and be required to complete testing and treatments that they might not have chosen in the course of routine clinical care. Kidney transplant programs may struggle with insufficient capacity, inefficient workflow, and challenging programmatic finances, and payers will need to absorb the increased expenses of upfront pretransplant costs. Increased referral in isolation may risk simply transmitting system stress and resulting disparities to downstream processes in this complex system. We argue that success in efforts to improve access through increased referrals hinges on adaptations to the pretransplant process more broadly. We call for an urgent re-evaluation and redesign at multiple levels of the pretransplant system in order to achieve the aim of equitable access to kidney transplantation for all patients with kidney failure.
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Affiliation(s)
- Catherine R Butler
- Division of Nephrology, Department of Medicine, Kidney Research Institute, University of Washington, Seattle, Washington; Veteran Affairs Health Services Research and Development Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington
| | - Peter P Reese
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Biostatistics, Epidemiology and Bioinformatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Xingxing S Cheng
- Division of Nephrology, Department of Medicine, Stanford University, Palo Alto, California.
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2
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Zheng WC, Evans N, Dinh D, Bloom JE, Brennan AL, Ball J, Lefkovits J, Shaw JA, Reid CM, Chan W, Stub D. Clinical Outcomes of Renal Transplant Recipients Undergoing Percutaneous Coronary Intervention. Heart Lung Circ 2024:S1443-9506(24)00073-8. [PMID: 38565437 DOI: 10.1016/j.hlc.2024.01.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/17/2024] [Accepted: 01/18/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Clinical outcomes of patients with renal transplant (RT) undergoing percutaneous coronary intervention (PCI) remain poorly elucidated. METHOD Between 2014 and 2021, data were analysed for the following three groups of patients undergoing PCI enrolled in a multicentre Australian registry: (1) RT recipients (n=226), (2) patients on dialysis (n=992), and (3) chronic kidney disease (CKD) patients (estimated glomerular filtration rate [eGFR], 30‒60 mL/min per 1.73 m2) without previous RT (n=15,534). Primary outcome was 30-day major adverse cardiac and cerebrovascular events (MACCEs)-composite of mortality, myocardial infarction, stent thrombosis, target vessel revascularisation, and stroke. RESULTS RT recipients were younger than dialysis and patients with CKD (61±10 vs 68±12 vs 78±8.2 years, p<0.001). Patients with RT less frequently had severe left ventricular dysfunction compared with dialysis and CKD groups (6.7% vs 14% and 8.5%); however more, often presented with acute coronary syndrome (58% vs 52% and 48%), especially STEMI (all p<0.001). Patients with RT and CKD had lower rates of 30-day MACCE (4.4% and 6.8% vs 11.6%, p<0.001) than the dialysis group. Three-year survival was similar between RT and CKD groups, however was lower in the dialysis group (80% and 83% vs 60%, p<0.001). After adjustment, dialysis was an independent predictor of 30-day MACCE (odds ratio [OR] 1.90, 95% confidence interval [CI] 1.44‒2.50, p<0.001), however RT was not (OR 0.91, CI 0.42‒1.96, p=0.802). Both RT (hazard ratio [HR] 2.07, CI 1.46‒2.95, p<0.001) and dialysis (HR 1.35, CI 1.02‒1.80, p=0.036) heightened the hazard of long-term mortality. CONCLUSIONS RT recipients have more favourable clinical outcomes following PCI compared with patients on dialysis. However, despite having similar short-term outcomes to patients with CKD, the hazard of long-term mortality is significantly greater for RT recipients.
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Affiliation(s)
- Wayne C Zheng
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia
| | - Nicole Evans
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia
| | - Diem Dinh
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia
| | - Jason E Bloom
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia; Clinical Research Domain, Baker Heart and Diabetes Institute, Melbourne, Vic, Australia
| | - Angela L Brennan
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia
| | - Jocasta Ball
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Clinical Research Domain, Baker Heart and Diabetes Institute, Melbourne, Vic, Australia
| | - Jeffrey Lefkovits
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - James A Shaw
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia
| | - Christopher M Reid
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia; School of Population Health, Curtin University, Perth, WA, Australia
| | - William Chan
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Clinical Research Domain, Baker Heart and Diabetes Institute, Melbourne, Vic, Australia; Department of Medicine, The University of Melbourne, Melbourne, Vic, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia.
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3
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Gill JS, Chadban SJ. Pretransplant screening for coronary artery disease: data are required before practice change. Kidney Int 2024; 105:470-472. [PMID: 37914085 DOI: 10.1016/j.kint.2023.09.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 09/07/2023] [Accepted: 09/25/2023] [Indexed: 11/03/2023]
Abstract
Declining rates of peritransplant cardiovascular death, an increasing burden of pretransplant tests, and concerns about the effectiveness of screening candidates for coronary artery disease have led many transplant programs to de-escalate screening protocols. Recent Kidney Disease: Improving Global Outcomes and American Heart Association scientific statements and guidelines neatly summarize current evidence, but also identify areas of need. Here, we argue that key questions should be addressed by adequately powered clinical trials before our long-held screening paradigms are completely rewritten.
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Affiliation(s)
- John S Gill
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Steven J Chadban
- Department of Renal Medicine, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia; Kidney Node, Charles Perkins Centre, University of Sydney, New South Wales, Australia.
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4
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Ozemek C, Hardwick J, Bonikowske A, Christle J, German C, Reddy S, Arena R, Faghy M. How to interpret a cardiorespiratory fitness assessment - Key measures that provide the best picture of health, disease status and prognosis. Prog Cardiovasc Dis 2024; 83:23-28. [PMID: 38417770 DOI: 10.1016/j.pcad.2024.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 02/25/2024] [Indexed: 03/01/2024]
Abstract
Graded exercise testing is a widely accepted tool for revealing cardiac ischemia and/or arrhythmias in clinical settings. Cardiopulmonary exercise testing (CPET) measures expired gases during a graded exercise test making it a versatile tool that helps reveal underlying physiologic abnormalities that are in many cases only present with exertion. It also characterizes one's health status and clinical trajectory, informs the therapeutic plan, evaluates the efficacy of therapy, and provides submaximal and maximal information that can be used to tailor an exercise intervention. Practitioners can also modify the mode and protocol to allow individuals of all ages, fitness levels, and most disease states to perform a CPET. When used to its full potential, CPET can be a key tool used to optimize care in primary and secondary prevention settings.
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Affiliation(s)
- Cemal Ozemek
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois, Chicago, IL, USA.
| | - Joel Hardwick
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois, Chicago, IL, USA
| | - Amanda Bonikowske
- Division of Preventive Cardiology, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jeffrey Christle
- Division of Cardiovascular Medicine, Stanford University, School of Medicine, Stanford, CA, USA
| | - Charles German
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Satyajit Reddy
- Department of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ, USA
| | - Ross Arena
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois, Chicago, IL, USA
| | - Mark Faghy
- Human Sciences Research Centre, College of Science and Engineering, University of Derby, UK
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5
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Corr M, Orr A, Courtney AE. The Minimisation of Cardiovascular Disease Screening for Kidney Transplant Candidates. J Clin Med 2024; 13:953. [PMID: 38398266 PMCID: PMC10889488 DOI: 10.3390/jcm13040953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 01/29/2024] [Accepted: 02/06/2024] [Indexed: 02/25/2024] Open
Abstract
Background: There is increasing evidence that cardiac screening prior to kidney transplantation does not improve its outcomes. However, risk aversion to perioperative events means that, in practice, testing remains common, limiting the availability of 'real-world' data to support any change. Our objective was to assess perioperative and 1-year post-transplant cardiovascular events in a kidney transplant candidate cohort who received minimal cardiovascular screening. Methods: The retrospective cohort study included all adult kidney-only transplant recipients in a single UK region between January 2015 and December 2021. Kidney transplant recipients asymptomatic of cardiac disease, even those with established risk factors, did not receive cardiac stress testing. The perioperative and 1-year post-transplant cardiovascular event incidences were examined. Logistic regression was used to identify variables of statistical significance that predicted cardiovascular or cerebrovascular events. Results: A total of 895 recipients fulfilled the inclusion criteria. Prior to transplantation, 209 (23%) recipients had an established cardiac diagnosis, and 193 (22%) individuals had a diagnosis of diabetes. A total of 18 (2%) patients had a perioperative event, and there was a 5.7% incidence of cardiovascular events 1 year post-transplantation. The cardiovascular mortality rate was 0.0% perioperatively, 0.2% at 3 months post-transplant, and 0.2% at 1 year post-transplant. Conclusions: This study demonstrates comparable rates of cardiovascular events despite reduced screening in asymptomatic recipients. It included higher risk individuals who may, on the basis of screening results, have been excluded from transplantation in other programmes. It provides further evidence that extensive cardiac screening prior to kidney transplantation is unlikely to be offset by reduced rates of cardiovascular events.
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Affiliation(s)
- Michael Corr
- Centre for Public Health, Institute of Clinical Sciences B, Royal Victoria Hospital, Queen’s University Belfast, Belfast BT12 6BA, UK
| | - Amber Orr
- Barnsley Hospital NHS Foundation Trust, Barnsley S75 2EP, UK
| | - Aisling E. Courtney
- Regional Nephrology & Transplant Unit, Belfast City Hospital, Lisburn Road, Belfast BT9 7AB, UK
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6
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Nimmo A, Graham-Brown M, Sharif A, Taylor D, Ravanan R. Multidisciplinary perspectives on cardiac assessment before kidney transplantation: Results from a UK survey. Clin Transplant 2024; 38:e15167. [PMID: 37855234 DOI: 10.1111/ctr.15167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/05/2023] [Accepted: 10/09/2023] [Indexed: 10/20/2023]
Affiliation(s)
- Ailish Nimmo
- Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | | | - Adnan Sharif
- Department of Nephrology and Transplantation, Queen Elizabeth Hospital, Birmingham, UK
| | - Dominic Taylor
- Renal Department, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Rommel Ravanan
- Renal Department, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
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Nielsen MB, Dahl JN, Jespersen B, Ivarsen P, Birn H, Winther S. External Validation of Proposed American Heart Association Algorithm for Cardiovascular Screening Before Kidney Transplantation. J Am Heart Assoc 2023; 12:e031150. [PMID: 38084711 PMCID: PMC10863782 DOI: 10.1161/jaha.123.031150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 09/22/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND Screening for cardiovascular disease is currently recommended before kidney transplantation. The present study aimed to validate the proposed algorithm by the American Heart Association (AHA-2022) considering cardiovascular findings and outcomes in kidney transplant candidates, and to compare AHA-2022 with the previous recommendation (AHA-2012). METHODS AND RESULTS We applied the 2 screening algorithms to an observational cohort of kidney transplant candidates (n=529) who were already extensively screened for coronary heart disease by referral to cardiac computed tomography between 2014 and 2019. The cohort was divided into 3 groups as per the AHA-2022 algorithm, or into 2 groups as per AHA-2012. Outcomes were degree of coronary heart disease, revascularization rate following screening, major adverse cardiovascular events, and all-cause death. Using the AHA-2022 algorithm, 69 (13%) patients were recommended for cardiology referral, 315 (60%) for cardiac screening, and 145 (27%) no further screening. More patients were recommended cardiology referral or screening compared with the AHA-2012 (73% versus 53%; P<0.0001). Patients recommended cardiology referral or cardiac screening had a higher risk of major adverse cardiovascular events (hazard ratio [HR], 5.5 [95% CI, 2.8-10.8]; and HR, 2.1 [95% CI, 1.2-3.9]) and all-cause death (HR, 12.0 [95% [CI, 4.6-31.4]; and HR, 5.3 [95% CI, 2.1-13.3]) compared with patients recommended no further screening, and were more often revascularized following initial screening (20% versus 7% versus 0.7%; P<0.001). CONCLUSIONS The AHA-2022 algorithm allocates more patients for cardiac referral and screening compared with AHA-2012. Furthermore, the AHA-2022 algorithm effectively discriminates between kidney transplant candidates at high, intermediate, and low risk with respect to major adverse cardiovascular events and all-cause death.
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Affiliation(s)
- Marie Bodilsen Nielsen
- Department of BiomedicineAarhus UniversityAarhusDenmark
- Department of Renal MedicineAarhus University HospitalAarhusDenmark
| | - Jonathan Nørtoft Dahl
- Department of Cardiology, Gødstrup HospitalHerningDenmark
- Department of Clinical MedicineAarhus UniversityAarhusDenmark
| | - Bente Jespersen
- Department of Renal MedicineAarhus University HospitalAarhusDenmark
- Department of Clinical MedicineAarhus UniversityAarhusDenmark
| | - Per Ivarsen
- Department of Renal MedicineAarhus University HospitalAarhusDenmark
- Department of Clinical MedicineAarhus UniversityAarhusDenmark
| | - Henrik Birn
- Department of BiomedicineAarhus UniversityAarhusDenmark
- Department of Renal MedicineAarhus University HospitalAarhusDenmark
- Department of Clinical MedicineAarhus UniversityAarhusDenmark
| | - Simon Winther
- Department of Cardiology, Gødstrup HospitalHerningDenmark
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8
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Vadalà G, Alaimo C, Buccheri G, Di Fazio L, Di Caccamo L, Sucato V, Cipriani M, Galassi AR. Screening and Management of Coronary Artery Disease in Kidney Transplant Candidates. Diagnostics (Basel) 2023; 13:2709. [PMID: 37627968 PMCID: PMC10453389 DOI: 10.3390/diagnostics13162709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/09/2023] [Accepted: 08/14/2023] [Indexed: 08/27/2023] Open
Abstract
Cardiovascular disease (CVD) is a major cause of morbidity and mortality in patients with chronic kidney disease (CKD), especially in end-stage renal disease (ESRD) patients and during the first year after transplantation. For these reasons, and due to the shortage of organs available for transplant, it is of utmost importance to identify patients with a good life expectancy after transplant and minimize the transplant peri-operative risk. Various conditions, such as severe pulmonary diseases, recent myocardial infarction or stroke, and severe aorto-iliac atherosclerosis, need to be ruled out before adding a patient to the transplant waiting list. The effectiveness of systematic coronary artery disease (CAD) treatment before kidney transplant is still debated, and there is no universal screening protocol, not to mention that a nontailored screening could lead to unnecessary invasive procedures and delay or exclude some patients from transplantation. Despite the different clinical guidelines on CAD screening in kidney transplant candidates that exist, up to today, there is no worldwide universal protocol. This review summarizes the key points of cardiovascular risk assessment in renal transplant candidates and faces the role of noninvasive cardiovascular imaging tools and the impact of coronary revascularization versus best medical therapy before kidney transplant on a patient's cardiovascular outcome.
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Affiliation(s)
- Giuseppe Vadalà
- Division of Cardiology, University Hospital Paolo Giaccone, 90100 Palermo, Italy;
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), University of Palermo, 90100 Palermo, Italy; (C.A.); (G.B.); (L.D.F.); (L.D.C.); (A.R.G.)
| | - Chiara Alaimo
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), University of Palermo, 90100 Palermo, Italy; (C.A.); (G.B.); (L.D.F.); (L.D.C.); (A.R.G.)
| | - Giancarlo Buccheri
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), University of Palermo, 90100 Palermo, Italy; (C.A.); (G.B.); (L.D.F.); (L.D.C.); (A.R.G.)
| | - Luca Di Fazio
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), University of Palermo, 90100 Palermo, Italy; (C.A.); (G.B.); (L.D.F.); (L.D.C.); (A.R.G.)
| | - Leandro Di Caccamo
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), University of Palermo, 90100 Palermo, Italy; (C.A.); (G.B.); (L.D.F.); (L.D.C.); (A.R.G.)
| | - Vincenzo Sucato
- Division of Cardiology, University Hospital Paolo Giaccone, 90100 Palermo, Italy;
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), University of Palermo, 90100 Palermo, Italy; (C.A.); (G.B.); (L.D.F.); (L.D.C.); (A.R.G.)
| | - Manlio Cipriani
- Institute of Transplant and Highly Specialized Therapies (ISMETT) of Palermo, 90100 Palermo, Italy;
| | - Alfredo Ruggero Galassi
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), University of Palermo, 90100 Palermo, Italy; (C.A.); (G.B.); (L.D.F.); (L.D.C.); (A.R.G.)
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9
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Nielsen MB, Dahl JN, Laursen R, Jespersen B, Ivarsen P, Winther S, Birn H. In a real-life setting, risk factors, coronary artery calcium score, and coronary stenosis at computed tomography angiography are associated with major adverse cardiovascular events and all-cause mortality among kidney transplant candidates. Am J Transplant 2023; 23:1194-1208. [PMID: 37172693 DOI: 10.1016/j.ajt.2023.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 05/03/2023] [Accepted: 05/04/2023] [Indexed: 05/15/2023]
Abstract
Kidney failure is associated with an increased risk of cardiovascular disease and death. This single-center, a retrospective study evaluated the association between risk factors, coronary artery calcium score (CACS), coronary computed tomography angiography (CTA), major adverse cardiovascular events (MACEs), and all-cause mortality in kidney transplant candidates. Data on clinical risk factors, MACE, and all-cause mortality were collected from patient records. A total of 529 kidney transplant candidates were included (median follow-up of 4.7 years). CACS was evaluated in 437 patients and CTA in 411. Both the presence of ≥3 risk factors, CACS of ≥400, as well as multiple-vessel stenoses or left main artery disease predicted MACE (hazard ratio, 2.09; [95% confidence interval, 1.35-3.23]; 4.65 [2.20-9.82]; 3.70 [1.81-7.57]; 4.90 [2.40-10.01]) and all-cause mortality (harad ratio, 4.44; [95% confidence interval, 2.54-7.76]; 4.47 [2.22-9.02]; 2.82 [1.34-5.94]; 5.41 [2.81-10.41]) in univariate analyses. Among patients eligible for CACS and CTA (n = 376), only CACS and CTA were associated with both MACE and all-cause mortality. In conclusion, risk factors, CACS, and CTA provide information on the risk of MACE and mortality in kidney transplant candidates. An additional value of CACS and CTA compared with risk factors was observed for the prediction of MACE in a subpopulation undergoing both CACS and CTA.
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Affiliation(s)
- Marie Bodilsen Nielsen
- Department of Biomedicine, Aarhus University, Aarhus C, Denmark; Department of Renal Medicine, Aarhus University Hospital, Aarhus C, Denmark.
| | - Jonathan Nørtoft Dahl
- Department of Cardiology, Gødstrup Hospital, Herning, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus C, Denmark
| | - Rasmus Laursen
- Department of Cardiology, Regional Hospital Central Jutland, Viborg, Denmark
| | - Bente Jespersen
- Department of Renal Medicine, Aarhus University Hospital, Aarhus C, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus C, Denmark
| | - Per Ivarsen
- Department of Renal Medicine, Aarhus University Hospital, Aarhus C, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus C, Denmark
| | - Simon Winther
- Department of Cardiology, Gødstrup Hospital, Herning, Denmark
| | - Henrik Birn
- Department of Biomedicine, Aarhus University, Aarhus C, Denmark; Department of Renal Medicine, Aarhus University Hospital, Aarhus C, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus C, Denmark
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10
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Abstract
Patients with chronic kidney disease (CKD) are at high risk to develop cardiovascular disease with its manifestations coronary artery disease, heart failure, arrhythmias, and sudden cardiac death. In addition, the presence of CKD has a major impact on the prognosis of patients with cardiovascular disease, leading to an increased morbidity and mortality if both comorbidities are present. Therapeutic options including medical therapy and interventional treatment are often limited in patients with advanced CKD, and in most cardiovascular outcome trials, patients with advanced CKD have been excluded. Thus, in many patients, treatment strategies for cardiovascular disease need to be extrapolated from trials conducted in patients without CKD. The current article summarizes the epidemiology, clinical presentation, and treatment options for the most prevalent manifestations of cardiovascular disease in CKD and discusses the currently available treatment options to reduce morbidity and mortality in this high-risk population.
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Affiliation(s)
- Katharina Schuett
- Department of Internal Medicine I (Cardiology), University Hospital, RWTH Aachen University, Germany
| | - Nikolaus Marx
- Department of Internal Medicine I (Cardiology), University Hospital, RWTH Aachen University, Germany
| | - Michael Lehrke
- Department of Internal Medicine I (Cardiology), University Hospital, RWTH Aachen University, Germany
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11
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Kopparam RV, Grady D, Redberg RF. Coronary Heart Disease Testing Before Kidney Transplant-A Call for Revised Guidance. JAMA Intern Med 2023; 183:287-288. [PMID: 36806879 DOI: 10.1001/jamainternmed.2022.6841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Affiliation(s)
| | - Deborah Grady
- Department of Medicine, University of California, San Francisco.,Deputy Editor, JAMA Internal Medicine
| | - Rita F Redberg
- Division of Cardiology, Department of Medicine, University of California, San Francisco.,Editor, JAMA Internal Medicine
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12
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Cheng XS, Liu S, Han J, Stedman MR, Baiocchi M, Tan JC, Chertow GM, Fearon WF. Association of Pretransplant Coronary Heart Disease Testing With Early Kidney Transplant Outcomes. JAMA Intern Med 2023; 183:134-141. [PMID: 36595271 PMCID: PMC9857067 DOI: 10.1001/jamainternmed.2022.6069] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 11/07/2022] [Indexed: 01/04/2023]
Abstract
Importance Testing for coronary heart disease (CHD) in asymptomatic kidney transplant candidates before transplant is widespread and endorsed by various professional societies, but its association with perioperative outcomes is unclear. Objective To estimate the association of pretransplant CHD testing with rates of death and myocardial infarction (MI). Design, Setting, and Participants This retrospective cohort study included all adult, first-time kidney transplant recipients from January 2000 through December 2014 in the US Renal Data System with at least 1 year of Medicare enrollment before and after transplant. An instrumental variable (IV) analysis was used, with the program-level CHD testing rate in the year of the transplant as the IV. Analyses were stratified by study period, as the rate of CHD testing varied over time. A combination of US Renal Data System variables and Medicare claims was used to ascertain exposure, IV, covariates, and outcomes. Exposures Receipt of nonurgent invasive or noninvasive CHD testing during the 12 months preceding kidney transplant. Main Outcomes and Measures The primary outcome was a composite of death or acute MI within 30 days of after kidney transplant. Results The cohort comprised 79 334 adult, first-time kidney transplant recipients (30 147 women [38%]; 25 387 [21%] Black and 48 394 [61%] White individuals; mean [SD] age of 56 [14] years during 2012 to 2014). The primary outcome occurred in 4604 patients (244 [5.3%]; 120 [2.6%] death, 134 [2.9%] acute MI). During the most recent study period (2012-2014), the CHD testing rate was 56% in patients in the most test-intensive transplant programs (fifth IV quintile) and 24% in patients at the least test-intensive transplant program (first IV quintile, P < .001); this pattern was similar across other study periods. In the main IV analysis, compared with no testing, CHD testing was not associated with a change in the rate of primary outcome (rate difference, 1.9%; 95% CI, 0%-3.5%). The results were similar across study periods, except for 2000 to 2003, during which CHD testing was associated with a higher event rate (rate difference, 6.8%; 95% CI, 1.8%-12.0%). Conclusions and Relevance The results of this cohort study suggest that pretransplant CHD testing was not associated with a reduction in early posttransplant death or acute MI. The study findings potentially challenge the ubiquity of CHD testing before kidney transplant and should be confirmed in interventional studies.
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Affiliation(s)
- Xingxing S. Cheng
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Sai Liu
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Jialin Han
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Margaret R. Stedman
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Michael Baiocchi
- Department of Statistics, Stanford University, Stanford, California
| | - Jane C. Tan
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Glenn M. Chertow
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - William F. Fearon
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
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13
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Cardiologist Evaluation and Approval Was the Primary Predictor of Kidney Transplant Candidacy and Transplantation Among Patients With Reduced Left Ventricular Ejection Fraction. Transplant Direct 2023; 9:e1421. [PMID: 36700060 PMCID: PMC9820781 DOI: 10.1097/txd.0000000000001421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 10/24/2022] [Accepted: 11/01/2022] [Indexed: 01/27/2023] Open
Abstract
End-stage kidney disease patients with concomitant heart failure (HF) with reduced ejection fraction are often denied kidney transplantation. The aims of this study were to explore factors predictive of suitability for kidney transplant and to assess cardiovascular outcomes in patients with impaired left ventricular ejection fraction (LVEF) after transplant. Methods We evaluated 109 consecutive adults with LVEF ≤40% at the time of initial kidney transplant evaluation between 2013 and 2018. Posttransplant cardiovascular outcomes were defined as nonfatal myocardial infarction (MI), admission for HF, cardiovascular death, and all-cause mortality. Results A cardiologist participated in kidney transplant evaluation for 87% of patients and was present at 49% of transplant selection conferences. Twenty-four patients (22%) were denied by a cardiologist for kidney transplant' and 59 (54%) were denied by the selection committee, of whom 43 were because of cardiovascular risk. Forty-two (38%) patients were approved for kidney transplant. On univariate analysis, the variables associated with denial for kidney transplant included cardiologist denial, higher cardiac troponin T, prior coronary intervention, cardiovascular event, positive stress study, lower ejection fraction, and lower VO2 max (all P < 0.05). Cardiologist denial was the most significant predictor of denial for kidney transplant in different multivariate models. At a median follow-up of 15 mo, 5 (5%) suffered nonfatal MI, 13 (12%) were hospitalized for HF exacerbation, and 17 (16%) died. Only 22 patients, 52% of those approved, underwent kidney transplant. After kidney transplant, there was 1 death, 1 nonfatal MI, and 3 hospitalizations for HF. Median LVEF improved from 38% before listing to 55% posttransplant. Conclusions Cardiologist denial was the primary predictor of rejection for kidney transplant. Despite careful selection, prevalence of cardiovascular events and mortality after kidney transplant was 23%. There is need for a structured multidisciplinary approach for patients with impaired LVEF.
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14
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Cheng XS, VanWagner LB, Costa SP, Axelrod DA, Bangalore S, Norman SP, Herzog C, Lentine KL. Emerging Evidence on Coronary Heart Disease Screening in Kidney and Liver Transplantation Candidates: A Scientific Statement From the American Heart Association: Endorsed by the American Society of Transplantation. Circulation 2022; 146:e299-e324. [PMID: 36252095 PMCID: PMC10124159 DOI: 10.1161/cir.0000000000001104] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Coronary heart disease is an important source of mortality and morbidity among kidney transplantation and liver transplantation candidates and recipients and is driven by traditional and nontraditional risk factors related to end-stage organ disease. In this scientific statement, we review evidence from the past decade related to coronary heart disease screening and management for kidney and liver transplantation candidates. Coronary heart disease screening in asymptomatic kidney and liver transplantation candidates has not been demonstrated to improve outcomes but is common in practice. Risk stratification algorithms based on the presence or absence of clinical risk factors and physical performance have been proposed, but a high proportion of candidates still meet criteria for screening tests. We suggest new approaches to pretransplantation evaluation grounded on the presence or absence of known coronary heart disease and cardiac symptoms and emphasize multidisciplinary engagement, including involvement of a dedicated cardiologist. Noninvasive functional screening methods such as stress echocardiography and myocardial perfusion scintigraphy have limited accuracy, and newer noninvasive modalities, especially cardiac computed tomography-based tests, are promising alternatives. Emerging evidence such as results of the 2020 International Study of Comparative Health Effectiveness With Medical and Invasive Approaches-Chronic Kidney Disease trial emphasizes the vital importance of guideline-directed medical therapy in managing diagnosed coronary heart disease and further questions the value of revascularization among asymptomatic kidney transplantation candidates. Optimizing strategies to disseminate and implement best practices for medical management in the broader end-stage organ disease population should be prioritized to improve cardiovascular outcomes in these populations.
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Affiliation(s)
| | | | | | | | | | | | - Charles Herzog
- Hennepin Healthcare/University of Minnesota, Minneapolis, MN
| | - Krista L. Lentine
- Saint Louis University Center for Abdominal Transplantation, St. Louis, MO
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15
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Cardiac Imaging and Management of Cardiac Disease in Asymptomatic Renal Transplant Candidates: A Current Update. Diagnostics (Basel) 2022; 12:diagnostics12102332. [PMID: 36292020 PMCID: PMC9600087 DOI: 10.3390/diagnostics12102332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 09/06/2022] [Accepted: 09/19/2022] [Indexed: 11/30/2022] Open
Abstract
Given the high cardiovascular risk accompanying end-stage kidney disease, it would be of paramount importance for the clinical nephrologist to know which screening method(s) identify high-risk patients and whether screening asymptomatic transplant candidates effectively reduces cardiovascular risk in the perioperative setting as well as in the longer term. Within this review, key studies concerning the above questions are reported and critically analyzed. The lack of unified screening criteria and of a prognostically sufficient screening cardiovascular effect for renal transplant candidates sets the foundation for a personalized patient approach in the near future and highlights the need for well-designed studies to produce robust evidence which will address the above questions.
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16
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Ewing EC, Edwards AR. Cardiovascular Disease Assessment Prior to Kidney Transplantation. Methodist Debakey Cardiovasc J 2022; 18:50-61. [PMID: 36132581 PMCID: PMC9461695 DOI: 10.14797/mdcvj.1117] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 06/20/2022] [Indexed: 11/11/2022] Open
Abstract
Cardiovascular disease is highly prevalent and the leading cause of mortality in patients with chronic kidney disease, end-stage kidney disease, and kidney transplantation. However, kidney transplantation offers improved survival and quality of life, with an overall reduction in cardiovascular disease events; therefore, it remains the optimal treatment choice for those with advanced kidney disease. Pretransplantation cardiovascular assessment is performed prior to wait-listing and at routine intervals with the principal goal of screening for asymptomatic cardiac disease, intervening when necessary to improve long-term patient and allograft survival. Current clinical practice guidelines are based on expert opinion, with a lack of high-quality evidence to guide standardized screening practices. Recent studies support de-escalation in screening with avoidance of preemptive revascularization in asymptomatic patients, but they fail to provide clear guidance on how best to assess the cardiovascular fitness of this high-risk group. Herein we summarize current practice guidelines, discuss key study findings, highlight the role of optimal medical therapy, and evaluate future directions for cardiovascular disease assessment in this population.
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Affiliation(s)
- Elise C Ewing
- Division of Renal Diseases and Hypertension, Houston Methodist Hospital, Houston, Texas, US
| | - Angelina R Edwards
- Division of Renal Diseases and Hypertension, Houston Methodist Hospital, Houston, Texas, US.,Texas A&M College of Medicine, Houston, Texas, US
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17
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Steinmetz T, Perl L, Zvi BR, Atamna M, Kornowski R, Shiyovich A, Hamdan A, Nesher E, Rahamimov R, Gal TB, Skalsky K. The prognostic value of pre-operative coronary evaluation in kidney transplanted patients. Front Cardiovasc Med 2022; 9:974158. [PMID: 35990935 PMCID: PMC9389011 DOI: 10.3389/fcvm.2022.974158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 07/11/2022] [Indexed: 11/25/2022] Open
Abstract
Aims Non-invasive coronary assessment using single-photon emission computerized tomography (SPECT) testing for potential cardiac ischemia is an essential part of the evaluation of kidney transplant candidates. We aimed to examine the prognostic value of preoperative SPECT test results in kidney transplanted patients. Methods and results We retrospectively analyzed the pre-surgical nuclear SPECT test results in a registry of kidney transplanted patients. Follow-up at 1 month and 1 year recorded major adverse cardiac events (MACE) including non-fatal myocardial infarction, all-cause mortality and hospitalization due to cardiovascular disease following the renal transplantation. Of 577 patients available for analysis, 408 (70.9%) patients underwent nuclear SPECT test pre-transplant and 83 (20.3%) had abnormal results with either evidence of ischemia or infarct. A significantly higher incidence of post-operative MACE at 1 month was evident among patients with abnormal SPECT test compared to patients with no evidence of ischemia (10.8 vs. 4.3% respectively; P = 0.019). Differences were mostly derived from significantly increased rates of myocardial infarction events (8.4 vs. 1.8%; P = 0.002). Yet, MACE rate was not statistically different at 1 year (20.5 vs. 13.1%; P = 0.88). Importantly, the prognostic impact of an abnormal SPECT was significantly attenuated for all outcomes following multivariable adjusting for conventional cardiovascular risk factors and coronary revascularization. Conclusion Pre-surgical cardiac risk assessment of kidney transplant candidates with nuclear SPECT test was found to be predictive of post-operative MACE, yet apparently, its prognostic value was significantly attenuated when adjusted for cardiac risk factors.
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Affiliation(s)
- Tali Steinmetz
- Department of Nephrology, Rabin Medical Center, Petach-Tikva, Israel
- Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Leor Perl
- Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Cardiology, Rabin Medical Center, Petach-Tikva, Israel
| | - Benaya Rozen Zvi
- Department of Nephrology, Rabin Medical Center, Petach-Tikva, Israel
- Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mohamad Atamna
- Department of Nephrology, Rabin Medical Center, Petach-Tikva, Israel
- Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ran Kornowski
- Department of Nephrology, Rabin Medical Center, Petach-Tikva, Israel
- Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Arthur Shiyovich
- Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Cardiology, Rabin Medical Center, Petach-Tikva, Israel
| | - Ashraf Hamdan
- Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Cardiology, Rabin Medical Center, Petach-Tikva, Israel
| | - Eviatar Nesher
- Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Transplantation, Rabin Medical Center, Petach-Tikva, Israel
| | - Ruth Rahamimov
- Department of Nephrology, Rabin Medical Center, Petach-Tikva, Israel
- Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tuvia Ben Gal
- Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Cardiology, Rabin Medical Center, Petach-Tikva, Israel
| | - Keren Skalsky
- Affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Cardiology, Rabin Medical Center, Petach-Tikva, Israel
- *Correspondence: Keren Skalsky
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18
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Chaitman BR, Cyr DD, Alexander KP, Pracoń R, Bainey KR, Mathew A, Acharya A, Kunichoff DF, Fleg JL, Lopes RD, Sidhu MS, Anthopolos R, Rockhold FW, Stone GW, Maron DJ, Hochman JS, Bangalore S. Cardiovascular and Renal Implications of Myocardial Infarction in the ISCHEMIA-CKD Trial. Circ Cardiovasc Interv 2022; 15:e012103. [PMID: 35973009 PMCID: PMC10865178 DOI: 10.1161/circinterventions.122.012103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND ISCHEMIA-CKD (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches-Chronic Kidney Disease) reported an initial invasive treatment strategy did not reduce the risk of death or nonfatal myocardial infarction (MI) compared with a conservative treatment strategy in patients with advanced chronic kidney disease, stable coronary disease, and moderate or severe myocardial ischemia. The cumulative frequency of different MI type after randomization and subsequent prognosis have not been reported. METHODS MI classification was based on the Third Universal Definition for MI. For procedural MI, the primary MI definition used creatine kinase-MB as the preferred biomarker, whereas the secondary MI definition used cTn (cardiac troponin); both definitions included elevated biomarker-only events with higher thresholds than nonprocedural MIs. The cumulative frequency of MI type according to treatment strategy was determined. The association of MI with subsequent all-cause death and new dialysis initiation was assessed by treating MI as a time-dependent covariate. RESULTS The 3-year incidence of type 1 or 2 MI with the primary MI definition was 11.2% in invasive treatment strategy and 13.6% in conservative treatment strategy (hazard ratio [HR], 0.66 [95% CI, 0.42-1.02]). Procedural MIs were more frequent in invasive treatment strategy and accounted for 9.8% and 28.3% of all MIs with the primary and secondary MI definitions, respectively. Patients had an increased risk of all-cause death after type 1 MI (adjusted HR, 4.35 [95% CI, 2.73-6.93]) and after procedural MI with the primary (adjusted HR, 2.75 [95% CI, 0.99-7.60]) and secondary MI definitions (adjusted HR, 2.91 [95% CI, 1.73-4.88]). Dialysis initiation was increased after a type 1 MI (HR, 6.45 [95% CI, 2.59-16.08]) compared with patients without an MI. CONCLUSIONS In ISCHEMIA-CKD, the invasive treatment strategy had higher rates of procedural MIs, particularly with the secondary MI definition, and lower rates of type 1 and 2 MIs. Procedural MIs, type 1 MIs, and type 2 MIs were associated with increased risk of subsequent death. Type 1 MI increased the risk of dialysis initiation. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01985360.
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Affiliation(s)
| | - Derek D. Cyr
- Duke Clinical Research Institute and Duke University, Durham, NC, USA
| | | | - Radosław Pracoń
- Coronary and Structural Heart Diseases Department, Institute of Cardiology, Mazowieckie, Poland
| | - Kevin R. Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
| | - Anoop Mathew
- MOSC Medical College Hospital, Kolenchery, India
| | | | | | - Jerome L. Fleg
- National National Heart Lung and Blood Institute, Bethesda, MD, USA
| | - Renato D. Lopes
- Duke Clinical Research Institute and Duke University, Durham, NC, USA
| | | | | | - Frank W. Rockhold
- Duke Clinical Research Institute and Duke University, Durham, NC, USA
| | - Gregg W. Stone
- Icahn School of Medicine at Mount Sinai, New York, NY, USA and the Cardiovascular Research Foundation, New York, NY, USA
| | - David J. Maron
- Stanford University School of Medicine, Stanford, CA, USA
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19
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Tan S, Thang YW, Mulley WR, Polkinghorne KR, Ramkumar S, Cheng K, Chan J, Galligan J, Nolan M, Brown AJ, Moir S, Cameron JD, Nicholls SJ, Mottram PM, Nerlekar N. Prognostic Value of Exercise Capacity in Kidney Transplant Candidates. J Am Heart Assoc 2022; 11:e025862. [PMID: 35699178 PMCID: PMC9238638 DOI: 10.1161/jaha.121.025862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Exercise stress testing for cardiovascular assessment in kidney transplant candidates has been shown to be a feasible alternative to pharmacologic methods. Exercise stress testing allows the additional assessment of exercise capacity, which may have prognostic value for long-term cardiovascular outcomes in pre-transplant recipients. This study aimed to evaluate the prognostic value of exercise capacity on long-term cardiovascular outcomes in kidney transplant candidates. Methods and Results We retrospectively evaluated exercise capacity in 898 consecutive kidney transplant candidates between 2013 and 2020 who underwent symptom-limited exercise stress echocardiography for pre-transplant cardiovascular assessment. Exercise capacity was measured by age- and sex-predicted metabolic equivalents (METs). The primary outcome was incident major adverse cardiovascular events, defined as cardiac death, non-fatal myocardial infarction, and stroke. Cox proportional hazard multivariable modeling was performed to define major adverse cardiovascular events predictors with transplantation treated as a time-varying covariate. A total of 429 patients (48%) achieved predicted METs. During follow-up, 93 (10%) developed major adverse cardiovascular events and 525 (58%) underwent transplantation. Achievement of predicted METs was independently associated with reduced major adverse cardiovascular events (hazard ratio [HR] 0.49; [95% CI 0.29-0.82], P=0.007), as was transplantation (HR, 0.52; [95% CI 0.30-0.91], P=0.02). Patients achieving predicted METs on pre-transplant exercise stress echocardiography had favorable outcomes that were independent (HR, 0.78; [95% CI 0.32-1.92], P=0.59) and of similar magnitude to subsequent transplantation (HR, 0.97; [95% CI 0.42-2.25], P=0.95). Conclusions Achievement of predicted METs on pre-transplant exercise stress echocardiography confers excellent prognosis independent of and of similar magnitude to subsequent kidney transplantation. Future studies should assess the benefit on exercise training in this population.
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Affiliation(s)
- Sean Tan
- Monash Cardiovascular Research Centre, Victorian Heart Institute Monash University Melbourne Victoria Australia.,Monash Heart Monash Health Melbourne Victoria Australia
| | - Yi Wen Thang
- Department of Nephrology Monash Health Melbourne Victoria Australia
| | - William R Mulley
- Department of Nephrology Monash Health Melbourne Victoria Australia.,Department of Medicine Monash University Melbourne Victoria Australia
| | - Kevan R Polkinghorne
- Department of Nephrology Monash Health Melbourne Victoria Australia.,Department of Medicine Monash University Melbourne Victoria Australia
| | - Satish Ramkumar
- Monash Cardiovascular Research Centre, Victorian Heart Institute Monash University Melbourne Victoria Australia.,Monash Heart Monash Health Melbourne Victoria Australia
| | - Kevin Cheng
- Monash Cardiovascular Research Centre, Victorian Heart Institute Monash University Melbourne Victoria Australia.,Monash Heart Monash Health Melbourne Victoria Australia
| | - Jasmine Chan
- Monash Cardiovascular Research Centre, Victorian Heart Institute Monash University Melbourne Victoria Australia.,Monash Heart Monash Health Melbourne Victoria Australia
| | - John Galligan
- Monash Cardiovascular Research Centre, Victorian Heart Institute Monash University Melbourne Victoria Australia.,Monash Heart Monash Health Melbourne Victoria Australia
| | - Mark Nolan
- Baker Heart and Diabetes Institute Melbourne Victoria Australia
| | - Adam J Brown
- Monash Cardiovascular Research Centre, Victorian Heart Institute Monash University Melbourne Victoria Australia.,Monash Heart Monash Health Melbourne Victoria Australia
| | - Stuart Moir
- Monash Cardiovascular Research Centre, Victorian Heart Institute Monash University Melbourne Victoria Australia.,Monash Heart Monash Health Melbourne Victoria Australia
| | - James D Cameron
- Monash Cardiovascular Research Centre, Victorian Heart Institute Monash University Melbourne Victoria Australia
| | - Stephen J Nicholls
- Monash Cardiovascular Research Centre, Victorian Heart Institute Monash University Melbourne Victoria Australia.,Monash Heart Monash Health Melbourne Victoria Australia
| | - Philip M Mottram
- Monash Cardiovascular Research Centre, Victorian Heart Institute Monash University Melbourne Victoria Australia.,Monash Heart Monash Health Melbourne Victoria Australia
| | - Nitesh Nerlekar
- Monash Cardiovascular Research Centre, Victorian Heart Institute Monash University Melbourne Victoria Australia.,Monash Heart Monash Health Melbourne Victoria Australia.,Baker Heart and Diabetes Institute Melbourne Victoria Australia
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20
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Anderson B, Qasim M, Evison F, Gallier S, Townend JN, Ferro CJ, Sharif A. A population cohort analysis of English transplant centers indicates major adverse cardiovascular events after kidney transplantation. Kidney Int 2022; 102:876-884. [PMID: 35716956 DOI: 10.1016/j.kint.2022.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 04/27/2022] [Accepted: 05/09/2022] [Indexed: 11/16/2022]
Abstract
Major adverse cardiovascular event (MACE) rates immediately after kidney transplantation remain uncertain due to heterogeneous reporting in the literature. To clarify this, we retrospectively studied every eligible kidney transplant procedure performed in England between April 1, 2002 and March 31. 2018 with follow-up through August 31, 2019. The primary outcome of interest was MACE broadly defined as any hospital admission with myocardial infarction, stroke, unstable angina, heart failure, any coronary revascularisation procedure and/or any cardiovascular death. Among 30,325 kidney transplant recipients, MACE occurred in 781 within the first year after transplantation (2.6% of all kidney transplant procedures). Of these 781 events, 201 occurred during the index admission for kidney transplantation surgery representing 25.7% of all first-year MACE and 0.7% of all kidney transplant procedures. Kidney transplant recipients who suffered a non-fatal MACE within the first year had significantly decreased 1-, 3-, 5- and 10-year patient survival of 80.5%, 70.2%, 59.5% and 38.6% respectively, compared to 97.4%, 94.4%, 90.7% and 78.4% for kidney transplant recipients not developing MACE.. In an adjusted Cox proportional hazard model, non-fatal MACE within the first-year post-transplant was associated with significant long-term mortality risk (hazard ratio 2.59; 95% confidence interval 2.34-2.88). Kidney transplant recipients experiencing MACE during the index admission compared to subsequent admissions were differentiated by age, sex and previous cardiac history but had similar patient survival. These rates are significantly lower than those reported in North America. Thus, our data confirms MACE is not a benign post-transplant event and has a strong association with long-term mortality risk.
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Affiliation(s)
- Benjamin Anderson
- Department of Nephrology and Transplantation, Queen Elizabeth Hospital, Birmingham, UK
| | - Muhammad Qasim
- Department of Nephrology and Transplantation, Queen Elizabeth Hospital, Birmingham, UK
| | - Felicity Evison
- Department of Health Informatics, Queen Elizabeth Hospital, Birmingham, UK
| | - Suzy Gallier
- Department of Health Informatics, Queen Elizabeth Hospital, Birmingham, UK
| | - Jonathan N Townend
- Department of Cardiology, University Hospitals Birmingham, UK; Institute of Cardiovascular Sciences, University of Birmingham, UK
| | - Charles J Ferro
- Department of Nephrology and Transplantation, Queen Elizabeth Hospital, Birmingham, UK; Institute of Cardiovascular Sciences, University of Birmingham, UK
| | - Adnan Sharif
- Department of Nephrology and Transplantation, Queen Elizabeth Hospital, Birmingham, UK; Institute of Immunology and Immunotherapy, University of Birmingham, UK.
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21
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St Jules R, Blech D, Smith NK, Sakai T. Abdominal Organ Transplantation: Noteworthy Literature in 2021. Semin Cardiothorac Vasc Anesth 2022; 26:140-153. [PMID: 35608409 DOI: 10.1177/10892532221093955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This review highlights noteworthy literature pertinent to anesthesiologists and critical care physicians caring for patients undergoing abdominal organ transplantation. In 2021, we identified noteworthy papers from over 1,200 peer-reviewed publications on pancreatic transplantation, over 1,400 on intestinal transplantation, and over 9,000 on kidney transplantation. The liver transplantation section focuses on clinical trials and systematic reviews and meta-analyses published in 2021 and features 20 selected papers. COVID-19 and abdominal organ transplantation are featured in an independent section.
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Affiliation(s)
- Robert St Jules
- Department of Anesthesiology, Perioperative and Pain Medicine, The Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Daniel Blech
- Department of Anesthesiology, Perioperative and Pain Medicine, The Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Natalie K Smith
- Department of Anesthesiology, Perioperative and Pain Medicine, The Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Tetsuro Sakai
- Department of Anesthesiology and Perioperative Medicine, UPMC (University of Pittsburgh Medical Center), Pittsburgh, PA, USA
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22
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Costa SP, Lentine KL. Silent myocardial infarction on preoperative electrocardiogram for kidney transplant patients: Impact on clinical outcomes may not be silent. Am J Transplant 2022; 22:1009-1011. [PMID: 35092141 PMCID: PMC9275814 DOI: 10.1111/ajt.16973] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 01/21/2022] [Accepted: 01/21/2022] [Indexed: 01/25/2023]
Affiliation(s)
| | - Krista L. Lentine
- Saint Louis University Center for Abdominal Transplantation, St. Louis, MO
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23
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Ramos GK, Charytan DM. Screening for Cardiovascular Disease in CKD: CON. KIDNEY360 2022; 3:1836-1838. [PMID: 36514402 PMCID: PMC9717625 DOI: 10.34067/kid.0004742021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 11/15/2021] [Indexed: 01/12/2023]
Affiliation(s)
- Giana K. Ramos
- Nephrology Division, New York University Grossman School of Medicine, New York, New York
| | - David M Charytan
- Nephrology Division, New York University Grossman School of Medicine, New York, New York
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24
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Skalsky K, Shiyovich A, Steinmetz T, Kornowski R. Chronic Renal Failure and Cardiovascular Disease: A Comprehensive Appraisal. J Clin Med 2022; 11:jcm11051335. [PMID: 35268426 PMCID: PMC8911484 DOI: 10.3390/jcm11051335] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 02/23/2022] [Accepted: 02/24/2022] [Indexed: 02/01/2023] Open
Abstract
Coronary artery disease is highly prevalent in patients with chronic kidney disease. The concomitant renal disease often poses a major challenge in decision making as symptoms, cardiac biomarkers and noninvasive studies for evaluation of myocardial ischemia have different sensitivity and specificity thresholds in this specific population. Moreover, the effectiveness and safety of intervention and medical treatment in those patients is of great doubt as most clinical studies exclude patients with advance CKD. In the present paper, we discuss and review the literature in the diagnosis, treatment and prevention of CAD in the acute and chronic setting, in patients with CKD.
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Affiliation(s)
- Keren Skalsky
- Department of Cardiology, Rabin Medical Center, Petah Tikva 4941492, Israel; (A.S.); (R.K.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel;
- Correspondence: or ; Tel.: +972-39372251; Fax: +972-39372460
| | - Arthur Shiyovich
- Department of Cardiology, Rabin Medical Center, Petah Tikva 4941492, Israel; (A.S.); (R.K.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel;
| | - Tali Steinmetz
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel;
- Department of Nephrology, Rabin Medical Center, Petah Tikva 4941492, Israel
| | - Ran Kornowski
- Department of Cardiology, Rabin Medical Center, Petah Tikva 4941492, Israel; (A.S.); (R.K.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel;
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25
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Siddiqui MU, Junarta J, Marhefka GD. Coronary Revascularization Versus Optimal Medical Therapy in Renal Transplant Candidates With Coronary Artery Disease: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2022; 11:e023548. [PMID: 35132876 PMCID: PMC9245820 DOI: 10.1161/jaha.121.023548] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Background Coronary artery disease (CAD) is highly prevalent in patients with chronic kidney disease and is a common cause of mortality in end‐stage renal disease. Thus, patients with end‐stage renal disease are routinely screened for CAD before renal transplantation. The usefulness of revascularization before transplantation remains unclear. We hypothesize that there is no difference in all‐cause and cardiovascular mortality in waitlisted renal transplant candidates with CAD who underwent revascularization versus those treated with optimal medical therapy before transplantation. Methods and Results This meta‐analysis was reported according to the Preferred Reporting Items for Systematic Review and Meta‐Analyses guidelines. MEDLINE, Scopus, and Cochrane Central Register of Controlled Trials were systematically searched to identify relevant studies. Risk of bias was assessed using the modified Newcastle‐Ottawa Scale and Cochrane risk of bias tool. The primary outcome of interest was all‐cause mortality. Eight studies comprising 945 patients were included (36% women, mean age 56 years). There was no difference in all‐cause mortality (risk ratio [RR], 1.16 [95% CI, 0.63–2.12), cardiovascular mortality (RR, 0.75 [95% CI, 0.29–1.89]), or major adverse cardiovascular events (RR, 0.78 [95% CI, 0.30–2.07]) when comparing renal transplant candidates with CAD who underwent revascularization versus those who were on optimal medical therapy before renal transplant. Conclusions This meta‐analysis demonstrates that revascularization is not superior to optimal medical therapy in reducing all‐cause mortality, cardiovascular mortality, or major adverse cardiovascular events in waitlisted kidney transplant candidates with CAD who eventually underwent kidney transplantation.
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Affiliation(s)
- Muhammad U Siddiqui
- Department of Medicine Thomas Jefferson University Hospitals Philadelphia PA
| | - Joey Junarta
- Department of Medicine Thomas Jefferson University Hospitals Philadelphia PA
| | - Gregary D Marhefka
- Jefferson Heart Institute Thomas Jefferson University Hospitals Philadelphia PA
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Truby LK, Mentz RJ, Agarwal R. Cardiovascular risk stratification in the noncardiac solid organ transplant candidate. Curr Opin Organ Transplant 2022; 27:22-28. [PMID: 34939961 PMCID: PMC9946722 DOI: 10.1097/mot.0000000000000942] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Solid organ transplantation (SOT) has become a widely accepted therapy for end-stage disease across the spectrum of thoracic and abdominal organs. With contemporary advances in medical and surgical therapies in transplantation, candidates for SOT are increasingly older with a larger burden of comorbidities, including cardiovascular disease (CVD). CVD, in particular, is a leading cause of morbidity and mortality in SOT candidates with end-stage disease of noncardiac organs [1]. RECENT FINDINGS Identification of coronary artery disease (CAD), heart failure, and valvular disease are important in noncardiac SOT to ensure both appropriate peri-transplant management and equitable organ allocation. Although the American College of Cardiology (ACC) and the American Heart Association (AHA) have published guidelines and recommendations for the perioperative cardiovascular evaluation of patients undergoing noncardiac surgery, the implications of both symptomatic and asymptomatic CVD differ in patients with end-stage organ failure being considered for SOT when compared to the general population. SUMMARY Herein, we review the epidemiology, diagnosis, and evidence for the management of CVD in kidney and liver transplantation, combining current guidelines from the 2012 ACC/AHA scientific statement on cardiac disease evaluation in SOT with more contemporary evidenced-based algorithms.
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Affiliation(s)
- Lauren K. Truby
- Division of Cardiology, Department of Medicine, Durham, North Carolina, USA
- Duke Molecular Physiology Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Robert J. Mentz
- Division of Cardiology, Department of Medicine, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Richa Agarwal
- Division of Cardiology, Department of Medicine, Durham, North Carolina, USA
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Shroff GR, Carlson MD, Mathew RO. Coronary Artery Disease in Chronic Kidney Disease: Need for a Heart-Kidney Team-Based Approach. Eur Cardiol 2021; 16:e48. [PMID: 34950244 PMCID: PMC8674634 DOI: 10.15420/ecr.2021.30] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 10/19/2021] [Indexed: 01/10/2023] Open
Abstract
Chronic kidney disease and coronary artery disease are co-prevalent conditions with unique epidemiological and pathophysiological features, that culminate in high rates of major adverse cardiovascular outcomes, including all-cause mortality. This review outlines a summary of the literature, and nuances pertaining to non-invasive risk assessment of this population, medical management options for coronary heart disease and coronary revascularisation. A collaborative heart-kidney team-based approach is imperative for critical management decisions for this patient population, especially coronary revascularisation; this review outlines specific periprocedural considerations pertaining to coronary revascularisation, and provides a proposed algorithm for approaching revascularisation choices in patients with end-stage kidney disease based on available literature.
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Affiliation(s)
- Gautam R Shroff
- Division of Cardiology, Department of Medicine, Hennepin Healthcare & University of Minnesota Medical School Minneapolis, MN, US
| | - Michelle D Carlson
- Division of Cardiology, Department of Medicine, Hennepin Healthcare & University of Minnesota Medical School Minneapolis, MN, US
| | - Roy O Mathew
- Division of Nephrology, Department of Medicine, Columbia VA Health Care System Columbia, SC, US
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Anderson K, Bavishi C, Kolte D, Gohh R, Arrighi JA, Stockwell P, Abbott JD. Relation of abnormal cardiac stress testing with outcomes in patients undergoing renal transplantation. PLoS One 2021; 16:e0260718. [PMID: 34855868 PMCID: PMC8638939 DOI: 10.1371/journal.pone.0260718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 11/15/2021] [Indexed: 11/18/2022] Open
Abstract
Cardiovascular risk stratification is often performed in patients considered for renal transplantation. In a single center, we sought to examine the association between abnormal stress testing with imaging and post-renal transplant major adverse cardiovascular events (MACE) using multivariable logistic regression. From January 2006 to May 2016 232 patients underwent renal transplantation and 59 (25%) had an abnormal stress test result. Compared to patients with a normal stress test, patients with an abnormal stress test had a higher prevalence of dyslipidemia, diabetes mellitus, obesity, coronary artery disease (CAD), and heart failure. Among those with an abnormal result, 45 (76%) had mild, 10 (17%) moderate, and 4 (7%) severe ischemia. In our cohort, 9 patients (3.9%) had MACE at 30-days post-transplant, 5 of whom had an abnormal stress test. The long-term MACE rate, at a median of 5 years, was 32%. After adjustment, diabetes (OR 2.37, 95% CI 1.12-5.00, p = 0.02), CAD (OR: 3.05, 95% CI 1.30-7.14, p = 0.01) and atrial fibrillation (OR: 5.86, 95% CI 1.86-18.44, p = 0.002) were independently associated with long-term MACE, but an abnormal stress test was not (OR: 0.83, 95% CI 0.37-1.92, p = 0.68). In conclusion, cardiac stress testing was not an independent predictor of long-term MACE among patients undergoing renal transplant.
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Affiliation(s)
- Kelsey Anderson
- Warren Alpert Medical School, Brown University, Providence, RI, United States of America
| | - Chirag Bavishi
- Cardiovascular Institute, The Warren Alpert Medical School at Brown University, Providence, RI, United States of America
| | - Dhaval Kolte
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Reginald Gohh
- Renal Division, Dept of Internal Medicine, Warren Alpert Medical School at Brown University, Providence, RI, United States of America
| | - James A. Arrighi
- Cardiovascular Institute, The Warren Alpert Medical School at Brown University, Providence, RI, United States of America
| | - Philip Stockwell
- Cardiovascular Institute, The Warren Alpert Medical School at Brown University, Providence, RI, United States of America
| | - J. Dawn Abbott
- Cardiovascular Institute, The Warren Alpert Medical School at Brown University, Providence, RI, United States of America
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Ferro CJ, Berry M, Moody WE, George S, Sharif A, Townend JN. Screening for occult coronary artery disease in potential kidney transplant recipients: time for reappraisal? Clin Kidney J 2021; 14:2472-2482. [PMID: 34950460 PMCID: PMC8690093 DOI: 10.1093/ckj/sfab103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 06/03/2021] [Indexed: 11/14/2022] Open
Abstract
Screening for occult coronary artery disease in potential kidney transplant recipients has become entrenched in current medical practice as the standard of care and is supported by national and international clinical guidelines. However, there is increasing and robust evidence that such an approach is out-dated, scientifically and conceptually flawed, ineffective, potentially directly harmful, discriminates against ethnic minorities and patients from more deprived socioeconomic backgrounds, and unfairly denies many patients access to potentially lifesaving and life-enhancing transplantation. Herein we review the available evidence in the light of recently published randomized controlled trials and major observational studies. We propose ways of moving the field forward to the overall benefit of patients with advanced kidney disease.
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Affiliation(s)
- Charles J Ferro
- Department of Renal Medicine, University Hospitals Birmingham, Birmingham, UK
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Miriam Berry
- Department of Renal Medicine, University Hospitals Birmingham, Birmingham, UK
| | - William E Moody
- Department of Cardiology, University Hospitals Birmingham, Birmingham, UK
| | - Sudhakar George
- Department of Cardiology, University Hospitals Birmingham, Birmingham, UK
| | - Adnan Sharif
- Department of Renal Medicine, University Hospitals Birmingham, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Jonathan N Townend
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Department of Cardiology, University Hospitals Birmingham, Birmingham, UK
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30
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Treating Myocardial Ischemia Before Kidney Transplantation: Time for a Reappraisal. J Am Coll Cardiol 2021; 78:362-364. [PMID: 34294271 DOI: 10.1016/j.jacc.2021.05.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 05/14/2021] [Accepted: 05/17/2021] [Indexed: 01/09/2023]
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