Cardiac risk assessment for end-stage renal disease patients on the renal transplant waiting list

Abstract

Cardiovascular disease is a leading cause of morbidity and mortality and is becoming more prevalent as the population ages and risk factors increase. This is most apparent in the end-stage renal disease (ESRD) patient population. In part, this is due to cofactors such as diabetes and hypertension commonly predisposing to progressive renal disease, as well as being a direct consequence of having renal failure. Of all major organ failures, kidney failure is the most likely to be managed chronically using renal replacement therapy and, ultimately, transplant. However, lack of transplant organs and a large renal failure cohort means waiting lists are often quite long and may extend to 5–10 years. Due to the cardiac risk factors inherent in patients awaiting transplant, many succumb to cardiac issues while waiting and present an increased per-procedural cardiac risk that extends into the post-transplant period. We aim to review the epidemiology of coronary artery disease in this population and the etiology as it relates to ESRD and its associated co-factors. We also will review the current approaches, recommendations and evidence for management of these patients as it relates to transplant waiting lists before and after the surgery. Recommendations on how to best manage patients in this cohort revolve around the available evidence and are best customized to the institution and the structure of the program. It is not clear whether the revascularization of patients without symptoms and with a good functional status yields any improvement in outcomes. Therefore, each individual case should be considered based on the risk factors, symptoms and functional status, and approached as part of a multi-disciplinary assessment program.

A propensity score–matched analysis indicates screening for asymptomatic coronary artery disease does not predict cardiac events in kidney transplant recipients

“…To assess differences in transplant-specific cardiovascular risk factors in the propensity groups, (26) 283 (23) 196 (16) 156 (12) 150 12) 55 (4) 76 (6) 6 (1286 (22) 259 (20) 229 (17) 151 (12) 118 (9) 159 (12) 84 6) 22 (2<0.001…”

“…It is unclear if abnormal stress-tests in asymptomatic transplant candidates predict cardiovascular outcomes, 2,8 and although patients with occult CAD have a higher rate of post-transplant cardiac events 9 there is no clear evidence that revascularisation in asymptomatic individuals reduces myocardial infarction and death. 2,10,11,12 Additionally, the cardiac outcomes of individuals excluded from transplantation based on abnormal screening tests are unknown, as is whether any individuals are unnecessarily deprived of this superior treatment option.…”

“…14,15 Patients may be selected based on perceived or calculated risk, or screened universally. 16,17 invasive coronary angiograms, 9,12 used according to local availability.…”

The assessment of coronary artery disease in patients with end-stage renal disease

“…Investigations for CAD can broadly be classified as invasive and non-invasive, with the latter commonly used first. There is significant controversy regarding the most appropriate screening modality for CAD in patients with ESRD [14, 18], resulting in centres using a variety of different protocols. This uncertainty partly stems from the exclusion or under-representation of patients with ESRD in most cardiovascular clinical trials, posing a major limitation to the applicability of their results to this patient group.…”

Diabetic kidney disease and transplantation options

“…stress testing, might be warranted on an individual basis. Coronary angiogram and subsequent revascularisation, where there is no clear evidence of benefit, have been a contentious issue in the past 33 . In the current era, most centres would not advocate undertaking routine angiography.…”