Coronary Artery Disease Screening of Asymptomatic Kidney Transplant Candidates: A Web-Based Survey of Practice Patterns in the United States

Cheng, Xingxing S.; Mathew, Roy; Parasuraman, Ravi; Tantisattamo, Ekamol; Levea, Swee Ling; Kapoor, Rajan; Dadhania, Darshana; Rangaswami, Janani

doi:10.1016/j.xkme.2020.04.006

Cited by 18 publications

(36 citation statements)

References 9 publications

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“…Medical treatment in that study consisted of only aspirin and calcium channel blocker, and its extraordinarily high event rate has not been replicated elsewhere. In a recent web-based survey of US kidney transplant programs, a full 26% reported using the coronary angiogram as first-line in dialysis-dependent kidney transplant candidates [4]. Our center practice, although aggressive, therefore accorded with a sizable minority of US transplant programs.…”

Section: Discussionmentioning

confidence: 99%

“…Whether 6MWT-based risk stratification will be similarly limited if applied early in the transplant evaluation process, before the patients have accrued comorbidities that place them at risk for waitlist removal and complicate the interpretation of 6MWT, is an open question. Our center’s protocol favors upfront use of invasive coronary angiography rather than noninvasive testing, in contrast with most other kidney transplant programs [4], and hence our rate of revascularization in asymptomatic patients will likely be higher than at other centers, inflating our CAD-related event rate.…”

Section: Discussionmentioning

confidence: 99%

“…We defined self-reported cardiac symptoms as chest pain, dyspnea, or unexplained upper gastrointestinal symptom, elicited through history and review of systems. Of the risk factor guidelines, we chose the 2012 American Heart Association/American College of Cardiology Foundation Scientific Statement endorsed by the American Society of Transplantation (hereafter referred to as “AHA/ACCF criteria”) [6], reported to be the most commonly used in a recent survey of kidney transplant professionals in the United States [4].…”

Section: Methodsmentioning

confidence: 99%

“…Recent advances have questioned the utility of CAD screening, especially as revascularization of stable, asymptomatic CAD lesions has not been shown to improve outcomes in multiple patient populations [2, 3]. However, in practice, pretransplant screening remains ubiquitous [4]. A rational first step may be thus to reduce the number of patients screened, starting with risk stratification that appropriately focuses testing on a subset of high-risk patients while shielding low-risk patients from unnecessary testing.…”

Section: Introductionmentioning

confidence: 99%

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Performance versus Risk Factor-Based Approaches to Coronary Artery Disease Screening in Waitlisted Kidney Transplant Candidates

et al. 2021

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Introduction: Current screening algorithms for coronary artery disease (CAD) before kidney transplantation result in many tests but few interventions. Objective: The aim of this study was to study the utility of 6-minute walk test (6MWT), an office-based test of cardiorespiratory fitness, for risk stratification in this setting. Methods: We enrolled 360 patients who are near the top of the kidney transplant waitlist at our institution. All patients underwent CAD evaluation irrespective of 6MWT results. We examined the association between 6MWT and time to CAD-related events (defined as cardiac death, revascularization, nonfatal myocardial infarction, and removal from the waitlist for CAD), treating noncardiac death and waitlist removal for non-CAD reasons as competing events. Results: The 6MWT-based approach designated approximately 45% of patients as “low risk,” whereas a risk factor- or symptom-based approach designated 14 and 81% of patients as “low risk,” respectively. The 6MWT-based approach was not significantly associated with CAD-related events within 1 year (subproportional hazard ratio [sHR] 1.00 [0.90–1.11] per 50 m) but was significantly associated with competing events (sHR 0.70 [0.66–0.75] per 50 m). In a companion analysis, removing waitlist status from consideration, 6MWT result was associated with the development of CAD-related events (sHR 0.92 [0.84–1.00] per 50 m). Conclusions: The 6MWT designates fewer patients as high risk and in need of further testing (compared to risk factor-based approaches), but its utility as a pure CAD risk stratification tool is modulated by the background waitlist removal rate. CAD screening before kidney transplant should be tailored according to a patient’s actual chance of receiving a transplant.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Performance versus Risk Factor-Based Approaches to Coronary Artery Disease Screening in Waitlisted Kidney Transplant Candidates

et al. 2021

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“…Our survey highlights variation in screening practice across the United Kingdom ( Figure 1 ). Similar heterogenous practice has been shown in the United States [ 4 ], although our survey was undertaken following publication of ISCHEMIA-CKD [ 5 ]. Whilst no centres perform universal screening and many have recently updated their protocols, which may represent a trend away from routine screening, responses highlight nephrologists’ concerns over the evidence upon which practice is based.…”

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confidence: 99%

Pre-Kidney Transplant Screening for Coronary Artery Disease: Current Practice in the United Kingdom

et al. 2022

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Dear Editors,Randomised control trial (RCT) evidence is not available to guide screening for asymptomatic coronary artery disease before kidney transplantation [1]. United Kingdom observational data show no clear benefit from screening [2]. To gain data representative of current practice in the United Kingdom, we invited a lead transplant nephrologist from each kidney transplant centre to complete a survey examining cardiac screening practice, work-up pathways, and appetite for a national RCT in June 2021. Ethical approval was not required.Responses were received from all 23 (100%) centres, of which 22 had a protocol for cardiac assessment prior to listing. In three centres, asymptomatic individuals were not required to undergo cardiac investigation beyond an ECG or echocardiogram prior to transplantation. The remainder followed a risk-stratified approach; no centres performed universal screening.In centres adopting risk-stratified screening, factors used to screen patients included a history of ischaemic heart disease (100% of centres), diabetes (100%), peripheral vascular disease (50%), smoking (50%), stroke (35%), limited exercise capacity (35%), hyper/hypotension (15%), or an abnormal echocardiogram (95%) or ECG (70%). Two centres stratified using the Newcastle Risk Index [3]. Thirteen centres had a specific age threshold (mostly 50 or 60 years), whilst others included age in combination with additional risk factors or Newcastle Risk Index scores.The most frequent screening investigation was a myocardial perfusion scan (55%) followed by stress echocardiogram (20%). Coronary angiography and cardiopulmonary exercise testing were the initial investigation in one centre each. Other indications for coronary angiography included an abnormal initial screening test (39%) or on cardiology advice (35%). In one third of centres, the waiting time for investigations was over 10 weeks.Nine centres had cardio-renal multidisciplinary meetings, whilst 14 had a designated cardiologist providing transplant candidate assessments. In 16 centres cardiology review was only needed for patients with abnormal screening tests, whilst in three cardiologists reviewed all screened patients.Of 23 centres, 10 had updated their screening protocol within the past 2 years and three were in the process of an update. Whilst 19 centres reported experience of patient declines from listing based on an abnormal screening test, this amounted to one patient per month or less in 11 centres.Respondents commented on the challenges of outdated evidence, reliance on observational data, and differences between real-world cohorts and RCT study populations when assessing the evidence for cardiac screening. The importance of cardio-renal meetings was noted in units not adopting

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Association of Pretransplant Coronary Heart Disease Testing With Early Kidney Transplant Outcomes

et al. 2023

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ImportanceTesting 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.ObjectiveTo estimate the association of pretransplant CHD testing with rates of death and myocardial infarction (MI).Design, Setting, and ParticipantsThis 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.ExposuresReceipt of nonurgent invasive or noninvasive CHD testing during the 12 months preceding kidney transplant.Main Outcomes and MeasuresThe primary outcome was a composite of death or acute MI within 30 days of after kidney transplant.ResultsThe 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 &lt; .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 RelevanceThe 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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Coronary Artery Disease Screening of Asymptomatic Kidney Transplant Candidates: A Web-Based Survey of Practice Patterns in the United States

Cited by 18 publications

References 9 publications

Performance versus Risk Factor-Based Approaches to Coronary Artery Disease Screening in Waitlisted Kidney Transplant Candidates

Performance versus Risk Factor-Based Approaches to Coronary Artery Disease Screening in Waitlisted Kidney Transplant Candidates

Pre-Kidney Transplant Screening for Coronary Artery Disease: Current Practice in the United Kingdom

Association of Pretransplant Coronary Heart Disease Testing With Early Kidney Transplant Outcomes

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