Non-invasive cardiac stress studies may not offer significant benefit in pre-kidney transplant evaluation: A retrospective cohort study

Kanigicherla, Durga; Bhogal, Talvinder; Stocking, Katie; Chinnadurai, Rajkumar; Gray, Simon; Javed, Saad; Fortune, Christien; Augustine, Titus; Kalra, Philip A.

doi:10.1371/journal.pone.0240912

Cited by 9 publications

(12 citation statements)

References 35 publications

(40 reference statements)

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“… 33 Cardiac testing‚ while perhaps important for risk stratification‚ may not lead to therapeutic interventions that enhance survival and has been shown to delay the transplant evaluation process. 34 Simultaneously, there is growing appreciation for the value of functional or frailty assessments during candidate selection as important prognosticators of transplant and waitlist outcomes. Serially measuring BNP at the time of transplant re-evaluation may augment the cardiac re-evaluation process in transplant.…”

Section: Discussionmentioning

confidence: 99%

Walking Ability and Brain Natriuretic Peptide Are Highly Predictive of Kidney Transplant Waiting List Removal

Katz

Eyck

Binns

et al. 2023

Transplantation Direct

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K idney transplant waiting times are long, exceeding 5 y in many programs. 1 US programs have on average over 400 waitlisted patients and 9% of programs manage over 1000 listed patients. 2 Simultaneously, as outcomes have improved, transplant selection has been expanded to include older and more medically complex patients. 1 Also, attrition among chronic renal failure patients is inherently high. 3 For these reasons, ensuring patients' continued suitability for transplant is challenging and programs expend considerable effort on waitlist management.Frailty and functional metrics are associated with pretransplant and posttransplant outcomes including waiting list and Kidney TransplantationBackground: Kidney transplant waitlist management is complex because waiting time is long, and the patients have significant comorbidities. Identification of patients at highest risk for waiting list removal for death and medical complications could allow better outcomes and allocation of resources. Methods: Demographics, functional and frailty assessment‚ and biochemical data were retrospectively analyzed on 313 consecutive patients listed for kidney transplant. Troponin, brain natriuretic peptide, components of the Fried frailty metrics, pedometer activity, and treadmill ability were measured at the time of transplant evaluation and at subsequent re-evaluations. Cox proportional hazards models were used to identify factors associated with death or waiting list removal for medical reasons. Multivariate models were created to identify significant predictor sets. Results: Among 249 patients removed while waitlisted, 19 (6.1%) died and 51 (16.3%) were removed for medical reasons. Mean follow-up duration was 2.3 y (±1.5 y). 417 sets of measurements were collected. Significant (P < 0.05) non-time-dependent variables associated with the composite outcome identified on univariate analysis included N-terminal probrain natriuretic peptide (BNP), treadmill ability, pedometer activity, diagnosis of diabetes and the Center of Epidemiological Studies Depression Scale question asking how many days per week could you not get going. Significant time-dependent factors included BNP, treadmill ability, Up and Go, pedometer activity, handgrip, 30 s chair sit-stand test, and age. The optimal time-dependent predictor set included BNP, treadmill ability, and patient age. Conclusions: Changes in functional and biochemical markers are predictive of kidney waitlist removal for death and medical reasons. BNP and measures of walking ability were of particular importance.

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Section: Discussionmentioning

confidence: 99%

Walking Ability and Brain Natriuretic Peptide Are Highly Predictive of Kidney Transplant Waiting List Removal

Katz

Eyck

Binns

et al. 2023

Transplantation Direct

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“…Data were not available for those who were screened and not listed due to an abnormal screening test, or listed but not transplanted due to MACE that occurred on the waitlist. Screening results are just one factor in a complex assessment of patients for transplantation, with the proportion of patients excluded due to cardiac screening abnormalities estimated at 1%–4% ( 71 , 72 , 73 ). In a target trial examining whether cardiac screening improves post-transplant outcomes these data would ideally be known, and neither PS or IV techniques specifically address this issue.…”

Section: Does Screening For Coronary Artery Disease Reduce Post-trans...mentioning

confidence: 99%

Propensity Score and Instrumental Variable Techniques in Observational Transplantation Studies: An Overview and Worked Example Relating to Pre-Transplant Cardiac Screening

et al. 2022

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Inferring causality from observational studies is difficult due to inherent differences in patient characteristics between treated and untreated groups. The randomised controlled trial is the gold standard study design as the random allocation of individuals to treatment and control arms should result in an equal distribution of known and unknown prognostic factors at baseline. However, it is not always ethically or practically possible to perform such a study in the field of transplantation. Propensity score and instrumental variable techniques have theoretical advantages over conventional multivariable regression methods and are increasingly being used within observational studies to reduce the risk of confounding bias. An understanding of these techniques is required to critically appraise the literature. We provide an overview of propensity score and instrumental variable techniques for transplant clinicians, describing their principles, assumptions, strengths, and weaknesses. We discuss the different patient populations included in analyses and how to interpret results. We illustrate these points using data from the Access to Transplant and Transplant Outcome Measures study examining the association between pre-transplant cardiac screening in kidney transplant recipients and post-transplant cardiac events.

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“…Although there are no other RCTs examining whether more screening for asymptomatic coronary artery disease in prospective KTR improves survival or reduces CV events after transplantation, two important observational studies have reported recently. An intensive CV risk stratification protocol implemented nationwide in Austria in 2007 resulted in over 50% of transplanted patients having a coronary angiogram but failed to demonstrate any improvement in patient survival or a reduction in coronary events in patients transplanted directly after (2008–11) or 5 years after (2012–15) compared with historical data (2003–07) [ 31 , 33 ]. A prospective study of 2572 UK KTR who received a transplant in 2011–17 in 18 centres found that 51% underwent cardiac screening pre-transplantation with screening by centre varying from 5% to 100% [ 32 ].…”

Section: Value Of Revascularization In Stable Ischaemic Heart Diseasementioning

confidence: 99%

“…The very considerable differences in screening practices both within [ 33 ] and between countries raise concern about whether patients in many centres are being denied access to a kidney transplant without supportive evidence while patients with similar characteristics in other centres are wait-listed promptly [ 75 ]. In the UK, a recent study found that the proportion of KTRs that had undergone CV screening with either a stress test or coronary angiogram ranged between 5% and 100% [ 33 ]. An important and uncomfortable question is raised: how many patients in the centres with high screening rates were, potentially unnecessarily, denied access to transplantation [ 76 ]?…”

Section: Evidence That Conventional Approach To Cardiac Screening Causes Harmmentioning

confidence: 99%

Screening for occult coronary artery disease in potential kidney transplant recipients: time for reappraisal?

Ferro

Berry

Moody

et al. 2021

Clinical Kidney Journal

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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 socio-economic backgrounds and unfairly denies many patients access to potentially lifesaving and life-enhancing transplantation. In this article, we review the available evidence in the light of recently published randomised 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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Non-invasive cardiac stress studies may not offer significant benefit in pre-kidney transplant evaluation: A retrospective cohort study

Cited by 9 publications

References 35 publications

Walking Ability and Brain Natriuretic Peptide Are Highly Predictive of Kidney Transplant Waiting List Removal

Walking Ability and Brain Natriuretic Peptide Are Highly Predictive of Kidney Transplant Waiting List Removal

Propensity Score and Instrumental Variable Techniques in Observational Transplantation Studies: An Overview and Worked Example Relating to Pre-Transplant Cardiac Screening

Screening for occult coronary artery disease in potential kidney transplant recipients: time for reappraisal?

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