Cardiac Disease Evaluation and Management Among Kidney and Liver Transplantation Candidates

T he challenges inherent in conducting accurate, clinically effective, and cost-effective cardiac evaluations among transplantation candidates relate to the large size of the target population, the prevalence of disease, the limited number of donated organs, and the often extended waiting periods between initial evaluation and transplantation surgery.According to Organ Procurement and Transplant Network (OPTN) records, nearly 85 000 candidates were on the waiting list for kidney transplantation in 2010, and Ϸ17 700 kidney transplantations (including 828 kidney-pancreas transplantations) were performed.1 Also in 2010, 16 000 people were awaiting liver transplantation and 6000 received liver allografts. 1 Marked shifts in the age composition of transplant waitlists toward older adults are also raising the average medical complexity and comorbidity burden among listed candidates.In 2011, 62% of kidney transplantation candidates were Ն50 years of age compared with 28.7% of kidney transplantation candidates in 1991. 1 A similar shift in age distribution has occurred among liver transplantation candidates; now, 77% are Ն50 years of age. 1 Cardiovascular disease is a leading cause of morbidity and mortality among patients with end-stage failure of noncardiac organs before and after transplantation.Estimates of the cumulative incidence of myocardial infarction (MI) based on Medicare billing claims have ranged from 8.7% to 16.7% by 3 years after kidney transplant listing and from 4.7% to 11.1% after kidney transplantation.2,3 Observational data suggest particularly high frequencies of cardiovascular events in the first months after kidney transplantation.2,4,5 Cardiovascular diseases in aggregate make up the most common cause of death in patients with functioning allografts at all times after kidney transplantation, accounting for 30% of mortality overall, with highest rates in the peritransplantation period.6 Guidelines and position papers by national organizations can serve as useful tools for informing cardiac evaluation practices before noncardiac surgery.However, the discrepancies among existing guidelines and the unique clinical characteristics of patients with end-stage organ failure raise questions about the applicability of available recommenda-The American Heart Association and the American College of Cardiology Foundation make every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel.Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.