Key result
In prospective renal transplant recipients, significant coronary artery disease requiring intervention was not significantly associated with worse event-free survival after correction for cardiovascular risk factors (HR 3.17, p=0.215).
Why the study?
Does a standardised cardiovascular assessment protocol using dobutamine stress echocardiography effectively risk-stratify chronic kidney disease patients prior to kidney transplantation?
Cohort (n=231)
No
Does a standardised cardiovascular assessment protocol using dobutamine stress echocardiography effectively risk-stratify chronic kidney disease patients prior to kidney transplantation?
Hazard Ratio: 3.17 (95% CI 0.51–19.59)
Absolute Event Rate: 56% vs 83%
p-value: p=0.215
A stratified cardiovascular risk assessment protocol using dobutamine stress echocardiography effectively identifies high-risk kidney transplant candidates with coronary artery disease, though pre-emptive coronary interventions were not associated with improved survival.
BACKGROUND: Despite pre-kidney-transplant cardiovascular (CV) assessment being routine care to minimise perioperative risk, the utility of such assessment is not well established. The study reviewed the evaluation and outcome of a standardised CV assessment protocol. METHODS: Data were analysed for 231 patients (age 53.4 ± 12.9 years, diabetes 34.6%) referred for kidney transplantation between 1/2/2012-31/12/2014. One hundred forty-three patients were high-risk (age > 60 years, diabetes, CV disease, heart failure, peripheral vascular disease) and offered dobutamine stress echocardiography (DSE); 88 patients were low-risk and offered ECG and echocardiography with/without exercise treadmill test. RESULTS: At the end of follow-up (579 ± 289 days), 35 patients underwent kidney transplantation and 50 were active on the waitlist. There were 24 events (CV or death), none were perioperative. One hundred fifteen patients had DSE with proportionally more events in DSE-positive compared to DSE-negative patients (6/34 vs. 7/81, p = 0.164). In 42 patients who underwent coronary angiography due to a positive DSE or ischaemic heart disease symptoms, 13 (31%) had events, 6 were suspended, 11 removed from waitlist, 3 wait-listed, 1 transplanted and 17 still undergoing assessment. Patients with significant coronary artery disease requiring intervention had poorer event-free survival compared to those without intervention (56% vs. 83% at 2 years, p = 0.044). However, the association became non-significant after correction for CV risk factors (HR = 3.17, 95% CI 0.51-19.59, p = 0.215). CONCLUSIONS: The stratified CV risk assessment protocol using DSE in all high-risk patients was effective in identifying patients with coronary artery disease. The coronary angiograms identified the event-prone patients effectively but coronary interventions were not associated with improved survival.
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Ramphul et al. (2018) conducted a cohort in Chronic kidney disease prior to kidney transplantation (n=231). Significant coronary artery disease requiring intervention vs. No intervention was evaluated on Cardiovascular events or death (HR 3.17, 95% CI 0.51-19.59, p=0.215). In prospective renal transplant recipients, significant coronary artery disease requiring intervention was not significantly associated with worse event-free survival after correction for cardiovascular risk factors (HR 3.17, p=0.215).
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