Cardiac evaluation prior to kidney transplantation

Abstract

Kidney transplantation is the treatment of choice for most patients with stage 5 chronic kidney disease and end-stage renal disease (ESRD), offering improved quality of life and overall survival rates. However, the limited supply of available organs makes this a scarce resource. Cardiovascular complications continue to be the leading cause of mortality in the kidney transplant population, accounting for over 30% of deaths with a functioning allograft. Thus, preoperative cardiac risk assessment is critical to optimize patient selection and outcomes. Currently there is no consensus for cardiovascular evaluation in the chronic kidney disease and ESRD population prior to kidney transplantation; the recommendations of the American Society of Nephrology and American Society of Transplantation differ from those of the American Heart Association and the American College of Cardiology. Previously developed risk scores have also been used to risk stratify this population. In this review, we discuss two cases that illustrate the difficulties of interpreting the prognostic value of current testing strategies. We also discuss the importance of different tests for cardiovascular evaluation as well as previous nonkidney transplant specific risk scores used in the pre-kidney transplant population.

Figure 1

Proposed pre-transplant cardiac evaluation algorithm. A calculated risk score designed and validated in the kidney transplant population can be integrated into a cardiac evaluation schema. The risk score would designate patients into a low, intermediate, and high risk category. Following the schema low risk patients can be listed without additional testing. High risk patients undergo cardiac catheterization. Intermediate risk patients undergo non-invasive testing and have cardiac catheterization if the non-invasive testing is positive for ischemia.