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. 2021 Dec 9;3(3):516-523.
doi: 10.34067/KID.0005282021. eCollection 2022 Mar 31.

Trends in Coronary Artery Disease Screening before Kidney Transplantation

Xingxing S Cheng  1 , Sai Liu  1 , Jialin Han  1 , Margaret R Stedman  1 , Glenn M Chertow  1 , Jane C Tan  1 , William F Fearon  2
Affiliations

Trends in Coronary Artery Disease Screening before Kidney Transplantation

Xingxing S Cheng et al. Kidney360. .

Abstract

Background: Coronary artery disease (CAD) screening in asymptomatic kidney transplant candidates is widespread but not well supported by contemporary cardiology literature. In this study we describe temporal trends in CAD screening before kidney transplant in the United States.

Methods: Using the United States Renal Data System, we examined Medicare-insured adults who received a first kidney transplant from 2000 through 2015. We stratified analysis on the basis of whether the patient's comorbidity burden met guideline definitions of high risk for CAD. We examined temporal trends in nonurgent CAD tests within the year before transplant and the composite of death and nonfatal myocardial infarction in the 30 days after transplant.

Results: Of 94,832 kidney transplant recipients, 37,139 (39%) underwent at least one nonurgent CAD test in the 1 year before transplant. From 2000 to 2015, the transplant program waitlist volume had increased as transplant volume stayed constant, whereas patients in the later eras had a slightly higher comorbidity burden (older, longer dialysis vintage, and a higher prevalence of diabetes mellitus and CAD). The likelihood of CAD test in the year before transplant increased from 2000 through 2003 and remained relatively stable thereafter. When stratified by CAD risk status, test rates decreased modestly in patients who were high risk but remained constant in patients who were low risk after 2008. Death or nonfatal myocardial infarction within 30 days after transplant decreased from 3% in 2000 to 2% in 2015. Nuclear perfusion scan was the most frequent modality of testing throughout the examined time periods.

Conclusions: CAD testing rates before kidney transplantation have remained constant from 2000 through 2015, despite widespread changes in cardiology guidelines and practice.

Keywords: cardiovascular disease; coronary artery disease; epidemiology and outcomes; mass screening; transplantation.

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Conflict of interest statement

G.M. Chertow reports having consultancy agreements with Akebia, Amgen, Ardelyx, AstraZeneca, Baxter, Cricket, DiaMedica, Gilead, Miromatrix, Reata, Sanifit, Unicycive, and Vertex; reports having an ownership interest in Ardelyx, CloudCath, Durect, DxNow, Eliaz Therapeutics, Outset, Physiowave, and PuraCath; reports receiving research funding from National Institute of Diabetes and Digestive and Kidney Diseases, and National Institute of Allergy and Infectious Diseases; reports being a scientific advisor or membership of the Board of Directors, Satellite Healthcare, and Co-Editor, Brenner & Rector's The Kidney (Elsevier); and reports other interests/relationships with the Data and Safety Monitoring Board service: Angion, Bayer, National Institute of Diabetes and Digestive and Kidney Diseases, and ReCor. W.F. Fearon reports having consultancy agreements with CathWorks, and Siemens; reports having an ownership interest in HeartFlow; and reports receiving research funding from Abbott Vascular, Boston Scientific, and Medtronic. X.S. Cheng reports receiving honoraria from ClarityCo and Medscape Education. All remaining authors have nothing to disclose.

Figures

None
Graphical abstract
Figure 1.
Figure 1.
Cohort assembly and definition of nonurgent coronary artery disease (CAD) testing in the year before kidney transplant (KTx). ED, emergency department.
Figure 2.
Figure 2.
Trend in CAD testing over time, unadjusted (dark solid line) and adjusted (dark dotted line) for transplant program characteristics, patient demographics, transplant type, and comorbidities. The 95% confidence bands are shown in light gray. Center-specific reports were available online to the public since 1999. The Centers for Medicare and Medicaid Services (CMS) started issuing of conditions of participation (COP) to transplant programs in 2007. Three landmark negative trials in CAD screening were published in 2003 (2), 2007 (3), and 2009 (4).
Figure 3.
Figure 3.
Trend in CAD testing over time, in patients who are low CAD risk (top panel) and high CAD risk (bottom panel), unadjusted (dark solid line) and adjusted (dark dotted line) for transplant program characteristics, patient demographics, and transplant type. The 95% confidence bands are shown in light gray. High CAD risk is defined as meeting ≥3 of eight risk factors by the 2012 American College of Cardiology/American Heart Association Clinical (ACC/AHA) guidelines (7). Center-specific reports were available online to the public since 1999. The CMS started issuing of COP to transplant programs in 2007. Three landmark negative trials in CAD screening were published in 2003 (2), 2007 (3), and 2009 (4). CARP, coronary-artery revascularization prophylaxis; COURAGE, clinical outcomes utilization revascularization and aggressive drug evaluation; DIAD, detection of ischemia in asymptomatic diabetes.
Figure 4.
Figure 4.
Modality of nonurgent CAD testing by year. Where more than one test was done, the first test is shown. EKG, electrocardiogram; CCTA, coronary computed tomography angiography.
Figure 5.
Figure 5.
Incidence of 30-day adverse events (death, graft failure, or myocardial infarction) after kidney transplantation each calendar year, all study patients, unadjusted (dotted) and adjusted (black) for transplant program characteristics, patient demographics, transplant type, and comorbidities.
See this image and copyright information in PMC

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