Pretransplant cardiac investigations in the Irish renal transplant population--the effectiveness of our current screening techniques in predicting cardiac events

BACKGROUND: Coronary artery disease (CAD) is prevalent among endstage renal failure patients and remains the major cause of mortality following renal transplantation. Death with a functioning transplant institute remains the most common cause of kidney graft failure. In this study we attempt to evaluate the effectiveness of the clinical history and current screening techniques available in predicting posttransplant CAD and also assess the role of coronary angiography as a pretransplant screening technique. METHODS: Clinical data of 190 renal transplant patients was analyzed. Any clinical history of cardiac disease and all preoperative cardiac screening data was recorded for each patient. The study endpoints were the subsequent development of myocardial infarction (MI), undergoing coronary artery bypass graft (CABG) or death. RESULTS: Factors that were significantly associated with reaching a study endpoint included: age at transplant [Hazard Ratio (HR) 1.91, P<0.001], history of heart failure (HR 8.22, P<0.001), presence of CAD on coronary angiography (HR 5.55, P=0.033), anterior Q wave on electrocardiograph (ECG) (HR 8.6, P<0.001), carotid artery disease (HR 3.74, P=0.030) and history of a cerebrovascular accident (HR of 4.32, P=0.008). The screening techniques of exercise stress testing and echocardiography were not conclusive as predictive variables of outcome. CONCLUSION: Clinical history and ECG results are good, practical and low-cost screening methods. In our study exercise stress testing and echocardiography were found to be of limited value. Coronary angiography is appropriate in certain high-risk groups but not necessary as part of screening in all potential renal transplant recipients.     

Pretransplant Cardiac Investigations in the Irish Renal Transplant Population—The Effectiveness of Our Current Screening Techniques in Predicting Cardiac Events

Background. Coronary artery disease (CAD) is prevalent among endstage renal failure patients and remains the major cause of mortality following renal transplantation. Death with a functioning transplant institute remains the most common cause of kidney graft failure. In this study we attempt to evaluate the effectiveness of the clinical history and current screening techniques available in predicting posttransplant CAD and also assess the role of coronary angiography as a pretransplant screening technique. Methods. Clinical data of 190 renal transplant patients was analyzed. Any clinical history of cardiac disease and all preoperative cardiac screening data was recorded for each patient. The study endpoints were the subsequent development of myocardial infarction (MI), undergoing coronary artery bypass graft (CABG) or death. Results. Factors that were significantly associated with reaching a study end‐point included: age at transplant [Hazard Ratio (HR) 1.91, P < 0.001], history of heart failure (HR 8.22, P < 0.001), presence of CAD on coronary angiography (HR 5.55, P = 0.033), anterior Q wave on electrocardiograph {ECG} (HR 8.6, P < 0.001), carotid artery disease (HR 3.74, P = 0.030) and history of a cerebrovascular accident (HR of 4.32, P = 0.008). The screening techniques of exercise stress testing and echocardiography were not conclusive as predictive variables of outcome. Conclusion. Clinical history and ECG results are good, practical and low‐cost screening methods. In our study exercise stress testing and echocardiography were found to be of limited value. Coronary angiography is appropriate in certain high‐risk groups but not necessary as part of screening in all potential renal transplant recipients.     

Prevalence and Distribution of Coronary Disease in Claudicants Using 12-Lead Precordial Stress Electrocardiography

AIMS: to evaluate the prevalence of coronary artery disease (CAD) by means of modified stress electrocardiography in patients presenting with intermittent claudication. METHODS: three hundred consecutive patients (188 male) with intermittent claudication (post-exercise ankle brachial index <0.8), and 100 age and sex-matched controls, were assessed for CAD with resting and stress 12-lead-precordial ECG. A history of angina and previous myocardial infarction (MI) was recorded. Exclusion criteria: recent (<1 month) MI; unstable angina; prior coronary intervention; arrhythmias; conduction abnormalities; uncontrolled hypertension; heart failure, digoxin therapy, and inability to perform tests. RESULTS: based on antecedent angina, MI and abnormal resting ECG, CAD prevalence was 47% in claudicants and 6% in controls; on 12-lead-precordial ECG stress testing, CAD prevalence was 46% (95% CI: 40.1-51.7%) in claudicants and 11% (95% CI: 4.8-17.2%) in controls (both p <0.0001). Only 67% of claudicants (n=141) with antecedent angina, MI or an abnormal resting ECG, met the criteria of CAD on stress testing; also 28% of claudicants without antecedent angina, MI and a normal resting ECG (n=159) had evidence of CAD. The odds ratio for CAD in claudicants was 6.9. Based on 12-lead-precordial ECG stress testing we detected the presence of: one-, two- and three-vessel disease in 14.7% (95% CI: 10.6-18.7%), 19% (95% CI: 14.5-23.5%) and in 12.3% (95% CI: 8.6-16%) of claudicants; and in 8, 3 and 0% of controls, respectively. CONCLUSIONS: forty six percent of patients with intermittent claudication had concomitant CAD, and 31% two- or three-vessel disease. In the presence of claudication the odds ratio for CAD is 6.9 (95% CI: 3.5-13.4) and for two- or three-vessel disease 14.8. Non-invasive modified stress electrocardiography by enabling identification of those with multi-vessel CAD and thus by providing cardiac risk stratification may help bridge the gap between clinical evaluation and invasive coronary imaging.     

Influence of fluid removal rate during hemodialysis on left ventricular performance and exercise tolerance in patients with coronary artery disease

The effect of hemodialysis (HD) on left ventricular (LV) function and exercise tolerance were measured at rest and during exercise using gated equilibrium radionuclide ventriculography in seven patients with confirmed coronary artery disease (CAD). To separate the effects of fluid removal rate on LV function in CAD, we investigated the same patients with identical overall volume loss of 4 liters during two different treatment times (4 hr and 2 hr). HD significantly increased resting LV ejection fraction (EF) from 55.7 +/- 8% to 64.7 +/- 8% (P less than 0.01) during the 4 hr HD and from 58.1 +/- 9 to 68.1 +/- 10 (P less than 0.05) during the 2 hr HD. Indicating ischemia, EF decreased at pre- and postdialysis peak exercise without differences between both treatments. HD also resulted in an improved segmental wall motion score. Exercise duration as well as S-T segment depression and angina score improved during HD, whereas heart rate, blood pressure and double product remained unchanged. We conclude that HD improves global and regional resting LV function and exercise tolerance in patients with CAD. The degree of interdialytic hydration and not the degree of fluid removal per time affects LV performance in CAD. Since LV function is the major prognostic factor in CAD, those patients require volume restriction and/or shorter interdialytic phases.     

Ischaemia imaging in type 2 diabetic kidney transplant candidates--is coronary angiography essential?

BACKGROUND: Coronary artery disease (CAD) remains the leading cause of death in type 2 diabetes mellitus (DM) patients undergoing renal transplantation. There is a high prevalence of silent CAD in these patients. Controversy exists regarding the role of dobutamine stress echocardiography (DSE) in detection of CAD. Our purpose was to compare DSE with coronary angiography (CA) for the detection of CAD in type 2 diabetic patients undergoing evaluation for renal transplantation. METHODS: Forty (36 male, four female) type 2 diabetic patients with end-stage renal disease (ESRD) were subjected to DSE followed by CA as a part of their pre-renal transplant evaluation. The ability of DSE to predict 70% stenosis in one or more coronary arteries as determined by CA was evaluated. Mean age of the patients was 49.2 +/- 5 years (range 39-60 years). RESULTS: DSE was positive in 10 (25%) patients, while 19 patients (48%) had a more than 70% lesion in at least one epicardial vessel on CA (six patients had single vessel, three had double vessel and 10 had triple vessel disease). The sensitivity and specificity in identifying CAD was 47.3 and 95.2%, respectively, while positive predictive value and negative predictive value was 90% and 66%. Accuracy of DSE was 72.5%. All four patients with diffuse diabetic coronary artery disease had negative DSE. CONCLUSION: DSE is a poor predictor of coronary artery disease in type 2 DM patients being evaluated for renal transplantation. CA should be included in evaluation of type 2 diabetic patients who are renal transplant candidates.     

Relationship between dobutamine-induced regional wall motion abnormalities and coronary flow reserve in heart transplant patients without angiographic coronary artery disease.

BACKGROUND: Regional wall motion abnormalities (RWMA) demonstrated by dobutamine stress echocardiography (DSE) are a sensitive predictor of coronary artery disease (CAD) in heart transplant recipients. However, RWMA have been shown to occur in patients with angiographically "normal" coronary arteries. The reasons for this are unknown. We sought to determine if abnormal responses to dobutamine in this setting can be explained by microvascular dysfunction in the coronary circulation as detected by decreased coronary flow reserve (CFR). METHODS: Twenty-six consecutive heart transplant patients were evaluated prospectively. Five of 26 (19.2%) patients (seven coronary arteries) were excluded for poor acoustic windows on echocardiography. Another three patients were excluded for angiographically apparent CAD. CFR and wall motion score index (WMSI) derived from DSE were measured in the remaining 18 patients and formed the basis of this study. Patients were divided into two groups based on the absence (Group 1; n = 5) or presence (Group 2; n = 13) of RWMA on DSE. CFR was measured with the Doppler Flo-Wire in 34 coronary arteries (18 patients) and correlated with WMSI. RESULTS: In Group 1 patients, CFR measured in eight coronary arteries was normal (2.6 +/- 0.4). In Group 2 patients, CFR measured in 26 coronary arteries also was normal (2.2 +/- 0.6; p = NS vs Group 1). In Group 2, CFR was measured in 20 of 24 vessels assigned to segments that developed RWMA. Only 6 of these 20 vessels (30%) had abnormal CFR. Overall, there was no correlation between decreased CFR and the presence of RWMA induced by dobutamine. CONCLUSIONS: These data suggest that, in cardiac transplant patients with angiographically "normal" coronary arteries, inducible wall motion abnormalities during DSE cannot be attributed to coronary microvascular dysfunction as manifested by decreased CFR.     

Predictors of coronary disease in patients with end stage renal disease.

Patients with end stage renal disease have a high prevalence of cardiovascular disease and coronary arteriography is often routinely performed prior to kidney transplantation. However, the value of the conventional risk factors and non-invasive markers of coronary artery disease (CAD) in triaging patients for coronary arteriography has not been fully examined. 116 patients with end stage renal disease were evaluated. Coronary arteriography was performed in all patients either for a suspicion of CAD or as part of a routine pre-transplant evaluation. Lesions causing > or = 50% luminal diameter stenosis in any of the three major coronary artery systems were considered significant. The mean age was 53.3 +/- 9.3 years. Significant CAD was present in 69 patients (60%). Increasing age, family history of premature ischemic heart disease, the presence of angina, abnormal Q waves on the ECG or abnormal ST segment depression and the presence of coronary calcification were significant markers of coronary artery disease. However male gender, diabetes mellitus and obesity did not correlate with coronary disease. Even though hypertension, hypercholesterolemia and smoking were also not useful predictors these could have been modified by the renal failure. In conclusion increasing age, a family history of premature ischemic heart disease and some non-invasive markers were useful predictors of coronary disease.     

Screening asymptomatic diabetic patients for coronary artery disease prior to renal transplantation

BACKGROUND: Coronary artery disease (CAD) is a significant contributor to excess mortality in renal transplant candidates with diabetes mellitus (DM). Prior studies relating to risk stratification for significant CAD in diabetics are confined to Caucasian type 1 DM patients. METHODS: To assess the prevalence of clinically silent CAD and to identify variables that are associated with CAD, we retrospectively analyzed the cardiac catheterization data of 97 asymptomatic type 1 and 2 DM kidney and kidney-pancreas transplant candidates. RESULTS: Thirty-three percent of type 1 and 48% of type 2 DM patients had significant stenosis (> or = 70%) in 1 or more coronary arteries. On multivariate logistic regression analysis, body mass index (BMI) >25 was significantly associated with CAD (relative risk = 4.8, P = 0.002). The age of the patient (7% increase in risk/year, P = 0.01; or relative risk = 3.0 if age >47 years, P = 0.032) and smoking history (2% increase in risk/pack-year of smoking, P = 0.10) were also associated with CAD. African American patients, who comprised 30% of the sample, had a 71% lower risk compared with Caucasian patients (P = 0.03). Factors that were not significantly associated with CAD included gender, type of diabetes, and whether dialyzed for >6 months prior to catheterization. CONCLUSIONS: We conclude that a notable proportion (approximately one-third to one-half) of asymptomatic type 1 and type 2 diabetic renal transplant candidates have significant CAD. Additionally, young African American DM patients with no smoking history and a BMI 相似文献   

Coronary artery,aortic wall,and valvular calcification in nondialyzed individuals with type 2 diabetes and renal disease

BACKGROUND: Individuals with end-stage renal disease (ESRD) have highly prevalent and severe vascular and valvular calcification. We undertook this study to test the hypothesis that vascular and valvular calcification begins and is often severe long before diabetic renal disease progresses to ESRD. METHODS: A total of 32 nondialyzed individuals with type 2 diabetes mellitus and diabetic renal disease (albumin excretion rate>30 microg/min) [mean glomerular filtration rate (GFR), 49.8 +/- 6.1 mL/min/1.73 m2] were identified and compared with a group of 18 normoalbuminuric diabetics. We used 3:1 matching to identify 95 nondiabetic controls without renal disease, matched for age, gender, ethnicity, and the presence/absence of dyslipidemia, hypertension, and known coronary artery disease (CAD). RESULTS: Using electron beam computed tomography (CT), the prevalence of coronary artery calcification was significantly greater among diabetic renal disease individuals (prevalence, 94% vs. 59%, P < 0.001; median score, 238 vs. 10, P < 0.001) than the nondiabetic controls. The coronary artery calcification scores were significantly more severe among diabetic renal disease individuals than either the diabetic or nondiabetic controls. Among individuals with diabetic renal disease, the coronary artery calcification and aortic wall calcification scores were several-fold greater among those with known CAD than among those without. There was also a significantly greater prevalence of aortic and mitral valve calcification among diabetic renal disease individuals than nondiabetic controls (aortic, 23% vs. 6%, P = 0.03; mitral, 25% vs. 2%, P < 0.001). Multivariate analysis using all three groups reproduced these findings and also consistently identified age and diabetic renal disease as additional predictors for the presence or severity of coronary artery and aortic wall calcification. CONCLUSION: In this first, systematic analysis among nondialyzed individuals with diabetic renal disease, these data demonstrate that vascular and valvular calcification is present and often severe long before the disease progresses to ESRD. The data also suggest that the coronary artery and aortic wall calcification may represent atherosclerosis.     

Coronary angiography prior to renal transplantation

Summary: A retrospective analysis of coronary angiography in 89 patients (57 male, 32 female) on regular dialysis treatment, prior to their acceptance onto the cadaveric renal transplant waiting list, was performed. Patients studied included those older than 40 years and those symptomatic of coronary artery disease (CAD) or diabetics. Thirty patients (34%) had significant CAD: 18 one-vessel, 8 two-vessel, 3 three-vessel and 1 four-vessel disease. Significant predictors of CAD were a history of cardiac ischaemic symptoms, a diagnosis of diabetes mellitus, and a family history of CAD. There was no difference in survival between those with and those without CAD. Total mortality, and that due to myocardial infarction, was similar in patients with one- and two-vessel disease and those without CAD, but increased in those with three- or four-vessel disease ( P <0.001). Thirteen patients (11 with CAD) were excluded from the transplant waiting list, and their survival was significantly worse ( P <0.001). Restriction of coronary angiography to patients who were either symptomatic or diabetic would have resulted in 63% fewer angiograms without altering acceptance onto the transplantation waiting list for any patient.     

The impact of left ventricular systolic dysfunction on survival after renal transplantation

BACKGROUND: Gated single photon emission computed tomography (SPECT) provides information on myocardial perfusion and left ventricular ejection fraction (LVEF), which correlates with risk of cardiac events in patients with known or suspected coronary artery disease (CAD). We hypothesize that decreased LVEF at time of renal transplant evaluation is an independent risk factor for cardiac death and nonfatal events after transplant. METHODS AND RESULTS: A total of 653 recipients of renal allografts between 1998 and 2005 had stress SPECT imaging before transplantation. One hundred and nineteen (18%) patients had left ventricular (LV) systolic dysfunction (LVEF 相似文献   

Influence of coronary artery disease assessment and treatment in the incidence of cardiac events in renal transplant recipients

De Lima JJG, Gowdak LHW, de Paula FJ, Arantes RL, Ianhez LE, Ramires JAF, Krieger EM. Influence of coronary artery disease assessment and treatment in the incidence of cardiac events in renal transplant recipients.
Clin Transplant 2010: 24: 474–480.
© 2009 John Wiley & Sons A/S. Abstract: Background: The best strategy for pre‐transplant investigation and treatment of coronary artery disease (CAD) is controversial. Methods: We evaluated 167 renal transplant recipients before transplantation to determine the incidence of cardiac events and death. We performed clinical evaluations and myocardial scans in all patients and coronary angiography in select patients. Results: Asymptomatic patients with normal myocardial scans (n = 57) had significantly fewer cardiac events (log‐rank = 0.0002) and deaths (log‐rank = 0.0005) than did patients with abnormal scans but no angiographic evidence of CAD (n = 76) and individuals with CAD (n = 34) documented angiographically. CAD increased the probability of events (HR = 2.27, % CI 1.007–5.11; p = 0.04). The incidence of cardiac events (log‐rank = 0.349) and deaths (log‐rank = 0.588) was similar among patients treated medically (n = 23) or by intervention (n = 11). Conclusion: Asymptomatic patients with normal myocardial scans had a better cardiac prognosis than did patients with or without CAD and positive for myocardial ischemia. Patients with altered scan and CAD had the poorer outcome. Guideline‐oriented medical treatment is safe and yields results comparable to coronary intervention in renal transplant patients with CAD. The data do not support pre‐emptive myocardial revascularization for renal transplant candidates.     

Prognostic value of inducible myocardial ischemia in predicting cardiovascular events after renal transplantation

BACKGROUND: The aims of the present study were to determine the prevalence of inducible myocardial ischemia (IMI) in renal transplant recipients (RTR) more than 50 years old, to identify predictors of IMI, and to search for its prognostic value. METHODS: Among the 377 renal transplantations performed between 1989 and 1998 in a single institution, 120 were done in patients > or =50 years old, and 97 were recruited for the study. During the last quarter of 1998, all of them underwent an exercise test (EST), an exercise-thallium 201 single photon emission computed tomography coupled with dipyridamole (SPECT), and 81% of them had a dobutamine stress echocardiography (DSE). Patients with IMI subsequently underwent coronary angiography to detect coronary stenosis. RESULTS: IMI was present in 12 of the 97 patients (10%). The diagnosis was evidenced by EST in four cases, by SPECT in 11 cases, and DSE in three cases. Five of these 12 patients (42%) had significant coronary artery stenosis (> or =50%). Multivariate analysis of several pre- and post-transplant variables evidenced acute rejection and left ventricular hypertrophy as significant correlates of IMI (both P < 0.03). Patients were prospectively followed-up for 48 months for the occurrence of major cardiovascular events. Kaplan-Meier analysis revealed a significant increase in cardiovascular events in the IMI group (P < 0.0001). In addition, the Cox proportional hazards model revealed that IMI and diabetes mellitus had an independent significant effect on the occurrence of major cardiovascular events. CONCLUSION: IMI was present in 10% of RTR aged > or =50 years, and was predicted by acute rejection and left ventricular hypertrophy. IMI had a strong effect on major cardiovascular events in this population.     

PREDICTORS OF CORONARY DISEASE IN PATIENTS WITH END STAGE RENAL DISEASE

Patients with end stage renal disease have a high prevalence of cardiovascular disease and coronary arteriography is often routinely performed prior to kidney transplantation. However, the value of the conventional risk factors and non-invasive markers of coronary artery disease (CAD) in triaging patients for coronary arteriography has not been fully examined. 116 patients with end stage renal disease were evaluated. Coronary arteriography was performed in all patients either for a suspicion of CAD or as part of a routine pre-transplant evaluation. Lesions causing ≥ 50% luminal diameter stenosis in any of the three major coronary artery systems were considered significant. The mean age was 53.3 ± 9.3 years. Significant CAD was present in 69 patients (60%). Increasing age, family history of premature ischemic heart disease, the presence of angina, abnormal Q waves on the ECG or abnormal ST segment depression and the presence of coronary calcification were significant markers of coronary artery disease. However male gender, diabetes mellitus and obesity did not correlate with coronary disease. Even though hypertension, hypercholesterolemia and smoking were also not useful predictors these could have been modified by the renal failure. In conclusion increasing age, a family history of premature ischemic heart disease and some non-invasive markers were useful predictors of coronary disease.     

Non-invasive assessment of left ventricular function in coronary artery disease by Doppler stress testing

Left ventricular (LV) function in 62 patients presenting with chest pain typical of angina was studied non-invasively at rest and at maximum-tolerated supine exercise using the continuous-wave Doppler technique of transcutaneous aorto-velography (TAV). The signals were analysed to derive peak velocity (Vp), systolic velocity integral [an index of stroke volume or stroke distance (Sd)], and minute distance (Md; index of cardiac output = Sd X heart rate). Comparison was made with results obtained from 66 normal volunteers. The percentage change in stroke distance with exercise (% delta Sd) was significantly related to the resting ejection fraction (EF) calculated from left ventriculography (r = 0.84), and was below 6% (lowest value observed in normal volunteers) in all of the 23 patients with coronary artery disease (CAD) whose EF was below 60%. No significant difference was observed in the % delta Sd between normal individuals and the 12 patients presenting with chest pain but who had normal coronary arteriograms. However, the % delta Vp, delta % Sd and % delta Md in the 50 patients with CAD were significantly lower than the normal individuals and the 12 patients with normal coronary arteriograms. Lower TAV measurements were observed with exercise, rather than at rest, with increasing number of coronary arteries with significant stenoses and the presence of history of myocardial infarction (linear trend p less than 0.003). These results suggest that Doppler recording of aortic blood velocity with exercise is a clinically useful non-invasive technique for studying LV performance in patients with CAD.(ABSTRACT TRUNCATED AT 250 WORDS)     

Urgent surgical revascularization of unstable angina. Influence of double mammary arteries.

OBJECTIVE: Aim of this study was to evaluate retrospectively: (1) the outcome in patients with unstable angina (UA) refractory to the medical therapy undergoing urgent-emergent CABG; (2) the influence of both IMAs employment. PATIENTS AND METHODS: Between January 1995 and July 2000, 576 (28.5%) consecutive patients with UA underwent CABG procedure. 182 (31.6%, Group I) patients, presenting unstable hemodynamic or angina pectoris refractory to the maximal medical therapy, underwent urgent/emergent CABG. 397 (68.4%, Group II) patients, after the maximal medical therapy did not present angina's episodes or ECG alterations and underwent elective CABG procedure. Preoperative data were similar in the two groups. Both IMAs were used in 68 (37.4%) patients of I and 152 (38%) of II (P>0.05) to left side revascularization. RESULTS: CAD extension was greater in Group I: 45 (24.7%) patients presented ischemia in >1 area vs 53 (13.5%) in II (P<0.001). Incidence of anteroseptal ischemia resulted significantly higher in I (P=0.017); left main coronary artery stenosis was present in 68 (37%) patients in I vs 108 (27%) in II (P=0.01). LV function resulted significantly depressed in I, demonstrated by a significantly lower LVEF (P<0.001), higher NYHA class (P<0.001) and preoperative incidence of IABP (P<0.001). Intraoperative data analysis did not reveal any difference between groups. Hospital mortality was 13 (7%) and 21 (5.3%) patients in I and II respectively (P=ns). Multivariate analysis of all preoperative and intraoperative variables revealed the age >65 years (P=0.01), congestive heart failure (P<0.001), LVEF<35% (P=0.03), >1 ischemic area (P=0.02) as strong predictors for poor overall survival, and LIMA (P=0.006) and both IMAs (P=0.001) as strong predictors for good overall survival. Actuarial survival at 1, 3 and 5 years resulted to be 98.5, 96.5 and 90% in I and 99, 96 and 92% in II (P=ns). CONCLUSION: CABG has been associated with acceptable outcome in patients with UA which should be applied soonest possible in patients refractory to medical treatment. Total coronary revascularization and employment of both IMAs for left myocardial side are associated with low operative risk and incidence of complications, permit to have acceptable short and long-term outcome in this pool of patients.     

Predictors of cardiovascular events and associated mortality of kidney transplant recipients

BACKGROUND: Cardiovascular disease is the most common cause of death after renal transplantation. Furthermore, acute coronary syndrome (ACS) attributable to coronary artery disease (CAD) accounts for the majority of deaths due to cardiovascular disease posttransplant. Although renal transplantation is the treatment of choice for end-stage renal disease, understanding the causes of graft and patient loss is exceedingly important to improve outcomes. METHODS: This observational study included 1200 patients who underwent a kidney transplant between 1988 and 2003. The outcome was the occurrence of an ACS event within a maximum of 15 years after renal transplantation. RESULTS: Of all 215 deaths, 28.3% were caused by complications of CAD, the most common cause of death at our center. On multivariate analysis, diabetes (P = .005), prior transplant (P = .047), body mass index (BMI) at the time of transplant (P = .01), cholesterol level (P = .012), and low-density lipoprotein (LDL) level (P = .007) during 3 years after transplant were associated with early ACS. In conclusion, diabetes, prior transplant, BMI, cholesterol, and LDL were significantly associated with early ACS highlighting the importance of improved screening and perioperative management.     

The effect of coronary angiography on renal function in preemptive renal transplant candidates

Lorenz EC, Stegall MD, Cosio FG, Gloor JM, Larson TS, Taler SJ. The effect of coronary angiography on renal function in preemptive renal transplant candidates.
Clin Transplant 2011: 25: 594–599. © 2010 John Wiley & Sons A/S. Abstract: Background: Increasing numbers of patients undergo preemptive renal transplantation. Obtaining cardiac catheterizations prior to transplantation to screen for coronary artery disease is controversial because of the perceived risk of inducing contrast nephropathy and the need for dialysis in patients with marginal renal function. We sought to examine the true impact of cardiac catheterization on time to dialysis in a cohort of preemptive renal transplant candidates. Methods: From a cohort of 376 transplant candidates evaluated preemptively at our program between 2/2001 and 4/2005, 34 patients had positive dobutamine stress echocardiograms. We reviewed the subsequent need for dialysis in these patients. Results: Among candidates undergoing angiography, 8.7% required dialysis within 14 d of contrast administration and 26% eventually needed dialysis prior to transplantation at 5.3 ± 3.7 months after their pre‐transplant evaluation. Among patients who did not undergo angiography, 27% needed dialysis prior to transplantation at 2.4 ± 1.8 months after pre‐transplant evaluation. Conclusions: Our results demonstrate a low risk of hastening the need for dialysis after coronary angiography in preemptive renal transplant candidates. Undergoing angiography had no effect on the ultimate need for or timing of dialysis initiation. These findings support completion of full cardiac evaluation as indicated for high‐risk preemptive renal transplant candidates.     

Prevalence and prediction of renal artery stenosis in patients with coronary and supraaortic artery atherosclerotic disease.

BACKGROUND: Renal atherosclerosis is associated with increased cardiovascular mortality. This study aimed to determine the prevalence and predictors of renal artery stenosis (RAS) in patients with coronary artery disease (CAD) and supraaortic arteries (SA) stenosis. METHODS: Renal angiography was performed in 1193 (807 men) consecutive patients referred for coronary or SA angiography. Group I included 296 (136 men, 60.1 +/- 9.5 years) patients with no significant (< 50%) lesion in coronary arteries or SA; group II included 706 (526 men, 62.2 +/- 9.7 years) patients with stenosis > or = 50% within single arterial territory (coronary arteries or SA) and group III included 191 (145 men, 64.9 +/- 8.5 years) patients with stenosis > or = 50% in both territories. RESULTS: Some RAS was found in 55 (18.6%) patients in group I, 250 (35.4%) patients in group II and 115 (60.2%) patients in group III (P < 0.001). The proportion of patients with RAS > or = 50% in groups I, II and III was 3.3, 6.2 and 18.3%, respectively (P < 0.001). RAS prevalence increased with the number of stenosed coronary arteries (38.4% in 1-vessel, 42.1% in 2-vessel, 48.5% in 3-vessel CAD, P < 0.001). Independent predictors of RAS > or = 50% identified by logistic regression analysis were SA stenosis [relative risk (RR) = 3.28, P < 0.001], 2-3-vessel-CAD (RR = 2.04, P = 0.002), creatinine level > or = 1.07 mg/dl (RR = 2.95, P < 0.001), hypertension (RR = 2.97, P = 0.012) and body mass index < 25 kg/m(2) (RR = 1.42, P = 0.169). A calculated score for RAS > or = 50% prediction (based on the regression model) was reliable (coefficient of determination, R = 0.978) and showed a sensitivity of 77.5% and a specificity of 63.9%. CONCLUSIONS: RAS prevalence and severity increases with the number of arterial territories involved and CAD severity. The following independent predictors of RAS > or = 50% were identified: SA involvement, 2-3-vessel-CAD, serum creatinine level and hypertension.     

Diagnostic and prognostic value of dobutamine thallium-201 single-photon emission computed tomography after heart transplantation.

BACKGROUND: Cardiac allograft vasculopathy (CAV) is a major cause of mortality in heart transplant recipients. We investigated the diagnostic and prognostic value of dobutamine thallium-201 ((201)Tl) single-photon emission computed tomography (SPECT) in heart transplant recipients. METHODS: We studied 47 patients (age 51.6 +/- 11.7 years, 37 men), at a mean of 34.0 +/- 21.4 months after heart transplant, who received dobutamine (201)Tl SPECT, echocardiography and coronary angiography within 1 month of each other. SPECT was considered abnormal in the presence of reversible or fixed defects in >/=2 segments. Significant CAV was defined as >/=50% luminal stenosis. RESULTS: Coronary angiograms were normal in 37 patients. Non-significant CAV was detected in 1 patient and significant CAV in 9 patients. The sensitivity, specificity, positive predictive value and negative predictive value of SPECT for the detection of significant angiographic CAV were 89%, 71%, 42% and 96%, respectively. Large reversible perfusion defects (>/=6 segments) always indicated significant CAV. In patients with normal left ventricular function, a lung/heart ratio (LHR) of >/=0.37 during stress was also an independent predictor of significant CAV (odds ratio 15.5, p = 0.04). A higher stress LHR was associated with greater vessel involvement (r = 0.516, p = 0.0002). Patients with impaired left ventricular function also had higher stress and resting LHR. Over 40.3 +/- 21.9 months after the first SPECT, 1 patient developed significant angiographic CAV and another 4 had cardiac death. Large reversible perfusion defect was a significant predictor of cardiac death (p = 0.002). CONCLUSIONS: Dobutamine (201)Tl SPECT is a useful method for detecting patients with significant CAV and assessing prognosis. It is reasonable and safe to design individualized surveillance intensity of coronary angiography for post-transplant patients on the basis of non-invasive monitoring of dobutamine (201)Tl testing.