Cardiovascular disease care fragmentation in kidney transplantation: a call for action

Coronary Revascularization Versus Optimal Medical Therapy in Renal Transplant Candidates With Coronary Artery Disease: A Systematic Review and Meta-Analysis

Background

Coronary artery disease (CAD) is highly prevalent in patients with chronic kidney disease and is a common cause of mortality in end‐stage renal disease. Thus, patients with end‐stage renal disease are routinely screened for CAD before renal transplantation. The usefulness of revascularization before transplantation remains unclear. We hypothesize that there is no difference in all‐cause and cardiovascular mortality in waitlisted renal transplant candidates with CAD who underwent revascularization versus those treated with optimal medical therapy before transplantation.

Methods and Results

This meta‐analysis was reported according to the Preferred Reporting Items for Systematic Review and Meta‐Analyses guidelines. MEDLINE, Scopus, and Cochrane Central Register of Controlled Trials were systematically searched to identify relevant studies. Risk of bias was assessed using the modified Newcastle‐Ottawa Scale and Cochrane risk of bias tool. The primary outcome of interest was all‐cause mortality. Eight studies comprising 945 patients were included (36% women, mean age 56 years). There was no difference in all‐cause mortality (risk ratio [RR], 1.16 [95% CI, 0.63–2.12), cardiovascular mortality (RR, 0.75 [95% CI, 0.29–1.89]), or major adverse cardiovascular events (RR, 0.78 [95% CI, 0.30–2.07]) when comparing renal transplant candidates with CAD who underwent revascularization versus those who were on optimal medical therapy before renal transplant.

Conclusions

This meta‐analysis demonstrates that revascularization is not superior to optimal medical therapy in reducing all‐cause mortality, cardiovascular mortality, or major adverse cardiovascular events in waitlisted kidney transplant candidates with CAD who eventually underwent kidney transplantation.

Role of a cardio-renal multi-disciplinary team meeting in managing cardiovascular risk in patients on kidney transplant waitlists

BACKGROUND

Waitlisted kidney transplant patients suffer from excess cardiovascular events. The benefits of regular cardiac investigations, potentially harmful and expensive, are unknown. We investigate the effectiveness of a cardio-renal MDT in managing high cardiovascular risk waitlisted transplant patients to prevent events and enable transplantation.

METHODS

Clinical outcomes in waitlisted transplant candidates managed by our cardio-renal MDT protocol were compared against our standard protocol. Data compared include the transplantation, event, and death rates, cost of cardiac investigations and procedures, and graft, patient survival, and re-hospitalization rates in transplanted patients.

RESULTS

207 patients were studied (81 standard, 126 cardio-renal MDT). Over 2.7 years, the cardio-renal MDT protocol transplanted more patients than the standard group (35% vs 21%; P = .02). The managing cost per patient per year was higher in the standard group (£692 vs £610). This was driven by more echocardiograms and more tests per patient in the standard group (P < .01). There was no difference in adverse events or death. There was no difference in re-hospitalization, graft or patient survival rate in transplanted patients.

CONCLUSIONS

Our cardio-renal MDT was effective in managing high-risk kidney transplant candidates with greater rates of transplantation and low rates of events at a lower cost.

Opportunities for Subspecialization in Nephrology

The interface between nephrology and other fields of medicine continues to expand. With the advent of novel therapies in cancer, diagnostics and therapeutics in lithology, novel devices in cardiology, advances in women's health issues, novel diagnostics and therapies in glomerular diseases, and the national priority in home-based dialysis, several subspecialties in nephrology have emerged. This article will discuss the subspecialties of onconephrology, cardionephrology, obstetric nephrology, uronephrology, glomerular disease specialization, and home-based dialysis in nephrology. We discuss the current state of each subspecialty, recommended educational content, length of training, available training opportunities, and potential career pathways for each.