The prognosis of kidney transplant recipients with aorto-iliac calcification: a systematic review and meta-analysis

Systematic, Pretransplant Screening by Aortoiliac CT Angiography: Impact on Surgical Decision-making and Clinical Outcomes

Background

Aortoiliac screening before kidney transplantation is suggested by some guidelines to select patients for transplantation and to assist surgical planning. We investigated the clinical outcomes of systematic screening for aortoiliac disease in potential kidney transplant candidates.

Methods

In this observational study, 470 potential kidney transplant candidates underwent aortoiliac computed tomography angiography. Patients were characterized by the presence of peripheral artery disease and calcification of iliac arteries and aortoiliac arteries. The risk of graft loss and graft function at 1 y posttransplant were examined and clinical decisions based on the vascular findings were assessed.

Results

Clinically diagnosed peripheral artery disease was present in 66 patients (14%), circular calcifications in 101 patients (21%), and aortoiliac stenosis in 77 patients (16%). In 326 patients undergoing kidney transplantation, circular calcification or aortoiliac stenosis was not associated with an increased risk of graft loss (P = 0.45 and P = 0.28) or estimated glomerular filtration rate (P = 0.23 and P = 0.76) at 1 y posttransplant. When evaluated for transplantability, clinical decision-making based on vascular findings was recorded in 67 of 429 patients (16%), including rejection for transplantation in 7 patients (2%) and laterality for surgical implantation in 52 patients (12%).

Conclusions

Systematic screening by aortoiliac computed tomography angiography may assist in surgical planning but seems of limited clinical value in assessing the risk of future graft loss and graft function in patients undergoing kidney transplantation.

Findings of Cardiovascular Workup of Kidney Transplant Candidates: A Retrospective Study of a Single-Center in Saudi Arabia

Background

There are limited data about the prevalence of cardiovascular (CV) risk factors and the findings of CV workup among kidney transplant (KTx) recipients (KTRs) in Saudi Arabia.

Methods

A single-center retrospective study of KTRs who underwent KTx from 2017 to 2020 was performed. We reviewed the prevalence of CV risk factors and the results of the pre-KTx CV workup which was derived from the American Heart Association guidelines.

Results

We included 254 KTRs. The mean age was 43.1 ± 15.9 years, and 55.5% were men and 79.5% were living-donor KTRs. Pre-emptive KTx was 9.8%, peritoneal dialysis was 11.8%, and hemodialysis was 78.3% (arteriovenous fistula: 33.1% versus hemodialysis catheter: 66.9%). The mean dialysis vintage was 4.8 ± 3.3 years for deceased-donor KTRs versus 2.4 ± 2.6 years for living-donor KTRs. CV risk factors were hypertension: 76%, diabetes: 40.6% (type 1 : 25.2% versus type 2 : 74.7%), hyperlipidemia (low-density lipoprotein >2.6 mmol/L): 40.2%, coronary artery disease (CAD): 12.6%, smoking: 9.1%, peripheral vascular disease: 2.8%, and cerebral vascular disease: 2.4%. The prevalence of obesity stage 1 was 19.7% and obesity stage 2 was 4%. Left ventricular hypertrophy was present in 38.5%. The ejection fraction was abnormal (<55%) in 22%. Abnormal wall motion was present in 34 patients (13.4%). A cardiac (PET-CT) stress test was conducted on 129 patients (50.8%) which showed abnormal perfusion in 37 patients (28.7%). Out of those who required PET-CT, 18.6% had a coronary artery calcium scoring (CACS) of more than 400, 41.8% had a CACS of zero, 29.4% had a CACS of 1-100, and 14.7% had a CACS of 100-400. Coronary angiogram was required in only 41 patients (16.1%), 12 (29.3%) required coronary interventions, 25 (61%) were treated medically, and 4 (9.8%) did not have any CAD. CT scans of pelvic arteries were performed in 118 patients (46.5%). It showed moderate or severe calcifications in only 7 patients (5.9%), whereas it was normal in 97 patients (82.2%), or it showed only mild calcifications in 14 patients (11.9%).

Conclusion

This study outlines the prevalence of CV risk factors and the findings of the pretransplant CV workup among KTx candidates who underwent KTx. Multicenter national studies will be helpful to validate the generalizability of these findings.

Association between sclerostin levels and vascular outcomes in kidney transplantation patients

BACKGROUND

The impact of circulating sclerostin levels on vascular calcification has shown conflicting results depending on the target population and vascular anatomy. This study investigated the associations of sclerostin levels with vascular outcomes in kidney transplant patients.

METHODS

In a prospective observational study of the Korean Cohort Study for Outcome in Patients with Kidney Transplantation, 591 patients with serum sclerostin level data prior to transplantation were analyzed. The main predictor was the pre-transplant sclerostin level. Vascular outcomes were the abdominal aortic calcification score and brachial-ankle pulse wave velocity measured at pre-transplant screening and three and five years after kidney transplantation.

RESULTS

In linear regression analysis, sclerostin level positively correlated with changes in abdominal aortic calcification score between baseline and five years after kidney transplantation (coefficient of 0.73 [95% CI, 0.11-1.35] and 0.74 [95% CI, 0.06-1.42] for second and third tertiles, respectively, vs the first tertile). In a longitudinal analysis over five years, using generalized estimating equations, the coefficient of the interaction (sclerostin × time) was significant with a positive value, indicating that higher sclerostin levels were associated with faster increase in post-transplant abdominal aortic calcification score. Linear regression analysis revealed a positive association between pre-transplant sclerostin levels and changes in brachial-ankle pulse wave velocity (coefficient of 126.7 [95% CI, 35.6-217.8], third vs first tertile). Moreover, a significant interaction was identified between sclerostin levels and brachial-ankle pulse wave velocity at five years.

CONCLUSIONS

Elevated pre-transplant sclerostin levels are associated with the progression of post-transplant aortic calcifications and arterial stiffness.

Lower Extremity Peripheral Arterial Disease and Its Relationship with Adverse Outcomes in Kidney Transplant Recipients: A Retrospective Cohort Study

The purpose of the study was to characterize lower extremity peripheral arterial disease (LEPAD) in a series of kidney transplant patients and to assess the impact on adverse outcomes. A retrospective cohort study was conducted including kidney transplant recipient patients who underwent screening for LEPAD. The outcomes evaluated were classified as perioperative and post-transplant, including cardiovascular events, amputation, mortality, and loss of the graft. A total of 141 renal transplant patients screened for LEPAD were identified, with an average follow-up of 3 years. LEPAD occurred in 14.2% (20/141). No differences in cardiovascular risk factors were found between the groups, except for smoking (45% vs. 24%, p < 0.05). In the group with LEPAD, the most compromised anatomical segment was the infrapopliteus, with no iliac involvement found. The Cox proportional hazards model indicated that the variables age, gender, and weight were significant in patients with LEPAD. There were no differences between the groups in terms of graft loss and death. The infrapopliteal segment is the area of greatest stenosis in kidney transplant patients with LEPAD. Together with smoking, they can explain the presence of major amputations in kidney transplant patients; however, they had no impact on graft functionality or death.

Findings of Cardiovascular Workup of Kidney Transplant Candidates: A Retrospective Study of a Single-Center in Saudi Arabia.. [DOI: 10.21203/rs.3.rs-3030184/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Background: There are limited data about the prevalence of cardiovascular (CV) risk factors and the findings of CV workup among kidney transplant (KTx) recipients (KTRs) in Saudi Arabia. Method: A single-center retrospective study of KTRs who underwent KTx from 2017 to 2020. We reviewed the prevalence of CV risk factors and the results of the pre-KTx CV workup which was derived from the American Heart Association guidelines. Results: We included 254 KTRs. The mean age was 43.1±15.9 years, 55.5% were men and 79.5% were living-donor KTRs. Pre-emptive KTx was 9.8%, peritoneal dialysis: 11.8% and hemodialysis: 78.3% (arteriovenous fistula: 33.1% versus hemodialysis catheter: 66.9%). Mean dialysis vintage was 4.8±3.3 years for deceased-donor KTRs versus 2.4±2.6 years for living-donor KTRs. CV risk factors were hypertension: 76%, diabetes: 40.6% (type 1: 25.2% versus type 2: 74.7%), hyperlipemia (low-density lipoprotein> 2.6 mmol/L): 40.2%, coronary artery disease (CAD): 12.6%, smoking: 9.1%, peripheral vascular disease: 2.8%, and cerebral vascular disease: 2.4%. The prevalence of obesity stage 1 was 19.7% and obesity stage 2 was 4%. Left ventricular hypertrophy was present in 38.5%. Ejection fraction was abnormal (<55%) in 22%. Abnormal wall motion was present in 34 patients (13.4%). Cardiac (PET-CT) stress test was indicated in 129 patients (50.8%) and showed abnormal perfusion in 37 patients (28.7%). Out of those who required PET-CT, 18.6% had coronary artery calcium scoring (CACS) more than 400, 41.8 had CACS of zero, 29.4% had CACS of 1-100, and 14.7% had CACS of 100-400. Coronary angiogram was required in only 41 patients (16.1%), 12 (29.3%) required coronary interventions, 25 (61%) were treated medically, and 4 (9.8%) did not have any CAD. CT scans of pelvic arteries were performed in 118 patients (46.5%). It showed moderate or severe calcifications in only 7 patients (5.9%), whereas it was normal in 97 patients (82.2%), or it showed only mild calcifications in 14 patients (11.9%). Conclusion: This study outlines the prevalence of CV risk factors and the findings of the pretransplant CV workup among KTx candidates who underwent KTx. Multicenter national studies will be helpful to validate the generalizability of these findings.

Ipsilateral Aorto-Iliac Calcification is Not Directly Associated With eGFR After Kidney Transplantation: A Prospective Cohort Study Analyzed Using a Linear Mixed Model

Aorto-iliac calcification (AIC) is a well-studied risk factor for post-transplant cardiovascular events and mortality. Its effect on graft function remains unknown. The primary aim of this prospective cohort study was to assess the association between AIC and estimated glomerular filtration rate (eGFR) in the first year post-transplant. Eligibility criteria were: ≥50 years of age or ≥30 years with at least one risk factor for vascular disease. A non-contrast-enhanced CT-scan was performed with quantification of AIC using the modified Agatston score. The association between AIC and eGFR was investigated with a linear mixed model adjusted for predefined variables. One-hundred-and-forty patients were included with a median of 31 (interquartile range 26-39) eGFR measurements per patient. No direct association between AIC and eGFR was found. We observed a significant interaction between follow-up time and ipsilateral AIC, indicating that patients with higher AIC scores had lower eGFR trajectory over time starting 100 days after transplant (p = 0.014). To conclude, severe AIC is not directly associated with lower post-transplant eGFR. The significant interaction indicates that patients with more severe AIC have a lower eGFR trajectory after 100 days in the first year post-transplant.

Atherosclerosis and Intrarenal Resistance Index in Kidney Transplant Recipients

Atherosclerosis of the aortoiliac vessels can adversely affect kidney perfusion after kidney transplantation. Atherosclerosis severity can be determined using the calcium score (CaScore). Potential problems with posttransplantation kidney perfusion can be determined using the intrarenal resistance index (RI). This study investigated the association between aortoiliac CaScore and RI in kidney transplant recipients.

Methods

Kidney transplant recipients (2004-2019), for whom the CaScore and RI were determined, were included in this dual-center cohort study. CaScore was measured in 3 aortoiliac segments using noncontrast CT imaging. RI was determined using Doppler ultrasound. Multivariable linear regression analyses were performed between the CaScore and RI, adjusted for confounding variables.

Results

The mean age of the 389 included patients was 59 (±13) y. The mean RI (unitless) was 0.71 (±0.09)' and the median CaScore (unitless) was 3340 (399-7833). In univariable linear regression analyses with RI as the dependent variable, CaScore (β = 0.011; P < 0.001) was positively associated with RI. Moreover, recipient age (β = 0.014; P < 0.001), history of diabetes (β = 0.029; P = 0.003), recipient history of vascular interventions (β = 0.032; P = 0.002), prior dialysis (β = 0.029; P = 0.003), deceased donor transplantation (β = 0.042; P < 0.001), donation after cardiac death (β = 0.036; P = 0.001), an increase in cold ischemia time (β = 0.011; P < 0.001), and the Comprehensive Complication Index (β = 0.006; P = 0.002) were also positively associated with RI, whereas preoperative recipient diastolic blood pressure (β = -0.007; P = 0.030) was inversely associated. In multivariable analyses, CaScore and RI remained significantly (P = 0.010) associated, independent of adjustment for potential confounders. Furthermore, in univariable linear regression analyses, multiple graft function characteristics were associated with RI.

Conclusions

A significant association was found between CaScore and RI, independent of adjustment for multiple potential confounding factors, leading to a better insight into the development and interpretation of RI. Aortoiliac atherosclerosis should be considered when interpreting the RI and determining the possible cause of malperfusion and graft failure after kidney transplantation.

A CT-based pelvic calcification score in kidney transplant patients is a possible predictor of graft and overall survival

OBJECTIVES

Computerized tomography (CT) is the most accurate method for evaluating pelvic calcifications, which are of utmost importance for planning kidney transplantation (KT). The aim of our study was to evaluate the incidence and distribution of iliac artery calcifications and correlate the novel pelvic calcification score (PCS) with cardiovascular risk factors and graft and overall survival in KT patients.

METHODS

We retrospectively included 118 KT patients operated at our institution with pretransplant pelvic CT. Calcification morphology, circumference and length of both common and external iliac arteries were independently scored by two uroradiologists. PCS was calculated as the total score sum of all three calcification features in all vessels. PCS correlation with graft and patient survival was performed.

RESULTS

Calcification in at least one vascular segment was found in 79% of patients. PCS was significantly higher in male patients (p = 0.006), patients over 55 years (p < 0.001), and patients on haemodialysis (p = 0.016). Patients with a PCS >3 had significantly shorter graft and overall survival rates (p = 0.041 and p = 0.039, respectively).

CONCLUSIONS

The extent of iliac artery calcification in KT recipients quantified by PCS on pretransplant CT correlates with graft and overall patient survival. A PCS over three was associated with worse clinical outcomes and could become a possible prognostic factor.

ADVANCES IN KNOWLEDGE

Our novel PCS is a robust method for quantifying iliac artery calcification burden. Since higher a PCS correlates with worse patient and graft survival, PCS has the potential to become a prognostic factor in kidney transplant patients.

Association of Abdominal Arterial Calcification Score with Patients' Survival and Kidney Allograft Function after Kidney Transplant

BACKGROUND

Abdominal arterial calcification (AAC) is common among candidates for kidney transplant. The aim of this study is to correlate AAC score value with post-kidney transplant outcomes.

METHODS

We modified the coronary calcium score by changing the intake data points and used it to quantitate the AAC. We conducted a retrospective clinical study of all adult patients who were transplanted at our center, between 2010 and 2013, and had abdominal computed tomography scan done before transplantation. Outcomes included mortality, pulse pressure (PP) measured by 24 h ambulatory blood pressure monitoring system, and kidney allograft function measured by iothalamate clearance.

RESULTS

For each 1000 increase of AAC score value, there is an associated 1.05 increase in the risk of death (95% CI 1.02, 1.08) (p < 0.001). Overall median AAC value for all patients was 1784; Kaplan-Meier curve showed reduced survival of all-cause mortality for patients with AAC score value above median and reduced survival among patients with cardiac related mortality. The iothalamate clearance was lower among patients with total AAC score value above the median. Patients with abnormal PP (< 40 or > 60 mmHg) had an elevated median AAC score value at 4319.3 (IQR 1210.4, 11097.1) compared to patients with normal PP with AAC score value at 595.9 (IQR 9.9, 2959.9) (p < 0.001).

CONCLUSION

We showed an association of AAC with patients' survival and kidney allograft function after kidney transplant. The AAC score value could be used as a risk stratification when patients are considered for kidney transplant.

Risk of post-transplant cardiovascular events in kidney transplant recipients with preexisting aortoiliac stenosis

Prediction of the risk of cardiovascular events (CVE's) is important to optimize outcomes after kidney transplantation. Aortoiliac stenosis is frequently observed during pre‐transplant screening. We hypothesized that these patients are at higher risk of post‐transplant CVE's due to the joint underlying atherosclerotic disease. Therefore, we aimed to assess whether aortoiliac stenosis was associated with post‐transplant CVE's. This retrospective, single‐center cohort study included adult kidney transplant recipients, transplanted between 2000 and 2016, with contrast‐enhanced imaging available. Aortoiliac stenosis was classified according to the Trans‐Atlantic Inter‐Society Consensus (TASC) II classification and was defined as significant in case of ≥50% lumen narrowing. The primary outcome was CVE‐free survival. Eighty‐nine of 367 patients had significant aortoiliac stenosis and were found to have worse CVE‐free survival (median CVE‐free survival: stenosis 4.5 years (95% confidence interval (CI) 2.8–6.2), controls 8.9 years (95% CI 6.8–11.0); log‐rank test P < .001). TASC II C and D lesions were independent risk factors for a post‐transplant CVE with a hazard ratio of 2.15 (95% CI 1.05–4.38) and 6.56 (95% CI 2.74–15.70), respectively. Thus, kidney transplant recipients with TASC II C and D aortoiliac stenosis require extensive cardiovascular risk management pre‐, peri,‐ and post‐transplantation.

Screening, Management, and Acceptance of Patients with Aorto-Iliac Vascular Disease for Kidney Transplantation: A Survey among 161 Transplant Surgeons

INTRODUCTION

Aorto-iliac vascular disease (AVD) is frequently found during the workup for kidney transplantation. However, recommendations on screening and management are lacking. We aimed to assess differences in screening, management, and acceptance of these patients for transplantation by performing a survey among transplant surgeons. Second, we aimed to identify center- and surgeon-related factors associated with decline or acceptance of kidney transplant candidates with AVD.

METHODS

A survey was sent to transplant surgeons and urologists. The survey contained general questions (part I) and 2 patient-based cases (part II) with Trans-Atlantic Inter-Society Consensus (TASC) D and B AVD supported with videos of their CT scans.

RESULTS

One hundred ninety-one (20.3%) participants responded; 171 were currently involved in kidney transplantation: 161 (94.2%) completed part I and 145 (84.8%) part II. Screening for AVD was often (38.5%) restricted to high-risk patients. The majority of respondents (67.7%) rated "technical problems" as the most important concern in case of AVD, followed by "increased mortality risk because of cardiovascular comorbidity" (29.8%). Pretransplant vascular interventions to facilitate transplantation were infrequently performed (71.4% mentioned <10 per year). Ninety (64.3%) respondents answered that an open vascular procedure should preferably be performed prior to kidney transplantation while 42 (30.0%) respondents preferred a simultaneous open vascular procedure. The decline rate was higher in the TASC D case compared to the TASC B case (26.9% and 9.7%, respectively). Respondents from centers with expertise in pretransplant vascular interventions were more likely to accept both patients with TASC D and B for transplantation.

CONCLUSION

There is no uniformity in the screening, management, and acceptance of patients with AVD for transplantation. If a center declines a patient with AVD because of technical concerns, the patient should be referred for a second opinion to a tertiary center with expertise in pretransplant vascular interventions. Multidisciplinary meetings including a vascular surgeon and a cardiologist could help optimize these patients for transplantation.

Selective screening imaging of the aortoiliac arterial system in kidney transplant candidates with non-contrast pelvic computed tomography

Non-contrast pelvic computed tomography (CT) can detect severe iliac artery calcifications that present technical contraindications to kidney transplantation (TCT). We screened 454 asymptomatic patients with a history of any of the following: hemodialysis >10 years, diabetes mellitus >20 years, coronary artery disease (CAD) with percutaneous or surgical interventions, carotid disease, diabetes with below-/above-knee amputations, and heart-kidney transplantation candidacy. Patients with normal dorsalis pedis and/or tibialis posterior pulses were not screened. A total of 8.4% had severe calcifications with TCT; CT determined laterality for implantation in 13.9%. No patients with the following characteristics were classified as TCT: age <40 years, hemodialysis >10 years, carotid arterial disease, prior lower extremity amputation, or heart-kidney transplantation candidacy. CAD was associated with TCT in univariate though not multivariate analysis. Limiting screening to patients >40 years, with DM >20 years, or with CAD, 9.8% had a TCT and CT determined transplant laterality in 14.2%. Screening for severe iliac artery calcifications is useful for selected kidney transplantation candidates over age 40. It can assist with laterality choice or surgeon determination of TCT. Cost and radiation exposure risks should be weighed against the morbidity risks from unnecessary surgery.

Working towards an ERAS Protocol for Pancreatic Transplantation: A Narrative Review

Enhanced recovery after surgery (ERAS) initially started in the early 2000s as a series of protocols to improve the perioperative care of surgical patients. They aimed to increase patient satisfaction while reducing postoperative complications and postoperative length of stay. Despite these protocols being widely adopted in many fields of surgery, they are yet to be adopted in pancreatic transplantation: a high-risk surgery with often prolonged length of postoperative stay and high rate of complications. We have analysed the literature in pancreatic and transplantation surgery to identify the necessary preoperative, intra-operative and postoperative components of an ERAS pathway in pancreas transplantation.

Cardiovascular calcifications in kidney transplant recipients

Vascular and valvular calcifications are highly prevalent in kidney transplant recipients and are associated with an increased risk of cardiovascular events, which represent the leading cause of long-term mortality in these patients. However, cardiovascular calcification has been traditionally considered as a condition mostly associated with advanced chronic kidney disease stages and dialysis, and comparatively fewer studies have assessed its impact after kidney transplantation. Despite partial or complete resolution of uremia-associated metabolic derangements, kidney transplant recipients are still exposed to several pro-calcifying stimuli that favour the progression of pre-existing vascular calcifications or their de novo development. Traditional risk factors, bone mineral disorders, inflammation, immunosuppressive drugs and deficiency of calcification inhibitors may all play a role, and strategies to correct or minimize their effects are urgently needed. The aim of this work is to provide an overview of established and putative mediators involved in the pathogenesis of cardiovascular calcification in kidney transplantation, and to describe the clinical and radiological features of these forms. We also discuss current evidence on preventive strategies to delay the progression of cardiovascular calcifications in kidney transplant recipients, as well as novel therapeutic candidates to potentially prevent their long-term deleterious effects.

Aorto-Iliac Artery Calcification and Graft Outcomes in Kidney Transplant Recipients

While the association of vascular calcification with inferior patient outcomes in kidney transplant recipients is well-established, the association with graft outcomes has received less attention. With this dual-centre cohort study, we aimed to determine the clinical impact of recipient pre-transplant aorto-iliac calcification, measured on non-contrast enhanced computed tomography (CT)-imaging within three years prior to transplantation (2005-2018). We included 547 patients (61.4% male, age 60 (interquartile range 51-68) years), with a median follow-up of 3.1 (1.4-5.2) years after transplantation. The aorto-iliac calcification score (CaScore) was inversely associated with one-year estimated-glomerular filtration rate (eGFR) in univariate linear regression analysis (standard β -3.3 (95% CI -5.1 to -1.5, p < 0.0001), but not after adjustment for potential confounders, including donor and recipient age (p = 0.077). In multivariable Cox regression analyses, a high CaScore was associated with overall graft failure (p = 0.004) and death with a functioning graft (p = 0.002), but not with death-censored graft failure and graft function decline. This study demonstrated that pre-transplant aorto-iliac calcification is associated with one-year eGFR in univariate, but not in multivariable linear regression analyses. Moreover, this study underlines that transplantation in patients with a high CaScore does not result in earlier transplant function decline or worse death censored graft survival, although ongoing efforts for the prevention of death with a functioning graft remain essential.

Aorto-Iliac Artery Calcification Prior to Kidney Transplantation

As vascular calcification is common in kidney transplant candidates, aorto-iliac vessel imaging is performed for surgical planning. The aim of the present study was to investigate whether a novel non-contrast enhanced computed tomography-based quantification technique for aorto-iliac calcification can be used for cardiovascular risk stratification prior to kidney transplantation. In this dual-center cohort study, we measured the aorto-iliac calcium score (CaScore) of 547 patients within three years prior to transplantation (2005-2018). During a median (interquartile range) follow-up of 3.1 (1.4, 5.2) years after transplantation, 80 (14.7%) patients died, of which 32 (40.0%) died due to cardiovascular causes, and 84 (15.5%) patients had a cardiovascular event. Kaplan-Meier survival curves showed significant differences between the CaScore tertiles for cumulative overall-survival (Log-rank test p < 0.0001), cardiovascular survival (p < 0.0001), and cardiovascular event-free survival (p < 0.001). In multivariable Cox regression, the aorto-iliac CaScore was associated with all-cause mortality (hazard ratio 1.53, 95%CI 1.14-2.06, p = 0.005), cardiovascular mortality (2.04, 1.20-3.45, p = 0.008), and cardiovascular events (1.35, 1.01-1.80, p = 0.042). These independent associations of the aorto-iliac CaScore with the outcome measures can improve the identification of patients at risk for (cardiovascular) death and those who could potentially benefit from stringent cardiovascular monitoring to improve their prognosis after transplantation.