Preoperative Cardiovascular Assessment of the Renal Transplant Recipient: A Narrative Review

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.

Screening and Management of Coronary Artery Disease in Kidney Transplant Candidates

Cardiovascular disease (CVD) is a major cause of morbidity and mortality in patients with chronic kidney disease (CKD), especially in end-stage renal disease (ESRD) patients and during the first year after transplantation. For these reasons, and due to the shortage of organs available for transplant, it is of utmost importance to identify patients with a good life expectancy after transplant and minimize the transplant peri-operative risk. Various conditions, such as severe pulmonary diseases, recent myocardial infarction or stroke, and severe aorto-iliac atherosclerosis, need to be ruled out before adding a patient to the transplant waiting list. The effectiveness of systematic coronary artery disease (CAD) treatment before kidney transplant is still debated, and there is no universal screening protocol, not to mention that a nontailored screening could lead to unnecessary invasive procedures and delay or exclude some patients from transplantation. Despite the different clinical guidelines on CAD screening in kidney transplant candidates that exist, up to today, there is no worldwide universal protocol. This review summarizes the key points of cardiovascular risk assessment in renal transplant candidates and faces the role of noninvasive cardiovascular imaging tools and the impact of coronary revascularization versus best medical therapy before kidney transplant on a patient's cardiovascular outcome.

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.

Interplay between Risk Factors and Coronary Artery Calcium in Middle-Aged and Elderly Symptomatic Patients

Background

The prognostic value of coronary artery calcium (CAC) combined with risk factor burdens in middle-aged and elderly patients with symptoms is unclear.

Methods

A cohort study comprising 7432 middle-aged and elderly symptomatic patients (aged above 55 years) was conducted between December 2013 and September 2020. All patients had undergone coronary computed tomography angiography, and the Agatston score were used to measure CAC scores. The primary outcome was major adverse cardiac and cerebrovascular events (MACCE), which was defined as a composite outcome of nonfatal myocardial infarction, revascularization (percutaneous coronary intervention or coronary artery bypass graft), stroke, and cardiovascular death. Congestive heart failure, cardiogenic shock, malignant arrhythmia, and all-cause mortality were defined as the secondary outcomes.

Results

There are 970 (13%) patients with CAC 0-10, 2331 (31%) patients with CAC 11-100, and 4131 (56%) patients with CAC ≥ 101. The proportion of patients aged 55-65 years, 65-75 years and ≥ 75 years was 40.7%, 38.1% and 21.2%, respectively. The total number of MACCEs over the 3.4 years follow-up period was 478. The percentage of CAC ≥ 101 was higher among the 75-year-old group than the 55-65-year-old group, increasing from 46.5% to 68.2%. With the increase in the CAC score, the proportion of patients aged ≥ 75 years increased from 12.9% to 25.8%, compared to those aged 55-65 years. The number of risk factors gradually increased as the CAC scores increased in the symptomatic patients aged over 55 years and the similar tendencies were observed among the different age subgroups. The proportion of non-obstructive coronary artery disease (CAD) was comparable between the three age groups (53.5% vs 51.9% vs 49.1%), but obstruction CAD increased with age. The incidence of MACCE in the group with CAC ≥ 101 and ≥ 4 risk factors was 1.71 times higher (95% confidence interval (CI) 1.01-2.92; p = 0.044) than the rate in the group with CAC ≥ 101 and 1 risk factor. In the CAC 0-10 group, the incidence of MACCE in patients aged ≥ 75 years was 12.65 times higher (95% CI: 6.74-23.75; p < 0.0001) than that in patients aged 55-65 years. By taking into account the combination of CAC score, age, and risk factor burden, the predictive power of MACCE can be increased (area under the curve (AUC) = 0.614).

Conclusions

In symptomatic patients aged 55 or above, a rise in age, CAC scores, and risk factor burden was linked to a considerable risk of future MACCE. In addition, combining CAC scores, age and risk factors can more accurately predict outcomes for middle-aged and elderly patients with symptoms.

Low dose sacubitril/valsartan is effective and safe in hemodialysis patient with decompensated heart failure and hypotension: A case report

RATIONALE

Severe heart failure in chronic hemodialysis (HD) patients is a great treatment challenge. Here we reported a chronic HD patient with the lowest ejection fraction reported so far and hypotension who well tolerated and benefited from angiotensin-receptor neprilysin inhibitor (ARNI) treatment.

PATIENT CONCERNS

This case was a 67 year old lady with decompensated heart failure and hypotension who was on regular HD. Intensified hemofiltration failed to improve her heart failure symptoms and was also retarded by hypotension.

DIAGNOSIS

Chronic HD with decompensated heart failure.

INTERVENTIONS

In addition to regular HD, low does sacubitril/valsartan was initiated and titrated from 12/13 mg to 24/26 mg twice daily.

OUTCOMES

Sacubitril/valsartan treatment was well tolerated and did not affect ultrafiltration during HD treatment. Transthoracic echocardiology at 3 months after initiation of ARNI treatment indicated significant improvement of both systolic and diastolic cardiac function. The patient has improved from New York Heart Association class 4 to class 2.

LESSONS

Low does ARNI treatment could effectively improve cardiac function in HD patients with heart failure and hypotension. It was also safe and well tolerated.