Inequity in Access to Transplantation in the United Kingdom

Impact of Asian and Black Donor and Recipient Ethnicity on the Outcomes After Deceased Donor Kidney Transplantation in the United Kingdom

Patients of Asian and black ethnicity face disadvantage on the renal transplant waiting list in the UK, because of lack of human leucocyte antigen and blood group matched donors from an overwhelmingly white deceased donor pool. This study evaluates outcomes of renal allografts from Asian and black donors. The UK Transplant Registry was analysed for adult deceased donor kidney only transplants performed between 2001 and 2015. Asian and black ethnicity patients constituted 12.4% and 6.7% of all deceased donor recipients but only 1.6% and 1.2% of all deceased donors, respectively. Unadjusted survival analysis demonstrated significantly inferior long-term allograft outcomes associated with Asian and black donors, compared to white donors. On Cox-regression analysis, Asian donor and black recipient ethnicities were associated with poorer outcomes than white counterparts, and on ethnicity matching, compared with the white donor-white recipient baseline group and adjusting for other donor and recipient factors, 5-year graft outcomes were significantly poorer for black donor-black recipient, Asian donor-white recipient, and white donor-black recipient combinations in decreasing order of worse unadjusted 5-year graft survival. Increased deceased donation among ethnic minorities could benefit the recipient pool by increasing available organs. However, it may require a refined approach to enhance outcomes.

Bariatric Surgery as a Bridge to Facilitate Renal Transplantation in Patients with End-Stage Renal Disease

PURPOSE

Renal transplantation (RT) is not recommended above BMI 40 kg/m2 as post-operative risks (delayed graft function, wound complications) are increased. Bariatric surgery (BS) results in sustained long-term weight loss. However, renal failure (RF) patients are theoretically higher risk candidates. We aim to investigate the safety of BS in patients with RF and the effect of BS on access to renal transplantation.

METHODS

We reviewed data from 31 patients with RF referred for BS between 2013 and 2021. We compared the outcomes of patients with RF who underwent BS to those who were referred but did not undergo BS. Controls matched for age/BMI/comorbidity (MC) but without RF were used for comparison.

RESULTS

Of 31 patients referred, 19 proceeded with BS (68% female, median age 52 years, BMI 46.2 ± 4.9 kg/m2) and 12 did not (58% female, median age 58, mean BMI 41.5 ± 4.1). Excess body weight loss (EBWL) was 71.2% ± 20.2% at 2 years in RF patients versus 66.0% ± 28.0% in MC patients. In the operated group, 11/19 (58%) patients reached their treatment target (six transplanted, five placed on waiting list) versus 3/12 (25%) in unoperated patients (three transplanted). There was no difference in perioperative complications between RF and MC groups. Long-term, there were seven deaths amongst RF patients (two operated, five unoperated), none amongst the MC group.

CONCLUSION

BS in patients with RF increased access to RT and was safe and effective. We therefore recommend consideration of BS in patients with obesity and RF in specialised units.

Spatial analysis of care for patients undergoing dialysis therapy in the state of Minas Gerais, Brazil, between 2015 and 2019

OBJECTIVE

To analyze the spatial flow of care for patients undergoing dialysis therapy in the health regions of the State of Minas Gerais.

METHODS

Ecological study whose population was patients undergoing dialysis therapy in public, philanthropic institutions or whose treatment was paid for by the Unified Health System in private clinics in partnership, in the State of Minas Gerais. Patients were grouped by health region of residence. The proportions of patients who underwent dialysis were calculated, as well as enrollment on the kidney transplant list in their own region of residence or outside it. Person correlations of these proportions with socioeconomic and care indicators of the health regions were estimated. Spatial exploratory techniques estimated general (Moran's I) and local (LISA) spatial correlation coefficients.

RESULTS

Regions with higher GDP had a higher number of nephrologists and a higher proportion of registrations in the region of residence. A cluster of regions with low GDP was identified further to the northeast of the State (also with lower nephrologist ratio values), a cluster with a high proportion of those registered on the transplant list in the center of the State, and a cluster with a low proportion of dialysis in the same region of residence further southeast.

CONCLUSION

Regional disparities were evident in relation to the proportion of patients registered on the waiting list for kidney transplantation, the proportion of patients undergoing dialysis in the same region of residence and the proportion of patients registered on the waiting list for kidney transplantation in the same region of residence. residence.

An introduction to realist evaluation and synthesis for kidney research

Realist research describes a methodological approach that aims to explore how and why interventions work, for whom, and under what circumstances. Rather than quantifying how well an intervention works under specific conditions, realist theory explores the function of interventions in detail and specifically considers how the contexts in which interventional components are delivered influence the mechanisms that lead to outcomes. Realist methods can be applied to primary data (realist evaluation) or secondary data (realist synthesis). Although realist techniques are increasingly being used in the evaluation of complex interventions, there are relatively few published studies in the field of kidney care. In this review, we outline the theory and principles behind realist methods through discussion of a published realist synthesis describing complex interventions promoting delivery of optimal chronic kidney disease care. We discuss other kidney studies that have used realist methodology and situations where realist techniques could be applied to advance our understanding of how to best deliver care to patients with kidney disease.

Mitigating Health Disparities in Transplantation Requires Equity, Not Equality

Despite decades of research and evidence-based mitigation strategies, disparities in access to transplantation persist for all organ types and in all stages of the transplant process. Although some strategies have shown promise for alleviating disparities, others have fallen short of the equity goal by providing the same tools and resources to all rather than tailoring the tools and resources to one's circumstances. Innovative solutions that engage all stakeholders are needed to achieve equity regardless of race, sex, age, socioeconomic status, or geography. Mitigation of disparities is paramount to ensure fair and equitable access for those with end-stage disease and to preserve the trust of the public, upon whom we rely for their willingness to donate organs. In this overview, we present a summary of recent literature demonstrating persistent disparities by stage in the transplant process, along with policies and interventions that have been implemented to combat these disparities and hypotheses for why some strategies have been more effective than others. We conclude with future directions that have been proposed by experts in the field and how these suggested strategies may help us finally arrive at equity in transplantation.

Disparities in lung transplantation in children

Lung transplantation is a recognized therapy for end-stage respiratory failure in children and young people. It is only available in selected countries and is limited by access to suitable organs. Data on disparities in access and outcomes for children undergoing lung transplantation are limited. It is clear from data from studies in adults, and from studies in other solid organ transplants in children, that systemic inequities exist in this field. While data relating specifically to pediatric lung transplantation are relatively sparse, professionals should be aware of the risk that healthcare systems may result in disparities in access and outcomes following lung transplantation in children.

Pre-dialysis care trajectory and post-dialysis survival and transplantation access in patients with end-stage kidney disease

BACKGROUND

The pre-dialysis care trajectory impact on post-dialysis outcomes is poorly known. This study assessed survival, access to kidney transplant waiting list and to transplantation after dialysis initiation by taking into account the patients' pre-dialysis care consumption (inpatient and outpatient) and the conditions of dialysis start: initiation context (emergency or planned) and vascular access type (catheter or fistula).

METHODS

Adults who started dialysis in France in 2015 were included. Clinical data came from the French REIN registry and data on the care trajectory from the French National Health Data system (SNDS). The Cox model was used to assess survival and access to kidney transplantation.

RESULTS

We included 8856 patients with a mean age of 68 years. Survival was shorter in patients with emergency or planned dialysis initiation with a catheter compared to patients with planned dialysis with a fistula. The risk of death was lower in patients who were seen by a nephrologist more than once in the 6 months before dialysis than in those who were seen only once. The rate of kidney transplant at 1 year post-dialysis was lower for patients with emergency or planned dialysis initiation with a catheter (respectively, HR = 0.5 [0.4; 0.8] and HR = 0.7 [0.5; 0.9]) compared to patients with planned dialysis start with a fistula. Patients who were seen by a nephrologist more than three times between 0 and 6 months before dialysis start were more likely to access the waiting list 1 and 3 years after dialysis start (respectively, HR = 1.3 [1.1; 1.5] and HR = 1.2 [1.1; 1.4]).

CONCLUSIONS

Nephrological follow-up in the year before dialysis initiation is associated with better survival and higher probability of access to kidney transplantation. These results emphasize the importance of early patient referral to nephrologists by general practitioners.

Inequities in Organ Donation and Transplantation Among Immigrant Populations in Italy: A Narrative Review of Evidence, Gaps in Research and Potential Areas for Intervention

Immigrants from outside Europe have increased over the past two decades, especially in Southern European countries including Italy. This influx coincided with an increased number of immigrants with end-stage organ diseases. In this narrative review, we reviewed evidence of the gaps between native-born and immigrant populations in the Organ Donation and Transplantation (ODT) process in Italy. Consistent with prior studies, despite the availability of a publicly funded health system with universal healthcare coverage, non-European-born individuals living in Italy are less likely to receive living donor kidney transplantation and more likely to have inferior long-term kidney graft function compared with EU-born and Eastern European-born individuals. While these patients are increasingly represented among transplant recipients (especially kidney and liver transplants), refusal rates for organ donation are higher in some ethnic groups compared with native-born and other foreign-born referents, with the potential downstream effects of prolonged waiting times and inferior transplant outcomes. In the process, we identified gaps in relevant research and biases in existing studies. Given the Italian National Transplant Center's (CNT) commitment to fighting inequities in ODT, we illustrated actions taken by CNT to tackle inequities in ODT among immigrant communities in Italy.

Variation in Kidney Transplant Referral Across Chronic Kidney Disease Programs in Ontario, Canada

Background

Eligible patients with kidney failure should have equal access to kidney transplantation. Transplant referral is the first crucial step toward receiving a kidney transplant; however, studies suggest substantial variation in the rate of kidney transplant referral across regions. The province of Ontario, Canada, has a public, single-payer health care system with 27 regional chronic kidney disease (CKD) programs. The probability of being referred for kidney transplant may not be equal across CKD programs.

Objective

To determine whether there is variability in kidney transplant referral rates across Ontario's CKD programs.

Design

Population-based cohort study using linked administrative health care databases from January 1, 2013, to November 1, 2016.

Setting

Twenty-seven regional CKD programs in the province of Ontario, Canada.

Patients

Patients approaching the need for dialysis (advanced CKD) and patients receiving maintenance dialysis (maximum follow-up: November 1, 2017).

Measurements

Kidney transplant referral.

Methods

We calculated the 1-year unadjusted cumulative probability of kidney transplant referral for Ontario's 27 CKD programs using the complement of Kaplan-Meier estimator. We calculated standardized referral ratios (SRRs) for each CKD program, using expected referrals from a 2-staged Cox proportional hazards model, adjusting for patient characteristics in the first stage. Standardized referral ratios with a value less than 1 were below the provincial average (maximum possible follow-up of 4 years 10 months). In an additional analysis, we grouped CKD programs according to 5 geographic regions.

Results

Among 8641 patients with advanced CKD, the 1-year cumulative probability of kidney transplant referral ranged from 0.9% (95% confidence interval [CI]: 0.2%-3.7%) to 21.0% (95% CI: 17.5%-25.2%) across the 27 CKD programs. The adjusted SRR ranged from 0.2 (95% CI: 0.1-0.4) to 4.2 (95% CI: 2.1-7.5). Among 6852 patients receiving maintenance dialysis, the 1-year cumulative probability of transplant referral ranged from 6.4% (95% CI: 4.0%-10.2%) to 34.5% (95% CI: 29.5%-40.1%) across CKD programs. The adjusted SRR ranged from 0.2 (95% CI: 0.1-0.3) to 1.8 (95% CI: 1.6-2.1). When we grouped CKD programs according to geographic region, we found that patients residing in Northern regions had a substantially lower 1-year cumulative probability of transplant referral.

Limitations

Our cumulative probability estimates only captured referrals within the first year of advanced CKD or maintenance dialysis initiation.

Conclusions

There is marked variability in the probability of kidney transplant referral across CKD programs operating in a publicly funded health care system.

Motivos referidos pelos indivíduos que não estavam em lista de espera para o transplante renal

RESUMO Objetivo: Descrever os motivos referidos pelos indivíduos em hemodiálise que não estavam cadastrados em lista de espera para o transplante renal. Métodos: Estudo transversal realizado no Rio Grande do Sul, Brasil em seis serviços de terapia de substituição renal com 214 indivíduos em hemodiálise que referiram os motivos de não estarem cadastrados em lista de espera para o transplante renal. A coleta de dados foi realizada por meio de questionário entre março de 2016 e março de 2017. Para a análise estatística descritiva e do teste de independência, utilizou-se o software Stata. Resultados: Os principais motivos referidos pelos 214 indivíduos que não estavam cadastrados em lista de espera para o transplante renal foram: a falta de informação dos indivíduos, não desejar estar em lista, o impedimento por multimorbidade e a idade. Conclusões: A falta de informação apresentou associação com as variáveis baixa escolaridade, sexo masculino, ≤ 5 anos de tempo de diagnóstico e ≤ 5 anos em terapia de substituição renal. O motivo não desejar estar em lista esteve associado com as variáveis não saber ler e idade.

Reasons referred by individuals who were not on kidney transplantation waiting lists

OBJECTIVE

To describe the reasons reported by individuals in hemodialysis that were not registered on kidney transplantation waiting lists.

METHODS

Cross-sectional study conducted in six renal replacement therapy services in Rio Grande do Sul, Brazil with 214 individuals undergoing hemodialysis who reported the reasons for not being registered on kidney transplantation waiting lists. The data collection was carried out through a questionnaire from March 2016 to March 2017. The Stata software was used to the statistical analysis and independence test.

RESULTS

The main reasons reported by the 214 individuals who were not registered on kidney transplantation waiting lists were due to the lack of information of the individuals, not wanting to be on list, due to morbidities and age.

CONCLUSIONS

The lack of information was associated with the variables low education, male, ≤ 5 years of time since diagnosis and ≤ 5 years in renal replacement therapy. The reason for not wanting to be on the list was associated with the variables illiteracy and age.

Perception of social inequities in the access to the kidney transplant waiting list by nephrology trainees: a national survey

BACKGROUND

Social inequalities in health are responsible for disparities in access to the kidney transplant waiting list (KTWL). The perception of disparities by nephrologists has consequences for the registration on the KTWL. The purposes of our study were to assess the perception of the factors implicated in the disparities in access to the KTWL by nephrology trainees and to assess the quality of the questionnaire.

METHODS

A questionnaire was developed to assess the perception of the determinants of the inequities in access to waitlisting. Continuous variables were described by median, 1st and 3rd quartiles. Categorical variables were described by frequencies and percentages. A principal component analysis and a hierarchical cluster analysis were performed to approach the correlation between the variables. A scree plot and a factor analysis were performed to determine the dimensions of the questionnaire. The internal consistency was estimated by Cronbach's coefficient.

RESULTS

The response rate was 98/110 (89%). The determinants of inequities in the access to KTWL not perceived by the nephrology trainees were "female sex", "income level" and "the centre provision to adapt the information to all of the patients" (18,3%, 36,7, 47% respectively). "Age", "being born abroad", "place of living", "education level", "transplant centre", "the health care provider" were determinants of disparities perceived by most of the trainees (85,7%, 75,5%, 82,6%, 78,6%, 73,5% et 78,5% respectively). Items related to the transplant centre were positively correlated, as well as "being born abroad", "education level" and "income level". The Cronbach's coefficient was 0,60.

CONCLUSION

Social inequalities in health are partially perceived by nephrology trainees. A teaching session could raise nephrologists' awareness of this issue and could help reduce the impact of these disparities on the course of ESKD (end-stage kidney disease) patients.

Care processes and outcomes of deprivation across the clinical course of kidney disease: findings from a high-income country with universal healthcare

BACKGROUND

No single study contrasts the extent and consequences of inequity of kidney care across the clinical course of kidney disease.

METHODS

This population study of Grampian (UK) followed incident presentations of AKI, and incident eGFR thresholds of < 60, <45 and < 30 in separate cohorts (2011-2021). The key exposure was area-level deprivation (lowest quintile of the Scottish Index of Multiple Deprivation). Outcomes were care processes (monitoring, prescribing, appointments, unscheduled care); long-term mortality; and kidney failure. Modelling involved multivariable logistic regression, negative binomial regression, and cause specific Cox models with/without adjustment of comorbidities.

RESULTS

There were 41 313, 51 190, 32 171, and 17 781 new presentations of AKI, and eGFR thresholds < 60, <45 and < 30. 6.1-7.8% were from deprived areas, and (vs all others) presented on average five years younger, with more diabetes, pulmonary and liver disease. Those from deprived areas were more likely to present initially in hospital, less likely to receive community monitoring, less likely to attend appointments, and more likely to have an unplanned emergency department or hospital admission episode. Deprivation had greatest association with long-term kidney failure at the eGFR < 60 threshold (adjusted HR 1.48, 1.17-1.87), and this association attenuated with advancing disease severity (HR 1.09, 0.93-1.28 at eGFR < 30); with a similar pattern for mortality. Across all analyses the most detrimental associations of deprivation were at an eGFR < 60 threshold, AKI, males, and those aged < 65 years.

CONCLUSIONS

Even in a high-income country with universal healthcare, serious and consistent inequities of kidney care exist. The poorer care and outcomes with area-level deprivation were greater earlier in the disease course.

Pancreas Transplantation in Black, Asian and Minority Ethnic Patients-Single Centre Experience in the UK

Ethnic disparities in the outcomes after simultaneous pancreas kidney (SPK) transplantation still exist. The influence of ethnicity on the outcomes of pancreas transplantation in the UK has not been reported and hence we aimed to investigate our cohort. A retrospective analysis of all pancreas transplant recipients (n = 171; Caucasians = 118/Black Asian Ethnic Minorities, BAME = 53) from 2006 to 2020 was done. The median follow-up was 80 months. Patient &amp; pancreas graft survival, rejection rate, steroid free maintenance rate, HbA1c, weight gain, and the incidence of secondary diabetic complications post-transplant were compared between the groups. p &lt; 0.003 was considered significant (corrected for multiple hypothesis testing). Immunosuppression consisted of alemtuzumab induction and steroid free maintenance with tacrolimus and mycophenolate mofetil. Pancreas graft &amp; patient survival were equivalent in both the groups. BAME recipients had a higher prevalence of type-2 diabetes mellitus pre-transplant (BAME = 30.19% vs. Caucasians = 0.85%, p &lt; 0.0001), and waited for a similar time to transplantation once waitlisted, although pre-emptive SPK transplantation rate was higher for Caucasian recipients (Caucasians = 78.5% vs. BAME = 0.85%, p &lt; 0.0001). Despite equivalent rejections &amp; steroid usage, BAME recipients gained more weight (BAME = 7.7% vs. Caucasians = 1.8%, p = 0.001), but had similar HbA1c (functioning grafts) at 3-,12-, 36-, and 60-months post-transplant.

Screening for occult coronary artery disease in potential kidney transplant recipients: time for reappraisal?

Screening for occult coronary artery disease in potential kidney transplant recipients has become entrenched in current medical practice as the standard of care and is supported by national and international clinical guidelines. However, there is increasing and robust evidence that such an approach is out-dated, scientifically and conceptually flawed, ineffective, potentially directly harmful, discriminates against ethnic minorities and patients from more deprived socioeconomic backgrounds, and unfairly denies many patients access to potentially lifesaving and life-enhancing transplantation. Herein we review the available evidence in the light of recently published randomized controlled trials and major observational studies. We propose ways of moving the field forward to the overall benefit of patients with advanced kidney disease.

The Impact of Recipient Demographics on Outcomes from Living Donor Kidneys: Systematic Review and Meta-Analysis

Background and Aims: Recipient demographics affect outcomes after kidney transplantation. The aim of this study was to assess, for kidneys retrieved from living donors, the effect of recipient sex, ethnicity, and body mass index (BMI) on delayed graft function (DGF) and one-year graft function, incidence of acute rejection (AR), and recipient and graft survivals. Methods: A systematic review and meta-analysis was performed. EMBASE and MEDLINE databases were searched using algorithms through Ovid. Web of Science collection, BIOSIS, CABI, Korean Journal database, Russian Science Citation Index, and SciELO were searched through Web of Science. Cochrane database was also searched. Risk of bias was assessed using the NHBLI tools. Data analysis was performed using Revman 5.4. Mean difference (MD) and risk ratio (RR) were used in analysis. Results: A total of 5129 studies were identified; 24 studies met the inclusion criteria and were analysed. Female recipients were found to have a significantly lower serum creatinine 1-year-post renal transplantation (MD: −0.24 mg/dL 95%CI: −0.18 to −0.29 p < 0.01) compared to male recipients. No significant difference in survival between male and female recipients nor between Caucasians and Africans was observed (p = 0.08). However, Caucasian recipients had a higher 1-year graft survival compared to African recipients (95% CI 0.52−0.98) with also a lower incidence of DGF (RR = 0.63 p < 0.01) and AR (RR = 0.55 p < 0.01). Recipient obesity (BMI > 30) was found to have no effect on 1-year recipient (p = 0.28) and graft survival (p = 0.93) compared to non-obese recipients although non-obese recipients had a lower rate of DGF (RR = 0.65 p < 0.01) and AR (RR = 0.81 p < 0.01) compared to obese recipients. Conclusions: Gender mismatch between male recipients and female donors has negative impact on graft survival. African ethnicity and obesity do not to influence recipient and graft survival but negatively affect DGF and AR rates.

Effect of age and care organization on sources of variation in kidney transplant waiting list registration

Despite national guidelines, medical practices and kidney transplant waiting list registration policies may differ from one dialysis/transplant unit to another. Benefit risk assessment variations, especially for elderly patients, have also been described. The aim of this study was to identify sources of variation in early kidney transplant waiting list registration in France. Among 16 842 incident patients during the period 2016-2017, 4386 were registered on the kidney transplant waiting list at the start of, or during the first year after starting, dialysis (26%). We developed various log-linear mixed effect regression models on three levels: patients, dialysis networks, and transplant centers. Variability was expressed as variance from the random intercepts (± standard error). Although patient characteristics have an important impact on the likelihood of registration, the overall magnitude of variability in registration was low and shared by dialysis networks and transplant centers. Between-transplant center variability (0.23 ± 0.08) was 1.8 higher than between-dialysis network variability (0.13 ± 0.004). Older age was associated with a lower probability of registration and greater variability between networks (0.04, 0.20, & 0.93 in the 18-64, 65-74, and 75-84 age groups). Targeted interventions should focus on elderly patients and/or certain regions with greater variability in waiting list access.

Equity of access to renal transplantation: a European perspective

PURPOSE OF REVIEW

Renal transplantation offers the chance for patients with end-stage renal disease (ESRD) to have a significantly longer, healthier and better quality life compared with remaining on dialysis. Inequities have been demonstrated at multiple points in the transplantation pathway. In this review, the factors contributing to inequity in access to renal transplantation will be explored from a European perspective.

RECENT FINDINGS

Despite improvements in patient assessment and revision of organ-offering schemes, there remain persistent inequities in access to the waiting list, allocation of a deceased donor transplant, receiving a living donor transplant and achieving preemptive transplantation. Older age, lower socioeconomic status and health literacy are key factors that continue to impact equity of access to transplantation.

SUMMARY

A number of modifiable factors have been identified affecting access to transplantation, Increased patient education together with a better access to and promotion of living donation may help address some of these inequities.

Cardiac screening prior to renal transplantation-good intentions, rather than good evidence, dictate practice

Cardiovascular disease is the leading cause of death in kidney transplant recipients in many transplant registries. An analysis of transplant recipients from the United Kingdom using propensity score matching (PSM) suggests there are limited or no benefits to cardiovascular screening before transplant listing. We suggest that short of a randomized controlled trial (RCT) in this area, these data are sufficient to suggest that transplant centers should reflect on their current protocols for cardiovascular workup required before transplantation.

A propensity score-matched analysis indicates screening for asymptomatic coronary artery disease does not predict cardiac events in kidney transplant recipients

Screening for asymptomatic coronary artery disease prior to kidney transplantation aims to reduce peri- and post-operative cardiac events. It is uncertain if this is achieved. Here, we investigated whether pre-transplant screening with a stress test or coronary angiogram associated with any difference in major adverse cardiac events (MACE) up to five years post-transplantation. We examined a national prospective cohort recruited to the Access to Transplant and Transplant Outcome Measures study who received a kidney transplant between 2011-2017, and linked patient demographics and details of cardiac screening investigations to outcome data extracted from the Hospital Episode Statistics dataset and United Kingdom Renal Registry. Propensity score matched groups were analyzed using Kaplan-Meier and Cox survival analyses. Overall, 2572 individuals were transplanted in 18 centers; 51% underwent screening and the proportion undergoing screening by center ranged from 5-100%. The incidence of MACE at 90 days, one and five years was 0.9%, 2.1% and 9.4% respectively. After propensity score matching based on the presence or absence of screening, 1760 individuals were examined (880 each in screened and unscreened groups). There was no statistically significant association between screening and MACE at 90 days (hazard ratio 0.80, 95% Confidence Interval 0.31-2.05), one year (1.12, 0.51-2.47) or five years (1.31, 0.86-1.99). Age, male sex and history of ischemic heart disease were associated with MACE. Thus, there is no association between screening for asymptomatic coronary artery disease and MACE up to five years post-transplant. Practices involving unselected screening of transplant recipients should be reviewed.