Coronary Heart Disease Testing Before Kidney Transplant—A Call for Revised Guidance

Abstract

End-stage kidney disease (ESKD) is a debilitating chronic illness for which kidney transplant is the treatment of choice, as it reduces mortality, improves quality of life, and lowers costs compared with dialysis. Professional societies recommend cardiac evaluation for transplant candidacy because patients with ESKD are at increased risk of cardiovascular disease. 1 There has been substantial debate regarding the risks and benefits of such pretransplant evaluation, but to our knowledge few clinical data. To fill this evidence gap, the study in a recent issue of JAMA Internal Medicine by Cheng and colleagues 2 examined the association between pretransplant coronary heart disease (CHD) testing in asymptomatic patients and early postoperative adverse events. Using Medicare data on all 79 334 patients undergoing first-time kidney transplant from 2000 to 2014, they found that pretransplant CHD testing was performed in 56% of patients at the most test-intensive transplant programs compared with 24% at the least testintensive programs. Routine pretransplant CHD testing was not associated with significant reduction in death or acute myocardial infarction within 30 days of transplant. In fact, they found a nonsignificant increase in adverse events at centers with higher rates of CHD testing. Cheng et al 2 were not able to include outcomes of CHD testing in patients who did not proceed to undergo transplant. While the consequences of such testing in patients who are not ultimately listed for transplant is unknown, to our knowledge there is no study in any population that shows a benefit to CHD testing in asymptomatic persons, with or without ESKD.This study should inform professional society guidelines surrounding pretransplant CHD testing. New guidelines from the American Heart Association and American College of Cardiology 3 (and endorsed by the American Society of Transplantation) recommend screening electrocardiogram and echocardiogram for asymptomatic patients with unknown CHD status before transplant listing, updating previous guidelines that recommended noninvasive stress testing regardless of functional status in patients with 3 or more risk factors (diabetes, greater than 1 year receiving dialysis, prior cardiovascular disease, left ventricular hypertrophy, older than 60 years, smoking history, hypertension, or dyslipidemia). 4 The nonprofit