Role of Coronary Angiography in the Assessment of Cardiovascular Risk in Kidney Transplant Candidates.

Cardiovascular disease is the leading cause of death among those with renal insufficiency, those requiring dialysis, and in recipients of kidney transplants reflecting the greatly increased cardiovascular burden that these patients carry. The best method by which to assess cardiovascular risk in such patients is not well established. In the present study, 1,225 patients seeking a kidney transplant, over a 30-month period, underwent cardiovascular evaluation. Two hundred twenty-five patients, who met selected criteria, underwent coronary angiography that revealed significant coronary artery disease (CAD) in 47%. Those found to have significant disease underwent revascularization. Among the patients found to have significant CAD, 74% had undergone a nuclear stress test before angiography and 65% of these stress tests were negative for ischemia. The positive predictive value of a nuclear stress test in this patient population was 0.43 and the negative predictive value was 0.47. During a 30-month period, 28 patients who underwent coronary angiography received an allograft. None of these patients died, experienced a myocardial infarction, or lost their allograft. The annual mortality rate of those who remained on the waiting list was well below the national average. In conclusion, our results indicate that, in renal failure patients, noninvasive testing fails to detect the majority of significant CAD, that selected criteria may identify patients with a high likelihood of CAD, and that revascularization reduces mortality both for those on the waiting list and for those who receive an allograft.

The Kidney Transplant Morbidity Index (KTMI): a simple prognostic tool to help determine outcome risk in kidney transplant candidates.

BACKGROUND: The Kidney Transplant Morbidity Index (KTMI) is a novel prognostic morbidity index to help determine the impact that pretransplant comorbid conditions have on transplant outcome. OBJECTIVE: To use national data to validate the KTMI. DESIGN: Retrospective analysis of the Organ Procurement and Transplant Network/United Network for Organ Sharing database. SETTING AND PARTICIPANTS: The study sample consisted of 100 261 adult patients who received a kidney transplant between 2000 and 2008. MAIN OUTCOME MEASURE: Kaplan-Meier survival curves were used to demonstrate 3-year graft and patient survival for each KTMI score. Cox proportional hazards regression models were created to determine hazards for 3-year graft failure and patient mortality for each KTMI score. RESULTS: A sequential decrease in graft survival (0 = 91.2%, 1 = 88.2%, 2 = 85.4%, 3 = 81.7%, 4 = 77.8%, 5 = 74.0%, 6 = 69.8%, and ≥ 7 = 68.7) and patient survival (0 = 98.2%, 1 = 96.6%, 2 = 93.7%, 3 = 89.7%, 4 = 84.8%, 5 = 80.8%, 6 = 76.0%, and ≥ 7 = 74.7%) is seen as KTMI scores increase. The differences in graft and patient survival between KTMI scores are all significant (P< .001) except between 6 and ≥ 7. Multivariate regression analysis reveals that KTMI is an independent predictor of higher graft failure and patient mortality rates and that risk increases as KTMI scores increase. CONCLUSION: The KTMI strongly predicts graft and patient survival by using pretransplant comorbid conditions; therefore, this easy-to-use tool can aid in determining outcome risk and transplant candidacy before listing, particularly in candidates with multiple comorbid conditions.

The impact of morbid obesity on hospital length of stay in kidney transplant recipients.

OBJECTIVES: Obesity is often associated with higher hospital costs because of longer length of stay (LOS) but this has not been well studied in the kidney transplant population. Therefore, we used national data to compare LOS in select groups of morbidly obese and normal weight recipients after kidney transplant. DESIGN: This study was a retrospective analysis of the Organ Procurement and Transplant Network/United Network for Organ Sharing database. SUBJECTS: The study sample consisted of 42,787 morbidly obese (body mass index 35-40 kg/m(2)) and normal weight (body mass index 18.5-24.9 kg/m(2)) who underwent primary kidney-only transplantation between 2000 and 2008. MAIN OUTCOME MEASURES: Morbidly obese and normal-weight subgroups were crudely evaluated for prolonged LOS (>7 days). Logistic regression modeling compared LOS in morbidly obese and normal-weight subgroups with varying characteristics and determined predictors of prolonged LOS. RESULTS: All morbidly obese subgroups had significantly higher crude rates of prolonged LOS (P < .05). However, no significant differences in prolonged LOS were seen between any of the morbidly obese or normal-weight subgroups in multivariate analysis. Morbid obesity was an independent predictor of prolonged LOS (P < .001) but not a stronger predictor than that of being African American, having coronary artery disease, diabetes mellitus, or peripheral vascular disease, being 50 to 80 years of age, having a previous transplant or poor functional status. Receiving a deceased-donor transplant and being dialysis dependent >4 years were significantly better predictors of prolonged LOS compared with morbid obesity (P < .05). CONCLUSIONS: Some morbidly obese populations have LOS rates that are not significantly different than many commonly transplanted normal weight populations, and the impact morbid obesity has on LOS is not different than many other factors often seen in kidney transplant recipients; therefore, morbid obesity alone should not be a financial consideration in kidney transplant.

Impact of renal posttransplantation amputation on allograft outcomes: a study of United States renal data system.

BACKGROUND: The prevalence of renal posttransplantation amputation and its impact on allograft and patient survival have not been widely reported. METHODS: We used an incident cohort of patients who underwent renal transplantation between June 2004 and September 2009. Amputation data were obtained using Medicare institutional claim forms. Baseline demographics and comorbidities, such as peripheral vascular disease (PVD), diabetes, ischemic heart disease, cerebrovascular disease, hypertension, and smoking, were captured. The chi-square and t tests were used for statistical associations. Kaplan-Meier survival curves were plotted for renal allograft and patient survival. Independent associations between patient factors and amputation were examined using multivariable Cox regression analysis. RESULTS: Of the 85,873 renal transplant recipients, 1062 patients had amputation. The prevalence of amputation was higher in those with PVD versus those without PVD at listing (5.6% vs. 1%; P=0.0001). Mean allograft survival was 55.5±0.55 months in patients with amputation versus 60.6±0.06 months in patients without amputation (P=0.0001). All-cause mortality was higher in patients with amputation versus those without amputation (19.9% vs. 7.3%; P=0.0001). Mean allograft survival was 60.97±0.67 months in non-African Americans without amputation versus 55.7±0.65 months in non-African Americans with amputation. Allograft survival was 59.73±0.13 months in African Americans without amputation versus 54.9±1.06 months in African Americans with amputation. In patients with amputation, race did not have any impact. Infectious complications were noted in 39 patients leading to death. CONCLUSIONS: Amputation is associated with decreased allograft and patient survival. Early detection and preventive strategies for PVD may decrease amputation rate and improve survival.