Influence of coronary artery disease assessment and treatment in the incidence of cardiac events in renal transplant recipients.

UNLABELLED: BACKGROUND: The best strategy for pre-transplant investigation and treatment of coronary artery disease (CAD) is controversial. METHODS: We evaluated 167 renal transplant recipients before transplantation to determine the incidence of cardiac events and death. We performed clinical evaluations and myocardial scans in all patients and coronary angiography in select patients. RESULTS: Asymptomatic patients with normal myocardial scans (n=57) had significantly fewer cardiac events (log-rank=0.0002) and deaths (log-rank=0.0005) than did patients with abnormal scans but no angiographic evidence of CAD (n=76) and individuals with CAD (n=34) documented angiographically. CAD increased the probability of events (HR=2.27, % CI 1.007-5.11; p=0.04). The incidence of cardiac events (log-rank=0.349) and deaths (log-rank=0.588) was similar among patients treated medically (n=23) or by intervention (n=11). CONCLUSION: Asymptomatic patients with normal myocardial scans had a better cardiac prognosis than did patients with or without CAD and positive for myocardial ischemia. Patients with altered scan and CAD had the poorer outcome. Guideline-oriented medical treatment is safe and yields results comparable to coronary intervention in renal transplant patients with CAD. The data do not support preemptive myocardial revascularization for renal transplant candidates.

Surgical complications of graft nephrectomy in the modern transplant era.

PURPOSE: Transplant nephrectomy has been considered a hazardous procedure throughout transplantation history. Better surgical techniques and clinical treatment of patients have improved the results of this surgery in the last decades. We report the surgical complications of nephrectomy of early and late failed kidneys performed at a referral center. MATERIALS AND METHODS: The charts of 70 consecutive patients who underwent graft nephrectomy between May 1994 and April 2002 were reviewed regarding surgical complications. Patients were divided into 2 groups according to the timing of graft removal. Early nephrectomy group 1 included 23 procedures performed in the first 60 days after transplantation and late nephrectomy group 2 included 47 performed after that interval. Groups were compared concerning outcome, blood loss and amount of blood transfused in the perioperative period, and the incidence of surgical complications according to the surgical technique, immunosuppressive regimen and timing of surgery. RESULTS: Mean blood loss was 434 ml (range 20 to 3,000) in group 1 and 546 (range 60 to 2,200) in group 2 (p = 0.02). Nine group 1 patients (39.1%) and 22 in group 2 (46.8%) received blood transfusion in the perioperative period (p = 0.62). The mean amount of blood transfused was 516.7 ml in group 1 and 436.3 ml in group 2 (p = 0.36). Four and 2 minor surgical complications occurred in groups 1 and 2 (17.4% and 4.3%, respectively, p = 0.09). Seven major complications were noted in group 2 (14.9%), while there were none in group 1 (p = 0.05). Three complications (25%) occurred in patients who received antirejection globulins or methylprednisolone and 1 (9.1%) developed when these agents were not administered (p = 0.33). The incidence of surgical complications after intracapsular and extracapsular nephrectomy was 20% and 17.6%, respectively (p = 0.58). Mean blood loss and the mean amount of blood transfused was 638 and 525 ml for intracapsular nephrectomy and 383 and 350 ml for extracapsular nephrectomy, respectively, respectively. Surgical complications occurred in 3 patients who received mycophenolate mofetil (23.1%) and in 6 (17.6%) who did not received this drug (p = 0.48). CONCLUSIONS: Blood loss and surgical complication rates were higher in late failed graft nephrectomies. Surgical complications in intracapsular vs extracapsular nephrectomies were similar but blood loss and transfusions were higher for intracapsular nephrectomy. Acute rejection treatment, or prophylaxis with methylprednisolone or globulins increased the incidence of surgical complications.

Coronary angiography is the best predictor of events in renal transplant candidates compared with noninvasive testing.

Guidelines for the detection of coronary artery disease (CAD) and assess of risk in renal transplant candidates are based on the results of noninvasive testing, according to data originated in the nonuremic population. We evaluated prospectively the accuracy of 2 noninvasive tests and risk stratification in detecting CAD (>or=70% obstruction) and assessing cardiac risk by using coronary angiography (CA). One hundred twenty-six renal transplant candidates who were classified as at moderate (>or=50 years) or high (diabetes, extracardiac atherosclerosis, or clinical coronary artery disease) coronary risk underwent myocardial scintigraphy (SPECT), dobutamine stress echocardiography, and CA and were followed for 6 to 48 months. The prevalence of CAD was 42%. The sensitivities and negative predictive values for the 2 noninvasive tests and risk stratification were <75%. After 6 to 48 months, there were 18 cardiac events, 9 fatal. Risk stratification (P=0.007) and CA (P=0.0002) predicted the crude probability of surviving free of cardiac events. The probability of event-free survival at 6, 12, 24, 36, and 48 months were 98%, 98%, 94%, 94%, and 94% in patients with <70% stenosis on CA and 97%, 87%, 61%, 56%, and 54% in patients with >or=70% stenosis. Multivariate analysis showed that the sole predictor of cardiac events was critical coronary lesions (P=0.003). Coronary angiography may still be necessary for detecting CAD and determining cardiac risk in renal transplant candidates. The data suggest that current algorithms based on noninvasive testing in this population should be revised.