P51
Optimising post-transplant cardiac outcomes: use of risk stratification to guide
appropriate workup
Authors: Heather Edwards, Sudhakar Venturi, Dominika Budzbon, Richard Wheeler, Siân
Griffin, University Hospital Wales
Introduction
Successful renal transplantation improves the increased cardiovascular risk inherent to end
stage renal disease. In the absence of a definitive pre-operative investigation reliably predictive
of post-operative outcome, there is as yet no consensus on the optimal work-up of potential
recipients. We have previously reported the effectiveness of a risk stratified cardiac assessment
protocol on 30 day post transplant cardiac events (BTS/RA annual meeting, 2013). We now
report the results of a one year follow up period of this patient cohort.
Methods
Demographic data, details of prior cardiac evaluation and postoperative outcomes were
collected for 145 consecutive patients receiving a renal transplant between 17/11/11 and
26/11/12. Patients were stratified according to their cardiovascular risk. We classified 103
(71%) as high risk on the basis of age (> 50 years), known ischemic heart disease, diabetes, or
the presence of > 2 other conventional risk factors (smoking history, hypercholesterolemia,
hypertension and family history). Our current cardiac assessment protocol recommends that
all renal transplant candidates should have an ECG and echocardiogram. In addition, high risk
candidates undergo dynamic testing and/or a coronary angiogram. Once active on the
transplant waiting list, cardiac testing is not repeated unless there is a change in the ECG or
functional status. A record was made of all cardiac complications occurring in the first 30 days,
and subsequent year following transplantation.
Results
The mean age of the cohort was 51 (range 18 – 80) years, 92 (63%) were male and 59 (41%)
diabetic. Thirty five patients (24%) were pre-dialysis, and the mean duration of dialysis for the
remaining recipients was 30.6 months (range 1 – 151) months. The median number of
conventional cardiac risk factors per patient was 2.5. 71% were considered high risk by the
above criteria. Overall, 63 (43%) recipients had undergone dynamic testing and/or a coronary
angiogram. There were 3 deaths between 30 days and 1 year, 1 of these was due to cardiac
causes. Nine recipients (6%) had a cardiac event within 30 days of transplantation, and a
further 2 (1%) between 30 days and one year. 4 of these recipients were diabetic and 5 had a
prior history of IHD. There were 2 deaths due to non cardiac causes between 30 days and 1
year.
High Risk
(% of this
group)
Low Risk
(% of this
group)
Number
Echo
Echo + other
103
92 (89%)
55 (53%)
42
17 (40%)
5 (12%)
Cardiac Events
< 30 days
>30 days – one year
9 (9%)
2 (2%)
0
0
Conclusions
A detailed clinical cardiac evaluation with appropriate investigations for selected patients
allows renal transplantation to be safely performed in a high risk population. The incidence of
cardiac events following transplantation was low, with the majority occurring in the early postoperative period. There remains a need to develop specific peri-operative interventions to
minimise cardiovascular complications.