On July 2, the ACC Foundation (ACCF), in partnership with the American Heart Association, released an expert consensus document, "Cardiac Disease Evaluation and Management Among Kidney and Liver Transplantation Candidates," which explored and evaluated the current evidence available for kidney and liver transplantation.
"Cardiovascular disease is a leading cause of morbidity and mortality among patients with end-stage failure of non-cardiac organs before and after transplantation," note the authors. However, there are discrepancies among existing guidelines, and the "unique clinical characteristics of patients with end-stage organ failure raise questions about the applicability of available recommendations to transplantation candidates." The new statement, which evaluates literature on kidney and liver transplantation candidates from 1990 to March 2010, aims to provide additional evidence-based recommendations targeting these discrepancies.
Specifically, the recommendations address:
- Perioperative risk assessment based on symptoms and exercise tolerance;
- Imperfect correlations of angiographic coronary artery disease (CAD) and clinical outcomes in end-stage renal disease (ESRD);
- Accuracy of noninvasive testing for CAD in kidney transplantation candidates;
- Considerations for kidney transplantation candidates with diabetes mellitus;
- Noninvasive stress testing in kidney transplantation candidates without active cardiac conditions;
- Cardiac surveillance after listing for transplantation;
- Supplemental testing;
- Evidence on prophylactic coronary revascularization to reduce perioperative cardiac complications;
- Percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) in patients with ESRD;
- PCI versus CABG in patients with diabetes mellitus;
- Coordination of care for referral to a cardiologist;
- Coronary revascularization and related care before kidney transplantation;
- Preoperative cardiovascular risk factor modification in renal transplantation candidates;
- Perioperative medical management of cardiovascular risk before kidney transplantation;
- Postoperative medical management of cardiovascular risk after kidney transplantation;
- Evaluation for CAD in liver transplantation candidates;
- Management of flow-limiting CAD in liver transplantation candidates;
- Evaluation for pulmonary hypertension in liver transplantation candidates; and
- Medical management of cardiovascular risk in liver transplantation candidates.
The authors conclude, "at this time, there is no strong evidence for or against routine cardiac screening of asymptomatic transplantation candidates. More evidence is required, ideally from randomized clinical trials, to guide strategies for pretransplantation cardiac risk assessment in potential kidney or liver transplantation candidates and to optimize risk factor management before, during and after transplantation."
The statement was also endorsed by the American Society of Transplant Surgeons, American Society of Transplantation and National Kidney Foundation.