Box 1.

Evidence regarding pretransplant evaluation for coronary heart disease considered according to the World Health Organization principles for screening (1968).

Public Health Impact

The condition should be an important health problem1 Cardiovascular disease is the most common cause of death with graft function at all times after transplant8. Reports of angiography in patients undergoing transplant evaluation document CAD in 42%–81%15–22.

Natural History of Disease includes a Latent Stage for Detection and Intervention

There should be a latent stage of the disease1 The natural history of the disease should be adequately understood1 Some observational studies report higher unadjusted risk of all-cause mortality and major cardiovascular events in potential transplant candidates with angiographic CAD15,16,18. Other investigations identified risk only certain patient sub-groups, such as those with proximal CAD17 or with non-diabetic renal failure19. Still other recent studies have found no associations of CAD with subsequent survival in this population20–22. General population studies have shown that a coronary artery does not have to contain an angiographic stenosis to suddenly occlude and produce myocardial infarction23.

Availability of Testing

There should be a test or examination for the condition1 The test should be acceptable to the population1 Case-finding should be a continuous process, not just a “once and for all” project1 – i.e., there is a role for surveillance “Gold-standard” angiography poses risks including contrast nephropathy59–62 and is more expensive than non-invasive testing. Non-invasive testing for CAD includes MPS, stress echocardiography and cardiac computed tomographic angiography. Non-invasive tests for CAD have imperfect sensitivity and specificity in patients with renal failure, or in the case of tomographic angiography, have not been evaluated in this population. Reported sensitivities and specificities of non-invasive modalities for the detection of angiographic CAD in ESRD patients are 37–90% and 40–90%, respectively for MPS26–29 and 37–95% and 71–95%, respectively, for DSE15,35–39. One single-center observational study found that cardiac surveillance on the waitlist based on ongoing clinical assessment resulted in fewer investigations than suggested by guidelines and no difference in total cardiovascular event rates78.

Availability of Treatment

There should be a treatment for the condition1 There should be an agreed policy on who to treat1 Facilities for diagnosis and treatment should be available1 There are limited direct data on the efficacy of coronary revascularization in ESRD patients. A 1992 trial in 31 insulin-dependent diabetic transplant candidates found benefit with revascularization compared to medical therapy with a calcium channel blocker and aspirin65, but contemporary relevance of these findings is limited by the small study sample size, high event rate among the medically-managed group, and subsequent advances in “standard” medical management of CAD.

Cost-effectiveness

The total cost of finding a case should be economically balanced in relation to medical expenditure as a whole1 Insufficient data currently available. However, the relatively low use of coronary interventions after pretransplant cardiac evaluation questions the cost effectiveness of pretransplant cardiac evaluation as currently applied. Several single center observational and a registry study have found that only 2.9%–9.5% of patients who receive pre-transplant cardiac testing proceed to angioplasty or surgical bypass21,31,43,66,67

Abbreviations: CAD, coronary artery disease; DSE, dobutamine stress echocardiography; ESRD, end-stage renal disease; MPS, myocardial perfusion studies