Date Published: February 1, 2019
Publisher: Public Library of Science
Author(s): Tim Dunn, Mohammed J. Saeed, Adam Shpigel, Eric Novak, Tarek Alhamad, Dustin Stwalley, Michael W. Rich, David L. Brown, Bala Subramaniam.
Although periodic cardiac stress testing is commonly used to screen patients on the waiting list for kidney transplantation for ischemic heart disease, there is little evidence to support this practice. We hypothesized that cardiac stress testing in the 18 months prior to kidney transplantation would not reduce postoperative death, total myocardial infarction (MI) or fatal MI.
Using the United States Renal Data System, we identified ESRD patients ≥40 years old with primary Medicare insurance who received their first kidney transplant between 7/1/2006 and 11/31/2013. Propensity matching created a 1:1 matched sample of patients with and without stress testing in the 18 months prior to kidney transplantation. The outcomes of interest were death, total (fatal and nonfatal) MI or fatal MI within 30 days of kidney transplantation.
In the propensity-matched cohort of 17,304 patients, death within 30 days occurred in 72 of 8,652 (0.83%) patients who underwent stress testing and in 65 of 8,652 (0.75%) patients who did not (OR 1.07; 95% CI: 0.79–1.45; P = 0.66). MI within 30 days occurred in 339 (3.9%) patients who had a stress test and in 333 (3.8%) patients who did not (OR 1.03; 95% CI: 0.89–1.21; P = 0.68). Fatal MI occurred in 17 (0.20%) patients who underwent stress testing and 15 (0.17%) patients who did not (OR 0.97; 95% CI: 0.71–1.32; P = 0.84).
Stress testing in the 18 months prior to kidney transplantation is not associated with a reduction in death, total MI or fatal MI within 30 days of kidney transplantation.
Cardiovascular disease is a major cause of morbidity and mortality for patients with end stage renal disease (ESRD) on the waiting list for kidney transplantation and is the leading cause of death after kidney transplantation [1–5]. Thus, reducing cardiovascular mortality after kidney transplantation is critically important as donor kidneys are a limited resource that should not be allocated to patients who are at high risk of potentially fatal perioperative cardiovascular events.
The significant findings of this observational cohort study of cardiac stress testing in ESRD patients after placement on the waiting list but prior to kidney transplantation are two-fold. First, patients who are placed on the waiting list for kidney transplantation are at relatively low risk of perioperative death, MI or fatal MI. Second, and most importantly, cardiac stress testing in the 18 months prior to renal transplantation is not independently associated with a reduction in 30-day death, MI or fatal MI after adjustment for differences in demographics and comorbidities by logistic regression and propensity matching techniques.