Coronary artery disease screening in renal transplant candidates: insights from a large prospective cohort

Abstract Background There is currently no specific consensus regarding the screening strategy for CAD in renal transplant candidates. Purposes To describe in renal transplant candidates 1/ Strategies and results of CAD screening and 2/ renal and cardiovascular outcomes in this population Methods All patients registered on kidney transplant waiting list in our tertiary centre were classified into no screening for CAD (unscreened), screened, or with prior CAD. Unscreened was defined as no ischemia or anatomic testing while on waiting list or within the year prior to listing. Screening was considered as "positive" when it led to diagnostic of obstructive CAD (stenosis > 50%). Primary outcome was a composite outcome defined as [death or unplanned revascularization]. Primary outcome and renal transplant were analysed using multivariable Cox model. Results From 2005 to 2023, 3248 patients were registered as candidates for kidney transplantation, 228 (7.0%) patients had a history of CAD, 1987 (61.2%) patients were screened for CAD and 1033 (31.8%) were unscreened. Initial screening investigation were mainly stress cardiovascular MRI (33.7%), stress TTE (27.7%) or myocardial perfusion imaging (26.4%). Among screened patients, 133 (6.7%) patients had a positive screening for obstructive CAD. Within 4.7 [1.2 – 7.2] years, using patients with a negative screening as a reference, patients with positive screening and known CAD were less likely to receive renal transplant (aHR 0.70 [0.53 ; 0.93] and 0.64 [0.49 ; 0.84] respectively), while patients without screening were similarly transplanted (aHR 1.01 [0.89 ; 1.15]). Patients without screening or with a prior history of CAD were at higher risk of primary outcome compared with patients with negative screening (aHR 1.49 [1.16; 1.91]) and aHR 1.97 [1.48; 2.62] respectively), along with patients on dialysis at registration (1.37 [1.13; 1.66]), diabetic patients (1.79 [1.47; 2.18]) and smokers (1.25 [1.03; 1.53]). Age was an interaction factor between unscreening and primary outcome, as there was no association in younger patients (aHR 1.21 [0.81; 1.81]). Conclusion Among candidates for kidney transplantation, 2 out of 3 patients underwent non-invasive testing for obstructive CAD resulting in less than 10 % of positive cases. Positive testing and history of CAD were associated with a lower opportunity for kidney transplantation compared with negative testing or absence of screening. Nonetheless, absence of screening was associated with a higher risk of [death + unplanned revascularization], especially in older patients.Central illustration