A Second Opinion: The Role of Cardiac Revascularization in Kidney Transplant Candidates

Background: Pre-kidney transplant (KTX) cardiac risk stratification currently relies on protocols developed for non-transplant end-stage renal disease (ESRD) populations and a positive stress test (+ST) is often not followed by cardiac catheterization (CC). We investigated whether patients who receive CC after +ST and +/- revascularization improve survival and transplant outcomes. Methods: Using the TriNetX Research Network, we identified adults who underwent KTX (2004–2024) and had a +ST within five years prior. +ST patients were grouped by whether they received CC (n=11,171) or not (n=47,833) and whether those with CC had following revascularization (n = 2,891) or not (n=8,280). Propensity score matching by demographic and cardiovascular factors yielded 2,853 patients per group. Primary outcomes were one-year mortality and five-year transplant complications.Using the TriNetX Research Network, we identified adults who underwent KTX (2004–2024) and had a +ST within five years prior. +ST patients were grouped by whether they received CC (n=11,171) or not (n=47,833) and whether those with CC had following revascularization (n = 2,891) or not (n=8,280). Propensity score matching by demographic and cardiovascular factors yielded 2,853 patients per group. Primary outcomes were one-year mortality and five-year transplant complications. Results: Among propensity matched KTX recipients, those who underwent CC with subsequent revascularization experienced significantly lower one-year mortality (RR, 1.446; 95% CI, 1.034-2.062) and five-year kidney transplant complications (RR: 0.847; 95% CI, (0.782-0.916) compared to those who did not. This suggests a potential benefit of CC following +ST and revascularization in optimizing patient survival and early post-transplant outcomes. Conclusion: In our cohort, patients who underwent +ST evaluation with subsequent revascularization exhibited the highest survival rates.These data suggest that during pre-KTX evaluation, CC should routinely follow a +ST, and revascularization should be pursued when indicated. This approach is associated with the best survival in this patient population. Funding: Other NIH Support - Study supported in part by a Clinical and Translational Science Award (UL1 TR001439)