Association of pre-transplant cardiac risk phenotype and coronary revascularization strategy with one-year mortality after living-donor kidney transplantation: a single-center cohort

Cardiovascular disease is a leading cause of early mortality after kidney transplantation; however, the associations of pre-transplant cardiac risk markers and coronary management strategy with early post-transplant outcomes remain incompletely characterized. This study aimed to evaluate the association between pre-transplant cardiac risk phenotype, coronary management strategy, and 1-year mortality in living-donor kidney transplant recipients. In this retrospective single-center cohort, 178 adult living-donor kidney transplant recipients (June 2021–August 2024) with at least 12 months of follow-up were included. Patients were categorized according to pre-transplant coronary management: no revascularization (n = 155), percutaneous coronary intervention (PCI) (n = 15), or minimally invasive coronary artery bypass grafting (MIDCAB) (n = 8). The primary outcome was 1-year all-cause mortality. Survival was assessed using Kaplan–Meier analysis and log-rank testing. To minimize overfitting given the limited number of events (n = 13), the primary multivariable Cox model included three clinically pre-specified variables reflecting global vulnerability: age, left ventricular ejection fraction (EF < 55%), and dialysis duration (months). Overall 1-year survival was 92.7% (165/178). Survival was 92.9% in the no-revascularization group, 86.7% after PCI, and 75.0% after MIDCAB, with no statistically significant between-group difference (log-rank p = 0.160). The study was not powered to exclude clinically meaningful differences between these groups. In the primary parsimonious Cox model, longer dialysis duration was associated with higher 1-year mortality (HR per month 1.18, 95% CI 1.04–1.35; p = 0.011), as was reduced left ventricular ejection fraction (< 55%) (HR 8.74, 95% CI 1.60–47.60; p = 0.011). Age was not independently associated with mortality (HR per year 1.04, 95% CI 0.98–1.11; p = 0.189). Renal function trajectories did not differ significantly among coronary management groups. This study did not detect a statistically significant survival difference between coronary management strategies. Reduced EF and longer dialysis duration were independently associated with mortality, although these findings should be interpreted cautiously because of the limited number of events. Larger adequately powered multicenter studies with longer follow-up are needed to confirm these observations. 1. No statistically significant difference in 1-year survival was detected among patients managed without revascularization, with PCI, or with MIDCAB; however, the study was underpowered to exclude clinically meaningful differences. 2. Reduced left ventricular ejection fraction and longer dialysis duration were associated with higher 1-year mortality in a parsimonious Cox model, but the limited number of events requires cautious interpretation. 3. The findings are consistent with the uncertainty regarding routine revascularization in stable advanced CKD described in ISCHEMIA-CKD, but they do not establish the comparative effectiveness of PCI, MIDCAB, and medical management.