Abstract 12515: Risk Stratification of Patients Referred for Renal Transplant
Cardiovascular disease accounts for nearly 50% of deaths in patients with endstage renal disease on dialysis and diabetics are at highest risk. The 2012 AHA/ACCF guidelines gave only Class IIb recommendations for cardiac testing of patients referred for renal transplant. In 2007, we adopted an invasive-only approach for assessment of CAD in diabetics (n=365) referred for renal transplant. Prevalence of CAD and risk factors were identified.
Methods: All patients underwent coronary angiography at the time of referral. Binary logistic regression was used to identify predictors of CAD. The initial model was fit and then respecified by removal of nonsignificant interaction items.
Results: Patients were 55.3% male and 72.8% African-American. Median age was 55 years. Hypertension (HTN) was present in 98.4%, smoking in 44% and hyperlipidemia in 53%. CAD, defined as >70% stenosis of a major vessel, was found in 32.1% (13.2% 1-vessel, 9.6% 2-vessel and 9.3% 3-vessel). Significant (p≤0.05) bivariate predictors of CAD (Odds Ratio, OR) were referral age (OR=1.1), history of CAD (OR=8.0), history MI (OR=4.3), angina (OR=4.2), peripheral vascular disease (OR=2.3), stroke (OR=2.3), history revascularization (OR=7.9) and smoking (OR=1.9). Significant multivariate predictors were history of CAD (OR=6.9, p≤0.001) and advancing age (1.06 for each year, p≤0.001).
In patients with history of MI, heart failure, stroke or CAD, risk for significant CAD was 48.7% whereas in patients with none of these factors, risk was 16.7%. For each additional past history element, risk increased 2.49 times (p≤0.01). Of traditional risk factors for CAD (HTN, smoking, gender), only smoking proved significant (OR=1.93, p=0.006) in multivariate analysis.
Patients with CAD defined at catheterization were more likely to experience major adverse cardiovascular events (MACE) (OR=1.83, p=0.021) and patients with MACE were more likely to due while waiting (OR=45.1, p≤0.001).
CONCLUSIONS: Past medical history and traditional risk factors can be used to stratify diabetics referred for renal transplant and allow targeted use of invasive testing. Further stratification of low risk patients may be possible with noninvasive testing but high risk patients should undergo initial invasive testing.
- © 2013 by American Heart Association, Inc.