A Preoperative Echocardiographic Predictive Model for Assessment of Cardiovascular Outcome after Renal Transplantation

Objective

Major adverse cardiac events (MACE) frequently determine the outcome of renal transplantation (RT). Stress testing is advocated for preoperative risk assessment, but limited information is available on the prognostic value of these tests. We aimed to retrospectively assess the value of preoperative dobutamine stress echocardiography (DSE) in predicting MACE in patients undergoing RT.

Methods

A total of 185 patients (age 56 ± 11 years, 64% were men, creatinine level of 7.3 ± 2.9 mg/d, 27% were smokers, 86% had hypertension, 54% had diabetes, 57% were dyslipidemic) with end-stage renal disease (ESRD) underwent DSE before RT. A standard DSE protocol was used with the administration of 5-50 μg/kg/min incremental doses in 3-minute intervals and up to 1 mg of atropine if needed to reach prespecified end points.

Results

Regional left ventricular wall motion abnormality (WMA) at rest (fixed), with stress (inducible), or both were present in 54, 35, and 18 patients, respectively. In 38 patients who underwent coronary angiography, the sensitivity, specificity, and positive and negative predictive values of inducible WMA for predicting angiographic coronary artery disease (≥70% luminal diameter reduction) were 88%, 62%, 65%, and 87%, respectively. Cox regression analysis identified the presence of combined fixed and inducible WMA (ie, resting WMA that did not change during DSE, accompanied by new WMA evident during DSE; hazard ratio [HR] 5.6, P = .012), left atrial enlargement (HR 4.2, P = .002), and aortic valve sclerosis (HR 3.9, P = .013) as independent predictors of 48-month MACE (cardiac death, nonfatal acute myocardial infarction, and coronary revascularization after RT). Patients with all 3 predictors had a 48-month MACE of 60% compared with 5% in those with none (P = .007). Compared with those without WMA, patients with both fixed and inducible WMA had a higher rate of MACE at 48 months (7% vs 33%, P = .004).

Conclusion

In RT candidates, DSE can effectively identify those at low and high risk of MACE.

Keywords: Coronary artery disease, Dobutamine stress echocardiography, Major adverse cardiac event, Preoperative risk stratification, Renal transplantation

Abbreviations: CAD, Coronary artery disease, CKD, Chronic kidney disease, DSE, Dobutamine stress echocardiography, ESRD, End-stage renal disease, MACE, Major adverse cardiac events, WMA, Wall motion abnormality