A call to action: Variability in guidelines for cardiacevaluation before renal transplantation

Candidates for renal transplantation are at increased risk for complications relatedto cardiovascular disease; however, the optimal strategy to reduce this risk is not clear. The aim ofthis study was to evaluate the variability among existing guidelines for preoperative cardiac evaluation ofrenal transplant candidates.Design, setting, participants, & measurements A consecutive series of renal transplant candidates (n = 204)were identified, and four prominent preoperative cardiac evaluation guidelines, pertaining to this population,were retrospectively applied to determine the rate at which each guideline recommended cardiacstress testing.Results The rate of pretransplant cardiac stress testing would have ranged from 20 to 100% depending onwhich guideline was applied. The American Heart Association/American College of Cardiology (ACC/AHA) guideline resulted in the lowest rate of testing (20%). In our population, 178 study subjects underwentstress testing: 17 were found to have ischemia and 10 underwent revascularization. The ACC/AHAapproach would have decreased the number of noninvasive tests from 178 to 39; it would have identifiedonly 4 of the 10 patients who underwent revascularization. The three other guidelines (renal transplant-specific guidelines) recommended widespread pretransplant cardiac testing and thus identified nearly allpatients who had ischemia on stress testing.Conclusions The ACC/AHA perioperative guideline may be inadequate for identifying renal transplantcandidates with coronary disease; however, renal transplant-specific guidelines may provoke significantovertesting. An intermediate approach based on risk factors specific to the ESRD population may optimizedetection of coronary disease and limit testing.