1. A 59-year-old CKD 5 female on HD due to diabetic nephropathy. She received a kidney offer from his daughter, 111 mismatch with no DSA. During the routine pre-transplant work up, MYOVIEW scan (cardiac scintigraphy) reported postro-lateral perfusion defect with no reversibility NOT due to artefact. Echocardiogram reported moderate to severe hypokinesia with EFR of 39%.
- Would you proceed for transplantation provided all other investigations are satisfactory?
- If yes, what are the precautions?
Dear Colleagues
Coronary Angiogram (CA) will add nothing. We know that she had MI. Myocardial Perfusion Scan did not show any area of reversible ischamia, so there is nothing to correct. CA is required if there is a possibility of angioplasty.
Then TRANSPLANTATION in the intensive care setting
This recipient is a high risk patient with diabetes and diabetic nephropathy…2Decho showed moderate LV hypokinesia of 39%…Myocardial perfusion scan revealed postero lateral defect with no reversilbility…This indicates an evolved MI and there is no need for CAG as we are not looking into the reversibility of the lesion
I will proceed for transplantation
The patient needs a CVP line monitoring, Avoidance of severe hypovolemia, pulmonary catheter wedge pressure monitoring for Ra,RV pressure monitoring if they are abnormal…Fluid overload should be avoided in the intra operative and post operative period…
Although the patient has several risk factors for complications, if there is no excluding factor for the transplant, the transplant would be performed.
Try to control in the preoperative period factors that may harm the cardiac condition in the peri and postoperative periods:
– Avoid hypervolemia, performing HD session to control fluids;
– Intensive control of blood glucose and blood pressure levels;
– Return of medications for the treatment of heart disease as soon as possible;
High reisk cardiac patient with history of
CKD 5 on RHD , diabetic and cardiac scintigraphy) reported postro-lateral perfusion defect with no reversibility and Echocardiogram reported moderate to severe hypokinesia with EFR of 39% .
So careful cardiac assessment is mandatory
Coronary angiography with or without angioplasty
Post-operative ICU admission with cautios fluid replacement and close cardiac follow up.
Would you proceed for transplantation provided all other investigations are satisfactory?
If yes, what are the precautions?
Renal transplantation is the ever-best options for patients with ESRD as regard for patient survival and better quality of life. Provided that there is no absolute contraindication for transplantation, I would proceed to transplant this patient.
The patient has many risk factors; diabetes, IHD, impaired cardiac function (EF 39%), and irreversible posterolateral myocardial defect.
His immunological risk is low 1:1:1 mismatch and no DSAs
Precautions include
Meticulous perioperative care for fluid state avoiding overload and new cardiac insults
Good glycemic control
As the myocardial perfusion defect is fixed, there is no need for coronary angiography
Would you proceed for transplantation provided all other investigations are satisfactory?
59 year old ESKD on Hdx due to diabetes …. ECHO shows severe hypokinesia with EF 39% with MPI showing irreversible ischemia for furthur cardiology consultation for the possibility of Angio if needed
Yet , I will proceed for Transplantation.
The presence of related donor being with 111 mismatch and no DSA, but only after detailed cardiology evaluation and a go ahead from cardiologist
yes, what are the precautions ?
Yes , the the patients needs ICU post Tx and strict risk factors assessment as control BP , DM and cardiology assessment.
Diabetes mellitus and coronary artery disease are present in the patient, and a MYOVIEW scan reveals an old myocardial infarction (perfusion defect with no reversibility).Since there is absence of reversible ischemia, no need for invasive cardiac evaluation. Based on the echocardiography and EFR, as well as the results of all other tests being normal, it is best to proceed with the transplant.
Precautions:
1.Yes, I will proceed for transplantation, the mismatch 111 is acceptable and there is no DSA .
The patient has postro-lateral defect on MPI and by ECHO,EFR is 39%,there is no contraindication for kidney transplantation.
Even more, multiple studies showed that kidney transplantation of patients with advanced systolic heart failure results in increase in LVEF, improves functional status of heart failure, and increase survival.
The fixed defect indicates old MI,nothing to do , there is no indication for coronary angiography.
Indication of coronary angiography according noninvasive results
Severe resting LVF less than 35%..
Severe exercise LVF less than 35%.
Anterior stress induced large perfusion defect or small multiple defects.
Evidence of extensive ischemia.
Large fixed perfusion defect with left ventricular dilatation or increased lung uptake.
2.The patient is diabetic,old age(59 years)and has old MI,she is at high risk for future cardiovascular events after kidney transplantation,so we must modify risk factors as can as possible:
Control of dyslipedemia ,glycemic control.
Life style modification : diet,weight reduction,encourage physical activity,smoking cessation,if she is smoker, cardiac rehabilitation program if it is tolerated.
Drug therapy ( anti-platelets,Statins,B-blockers,ACE inhibitors).
The patient has CKD and on dialysis, if anaemic we should treat anaemia, control volume overload and achieving dry weight.
.
Would you proceed for transplantation provided all other investigations are satisfactory?
Ø The patient considers at risk for cardiovascular disease: being male > 50 years, DM, on dialysis, low EFR of 39%.
Ø MYOVIEW scan (cardiac scintigraphy) * non-invasive nuclear imaging done as part of his cardiovascular assessment reported Fixed defect no reversibility postro-lateral indicate myocardial scarring or chronic hypo perfusion ischemia not requiring coronary angio before transplantation
Ø the patient is high risk cardiac need extensive cardiac assessment and follow up even during and post-surgery.
Ø MDT approach with the cardiologist is crucial in such case
If yes, what are the precautions?
Ø High risk patient with CCU care
Ø Cardiologist close follow-up
Ø Optimization of blood pressure and cardiac function
Cardiovascular death is responsible for 30% of death with a functioning graft. This is due to
· traditional risk factors like advanced age, anemia, hypertension, diabetes, and smoking
· nontraditional risk factors like dialysis, FGF-32, hyperphosphatemia, and proteinuria.
So, pretransplant of all these parameters should be assessed and controlled to decrease risk.
Cardiac assessment pretransplant is based on center experience and there is no clear guideline.
Cardiac Evaluation Sheffield Protocol
• Low Risk (< 50, Asymptomatic and Nondiabetic): ECG and ECHO
• High Risk (>50 And Diabetic): MPI, if showed reversible ischemia, coronary angiogram. If irreversible ischemia (fixed perfusion defect), ECHO
• Very High Risk (Symptomatic): Coronary angiography
Back to our case
This patient is 59y and diabetic (high risk) so an evaluation was done by MPI which showed a fixed perfusion defect which means old MI so, after discussion with cardiology I will proceed directly after counseling the patient and controlling modifiable risk factors.
Transplant recipients have a lower risk of cardiovascular events ( fatal and ) in comparison with waitlisted patients on dialysis, but higher risk in with the general population .
40 to 60 % of posttransplant deaths are attributable to cardiovascular disease; the leading cause.
Cardiovascular disease is the most common cause of death with graft function following transplant; 30 % of graft loss from death overall, with the greatest rates early after transplant .
Of note, the incidence of cardiovascular death following transplantation appears to be declining despite the aging and increased comorbidities. Transplantation in this patient is high risk could be after detailed counselling to the patient about cardiovascular risk and the need for critical coronary care following transplantation . Multidisciplinary approach;
cardiology, nephrology and anaesthesia teams must evaluate the condition together and manage all risk factors including anemia ,dyslipidemia, body weight ,DM, hypertension , hyperphosphatemia ,volume status.
Q1: this patient is a high-risk recipient. She had old MI and decreased EF on Echo. In addition, she was diabetic which caused her ESKD and risk factor for CVD. However, kidney TX is the optimal treatment for ESKD patients. The donor has acceptable matching for HLA with no DSA, hence, it’s preferable to proceed for this high-risk TX with precaution.
Q2: she should be evaluated by a cardiologist and receive appropriate medications according to her situation. Risk factors such as blood sugar, smoking, drinking, calcium-phosphate product, PTH level, and anemia should be controlled. She should transplant with an ICU setting to have good post operative monitoring.
This elderly patient has ESRD, DM, Fixed defect (no reversible ischemia) which means it is old fibrosis.
But, the ejection fraction is 39%.
No coronary angiography needed at present
She needs to undergo proper vascular imaging before transplant
She can undergo kidney transplantation where critical care facility is available
Points to be noted before transplant
I will proceed with kidney transplantation.
Pre op:
1) Review patient baseline investigations. Ensure hemoglobin, calcium, phosphate, iPTH within target range. Ensure good diabetic control ,good blood pressure control before transplant.
2)Modifiable risk factors: smoking/ alcoholism.
3)Multidisciplinary meeting with family to explained perioperative and post operative cardiac complications vs benefits of living related renal transplant
3)Review patient medication and to consult cardiologist regarding suitable duration to withhold antiplatelets or anticoagulants.
Post op:
1) Emphasize on blood sugar , blood pressure and body weight control.
2) Lifestyle modification.
Would you proceed with transplantation provided all other investigations are satisfactory?
Kidney transplantation is the treatment of choice for most patients with stage 5 chronic kidney disease and end-stage renal disease (ESRD), offering improved quality of life and overall survival rates.
There is consensus that cardiovascular assessment is needed in high-risk patients prior to kidney transplantation.
Our patient is a high-risk candidate for many reasons
– Old age
– DM which is a leading cause of ESRD
– IHD (MPI revealed postero-lateral perfusion defect with no reversibility)
– Echocardiography revealed severe hypokinesia with an ejection fraction of 39%.
Her immunological work-up is good her donor is a live-related donor with a reasonable match and she has no DSA.
So there is no absolute contraindication for transplantation, but the patient needs further cardiological assessment before preparing to transplant.
The accuracy of MPS in patients with ESRD is moderate and is less sensitive and less specific.
Several studies have assessed the prognostic ability of MPS in patients with CKD and ESRD.
They found that a normal MPS scan in patients with CKD was associated with significantly higher unadjusted cardiac death rates compared with a normal scan in patients without CKD, potentially limiting the value of this technique in the ESRD population.
This patient should be referred to an expert cardiologist to give his opinion and clearance as to proceed or not.
If yes, what are the precautions?
– Anti-ischemic therapy
– Increase hemodialysis sessions to decrease volume overload
– Follow-up by cardiologist
-Control of blood sugur .BP.Anemia
Reference;
– Foley RN, Parfrey PS, Sarnak MJ. Epidemiology of cardiovascular disease in chronic renal disease. J Am Soc Nephrol. 1998;9:S16–S23. [PubMed] [Google Scholar]
– Kasiske BL The coronary screening for kidney transplantation (COST) study. Organization: University of Minnesota Twin Cities; 2008. National Institute of Diabetes and Digestive and Kidney Diseases. (Electronic version) Project number: 5R21DK080315-02.
This patient has multiple risk factors before renal transplantation including age 59 (>50 years), DM, ESRD on HD, and low EF 39%
She doesn’t have any absolute contra-indication for renal transplantation.
She had got a good transplantation offer from her daughter with 111 mismatch, no DSA.
Her myocardial perfusion scan didn’t show reversible ischaemia, however she has got evidence of old ischaemia.
I would go ahead with transplantation with the following precautions:
1- MDT approach including cardiologist.
2- Tight glycemic control.
3- Tight BP control.
4- Optimization of medical treatment of IHD including: B-blockers, ACE.I, statins, anti-platelets.
5- Good HD with optimization of target weight.
6- Anaemia treatment.
As this patient has many high risk factors like : DM, CKD on HD , posterolateral cardiac insult with no reversibility on MPI and low ejection fraction , So she is vulnerable to cardiovascular event post transplantation which is the most important cause of death .
MDT approach with cardiology and pulmonologist opinion is mandatory ,
Optimizing her management regarding the risk factors like proper glycemic control, blood pressure control, dyslipidemia and maintenance HD with UF .
CPET will add a lot to our information about the cardiac , respiratory, musculoskeletal and neurological reserve.
Transplantation must be done in center with ICU .
counseling regarding the cardiovascular risk post transplantation .
We can do the renal transplantation after optimization all the above risk factors.
The patient is considered a high risk to proceed to kidney transplantation, due to her age & comorbidities, DM, & CAD, though she has a matched living donor, which gives better preparation & optimizes her condition pre-transplant. This case needs special counseling of the donor & recipient in terms of the pros& cons of transplant & high-risk consent of death in the perioperative period.
Non-reversible ischemia in a diabetic patient with current moderate to severe hypokinesia & EF 39%, needs optimizing the condition by a cardiologist & might needs time to do. & optimize her HD , and correct anemia pre-transplant, all done in a multidisciplinary discussion including transplant surgeon , cardiologist, anesthetist, and nephrologist.
So I will proceed with the high-risk transplant, with precautions :
1- optimize her condition by cardiologist , aggressive hemodialysis & correct her anemia.
2- Intraoperative, avoid fluid overload, quick surgery & to be in the intensive unit post-transplant.
3- might needs anticoagulant post-operative to start as soon as , preferly , heparin & aspirin .
Irreversible perfusion defect in cardiac scintography implies the prescence of MI with irreversible damage. Low EF 39% with hypokinesia indicate heart failure. The patient has multiple comorbidities.
We can proceed with transplantation in ccordination with the cardiology, anesthesia and intesive care teams.
the is no absolute contraindication to transplantation.
but we need to discuss the risk with the donor and recipient as the recipient is a high cardiac risk. perioperative risk also should be considered
we need to discuss the case with a multidisciplinary team including a cardiologist to evaluate the further cardiac risk of the recipients. As MPS has lower sensitivity and specificity in CKD patients,
Exercise tolerance needs to be assessed.
she should be on maximal anti-ischemic therapy, dialysis should increase the frequency or dose to optimize the volume status of the patients.
1- Would you proceed for transplantation provided all other investigations are satisfactory?
This patient is diabetic , above 50 years old, he is on dialysis, cardiac scintigraphy shows perfusion defect , all these factors make patient to be in high risk group for perioperative and postoperative (post kidney transplantation ) cardiovascular complication .
Patient has a good offer of living related donor with acceptable crossmatch.
This patient needs careful adequate assessment to define the cardiovascular state befor operation .
As following
History taking
Regarding ischemic chest pain, TIA, CVA , intermittent cludication, peripheral vascular disease.
Exam. Redial Pulse , blood pressure , carotid bruit, renal bruit , femoral pulse , posterior tibial, dorsalis pedis .
Investigation
There is no consensus about specific guideline for investigating such a patients .
Resting ECG has poor specificity and poor sensitivity.
Exercise tests (exercise ECG, exercise ECHO,) has moderate specificity and sensitivity.
But the problem with exercise based tests is that patient with ESRD usually has limited physical tolerance and has poor ability to complete the test and to reach the required peak heart rate.
Medication stress test has moderate sensitivity and specificity, again there may be a problem a problem with reaching the target age matched peak heart rate.
Myocardial perfusion scan, has moderate to high sensitivity and specificity but it is not available widely.
CPET – is a test that assesses the cardiac , pulmonary,muscloskeltal, hematological ,neurological general statusand general physical status of patient . it is associated with post operative outcome .
Invasive technique .
Coronary angiography. It is gold standard for assessing the coronary disease . but it has its own complication ,and does not diagnos the microvascular corornary disease.
It is indicated in
1- high risk patient .
2- positive stress test.
3- Old age patient above 50 years .
4- Diabetic patients .
Yes I will proceed with transplantation .
As there is no absolute contraindication . and patient has good donor offer .
This patient will need multidisciplinary team work. ( nephrologist , transplant surgery , anesthetist, cardiologist, immunologist ,transplant pharmacist )
As this patient has non reversible defect on scintgraphy ,which means no significant reversible changes the patient may need no more investigation regarding coronary assessment but the last decision will be for cardiologist
2- If yes, what are the precautions?
This patient ha ahigh risk for perioperative complication . because of
1- Old age.
2- Diabetic with complication.
3- HD history.
4- Heart failure .
This patient needs adequate treatment with
Diuretic if there is urine output , ACEI or ARB, aspirin, statin, blood sugar control, blood pressure control, volume status assessment and treatment , adequate hemodialysis and ultrafiltration.
Use of beta blocker may reduce postoperative cardiovascular complication.
Postoperative intensive care unit monitoring .
Close post operative long term follow up for cardiovascular complication as the most common cause of death is cardiovascular causes .
Monitoring for drug side effects ( NODAT, dyslipidemia )
Monitoring for postoperative hyperparathyroidisim .
Cardiac function monitoring as there is a chance of improvement of heart failure post op.
2 issues in the donor regarding cardiovascular risk :
1-Irreversible CAD
2-Myocardial dysfunction which is likely irreversible also as it is due to irreversible myocardial insult
so I think there is nothing correctable and this is very high risk for kidney transplantation so I would not proceed for transplantation
This is very high risk patient for renal transplantation as she has diabetes mellitus, CKD, Possible old infarction and LV dysfunction. Whether she has overt CCF has not been mentioned. According to Canadian Society of transplantation consensus guidelines on eligibility for kidney transplantation, A very high risk patient should be considered for angiography even with negative non-invasive test.
Hence i would like to consider her for CAG before transplantation to know about exact burden of CAD and revascularization if needed prior to transplant.
She may have TVD or Disease in other artery which may require revascularization before kidney transplant.
If no significant disease found, optimal medical therapy should be continued.
we need opinion of cardiologist in this case.
Kidney transplant considered best mode of renal replacement therapy, offering improved quality of life and overall survival rates the current case is not considered contraindication for the transplant though high risk for the procedure.
She has a donor with good immunological match with no DSA.
Considered high risk due to
Her age
Diabetes
?old MI
Low EFR of 395
I would discuss the case with the cardiologist to optimize her medical treatment and improve the out come.
She will require CPET
She will require entresto
ACE I/ A 2 blocker
Betablocker
In addition to that her dialysis has to be optimized with adequate ultrafiltration , she might require short session (3hrs) 4 days a week.
Her anemia should be treated adequately, HB should be up to the target.
her post kidney transplant cardiovascular out come is controversial. as reported by Rowena B et al 2010, it is difficult to predict which candidates are at high risk for a cardiac event post-transplantation.
References:
1. Low dose sacubitril/valsartan is effective and safe in hemodialysis patient with decompensated heart failure and hypotension.Feng, Yunlin MD; Li, Wenhua MD; Liu, Hongjun BS; Chen, Xiuling BS; Medicine: April 15, 2022 – Volume 101 – Issue 15 – p e29186
2. Cardiac Evaluation prior to Kidney Transplantation. Rowena B. Delos Santos, Aleksandra Gmurczyk, Jagdeep S. Obhrai, and Suzanne G. Watnick Semin Dial. 2010 May-Jun; 23(3): 324–329.
Precautions:
-Need to evaluate by multidisciplinary team, specially cardiologist for more concern.
-Optimum medical management of Diabetes, hypertension and ischemic heart disease.
-Continue on dialysis to avoid fluid overload.
-Correction of anaemia and bone mineral disease if any.
-Consider CPET for further evaluation.
Yes, I will proceed for transplantation if all other investigations are normal. The perfusion defect has no reversibility which indicates it to be an old event and no active intervention will further help to improve or correct it.
EFR of 39% can be due to dual contribution of an old MI and ongoing hypertension (Though there is no comment on BP status of patient in scenario). This does not make kidney transplantation a contraindication.
I will proceed for this transplantation though this patient is considered high risk patient with EF 39 % as there is no absolute contraindication of renal transplantation.
Precautions:
-Need to evaluate by multidisciplinary team, specially cardiologist for more concern.
-Optimum medical management of Diabetes, hypertension and ischemic heart disease.
-Continue on dialysis to avoid fluid overload.
-Correction of anaemia and bone mineral disease if any.
-Consider CPET for further evaluation.
Would you proceed with transplantation provided all other investigations are satisfactory?
Kidney transplantation is the treatment of choice for most patients with stage 5 chronic kidney disease and end-stage renal disease (ESRD), offering improved quality of life and overall survival rates.
There is consensus that cardiovascular assessment is needed in high-risk patients prior to kidney transplantation.
Our patient is a high-risk candidate for many reasons
– Old age
– DM which is a leading cause of ESRD
– IHD (MPI revealed postero-lateral perfusion defect with no reversibility)
– Echocardiography revealed severe hypokinesia with an ejection fraction of 39%.
Her immunological work-up is good her donor is a live-related donor with a reasonable match and she has no DSA.
So there is no absolute contraindication for transplantation, but the patient needs further cardiological assessment before preparing to transplant.
The accuracy of MPS in patients with ESRD is moderate and is less sensitive and less specific.
Several studies have assessed the prognostic ability of MPS in patients with CKD and ESRD.
They found that a normal MPS scan in patients with CKD was associated with significantly higher unadjusted cardiac death rates compared with a normal scan in patients without CKD, potentially limiting the value of this technique in the ESRD population.
This patient should be referred to an expert cardiologist to give his opinion and clearance as to proceed or not.
If yes, what are the precautions?
– Anti-ischemic therapy
– Increase hemodialysis sessions to decrease volume overload
– Follow-up by cardiologist
-Control of blood sugur .BP.Anemia
Reference;
– Foley RN, Parfrey PS, Sarnak MJ. Epidemiology of cardiovascular disease in chronic renal disease. J Am Soc Nephrol. 1998;9:S16–S23. [PubMed] [Google Scholar]
– Kasiske BL The coronary screening for kidney transplantation (COST) study. Organization: University of Minnesota Twin Cities; 2008. National Institute of Diabetes and Digestive and Kidney Diseases. (Electronic version) Project number: 5R21DK080315-02.
The degree of reversibility of a perfusion defect is identified on post-stress images as an area of decreased radiopharmaceutical activity that improves or disappears on rest or redistribution images.
Non-reversible defect (fixed) shows no significant changes in activity between post-stress or rest images,
Yes we would go for transplant as it’s an absolute contradiction
MYOVIEW showed fixed defect, meaning thereby there was a past history of MI. She must be on medical management. If there is a history of stent placement and on dual anti platelets so that must be discussed with cardiologist that before surgery it has to be stopped as they are at high risk of In stent thrombosis.
Nevertheless MPS has lower sensitivity and specificity in CKD patient
During peri operative and post operative period, we have to be cautious for the fluid replacement as EF is 39%
Proper pre-transplant plan and preparation is one of the keys for the transplant success .The need for multidisciplinary team is a cornerstone for achieving safe transplant .
The patient is above 50 , diabetic hence proper cardiological consultation prior to surgery is a must , she must be checked by the anesthesia too prior to any intervention .
Yes I would definitely go for the transplantation if taken the cardiological consultation green card , as no absolute contraindications present ( severe cardiac disease unamenable to treatment is not the case here )
The findings of the myocardial perfusion imaging indicate that she suffered myocardial infarction that appears as a perfusion defect in both rest and stress so no role for CA .
MPI has a sensitivity and specificity of 67% and 77% in CKD respectively although being better in non-CKD population due to :
-CKD hemodynamic and anatomical abnormalities
-LVH
-Endothelial dysfunction in absence of CKD
-volume overload decreases the image quality
Cardiac assessment prior to transplant includes many modalities :
*Exercise ECG poor sensitivity 36% in CKD due to some factors including exercise intolerance , abnormal baseline ECG of CKD patients due to HTN and impaired H rate response to exercise .
*Dobutamine stress Echo of sensitivity less than 80% in CKD.
*Coronary CT angiography in CKD of sensitivity 93% and specificity of 63% ( decreased due to increased calcium burden in CKD) .
*Coronary artery calcium score in ESKD of sensitivity and specificity 88% and 53% respectively
* Invasive coronary angiography ( not useful here in the case )
* Cardiopulmonary exercise test
-an anerobic threshold of less than 11ml/min/Kg is considered at risk of major post.op.events.
Further studies are needed for best modality to implement and better understanding.
Proper preoperative BP , blood sugar , lipid profile control.
BMI optimization as possible
ICU admission post op
EF of 39% and nonreversible perfusion defect is consistent with a previous MI that needs medical treatment, which we suppose is already present. Previous CAG reports will give us information about the coronary arteries and whether are stented or not. If stented and no new symptomatic ischemia, this will be with proceeding with transplantation in accordance with professional cardiologist evaluation. Being diabetic is a risk for multiple CAD. CPET will help us but may not add on MYOVIEW.
Manal Malik
3 days ago
1- Although he has living related donor with acceptable matching and no DSA but he has high CVS risk factor include DM ,ckd on HD ,moderate to sever hypokinesia with Ej fraction 39% and cardiac scintigraphy reported postro-lateral perfusion defect, so need MDT approach involve the cardiologist for further assessment and management before transplantation.
Also need to discuss with patient the risk versus advantage.
After all assessment if patient has no other comorbidities ,there is no non operable 3 vesseles and has no HF with NYHA grate 3 or 4 ,I prefer to proceed after cardiologist clearence.
2-IFyes what the precaution ?
Evolution for the presence of sever cardiac disease ,first history ,identified symptoms of CAD such as anginal symptom ,exercise indolence ,shortness of breath-morbidities and quality of life.
Physical examination :assess the presence of peripheral atrial disease ,anaemia ,HTN,hypotension,abdominal obesity ,Arrythmia ,HF and valvular disease.
Refer to cardiologist for possible angio plastyu so management being considered before transplan such as angioplasty .
Post operative care is need attention such as ICU setting for close monitoring for this patient.
reference
1- Tabriziani H., Baron P., Abudayyeh I., Lipkowitz M. Cardiac risk assessment for end-stage renal disease patients on the renal transplant waiting list. Clin. Kidney J. 2019;12:576–585. doi: 10.1093/ckj/sfz039. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
yes, as there is* no absolute Contraindications THOUGH she is consider as high risk
* the donor is living/related and no DSA
This patient is at high cardiac risk both pre and post transplant, becuse of: Diabetic , Age 59 yrs, on HD ,With irreversible postro-lateral perfusion defect, and Echo reported moderate to severe hypokinesia with EFR of 39%.
We need to take more history about the duration of HD, DM, tobacco use, hypertension, hyperlipidemia, family history,A prior history of ischemic heart disease,myocardial infarction or congestive heart failure.
The Evaluation Process:
-A detailed medical history and examination
-MDT including the Nephrologists, Endocinologist,Surgeons , dietion,Renal Pharmacist, Renal Psychologists.
-Further detailed cardiac evaluatin after discussion with cardiologist as apart from MDT and optimization of medical therapy
-BEFORE TRANSPLANT:
*this patient need good controle of BP, DM, dyslipidemia and CKD complications specialy amaemia.
*she needs aqeuate dialysis to reach the dry weight
*all the risk factors pre/post transplant must be discussed with the patient
-AFTER TRANSPLANT:
SIXTH EDITION Handbook of Kidney Transplantation
(From Pilmore H. Cardiac assessment for renal transplantation. Am J Transplant 2006;6:659–665, with permission.)
Would you proceed for transplantation provided all other investigations are satisfactory?
I will proceed for this transplantation
despite this patient is considered high risk old age more than 50 years , diabetic, cardiac with EF 39 % and end stage renal disease on regular haemodialysis.
there’s no absolute contraindication ( no malignancy , no sever cardiac disease which is refractory to medical therapy , not liver cirrhosis, not considered non compliant not psychiatric or drug abusal , not recurrent aggressive native disease as infected renal stone as stag horn stone not morbid obese )
Firstly, we must evaluated and accepted by multidisciplinary team
( surgeons , nephrologist, trans presentation coordination , tissue typing , lab , renal pharmacists renal psychologist, Anathesia and cardiologists.
-If patient evaluated and accepted by teams , we must –
Tight Control of blood sugar with target haremoglobin A1C from 7 to 8.
Medical management: anti-ischeniic measures , statin , BB , ACEI and dual antiplatelet therapy
Tight control of blood pressures
Continue on dialysis to avoid to be overloaded with concomitant diuretic therapy
Body wight reduction
Correction of anaemia and bone mineral disease
We must considered CPET to asses physiological reserve of cardio-vascular , pulmonary, muscular and neuropsychological response during exercise
not allowed at rest.
Very good Amal.
Hi Amal,
What kind of threshold you are looking for CPET when deciding to go ahead with transplant or keeping him on maintenance dialysis?
Yes, Amal.
In some patients, EF is underestimated when overloaded with fluid. It would be worthwhile repeating EF after this patient has been on maintenance dialysis for few weeks.
Transplant recipients have a lower risk of fatal and nonfatal cardiovascular events compared with waitlisted patients on dialysis, but a much higher risk compared with the general population .
40 to 60 % of posttransplant deaths with a reported cause are attributable to cardiovascular disease, with an incidence of ischemic heart disease of approximately 1 per 100 person-years at risk .
Cardiovascular disease is the most common cause of death with graft function after transplant and accounts for 30 % of graft loss from death overall, with the greatest rates early after transplant .
Notably, the incidence of cardiovascular death after transplantation appears to be declining somewhat despite the aging and increased comorbidity burden
Transplantation in this patient is high risk after Detailed information to the patient about cardiovascular risk and the need for ccu after transplantation
Cardiology, Nephrology and anaesthesia team must evaluate the condition togerther and correct all risk factors sush as anaemia ,dyslipidemia, body weight ,HBA1C, Bp, hyerphosphatemia ,fluid stuts
Authors:John Vella, MD, FACP, FRCP, FASN, FASTKrista L Lentine,uptodate Aug 06, 2020.
Thankyou
But would you proceed?
No contraindication to transplantation and I will proceed after cardiovascular consultation for fitness for surgery
Diabetes mellitus with micro (diabetic nephropathy)and macrovascular complications (cardiac insult-posterolateral perfusion defects with no reversibility and low ejection fraction),age >50 years place the patient at high risk case for renal transplantation.Therefore ,need cardiologist opinion and fitness before transplantation and close follow up post op..
▪︎If yes, what are the precautions?
Multidisciplinary team should be involved including cardiologist and pulmonologist on board and transplant should be done in a center who have ICU facility with them.Counselling of the cardiac risks,DGFand allograft failure should be explained . Functional assessment done with CPET.Risk factors i.e., DM,Hypertension and dyslipidemia should be addressed,Dialysis and fluid balance and IHD treatment should be optimized ,anemia and ckd-mbd addressed and electrolytes corrected before transplant.
REFERENCES:
Kotta PA, Elango M, Papalois V. Preoperative Cardiovascular Assessment of the Renal Transplant Recipient: A Narrative Review. J Clin Med. 2021 Jun 7;10(11):2525.
Very good
Cardiovascular disease is the leading cause of death in KTR and The risk of CAD is higher in renal patients on dialysis and on waiting list compared to the kidney receipients , so kidney transplantation is the best therapeutic option for this IHD patient , but this patient is a high risk cardiac patient
-(older >50, diabetic, advanced CKD )
-MPI show irreversible postero lateral ischemia indicating old MI that can’t be corrected with revascularization .presence of pretransplantation MPI is associated with 6 fold increase risk for cardiac death post transplant
-Echo show moderate wall hypokinesia and EF 39%
In this patient, we must balance between increase risk of cardiac death ( expected from MPI finding of irreversible ischemia ) and long term decrease CAD
So this patient need cardiac expert clearance to proceed for transplantation and explain her the risk
If the cardiologist accepted her as a recipient, management plan would include
– General anti ischemic measures as
– Tight glycemic control (DM and dyslipidemia require close monitoring specially with treatment with steroid and CNI associated hyperglycemia and dyslipidemia)
– Strict blood pressure control
– continue on dual antiplatlets, BBs and statins.
-life style modification (regular exercise, Wt reduction if obese, stop smoking).
– Adequate dialysis to avoid hypervolemia
– correct BMD specially hyperparathyroidism
-Correction of anemia
Very good.
As patient has postro-lateral perfusion defect with no reversibility and Echocardiogram reported moderate to severe hypokinesia with EFR of 39%.mortality mainly post transplant from cardiac event and this patient consider high risk
so not suitable for transplantation except cardio-renal transplantation
Introduction:
-Renal transplantation is the best RRT modality to improve both patient survival and quality of life in CKD patients provided that there is no absolute contraindications.
-cardiovascular complications is the leading cause of mortality in CKD and kidney transplant recipients
-Cardiovascular assessment represents an integral part of kidney transplant recipient evaluation. However, there is still a debate regarding the best diagnostic modality in evaluating cardiovascular risks in kidney transplant recipients.
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Would you proceed for transplantation provided all other investigations are satisfactory?
-I will proceed to transplant this case provided that there is no absolute contraindication for renal transplantation. This is a good offer from a living donor with an acceptable mismatch and no DSA. However being at high risk for CV complications (age>50, diabetic, previous MI with impaired EF), a careful cardiac evaluation and involvement of multidiscipline team is required (nephrologist, cardiologist, transplant surgeons, anesthetist).
-The Non-invasive MPI revealed a fixed posterior-lateral perfusion defect indicating a previous infarction along the RT coronary or circumflex territories(A positive MPI test is associated with a 5 risk of cardiac death in kidney transplant recipients). This is reflected in the ECHO finding of impaired EF (39%) and the RWMA.
-Coronary revascularization could be considered. However, it is suspected to provide no added benefit with that irreversible ischemia. Additionally, multiple studies could not elicit a difference in outcome between revascularization VS optimal medical treatment except in patients with triple vessel disease, Accordingly. optimizing medical treatment is the key to successful Kidney transplantation in the above scenario.
-Carrying a CPET would be helpful in this case to assess the functional exercise capacity and cardiovascular reserve and is considered a strong predictor of transplant outcomes.
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If yes, what are the precautions?
-Optimizing dialysis adequacy and fluid status(target weight adjustment). Follow up ECHO may be done to check for improved EF after adjusting optimum target weight.
-Tight glycemic and blood pressure control and life style advice regarding obesity, exercise and smoking cessation.
– Treatment of anemia and MBD according to guide lines(vascular calcifications may worsen CAC score).
– Secondary prevention of CAD using anti-PLT, statins, beta blockers and ACE inhibitors
-Evaluation of the transplant vasculature (for any aorto-iliac stenosis that may require re-vascularization before transplantation).
– Intra-operatively, careful fluid management and blood pressure control
– A close post-operative monitoring of fluid status and cardiovascular events are necessary in ITU setting
-Careful long term follow-up post-transplant specially during the first year. careful adjustment of immunosuppression and medical management for diabetes, hypertension and CAD is mandatory being at high risk for cardiovascular morbidity and mortality.
References:
1.Baman JR, Knapper J, Raval Z, Harinstein ME, Friedewald JJ, Maganti K, Cuttica MJ, Abecassis MI, Ali ZA, Gheorghiade M, Flaherty JD. Preoperative Noncoronary Cardiovascular Assessment and Management of Kidney Transplant Candidates. Clin J Am Soc Nephrol. 2019 Nov 7;14(11).
2. Poli FE, Gulsin GS, McCann GP, Burton JO, Graham-Brown MP. The assessment of coronary artery disease in patients with end-stage renal disease. Clin Kidney J. 2019 Aug 14;12(5):721-734.
3.Lecture of Prof Ahmed Halawa
Exellent as usual
Would you proceed for transplantation provided all other investigations are satisfactory?
Yes, I will proceed for transplantation if all other investigations are normal. The perfusion defect has no reversibility which indicates it to be an old event and no active intervention will further help to improve or correct it.
EFR of 39% can be due to dual contribution of an old MI and ongoing hypertension (Though there is no comment on BP status of patient in scenario). This does not make kidney transplantation a contraindication.
If yes, what are the precautions?
There are quiet a precautions that should be considered before moving ahead for transplantation. Before enumerating them, I will first comment on one of the most important factors which precipitates or aggravates cardiac morbidity post transplantation i.e FLUID SHIFTS AND IMBALANCES. This needs most strict and continuous monitoring in ICU for for first 3 to 4 days.
Fast fall in Chronically raised BP post transplant, high volume IV fluid supplementation immediate post transplant can be major factors which can hit compromised heart as in above scenario.
Other precautions that need to be followed are:
Thankyou for highlighting the impact of fluid balance.
ICU management for that.
MDT control.
I would proceed to transplantation provided all other investigations are satisfactory. I would make sure CPET is done and values from CPET are not in the high risjk range. In fact, there is no established cut off EF below which we can’t proceed to transplantation. In addition she has no severe HFrEF in terms of EF reduction. also, EF can possible improve after transplantation, after breaking the vicious circle of cardiorenal syndrome. What would matter the most perioperatively, is the close observation of the volume status, not being very liberal with postop IV fluids.
Thank you, but there is always room to improve the cardiac condition prior to transplantation, as indicated before through good dialysis, improve the volume status, BP control, excersis, etc
☆The burden of CVD in ESKD is reduced after renal transplantation ; however, it still remains the leading cause of premature patient and allograft loss, as well as a source of significant morbidity and healthcare costs. Most phenotypes of CVD are represented in the KT recipient population. Pre-existing risk factors for CVD in the KT recipient are amplified by superimposed cardio-metabolic derangements after transplantation such as the metabolic effects of immunosuppressive drugs, obesity, DM, hypertension, dyslipidemia and allograft dysfunction [1].
☆In this scenario:
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▪︎Would you proceed for transplantation provided all other investigations are satisfactory?
I think this is a high risk transplant recipient due to many factors:
Old age , Diabetes Mellitus with microvascular complications( diabetic nephropathy), history of previous cardiac insult ( Posterolateral perfusion defects) and low ejection fraction. However, this lady has a chance for renal transplantation, but before proceeding:
1.We shall consult a cardiologist to re-assess her.
{But it is important to Know that: at present there is no consensus regarding the appropriate cardiac risk assessment strategy for CKD and ESRD patients awaiting transplantation. The American Society of Nephrology and the American Society of Transplantation recommend myocardial perfusion imaging as part of the pre-operative evaluation. Depending on test results, the patient could require revascularization. In comparison, the American College of Cardiology and the American Heart Association recommend no pre-operative cardiac evaluation given that kidney transplantation poses an intermediate risk if the patient has good functional status, which we outline more fully in our later discussion [2]}.
2. Close flow up.
3. Re-evaluate her.
▪︎If yes, what are the precautions?
1. Control of her DM, HTN and dyslipidemia.
2. Keep our patient under cardiology observation.
with serial cardiac assessment measures.
3. Prophylactic anti-ischemic drugs.
4. Adequate renal replacement therapy
5. Finally, Transplantation should be under intensive care setting which involve a multidisciplinary team with the cardiologist.
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Ref:
[1] J. Rangaswami etal. Cardiovascular disease in the kidney transplant recipient: epidemiology, diagnosis & management strategies. Nephrol Dial Transplant. 2019.
[2] Rowena B. Delos Santos, etal. Cardiac Evaluation prior to Kidney Transplantation.
Thank you
# Would you proceed for transplantation provided all other investigations are satisfactory?
*The immunological workup are acceptable, HLA mismatch 1_1_1, no DSA and living related donor
*The medical risk factors are
59 year old, diabetic nephropathy, postro-lateral perfusion defect with no reversibility, moderate to sever hypokinesia and EFR of 39%, so she has high risk of morbidity and mortality
*Yes, I would proceed for transplantation, but very carefully( there is no absolute contraindication ).
# If yes, what are the precautions?
*Involving of the cardiologist from the start with other MDT is an important
*Non-invasive test to check the cardiac, respiratory and functional performance such as CPET
*Optimize the fluid intake increase the dialysis sessions
*Control BP, DM, electrolyts and the anemia.
And other drugs like anti ischemic Beta blockers,ACE, inhibitorAngiotensin receptor blockers
,Neprilysin inhibitors
*The transplantion should be done in intensive care setting
Thank you
Kidney transplantation is the best RRT for ESRD patients, and every ESRD patient can be considered for kidney transplantation unless cotraindicated
contraindication to kidney transplantation :
1- severe cardiac disease
2- liver cirrhosis
3- severe lung disease
4- malignancy
5- morbid obesity
6- severe native kidney disease with recurrent risk
our case is 59 years old, Diabetic, with DN, On hemodialysis, EF 39%
MPS shows fixed area of hypoperfusion indicate old ischemia
she is high risk patient for perioperative and postoperative complications.
she needs to assess her functional status { exercise tolerance} with CPET. needs to optimise the antifailure treatment (ARABs, Or ACEi, aldactone, Valsartan) under cardiologiest guide, optimise the dialysis therapy to achieve dry body weight.
counselling the patient and her family about her risk (cardiac risk and DGF or failure)
tight glycemic control as she will use drugs that may worse the glycemic control.
discuss the importance of drug compliance, her need for postoperative intensive care admission. high risk consent.
the discion of transplant better to be based on MDT discussion including cardiologist, anaesthesia, nephrologist etc.
she may be better to do invasive cardiac test looking for silent ischemia that may improve with stent.
if yes transplanted, she needs postoperative ICU care with close monitoring to fluid status, electrolyte, blood sugar, graft function, and sign of infection.
Thank you
*The patient has no reversibility in cardiac scintigraphy so, there is no role for CA.
Regarding renal transplantation, there is not an absolute contra-indication for RTX but take into consideration , she will be considered as high risk patient for cardiac insult , CVS mortality post renal transplantation due to ( low EF 39% ).Fixed defect in Myocardial perfusion scan denotes stabilized myocardial infarction. So; we can proceed for transplantation after cardiologist clearance and to be monitored in ICU.
* There are some precautions should be take :
Thank you, Dina, but this a short answer
THIS PATIENT CAN PROCEED WITH RENAL TRANSPLANTATION AS HE HAS NO ABSOLUTE CONTRAINDICATION .
THE PATIENT IS MORE THAN 50 YR , Hx OF DM , THE CARDIOLOGIST SHOULD BE INVOLVED IN TRANSPLANTATION WORK UP
AS THE PATIENT HAD NO REVERSIBILITY IN THE ( cardiac scintigraphy ) THERE IS NO INDICATION FOR CORONARY ANGIOGRAPHY .
THE TRANSPLANTATION ITSELF INCREASE THE RISK OF CAD AND IN THIS PATIENT THE RISK IS MORE AS HE HAD CARDIAC PROBLEM BEFORE THE TRANSPLANTATION ( LOW EF WITH HYPOKINESIA ) ,
THIS PATIENT SHOULD HAVE CPT ( IF AVAILABLE )
THIS PATIENT SHOULD BE ADMITTED TO ICU POST TRANSPLANATION FOR FLUID STATUS EVALUATION ( FREQUENT EXAMINATION , V/S ,URINE OUT PUT ) TO PREVENT FLUID OVERLOAD
STRICT MANAGEMENT OF MODIFIABLE RISK FACTOR
1- BP 2 – GOOD GLYCEMIC CONTROL 3 – TRAT DYSLIPIDEMIA
4- FREQUENT EVALUATION WITH CARDIOLOGIST .
5- STOP SMOKING
6- ENCOURAGE EXERCISE AND HEALTHY DIET
Thank you, Please in small letters
Case scenario 1:
ü Regarding the immunological w- up the patient has acceptable HLA mm, NO DSA and the donor is a living.
ü And regarding her medical conditions she has NO absolute contraindications for transplantation but she is a high risk patient for transplantation through her age, comorbidity, previous myocardial ischemia which approved through MPS and recent cardiac function status (EF 39 percent that approved by Echo).
ü So I will proceed for transplantation with precautions.
ü Proper glycaemic control through endocrinology specialist
ü Medical adjustment for kidney functions and electrolytes state
ü Modifications for HD sessions and settings to reduce the cardiac overload trying to improve her Ejection fraction.
ü Thorough follow up with a cardiology specialist pre and also post transplantation.
ü Important to be counselled with the degree of risk to be transplanted as a high risk patient that she need close monitoring and follow up.
Thank you
I will accept this patient for transplantation, however she is a high risk patient as her cardiac assessment revealed EF of 39% and fixed perfusion defect consistent with a scarred myocardium consequent to myocardium infarction. The 90 days post operative risk of major cardiac events hover above 10 % ..As it was clearly shown in more than one study the direct relation between the level of heart failure and EF and the risk of cardiac event including cardiac mortality post transplantation.
Elaborate assessment is pivotal in this context, in order to stratify the risk and fitness for surgery by looking for features of severity and decompensation such as JVP, 3rd and 4th heart sounds, atrial fibrillation, mitral regurgitation , hyponatremia, and features of organs hypoperfusion. Furthermore Pro BNP and EF evaluation are essential. Having said that the reported potential symptoms by the patient are reflective of the severity and class of HF.
Acute and decompensated HF are associated with mounting risk of MCE than the CAD.
investigating the underlying cause of Heart failure , however it was showing regional fixed defect.
Plan:
This patient has to be started on ACEi or preferably ARBs .with special attention to hyperkalemia.
angiotensine receptor-neprilysin inhibitor Sacubitril/valsartan.
Aldosteron receptor blocker is essential in the management ,proving that hyperkalemia is not reported.
B blockers is bsically an important line in the management.
Treatment of confounding factor:
treatment of hypertension,
Atrial fibrillation.
This plan of management has to continue for 3 months, and then to re-evaluate the cardiac function.
Thank you
This 59 year old patient who is on dialysis due to diabetic nephropathy has an offer for kidney with 111 mismatch with no DSA. Posterolateral perfusion defect with no reversibility was seen on cardiac scintigraphy. Echo showed EF 39 % with severe hypokinesia. She is definitely high risk cardiac patient for surgery.
Would you proceed for transplantation provided all other investigations are satisfactory?
There is no absolute contraindication ,So, YES.
Absolute Contraindications to Renal transplant
These include.
Acute infections
Severe cardiac, liver or lung disease
Malignancies
Significant native kidney diseases
BMI>40
If yes, what are the precautions?
Patient is high cardiac risk for surgery and i will refer him to cardiologist. This patient will need multimodality approach. I will involve cardiologist, nephrologist, intensivist , anaesthetist, transplant coordinators. I will make sure that medical issues are addressed and any co morbidities are optimized.
Successful treatment will only be possible if patient is fully on board. This will require patient education and counselling. Good glycemic control and weight loss will be helpful. Correction of any abnormality like anaemia , calcium and PTH abnormality. Renal replacement therapy has to be optimized .
Involvement of Multimodality team in perioperative settings. Such patient may require extensive motoring in CCU settings. . Serial cardiac monitoring post transplant is utmost important.
Thank you
yes, I will proceed for transplantation with post transplant icu care.
This is a very short answer Tufayel. Please read the other responses and get back to us.