IV. Revascularization versus Medical Management of Coronary Artery Disease in Prerenal Transplant Patients: A Meta-Analysis
- Summarise this article
- What is the level of evidence provided by this article?
- There is an obvious weakness(s) in this study, please identify it (them).
Level 1 evidence
The prevalence of coronary artery disease is high among the CKD patients because of activation of oxidative stress, cytokines, leading to atherosclerosis of the coronary vessels.
Six studies were included in this meta-analysis showing that, there is no significant post-transplant cardiac outcome between medical or surgical management of coronary artery disease , of the 6 studies, there were 338 patients on revascularization arm and 260 patients on medical treatment arm with exclusion criteria: studies conducted before 1997, Studies looked at one arm of the study, and studies recorded pre-transplantation results, studies in screening but not treatment of coronary artery disease and studies that did not report the crude data but hazard ratio.
Weaknesses : Small sample size for a meta-analysis.
introduction
Cardiovascular disease is the most common cause of mortality among patients with CKD, dialysis, and even post-kidney transplant. So, a simple EKG is not sufficient for evaluation of the cardiac condition of the recipient and investigations may reach doing invasive maneuvers such as coronary angiography and revascularization. This is a meta-analysis reviewing the outcomes of revascularization done preoperatively in transplant recipients with significant coronary obstructions
methods:
searching the web for only studies that compared revascularization and medical treatment
including crude data not only hazard ratio
results:
5 studies were included and showed no difference in outcomes between treatment group and revascularization
Objective :
In patients who are discovered to have severe obstructive coronary artery disease, we compare coronary revascularization versus medical therapy before kidney transplantation by meta-analysis.
Results :
This comprised 338 patients who had coronary revascularization and 260 individuals who received medical treatment. In the revascularization group, there were 36 occurrences, compared to 57 incidents in the medical management group. One research did not include CVD outcomes; it just provided hazard ratios
Discussion:
According to the findings of the meta-analysis, preoperative cardiac revascularization had no impact on posttransplantation mortality as compared to medical care for people receiving a kidney transplant.
Manske et al1992 .’s study is the first randomised trial to examine the therapy of CAD in renal transplant candidates. In this study, 151 people with insulin-dependent diabetes had coronary angiography, and 31 of them had obstructive coronary artery disease and 10 of the 13 patients in the medication arm and 2 of the 13 patients in the revascularization arm suffered cardiovascular events at the conclusion of the 8.4-month study. Additionally, 4 people died in the medical sector.
Conclusion :
According to a meta-analysis, there is no discernible difference between preoperative medical care and revascularization in terms of posttransplant cardiac outcomes.
Ideally, thorough preoperative hemodynamic monitoring, careful risk stratification utilising noninvasive testing, and tighter postoperative follow-up to check on medication adherence may result in improved results in this particular patient population
This meta-analysis showed that preoperative cardiac revascularization does not affect post transplantation mortality compared to medical management for individuals undergoing renal transplant.
According to the organ procurement and transplant registry 2012 annual survey, there were 88,874 people on the waiting list and 16,487 candidates successfully receiving transplants Individuals with CKD and ESRD requiring haemodialysis and have CAD or acute coronary syndromes have poorer outcomes. Therefore, it is imperative to balance the risk of preoperative coronary angiography accelerating the need for dialysis, potential bleeding risk with dual antiplatelet therapy, and potential delay in delivery of procured kidneys versus postprocedural atherosclerotic complications.
Manske et al. from 1992, randomized trial exploring management of CAD in renal transplant candidates performed coronary angiography in 151 individuals with insulin-dependent diabetes and found obstructive CAD in 31 subjects. Twenty-six of the subjects agreed to randomization. At the end of 8.4 months, 10 of 13 individuals in the medical arm and 2 of 13 individuals in the revascularization arm had cardiovascular events. There were also 4 deaths in the medical arm. It is important to note that the medical arm in this study consisted of aspirin and calcium channel blockers. Since the study by Manske et al. advances in preoperative medical management have led to improvement in postoperative cardiovascular outcomes, which is comparable to preoperative invasive management of CAD.
Additionally, the BARI 2D trial has shown that diabetic patients are more likely to have diffuse CAD and have improved outcomes when treated with coronary artery bypass graft and optimal medical therapy.
Kumar et al. have noted that pre-emptive revascularization prior to transplantation leads to increased survival at 1 and 3 years posttransplant. The conclusions of this study are limited as it was nonrandomized, and participants were asked if they wanted revascularization or not. Refusing revascularization may be an indicator of poor underlying medical condition and inability to adhere to medical therapy.
Singh et al. found that if the pretransplant stress test result was negative, transplantation could proceed with a low risk of posttransplant adverse cardiac events. This supports the use of non-invasive stress testing to risk stratify pretransplant candidates. In addition, Singh et al. found no significant difference between the patients with no significant CAD and those with significant lesions who underwent revascularization.
Interestingly, both studies, compared to Lindley et al. and Kahn et al, had better preoperative non-invasive echocardiography sensitivity and negative predictive values.
Therefore, modest differences in non-invasive stress imaging can help identify individuals that will benefit from medical management and reduce the need for invasive diagnosis.
The study by Eschertzhuber et al.in the meta-analysis favours revascularization. Eschertzhuber et al. found that patients awaiting transplant with proven high-risk profile for posttransplant cardiac events can undergo transplantation safely if they are revascularized. In addition, they concluded that candidates for kidney transplant who had a history of CAD but no workup or treatment were at tremendous risk for posttransplant cardiac events.
Felix et al. present a unique perspective on anatomic data of posttransplant CAD. Of the 33 subjects in this analysis who experienced posttransplant primary outcome requiring coronary angiography, 74% were observed to have CAD progression in a new anatomic location. This posttransplant cardiovascular outcome would not have been prevented simply with pretransplant revascularization. This suggests that plaque stability and progression are commonly vulnerable in this population despite transplant. Complicating the postoperative management further is the fact that reported compliance to optimal medical therapy is in the range of 10–60%
Preoperative medical management versus revascularization does not lead to significant difference in posttransplant cardiac outcomes. Theoretically, careful risk stratification using non-invasive testing, meticulous perioperative hemodynamic monitoring, and closer postoperative follow-up to monitor for medication adherence can possibly lead to better outcomes in this particular patient population
This a meta analysis so level 1 evidence
it includes 6 studies with total patients of 260 patients
it aim to compare medical therapy versus re vascularisation of the coronary arteries pre transplant,the result was no difference between two modalities in treatment.
the weak point is small numbers of studies included and numbers of patients
CV disorders are a common cause for morbidity and mortality among CKD patients and are caused by traditional and non traditional risk factors. Causes of CAD in CKD patients include chronic inflammatory status , activation of RAS system and increase cytokines production that in turn leads to myocardial structural and functional abnormalities.
Diagnosis of CAD in CKD could be difficult as most non invasive investigations as ECG , resting , exercise and stress echo are of limited sensitivity and specificity in CKD patients. While coronary catheterization can accurately diagnose and stratify severity of CAD but it’s invasive technique and carry the risk of contrast nephropathy.
In this meta analysis, the investigators aimed at comparing the effectiveness of medical Vs surgical revascularization in managing post kidney transplantion CV events. They reviewed 6 studies including renal patients involving 260 patients who recieved medical treatment and 338 patients who underwent coronary surgical revascularization
The CV events were higher among medically treated patients compared with patients who recieved coronary artery surgical revascularization 36 Vs 54 events respectively.
Comparing the efficacy of different medical and surgical treatment of CAD in CKD patients is not well studied issue as most CKD patients are excluded from these studies.The only randomized controlled trial that evaluated medical Vs surgical treatment of kidney recipients was performed by Manske et al. in 1992 and revealed more CV events in medically treated group 10 of 13 patients compared with only 2 of 13 patients in surgically treated group.
Limitation of this study includ small sample size , also medical treatment was limited only to asprin and CCB but recently several drugs have been used with improving post operative mortality rates in cardiac patients undergoing non cardiac surgeries such as metoprolol.
Conclusions
CKD patients commonly suffer from CV complications with increased morbidity and mortality rates and usually those patients are excluded from large trials comparing different treatment modalities for CAD . However , due to recent progress in medical management of CAD , both medical and surgical revascularization for CAD in renal patients could yeild comparable results.
This is a meta-analysis of 6 studies evaluating the pre-operative cardiac management of patients candidate for renal transplant. There was comparison of the outcome of medical therapy versus revascularization in the treatment of CAD .It was found in previous studies that advances in the pre-operative medical treatment have resulted in improvement in the post-operative cardiovascular outcome. CKD patients were included in POISE study with conclusion that use of metoprolol was associated with reduced incidence of MI in post-operative period. It was found in CARP trial that pre-operative revascularization of stable CAD patients did not reduce mortality, MI, stroke or death in first 30 days post-operatively.
BARI2D trial concluded that diabetic patients are more likely to have diffuse CAD and have improved outcome following CABG and optimal medical treatment. One study favored revascularization and suggested pre-operative noninvasive screening of patients with suspected CAD and should include, if indicated, coronary angiography.
Felix and co-workers found that 74% of 33 patients with CAD were having CAD progression in a new site.
level 1(meta-analysis) study
Weakness points
limited retrospective studies.
Revascularization versus Medical Management of Coronary Artery Disease in Prerenal Transplant Patients: A Meta-Analysis
Introduction:
Many patients who are referred for RT need to have their cardiovascular systems optimized, and they go through a thorough cardiac workup that can range from a simple ECGto coronary angiography.
The nature of this workup has been the subject of extensive inquiry during the past few years. The following question is posed when a patient with an abnormal stress test undergoes coronary angiography and significant coronary blockage is found.
In comparison to medical care, would revascularization (with either percutaneous coronary intervention or coronary artery bypass surgery) improve outcomes posttransplantation? This meta-analysis aims to analyze the research on the post-operative outcomes of patients who underwent coronary revascularization versus medical treatment but had severe coronary blockage before to RT.
Methods:
Pubmed search was done
Exclusion criteria included (1) studies prior to 1997,
(2) studies that only looked at one arm of the research (i.e., only a revascularization group),
(3) studies that only recorded pre-transplantation results,
(4) studies that compared percutaneous coronary inter- vention to coronary artery bypass surgery but not to a medical management group,
(5) studies that only looked at screening but not treatment of the CAD, and (6) studies that did not report the crude data but only hazard ratios or odds ratios.
All other studies were included.
Results:
6 studies included in the meta-analysis.
a total of 598 subjects.
260 were in the medical management group and 338 were in the revascularization group.
Of the 5 studies, there were 36 events in the revascularization and 57 events in the medical management group.
These findings suggest that posttransplant cardiovascular outcomes from medical care are comparable to those from pretransplant revascularization.
Discussion:
Our meta-findings analysis’s demonstrate that, when compared to medical care for patients receiving renal transplant, preoperative myocardial revascularization had no impact on posttransplantation mortality.
Our meta-findings analysis’s demonstrate that, when compared to medical care for patients receiving renal transplant, preoperative myocardial revascularization had no impact on posttransplantation mortality.
Our meta-analysis reveals that there is no significant difference in the post-transplant cardiac outcomes between preoperative medical treatment and revascularization. Theoretically, better outcomes in this particular patient population may result from rigorous risk stratification utilizing noninvasive diagnostics, meticulous perioperative hemodynamic monitoring, and tighter postoperative follow-up to check on medication adherence. To identify whether patient subgroups might benefit from revascularization or from pretransplant intensive medical treatment, additional prospective randomized trials are required.
Level of evidence 1
Point of weekness: only 6 studies used all are retrospective and not answering our meta-analysis questions.
Summary
This is a meta-analysis with level 1 evidence to compare coronary revascularization to medical management prior to renal transplantation in patients who are found to have significant obstructive coronary artery disease. A total of 6 studies were reviewed. It there is no difference in CVD outcomes between pretransplant treatment strategy. This observation suggests that the CVD outcomes post transplantation are not affected when optimal medical therapy is used instead of coronary revascularization.
Limitations
1. Small sample size.
2. Short observation period for the study.
3. Not RCT.
This is a meta-analysis of 6 studies out of reviewed 777 articles.
The main aim was to compare the post-transplant outcome of medical versus revasculartion approaches in patients with significant obstruction .
The total number was 598 divided in to :
260 who received medical management in whom 57 events occurred
338 who received coronary revascularization in whom 36 events occurred
The end results was that there is no differences in post-transplant events in patients undergoing either of pre-transplant medical or revasculartion treatment
What is the level of evidence provided by this article?
This is a meta-analysis so level I
There is an obvious weakness(s) in this study, please identify it (them).
Only 6 study were included and they are not addressing the main question of this meta-analysis. They are of different designs and are retrospective. The only RCT addressing the meta-analysis aim was excluded.
Introduction
ESRD is a known identifiable risk factor for coronary artery disease, the main dilemma arises when the patient has significant obstruction whether interventional procedure to be recommended or conservative treatment is the best option for this type of patients.
So, meta-analysis were carried out to review the literature of post-operative outcomes for patients with significant coronary obstruction prior to renal transplantation who did either coronary revascularization versus medical management.
Methods
Data collected on patients with obstructive CAD who underwent either revascularization or medical management after 1997, given that odds ratios are with 95% confidence intervals (CI).
Results
The meta-analysis involved 6 studies, a total of 598 subjects. Medical management group were 260, while 338 were in the revascularization group. The revascularization group had 36 events in comparison to 57 events in the medical management group. The results showed that there were no difference in post-transplant cardiovascular outcomes on comparing pretransplant revascularization to medical management. P value is considered significant when p < 0.01.
Discussion
Preoperative cardiac revascularization does not affect post transplantation mortality compared to medical management for renal transplant candidates according to the results of the study.
CKD and ESRD requiring hemodialysis who have CAD or acute coronary syndromes have poorer outcomes. So, the risk of preoperative coronary angiography advancing dialysis urgency and potential bleeding risk with dual antiplatelet therapy, leading to delay in renal transplantation should be seriously weighted against post procedural atherosclerotic hazards.
Acceleration of atherosclerosis in patients with renal impairment and ESRD is primarily due to activation of renin-angiotensin-aldosterone system, oxidative stress, and inflammation accompanied with increased cytokines as well as dyslipidemia. Myocardial structural changes, endothelial dysfunction, vascular calcification along with dialytic and electrolyte changes are related to a 14-fold increase in sudden cardiac death. Patients with renal insufficiency have platelet dysfunction combined with excess dosing of antiplatelet and antithrombotic medication leads to increased morbidity and mortality.
Nearly 80% of ESRD subjects and 75% of CKD subjects are excluded from trials of evidence-based pharmacologic interventions. Recent advances in preoperative medical management have shown improvement in postoperative cardiovascular outcomes, which is comparable to preoperative invasive management of CAD.
The POISE study came with the conclusion that the preoperative use of metoprolol succinate prior to intermediate or high-risk noncardiac surgery caused postoperative myocardial infarction reduction. The CARP trial concluded that revascularization of preoperative stable CAD did not show reduction of mortality, myocardial infarction, stroke, or death 30 days postoperatively. The BARI 2D trial has pointed that diabetic patients are more likely to have diffuse CAD and have improved outcomes after being treated with coronary artery bypass graft as well as optimal medical therapy.
Recently, Kumar et al. have assumed that preemptive revascularization prior to renal transplantation is accompanied with improved survival at 1 and 3 years post transplant.
The proposed fact that cardiac catheterization is the gold standard to define coronary anatomy, however it is not without risks. Noninvasive stress testing is the known preferred tool to assess CAD prior to transplantation leading to better medical management.
The study by Eschertzhuber et al. is in favor of revascularization, also it noted that patients with history of CAD without workup or treatment were at great risk for post transplant cardiac events. This augments the data recommending pretransplant screening for CAD in renal transplant candidates ought to include noninvasive testing and if needed, coronary angiography. The fact that estimated compliance to optimal medical therapy is in the range of 10–60% which is associated with more complications postoperatively.
Finally, the conclusion is that preoperative medical management versus revascularization has no significant difference in posttransplant cardiac outcomes.
The level of evidence is level 1.
Weakness of the study are: limited groups of studies as well as the data are retrospective from single transplant centers.
ESRD is a risk factor for cardiovascular disease. CKD patients undergo renal transplant should be have cardiovascular evaluation. If the patient have severe CAD , he needs to be treated
This meta-analysis review the outcomes in patients underwent either coronary revascularization versus medical treatment
6 studies from the PubMed , included 598 patients, of them ,260 were in the medical management group and 338 were in the revascularization group
The results showed no significant difference in terms of cardiovascular outcomes between two groups
Meta-analysis. Level 1 evidence
Weak points
Small sample only six studies with small numbers of patients
One study of them only reported the hazards ratio and the total number of cardiovascular events was not available
There is a very close relationship between Chronic kidney disease (CKD) and strong risk factor for cardiovascular disease and although patients with end-stage renal disease (ESRD) often benefit from renal transplantation (RT), it is the number one cause of mortality in this population is cardiovascular disease. So, questions were asked about revascularization (with either percutaneous coronary intervention or coronary artery bypass surgery) to improve posttransplantation outcomes in comparison to medical management, and this article is a meta-analysis sets out to review the literature.
To choose the articles, a search was carried out at PUBMED with the keywords: kidney transplant or renal transplant with either coronary revascularization, cardiovascular screening, major adverse cardiovascular events, percutaneous coronary intervention, or CAD management. Exclusion criteria were established such as: period prior to 1997, or that did not complete the two arms object of this title or studies that did not report their crude data. Mantel-Haenszel method was used for calculating the weighted pooled odds ratio under the fixed effects model, associated with the Heterogeneity statistic with the random effects model.
Through the evaluation of 6 studies, they were able to conclude that the performance of pre-transplant revascularization surgery does not change post-transplant mortality when compared with medical management of CAD. And probably the critical point is that few studies evaluate the medical management of this type of population.
What happens is that this population (CKD and ESRD) has a cascade of pathophysiological events with results in myocardial structural changes, endothelial dysfunction, and vascular calcification that are more challenging than the population normally studied. Another difference is that although cardiac catheterization to define coronary anatomy is the gold standard, noninvasive stress testing is thus preferred to evaluate for CAD prior to transplantation because cardiac catheterization is not without risks.
Thus, the critical point is that we do not have many studies that belong to the profile of this population studied, which is quite different from the general population, not only in its clinical characteristics, but also in the way it is studied.
In terms of meta-analysis, this level of evidence would be level 01, however the studies used were very weak, compromising the designs. In this way, it is more equivalent with level 05.
The Odds ratio confidence interval passes through the value 1.0, thus the assessment is invalid.
Summary:
This meta-analysis show that, preoperative cardiac revascularization does not affect posttransplantation mortality compared to medical management for individuals undergoing renal transplant.
Level of evidence: 1
Weakness of this study:
-Only 6 studies were included
-Small sample size: 260 patients who received medical management and 338 who received coronary revascularization.
-Out of six, only one study shows hazard ratio.
Summarize this article:
The first leading cause of death in ESRD is cardiovascular disease.
This study had conducted a meta-analysis of 6 studies to compare the outcome of medical therapy vs revascularization in ESRD patients before kidney transplantation.
Meta analysis of 6 studies involving 598 patients, 260 received medical treatment and338 patient had revascularization via coronary angiography.
They concluded that there was no difference in the 2 groups with respect to the CVD outcomes.
What is the level of evidence provided by this article?
Level of evidence: Level 1 (meta-analysis)
There is an obvious weakness(s) in this study, please identify it (them).
1- small number of patients included in those 6 studies.
2- they didn’t include RCT.
3- Heterogeneity of the study population
4- unavailability of CVD outcome, some studies were from single center.
5- Missed medical management details.
6- Duration of follow up was wide.
Summarise this article
-Chronic kidney disease (CKD) is known to be a strong risk factor for cardiovascular disease and although patients with end-stage renal disease (ESRD) often benefit from renal transplantation (RT), the number one cause of mortality in this population is cardiovascularmdisease .
-There are a total of 6 studies included in the meta-analysis. This resulted in a total of 598 subjects. Of these, 260 were in the medical management group and 338 were in the revascularization group.
Exclusion criteria included (1) studies prior to 1997
(2) studies that only looked at one arm of the research (i.e., only a revascularization group)
(3) studies that only recorded pre-transplantation results
(4) studies that compared percutaneous coronary intervention
to coronary artery bypass surgery but not to a medical management group
(5) studies that only looked at screening but not treatment of the CAD
(6) studies that did not report the crude data but only hazard ratios or odds ratios. All other studies were included.
-The results of our meta-analysis show that preoperative cardiac revascularization does not affect posttransplantation mortality compared to medical management for individuals undergoing renal transplant.
What is the level of evidence provided by this article?
Level 1
There is an obvious weakness(s) in this study, please identify it (them).
-Study designs for diagnosis of CAD varied between trials and all trials incorporated retrospective data from single transplant centers. There were different populations represented with varying incidences of CAD in this study
.
Cardiovascular disease is considered strong risk factor for mortality in end stage renal disease among Kidney transplant recipients.
Meta-analysis showed that persoperative cardiac revascularization not affect mortality in comparison to medical management.
POISE study showed that metoprolol succinate prior-to moderate to high risk non cordial Surgery showed to decrease post-operative myocardial infarction.
Despite of considering that cardiac catteterization is a gold standard in coronary anatomy but carried risks , there are other non-invasive test for detecting coronary ant y diseases.
-Meta-analysis showed that peri-operative stress echocardiography has been associated with better medical management.
It is concluded that pre-operative medical management versus revascularization hasn’t significant difference in post-transplant cardiac outcomes.
Level I meta-analysis.
study is done in single Center
Sample size is small.
IV. Revascularization versus Medical Management of Coronary Artery Disease in Prerenal Transplant Patients: A Meta-Analysis
Q1- Summarise this article
Introduction :
CAD is well known complication in patient with CKD. This is obvious and is caused by accelerated atherosclerosis. This makes cardiovascular event to be number one cause of mortality in CKD population. This high CAD prevalence comes from presence of both traditional and nontraditional (additional ) cardiovascular risk . the nontraditional risk involves activation of RAAS, oxidative stress, inflammation, structural changes, endothelial dysfunction, vascular calcificationand electrolyte changes. These risk factors increase the risk for cardiovascular event by 14 fold .
This ( META ANALYSIS ) study designed to answer this question .
Would revascularization (with either percutaneous coronary intervention or coronary artery by pass surgery) improve outcomes post transplantation in comparison to medical management?
Of the 5 studies enrolled in this , there were 36 events in the revascularization and 57 events in the medical management group.
These results indicate that compared to pre transplant revascularization, medical management is no different in terms of posttransplant cardiovascular outcomes
Discussion :
(( The results of our meta-analysis show that preoperative cardiac revascularization does not affect posttransplantation mortality compared to medical management for individualsundergoing renal transplant.))
Individuals with CKD or ESRD and CAD or develop acute coronary syndrome have poor prognosis..
-The only randomized trial by Manske et al. from 1992 .found obstructive CAD in 31 subjects.Twenty-six of the subjects randomized . In this study , 10 of 13 individuals in the medical arm and 2 of 13 individuals in the revascularization arm had cardiovascular events. There were also 4 deaths in the medical arm.advances in preoperative medical management have led to be comparable to preoperative invasive management of CAD.
-The POISE study has shown that preoperative use of metoprolol succinate leads to reduced postoperative myocardial infarction.
-the CARP trial showed that revascularization of preoperative stable CAD did not reduce mortality, myocardial infarction, stroke, or death 30 days postoperatively.
-the BARI 2D trial has shown that diabetic patients are more likely to have diffuse CAD and have improved outcomes when treated with coronary artery bypass graft and optimal medical therapy.
– Kumar et al. mentioned that preemptive revascularization priorto transplantation leads to increased survival at 1 and 3 years post transplant.
Although cardiac catheterization to define coronary anatomy is the gold standard, it is not without risks.
Singh et al. found that if the pre transplant stress test result was negative, transplantation could proceed with a low risk of post trans plant adverse cardiac events.
Eschertzhuber et al. favors revascularization. They found that patients awaiting transplant with proven high-risk profile for post transplant cardiac events can undergo transplantation safely if they are revascularized.
This suggest that pre transplant screening for CAD in candidates for renal transplant should include noninvasive testing and if needed, coronary angiography.
Q2- What is the level of evidence provided by this article?
This study is meta analysis – level 1
Q3- There is an obvious weakness(s) in this study, please identify it (them).
1- Study designs for diagnosis of CAD varied between trials
2- The trials incorporated retrospective data from single transplant centers.
3- There were different populations represented with varying inci dences
3-of CAD in this study.
· Summarise this article
Chronic kidney disease (CKD) is a prominent risk factor for cardiovascular disease (CVD), with sudden cardiac death being the most common cause mortality in patients with end-stage renal disease (ESRD). Lack of consensus in the pre-operative management of coronary artery disease (CAD) in CKD patients waiting for renal transplantation. has prompted the authors to conduct this meta-analysis. This retrospective article recruited 6 studies out of the 777 studies reviewed and included 260 patients receiving medical management and 338 patients receiving coronary revascularization as pre-operative CAD management while waiting for renal transplantation. Statistical analysis was performed, and the result showed no statistically significant difference in posttranslational CVD outcome between those receiving medical management and those undergoing coronary revascularization prior to kidney transplantation (95% CI (0.885–2.263), p = 0.147).
· What is the level of evidence provided by this article?
Level 1
· There is an obvious weakness(s) in this study, please identify it (them).
Retrospective single-centre analysis with small sample size is the major weakness in this study.
Introduction
Chronic kidney disease (CKD) is known to be a strong risk factor for cardiovascular
disease
many patients referred for RT require cardiovascular evaluation and undergo an extensive cardiac workup ranging from simply an EKG to coronary angiography. The nature of this workup has been the point of much research over the past few year.
Methods
PubMed search was performed using combinations of the keywords kidney transplant or renal transplant with coronary revascularization, cardiovascular screening, major adverse cardiovascular events, percutaneous coronary intervention, or CAD management.
Exclusion criteria included
(1) studies prior to 1997
(2) studies that only looked at one arm of the research (i.e., only a revascularization group)
(3) studies that only recorded pre-transplantation results
(4) studies that compared percutaneous coronary intervention to coronary artery bypass surgery but not to a medical management group
(5) studies that only looked at screening but not treatment of the CAD
(6) studies that did not report the crude data but only
Results
There are a total of 6 studies included in the meta-analysis. This resulted in a total of 598
subjects. Of these, 260 were in the medical management group and 338 were in the revascularization group.
Five studies reported the primary cardiovascular outcomes.
One study only reported the hazard ratio and thus, total number of cardiovascular outcomes was not available for this study.
Of the 5 studies, there were 36 events in the revascularization and 57 events in the medical management group.
Discussion
The results of our meta-analysis show that preoperative cardiac revascularization does
not affect posttransplantation mortality compared to medical management for individuals undergoing renal transplant.
According to the organ procurement and transplant registry 2012 annual survey, there
were 88,874 people on the waiting list and 16,487 candidates successfully receiving transplants Individuals with CKD and ESRD requiring hemodialysis and have CAD or acute coronary syndromes have poorer outcomes [8, 9]. Therefore, it is imperative to balance the risk of preoperative coronary angiography accelerating the need for dialysis, potential bleeding risk with dual antiplatelet therapy, and potential delay in delivery of procured kidneys versus postprocedural atherosclerotic complications.
The only randomized trial exploring management of CAD in renal transplant candidates
is by Manske et al. from 1992
In this study, they performed coronary angiography in 151 individuals with insulin-dependent diabetes and found obstructive CAD in 31 subjects. Twenty-six of the subjects agreed to randomization. At the end of 8.4 months, 10 of 13 individuals in the medical arm and 2 of 13 individuals in the revascularization arm had cardiovascular events. There were also 4 deaths in the medical arm. It is important to note that the medical arm in this study consisted of aspirin and calcium channel blockers. Since the study by Manske et al. advances in preoperative medical management have led to improvement in postoperative cardiovascular outcomes, which is comparable to preoperative invasive management of CAD.
Additionally, the BARI 2D trial has shown that diabetic patients are more likely to have diffuse CAD and have improved outcomes when treated with coronary artery bypass graft and optimal medical therapy.
Kumar et al. have noted that preemptive revascularization prior to transplantation leads to increased survival at 1 and 3 years posttransplant. The conclusions of this study are limited as it was nonrandomized and participants were asked if they wanted revascularization or not. Refusing revascularization may be an indicator of poor underlying medical condition and inability to adhere to medical therapy.
Singh et al. [24] found that if the pretransplant stress test result was negative, transplantation could proceed with a low risk of posttransplant adverse cardiac events. This supports the use of noninvasive stress testing to riskstratify pretransplant candidates. In addition, Singh et al. [24] found no significant difference between the patients with no significant CAD and those with significant lesions who underwent revascularization. Interestingly, both of these studies, compared to Lindley et al. [26] and Kahn et al. [27], had better preoperative noninvasive echocardiography sensitivity and negative predictive values [24–27]. Therefore, modest differences in noninvasive stress imaging can help identify individuals that will benefit from medical management and reduce the need for invasive diagnosis.
The study by Eschertzhuber et al.in our meta-analysis favors revascularization. Eschertzhuber et al. found that patients awaiting transplant with proven high-risk profile for posttransplant cardiac events can undergo transplantation safely if they are revascularized. In addition, they concluded that candidates for kidney transplant who had a history of CAD but no workup or treatment were at tremendous risk for posttransplant cardiac events.
Felix et al. present a unique perspective
on anatomic data of posttransplant CAD. Of the 33 subjects in this analysis who experienced posttransplant primary outcome requiring coronary angiography, 74% were observed to have CAD progression in a new anatomic location. This posttransplant cardiovascular outcome would not have been prevented simply with pretransplant revascularization. This suggests that plaque stability and progression are commonly vulnerable in this population despite transplant . Complicating the postoperative management further is the fact that reported compliance to optimal medical therapy is in the range of 10–60%
conclusion
preoperative medical management versus revascularization does not lead to significant difference in posttransplant cardiac outcomes. Theoretically, careful risk stratification using noninvasive testing, meticulous perioperative hemodynamic monitoring, and closer postoperative follow-up to monitor for medication adherence can possibly lead to better outcomes in this particular patient population
ESRD is considered a major risk for CV events and CAD and the main cause of death is CRadiac causes , so complete cardiac evaluation before transplantation is mandatory ranging from ECG , ECHO upto coronary angiography
Treatment of CAD is either medical treatment or revascularization
This study done to compare between pre transplant revascularization or medical treatment
For CAD.
This study showed no difference in post transplant CV outcome and revascularization not superior on medical treatment.
Strength points of the study :
-it incorporated recent data
-considered first meta analysis evaluating cardiac management in pre operative pt undergoing renal transplant
Limitations
• small sample size
• Single center
· Summary:
· The current study is a metanalysis comparing coronary revascularization versus medical management of CAD in kidney transplant recipients.
· An old study in 1992 (not included in the meta-analysis) suggested medical management was inferior to revascularization.
· Another study, included CKD patients, showed that preoperative use of metoprolol pre-non-cardiac surgery decreased risk of myocardial infarction.
· Another study concluded that non-invasive stress tests used in identifying patients who would benefit from medical management.
· another study suggested that High-risk of posttransplant cardiac events have better outcomes with pre-transplant revascularization.
· Conclusions:
· no significant difference was found regard CVS morbidity and mortality between optimum medical therapy and revasculaization.
· Level of evidence: Level I.
· limitations include: limited number of studies, all are reterospective cohort and review articles, no RCT, short duration of follow up
ESRD patients often has major risk factors for CAD ,cardiovascular events are the first leading cause of death of ESRD patients and transplant patients.
Extensive cardiac evaluation before transplantation is mandatory which may range from EKG,echocardiography up to cronary angiography.
Presense of CAD that requires revascularization by either PCI OR cronary Bypass surgry and the effect of revascularization after renal transplantation on patient’s survival was a point of interst in many studies
This meta-analysis study was done to evaluate patients with pre operative significant CAD comparing medical therapy with revascularization of coronary artery stenosis.
It included 6 studies ,598 patients, 260 of them were on medical management and 338 had revascularization .
In 5 studies, there were 36 events in the revascularization and 57 events in the medical management group.
So results indicated that compared to pretransplant revascularization, medical management showed no different in terms of posttransplant cardiovascular outcomes and revascularization wasn’t superior to medicalmanagement.
Strength points of the study :
-first meta-analysis evaluating the preoperative cardiac management of patients undergoing RT.
-it incorporated all the recent data within the past decade.
Limitations
-incorporated retrospective data from single transplant centers.
-small sample size
– the extent of CAD was different between patients with variable outcomes.
-diagnostic tool of CAD was different.
-medical management was different.
-excluded stage 5 CKD patients .
Cardiovascular disease is the leading cause of death in both kidney failure and non-kidney failure. Kidney failure patients have high cardiovascular mortality and morbidity. This is due to various risk factors like anemia, hypertension, fluid overload, etc. Since these patients have a high risk of cardiovascular disease, it is of utmost importance when they are being transplanted extensive cardiopulmonary studies must be performed to see if the patient is fit for transplant. The various studies that may indicate to analyze cardiovascular functions are EKG, ECHO, angiogram, etc. When patients are being studied and a coronary angiogram is requested and result in severe coronary obstruction, then various question needs to ask like what will be the patient outcome post revascularization and whether will it have any effect on transplant. Because of this burden question, a meta-analysis was set up to review other literature to find out the answer to the question.
The method used to investigate the patients are as follows: the research was conducted by PubMed and published in 1997, which involves the management and revascularization as treatment strategies for CAD in kidney failure.
The exclusion criteria are:
1) Studies prior to 1997
2) Studies that look to record pre-transplantation results
3) Studies that include one part of the research that is revascularization
4) Studies that do not include crude data but only hazard ratios or odd rations
5) Studies that look only at screening but not treatment of CAD and
All other studies were included in the studies.
The results found are as follows: a study with 598 patients from different populations, of which, 260 were managed medically. There were about 57 events in the medical management group while 36 events were noted in the revascularization group. One of the studies never reported the total number of cardiovascular outcomes. The odd pool ratio was about 95% CI for the fixed effects was 1.415 with p = 0.147. The result there showed that compared to pretransplant revascularization, medical management is no different in terms of post-transplant cardiovascular outcomes.
Based on the discussion, the study conducted was a meta-analysis study that showed that preoperative cardiac revascularization does not affect post-transplantation mortality compared with medical management in individuals going to have a renal transplant. Patients on dialysis with CAD or coronary disease have very poor outcomes. Knowing this fact, it is important to evaluate the preoperative cardiac management of patients undergoing renal transplants. It is important to highlight that cardiac catheterization to define coronary anatomy is the gold standard, but it is high risk or has numerous risks and should be properly evaluated. Now based on the different studies, it is found that patients that went through the revascularization post-transplant actually do well when compared to patients with a high risk of the coronary disease who never did revascularization. The latter group does worse post-transplant.
So, in conclusion, there weren’t any differences in the two groups of studies with respect to the CVD outcome. So, if proper medical therapy is used, then there should be a successful post-transplant without revascularization.
The level of evidence is level 1 meta-analysis.
1) The study included were single-center studies.
2) The details on the coronary disease were not specified
3) The follow-up was a very wide range
4) The total number of CVD outcomes was not available in one of the studies.
5) The only 6 groups studies were included
6) The diagnostic criteria of CAD differ between trials
7) The population had a different incidence of CAD.
1-Summary of Revascularization versus Medical Management of Coronary Artery Disease in Prerenal Transplant Patients: A Meta-AnalysisCVS is one cause of mortality in CKD and ESRD patients.
This meta-analysis sets out to review the literature of post-operative outcome of patients with significant coronary obstrucation prior to RT who underwent either coronary revascularization versus medical management
EXCLUSION CRITERIA
1-studies prior to 1997.
2=studies that only looked at one arm of the research.
3-studies that only recorded pre-transplantation result.
4-studies that compared percutaneous coronary intervention to coronary artery by pass suregery .
5- looked at screening but not treatment of the CAD .
6-studies that did not report the crude data but only hazard ratio or odds ratios.
RESULTS
Six studies included in the meta-analysis.
260 groups of medical management .
338 revascularization group.
Of 5 studies ,there were 36 events in the revascularization and 57 events in the medical management group.
Result include that compared revascularization ,medical management is no different in terms of posttransplant
Discussion
The result of our meta-analysis show that preoperative cardiac revascularization does not affect post transplantation mortality compared to medical management for individuals undergoing renal transplant.
There were different populations represented with varying incidence of CAD in this study.
There is emerging data highlighting the limited utilization of evidence-based pharmacologic therapies in patients with CKD or ESRD compared to those with normal renal function.
The only randomized trial exploring management of CAD in renal transplant candidates is by Manske et al from 1992.
The study by Eschertzhuber et al in our meta-analysis favors revascularization
Conclusion
Meta -analysis suggests that preoperative medical management versus revascularization does not lead to significant difference in posttransplant cardiac outcomes.
More prospective randomized trials are needed to define which subsets of patients might benefit from pretranspant intensified medical management or from revascularization.
2- level of evidence meta-analysis with systemic review level 1.
3- weakness of this study
1-small number of studies(only six).
2- only one randomized trial and was excluded from metaanalysis.
Abstract:
Introduction
Chronic kidney disease including ESKD on dialysis is linked with high cardiovascular morbidity and mortality due to chronic RAAS activation, increased oxidative stress, chronic inflammation, and endothelial dysfunction leading to premature atherosclerosis in addition to vascular calcifications all of which contribute to increased sudden cardiac death by 14 folds and is considered high surgical risk and this continued even after transplantation, till date no standardized cardiac assessment protocol for such high-cardiac risk kidney transplant candidates, more research is needed to address the post-transplant CVD outcome.
The aim of the study
This meta-analysis review of the studies comparing the CVD outcome between coronary revascularization to optimal medical therapy for high cardiac risk patients before transplantation.
Method:
A PubMed search, with a total of 6 studies were included, while the exclusion criteria include all studies before 1997, studies with a single arm treatment, studies comparing two interventions therapy (PCI VS CABG) with no medical arm, studies with pre-transplant results only, studies that looked to screening for CVD but no treatment outcome. Data were analyzed by using an odd ratio and 95% CI with heterogenicity.
Result:
Only 6 studies match the inclusion criteria with a total number of 589 patients, and 260 patients underwent medical therapy while 338 cases underwent revascularization with 36 events and another 57 events in the medical group
Previous DECREASE V study which is a pilot study with short FU, a composite of 30 days mortality, and 1 year FU this study concludes that coronary revascularization in the high-risk group prior to surgery was not associated with improved outcome
This meta-analysis did not show any difference in the mortality rate among the high cardiac risk transplant recipient who underwent revascularization compared to the optimal medical therapy group.
What is the level of evidence provided by this article?
Meta-analysis with systematic review provides Level 1
There is an obvious weakness(s) in this study, please identify it (them).
Although its meta-analysis review but most of the studies were of retrospective data collection from a single center with heterogenous studies designed for the diagnostic criteria of high cardiac risk including heterogenicity in the data collection, interpretation, and medical treatments ( one study using CCB in medical therapy arm ), small sample size as most of the studies excludes advanced CKD with GFR < 30ml/min, so still lacks the evidence and the CVD risk assessment and management should be individualized and always it needs multidisciplinary approach among transplant team and cardiology, cardiothoracic team, in our center still we preferred revascularization therapy once indicated prior to translation as we have a higher rate of DM with diffuse multi-vessel disease.
An additional weakness noticed in this meta-analysis is not all studies used noninvasive MPI for risk stratification prior to -transplant, two studies Singh et al, and Tita et al use stress echo cardiographs only .
Summarize this article
Cardiovascular disease is leading/major cause of morbidity and mortality in CKD stage 5 and post renal transplantation.
During workup in pretransplant candidates, there is dilemma whether to offer medical management or revascularization (Percutaneous transluminal Angioplasty [PTCA]/Coronary artery Bypass grafting [CABG]) procedure when significant coronary artery occlusion on coronary angiogram was found after an abnormal DSE.
However, there is paucity of data comparing medical management versus revascularization procedures in these subsets of patients in terms of major adverse cardiovascular events after kidney Transplantation.
This study aims to meta-analyse available studies to bridge this gap in literature.
Methods and Results:
After appropriate inclusion and exclusion criteria,6 studies were selected for meta-analysis, accumulating 598 subjects.
Out of total,260 subjects were there in medical management group and 338 in revascularization group.
One study out of 6 reported only hazard ratio and rest all mentions total number of cardiovascular outcomes.
Out of 5 studies, there were 36 and 57 cardiovascular events in revascularization versus medical management group respectively.
Forest plot showed pooled odds ratio was 1.4(95% CI 0.8-2.2).
This study included articles after 1997, since the advancement of medical management for managing significant CAD after that. Prior to 1997, CCB and aspirin was given as medical management in such patients.
Discussion:
The result of meta-analysis showed that no treatment arm (Medical Management versus revascularization [PTCA/CABG]) is superior to another in terms of cardiovascular outcomes/events post kidney transplant.
Major challenges in understanding treatment strategies in CKD stage 5 is exclusion of these patients in most of the trials comparing medical management versus revascularization and hence results can’t be extrapolated to these subsets of patient.
It also mentions one randomized trial by Manske et al 1992 which has significant implications and tried to answer research question but was excluded as difference in medical management for managing CAD.
This metanalysis have inherent weakness(s) but at the same time tried to answer the primary question/aim of study, with available data in the literature.
It also mentions the need of Prospective randomized trials in future which can accurately define management (Medical versus revascularization) in patients with ESRD with significant CAD on coronary angiogram.
What is the level of evidence provided by this article?
It is a meta-analysis, so Level of evidence is 1
There is an obvious weakness(s) in this study, please identify it (them)
All studies included for meta-analysis are trials which are retrospective from single transplant centre over a decade.
Diagnosis of CAD differs between these included study trials.
There is significant heterogenicity and varying incidences of CAD in population groups in different studies.
This article compared patients with CAD, that underwent medical treatment versus those underwent coronary revascularization, 6 studies includes 260 patients with coronary artery disease (CAD), underwent medical treatment , who 57% of them develop cardiac events, and 338 patients underwent revascularization, 36% of them develop cardiac events .
there is growing interest and improvement area of CKD, ESKD patients, receiving kidney transplantation, although ESKD patients benefit from transplantation, the No.1 cause of death in kidney transplantation is CAD .
the final result of this metanalysis, showed that , there is no significant differences in outcome for patients that underwent medical treatment than those underwent revascularization.
Imperative balance between risk of pre-op. coronary angiography, acceraelating need of dialysis, bleeding risk factor with dual antiplatelets therapy, and post-op. atherosclerosis complication.
Sudden cardiac arrest and death, increased 14 folds, in CKD,ESKD, due to RAAS activation, oxidative stress, infalmmation, increase cytokines, dyslipidemia, myocardial structural changes, endothelial dysfunction, vascular calcification, dialytic changes, and electrolytes abnormality.
platelet dysfunction, exess dosing of antiplatelet, and antithrombotic treatment , increases morbidity and mortality.
only study of post renal transplantation, coronary angiography that underwent for 151 patients with IDDM, with obstructive CAD of 31 patients after 8 month , 10 of 13 patient , underwent in medical arm develop cardiac events , and 4 patients died, while 2 out of 13 patients who underwents revascularization develop cardiac events.
2.POISE study :
used metoprolol pre-operatively, noticed that lead to reduce post-op. MI.
3.CARP trial:
showed revascularization of pre-op. stable CAD, did not decrease mortality,MI,stroke, or deaths 30 days post-op.
4.BARI 2D trial:
showed that diabetic patients have diffuse CAD, found that they have improved outcome, with bypass graft surgery.
5.Kumar et al. :
pre-op. revascularization, prior to transplantation, lead to increase survival at 1-3 year post transplantation.
6.Singh et al: and Tita et al:
used pre-op. stress Echo, to risk stratification patients , found no significant difference between patients with no significant CAD, and those with significant lesion who underwent revascularization.
7.Eschertzhuber et al :
favor revascularization of patients awaiting transplantation, proven high risk for post-transplantation, cardiac events, can undergo safely, if they are revascularized.
also noted that patients with transplantation with history of CAD, but no workup or treatment were at risk of post- transplantation cardiac events, this support data, suggesting pre-transplantation. screening of CAD, in candidate for renal transplantation, should include non-invasive testing and if needed coronary angiography.
8.Felix et al.:
study 33 subjects with post transplantation CAD, requiring coronary angiography, 74% observed CAD progression, and this post transplantation cardiac events would not have been prevented by simple revascularization pre-op.
@ weaknesses in the studies:
# Manske et al.:
small sample size, with suboptimal medical treatment, and optimal surgical treatment of DM, patients leading to +ve finding .
# CARP et al.:
exclude CKD , ESKD patients.
#Kumar et al.:
non-randomized, and participant asked if they wanted revascularization, or not, so refusing revascularization may be an indicator.
#Singh et al.;
not powered to assess the benefit, of pre-op. revascularization.
Level of evidence ((1)).
End-stage renal disease requiring renal transplantation comprises a growing patient population at risk for cardiovascular disease (CVD) morbidity and mortality in large part due to accelerated atherosclerosis. Consequently, these patients are at even higher risk of major surgical CVD mortality.
in renal transplant evaulating cardiovascular risk factors is of much important as the main cause of death in renal transplant is cardiac event so evaualtion with non invasive stress methods and treatment with even medical and revacularization was with same result according to this study and each case has specific managmanet
level of evidence1
obvious weakness
Number of studies included in the meta analysis only six which is small
Introduction
CKD is one of the most important risk factor for CAD due to traditional and non traditional ( protienurea , anemia , hyperphosphatemia , hyperparathyroidism and uremic vasculapathy .. etc ) risk factors
and as you know also transplantation itself increase the risk of CAD and the most common cause of death with normal kidney function post transplantation is CAD then malignancy ,
so patient who candidate for renal transplantation should undergo an extensive cardiac work up and optimization his cardiac status before transplantation ,
This meta-analysis sets out to review the literature and tries to find an answer for which is better for post transplantation out come revascularization or medical management ?
Methods
A PubMed search, meta-analysis we compare coronary revascularization to medical
management prior to renal transplantation included all studies with specific key wards except
(1) studies prior to 1997
(2) studies that only looked at one arm of the research
(3) studies that only recorded pre-transplantation results
(4) studies that compared percutaneous coronary intervention to coronary artery bypass surgery but not to a medical management group
(5) studies that only looked at screening but not treatment of the CAD
(6) studies that did not report the crude data but only hazard ratios or odds ratios. All other studies were included
Results:
There are a total of 6 studies included in the meta-analysis.
Conclusion:
no difference in post transplantation mortality between preoperative cardiac revascularization and medical management .
.
Level of evidence 1
There is an obvious weakness(s) in this study, please identify it (them).
Summary of the paper:
Introduction
Chronic kidney disease (CKD) is known a risk factor for cardiovascular disease and although patients with end-stage renal disease (ESRD) often benefit from renal transplantation (RT), the number one cause of mortality in this population is cardiovascular disease. As such, many patients referred for RT require cardiovascular optimization and undergo an extensive cardiac workup ranging from simply an EKG to coronary angiography.
When a patient with an abnormal stress test undergoes coronary angiography and is found to have significant obstruction of the coronaries, a question arises: would revascularization improve outcomes post transplantation in comparison to medical management? This meta-analysis sets out to review the literature and tries to find an answer for this question.
Methods
PubMed search was performed using combinations of the keyword’s kidney transplant or renal transplant with either coronary revascularization, cardiovascular screening, major adverse cardiovascular events, percutaneous coronary intervention, or CAD management.
Exclusion criteria included:
1. Studies prior to 1997
2. Studies that only looked at one arm of the research (i.e., only a revascularization group)
3. Studies that only recorded pre-transplantation results
4. Studies that compared percutaneous coronary intervention to coronary artery bypass surgery but not to a medical management group
5. Studies that only looked at screening but not treatment of the CAD, and
6. Studies that did not report the crude data but only hazard ratios or odds ratios. All other studies were included.
Of note is that only 1 randomized control study was found to address this question but was excluded as the study was performed in 1992 when the medical management included calcium channel blockers and aspirin.
The data was analyzed using CMA package V3 (Biostat, USA). Mantel-Haenszel method (Mantel and Haenszel, 1959) was used for calculating the weighted pooled odds ratio under the fixed effects model. Heterogeneity statistic was incorporated to calculate the summary odds ratio under the random effects model (DerSimonian and Laird, 1986). The data is reported as odds rations with 95% confidence intervals (CI).
Results
There are a total of 6 studies included in the meta-analysis. This resulted in a total of 598 subjects. Of these, 260 were in the medical management group and 338 were in the revascularization group. Five studies reported the primary cardiovascular outcomes. One study only reported the hazard ratio and thus, total number of cardiovascular outcomes was not available for this study. Of the 5 studies, there were 36 events in the revascularization and 57 events in the medical management group. The pooled odds ratio with 95% CI for the fixed effects was 1.415 (95% CI 0.885–2.263), p = 0.147. These results indicate that compared to pretransplant revascularization, medical management is no different in terms of posttransplant cardiovascular outcomes. The heterogeneity observed for the studies included was Q = 19.587, I2 = 74.47, p < 0.01.
Discussion
The results of our meta-analysis show that preoperative cardiac revascularization does not affect post transplantation mortality compared to medical management for individuals undergoing renal transplant. Individuals with CKD and ESRD requiring hemodialysis and have CAD or acute coronary syndromes have poorer outcomes. Therefore, it is imperative to balance the risk of preoperative coronary angiography accelerating the need for dialysis, potential bleeding risk with dual antiplatelet therapy, and potential delay in delivery of procured kidneys versus postprocedural atherosclerotic complications. There is emerging data highlighting the limited utilization of evidence-based pharmacologic therapies in patients with CKD or ESRD compared to those with normal renal function. This could partly be explained by the fact that nearly 80% of ESRD subjects and 75% of CKD subjects are excluded from trials and thus, evidence-based pharmacologic interventions cannot be readily applied to the renally impaired population.
Conclusion: our meta-analysis suggests that preoperative medical management versus revascularization does not lead to significant difference in posttransplant cardiac outcomes. Theoretically, careful risk stratification using noninvasive testing, meticulous perioperative hemodynamic monitoring, and closer postoperative follow-up to monitor for medication adherence can possibly lead to better outcomes in this patient population. Further prospective randomized trials are needed to define which subsets of patients might benefit from pretransplant intensified medical management or from revascularization.
Weakness of the study:
1-Number of studies included in the meta analysis was small, only six.
2-Each study was single center study.
3-Only one randamaized trial and was excluded from analysis because it was before 1997 but mentioned in the discussion.
Level of evidence: level 1, meta analysis.
Thank You, well done
End stage renal disease (ESRD) patients have high cardiovascular disease (CVD) morbidity and mortality. There is lack of data regarding post-transplant outcomes in ESRD patients having CVD with respect to treatment opted.
The study is a meta-analysis comparing medical management to coronary revascularization in ESRD patients, having significant obstructive coronary artery disease and receiving a kidney transplant.
Methods:
Pubmed search with studies published post 1997, involving both medical management and revascularization as treatment strategies for CAD in ESRD and reporting crude data. Out of 777 studies, only 6 could fit the inclusion criteria.
Results:
6 studies involved a total of 598 patients from different populations, 260 of which were on medical management alone. There were 57 events in the medical management group while 36 events were observed in the revascularization group in 5 studies. One study did not report the total number of cardiovascular outcomes.
A study published in 1992 (hence not included in the meta-analysis) suggested medical management was inferior to revascularization. Another study (POISE study), which had a small sample size and included CKD patients, showed that preoperative use of metoprolol pre-non-cardiac surgery decreased risk of myocardial infarction.
Another study supported use of non-invasive stress tests in identifying patients who would benefit from medical management. One study concluded that patients with high-risk of posttransplant cardiac events have better outcomes with pre-transplant revascularization.
Conclusions:
There was no difference in the 2 groups with respect to the CVD outcomes.
Hence if optimal medical therapy is used, the post-transplant cardiovascular outcomes are not significantly different from revascularization.
Level of evidence: Level 1 (meta-analysis)
The limitations/ weaknesses of the study include:
1) Only 6 studies included, a small number.
2) No RCT included (1 RCT found but excluded as the study was done in 1992 because all studies prior to 1997 were excluded)
3) Heterogeneity of the study population
4) Total number of cardiovascular outcomes was not available for one of the studies included.
5) The studies included were single centre studies
6) Details regarding degree of coronary artery disease not enumerated
7) Details regarding the medical management were missing.
8) Duration of follow-up was very wide ranging from 30 days to many months.
9) The title had a typographical error: “Revascularization versus Medical Management of Coronary Artery Disease in Prerenal Transplant Patients: A Meta-Analysis” should be ‘Revascularization versus Medical Management of Coronary Artery Disease in Prospective Renal Transplant Patients: A Meta-Analysis’
Thank You, well done
A meta-analysis comparison study between Renovascularization and medical management of coronary artery disease in pre transplant patients.
Introduction
Patients with end stage kidney disease still has the main cause of death is cardiovascular disease even after transplantation. So what is the best management for those before getting transplantation.
Methods
A PupMed search for the keywords, kidney transplant or renal transplant with either coronary revascularization, cardiovascular screening, major adverse cardiovascular events, percutaneous coronary intervention, or CAD management.
Exclusion criteria
(1) studies prior to 1997
(2) studies that only looked at one arm of the research (i.e., only a revascularization group)
(3) studies that only recorded pre-transplantation results
(4) studies that compared percutaneous coronary intervention to coronary artery bypass surgery but not to a medical management group
(5) studies that only looked at screening but not treatment of the CAD
(6) studies that did not report the crude data but only hazard ratios or odds ratios
Inclusion criteria: All other studies. The aim was to address other questions but also collected data on patients with obstructive CAD who underwent either revascularization or medical management.
Data analysis used method: CMA package V3 (Biostat, USA). Mantel-Haenszel method (Mantel and Haenszel, 1959) was used for calculating the weighted pooled odds ratio under the fixed effects model
Heterogeneity statistic was incorporated to calculate the summary odds ratio under the random effects model (DerSimonian and Laird, 1986).
The data is reported as odds rations with 95% confidence intervals (CI).
Population
777 articles obtained to review based on keywords, 685 of these articles were excluded as they were duplicates or not related to study hypothesis, and 92 articles chosen to review based on abstract or title.
86 articles of the chosen articles were excluded based on exclusion criteria, and 6 articles used for meta-analysis.
Results
There are a total of 6 studies included in the meta-analysis
One study only reported the hazard ratio and thus, total number of cardiovascular outcomes was not available for this study
Of the 5 studies, there were 36 events in the revascularization and 57 events in the medical management group
The pooled odds ratio with 95% CI for the fixed effects was 1.415 (95% CI 0.885–2.263), p = 0.147.
The heterogeneity observed for the studies included was Q = 19.587, I 2 = 74.47, p < 0.01.
Discussion
These results indicate that compared to pretransplant revascularization, medical management is no different in terms of posttransplant cardiovascular outcomes
The evidence of this article is I
There is an obvious weakness(s) in this study, please identify it (them)
1) Small number (6) used for the meta-analysis
2) The severity of CAD and medical management used not clear
3) Are there other comorbidities that may play a role in CAD events
4) One transplant center not enough
Thank you, well done
Summary of article
Revascularization versus Medical Management of Coronary Artery Disease in Prerenal Transplant Patients: A Meta-Analysis
Need for the metanalysis
Less is known about the optimal pre transplant treatment for CAD patients undergoing transplant.
This metanalysis aims to review literature about outcomes of patients with significant CAD managed by medical management versus surgical management.
Methods:
Only latest articles after 1998, studies looking at both the treatment arms, looking at post treatment outcomes were included in the metanalysis.
Results
6 studies evaluating 260 patients in medical and 338 patients in revascularization groups were included in the metanalysis.
Outcome: The metanalysis found not difference between medical and revascularization arms in terms of cardiovascular outcomes.
Conclusion:
No difference between medical versus invasive treatment for cardiovascular outcomes.
Meticulous preoperative risk stratification, intra-operative and post-operative follow-up is required in these subset of patients
Limitations:
Only six studies were included
Only one study was Randomized controlled trial
The heterogeneity for studies was significant (p<0.01)
Level of evidence: Level 1 (Metanalysis)
Thank you, well done
Summarise this article
Revascularization versus Medical Management of Coronary Artery Disease in Pre renal Transplant Patients: A Meta-Analysis
Introduction:
Chronic kidney disease (CKD) is known to be a strong risk factor for cardiovascular
disease and although patients with end-stage renal disease (ESRD) often benefit from renal
transplantation (RT), the number one cause of mortality in this population is cardiovascular
disease. The addressed question is whether revascularization would improve outcomes posttransplantation in comparison to medical management or not.
This meta-analysis reviews the literature on post-op outcomes of patients with significant coronary obstruction before RT who underwent either coronary revascularization or medical management.
Methods:
A Pub Med search using combinations of the keywords kidney transplant with either coronary revascularization, cardiovascular screening, major adverse cardiovascular events, percutaneous coronary intervention, or CAD management
Exclusion criteria:
(1) studies prior to 1997,
(2) studies that only looked at one arm of the research (i.e., only a revascularization group),
(3) studies that only recorded pre-transplantation results,
(4) studies that compared percutaneous coronary intervention to coronary artery bypass surgery but not to a medical management group,
(5) studies that only looked at screening but not treatment of the CAD,
(6) studies that did not report the crude data but only hazard ratios or odds ratios.
The data was analyzed using CMA package V3 (Biostat, USA). Mantel-Haenszel method (Mantel and Haenszel were used for calculating the weighted pooled odds ratio under the fixed effects model. Heterogeneity statistic was incorporated to calculate the summary odds ratio under the random effects model (DerSimonian and Laird, 1986). The data are reported as odds ratios with 95% confidence intervals.
Results:
· A total of 6 studies included in the meta-analysis resulted in a total of 598 subjects.
· 260 in the medical management group, and 338 in the revascularization group.
· Five studies reported the primary cardiovascular outcomes
· Of the five studies; there were 36 events in the revascularization and 57 events in the medical management group
· The pooled odds ratio with 95% CI for the fixed effects was 1.415 (95% CI 0.885–2.263), p = 0.147.
· These results indicate that compared to pretransplant revascularization, medical management is no different in terms of posttransplant cardiovascular outcomes.
· The heterogeneity observed for the studies included was Q = 19.587, I2 = 74.47, p < 0.01.
Conclusion:
This meta-analysis suggests that preoperative medical management versus
revascularization does not lead to significant difference in posttransplant cardiac outcomes.
What is the level of evidence provided by this article?
Level evidence 1 (meta-analysis)
There is an obvious weakness(s) in this study, please identify it (them).
Thank you, are you sure that there was no RCT included in this meta-analysis?
The below statements confused me honestly:
It should be noted that only 1 randomized control study was found to address this question but was excluded as the study was performed in 1992 when the medical management included calcium channel blockers and aspirin. All other studies included were aimed to address other questions but also collected
data on patients with obstructive CAD who underwent either revascularization or medical management.
Study designs for diagnosis of CAD varied between trials and all trials incorporated retrospective data from single transplant centers.
This is Met analysis study with level 1 evidence
A Meta-Analysis to compare coronary revascularization to medical management prior to renal transplantation
Cardiovascular disease is the most common cause of death in kidney transplant patients. Pre transplant evaluation for cardiac disease at times become very tricky making it difficult to decide whether to go for a transplant or cardiac revascularization first. This Meta analysis by Haroon et al has tried to answer this difficult question.
A total of 6 studies were selected out of 777 articles reviewed.
Keywords were: kidney transplant or renal transplant with either coronary revascularization, cardiovascular screening, major adverse cardiovascular events, percutaneous coronary intervention, or CAD management.
Exclusion criteria were:
1. studies prior to 1997
2. studies that only looked at one arm of the research
3. studies that only recorded pre-transplantation results
4. studies that compared percutaneous coronary intervention to coronary artery bypass surgery but not to a medical management group
5. studies that only looked at screening but not treatment of the CAD
6. studies that did not report the crude data but only hazard ratios or odds ratios
The 6 studies included 260 patients who received medical management and 338 who received coronary revascularization. There were 36 events in the revascularization and 57 events in the medical management group. Five studies reported the primary cardiovascular outcomes. One study only reported hazard ratios but no CVD outcomes and thus, total number of cardiovascular outcomes was not
available for this study
The pooled odds ratio with 95% CI for the fixed effects was 1.415 (95% CI 0.885–2.263), p = 0.147.
These results indicate that compared to pretransplant revascularization, medical management is no different in terms of posttransplant cardiovascular outcomes.
The heterogeneity observed for the studies included was Q=19.587, I2 = 74.47, p < 0.01.
Weaknesses of this study Rehab???
Summarise them, please. I like your explantations
Meta-analysis study level 1
Summery:
CVD is the major cause of morbidity & mortality in CKD & ESRD patients. So candidates for renal transplantation need thorough CV risk stratification through detailed & extensive investigation starting from simple techniques as resting ECG to invasive procedure as coronary angiography.
which is better medical management or re-vascularization in improving post transplant outcome?
Methods: meta-analysis study include 6 trials & 598 patients ( 260 patient on medical treatment & 338 patients with re-vascularization). Exclusion criteria include:
Results & discussion:
The result of this meta-analysis show no difference between re-vascularization & medical treatment effect on post transplant mortality.
Singh et al found that pre transplant negative stress test was associated with low risk of post transplant cardiac events, as well as no difference between non significant & significant lesion outcome that treated by re-vascularization. While Eschertzhuber et al found that pre-transplant re-vascularization for patients with high risk profile associated with better outcome. So pre-transplant CAD assessment can be done by non invasive techniques & if needed done with re-vascularization.
Limitation of the study:
In conclusion pre transplant medical treatment versus re-vascularization didn’t affect post transplant cardiac outcome. Careful risk assessment by non invasive techniques & close monitoring of peri-operative hemodynamic stability with good drug adherence can lead to better cardiac outcomes.
Thank you, well done
Cardiovascular disease is the most common cause of death in kidney transplant patients. Pre transplant evaluation for cardiac disease at times become very tricky making it difficult to decide whether to go for a transplant or cardiac revascularization first. This Meta analysis by Haroon et al has tried to answer this difficult question.
Methods
Methods
A PubMed search was performed using combinations of the keywords kidney transplant or renal transplant with either coronary revascularization, cardiovascular screening, major adverse cardiovascular events, percutaneous coronary intervention, or CAD management.
Exclusion criteria included
(1) studies prior to 1997,
(2) studies that only looked at one arm of the research (i.e., only a revascularization group),
(3) studies that only recorded pre-transplantation results,
(4) studies that compared percutaneous coronary inter- vention to coronary artery bypass surgery but not to a medical management group,
(5) studies that only looked at screening but not treatment of the CAD, and
(6) studies that did not report the crude data but only hazard ratios or odds ratios. All other studies were included. Heterogeneity statistic was incorporated to calculate the summary odds ratio under the random effects model
There are a total of 6 studies included in the meta-analysis. This resulted in a total of 598 subjects. Of these, 260 were in the medical management group and 338 were in the revascularization group. Five studies reported the primary cardiovascular outcomes.available for this study. Of the 5 studies, there were 36 events in the revascularization and 57 events in the medical management group.
The results of this meta analysis showed that pre transplant cardiac revascularization does not affect posttransplantation mortality compared to medical management for individuals undergoing renal transplant.
Level of evidence 1
I think the authors failed to clearly mention what type of patients were chosen for medical management and on what grounds these decision were made.
Thank you, well done
This meta-analysis reported the post-transplant cardiovascular outcomes based on pre-transplant approach to patients with cardiovascular risk. The meta-analysis compared coronary revascularization to medical management prior to renal transplantation in with CAD.
Study design:
– There are a total of 6 studies included in the meta-analysis.
– Total of 598 subjects. Of these, 260 were in the medical management group and 338 were in the revascularization group.
Exclusion criteria:
– Studies prior to 1997
– Studies that only looked at one arm of the research (i.e., only a revascularization group)
– Studies that only recorded pre-transplantation results
– Studies that compared percutaneous coronary intervention to coronary artery bypass surgery but not to a medical management group
– Studies that only looked at screening but not treatment of the CAD
– Studies that did not report the crude data but only hazard ratios or odds ratios.
Results
Post-transplant cardiac outcomes were not affected by the preoperative approach of treatment of severe CAD.
Level of evidence: 1 (meta-analysis)
There is an obvious weakness(s) in this study, please identify it.
– Small number of studies: only 6 studies only were included.
– Heterogeneity of populations in different studies with different incidence and severity of CAD.
– No clear indication for therapeutic approach: Is it only done based on high risk stratification or done in symptomatic patients.
-Medical management of patients was not clear enough in all patients
– The treatment regimen was not mentioned in all studies
Thank you, well done
Ø A Meta-Analysis to compare coronary revascularization to medical management prior to renal transplantation
Ø A total of 6 studies were selected out of 777 articles reviewed.
Keywords were: kidney transplant or renal transplant with either coronary revascularization, cardiovascular screening, major adverse cardiovascular events, percutaneous coronary intervention, or CAD management
Ø Exclusion criteria were:
1. studies prior to 1997
2. studies that only looked at one arm of the research
3. studies that only recorded pre-transplantation results
4. studies that compared percutaneous coronary intervention to coronary artery bypass surgery but not to a medical management group
5. studies that only looked at screening but not treatment of the CAD
6. studies that did not report the crude data but only hazard ratios or odds ratios
Ø The 6 studies included 260 patients who received medical management and 338 who received coronary revascularization. There were 36 events in the revascularization and 57 events in the medical management group. Five studies reported the primary cardiovascular outcomes. One study only reported hazard ratios but no CVD outcomes and thus, total number of cardiovascular outcomes was not
available for this study
Ø The pooled odds ratio with 95% CI for the fixed effects was 1.415 (95% CI 0.885–2.263), p = 0.147.
These results indicate that compared to pretransplant revascularization, medical management is no different in terms of posttransplant cardiovascular outcomes.
The heterogeneity observed for the studies included was Q=19.587, I2 = 74.47, p < 0.01.
Meta-analysis: level 1
Number of the studies: only 6
Study designs for diagnosis of CAD varied between trials and all trials incorporated retrospective data from single transplant centre
High heterogeneity
Thank you, well done
Summarise this article
* Introduction:
ESRD necessitating renal transplantation at risk for (CVD) morbidity and mortality due to accelerated atherosclerosis, as a result these patients are at increased incidence of major surgical CVD mortality.
A few studies had showed the outcomes of post transplantation CVD related to different treatment policy, accordingly, there are no specific preoperative guidelines regarding treatment of CAD in this high-risk patients go through RT.
*Objective:
This meta analysis compare coronary revascularization to management before RT in patients who are found to have significant obstructive CAD.
Methods
A PubMed search was performed using combinations of the keywords kidney transplant or renal transplant with either coronary revascularization, cardiovascular screening, major adverse cardiovascular events, percutaneous coronary intervention, or CAD management.
Exclusion criteria included
(1) studies prior to 1997
(2) studies that only looked at one arm of the research
(3) studies that only recorded pre-transplantation results
(4) studies that compared percutaneous coronary intervention to coronary artery bypass surgery but not to a medical management group
(5) studies that only looked at screening but not treatment of the CAD
(6) studies that did not report the crude data but only hazard ratios or odds ratios.
Included criteria
All other studies were included. All other studies included were aimed to address other questions but also collected data on patients with obstructive CAD who underwent either revascularization or medical management.
Results:
*A total of 6 studies were deemed suitable out of 777 articles reviewed.
*260 patients received medical management and 338 received coronary revascularization.
*There were 36 events in the revascularization and 57 events in the medical management group.
* One study only reported hazard ratios but no CVD outcomes.
*Comprehensive Meta-Analysis software was used to calculate pooled odds ratio with 95% confidence intervals (CI) for the fixed effects.
*The data is presented as forest plots.
*The pooled odds ratio with 95% CI for the fixed effects was 1.415 (95% CI 0.885–2.263), p = 0.147,
##There is no difference in CVD outcomes between pre transplant treatment strategy.
## This observation suggests that the CVD outcomes posttransplantation are not affected when optimal medical therapy is used instead of coronary revascularization.
What is the level of evidence provided by this article?
Level 1 Meta- analysis
There is an obvious weakness(s) in this study, please identify it (them)
*Title of the article is prerenal transplant patients it should be pretransplant
*Small sample size study a total of 6 studies out of 777 articles reviewed.
*Single center study
*The diagnostic stratification of patients regarding the extent and gravity of CAD is not clear
*The conclusions of this study are limited as it was nonrandomized and participants were asked if they wanted revascularization or not.
Excellent
This is a meta analysis which compare the efficacy medical management of coronary revascularization to medical management prior to RTx in significant CAD
Methods
Pubmed search included all studies with specific keywards except
(1) studies prior to 1997
(2) studies that only looked at one arm of the research
(3) studies that only recorded pre-transplantation results
(4) studies that compared percutaneous coronary intervention to coronary artery bypass surgery but not to a medical management group
(5) studies that only looked at screening but not treatment of the CAD
(6) studies that did not report the crude data but only hazard ratios or odds ratios. All other studies were included.
Results
6 studies included in the meta-analysis
260 were in the medical management
338 were in the revascularization
5 studies reported 36 events in revascularization and 57 in medical management
One study reported only hazard ratio
Discussion
The only study which approved that revascularization Had better outcomes after kidney transplant compared to medical treatment is Manske et al .
This study is excluded as it done in 1992 and it had limitations as small size sample and poor medical treatment
Recent studies as POISE study , CARP study , and BARI 2D trial showed that there is no difference in the outcomes between medical therapy and revascularization except with regard to diffuse CAD
advances in preoperative medical management have led to improvement in postoperative cardiovascular outcomes, which is comparable to preoperative invasive management of CAD.
Kumar et al study have noted that preemptive revascularization prior to transplantation leads to increased survival at 1 and 3 years posttransplant.
But it has limitations as nonrandomization and poorly adherence to medical therapy.
Only Eschertzhuber et al in our meta-analysis favors revascularization.
conclusion
preoperative medical management versus revascularization does not lead to significant difference in posttransplant cardiac outcomes.
We need further studies
Level evidence is 1
Weaknesspoint
* Heterogeneity in the patient groups
* Differences in medical treatments use and not mentioned
* There is a decrease in the rate of real events considering as there is one study
reported only hazard ratio
Thank you, well done
Cardiovascular disease is the commonest cause of mortality in kidney transplant patients so they need extensive cardiac workup to assess cardiovascular disease prior to transplantation.
This meta-analysis aims to compare revascularization versus medical management in patients with coronary artery disease before transplantation.
It included 6 studies with total 598 subjects, 260 received medical management and 338 had revascularization.
5 studies reported primary cardiovascular outcome with 36 events in revascularization and 57 events in medical management group.
One study reported the hazard ratio so total number of cardiovascular outcomes wasn’t available.
One randomized controlled trial addressed the question of the study and showed that cardiac events and deaths were more common in the medical management group than in revascularization group, this study was excluded as the medical management was aspirin and CCB and was performed before 1997 (according to the exclusion criteria)
More recent studies after advances in pre-operative medical management showed better postoperative cardiovascular outcomes.
The POISE study included patients with renal impairment showed that use of metoprolol leads to less postoperative myocardial infarction
CARP trial showed that revascularization in stable CAD didn’t reduce mortality, MI or death early post operative.
BARI 2D showed that diabetic patients have improved outcome with revascularization.
A non randomized study showed that revascularization increases the survival at one and three year post transplant
Non invasive stress imaging are preferred to evaluate CAD and are associated with better medical management and better stratification of transplant candidates.
A study showed that transplant candidate with high risk for cardiac events who have revascularization can undergo transplantation safely.
Risk stratification, perioperative hemodynamic monitoring and ensuring medication adherence can lead to better outcome.
Conclusion: no significant differences in post transplant cardiovascular outcome in patients who had preoperative medical management and those who had revascularization.
Level of evidence 1 (meta-analysis)
Weakness points:
6 studies only were included.
Heterogenous populations were represented with different incidence of CAD.
The diagnostic methods for cardiovascular disease wasn’t clear
The therapeutic regimen wasn’t mentioned in all studies
Medical management in CKD patients wasn’t the same in all studies.
The severity of CAD was not determined
Thank you, well done
Introduction :
CKD) is known risk factor for cardiovascular disease and although patients with end-
stage renal disease , often benefit from renal transplantation, the number one
cause of mortality in this population is cardiovascular disease.
The following question arises when a patient with an abnormal stress test undergoes
coronary angiography and is found to have significant obstruction of the coronaries.
Would revascularization (with either percutaneous coronary intervention or coronary
artery bypass surgery) improve outcomes posttransplantation in comparison to medical
management?
Methods:
A PubMed search, meta-analysis we compare coronary revascularization to medical
management prior to renal transplantation.
Results:
There are a total of 6 studies included in the meta-analysis.
Conclusion:
The results of our meta-analysis show that preoperative cardiac revascularization does
not affect posttransplantation mortality compared to medical management for individuals
undergoing renal transplant.
Level of evidence 1
There is an obvious weakness(s) in this study, please identify it (them).
Title pre renal not Pretransplant.
Noninvasive stress imaging used in some of studies shows good medical outcome with
limitation of noninvasive test CKD patient may be patient not having CAD.
They compare outcome of different Pretransplant protocols ,some use invasive others
used noninvasive screen test for risk stratification of patient with CAD.
Thank you,
Well done
Summery:
There is no difference in mortality between preoperative cardiac revascularization and medical management. However, study by Eschertzhuber et al. found that patients awaiting transplant with high risk profile for post transplant cardiac events can undergo transplant safely if they are revascularized.
Although cardiac catheterization is the gold standered, non invasive stress test is preferred to evaluate for CAD before transplantation.
Evidence:
Lvel I
Weakness of this study:
Observational; study
Thank you,
I know it is sometimes difficult, but we all learn by trying and trying. Thank you for the effort. I suggest reading the other’s reply and doing the same (please do not copy and paste)
IV. Revascularization versus Medical Management of Coronary Artery Disease in Pre renal Transplant Patients: A Meta-Analysis
Summarise this article
Introduction:
Chronic kidney disease (CKD) is a risk factor for cardiovascular disease, and patients who benefit from renal transplantation with pre-op revascularization did not improve outcomes. But little is known about patients with significant coronary artery disease (CAD) going for RT.
This meta-analysis reviews the literature on post-op outcomes of patients with significant coronary obstruction before RT who underwent either coronary revascularization or medical management.
Objective:
Through meta-analysis, we compare coronary revascularization to medical management before renal transplantation in patients who are found to have significant obstructive coronary artery disease.
Methods:
A Pub Med search using combinations of the keywords kidney transplant with either coronary revascularization, cardiovascular screening, major adverse cardiovascular events, percutaneous coronary intervention, or CAD management
Exclusion criteria :
(1) studies before 1997,
(2) studies that only looked at one arm of the research (i.e., only a revascularization group),
(3) studies that only recorded pre-transplantation results,
(4) studies that compared percutaneous coronary intervention to coronary artery bypass surgery but not to a medical management group,
(5) studies that only looked at screening but not treatment of the CAD,
(6) studies that did not report the crude data but only hazard ratios or odds ratios
Inclusion criteria:
All other studies were included
Data analysis :
The data was analyzed using CMA package V3 (Biostat, USA). Mantel-Haenszel method (Mantel and Haenszel were used for calculating the weighted pooled odds ratio under the fixed effects model. Heterogeneity statistic was incorporated to calculate the summary odds ratio under the random effects model (DerSimonian and Laird, 1986). The data are reported as odds ratios with 95% confidence intervals
Results:
· A total of 6 studies included in the meta-analysis
· resulted in 598 subjects.
· Two hundred sixty were in the medical management group, and 338 were in the revascularization group.
· Five studies reported the primary cardiovascular outcomes
· the five studies; there were 36 events in the revascularization and 57 events in the medical management group
· The pooled odds ratio with 95% CI for the fixed effects was 1.415 (95% CI 0.885–2.263), p = 0.147. These results indicate that compared to pretransplant revascularization, medical management is no different in terms of posttransplant cardiovascular outcomes. The heterogeneity observed for the studies included was Q = 19.587, I2 = 74.47, p < 0.01.
Conclusion:
· Preoperative medical management versus revascularization does not lead to a significant difference in posttransplant cardiac outcomes.
What is the level of evidence provided by this article?
Level 1 meta-analysis
There is an apparent weakness(s) in this study,
· single transplant centers
· small sample
Thank you, Well done
Article summary
A Meta analysis comparing revascularization versus medical management of CAD in prerenal transplant patients.
it is well known that patients with CKD or ESRD have increased risk of coronary artery disease and mortality from cardiovascular causes, many studies in the post transplant patients were conducted comparing medical and interventional treatment, no specific preoperative guidelines in these high risk patient management of coronary artery disease.
this meta analysis address this issue in the two treatment arm, from 6 studies out of 777 articles reviewed, one excluded because of no data available but hazard ratio (no total number of cardiovascular events known).
In the 6 studies there are 260 patients on medical treatment arm and 338 Pts on revascularization arm.
Exclusion criteria of the reviewed articles:
1. Studies conducted before 1997.
2. Studies looked at one arm of the study
3. Studies recorded pre-transplantion results.
4. Studies in screening but not treatment of CAD.
5. Studies did not report the crude data but hazard rati.
6. Studies compared PTCA to CABG but not medical treatment.
There are multiple factors that make the patients with CKD or ESRD make them
At 14 fold increased in cardiac death( ie.activation of angiotensin aldosterone system ,, oxidative stress, dyslipidemia , endothelial injury and vascular calcifications.
The results of the meta analysis show the preoperative cardiac revascularizationdoesn’t affect the posttransplant mortality in comparison to medical treatment.
The study is with non-invasive stress testing of pretransplantion preparation of these patients. And close monitoring of hemodynamics, and close observation and checking pts adherence leads to better out come post transplantation.
Level of evidence
level I of evidence.
Weakness points of the study
The study design varied between trials and They incorporated data from single transplant centers.
Limited use of evidence based pharmacological therapies with CKD or ESRD compared to normal renal function patients.
Small number of patients in each trial reviewed and accepted to this meta analysis.
One study address the hypothesis in 1992, with good results was excluded because of the inclusion criteria put by the author.
Thankyou
Thank you, Well done
Revascularization versus Medical Management of Coronary Artery Disease in Prerenal Transplant Patients: A Meta-Analysis
Summary:
This meta-analysis reviewed the literature of post-operative outcomes of patients with significant coronary obstruction prior to renal transplant who underwent either coronary revascularization Vs medical management.
Introduction
Cardiovascular disease is the number one cause of mortality in renal transplant pts.
Results
–6 studies were included in this meta-analysis. This included 598 subjects (260 were in the medical management group (MMG) and 338 were in the revascularization group(RVG)).
– Five studies reported the primary cardiovascular outcomes in which Of the there were 36 events in RVG and 57 events in the MMG.
-The total number of cardiovascular outcomes was not available for this study.
– These results indicate that compared to pretransplant revascularization, medical management is no different in terms of posttransplant cardiovascular outcomes.
Discussion
– The results of this meta-analysis showed that preoperative cardiac revascularization does not affect posttransplantation mortality compared to medical management for individuals undergoing renal transplant.
– Individuals with CKD and ESRD requiring hemodialysis and have CAD or acute coronary syndromes have poorer outcomes.
– Although cardiac catheterization to define coronary anatomy is the gold standard, it is not without risks.
-Noninvasive stress testing is preferred to evaluate for CAD prior to transplantation and can be used to risk stratify pretransplant cacandidates.
– Appropriate preoperative noninvasive stress imaging seems to be associated with better medical management.
– There is no significant difference between the patients with no significant CAD and those with significant lesions who underwent revascularization.
-Modest differences in noninvasive stress imaging can help identify individuals that will benefit from medical management and reduce the need for invasive diagnosis.
– Patients awaiting transplant with proven high-risk profile for posttransplant cardiac events can undergo transplantation safely if they are revascularized.
– Pretransplant screening for CAD in candidates for renal transplant should include noninvasive testing and if needed, coronary angiography.
Conclusion:
-Preoperative medical management versus revascularization does not lead to significant difference in posttransplant cardiac outcomes.
-Careful risk stratification using noninvasive testing, meticulous perioperative hemodynamic monitoring, and closer postoperative follow-up to monitor for medication adherence can possibly lead to better outcomes.
-Further prospective randomized trials are needed to define which subsets of patients might benefit from pretransplant intensified medical management or from revascularization.
*level of evidence: 1
*Weakness(s) of this study:
– Contain nonrandomized studies
-Single center
– Small sample size
-lack of clinical trails
Good critical analysis of the article but:
risk stratification of patients and individual coronary degree of lesion is not clear.
Title of the article statesPRERENAL CAD it should be pretransplant!
Ok , thanks Prof Dawlat
TITLE:
Revascularization versus Medical Management of Coronary Artery Disease in Prerenal Transplant Patient: A Meta-analysis
SUMMARY:
The population of patient with ESRD that requires kidney transplantation is growing and so is the incidence of morbidity and mortality especially through cardiovascular disease either before of after kidney transplantation. The prevalence of coronary artery disease among them is increasing because of activation of RAAS system, oxidative stress, cytokines, and inflammation which all contribute to atherosclerosis of the coronary vessels.
AIM:
To identify if revascularization is better than medical management of coronary artery disease in pretransplant patient.
METHOD:
A Pub Med search from 1997 was performed to identify different studies that meet the inclusion and exclusion criterial.
. study after 1997
. ESRD patient that underwent renal transplantation
. ESRD patient with CAD that was treated with medical or surgical method
. studies prior to 1997
. studies that only look at one arm of the research
. studies that only report pre-transplant results
. studies that compared percutaneous coronary intervention to coronary artery bypass surgery but not to medical management
. studies that only look at screening of CAD and not treatment
. studies that did not report the crude data
DATA ANALYSIS:
CMA package V3 (Biostat, USA) was used
RESULT:
Six studies were included in the meta-analysis, with a total of 598 subjects comprising of 260 of them in the medical arm and 338 subjects in the surgical intervention arm. However, one only reported hazard ratio without including the cardiovascular event in its outcome. Furthermore, from the remaining 5 studies, there were 36 and 57 cardiovascular events in the medical and revascularization group respectively.
CONCLUSION:
The outcome of the meta-analysis shows that, there is no significant post transplant cardiac outcome between medical or surgical management of coronary artery disease among patient planned for kidney transplantation
LEVEL OF EVIDENCE:
Level 1
WEAKNESS:
Very competent critical analysis
wrong title it is pretransplant not prerenal.
The diagnostic stratification of patients regarding the extent and gravity of cad is not clear.
“Study designs for diagnosis of CAD varied between trials and all trials incorporated retrospective data from single transplant centers.”
The above seems to me as if there is no uniform criteria to make the diagnosis of CAD
NOTED WITH THANKS
Summarize this article
This article is looking at optimal medical therapy versus revascularisation therapy in pre-transplant CKD patients who have coronary artery disease. ESKD patients have a very high prevalence of coronary artery disease and CVD disease is the leading cause of death in ESKD and even post kidney transplant. The dilemma facing clinicians is what is the best screening test to use and after getting a positive screening test, what should be the next step. A study done by Manske et al in 1992 was the first RCT looking at optimum medical therapy versus revascularization therapy in CKD patients. It is important to note that the medical therapy consisted of a CCB and aspirin. The revascularization arm had fewer events than the medical therapy. However, now newer drugs are available which have mortality benefits in patients with CAD
This meta analysis looked at six trials after screening 777 trials. They included 260 patients who received medical therapy and 338 patients who received revascularisation therapy. There were 36 events in the revascularisation group and 57 events in the medical therapy arm. One study reported hazards ration but no CVD outcomes. The results showed the there was no difference between coronary revascularisation versus medical therapy in pre-transplant CKD patients with CAD
What is the level of evidence provided by this article?
This is a meta analysis so its level 5
There is an obvious weakness(s) in this study, please identify it (them)
Sorry level 1
Introduction
End stage renal disease is associated with significant cardiovascular risks due to accelerated atherosclerosis. CVD is significant cause of mortality in ESRD patients. A Paucity of research has addressed post transplant CVD outcomes related to different treatments. There are no established preoperative guidelines for retament of CVD in transplant recipients.
Objective
In this meta analysis medical management was compared with coronary revascularization pre transplant in patients with significant CVD.
Results
A total of 777 articles were reviewed and only six studies were found suitable. 338 patients had coronary revascularization and 260 had medical management. 5 five studies reported cardiovascular outcomes. There were 57 events in medical treatment group and 36 events in revascularization group.
Conclusion
It was concluded that medical management is no different in term of cardiovascular outcomes as compared to coronary revascularization.
Careful risk stratification using non invasive testing, preoperative monitoring and close follow up can improve outcomes.
Level of Evidence
Meta analysis
Level -1
Weaknesses of study
It is a small retrospective study and there is lack of standard ttrials
Thankyou