Received November 30, 2007
Accepted on March 11, 2008

ORIGINAL ARTICLES

Cardiac Evaluation before Kidney Transplantation: A Practice Patterns Analysis in Medicare-insured Dialysis Patients

Krista L. Lentine ^*1, Mark A. Schnitzler ^*, Daniel C. Brennan , Jon J. Snyder , Paul J. Hauptman ^*||, Kevin C. Abbott ^¶, David Axelrod ^**, Paolo R. Salvalaggio ^*, and Bertram Kasiske

*Center for Outcomes Research, Division of Nephrology, and ||Division of Cardiology, Saint Louis University School of Medicine, St. Louis, Missouri; Division of Nephrology, Washington University School of Medicine, St. Louis, Missouri; Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota; ¶Nephrology Service, Walter Reed Army Medical Center, Washington, DC; **Department of Surgery, Dartmouth-Hitchcock Medical Center, Hanover, New Hamphsire; and Division of Nephrology, University of Minnesota, Minneapolis, Minnesota

¹ To whom correspondence should be addressed. E-mail: lentine.krista{at}stanfordalumni.org.

	Abstract

Background and objectives: Evaluation for ischemic heart disease (IHD) is a nonstandardized practice before kidney transplantation. We retrospectively studied pretransplant cardiac evaluation (CE) practices in a national sample of renal allograft recipients.

Design, setting, participants, & measurements: The USRDS data for Medicare beneficiaries transplanted in 1991 to 2004 with Part A&B benefits from dialysis initiation through transplantation were examined. Clinical traits defining "high" expected IHD risk were defined as diabetes, prior IHD, or 2 other coronary risk factors. Pretransplant CE were identified by billing claims for noninvasive stress tests and angiography. Patients were quantified with claims for coronary revascularization procedures between CE and transplant. Post-transplant acute myocardial infarction (AMI) events were abstracted from claims and death records.

Results: Among 27,786 eligible patients, 46.3% underwent CE before transplantation. Overall, 9.5% who received CE also received pretransplant revascularization, but only 0.3% of lower-risk patients undergoing CE had revascularization. The adjusted odds of transplant without CE increased sharply with younger age and shorter dialysis duration. Increased likelihood of transplant without CE also correlated with black race, female sex, and certain geographic regions. Among patients transplanted without CE, 3-yr incidence of post-transplant AMI was 3% in lower-risk and 10% in high-risk groups, and varied by individual traits within these groups. Among lower-risk patients transplanted without CE, blacks were higher risk for AMI than whites (adjusted hazards ratio 1.47, 95% CI 1.11–1.93).

Conclusions: Observed practices demonstrate infrequent use of pretransplant revascularization after CE but also raise concern for socio-demographic barriers to evaluation access.