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Background: Screening for cardiovascular disease is currently recommended before kidney transplantation. The present study aimed to validate the proposed algorithm by the American Heart Association (AHA-2022) considering cardiovascular findings and outcomes in kidney transplant candidates, and to compare AHA-2022 with the previous recommendation (AHA-2012)., Methods and Results: We applied the 2 screening algorithms to an observational cohort of kidney transplant candidates (n=529) who were already extensively screened for coronary heart disease by referral to cardiac computed tomography between 2014 and 2019. The cohort was divided into 3 groups as per the AHA-2022 algorithm, or into 2 groups as per AHA-2012. Outcomes were degree of coronary heart disease, revascularization rate following screening, major adverse cardiovascular events, and all-cause death. Using the AHA-2022 algorithm, 69 (13%) patients were recommended for cardiology referral, 315 (60%) for cardiac screening, and 145 (27%) no further screening. More patients were recommended cardiology referral or screening compared with the AHA-2012 (73% versus 53%; P <0.0001). Patients recommended cardiology referral or cardiac screening had a higher risk of major adverse cardiovascular events (hazard ratio [HR], 5.5 [95% CI, 2.8-10.8]; and HR, 2.1 [95% CI, 1.2-3.9]) and all-cause death (HR, 12.0 [95% [CI, 4.6-31.4]; and HR, 5.3 [95% CI, 2.1-13.3]) compared with patients recommended no further screening, and were more often revascularized following initial screening (20% versus 7% versus 0.7%; P <0.001)., Conclusions: The AHA-2022 algorithm allocates more patients for cardiac referral and screening compared with AHA-2012. Furthermore, the AHA-2022 algorithm effectively discriminates between kidney transplant candidates at high, intermediate, and low risk with respect to major adverse cardiovascular events and all-cause death.

Background: Although cardiovascular screening of kidney transplant candidates is recommended, the optimal approach is debated. Previous studies show that noninvasive imaging provides prognostic information, but systematic screening may have less recognized effects, such as additional investigations, incidental findings, procedural complications, and delay of transplantation. To address this, we characterized the diagnostic yield and clinical implications of systematic screening for cardiovascular disease using cardiac computed tomography (CT) in potential kidney transplant candidates., Methods: This was a single-center, observational cohort study including all potential kidney transplant candidates >40 years of age or with diabetes or on dialysis treatment for >5 years, systematically referred to cardiac computed tomography (CT; non-contrast CT and coronary CT angiography) between 2014 and 2019 before evaluation for kidney transplantation at Aarhus University Hospital. Patient records were examined for data on baseline characteristics, additional investigations and complications, plasma creatinine, dialysis initiation, time until wait-listing, and incidental findings., Results: Of 473 patients who underwent cardiac CT, additional cardiac investigations were performed in 156 (33%), and 32 (7%) were revascularized. Twenty-two patients had significant incidental nonvascular findings on cardiac CT. No patient was rejected for transplantation based on cardiac CT. In patients not yet on dialysis, the slope in the estimated glomerular filtration rate decline did not change significantly after coronary CT angiography., Conclusion: Screening by cardiac CT led to additional cardiac investigations in one-third of patients; only a few patients were revascularized, with unknown benefits in asymptomatic patients. Cardiac CT was safe in this population; however, the clinical consequences of the screening were limited., Competing Interests: Declaration of Competing Interest H.B. received a research grant from Glaxo Smith Kline and Vifor Pharma (paid to institution) and has received consulting fees and/or speaker honoraria from Vifor Pharma, AstraZeneca, Boehringer Ingelheim, GSK, Galapagos, Alexion, MSD and Novo Nordisk, as well as support for attending meetings from Novartis and AstraZeneca., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Cardiac screening using coronary computed tomography angiography (CCTA) in kidney transplant candidates before transplantation yields both diagnostic and prognostic information. Whether CT-derived fractional flow reserve (FFR CT ) analysis provides prognostic information is unknown. This study aimed to assess the prognostic value of FFR CT for predicting major adverse cardiac events (MACE) and all-cause mortality in kidney transplant candidates., Methods: Among 553 consecutive kidney transplant candidates, 340 CCTA scans (61%) were evaluated with FFR CT analysis. Patients were categorized into groups based on lowest distal FFR CT ; normal >0.80, intermediate 0.80-0.76, and low ≤0.75. In patients with ≥50% stenosis, a lesion-specific FFR CT was defined as; normal >0.80 and abnormal ≤0.80. The primary endpoint was MACE (cardiac death, resuscitated cardiac arrest, myocardial infarction or revascularization). The secondary endpoint was all-cause mortality., Results: Median follow-up was 3.3 years [2.0-5.1]. MACE occurred in 28 patients (8.2%), 29 patients (8.5%) died. When adjusting for risk factors and transplantation during follow-up, MACE occurred more frequently in patients with distal FFR CT ≤0.75 compared to patients with distal FFR CT >0.80: Hazard Ratio (HR): 3.8 (95%CI: 1.5-9.7), p ​< ​0.01. In the lesion-specific analysis with <50% stenosis as reference, patients with lesion-specific FFR CT >0.80 had a HR for MACE of 1.5 (95%CI: 0.4-4.8), p ​= ​0.55 while patients with lesion-specific FFR CT ≤0.80 had a HR of 6.0 (95%CI: 2.5-14.4), p ​< ​0.01. Abnormal FFR CT values were not associated with increased mortality., Conclusion: In kidney transplant candidates, abnormal FFR CT values were associated with increased MACE but not mortality. Use of FFR CT may improve cardiac evaluation prior to transplantation., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Objectives: This study sought to perform a prospective head-to-head comparison of the predictive value of clinical risk factors and a variety of cardiac imaging modalities including coronary artery calcium score (CACS), coronary computed tomography angiography (CTA), single-photon emission computed tomography (SPECT), and invasive coronary angiography (ICA) on major adverse cardiac events (MACE) and all-cause mortality in kidney transplantation candidates., Background: Current guidelines recommend screening for coronary artery disease in kidney transplantation candidates. Furthermore, noninvasive stress imaging is recommended in current guidelines, despite its low diagnostic accuracy and uncertain prognostic value., Methods: The study prospectively evaluated 154 patients referred for kidney transplantation. All patients underwent CACS, coronary CTA, SPECT, and ICA testing. The clinical endpoints were extracted from patients' interviews, patients' records, and registries., Results: The mean follow-up time was 3.7 years. In total, 27 (17.5%) patients experienced MACE, and 31 (20.1%) patients died during follow-up. In a time-to-event analysis, both risk factors and CACS significantly predicted death, but only CACS predicted MACE. Combining risk factors with CACS identified a very-low-risk cohort with a MACE event rate of 2.1%, and a 1.0% mortality rate per year. Of the diagnostic modalities, coronary CTA and ICA significantly predicted MACE, but only coronary CTA predicted death. In contrast, SPECT predicted neither MACE nor death., Conclusions: Compared with traditional risk factors and other cardiac imaging modalities, CACS and coronary CTA seem superior for risk stratification in kidney transplant candidates. Applying a combination of risk factors and CACS and subsequently coronary CTA seems to be the most appropriate strategy. (Angiographic CT of Renal Transplantation Candidate Study [ACToR]; NCT01344434)., (Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Patients with chronic kidney disease (CKD) frequently require radiographic examinations. We investigated the impact of repeated contrast administrations on short- and long-term kidney function and mortality in kidney transplantation candidates. In a prospective study, 81 predialysis transplantation candidates underwent computed tomography angiography (CTA) and invasive coronary angiography (ICA) as part of a pretransplant cardiovascular evaluation. Postcontrast plasma creatinine (P-creatinine) changes were compared with a precontrast control period. We identified postcontrast acute kidney injury (AKI) in 10 patients (13%) after CTA and in two patients (3%) after ICA. Compared with the control period, relative changes in P-creatinine were significantly higher after CTA (p < 0.001) and ICA (p < 0.01). Diabetic kidney failure (p < 0.05) and contrast dose >0.8 mL/kg (p < 0.001) were associated with increases in P-creatinine. All cases of postcontrast AKI were reversible, and we found no differences between the progression rates of the kidney failure during 12 months before and after contrast exposure (p = 0.56). In a Cox regression analysis, creatinine changes after CTA or ICA were not associated with increased need for dialysis treatment or mortality. Contrast exposure and transient postcontrast AKI did not increase the risk of accelerated CKD progression or the time to initiation of dialysis or death., (© Copyright 2015 The American Society of Transplantation and the American Society of Transplant Surgeons.)

Objectives: The goal of this study was to compare the diagnostic accuracy of the coronary artery calcium score (CACS), coronary computed tomography angiography (CTA), single-photon emission computed tomography (SPECT), and a combination of these tools in the diagnosis of obstructive coronary artery disease (CAD) in patients with chronic kidney disease referred for cardiac evaluation before kidney transplantation., Background: The optimal method for the detection of obstructive CAD in potential kidney transplant patients has not yet been identified. Previous studies have found that established noninvasive stress tests have low diagnostic accuracy, while the diagnostic performance of coronary CTA remains unknown., Methods: We prospectively studied 138 patients referred for pre-transplant cardiac evaluation (mean age 54 years; age range 22 to 72 years; 68% male; 43% treated with dialysis). All patients underwent CACS, coronary CTA, SPECT, and invasive coronary angiography. The results of the noninvasive tests were merged into integrated hybrid imaging results: Hybrid (CACS/SPECT) and Hybrid (coronary CTA/SPECT)., Results: The overall prevalence of obstructive CAD (≥50% reduction in luminal diameter) according to quantitative invasive coronary angiography was 22%. Two-thirds of the patients with obstructive CAD had a stenosis located in a proximal coronary segment. In a patient-level model, the sensitivity and specificity, respectively, for diagnosing obstructive CAD were as follows: CACS (threshold of 400), 67% and 77%; coronary CTA, 93% and 63%; SPECT, 53% and 82%; Hybrid (CACS/SPECT), 33% and 97%; and Hybrid (coronary CTA/SPECT), 67% and 86%. The sensitivity for diagnosing obstructive CAD in a proximal segment was 70% for CACS (threshold 400), 100% for coronary CTA, 60% for SPECT, 40% for Hybrid (CACS/SPECT), and 75% for Hybrid (coronary CTA/SPECT)., Conclusions: Coronary CTA is a reliable test with high sensitivity and a high negative predictive value for diagnosing obstructive CAD before kidney transplantation. A noninvasive approach with use of either coronary CTA or a combination of coronary CTA and SPECT to rule out obstructive CAD seems recommendable in kidney transplant candidates. (ACToR-Study: Angiographic CT of Renal Transplantation Candidate-Study; NCT01344434)., (Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background Screening for cardiovascular disease is currently recommended before kidney transplantation. The present study aimed to validate the proposed algorithm by the American Heart Association (AHA‐2022) considering cardiovascular findings and outcomes in kidney transplant candidates, and to compare AHA‐2022 with the previous recommendation (AHA‐2012). Methods and Results We applied the 2 screening algorithms to an observational cohort of kidney transplant candidates (n=529) who were already extensively screened for coronary heart disease by referral to cardiac computed tomography between 2014 and 2019. The cohort was divided into 3 groups as per the AHA‐2022 algorithm, or into 2 groups as per AHA‐2012. Outcomes were degree of coronary heart disease, revascularization rate following screening, major adverse cardiovascular events, and all‐cause death. Using the AHA‐2022 algorithm, 69 (13%) patients were recommended for cardiology referral, 315 (60%) for cardiac screening, and 145 (27%) no further screening. More patients were recommended cardiology referral or screening compared with the AHA‐2012 (73% versus 53%; P