Preexisting cardiac morbidity has no effect on patient or graft survival among ECD kidney recipients
Recipients of expanded-criteria donor (ECD) kidneys have similar patient and graft survival regardless of their history of pretransplant cardiac disease (PCD), even if the recipients had coronary revascularization prior to transplantation, a study shows.
The findings suggest that the use of ECD kidneys in end-stage renal disease patients with a history of PCD—whether or not treated with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG)—may be appropriate, said lead investigator Christina Klein, MD, a transplant fellow at the University of Wisconsin-Madison, who presented study findings.
She and her colleagues studied 272 patients who received ECD kidneys. Of the 182 (67%) patients who had PCD, 63 (34.6%) had a history of coronary revascularization, and 119 (65.4%) did not. The remaining 90 patients (33%) had no pretransplant cardiac disease (NPCD).
The estimated five-year patient survival was 53% and 68% for the revascularization and no revascularization groups, respectively, and 64% for NPCD patients. In addition, fatal cardiovascular events accounted for 33%, 25%, and 37.5% of deaths with a functioning graft. The five-year, death-censored graft survival was 66%, 57%, and 71%, respectively. None of the differences among the groups was statistically significant.
As to why the cardiovascular death rate was not lower in patients with pretransplant revascularization, Dr. Klein explained that although PCI or CABG can restore blood flow in blocked coronary arteries, fatal cardiovascular events can be due to a wide variety of problems that revascularization cannot prevent. More importantly, she said, all recipients of ECD kidneys had increased overall and cardiovascular mortality independent of documented pre-transplant coronary artery disease.
To further investigate this, in a separate analysis of patients receiving standard-criteria donor kidneys, Dr. Klein's group found that in contrast to findings in the ECD group, PCD patients with a history of revascularization had a markedly increased risk of overall and cardiovascular death following transplantation. The analysis included 731 transplant recipients, of whom 403 (55%) had PCD and 328 did not. A total of 93 (23%) underwent revascularization prior to transplantation.
Among the PCD patients, the estimated five-year survival was 53% for those who underwent revascularization compared with 88% for those who did not. The researchers observed no significant difference in estimated five-year survival between PCD patients without revascularization and NPCD patients (89%). Fatal cardiovascular events accounted for 35.7% of deaths among the revascularized patients, 23.5% of deaths among PCD patients without revascularization, and 15.4% of deaths among patients without a cardiac disease history.
Summarizing the findings for the entire group of deceased-donor recipients, the use of an ECD kidney was associated with markedly increased overall and cardiovascular mortality as well as decreased death-censored graft survival, whereas recipient history of pretransplant revascularization was associated only with decreased patient survival. Transplant recipients with a history of pretransplant coronary revascularization, however, had similar overall and cardiovascular death rates whether they received an ECD vs. an SCD kidney, illustrating the nonadditive effects of these donor and recipient factors, Dr. Klein said.