Asymptomatic coronary artery disease [CAD] is common in patients with end-stage renal disease [ESRD]. While coronary revascularization prior to transplantation is associated with improved patient survival, the timing of repeat angiographic screening is unclear. The objective of this study was to determine the rate of progression of CAD in patients with end-stage renal disease and to establish if successful transplantation has a protective effect on the rate of progression.

As part of an ethically-approved prospective interventional study, we approached patients three years following initial coronary angiography to facilitate transplantation. We included both patients who had either been subsequently transplanted or who, having commenced dialysis, continued to be wait-listed. Participants underwent further coronary angiography with intervention as clinically indicated. A quantitative assessment of CAD was made by a single observer using the SYNTAX scoring system for each angiogram.

Of 420 patients who had undergone initial angiography, 235 were eligible for inclusion in the study. Ultimately 76 patients (mean age 60.8 ± 5.9 years [±SD]) underwent a second angiogram 3.7 ± 0.6 years following the initial angiogram. Of this group, 42% had diabetes and 24% had undergone an intervention at the time of the first angiogram. Progressive CAD was seen in 18/56 (32%) angiograms available for scoring. However, only 5 patients required an intervention on the basis of the second angiogram, including 2 patients who did not have significant CAD at the time of the initial angiogram.

In longer term follow up (7.16 ± 1.32 years from the original angiogram), there was no difference between cardiac event-free survival in those who were eligible for the study but did not enrol and the study group, though transplantation did have a protective effect (hazard ratio 0.49 [0.27-0.91 95%CI] p=0.024) across both groups when matched for age, gender and ESRD vintage.

Though in this high-risk population progressive CAD can be seen at three years following initial coronary angiography, the rate of disease requiring intervention is low. Transplantation but not repeat angiography appears to have a protective effect on cardiac event-free survival compared to a wait-listed population. The appropriate time for re-screening with angiography in this high-risk population remains uncertain.

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