Patients with end stage renal failure are at high risk of coronary artery disease (CAD). In transplant patients death with function due to cardiovascular disease is an important cause of patient and graft loss. Accordingly identifying CAD and addressing risk factors before transplantation is an attractive proposition. Controversy exists regarding the role of screening coronary angiography (CA), and treatment of silent CAD, prior to kidney transplantation (KTx).

The patient records were examined of 235 patients undergoing CA during work up for KTx at our institution between 2000-2012. 200 patients (135M:65F; age 53.8±11 yrs; 69% HD, 14% PD, 16% Predialysis, 2% Failing KTx; duration of RRT 30.7 ±53.6 Mth; 43% DM; 56% current/ex smokers) were asymptomatic and had no past history of CAD. CA results were defined as ‘Significant’ (n=46: Diffuse/Obstructed 6, PCI 28, CABG 12) and ‘Not-Significant’ (n=154: Normal 82, Minor atheroma 72).

Patient survival (all cause mortality) was less good in asymptomatic patients with significant CAD, regardless of revascularisation (93.3 v 96.6% 1 year and 65.1 v 80.9% 5 year survival, p<0.05).

In univariate analysis age was the only predictor of significant CAD (58.4 ±9.8 v 52.4 ±11.0, p=0.001) with a trend towards more CAD in diabetics. Multivariate analysis showed that the absence of DM in patients <50 years was a strong negative predictor for CAD (2/34 vs 17/35, p=0.01).

Time to activation on KTx list was different in patients with significant CAD, 21.9 v 65.2% by 1 year and 71.1 v 87.1% by 3 years (p=0.001). To date 16 (35%) patients with significant CAD (DD 12, LD 3, SPK 1), compared to 66 (43%) without have been transplanted (DD 34, LD 21, SPK 11).

Time to transplant was not statistically different in patients with significant CAD, 2.2 v 20.9% by 1 year and 35.8 v 41.3% by 3 years (p=0.24). However by 1 year, in patients without significant CAD only 29.4% of recipients of DD kidneys had been transplanted compared to 45.5% of recipients of SPK and 71.9% of recipients of LD kidneys (p<0.05).

Screening 200 asymptomatic patients awaiting KTx with CA resulted in 40 revascularisations, only 15 of whom proceeded to KTx. It is likely that for the majority of patients CA screening may have delayed listing for KTx and is of questionable validity as the majority of patients screened had not received a KTx within 3 years of CA. CA has a limited role in KTx work up for asymptomatic patients without a LD, especially for younger non-diabetic patients.

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