Introduction: An important goal of pre-transplant evaluation is to identify candidates at risk for cardiovascular (CV) events and mortality post-transplant. Current approaches for risk assessment fail to adequately predict this risk. Herein, we assessed whether cardiac troponin T (cTnT) measured pre-transplant can better define risk during 1st-year post-transplant and beyond.

Methods: Included are 1199 adult recipients of kidney grafts from 2001-2010. Age 52 ±14years, follow-up 45±26months. High risk (HR) recipients had one or more of these pre-transplant factors: age>59, diabetes, CV disease or dialysis>2 years. Normal cTnT was <0.01ng/ml.

Results:756 of 1199 patients (63.2%) were HR. Compared to no HR, HR had higher mortality (HR=2.74 (1.60-4.68), p<0.0001). In addition, 684 of 1199 patients (57%) had elevated cTnT and higher cTnT also related to mortality (HR=2.43 (1.71-3.44), p<0.0001). cTnT related principally to 1-year mortality which was 0.6%, 1.7%, 4.3% and 8.6% with cTnT levels <0.01, 0.01-0.03, 0.04-0.1, and >0.1, respectively. Of interest, 30% of HR had normal cTnT and 58% had cTnT<0.03 suggesting very low risk. Conversely, 33% of low risk patients had high cTNT. In multivariate analyses 1-year mortality related to cTnT (HR=5.15, p<0.0001) and dialysis>2yrs (HR=3.40, p<0.0001) but not to other HR factors. In contrast, mortality beyond 1st-year related to all HR factors and not to cTnT. We next analyzed mortality in these subgroups, 1) no HR/low cTnT (considered <0.03); 2) no HR/high cTnT; 3) HR/low cTnT; and 4) HR/high cTnT. For example, compared to age<59 years/low cTnT (49%), age>59/high cTnT (13%) had markedly increased mortality throughout the f/u period (HR=7.85, p<0.0001) but age>59/low cTnT (18%) did not (p=0.079). Age<59/high cTnT (20%) had high mortality only during the first year (HR=2.32, p=0.016). Similarly, relative to no HR/low cTnT, mortality was higher throughout the f/u period in HR recipients with high cTnT, including 49% of candidates with CV disease (HR=4.86, p<0.0001); 51% of DM (HR=1.96, p=0.017); and 46% of those dialyzed>2y (HR=4.37, p<0.0001).

Conclusions. Approximately 50% of candidates clinically considered HR have low cTnT and low risk. Conversely, 33% of "low risk" candidates have high cTnT and HR. Candidate's risk stratification is much improved using cTnT and clinical parameters, allowing identification of patients who may benefit from additional cardiac evaluation and perhaps intervention.

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