Detection and Treatment of Coronary Artery Disease in Renal Transplantation Candidates A.J. Ghods and S. Ossareh D URING THE PAST three decades, despite the grad- ual but significant increase in the number of diabet- ics, elderly, and sick patients as renal transplant (Tx) recipients, the mortality rate following renal Tx has mark- edly decreased. Meanwhile, the main cause of death has changed from infection to cardiovascular disease (CVD). According to US Renal Data System, CVD is the most common cause of death in renal Tx recipients. 1 This finding is due to high prevalence of coronary artery disease (CAD) in this population. The risk is significantly higher among diabetic recipients. Reports from European Dialysis and Transplantation Association (EDTA) registry have also repeatedly emphasized the importance of CVD as the leading cause of death in both dialysis patients and renal Tx recipients, the incidence being higher than infectious caus- es. 2 As almost all Tx recipients who die with CVD have a functioning graft, their death not only decreases the rate of patient survival but also graft survival. In a study from Scandinavia, Lindholm et al reported 49% graft loss due to patient death versus 41% due to rejection during the 2- to 5-year follow-up period of 1347 renal Tx recipients. 3 Fifty- three percent of deaths with a functioning graft were due to ischemic heart disease (IHD) and 10% due to other vascu- lar events. Thus, more grafts were lost with patient mortal- ity, secondary to cardiac death than due to graft rejection. So it is expected that in future further advances to increase long-term patient and graft survival rates will be dependent on prevention and treatment of CVD rather than on prevention and treatment of infections or immunosuppres- sive therapies. 4 High prevalence of CAD (40%), left ventricular hyper- trophy (LVH) (75%), and congestive heart failure (CHF) (40%) before Tx is the most important cause of increased cardiovascular mortality in renal Tx recipients. CAD and LVH are precursors of cardiovascular death and CHF is an independent predictor of cardiovascular mortality. 5 The traditional risk factors of CVD, such as hypertension, diabetes, hyperlipidemia, and hyperhomocysteinemia, are also very common before and after renal transplantation. Nonatherosclerotic cardiovascular structural changes spe- cific to renal failure or uremic vasculopathy characterized by reduced capillary density, arteriolar wall thickening, and interstitial fibrosis of the heart has been shown in these patients. 6 The high prevalence of traditional risk factors of CVD not only does not decrease after transplantation but also becomes exacerbated by immunosuppressive drugs, such as cyclosporine, tacrolimus, sirolimus, and steroids. Aker et al compared the potential CVD risk factors 12 months before and 24 months after transplantation in 427 renal Tx recipients. 7 They showed that the prevalence of CVD risk factors is high before and increases significantly after Tx. In about 2 years of posttransplantation follow-up, 50 of their Tx recipients developed atherosclerotic cardio- vascular disease. The CVD risk factors were significantly more common in Tx recipients with atherosclerotic CVD than those without it and the pretransplantation CAD was the most powerful risk factor for posttransplantation car- diovascular mortality in these patients. There are guidelines to show how the screening strategies can be used to exclude patients with significant CAD, LVH, and CHF from transplantation to increase patient and graft survival. Renal transplantation candidates are divided into three groups of high risk, low risk, and intermediate risk. 8 All transplantation candidates with symptoms of CAD, evidence of previous myocardial infarction (MI) or CHF are included in high-risk group and cardiac catheterization should be performed to evaluate the left ventricular systolic function and the presence and significance of CAD. If cardiac catheterization reveals no or limited CAD, renal transplantation could be carried out. If it shows extensive CAD (such as left main CAD or 3-vessel disease), coronary artery bypass graft (CABG) is advised prior to transplanta- tion. If cardiac catheterization shows severely diffuse dis- ease with markedly depressed left ventricular systolic func- tion, the patient is a poor candidate for CABG and will be advised against renal transplantation. Young, nondiabetic patients with no history or symptoms of CAD or CHF and normal electrocardiogram (ECG) will be in the low-risk group and will not require coronary angiography before transplantation. The remaining patients are considered to be in the intermediate-risk group. These are older or From the Transplantation Unit, Hashemi-Nejad Kidney Hospi- tal, Iran University of Medical Sciences, Tehran, Iran. Address reprint requests to A.J. Ghods, Transplantation Unit, Hashemi-Nejad Kidney Hospital, Iran University of Medical Sci- ences, Vanak Square, 19396, Tehran, Iran. © 2002 by Elsevier Science Inc. 0041-1345/02/$–see front matter 655 Avenue of the Americas, New York, NY 10010 PII S0041-1345(02)03158-5 Transplantation Proceedings, 34, 2415–2417 (2002) 2415