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Canadian Society of Transplantation consensus guidelines on eligibility for kidney transplantation, continued

Canadian Society of Transplantation consensus guidelines on eligibility for kidney transplantation, continued
Cardiac disease
Recommendations
1. All patients should be assessed for the presence of IHD before kidney transplantation. The minimum required investigations include history, physical examination, ECG, and a chest radiograph (Grade A).
2. Further testing for IHD depends on the pretest probability of CAD. The following patients should have further noninvasive testing:
I. Symptomatic patients or patients with a prior history of CAD including
  • Previous history of myocardial infarction (Grade A)
  • Symptoms of angina (Grade A)
  • Signs or symptoms of heart failure (Grade A)
II. Asymptomatic patients with
  • Diabetes (type 1 or type 2) (Grade B)
  • Multiple risk factors for CAD (three or more) (Grade B)
    • Age >50 years
    • Prolonged duration of chronic kidney disease
    • Family history of CAD (first-degree relative)
    • Significant smoking history
    • Dyslipidemia (high-density lipoprotein level <0.9 mmol/L or total cholesterol >5.2 mmol/L), BMI ≥30 kg/m2
    • History of hypertension
3. All patients with a positive noninvasive test should be assessed by a cardiologist with a view to undergoing angiography (Grade B).
4. Very high-risk patients should be considered for angiography even with a negative noninvasive test (Grade C).
5. Patients with IHD should be eligible for kidney transplantation if they fall into one of the following categories:
  • Low-risk asymptomatic patients (Grade A)
  • Asymptomatic patients with negative noninvasive testing (Grade B)
  • Patients who have undergone successful intervention (Grade B)
  • Patients who on angiography have noncritical disease and are on appropriate medical therapy (Grade C)
6. Kidney transplantation is contraindicated in patients with IHD in the following situations:
  • Patients with progressive symptoms of angina (Grade A)
  • Patients with a myocardial infarction within six months (Grade A)
  • Patients without an appropriate cardiac work-up (Grade C)
  • Patients with severe diffuse disease, especially with positive noninvasive tests in whom intervention is not possible and in whom expected survival is sufficiently compromised so that transplantation is not reasonable (Grade C)
7. Patients with IHD should be reevaluated on a regular basis.
  • Reevaluation should include history, physical examination, ECG, and noninvasive testing (Grade C)
  • Reevaluation should occur any time a patient becomes symptomatic (Grade A)
  • Reevaluation should occur annually in all patients who are at high risk (see previous recommendation for high-risk groups) (Grade C)
  • A repeat angiogram may be considered in patients with known IHD before transplantation if waiting time has been prolonged and it is known that a transplant is likely within the next year (Grade C)
  • All high-risk patients on the waiting list should be treated aggressively with risk-factor reduction strategies (Grade A)
8. LV dysfunction is not necessarily a contraindication to kidney transplantation. LV function should be evaluated in all patients being assessed for transplantation with history, physical examination, ECG, and chest radiography (Grade A). An echocardiogram should be performed in patients with evidence of LV dysfunction (Grade B) or in patients at high risk for LV dysfunction (patients with diabetes, CAD, longstanding hypertension, longstanding kidney disease, or known valvular heart disease) (Grade C).
9. Uremic LV dysfunction may improve after transplantation; thus, it is not necessarily a contraindication to waitlisting (Grade B).
10. Patients with severe irreversible (nonuremic) cardiac dysfunction should not be listed for kidney transplantation alone. Selected patients may be candidates for combined heart-kidney transplants (Grade C).
11. Children with evidence of cardiomyopathy on echocardiography or with congenital heart disease should be evaluated for transplantation in consultation with a pediatric cardiologist (Grade C).
12. All patients should be monitored for aortic stenosis by history, physical examination, and echocardiogram where clinical suspicion is high (Grade C).
13. Patients with aortic stenosis should have regular follow-up echocardiograms, and consideration should be given to early surgical intervention as the disease is accelerated in renal failure (Grade C).
The strength of evidence supporting each recommendation was graded using the system developed by the Canadian Task Force on Preventive Health Care as follows:
  • Grade A - There is good evidence to support
  • Grade B - There is fair evidence to support
  • Grade C - The existing evidence is conflicting, but other factors may influence decision making
  • Grade D - There is fair evidence to recommend against
  • Grade E - There is good evidence to recommend against
IHD: ischemic heart disease; ECG: electrocardiogram; CAD: coronary artery disease; BMI: body mass index; LV: left ventricular.
Reproduced with permission from: Knoll G, Cockfield S, Blydt-Hansen T, et al. Canadian Society of Transplantation: Consensus guidelines on eligibility for kidney transplantation. CMAJ 2005; 173:S1. Copyright © 2005 CMA Media Inc.
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