Multidisciplinary perspectives on cardiac assessment before kidney transplantation: Results from a UK survey.

Screening patients for asymptomatic coronary artery disease prior to kidney transplantation is frequently performed, despite an absence of contemporary randomized controlled trial evidence to support this practice and a lack of clarity regarding how it determines patients’ cardiac risk. Analysis of observational data does not support routine screening,1 and coronary revascularization does not improve outcomes in transplant-listed patients with underlying coronary artery disease,2 as in the general population. Cardiac assessment pathways vary across the United Kingdom,3 but it is not known how these practices are viewed by the transplant multidisciplinary team. To explore this, an online survey was distributed to nephrologists, transplant surgeons, anesthetists, and cardiologists in the United Kingdom between April and July 2023. Study data were collected and managed using REDCap electronic data capture tools hosted at the University of Bristol4 and distributed via the lead transplant nephrologist from each kidney transplant center, Kidney Research UK Transplant and Cardio-Renal Clinical Study Groups, and the British Association for Renal Transplant Anesthesia. Completion of the survey was voluntary, and respondents were not paid or given gifts for participating. Consent was implied by survey completion. Ethical approval was not deemed necessary as the project was classed as a service evaluation of existing practice, participation was voluntary, and no patient-identifiable information was collected. Questions explored the minimum cardiac workup required before transplant listing, means of risk stratification that dictated investigation options, and what further investigation or management should entail (surveys included in Supplementary Material). Two survey rounds were distributed 8 weeks apart to explore if consensus on these matters could be achieved; consensus was defined as over 70% of respondents agreeing/strongly agreeing or disagreeing/strongly disagreeing with statements as has been adopted previously.5 Responses were received from 104 individuals in the first survey round (51 nephrologists, 23 anesthetists, 15 surgeons, 15 cardiologists), and 69 in the second round (35 nephrologists, 15 anesthetists, 8 surgeons, 11 cardiologists). Respondents were from all four nations of the United Kingdom and 55% had over 10 years of experience in their current role. As the survey was distributed through open contact lists an exact response rate could not be ascertained, however, responses were received from one or more clinicians from 21 of the 23 transplant centers in the United Kingdom. Of those completing the first survey round, 50% felt an echocardiogram should be performed as a minimum for patients being assessed for transplant, but this varied by specialty ranging from 23% of anesthetists to 87% of cardiologists. There was consensus that further cardiac investigation beyond an electrocardiogram (ECG) and echocardiogram was not required for patients under 60 years of age without additional cardiovascular risk factors (agreement in 82% of respondents) but was necessitated for patients with diabetes (agreement in 72%) or a history of cardiovascular disease (agreement in 89%). There was no consensus on whether patients aged over 60 years or with reduced exercise capacity required further assessment. Individuals were more likely to recommend further investigation for patients with raised body mass index, smoking history, or longer duration of kidney failure if these were present in combination with other risk factors (Figure 1). With respect to components of the cardiac assessment process, there was consensus that patients should be maintained on optimal medical therapy prior to transplantation (agreement in 97%) and that routine coronary angiography was not required (agreement in 75%). There was no consensus on whether workup should involve non-invasive cardiac investigations beyond an ECG or echocardiogram, or whether patients should be reviewed by a cardiologist or anesthetist. Despite the importance of medical management of cardiovascular disease, 34% reported that medications were not routinely reviewed at their transplant listing meetings. Peri-operative management of patients deemed to be at increased cardiovascular risk differed from the standard approach in 46% of respondents’ centers. These differences included which patients required: increased intra-operative invasive monitoring; post-operative care in a high dependency or intensive care environment; earlier intervention on post-operative hypotension; and selection of kidneys predicted to have a low risk of delayed graft function or consideration of live donor transplantation only. Two-thirds of respondents felt that cardiac assessment should be standardized in the United Kingdom. Only 16% reported that current processes aid equitable access to transplantation for patients, and only 30% felt they aid equitable use of the donor pool by identifying patients at high risk of early cardiovascular events. Free text questions explored opinions in relation to current cardiac assessment pathways, and whether these influence equity of access to transplantation (Table 1). Several themes emerged from these responses, demonstrating differing views on who should take ownership for assessing cardiac risk, which patients require a more thorough assessment, and how to balance the risks and benefits of cardiac investigations (e.g., imposing delays to transplant listing against the potential for increased peri-transplant morbidity and mortality if these were to be minimized). This survey highlights variations in opinion within the transplant multiprofessional team regarding which patients should undergo detailed cardiac assessment before transplant listing, and what such assessment should involve. Concerns are raised regarding the lack of standardization in practice and the resultant impact this could have on equity of access to transplantation. Further work is required to determine the optimal cardiac assessment pathway and acceptability of this to the multidisciplinary team, which is necessary to enable a standardized approach to pre-transplant cardiac assessment. All authors contributed to the study design and writing of the survey questions. Ailish Nimmo performed the analyses and wrote the letter under the supervision of Rommel Ravanan and Dominic Taylor. All authors contributed to manuscript preparation. We would like to thank the respondents to this survey. The authors declare no conflicts of interest. Funding from the Bristol Health Partners Kidney Disease Health Integration Team was received for the completion of this study. The data that support the findings of this study are available from the corresponding author upon reasonable request. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. 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