Management of CVD in ESRD Prior to Renal Transplantation: Medical or Revascularization?

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Kamran H, Kupferstein E, Sharma N, Singh G, Sowers JR, Whaley-Connell A, Yacoub M, Marmur JD, Salifu MO, McFarlane SI: Revascularization versus Medical Management of Coronary Artery Disease in Prerenal Transplant Patients: A Meta-Analysis. Cardiorenal Med 2018;8:192–198

The optimal management of ischemic coronary artery disease in patients with end-stage renal disease (ESRD) awaiting renal transplantation remains a conundrum. Avoidance of a cardiovascular (CV) death following renal transplantation with an otherwise successful grafting is a laudable goal. The decision as to whether medical management or a revascularization procedure (such as coronary artery bypass surgery (CABG) or percutaneous angioplasty with stenting) is the optimum choice in patients with ESRD awaiting renal transplantation is still controversial area. An individualized (personalized) approach is probably best, but such guidance is often clouded by numerous variables.

Karman and colleagues attempted to illuminate this arena of uncertainty by conducting a systemic review and meta-analysis of 6 studies involving 598 patients in which outcomes following transplantation could be compared between medical management alone and coronary revascularization (not specified as to surgical or angioplasty). Only 5 of the 6 studies selected contained post-transplant outcomes. The hazard rate for the primary composite outcome of major cardiovascular event (including death) were not different for medical management versus revascularization (HR= 1.42; 95% CI= 0.89–0.26) but the heterogeneity of the included studies was high (see Figure 1). Due to the small number of subjects the analysis could not be stratified for the degrees of coronary artery disease (number of vessels involved), the presence or absence of diabetes, the compliance to medical management, or the type of revascularization. These are significant limitations of the analysis.

Figure 1: Forrest plot showing odds of having cardiovascular mortality among patients with coronary artery disease receiving standard medical therapy (MM) versus revascularization (REV), post renal transplantation. (From Cardiorenal Med 2018;8:192–198)

Nevertheless, this study suggests that medical management alone does not confer a great disadvantage compared to revascularization for the post-transplant course of patient with ESRD. Clearly, additional large prospective trials are needed to clarify the optimum management strategy in patients with ESRD and overt coronary artery disease.

Richard Glassock

Quoted Karger Article

Revascularization versus Medical Management of Coronary Artery Disease in Prerenal Transplant Patients: A Meta-Analysis