1. Cardiac Disease Evaluation Among Kidney
Transplantation Candidates
ROYA ISA TAFRESHI, PEDIATRIC CARDIOLOGIST ,
IRAN UNIVERSITY OF MEDICAL SCIENCES
ALI-ASGHAR CHILDREN’S HOSPITAL
A BAN, 1 4 0 0
2. Pre -transplantation evaluation
▪Kidney transplantation is the treatment of choice for most patients with
ESRD.
▪Patients often have significant comorbidities.
▪comorbidity may affect perioperative risk, survival, transplant candidacy.
▪ The evaluation should be as efficient and cost effective as possible.
▪The purpose of pre- transplantation assessment is :
to detect and treat coexisting illnesses,
to detect who are at risk for having a peri-operative or post-operative
event.
3. Cardiovascular disease (CVD)
▪CKD is an important risk factor for CVD
▪CVD is the leading cause of death in both children with ESRD and in adults with childhood onset
of CKD, and following renal transplantation.(peri-operative cardiac mortality of ∼1.1% )
▪Cardiovascular death rates are similar in children on peritoneal dialysis and hemodialysis,
whereas transplant recipients have a relatively lower risk of cardiac death.
▪High prevalence of traditional and uremia-related CVD risk factors for developing cardiovascular
disease and accelerated atherosclerosis.
1. Traditional risk factors : obesity, hyperglycemia, Dyslipidemia, and hypertension.
2. Donor- recipient size mismatch: graft hypoperfusion and delayed graft function and
increased cardiac load.
▪Decreased renal function in transplant recipients is a major contributor to increased cardiac risk,(its negative
effects on hypertension, anemia, left ventricular hypertrophy, and dyslipidemia).
4. CVD risk factors
▪Traditional risk factors for accelerated atherosclerosis :obesity, hyperglycemia, Dyslipidemia
, and hypertension
▪Uremia related risk factors: uremia , oxidative stress ,abnormal mineral metabolism, graft failure,
anemia, increased fibroblast growth factor, chronic inflammation ,… lead to:
▪Early cardiovascular abnormalities in children with CKD:
▪Left ventricular hypertrophy,
▪ LV dysfunction,
▪ damage to the large arteries,( stiffness and increased intima-medial thickness (IMT) of the carotids),
▪coronary calcifications.
▪These markers are strong predictors of cardiac morbidity and mortality.
5. In advanced CKD, the myocardium is exposed to complex metabolic stressors :
1.uremia-related inflammation,2. oxidative stress, 3.renin-angiotensin-
aldosterone system activation,4. calcitriol and klotho deficiency,5. (FGF) 23,
6.changes in mineral metabolism.
This exposure leads to myocyte hypertrophy, reduced myocardial capillarization,
and nonvascularized interstitial fibrosis as well as arteriosclerosis and arterial
stiffening.
These ultrastructural changes reduce pump efficiency and increase cardiac
energy expenditure and myocardial oxygen consumption.
6. CVD in children with CKD
➢LVH is the Most Common Cardiac Abnormality in Children with CKD. LVH: LV mass> 51gr/ M 2.7
➢Children on Maintenance Dialysis Are at Highest Risk for LV Dysfunction.
➢Arterial Abnormalities Develop during Early CKD.
➢Coronary Artery Calcification Is Frequent in Children on Maintenance Dialysis.
▪Long -term dialysis is a major factor associated with poor outcomes in children with ESRD.
▪primary management strategies in childhood CKD/ESRD is the avoidance of long-term dialysis.
7. Leading cause of Cardiovascular mortality
▪Adult: coronary artery disease (CAD) and cardiomyopathy-
associated congestive heart failure are the leading causes of CVD
mortality.
▪Children: cardiac arrest is the most common cause, followed by
arrhythmia, cardiomyopathy.
8. Risk stratification in patients with CVS in non -
cardiac surgery
▪High Risk: new MI, Decompensated HF, AV block , Arrhythmias,
Severe valve D., PH
▪Intermediate Risk: Mild CAD , previous MI, compensated HF,
Diabetes, CKD
▪Low Risk: old age, abnormal ECG/AF, history of stroke,
hypertension
9. Goal of Pre-operative risk assessment : To detect
❑Major clinical risk factors: ( high risk patients for KT)
▪Heart failure
▪Coronary artery disease(CAD)
▪Severe valvular heart D.
▪Severe arrhythmia.
❑Intermediate risk:
▪ Mild angina pectoris (Canadian class I or II)
▪ Previous myocardial infarction by history or pathological Q waves
▪ Compensated or prior heart failure
▪ Kidney transplantation : intermediate risk surgery
▪ Anesthetic factors
10. Preoperative risk assessment(AHA/ACC: 2017)
▪Perioperative Risk Assessment Based on Symptoms and Exercise Tolerance
▪A thorough history and physical examination
▪Cardiac evaluation is recommended in patients without active cardiac conditions when:
▪ Abnormal functional class, Dialysis > one yr., Previous CVS, Hypertension, Traditional risk factors,
▪ Patients who could not walk 4 blocks and climb 2 flights of stairs were considered to have
intermediate risk. : noninvasive stress test , invasive tests,…
11. Preoperative risk assessment(AHA/ACC)
▪A 12-lead ECG is reasonable in potential kidney transplantation candidates without
known cardiovascular disease
▪ Echocardiography : LVH, LV function , pulmonary pressure, valvular disease.
▪pulmonary pressures are associated with adverse outcomes after renal
transplantation
▪PA pressure> 45 mm Hg, mean pulmonary artery pressure ≥25 mm Hg, (high risk
patients)
12. CVD management ( AHA/ACC :2017)
Hypertension, Dyslipidemias, Tobacco Use, and Obesity
HYPERTENSION :
• measuring blood pressure at each clinic visit. (1C)
• maintaining blood pressure at <130 mm Hg systolic and <80 mm Hg diastolic if ≥18 years
of age, and <90th percentile for sex, age, and height if <18 years old. (2C)
• To treat hypertension (Not Graded):
• • use any class of antihypertensive agent;
• • monitor closely for adverse effects and drug–drug interactions; and
• • when urine protein excretion ≥1 g/day for ≥18 years old and ≥600 mg/m2/24 h for <18 years
old, consider an ACE-I or an ARB as first-line therapy.
• In addition, evidence from RCTs in the general population has conclusively shown that reducing blood pressure reduces the
risk of CVD.
13. ▪For those children who are unwilling or unable to receive a kidney transplant, several strategies
should be used to reduce the cardiovascular risks associated with maintenance dialysis.
▪ Aggressive monitoring and management of hypertension, dyslipidemia, mineral metabolism,
anemia, nutrition, and inflammation cannot be overemphasized.
14. Anesthesia
A catabolic state with adaptive responses of tachycardia, hypertension, fluid retention and
hypercoagulability to maintain cardiovascular homeostasis.
The stress response to surgery
activation of the hypothalamic–pituitary–adrenal axis
and sympathetic nervous system.
+ volume depletion, hypothermia or hypoxia
Increased peri-operative mortality and
morbidity in ESRD.
15. conclusion
▪CKD is an important risk factor for CVD
▪Early onset cardiovascular abnormalities in children with CKD.
▪Avoidance of long-term dialysis
▪Kidney transplantation is a intermediate risk surgery
▪ High risk patients: Heart failure, Coronary artery disease, Severe valvular heart D., Severe
arrhythmia.
▪Pre- operative cardiac assessment to detect: : LVH, LV function , pulmonary pressure, valvular
disease.
