Cardiac evaluation before kidney transplantation: a practice patterns analysis in Medicare-insured dialysis patients.
OBJECTIVE
Evaluation for ischemic heart disease (IHD) is a nonstandardized practice before kidney transplantation. We retrospectively studied pretransplant cardiac evaluation (CE) practices in a national sample of renal allograft recipients.


METHODS
The USRDS data for Medicare beneficiaries transplanted in 1991 to 2004 with Part A&B benefits from dialysis initiation through transplantation were examined. Clinical traits defining "high" expected IHD risk were defined as diabetes, prior IHD, or > or = 2 other coronary risk factors. Pretransplant CE were identified by billing claims for noninvasive stress tests and angiography. Patients were quantified with claims for coronary revascularization procedures between CE and transplant. Post-transplant acute myocardial infarction (AMI) events were abstracted from claims and death records.


RESULTS
Among 27,786 eligible patients, 46.3% underwent CE before transplantation. Overall, 9.5% who received CE also received pretransplant revascularization, but only 0.3% of lower-risk patients undergoing CE had revascularization. The adjusted odds of transplant without CE increased sharply with younger age and shorter dialysis duration. Increased likelihood of transplant without CE also correlated with black race, female sex, and certain geographic regions. Among patients transplanted without CE, 3-yr incidence of post-transplant AMI was 3% in lower-risk and 10% in high-risk groups, and varied by individual traits within these groups. Among lower-risk patients transplanted without CE, blacks were higher risk for AMI than whites (adjusted hazards ratio 1.47, 95% CI 1.11-1.93).


CONCLUSIONS
Observed practices demonstrate infrequent use of pretransplant revascularization after CE but also raise concern for socio-demographic barriers to evaluation access.
Lentine
Krista L
KL
St. Louis University Center for Outcomes Research, Salus Center, 2nd Floor, 3545 Lafayette Avenue, St. Louis, MO 63104, USA. lentine.krista@stanfordalumni.org
Schnitzler
Mark A
MA
Brennan
Daniel C
DC
Snyder
Jon J
JJ
Hauptman
Paul J
PJ
Abbott
Kevin C
KC
Axelrod
David
D
Salvalaggio
Paolo R
PR
Kasiske
Bertram
B
D000328:Adult; D001741:Black or African American; D019985:Benchmarking; D017023:Coronary Angiography / Q000706:statistics & numerical data; D005080:Exercise Test / Q000706:statistics & numerical data; D005260:Female; D006297:Health Services Accessibility; D054625:Healthcare Disparities; D006801:Humans; D007676:Kidney Failure, Chronic / Q000150:complications / Q000601:surgery / Q000628:therapy*; D016030:Kidney Transplantation / Q000009:adverse effects; D008297:Male; D006278:Medicare / Q000706:statistics & numerical data; D008875:Middle Aged; D009203:Myocardial Infarction / Q000209:etiology / Q000517:prevention & control; D017202:Myocardial Ischemia / Q000150:complications / Q000175:diagnosis* / Q000601:surgery; D009204:Myocardial Revascularization; D016017:Odds Ratio; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data; D006435:Renal Dialysis; D012111:Residence Characteristics; D012189:Retrospective Studies; D018570:Risk Assessment; D012737:Sex Factors; D013997:Time Factors; D014481:United States