Coronary Angiography Before and After Renal Transplantation

Cardiovascular diseases are the leading cause of morbidity and mortality in both dialysis dependent patients and those either waiting for or following up after renal transplantation. Concerns about the risk of contrast-induced acute kidney injury (CI-AKI) associated with coronary angiography in patients with stage 4 or 5 chronic kidney disease (CKD) have sometimes resulted in coronary angiography being delayed until after transplantation. Pretransplant cardiovascular disease is a well established risk factor for post transplant cardiovascular disease and cardiovascular mortality. In addition, post transplant dyslipidemia, 1-3 hypertension, 4-7 allograft dysfunction, delayed or slow graft function8 and post transplant erythrocytosis 9, 10 are some of the more specific factors that increase cardiovascular risk in renal transplant recipients as compared to the general population. Prompt diagnosis and treatment of cardiovascular disease in CKD and end stage renal disease population prior to transplant is aimed to reduce cardiovascular morbidity and mortality in the perioperative period and beyond. Several studies have demonstrated that left ventricular function and hypertrophy improve after renal transplantation. Ferreira et al prospectively studied 24 patients with end stage renal disease and demonstrated a significant decrease in hypertension, reduction in left ventricular hypertrophy and dilation, and improvement in systolic function after successful renal transplantation.11 Wali et al followed up 103 renal patients with left ventricular ejection fraction less than 40% with radionuclide ventriculography and renal transplantation and found the mean left ventricular ejection fraction increased from 31.6% to 52.2% at 12 months after transplantation. A longer pre-transplantation interval decreased the likelihood of normalization of ejection fraction. New York Heart Association functional status improved significantly concordant with an improvement of ejection fraction. These studies indicate that renal transplantation should not be withheld for patients with severe cardiac dysfunction as both left ventricular function and survival are expected to improve with renal transplantation.12 This chapter will describe the approach to patients with CKD who are being considered for renal transplantation. Careful consideration to the background history, risk of cardiovascular disease, and risk of atherosclerotic events with the transplant operation will be discussed. The risks and benefits of coronary revascularization will be outlined in the