Survey reveals ‘knowledge gaps’ in coronary artery disease screening pre-kidney transplant
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A survey of transplant surgeons and nephrologists practicing in the United States revealed discrepancies in the way coronary artery disease screening is carried out for asymptomatic kidney transplant candidates.
“There is no standard practice for coronary artery disease (CAD) screening of asymptomatic patients prior to kidney transplant,” Xingxing S. Cheng, MD, MS, of Stanford University School of Medicine, and colleagues wrote.
According to the researchers, the last survey investigating pre-transplant cardiac screening among American transplant programs occurred more than 15 years ago.
Therefore, to examine contemporary screening practices, Cheng and colleagues administered a web-based survey to American Society of Transplant Kidney-Pancreas Community of Practice Cardiovascular Disease Workgroup members (71% were transplant nephrologists; 12% were transplant surgeons; 53% practiced at centers performing >100 transplants per year). Researchers noted that all 11 United Network of Organ Sharing regions were represented.
Responses indicated the most commonly followed guideline was the 2012 American Heart Association/American College of Cardiology Foundation Scientific Statement (42%), while 29% of those who selected following “other” guidelines suggested “no particular protocol existed.” Most respondents preferred non-invasive testing for their patients (91% for those not on dialysis; 74% for those receiving the treatment), with myocardial perfusion scintigraphy and dobutamine stress echocardiogram being the two most popular non-invasive testing modalities.
Researchers also provided respondents with various case scenarios regarding asymptomatic patients with no risk factors other than age, finding 61% to 68% of respondents preferred aggressive evaluation or revascularization in the case of a mildly “positive” stress test, and 85% did not monitor asymptomatic patients for ischemia after kidney transplant.
Free-text responses regarding perceived barriers to CAD screening in this patient population demonstrated transplant surgeons and nephrologists feel there is a lack of clarity about the goal of screening. In addition, respondents indicated there are challenges in clinical decision-making (related to population characteristics, diagnostic test performance and limited evidence), as well as a concern about contrast-induced nephropathy.
Health system factors also played a role, with respondents identifying challenges due to fragmentation in the health care system (and lack of access), variability at both the program and provider levels and restraints from regulatory bodies like CMS.
According to the researchers, it is “striking” that health care system factors were more discussed than medical factors, with the concerns emphasizing “the importance of incorporating systems-based practice into designing and testing interventions, and of expanding the community beyond transplant providers into cardiologists, policymakers and administrators.”
Further, they wrote, “we conclude that current practice in United States favors aggressive CAD detection before but not after kidney transplant. This practice is incongruous with the epidemiology of CAD in kidney failure and reflects confusion regarding the ultimate objective of pre-transplant cardiovascular testing.”
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