Manchester Institute of Nephrology & Transplantation, Manchester, United Kingdom.
Centre for Biostatistics, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom.
PLoS One. 2020 Oct 28;15(10):e0240912. doi: 10.1371/journal.pone.0240912. eCollection 2020.
Screening with cardiac non-invasive stress studies (NISS) prior to listing for kidney transplantation can help in identifying treatable coronary disease and is considered an integral part of pre-kidney transplant evaluation. However, few studies assessed their effectiveness in all patients evaluated for transplantation in clinical practice. To evaluate the role of NISS in pre-kidney transplant evaluation we analyzed their impact prior to waitlisting in 1053 adult CKD-5 patients consecutively evaluated in Greater Manchester, UK during a 6-year period.
918 waitlisted patients were grouped based on presence or absence of Diabetes or Cardio-Vascular Disease (CVD): Group-1 (255 DM-/CVD-/NISS-), Group-2 (368 DM-/CVD-/NISS+) and Group-3 (295 with DM or CVD).
Group-2 patients had longer 'time-to-listing' (5.5months in Group-1 vs 6.9months in 'Normal-NISS' vs 9.9months in 'Abnormal-NISS', p<0.01) but none with 'Abnormal-NISS' needed coronary revascularization before listing. NISS was followed by revascularization in 8 Group-3 patients (3%). In multi-variate analyses, there was no association of NISS on death or MACE in listed patients. During follow up, Transplantation was the most significant factor associated with improved outcomes in all subgroups (HR:0.97, p<0.001). 135 patients were considered unsuitable for waitlisting, with NISS influencing management in 11 of these patients (8%).
Pre-kidney transplant evaluation with NISS influenced clinical management in 19 of 1053 (2%) patients. Screening with NISS added limited benefit but contributes to significant delays in listing and adding resource implications. Further studies are needed to assess clinical and cost effectiveness of NISS in pretransplant evaluation to optimize outcomes and resources.
在进行肾脏移植之前，通过心脏非侵入性应激研究（NISS）进行筛查可以帮助识别可治疗的冠心病，并且被认为是肾脏移植前评估的一个组成部分。然而，很少有研究评估其在临床实践中所有接受移植评估的患者中的有效性。为了评估 NISS 在肾脏移植前评估中的作用，我们分析了在英国大曼彻斯特地区连续评估的 1053 名 CKD-5 成年患者在等待名单前进行 NISS 的影响。
根据是否存在糖尿病或心血管疾病（CVD），将 918 名等待名单上的患者分为三组：组 1（255 名无糖尿病且无 CVD 且无 NISS 异常）、组 2（368 名无糖尿病且无 CVD 且有 NISS 异常）和组 3（295 名有糖尿病或 CVD）。
组 2 患者的“等待时间”更长（组 1 为 5.5 个月，“正常 NISS”为 6.9 个月，“异常 NISS”为 9.9 个月，p<0.01），但没有“异常 NISS”的患者需要在等待名单前进行冠状动脉血运重建。8 名组 3 患者（3%）在进行 NISS 后进行了血运重建。多变量分析显示，在列入名单的患者中，NISS 与死亡或主要不良心血管事件（MACE）之间没有关联。在随访期间，移植是所有亚组中与改善结局最相关的因素（HR：0.97，p<0.001）。135 名患者被认为不适合等待名单，其中 NISS 影响了 11 名患者（8%）的治疗。
在 1053 名患者中的 19 名（2%）患者中，肾脏移植前评估中使用 NISS 影响了临床管理。NISS 筛查的获益有限，但导致了列表的显著延迟，并增加了资源影响。需要进一步研究来评估 NISS 在移植前评估中的临床和成本效益，以优化结果和资源。
