Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California.
Department of Statistics, Stanford University, Stanford, California.
JAMA Intern Med. 2023 Feb 1;183(2):134-141. doi: 10.1001/jamainternmed.2022.6069.
Testing for coronary heart disease (CHD) in asymptomatic kidney transplant candidates before transplant is widespread and endorsed by various professional societies, but its association with perioperative outcomes is unclear.
To estimate the association of pretransplant CHD testing with rates of death and myocardial infarction (MI).
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study included all adult, first-time kidney transplant recipients from January 2000 through December 2014 in the US Renal Data System with at least 1 year of Medicare enrollment before and after transplant. An instrumental variable (IV) analysis was used, with the program-level CHD testing rate in the year of the transplant as the IV. Analyses were stratified by study period, as the rate of CHD testing varied over time. A combination of US Renal Data System variables and Medicare claims was used to ascertain exposure, IV, covariates, and outcomes.
Receipt of nonurgent invasive or noninvasive CHD testing during the 12 months preceding kidney transplant.
The primary outcome was a composite of death or acute MI within 30 days of after kidney transplant.
The cohort comprised 79 334 adult, first-time kidney transplant recipients (30 147 women [38%]; 25 387 [21%] Black and 48 394 [61%] White individuals; mean [SD] age of 56 [14] years during 2012 to 2014). The primary outcome occurred in 4604 patients (244 [5.3%]; 120 [2.6%] death, 134 [2.9%] acute MI). During the most recent study period (2012-2014), the CHD testing rate was 56% in patients in the most test-intensive transplant programs (fifth IV quintile) and 24% in patients at the least test-intensive transplant program (first IV quintile, P < .001); this pattern was similar across other study periods. In the main IV analysis, compared with no testing, CHD testing was not associated with a change in the rate of primary outcome (rate difference, 1.9%; 95% CI, 0%-3.5%). The results were similar across study periods, except for 2000 to 2003, during which CHD testing was associated with a higher event rate (rate difference, 6.8%; 95% CI, 1.8%-12.0%).
The results of this cohort study suggest that pretransplant CHD testing was not associated with a reduction in early posttransplant death or acute MI. The study findings potentially challenge the ubiquity of CHD testing before kidney transplant and should be confirmed in interventional studies.
在移植前对无症状的肾移植候选者进行冠心病（CHD）检测在各种专业协会中得到广泛认可和支持，但它与围手术期结果的关系尚不清楚。
评估移植前 CHD 检测与死亡率和心肌梗死（MI）发生率的关系。
设计、设置和参与者：这是一项回顾性队列研究，纳入了美国肾脏数据系统中 2000 年 1 月至 2014 年 12 月期间首次接受肾移植的所有成年患者，且在移植前后至少有 1 年的医疗保险登记。采用工具变量（IV）分析，以移植年份的 CHD 检测率作为 IV。根据研究期间进行分层，因为 CHD 检测率随时间而变化。使用美国肾脏数据系统变量和医疗保险索赔来确定暴露、IV、协变量和结局。
在肾移植前 12 个月内接受非紧急侵入性或非侵入性 CHD 检测。
主要结局是肾移植后 30 天内死亡或急性 MI 的复合结局。
该队列包括 79334 名首次接受肾移植的成年患者（30147 名女性[38%]；25387 名黑人[21%]和 48394 名白人[61%]；2012 年至 2014 年期间的平均[SD]年龄为 56[14]岁）。4604 名患者（244 名[5.3%]；120 名[2.6%]死亡，134 名[2.9%]急性 MI）发生了主要结局。在最近的研究期间（2012-2014 年），在检测最密集的移植项目中（第五个 IV 五分位数），CHD 检测率为 56%，而在检测最少的移植项目中（第一个 IV 五分位数），检测率为 24%（P<0.001）；在其他研究期间也存在类似的模式。在主要的 IV 分析中，与未检测相比，CHD 检测与主要结局发生率的变化无关（发生率差异，1.9%；95%CI，0%-3.5%）。除了 2000 年至 2003 年，结果在各个研究期间均相似，在此期间，CHD 检测与更高的事件发生率相关（发生率差异，6.8%；95%CI，1.8%-12.0%）。
这项队列研究的结果表明，移植前 CHD 检测与移植后早期死亡或急性 MI 的减少无关。研究结果可能对肾移植前 CHD 检测的普遍性提出了挑战，应该在干预性研究中得到证实。
