Using routine healthcare data to investigate the utility of cardiac screening prior to kidney transplantation

Student thesis: Doctoral ThesisDoctor of Medicine (MD)

Abstract

Introduction
Kidney transplantation is the optimal treatment for most people with end stage kidney disease (ESKD). Before transplantation, patients are thoroughly assessed, which frequently includes investigating for asymptomatic coronary artery disease (CAD) due to the increased risk of major adverse cardiac events (MACE) in the peri-transplant period. However, there is no evidence that screening improves outcomes.

Methods
This thesis investigates:
1. Whether routinely collected healthcare data accurately record ischaemic heart disease diagnoses in patients with ESKD.
2. The incidence, associations, and impact of post-transplant MACE on kidney transplant recipients.
3. Factors associated with screening for CAD disease and whether screening associates with post-transplant MACE.
4. Current CAD screening practice in the UK.
Data from the Access to Transplant and Transplant Outcome Measures study and Hospital Episode Statistics (HES) were used to examine these aims.

Results
Ischaemic heart disease was recorded with a sensitivity and specificity of 82.6% and 93.4% within HES. The incidence of post-transplant MACE was 1.5%, 2.6% and 9.6% at 90-days, 1- and 5-years respectively, and associated with increased age, Asian ethnicity, ischaemic heart disease, diabetes, peripheral vascular disease, and smoking. Non-fatal MACE within 6 months of transplantation associated with reduced patient survival over median 6.7 years follow up. Screening practice varied by centre, ranging from 5-100% of recipients. There was no association between screening and MACE post-transplant. Of 23 transplant centres, 10 had recently updated their screening protocol and 22 reported willingness to participate in a randomised control trial to investigate utility of screening.

Conclusions
HES data has reasonable potential for recording study outcomes. Peri-transplant MACE associates with post-transplant mortality. Identifying ways to minimise this risk is vital, but routine screening for CAD did not reduce MACE in the studied cohort. There is appetite for a randomised control trial amongst nephrologists to give definitive evidence of benefits and harms of screening.
Date of Award21 Jun 2022
Original languageEnglish
Awarding Institution
  • University of Bristol
SupervisorDominic M Taylor (Supervisor), Rommel Ravanan (Supervisor) & Simon C Satchell (Supervisor)

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