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This is an open access article distributed under the terms of the Creative Commons Attribution License http: This article has been cited by other articles in PMC. Abstract Cardiovascular disease remains the most important cause of morbidity and mortality among kidney transplant recipients.
The ideal strategies to screen for coronary artery disease CAD in chronic kidney disease patients who are evaluated for kidney transplantation KT remain controversial.
Despite these recommendations, vast variations exist in the way these patients are screened for CAD at different transplant centers. The sensitivity and specificity of noninvasive cardiac tests in CKD patients is much lower than that in the general population.
This has prompted the use of direct diagnostic cardiac catheterization in high-risk patients in several transplant centers despite the risks associated with this invasive procedure. No large randomized controlled trials exist to date that address these issues. In this article, we review the existing literature with regards to the available data on cardiovascular risk screening and management options in CKD patients presenting for kidney transplantation and outline a strategy for approach to these patients.
Chronic kidney disease, kidney transplantation, renal transplantation, coronary artery disease, risk stratification, stress echocardiography, dobutamine echocardiography, coronary angiography, myocardial perfusion imaging.
Over half of these patients die with a functioning allograft, resulting in inefficient use of this scarce resource.
Therefore, aggressive CV risk screening and management before KT has become a priority. Though the overall survival is increased by KT, there is an initial increase in mortality, soon after KT, and the actual survival benefit of KT occurs beyond days of transplantation [ 3 ].
Hence, it is obvious that patients should survive beyond this period in order to be benefited from this whole process.
CV risk screening for KT is unique in that it needs to assess not only the perioperative risk, but also should ideally assess the CV risk beyond that period and into the early years of transplantation for the above mentioned reason.
Many conventional cardiac risk factors such as dyslipidemia, smoking and hypertension are less predictive of CAD in renal failure [ 6 ].
CKD population has additional CV risk related to non traditional factors including microalbuminuria, uremia, hyperuricemia, calcium — phosphorus disorder associated calcification, inflammation and hyperhomocysteinemia. Pre-KT CV risk factors often persist after KT and can worsen in the post transplantation period resulting in accelerated atherosclerosis.
Anti rejection therapy used in the post transplant period such as steroids, calcineurin inhibitors and sirolimus increase the development of or worsening of preexisting hypertension, dyslipidemia, hyperuricemia, weight gain and glucose intolerance.
All these factors make KT candidates a unique population that may require a different CV risk screening strategy as well as management. Severe CAD is common in asymptomatic patients with CKD, likely because of autonomic dysfunction secondary to uremia and diabetes [ 8 ].
A large proportion of these patients lead a sedentary lifestyle as a result of reduced exercise capacity which also contributes to the lack of symptoms.
The reduced exercise capacity is a result of muscle fatigue, anemia and a generalized feeling of being ill after dialysis likely secondary to rapid fluid and electrolyte shifts.In the Code of Practice on Assessment and all Appendices the term Section One Assessment Appeals Annexe 3 Guidelines for Students on Section Two Assessment Degree classification A means of distinguishing between the levels of achievement by different students of the outcomes of.
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