Special considerations in patients undergoing renal replacement therapy and kidney transplant patients

Abstract

Cardiovascular disease (CVD) is the leading cause of death in patients with end-stage kidney disease (ESKD) on dialysis, peri-transplant, and after transplantation. The coexistence of traditional cardiovascular risk factors with superimposed renal disease- and transplantation-related risk factors such as uraemia, vascular calcification, inflammation, electrolyte abnormalities, volume shifts, transplant surgery, infections, and immunosuppression makes assessment and treatment more complex when compared with patients without renal disease. For coronary artery disease, evidence suggests less benefit in ESKD and renal transplant patients compared to those with milder renal dysfunction of traditional primary and secondary prevention strategies including angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta blockers, statins, and antiplatelet agents. Prevention of sudden cardiac death is difficult and the use of implantable cardioverter defibrillators in ESKD patients is being investigated. The diagnosis of myocardial ischaemia in patients with ESKD is challenging given the frequent lack of typical symptoms, abnormal baseline electrocardiograms, and the reduced sensitivity of troponin measurements. Screening for CVD in asymptomatic dialysis patients awaiting transplantation is controversial. Non-invasive screening is recommended for those with significant risk factors although the test of choice is unclear. Positive stress-testing is predictive of cardiac events and death and must be investigated with coronary angiography. Once significant coronary artery disease is diagnosed, the optimal choice of revascularization strategy remains unclear. Coronary artery bypass grafting may be superior to angioplasty with stenting in ESKD and transplant patients. Many questions remain unsatisfactorily answered and much research is required to develop optimal strategies to manage CVD in ESKD and kidney transplant patients.