Should all type 1 diabetic patients (T1DM) undergo cardiac angiography for transplant evaluation?

A. Selek, V. Vidyasagar, M. Maha, J. Odorico, A. Djamali, G. Leverson, H. Sollinger, J. Pirsch
UW Madison, Surgery, Wisconsin, USA

Objectives: Cardiovascular disease is the leading cause of death after transplantation. Optimal work-up remains controversial. Since 2005, we have performed cardiac catheterization for all T1DM patients ≥35y unless deferred by the selection committee. Here, we ask: is pre-transplant cardiac stress testing predictive of cardiac outcome and are cardiac angiography findings associated with post-transplant graft/patient survival?

Methods: We conducted a retrospective analysis of 174 T1DM patients (mean age 41.8y) with no known coronary artery disease who received kidney-pancreas (SPK, n=150) or kidney transplant alone (n=24). Of these, 85 patients (75 SPK, 10 kidney alone) had at least one stress test (stress echo, exercise or pharmacological nuclear) followed by cardiac catheterization. We reviewed performance measures for various stress tests (sensitivity, specificity, PPV, NPV). Transplant outcomes were measured based on coronary angiography findings (≥70% occlusive disease) by Kaplan Meier analysis.

Results: Stress testing has poor sensitivity for all recipients but has a high NPV (table).

Patient survival was comparable between all T1DM and SPK recipients. Overall, patient/graft survival is better in patients who had cardiac catheterization although this was not statistically significant. Patients who did not undergo pre-transplant coronary angiography experienced the highest rate of mortality in the first year of transplantation.

Conclusion: Stress testing has low sensitivity and PPV, making it a poor screening test. Therefore, we recommend pre-transplant evaluation by coronary angiography to improve the mortality post transplantation in T1DM patients.