Transcript Are Patients at risk of malnutrition being identified in
Cardiovascular Assessment for Renal Transplantation: Are patients being managed appropriately in our hospital?
James Rigby (FY2 Doctor)
M. Gunning, S. Velu, K. Tomlinson
Departments of Cardiology & Renal Medicine, UHNS
Background (1)
Cardiovascular Assessment (1)
Low Risk
– Age <50 yrs – No Diabetes – – No PVD RRT <5 yrs
Medium Risk
– Age >50 yrs – Diabetes – IHD/CCF – PVD/CVD – RRT >5 yrs – BMI 30-35
High Risk
– Angina – Previous MI – Mod/Sev LV Impairment – Previous PCI/CABG
‘West Midlands Renal Network CV Assessment Guidelines’
Background (2)
Cardiovascular Assessment (2) MEDIUM RISK HIGH RISK LOW RISK CXR ECG ECHO
Abnormal
CXR ECG ECHO MIBI
Abnormal
CXR ECG ECHO CARDIAC CATHETER
Normal Normal Normal Abnormal
List for Transplant: ECG yearly, other tests 3-5 year intervals Revascularisation LVH on ECHO counts as Normal
‘West Midlands Renal Network CV Assessment Guidelines’
Background (3)
The Ideal CV management pathway: LOW RISK MEDIUM RISK HIGH RISK TRANSPLANT
No MACE
END TESTS Medical Tx TRANSPLANT
No MACE
Revascularisation END
•
Aims
Determine the effectiveness of current CV risk assessment used at UHNS • Establish if patients are investigated as recommended by the ‘West Midlands Renal Network CV Assessment Guidelines’ • Ascertain whether patients are attending the cardio renal clinic pre- or post-transplantation and assess if this impacts on MACE • Establish if re-vascularisation pre-transplantation impacts on MACE
Subjects & Methods
• Cardio-renal clinic started in 2003 by Dr. Mark Gunning • 116 patients had received renal transplant & contact with Cardiology dept. January 2003-June 2010 • 75 patients had Echo reviewed in Cardiology dept. (Low Risk...not seen in CR clinic) • 41 patients – Cardio-renal clinic with cardiac problem – 14 female (34%) and 27 male (66%) – Median age 51 yrs (Range 24-71) – Average time interval between transplantation and data collection = 3.25 yrs
Results (1)
Cardio-Renal Clinic attendance
• 28 patients (68%) seen in cardiology clinic pre transplantation –
All patients reviewed in the cardio-renal clinic were free of peri-transplant MACE
• 13 patients (32%) seen in cardiology clinic post transplantation
Results (2)
MACE = Cardiac Death & MI
MACE = 10% (4/41 patients) for patients seen in C-R clinic....see below:
• 3 patients (7.5%) ACS; – 2 patients STEMI, 1 patient NSTEMI • 1 patient (2.5%) Cardiac Death; – Cardiac Arrest • Average time interval between transplantation and MACE = 17 months
Results (3)
Revascularisation pre-transplant & MACE
6 patients (15%) had pre-transplantation revascularisation: –
None experienced MACE peri-transplantation
– Of these...2 patients had MACE post transplantation; • Cardiac Arrest • STEMI
Results (4a)
Clinical Timeline of events for MACE Patients (n = 4)
Patient A: 50 yrs, Male, Moderate CV Risk
Transplant Peri-op NSTEMI Cardio-renal clinic 12/2008 (early) 01/2009 Angio + Stent (single vessel) (end) 01/2009
Patient B: 49 yrs, Male, High CV Risk
STEMI & Angioplasty 10/2006 Cardio-renal clinic 01/2007 Angio + Stent (two vessels) Transplant 02/2007 02/2010
Results (4b)
Clinical Timeline of events for MACE Patients (n = 4)
Patient C: 54 yrs, Male, Moderate CV Risk
Cardio-renal clinic Transplant STEMI & Angio (3 vessels) 01/2003 12/2003 05/2007 CABG 10/2007
Patient D: 51 yrs, Male, High CV Risk
Cardio-renal clinic Angio (3 vessels) Angio + Stent (x2) Transplant Cardiac Arrest peri-op Ortho Surg. 2005 08/2005 12/2005 01/2006 04/2008 06/2008
Results (5)
Low Risk Patients not seen in cardiology clinic
• Subjects: 40 patients (53%) male, 35 patients (47%) female • Low risk patients not seen in CR clinic (Echocardiogram only): –
No MACE
Conclusions
• • Management of CAD prior to transplantation is contentious All patients reviewed in the C-R clinic were free of peri transplant MACE • • Low % MACE (C-R clinic 10%, Cardiology Dept 3.4%) Pre-transplantation revascularisation → No peri-transplant MACE • • ‘Low Risk’ patients (Ix in cardiology dept, not seen in C-R clinic) are being managed appropriately...No MACE Specialised C-R clinic at our hospital → effective management of CV risk in renal transplant patients