sábado, 3 de enero de 2015

Más de transplante renal/More on kidney transplant

Una llamada de acción. Variabilidad en las guías de valoración cardiaca antes de transplante renal
A call to action: variability in guidelines for cardiac evaluation before renal transplantation.
Friedman SE1, Palac RT, Zlotnick DM, Chobanian MC, Costa SP.
Clin J Am Soc Nephrol. 2011 May;6(5):1185-91. doi: 10.2215/CJN.09391010. Epub 2011 Apr 21.
BACKGROUND AND OBJECTIVES: Candidates for renal transplantation are at increased risk for complications related to cardiovascular disease; however, the optimal strategy to reduce this risk is not clear. The aim of this study was to evaluate the variability among existing guidelines forpreoperative cardiac evaluation of renal transplant candidates. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: A consecutive series of renal transplant candidates (n=204) were identified, and four prominent preoperative cardiac evaluation guidelines, pertaining to this population, were retrospectively applied to determine the rate at which each guideline recommended cardiac stress testing. RESULTS: The rate of pretransplant cardiac stress testing would have ranged from 20 to 100% depending on which guideline was applied. The American Heart Association/American College of Cardiology (ACC/AHA) guideline resulted in the lowest rate of testing (20%). In our population, 178 study subjects underwent stress testing: 17 were found to have ischemia and 10 underwent revascularization. The ACC/AHA approach would have decreased the number of noninvasive tests from 178 to 39; it would have identified only 4 of the 10 patients who underwent revascularization. The three other guidelines (renal transplant-specific guidelines) recommended widespread pretransplant cardiac testing and thus identified nearly allpatients who had ischemia on stress testing. CONCLUSIONS: The ACC/AHA perioperative guideline may be inadequate for identifying renal transplant candidates with coronary disease; however, renal transplant-specific guidelines may provoke significant overtesting. An intermediate approach based on risk factors specific to the ESRD population may optimize detection of coronary disease and limit testing.
Valoración cardiaca antes de transplante renal
Cardiac evaluation prior to kidney transplantation.
Delos Santos R, Gmurczyk A, Obhrai JS, Watnick SG.
Semin Dial. 2010 May-Jun;23(3):324-9. doi: 10.1111/j.1525-139X.2010.00725.x.
Kidney transplantation is the treatment of choice for most patients with stage 5 chronic kidney disease and end-stage renal disease (ESRD), offering improved quality of life and overall survival rates. However, the limited supply of available organs makes this a scarce resource. Cardiovascular complications continue to be the leading cause of mortality in the kidney transplant population, accounting for over 30% of deaths with a functioning allograft. Thus, preoperative cardiac risk assessment is critical to optimize patient selection and outcomes. Currently there is no consensus for cardiovascular evaluation in the chronic kidney disease and ESRD population prior to kidney transplantation; the recommendations of the American Society of Nephrology and American Society of Transplantation differ from those of the American Heart Association and the American College of Cardiology. Previously developed risk scores have also been used to risk stratify this population. In this review, we discuss two cases that illustrate the difficulties of interpreting the prognostic value of current testing strategies. We also discuss the importance of different tests for cardiovascularevaluation as well as previous nonkidney transplant specific risk scores used in the pre-kidney transplant population.
Consideraciones sobre el diseño y la viabilidad de un ensayo clínico para examinar el cribado coronario antes del trasplante de riñón
Design considerations and feasibility for a clinical trial to examine coronary screening before kidney transplantation (COST).
Kasiske BL1, Israni AK, Snyder JJ, Camarena A; COST Investigators.
Collaborators (26)
Am J Kidney Dis. 2011 Jun;57(6):908-16. doi: 10.1053/j.ajkd.2011.01.020. Epub 2011 Mar 15.
SETTING & PARTICIPANTS: Consecutive patients referred for kidney and/or pancreas transplant at 26 major transplant centers in the United States. PREDICTORS: Older age, diabetes, prior cardiovascular 
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