Protecting the Hearts of Patients Awaiting Kidney, Liver Transplants
August 10, 2012
While thousands of Americans - many of them age 50 and older - await a life-saving kidney or liver transplant, medical teams at Dartmouth-Hitchcock Medical Center and around the country are paying close attention to another organ: their hearts.
This month, a working group of clinicians co-chaired by D-H cardiologist Salvatore P. Costa, MD, is helping the American Heart Association (AHA) to reconcile the varied cardiac evaluation policies at US hospitals that assess a patient's overall health before transplant surgery.
Citing waiting lists of about 85,000 people needing kidney transplants and 16,000 in search of a liver, the AHA and its co-sponsor, the American College of Cardiology Foundation, this week published a scientific statement about the cardiac policies in Circulation and the Journal of the American College of Cardiology.
"Conducting clinically and cost-effective cardiac evaluation among patients being considered for kidney and liver transplantation is challenging due to the large size of these target populations, which face high cardiac disease prevalence; the organ shortage, which raises concerns for fairness and utility in transplantation; and the often extended periods between initial evaluation and transplant surgery," says working group co-chair Krista L. Lentine, MD, associate professor of medicine at the Saint Louis University Center for Outcomes Research and Department of Medicine/Division of Nephrology.
Costa, director of DHMC's echocardiography laboratory and an assistant professor of cardiology at the Geisel School of Medicine at Dartmouth, collaborated on the working group with Kim A. Eagle, MD, professor of cardiology at the University of Michigan. And Costa's fellow D-H cardiologist John Robb, MD, joined the extensive review of data regarding cardiac evaluation in kidney transplantation and liver transplantation. The resulting scientific statement considers the evidence regarding noninvasive stress testing in asymptomatic transplantation candidates; use of supplemental testing including echocardiography and cardiac biomarkers; coronary revascularization and related care before transplantation; and medical management of cardiovascular risk factors before, during and after transplant.
Among other recommendations, the group encourages surgeons to consider using procedures such as angioplasty which improves blood flow to the heart and relieves chest pain before transplantation, depending on each patient's symptoms, cardiac function, and extent of blockage in blood vessels.
"However," Costa notes, "we also recognize that in some asymptomatic transplantation candidates, the risk of coronary revascularization may outweigh the risk of transplantation, and these risks must be weighed by the multidisciplinary transplantation team on a case-by-case basis until further studies are performed in this population."
In an editorial about the statement, Christopher deFilipi, MD, an associate professor of medicine at the University of Michigan, points to use of these guidelines as "likely (to) improve uniformity of care across centers and minimize testing of limited value. Cohesion of cardiac pre-operative risk assessment and management across centers can't be understated with many transplant candidates seeking listing at multiple centers to potentially improve their chance of transplantation.
"Currently," deFilipi adds, "these patients are often faced with divergent opinions and conflicting requests for pre-operative cardiac testing ranging from no testing to routine coronary angiography."
In a survey of centers participating in the United Network for Organ Sharing, 8 percent of programs reported cardiac testing for all listed candidates, and 18 percent did not order routine cardiac testing for any asymptomatic patient group.
The authors address the need for separate guidelines for kidney and liver transplant patients. Kidney transplant recipients may have more common comorbidities, such as diabetes, than patients with liver failure. Heart disease is a common cause of death among those with end-stage kidney failure, while liver transplant candidates face their own unique problems such as pulmonary hypertension.
The group also advises hospitals to identify a primary cardiology consultant for questions related to potential transplant candidates.
"Overall, we hope this statement will offer a foundation for centers to coordinate and better standardize cardiac evaluation practices before kidney and liver transplantation according to best available evidence," says Eagle, a director of the University of Michigan's Cardiovascular Center. "We hope the document will provide an impetus to advancing the evidence basis for cardiac evaluation and management specifically in the population with end-stage organ failure being considered for transplantation, so that in the end we can reduce cardiac morbidity and mortality in this population and facilitate safe transplant surgery without incurring risks and expense from unnecessary testing."
Dartmouth-Hitchcock is a national leader in patient-centered health care and building a sustainable health system. Founded in 1893, the system includes New Hampshire's only Level 1 trauma center and its only air ambulance service, as well as the Norris Cotton Cancer Center, one of only 40 National Cancer Institute-designated Comprehensive Cancer Centers in the nation, and the Children's Hospital at Dartmouth-Hitchcock, the state's only Children's Hospital Association-approved, comprehensive, full-service children's hospital. As an academic medical center, Dartmouth-Hitchcock provides access to nearly 1,000 primary care doctors and specialists in almost every area of medicine, as well as world-class research at the Audrey and Theodor Geisel School of Medicine at Dartmouth.